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Is It Possible For An Echo Stress Test To Miss Atrial Fibrillation?

Posted on Tue, 5 May 2015

Question: Is it possible for an echo stress test to miss a fib or sick sinus syndrome? I am a 70 year old female, started having episodes of palpitations some 15 years ago, at first only lasting for an hour, now they can last up to two days. I periodically am given an ECG at a general practitioners which will show similarities to a heart attack. Then when I am sent for the stress test, it has all settled and I get an all clear. However during these episodes I now have lowered blood pressure, slow heart rate <60 and pre syncope, severe dizziness and exercise will cause non specific chest pain. My blood pressure went from as high as 225/110 and on four meds to way too low (dropping to as low as 79/48) and no meds in a month. What would you suggest please?

Answered by Dr. Ilir Sharka (41 minutes later)

Brief Answer:
An ambulatory ECG monitoring is helpful regarding your complains.

Detailed Answer:
Hello! Thank you for asking on HCM! Regarding your concern I would recommend:
(1) Atrial fibrillation when it presents alone, or as part of a sick sinus syndrome can be studied and confirmed by ambulatory 24 to 48 hours ECG monitoring (if the palpitation episodes are very frequent, on a daily basis). This may clarify the cardiac rhythm implications on those syncope episodes. Stress echo is not the test of choice for studying rhythm disorders. It is not recommended for such an investigation.
(2) Regarding your BP fluctuations I recommend you a very careful follow up of BP values (many BP measurements per day) and consulting your attending physician (internist or cardiologist) to decide the most appropriate maintenance therapy for you. Please don't forget to check all body systems (renal, adrenal, thyroid functions, etc) to rule out any possible secondary hypertension (if it is not performed already).
Hope to have been helpful to you. greetings! Dr. Iliri

Above answer was peer-reviewed by : Dr. Neel Kudchadkar

Follow up: Dr. Ilir Sharka (2 days later)

Thank you for your answer which I found quite helpful. It will help me in speaking to a doctor.
The palpition episodes are very spasmodic and can last for 30 minutes to 2 days but could be a week or more apart or every day for a few days. So ambulatory tests could not be useful unless I am experiencing an episode.
I have been having these episode for quite a long time, but they have become progressively more frequent and longer lasting.
Also my blood pressure has dropped from very high (hypertension 225/110) to very low (hypotension 97/46) in a very short time. I have gone from taking EXforge HCT 10/160/12.5 and Physiotens 400mcg daily to no medication at all (low BP reading is a no medication reading). Also my heart rate during episodes with palpitations is quite low - usually 52 to 56. My BP changes and the recurrence of palpitation episodes seem to be related.
I am concerned because during these palpitation episodes I can become extremely dizzy, pre syncope and very tired. I frequently have to lie down for several hours and often fall asleep, something that is rare during a normal day.
I have good exercise levels for my age, weigh 65 kgs and lead an active lifestyle and have no other medical problems other than some osteo arthritis.
Is there any other advice you can provide for me to try and get a reasonable resolution. I want to know how to manage my health and here in Australia the patient has to be pro active in order to get the diagnosis and understand what is happening.

Answered by Dr. Ilir Sharka (13 hours later)

Brief Answer:
I would give some important clues about ambulatory ECG and BP monitoring.

Detailed Answer:

Hello again dear XXXXXX!

You are right when you refer that a standard ambulatory ECG monitoring could not be useful, if palpitations episodes are not frequently enough to detect (not in a daily basis ar least). But there are two reasons why I recommended you ambulatory ECG monitoring:

(a) There exists no better way to detect possible cardiac rhythm or conductance disorders than continuous ECG monitoring. Your palpitations coupled with bradycardia and clinical symptoms (dizziness, presyncope, pronounced tiredness), raise strong suspicions for a possible sick sinus syndrome. At that point, ambulatory ECG monitoring is helpful not only for detecting a possible episodic atrial fibrillation, but even for showing a persistent bradycardia, which is the most prominent sign of sick sinus sydrome. And, if a traditional ambulatory 24 to 48 hours ECG monitoring doesn't meet the requirements for detecting such rare episodes of possible atrial arrhythmia, then we have the possibility to change the settings of ambulatory monitoring device to longer periods of working (there are Holter monitoring devices, that can be programmed for registering 7 days or longer).

(b) If strong suspicions for the above mentioned arrhythmic disorders are continuous, then a special ambulatory ECG monitoring is mandatory, that is an event recorder called "loop recorder". It is implanted under the skin and so, keeps registering your heart beats for long periodes of time (1 to 6 months or even longer, in case of very rare suspected events).

Regarding your BP, I insist in a very meticulous repeated frequently BP measurements and rechecking your BP therapeutic strategy again with your doctor (facing the registered values). Don't forget to check for other body systems disorders, as I mentioned when answering your first query.

Hope to have been helpful to you.

Feel free to ask me again! Best Regards!

Above answer was peer-reviewed by : Dr. Vinay Bhardwaj