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    Suggest treatment for shortness of breath and tachycardia

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Posted on Sat, 5 Aug 2017 in Hypertension and Heart Disease
Question: I was getting pre surgery testing and was told by my doctor that my EKG was abnormal on (July12) so they had me come in again the next day to the office and I had another EKG and they said it was abnormal again and they thought I may have had a heart attack and want me to see a cardiologist before I get surgery. On March I had been admitted to the hospital because of chest pain (that day) and shortness of breath and tachycardia for a while. They did a MRI and one set of cardiac enzymes and 2 ekgs. They said I was fine and sent me home. But now I am wondering if this really was a heart attack. The pain was intense, but it was worse in my arms than my chest. I have uploaded all EKGS and MRI report. Please let me know what you think of the EKGs from July 12 and 13th. If you see anything abnormal what leads are abnormal? The other EKGs were from March 7 and the one is when I began having chest pain. Also, how long does it take to show a heart attack on a MRI?
doctor
Answered by Dr. Ilir Sharka 7 hours later
Brief Answer:
I would explain as follows:

Detailed Answer:
Hello Elisabeth!

Welcome back on HCM!

After passing carefully through your medical history and uploaded tests, I would like to explain as follows:

1- Regarding your ECGs (from march up to july), I would explain that no specific signs of myocardial infarction are present. Instead of that these ECG findings mimic patterns similar to an incomplete Right Bundle Branch Block (RBBB), but it is not such the case. In fact we are in front of a J-wave syndrome pattern, that is better seen in the precordial leads V1-V3. It is denoted by a terminal spike inside the QRS complex.

Also the negative T waves (Twave invertion) are compatible with such findings. So, to conclude there is a suspicion of Brugada Syndrome, that is a high predisposition for the occurrence of complex and even life-threatening cardiac arrhythmia.

But meanwhile, the ECG machine doesn't recognize these patterns in general.

2- Regarding your cardiac MRI, I would say that there is not any signs of a heart attack

Considering your clinical symptomatology on March, I would explain that the chest pain doesn't seem to be related to any myocardial ischemia issues.

Nevertheless, If you experience new episodes of chest pain and even arm pain, I would recommend going through additional tests, like nuclear perfusional cardiac stress test or Dobutamine cardiac ultrasound, because cardiac ischemia is an issue to be first excluded when considering a differential diagnosis of Brugada Syndrome ECG patterns.

So finally, to conclude, I would say that it is not a heart attack issue that worries me (because there are no sufficient data to support this alternative), but you should discuss with your cardiologist on the option of a J-wave syndrome (Brugada Syndrome) and to see the opportunity of undergoing through a Aimaline provocative test (it is important to finally confirm or exclude Brugada Syndrome)

In addition, it is necessary to repeat a resting ECG with V1-V2 leads displaced to the second intercostal spaces and also performing ECG before and after having meals.

If Brugada Syndrome is confirmed at the end, an implanted cardioverter defibrilator (ICD) should be considered.

Hope to have been helpful!

Kind regards,

Dr. Iliri


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 7 hours later
Ok I will ask him about brugada. But which ekg did you see it on? A cardiologist that looked at the one ekg on July 12 signed it as a septal infarct compared to an ekg in march but I do not have access to that one so I uploaded one from XXXXXXX I don't know if that changes anything. It's the upload that says img. How soon after a heart attack would a MRI show damage?Also why would I need an ekg before and after meals?
doctor
Answered by Dr. Ilir Sharka 4 hours later
Brief Answer:
Opinion as follows:

Detailed Answer:
Hello again, dear Elizabeth!

That ECG (img) showing slightly inverted T waves in V1-V3 leads doesn't imply an antero-septal infarct has occurred; there were no cardiac enzymes elevation, no findings on cardiac MRI.

Regarding cardiac MRI, I would explain that reliable evidence of important cardiac ischemia leading to myocardial infarction may be found quite early through the evidence of myocardial edema on T2 MRI sequences within 30 minutes after the beginning of clinical angina (chest pain). So the diagnosis would be precise and in a fast manner.

Performing ECGs before and after having meals, especially when precordial V1-V2 leads are displaced in the second intercostal spaces are helpful for investigating J wave syndrome (Brugada). Ajmaline test would be important in this regards.

Hope to have clarified your questions!

Wishing you are having a pleasant weekend!

Regards,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 28 minutes later
Ok. One more thing I forgot to mention. They diagnosed me with POTS and since I have been taking salt tablets I feel a lot better. My shortness of breath and tachycardia mostly went away. They had put me on cardizem too because of the fast heart rate and chest pain. But I stopped taking it. I only take it once in a while if I get chest discomfort, arm pain or tachycardia. Could either the salt or cardizem cause any problems?
doctor
Answered by Dr. Ilir Sharka 22 minutes later
Brief Answer:
I would explain :

Detailed Answer:

I would explain that extensive data are available on the beneficial effect of salt in the management of POTS, meanwhile no established data on Cardizem.

Nevertheless, neither of them could be accused on your slightly abnormal ECG changes.

Regards,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 2 days later
I went to see a cardiologist and he said he wasn't really worried about my ekg- he did another one in the office and said an incomplete right bundle branch but said that could be normal. He also said inverted t waves in v3. I forgot to ask him about brugada. Is this something I should worry about? It seems like it would be a rare thing. And I shouldn't but I want to make sure. Also what could cAuse changes in an ekg.he said he didn't think I needed an echo cAuse I had one earlier this year and I was at the gym yesterday and did fine exercising. He said it was ok for me to get surgery. What do you think?
doctor
Answered by Dr. Ilir Sharka 14 hours later
Brief Answer:
Opinion as follows:

Detailed Answer:
Dear Elizabeth!

I totally agree with your doctor regarding surgery.

There are no medical data to postpone or avoid surgery program.

Now returning to your ECG discussion, I would say that it is true that ECG resembles an incomplete right bundle branch block, but the same is true also in J wave syndrome (J wave may mimic a R`wave (commonly found in right bundle branch block). It is necessary to consider a careful investigation in this regard.

The issues I mentioned earlier in our thread are advisable to be followed (V1-V2 on the second intercostal space, if enough suspicions are raised then Ajmaline test).

As you are heaving a previous history of tachycardia an cardiac symptomatology, it is necessary to carefully consider what the medical tests may suggest us.

Many times cardiologists may overlook rare cardiac syndromes as they don't seem familiar to them.

Anyway, you could get through the surgery program without worrying about serious issues.

That's my opinion.

Hope to have been helpful to you!

Regards,

Dr. Iliri

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 6 hours later
Last question. I promise! I've had on a 30 day monitor and it didn't show any crazy rhythms and the tachcardia mostly happens with standing so would that rule out that j wave syndrome .?
doctor
Answered by Dr. Ilir Sharka 19 hours later
Brief Answer:
I would explain:

Detailed Answer:
Dear XXXXXXX

I was talking about those J waves presence on V!-V2 leads that are evident in almost all the uploaded ECGs.

When an incomplete right bundle branch block pattern is present and the terminal portion of QRS complexes is much likely to be in fact a J wave, then it is necessary to consider a J wave syndrome (which in fact comprises 2 separated disorders: Brugada syndrome and early repolarization).

It would be prudent to perform some ECG maneuvers like repeating ECG by placing V1-V2 leads in the second intercostals spaces. If suspicions are raised then an Ajmaline test is warranted.

The tachycardia appearing when standing up doesn’t seem to be related to what we are talking.

Without investigating through the above mentioned procedures, we couldn’t rule out or confirm such an alternative.

Let me know if you have any further questions.

Regards,

Dr. Iliri

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 4 hours later
Thank you so much Dr. Iliri. I'll make sure to give you a good review!
doctor
Answered by Dr. Ilir Sharka 40 minutes later
Brief Answer:
You are welcome!

Detailed Answer:
I am glad to have been helpful to you!

Wishing all the best!

Dr.Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Ilir Sharka

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