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Hello, I have been a runner for 10 years, up

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Posted on Fri, 1 Mar 2019
Question: Hello, I have been a runner for 10 years, up until 6 months ago when I started to have trouble breathing and struggled with dizziness and palpitations. I am a 35 yr old female and got some results from my Holter monitor.

-Heart rates greater than 100 BPM were noted 8% of the time. Heart rates less than 60 BPM were noted 51% of the time.
-38189 ventricular ectopics, which represented 20% of the total beat count, were noted
-Ventricular ectopics were observed as 38004 isolated beat(s), as 76 couplet(s) and as 8 run(s). Some of the ventricular beats occurred in bigeminal cycles
-Multiple episodes of ST depression were noted in channel 1. The maximum depression of -2.0 mm occurred
-Multiple episodes of ST depression were noted in channel 2. The maximum depression of -1.9 mm occurred
-Multiple episodes of ST depression (defined as -1.0 mm or more) were noted in channel 3.
-79 ventricular couplets. 8 short runs of NSVT up to 4 beats long.

Most symptoms of palpitations correlated with PVCs but some with sinus rhythm.
Symtpoms of dizziness correlated with sinus rhythm and with PVcs.

Can anyone help me interpret this data? I don't know what ST depression means or much of the other stuff! Also, I get dizzy and weak every time I stand up from a horizontal position.
doctor
Answered by Dr. Sameer Maheshwari (1 hour later)
Brief Answer:
Detailed answer ahead

Detailed Answer:
Hi,
Welcome.
This is Dr Sameer, cardiologist.
Holter monitoring is a 24hr continuous ECG monitoring of heart.
The heart rhythm is normally called as sinus rhythm. Ectopics (VPC's) are some extra beats originating from some places other than the normal conducting system of heart. They can be normal or abnormal depending on the condition of heart.
When they occur in pairs it is called as couplet and when 3 occur together it is called as triplet.
Bigeminy is one normal sinus beat and one VPC occuring in sequence.
ST depression generally denotes underlying ischemia of the heart (means heart is not getting enough blood), this could be due to blockage in vessels of heart or some other underlying structural heart disease.
All this is abnormal.
I will first advise you to get a 2D Echo done to rule out structural heart disease. I expect we will find something in that. If that comes normal than only go for Tread mill test (TMT) to rule out ischemia.
The further treatment will depend on the results of these tests.
I hope you get well soon.
Please do follow up after these tests results so that I can help you ahead.
Thanks and take care
Above answer was peer-reviewed by : Dr. Nagamani Ng
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Follow up: Dr. Sameer Maheshwari (1 hour later)
Sorry but I included the results from my stress echo under treatment (2D with treadmill test). Please read my question again, as I have paid for specific advice but you have given such general answers.

How does ischemia show up on treadmill test? Also, is the number of PVCs I have too many? Also is a heart rate under 60 bpm 50% of the time normal?

I would like much more detail and analysis.

Stress Echo
Stress Echo: Resting ECG:Sinus rhythm, normal axis, St-T wave changes. Rest Echo Findings:The study was technically adequate. Normal LV cavity size and wall thickness. LVEF by Simpsons is 58% with no segmental abnormalities. There is normal diastolic function. Normal right ventricular size and systolic function. RVSP is estimated at 19mmHg (RAP = 3mmHg). Normal left atrial volume per ASE 2015 guidelines. The right atrial size is normal. Trileaflet aortic valve structurally normal with no stenosis or regurgitation. Structurally normal mitral valve with trace (physiologic) regurgitation. The tricuspid valve is structurally normal with trace (physiologic) regurgitation. Pulmonic valve is structurally normal with trace regurgitation. LVOT, Sinus of Valsalva, Sinotubular Junction, Ascending Aorta and Arch are of normal caliber. No doppler evidence of coarctation. The inferior vena cava is of normal caliber and collapses >50% on inspiration. No evidence of PFO/ASD/VSD by 2D or colour doppler. No pericardial effusion. Protocol:Bruce protocol. Informed consent was obtained. Symptoms:No symptoms of chest pain. The test was stopped because the target heart rate was achieved. Exercise ECG:Sinus rhythm. Stress Echo Findings: CONCLUSIONS ----------- 1. Baseline ECHO: Normal bi-ventricular size and systolic function. There is no hemodynamically significant valvular heart disease. 2. Average exercise tolerance. 3. Normal blood pressure response to exercise. 4. Symptom negative test. 5. Non-specific repolarization changes on baseline ECG. No ECG changes diagnostic for ischemia with exercise. 6. Stress echo: The basal inferoseptal segment is appears tardokinetic. However, the segment wall thickening in systole is normal. This may be influenced by the image aquisition probe angle (off axis view). Overall, this is probably a negative stress echo study. 7. Overall, the likelihood of significant CAD is reduced. Indications: tachy/bradcardia
doctor
Answered by Dr. Sameer Maheshwari (22 hours later)
Brief Answer:
Detailed answer ahead

Detailed Answer:
Hi,
Welcome back.
The stress echo report is normal (sorry I missed that).
Coming to your questions first and then the interpretation of your Holter and stress echo.
1) How does ischemia show on treadmill -
As you have already done the stress echo, their is no need to get the Treadmill done. If their would have been ischemia, TMT would have shown ST depression during exercise and their would have been wall motion abnormality in 2D Echo after the exercise (which is not their) and thus their is no evidence of ischemia.
2) Is heart rate below 60 normal -
Yes it is absolutely normal. Athletes generally have low heart rate to decrease the metabolism of heart. Chronic athletes could have heart rate in range 40.
It is normal until you do not have symptoms with it ( like giddiness or dizziness). Their is one extra column written with the report, MINIMUM HEART RATE, please mention what is this.

Coming to the interpretation of Holter -
You do not have a structural heart disease (as confirmed on Echo) and have a significantly large number of VPC's.
One more thing which is missing from the report is, whether the VPCs are of Left Ventricular(LV) or Right Ventricular(RV) origin. It is very important.
If you can send a picture of ECG with VPCs, I'll tell you their origin.
Both have different causes and treatment.
Their are certain abnormality which are sometimes not seen on simple 2D Echo and require more imaging.
As the echo is normal, you should go for a CARDIAC MRI.

Patients without structural heart disease and low-to-modest PVC burdens do not always require treatment. PVCs at higher burdens (typically more than 15% to 20% of heartbeats) or strung together in runs of ventricular tachycardia pose a higher risk of tachycardia-related cardiomyopathy (weakening of heart) and heart failure, even if asymptomatic and should be treated.

I hope this answers your question.
I will be happy to answer if you have any more queries.
Thanks and regards

Above answer was peer-reviewed by : Dr. Raju A.T
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Dr. Sameer Maheshwari

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Practicing since :2010

Answered : 815 Questions

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Hello, I have been a runner for 10 years, up

Brief Answer: Detailed answer ahead Detailed Answer: Hi, Welcome. This is Dr Sameer, cardiologist. Holter monitoring is a 24hr continuous ECG monitoring of heart. The heart rhythm is normally called as sinus rhythm. Ectopics (VPC's) are some extra beats originating from some places other than the normal conducting system of heart. They can be normal or abnormal depending on the condition of heart. When they occur in pairs it is called as couplet and when 3 occur together it is called as triplet. Bigeminy is one normal sinus beat and one VPC occuring in sequence. ST depression generally denotes underlying ischemia of the heart (means heart is not getting enough blood), this could be due to blockage in vessels of heart or some other underlying structural heart disease. All this is abnormal. I will first advise you to get a 2D Echo done to rule out structural heart disease. I expect we will find something in that. If that comes normal than only go for Tread mill test (TMT) to rule out ischemia. The further treatment will depend on the results of these tests. I hope you get well soon. Please do follow up after these tests results so that I can help you ahead. Thanks and take care