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What Do My Lab Test Reports Indicate?
Question: Hi Dr. Iliri,
I am back again to ask you a few questions!
I didn't realize I could request you and I asked a question this morning and another doctor answered. I am concerned with his answer and saw that I could request you. I was wondering if you could give me another opinion?
I will attach my reports again for you to see. I am also providing the answer the doctor gave me this morning for you to review.
We have discussed before that I was diagnosed with PVCs a month ago. I saw a cardiologist on Aug. 15 who did an ultrasound of my heart, reviewed all tests I have had done, and said he saw nothing alarming. In his report to my doctor, he said he believes I suffer from anxiety. My doctor also believes most or all of my symptoms are due to anxiety. I think you had also felt it was reasonable to assume much of my problem is anxiety. I spoke with a friend of ours who is an internist. He saw my Holter monitor report and he did not think my PVCs were a problem.
I am trying to relieve my stress, but it has been tough. I have still been feeling like I have climbed 4 flights of stairs when only climbing one flight or doing other activities and get that achy feeling in my legs. My doctor is sending me for an Ankle Brachial Indices on Friday. He still thinks anxiety is my problem, but he is sending me for it to make me feel better!
The cardiologist is sending me for a stress test on Sept. 21. He is also doing it to make me feel better! He did not think there will be problems with my heart.
The reason I asked a question today is that I have been getting an internal shaky feeling, mostly in my arms, but through my body. I have not had any caffeine in a few weeks, but it feels like I have had too much caffeine - that jittery feeling. It comes and goes and I do not have it every day. I have woke up with it sometimes. One time I woke up with it I tried to relax and it went away. I was wondering if this could also be due to anxiety? I have been eating well, so I don't think it is blood sugar.
When I asked this question today, a cardiologist responded. He scared me about my Holter monitor results. Here is what he said:
"First I would tell you that your Holter report is not normal. It has episodes of bigeminy(which can be there in a normal heart) & a run of non sustained VT(which needs treatment & other evaluation).
Your cardiologist has rightly advised you for a stress echo which you should try to do as early as possible. A normal echo does not rule out a normal heart.
Anxiety & panic attacks can cause frequent VPC's(ectopic beats) but it will not cause VT.
Frequent symptomatic PVC's definitely needs treatment.
For such cases we advise to start on a beta blocker - PROPANOLOL starting from 40mg twice daily which can be increased gradually.
It will take care of both PVC's & Anxiety. "
I am not sure I even understand what all of that means! I am also worried now that my stress test is too far away - I go on Sept. 21
This answer has caused me much concern. I went to emergency 3 weeks ago (before I saw the cardiologist). That doctor also scared me as she said that all of my tests came back normal. In the ER she could only see that I had PVCs. BUT she said that my Holter monitor report was not normal and that I could not drive, could not be alone, could not have a bath/shower (wash hair in sink). She seemed so concerned. I left there terrified!!
When I saw my family doctor and the cardiologist, they both felt the ER doctor had gone too far and told me to resume my normal life and that I have nothing to worry about. Again, they felt my problem is mostly stress.
I would appreciate your opinion (again!) I noticed in your bio that you have more years of experience than the doctor who answered my question this morning. I would appreciate your help.
Thank you!
I am back again to ask you a few questions!
I didn't realize I could request you and I asked a question this morning and another doctor answered. I am concerned with his answer and saw that I could request you. I was wondering if you could give me another opinion?
I will attach my reports again for you to see. I am also providing the answer the doctor gave me this morning for you to review.
We have discussed before that I was diagnosed with PVCs a month ago. I saw a cardiologist on Aug. 15 who did an ultrasound of my heart, reviewed all tests I have had done, and said he saw nothing alarming. In his report to my doctor, he said he believes I suffer from anxiety. My doctor also believes most or all of my symptoms are due to anxiety. I think you had also felt it was reasonable to assume much of my problem is anxiety. I spoke with a friend of ours who is an internist. He saw my Holter monitor report and he did not think my PVCs were a problem.
I am trying to relieve my stress, but it has been tough. I have still been feeling like I have climbed 4 flights of stairs when only climbing one flight or doing other activities and get that achy feeling in my legs. My doctor is sending me for an Ankle Brachial Indices on Friday. He still thinks anxiety is my problem, but he is sending me for it to make me feel better!
The cardiologist is sending me for a stress test on Sept. 21. He is also doing it to make me feel better! He did not think there will be problems with my heart.
The reason I asked a question today is that I have been getting an internal shaky feeling, mostly in my arms, but through my body. I have not had any caffeine in a few weeks, but it feels like I have had too much caffeine - that jittery feeling. It comes and goes and I do not have it every day. I have woke up with it sometimes. One time I woke up with it I tried to relax and it went away. I was wondering if this could also be due to anxiety? I have been eating well, so I don't think it is blood sugar.
When I asked this question today, a cardiologist responded. He scared me about my Holter monitor results. Here is what he said:
"First I would tell you that your Holter report is not normal. It has episodes of bigeminy(which can be there in a normal heart) & a run of non sustained VT(which needs treatment & other evaluation).
Your cardiologist has rightly advised you for a stress echo which you should try to do as early as possible. A normal echo does not rule out a normal heart.
Anxiety & panic attacks can cause frequent VPC's(ectopic beats) but it will not cause VT.
Frequent symptomatic PVC's definitely needs treatment.
For such cases we advise to start on a beta blocker - PROPANOLOL starting from 40mg twice daily which can be increased gradually.
It will take care of both PVC's & Anxiety. "
I am not sure I even understand what all of that means! I am also worried now that my stress test is too far away - I go on Sept. 21
This answer has caused me much concern. I went to emergency 3 weeks ago (before I saw the cardiologist). That doctor also scared me as she said that all of my tests came back normal. In the ER she could only see that I had PVCs. BUT she said that my Holter monitor report was not normal and that I could not drive, could not be alone, could not have a bath/shower (wash hair in sink). She seemed so concerned. I left there terrified!!
When I saw my family doctor and the cardiologist, they both felt the ER doctor had gone too far and told me to resume my normal life and that I have nothing to worry about. Again, they felt my problem is mostly stress.
I would appreciate your opinion (again!) I noticed in your bio that you have more years of experience than the doctor who answered my question this morning. I would appreciate your help.
Thank you!
Brief Answer:
My answer as follows:
Detailed Answer:
Dear XXXXXXX
Welcome back on HCM!
I am sorry to hear that you have been worried too much from having the previous medical information and at the meantime, I would like to let you know that your actual clinical symptomatology may be triggered by an increased level of circulating catecholamines.
I know that it seems too much concerning discussing about ventricular tachycardia (VT), as it may frequently signify a pathological myocardial substrate (that is certain certain cardiac muscle areas with abnormally altered structural properties leading very often to complex cardiac arrhythmia).
But arrhythmia may be triggered even in the absence of such prerequisites (myocardium damage); and this is the case when certain extra-cardiac stimuli represent a stressful environment for the heart.
Such stimuli may be also increased blood levels of circulating catecholamines (due also to persistent anxiety, certain pulmonary disorders leading to hypoxemia (low level of blood oxygen), certain blood electrolytes disorder (potassium, magnesium, phosphorus and calcium disorders), certain hormonal imbalances, persistent fever (high blood temperature), etc.
As you may see dear XXXXXXX there are a lot of factors leading to arrhythmic phenomena.
Once detected the exact triggering factor and properly treated, those palpitations and associated symptoms will certainly disappear.
Considering your clinical background, previous medical treatment, age and the fact your medical tests have resulted normal (generally normal cardiac structure on resting cardiac echo) the role of anxiety seems quite likely.
Coming to this point, I don't think you are in any great danger of life-threatening arrhythmic conditions.
Arrhythmic events in a structurally normal heart have not the same significance when considering any potential dangerous complications (in the absence of any congenital arrhythmogenic disorder, pre-excitation, long or short QT syndrome, channelopathies, etc. which are primarily excluded in your case).
Furthermore, I am a bit reluctant in regards of the real nature of the so-called runs of VT as not rarely supraventricular arrhthymias are mistakenly mentioned as ventricular. A careful review of the whole ECG Holter strips should be done.
So, there is no need tor hurry up with the recommended cardiac tests.
The recommended cardiac stress echo would give important clues in this regard.
In the meantime, it is very important trying to minimize the effects of anxiety.
For this reason, I would recommend practicing Yoga and a lot of physical activity (recreational sports, walking, etc.).
It is also necessary avoid taking caffeine intake, which can trigger anxiety.
If you have any other questions, please don't hesitate to ask me again!
Hope you will find this answer helpful!
Kind regards,
Dr. Iliri
My answer as follows:
Detailed Answer:
Dear XXXXXXX
Welcome back on HCM!
I am sorry to hear that you have been worried too much from having the previous medical information and at the meantime, I would like to let you know that your actual clinical symptomatology may be triggered by an increased level of circulating catecholamines.
I know that it seems too much concerning discussing about ventricular tachycardia (VT), as it may frequently signify a pathological myocardial substrate (that is certain certain cardiac muscle areas with abnormally altered structural properties leading very often to complex cardiac arrhythmia).
But arrhythmia may be triggered even in the absence of such prerequisites (myocardium damage); and this is the case when certain extra-cardiac stimuli represent a stressful environment for the heart.
Such stimuli may be also increased blood levels of circulating catecholamines (due also to persistent anxiety, certain pulmonary disorders leading to hypoxemia (low level of blood oxygen), certain blood electrolytes disorder (potassium, magnesium, phosphorus and calcium disorders), certain hormonal imbalances, persistent fever (high blood temperature), etc.
As you may see dear XXXXXXX there are a lot of factors leading to arrhythmic phenomena.
Once detected the exact triggering factor and properly treated, those palpitations and associated symptoms will certainly disappear.
Considering your clinical background, previous medical treatment, age and the fact your medical tests have resulted normal (generally normal cardiac structure on resting cardiac echo) the role of anxiety seems quite likely.
Coming to this point, I don't think you are in any great danger of life-threatening arrhythmic conditions.
Arrhythmic events in a structurally normal heart have not the same significance when considering any potential dangerous complications (in the absence of any congenital arrhythmogenic disorder, pre-excitation, long or short QT syndrome, channelopathies, etc. which are primarily excluded in your case).
Furthermore, I am a bit reluctant in regards of the real nature of the so-called runs of VT as not rarely supraventricular arrhthymias are mistakenly mentioned as ventricular. A careful review of the whole ECG Holter strips should be done.
So, there is no need tor hurry up with the recommended cardiac tests.
The recommended cardiac stress echo would give important clues in this regard.
In the meantime, it is very important trying to minimize the effects of anxiety.
For this reason, I would recommend practicing Yoga and a lot of physical activity (recreational sports, walking, etc.).
It is also necessary avoid taking caffeine intake, which can trigger anxiety.
If you have any other questions, please don't hesitate to ask me again!
Hope you will find this answer helpful!
Kind regards,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Hi Dr. Iliri,
Thank you so much for your kind and detailed response. I really appreciate it. This whole situation has been very confusing and stressful for me.
I do have a couple of questions:
When you said that "congenital arrhythmogenic disorder, pre-excitation, long or short QT syndrome , channelopathies, etc" were primarily excluded in my case, were they excluded on the basis of the ultrasound of my heart? Would those conditions have shown up on the ultrasound?
When you said you are "a bit reluctant in regards of the real nature of the so-called runs of VT as not rarely supraventricular arrhthymias are mistakenly mentioned as ventricular. A careful review of the whole ECG Holter strips should be done", I am not quite sure what you mean. Do you think it is possible an error has been made? My cardiologist said he was not given the strips of the Holter and was hoping he could have seen them. I know that an Internist read them and sent the report to my family doctor, but I don't think my doctor received the strips either. Should I ask for the strips to be sent to the cardiologist? Should I ask for another Holter to be done? I am just wondering if you are unsure of my results.
I'm sorry, sometimes it takes me a while to understand medical terms!
Thank you again for your help.
Thank you so much for your kind and detailed response. I really appreciate it. This whole situation has been very confusing and stressful for me.
I do have a couple of questions:
When you said that "congenital arrhythmogenic disorder, pre-excitation, long or short QT syndrome , channelopathies, etc" were primarily excluded in my case, were they excluded on the basis of the ultrasound of my heart? Would those conditions have shown up on the ultrasound?
When you said you are "a bit reluctant in regards of the real nature of the so-called runs of VT as not rarely supraventricular arrhthymias are mistakenly mentioned as ventricular. A careful review of the whole ECG Holter strips should be done", I am not quite sure what you mean. Do you think it is possible an error has been made? My cardiologist said he was not given the strips of the Holter and was hoping he could have seen them. I know that an Internist read them and sent the report to my family doctor, but I don't think my doctor received the strips either. Should I ask for the strips to be sent to the cardiologist? Should I ask for another Holter to be done? I am just wondering if you are unsure of my results.
I'm sorry, sometimes it takes me a while to understand medical terms!
Thank you again for your help.
Brief Answer:
My opinion as follows:
Detailed Answer:
Hi again, dear xxxx!
Regarding your latest questions I would explain:
All the above mentioned rhythm disorders (pre-excitation, long or short QT syndrome, channelopathies, etc") are primarily discovered by ECG (not cardiac ultrasound).
You said all your cardiac tests have resulted normal (including ECG as one of the basic tests).
I hope that your ECGs reviews have been done by a cardiologist or your cardiologist has a full knowledge of them.
The second question is almost answered by your mentioned conclusion: sometimes conclusions of Holter monitoring are given by a technician or internist only on the basis of what the computer analyses without a full review by a specialist’s eye of every ECG strip.
This strategy confers also some errors as the computer may assume a supraventricular arrhythmic event as ventricular or vice versa.
In conclusion, I would say that if your cardiologist has not reviewed the Holter recordings by himself, then it is not surprising that some errors are present on your actual Holter conclusion.
In such case, two rational alternatives are advisable to follow: one that your cardiologist could review the already concluded Holter and second a new Holter should be done.
Hope to have been clear with my explanations.
In you have further questions do not hesitate to send them to me.
I remain at your disposal for further discussions.
Kind regards,
Dr. Iliri
My opinion as follows:
Detailed Answer:
Hi again, dear xxxx!
Regarding your latest questions I would explain:
All the above mentioned rhythm disorders (pre-excitation, long or short QT syndrome, channelopathies, etc") are primarily discovered by ECG (not cardiac ultrasound).
You said all your cardiac tests have resulted normal (including ECG as one of the basic tests).
I hope that your ECGs reviews have been done by a cardiologist or your cardiologist has a full knowledge of them.
The second question is almost answered by your mentioned conclusion: sometimes conclusions of Holter monitoring are given by a technician or internist only on the basis of what the computer analyses without a full review by a specialist’s eye of every ECG strip.
This strategy confers also some errors as the computer may assume a supraventricular arrhythmic event as ventricular or vice versa.
In conclusion, I would say that if your cardiologist has not reviewed the Holter recordings by himself, then it is not surprising that some errors are present on your actual Holter conclusion.
In such case, two rational alternatives are advisable to follow: one that your cardiologist could review the already concluded Holter and second a new Holter should be done.
Hope to have been clear with my explanations.
In you have further questions do not hesitate to send them to me.
I remain at your disposal for further discussions.
Kind regards,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you so much for explaining everything to me! I really appreciate it.
You know, I was pretty stressed the last few months. Then one night a month ago I go to bed and the PVCs came out of nowhere. That increased my stress level. A few days later I was having the shortness of breath and achy feeling in my legs and arms upon climbing stairs and other activities. This increased my anxiety further. Then I went to the ER and the doctor frightened me pretty bad. This increased my stress even further. I felt better after seeing my cardiologist, my family doctor and speaking with you. I was starting to relax over the last 2 weeks (but still kind of stressed), but then I started to get that internal shaky feeling (which I now think is from stress) and I asked that other doctor on this site about it yesterday morning. He got me all nervous again about the Non sustained VT on my Holter report. As yesterday went on, I noticed that the achy feeling in my legs and arms was getting worse again (like a couple of weeks ago) and realized that maybe that feeling really is due to stress. I was grateful to speak with you as you are able to explain things better for me and calm my nerves! I will try to get the anxiety under control because otherwise the physical symptoms will keep getting worse or stay the same and that will make me keep worrying about what could be wrong with me. It is a such vicious cycle.
Yes I do think the cardiologist saw the results of my ECGs from the ER. I had a regular ECG and a long strip ECG done in the ER in Aug. I also had an ECG done in July for a different ER visit. Back in February I was having chest pain (ended up being my back) and had an ECG done at that time as well. I was told they were all negative.
Thank you for explaining about the Holter. I think I will request another Holter be done for my cardiologist to read instead of the Internist.
I do have a few questions:
If I have Non sustained VT, does it leave me susceptible to sustained VT or heart disease? Should it be treated if my heart is found to be healthy after the stress test? I feel like a ticking time bomb!
I think what you had said is that in the absence of a structural abnormality, it is possible that the Non sustained VT may have been triggered by catecholamines in my blood possibly triggered by anxiety or another trigger. When that trigger is identified and treated (such as anxiety) I know that the PVCs will likely improve, but will it also improve the Non sustained VT (if that is what I have - I will ask for another Holter)? The doctor who had answered my question yesterday morning had said VT is not caused by anxiety.
You had mentioned that I should exercise to relieve anxiety. Is exercise safe for my heart at this point?
Also, is it safe for me to fly? We are not planning a trip until next year, but I was just curious.
Thank you SO much again for all of your help and patience with me! It is so hard to be an anxious person and have issues with a major organ! It causes a lot of fear and confusion. I also need to stop looking on Google!! That can make me feel very stressed!!
Thanks again!
You know, I was pretty stressed the last few months. Then one night a month ago I go to bed and the PVCs came out of nowhere. That increased my stress level. A few days later I was having the shortness of breath and achy feeling in my legs and arms upon climbing stairs and other activities. This increased my anxiety further. Then I went to the ER and the doctor frightened me pretty bad. This increased my stress even further. I felt better after seeing my cardiologist, my family doctor and speaking with you. I was starting to relax over the last 2 weeks (but still kind of stressed), but then I started to get that internal shaky feeling (which I now think is from stress) and I asked that other doctor on this site about it yesterday morning. He got me all nervous again about the Non sustained VT on my Holter report. As yesterday went on, I noticed that the achy feeling in my legs and arms was getting worse again (like a couple of weeks ago) and realized that maybe that feeling really is due to stress. I was grateful to speak with you as you are able to explain things better for me and calm my nerves! I will try to get the anxiety under control because otherwise the physical symptoms will keep getting worse or stay the same and that will make me keep worrying about what could be wrong with me. It is a such vicious cycle.
Yes I do think the cardiologist saw the results of my ECGs from the ER. I had a regular ECG and a long strip ECG done in the ER in Aug. I also had an ECG done in July for a different ER visit. Back in February I was having chest pain (ended up being my back) and had an ECG done at that time as well. I was told they were all negative.
Thank you for explaining about the Holter. I think I will request another Holter be done for my cardiologist to read instead of the Internist.
I do have a few questions:
If I have Non sustained VT, does it leave me susceptible to sustained VT or heart disease? Should it be treated if my heart is found to be healthy after the stress test? I feel like a ticking time bomb!
I think what you had said is that in the absence of a structural abnormality, it is possible that the Non sustained VT may have been triggered by catecholamines in my blood possibly triggered by anxiety or another trigger. When that trigger is identified and treated (such as anxiety) I know that the PVCs will likely improve, but will it also improve the Non sustained VT (if that is what I have - I will ask for another Holter)? The doctor who had answered my question yesterday morning had said VT is not caused by anxiety.
You had mentioned that I should exercise to relieve anxiety. Is exercise safe for my heart at this point?
Also, is it safe for me to fly? We are not planning a trip until next year, but I was just curious.
Thank you SO much again for all of your help and patience with me! It is so hard to be an anxious person and have issues with a major organ! It causes a lot of fear and confusion. I also need to stop looking on Google!! That can make me feel very stressed!!
Thanks again!
Brief Answer:
My answer as follows:
Detailed Answer:
Dear xxxxx!
I think that the best strategy to follow is requesting a new Holter test reviewed by a specialist.
In that way would be properly confirmed the real nature of those short runs of wide QRS complexes tachycardia (whether they are supraventricular with aberrant conduction or ventricular).
Sometimes it is not easy to differentiate between them, but most often it is not difficult due to the characteristic ECG patterns idiopathic tachycardia or so called ventricular outflow tract tachycardia (left bundle branch block with inferior axis of the QRS complex) in the settings of a structurally normal heart.
These forms exert a catecholamine-dependent behaviour as endogenous (such as excessive stress and anxiety) or exogenous catecholamines may facilitate tachycardia induction. Though different mechanisms may be responsible, in general increased cyclic adenosine monophosphate and intra-celular calcium are commonly the cause.
But before considering these complex theoretical discussions you should know that even if non sustained VT were present, they do not denote an increased risk of heart disease.
Even in the extreme alternative that those episodes of tachycardia were VTs, you should not be worried as there is always a solution, they could be easily managed wit ha wide range of interventions, from simple anti-arrhythmics to cardiac ablation.
These few arrhythmic episodes are not an indicator that yould should limit your daily activity or travel plans.
Also, physical activity are not dangerous, you should avoid only those strenuous and extreme physical exertions that may increase circulating catecholamines levels.
I continue to believe that once you manage your excessive anxiety all those episodic rhythm disorders will decrease and disappear.
Wishing you a pleasant weekend!
Regards,
Dr. Iliri
My answer as follows:
Detailed Answer:
Dear xxxxx!
I think that the best strategy to follow is requesting a new Holter test reviewed by a specialist.
In that way would be properly confirmed the real nature of those short runs of wide QRS complexes tachycardia (whether they are supraventricular with aberrant conduction or ventricular).
Sometimes it is not easy to differentiate between them, but most often it is not difficult due to the characteristic ECG patterns idiopathic tachycardia or so called ventricular outflow tract tachycardia (left bundle branch block with inferior axis of the QRS complex) in the settings of a structurally normal heart.
These forms exert a catecholamine-dependent behaviour as endogenous (such as excessive stress and anxiety) or exogenous catecholamines may facilitate tachycardia induction. Though different mechanisms may be responsible, in general increased cyclic adenosine monophosphate and intra-celular calcium are commonly the cause.
But before considering these complex theoretical discussions you should know that even if non sustained VT were present, they do not denote an increased risk of heart disease.
Even in the extreme alternative that those episodes of tachycardia were VTs, you should not be worried as there is always a solution, they could be easily managed wit ha wide range of interventions, from simple anti-arrhythmics to cardiac ablation.
These few arrhythmic episodes are not an indicator that yould should limit your daily activity or travel plans.
Also, physical activity are not dangerous, you should avoid only those strenuous and extreme physical exertions that may increase circulating catecholamines levels.
I continue to believe that once you manage your excessive anxiety all those episodic rhythm disorders will decrease and disappear.
Wishing you a pleasant weekend!
Regards,
Dr. Iliri
Note: For further follow up on related General & Family Physician Click here.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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