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What does chest pain with abnormal ECG results indicate?

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Cardiologist
Practicing since : 2001
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I have been diagnosed with very frequent premature ventricular complex. I have had 4 ECG all borderline or abnormal with different automated messages:
1. probable anteroseptal infarct old
2. negative T wave anterior
3. minimal ST depression.

All the cardiologist that I have shown them just brushed it off and said there are no pathological Q,R,S,T waves and only abnormality is PVC. Otherwise they said ECG is normal.

I have also done a 24HR HOLTER and results of this are 11,787 PVC in 24 HRS (11% of total heart beat) and the PVC is isolated and monomorphic.

I have also done 2 echo cardiogram and these are also normal. Only ectopics are noted in the echo cardiogram.

I have also done 1 tread mill test and this is also normal except for some PVC. No ST deviation and test is negative for inducible ischemia.

Chest X Ray and abdominal ultrasound results are also normal.

I continue to have palpitations and dull chest pains only on the left side. I also have a very brief burning sensation in the upper back for a few seconds that comes and goes and does not appear muscular in nature. These chest pains have been on and off for the past 5 months.

Please advise if any further investigation should be done? Do you think a cardiac MRI will help identify any other reason not identifiable on 2D ECHO. Is this presentation likely to be coronary artery disease or any other issue. Why is every ECG that I have taken abnormal?

Please advise as I am worried that the PVC may be because of some underlying cardiac issues.

My profile -
34yrs old Male
Non smoker and very occasional alcohol
Height is - 175 cms
Weight is - 73 kgs (more body fat at 23% - BMI normal)
LDL - 135
HDL - 50
Total Cholesterol - 192
Triglycerides - 100
Homocysteine - Elevated at 21
HsCRP - Normal
Thu, 26 Apr 2018 in Hypertension and Heart Disease
 
 
Answered by Dr. Ilir Sharka 1 hour later
Brief Answer:
I would explain as follows:

Detailed Answer:
Hello!

Welcome on HCM!

I passed carefully through your medical history and uploaded medical reports and would like to explain that it is possible that your PVCs may be originating from RVOT (right ventricular outflow tract), but additional ECG recordings with PVCs presence in all the leads are necessary for a more careful conclusion.

Please could you upload other more prolonged ECG recordings for a second professional opinion?


Considering your clinical symptomatology (recurrent chest discomfort) and facing with frequent extrasystolic ventricular arrhythmia, first it is necessary to rule out cardiac ischemia.

Regardless of the normal cardiac echo and stress test results, it is necessary to proceed further on coronary artery exploration.

Coming to this point, one of the following cardiac tests would be advisable:

- coronary angio CT,
- nuclear perfusional cardiac stress test,
- coronary angiography (more conclusive and direct information)

In case a coronary atherosclerotic or congenital abnormality is excluded, the next step would be to exactly delineate the real arrhythmogenic focus of your arrhythmia.

Serving such purpose, it would be necessary to perform a cardiac MRI with LGE (late gadolinium enhancement) for detecting possible myocardial fibrosis as the originating substrate of arrhythmia.

In addition, a cardiac electrophysiological study (EPS) is required to make a clear definition of arrhythmia class and proceed with cardiac ablation by carefully isolating and subsequently burning the arrhythmogenic focus.

This could be a reasonable strategy to definitely resolve your cardiac arrhythmia issue.

Meanwhile, I encourage you to continue following a healthy life-style (healthy diet, avoid smoking contact, be physically active, etc.)

Hope to have been helpful to you!

I remain at your disposal for any further discussions.

Kind regards,

Dr. Iliri
Above answer was peer-reviewed by
 
Follow-up: What does chest pain with abnormal ECG results indicate? 40 minutes later
Hello doctor and thank you for your advice. I have uploaded a new report with all the ECG as per your request in them. Some of them have become faded and you will probably need to look closely to identify the ectopics.

Please let me know your insights after looking at the latest reports.

Thank you.

Latest report attached - "ECG_All_Sabapathy"
 
 
Answered by Dr. Ilir Sharka 7 hours later
Brief Answer:
Opinion as follows:

Detailed Answer:
Hello again!

Your latest uploaded ECG shows only one PVC at the beginning of recording (correspondent with leads I,II,III). No PVCs are caught in other leads including precordial leads (VI-V6).

In case you have other ECGs where PVCs are more frequent and widely spread in other ECG leads as well.

Nevertheless, the pathway I suggested you is a rationale approach to handle with this issue.

Wishing you are having a pleasant weekend!

Regards,

Dr. Iliri
Above answer was peer-reviewed by
 
Follow-up: What does chest pain with abnormal ECG results indicate? 6 hours later
Hello Doctor,

Thanks again - I am attaching some more reports from the stress test that shows the ectopics from pre-test to recovery. Please take a look and let me know if that provides any further information.

I am also curious to know if the chest pain that I have is characteristic of cardiac pain - let me explain:

1. Chest pain is not present when sleeping - I do not notice while sleeping
2. When I exercise - pain characteristics do not change. I run about 2KMS every other day during which my heart rate monitor shows my heart beat in upper 150 and still no changes in pain.
3. The pain is dull and constant at times - sometime for the entire day
4. Only the palpitations make me think the pain is cardiac related.
5. Pain is more on left side in an area roughly 2 inches below the left nipple. Nothing directly under sternum.

Also - you mentioned RVOT origination - how is that diagnosed and what does that mean.

How is a benign PVC identified from a malignant one?

I am trying to understand if CT angiogram / MRI is necessary to do and if yes - what will they uncover that ECHO and stress test have not. I have anxiety and phobia and going to the hospital and getting tested makes me very stressed and uncomfortable. I definitely do not want to do ablation if these are benign and also any invasive procedure like coronary angiogram.

Thank you again so much for your time and appreciate your insight into this as well.
 
 
Answered by Dr. Ilir Sharka 17 hours later
Brief Answer:
I would explain:

Detailed Answer:
Hello again!

I reviewed carefully your stress test ECGs and would like to explain that only isolated rare PVCs are present. They are quite harmless and not dangerous.

Also, your ECGs do not show signs of cardiac ischemia during and after physical stress.

Considering your chest pain characteristics I would say that it is more likely to be of extra-cardiac origin (not cardiac related). This conclusion is supported by the fact your pain disappears while on sleep; it is prolonged and well localized and furthermore is not modulated (aggravated) bu physical exertion.

Palpitations are a normal physiological reaction to every king of stress (including body pain) and could not be a reliable indicator of a cardiac related issue.

Regarding the clinical significance of PVCs arrhythmia, I would explain that it is generally considered benign when not associated with more complex arrhythmia (such as ventricular tachycardia) and furthermore present in an apparently structurally normal heart such as in your case.

RVOT PVCs may sometimes be associated with more complex and dangerous ventricular arrhythmias that deserve special attention.

If structural abnormalities are excluded by several imagine tests then it could be concluded with a high probability that isolated PVCs are benign.

In general, coming to this point they do not deserve treatment.

As you are you are against any invasive diagnostic and therapeutic procedures (such as coronary angiogram, cardiac ablation, etc.), the most suitable tests would be a coronary angio CT (which could reveal any potential silent coronary lesion) and cardiac MRI for exploring any potential structural arrhythmogenic focus inside the myocardium. Cardiac ultrasound and the standard stress test can't reveal such valuable information.

Hope to have clarified some of your uncertainties!

I remain at your disposal for any further discussions, in case you will need.

Regards,

Dr. Iliri



Above answer was peer-reviewed by
 
Follow-up: What does chest pain with abnormal ECG results indicate? 3 days later
Hi Doctor - just one more final and quick question. I have added one more attachment to the question - TMT_HISTORICAL_Saba.pdf

This includes cover page of stress test from 2014 and more recently from 2017. I have used a red arrow to indicate PVC column. Is my understanding correct that this is the indicator of PVC's?

If yes - then these have been recorded for me on a routine medical check up in 2014 and again now in 2017. My question is there any significance to having PVC over such a long term? Should I be concerned if there is any increase in frequency over this period.

I am trying to understand if there is any significance to these from before and now?

Thanks and appreciate your time on these questions.
 
 
Answered by Dr. Ilir Sharka 12 hours later
Brief Answer:
Opinion as follows:

Detailed Answer:
Hello again, dear MR. Sabapathy!

I reviewed your newly uploaded ECG reports.

You are correct when indicating by the red arrow the PVCs column.

At the mean time, iwould explain that your PVCs in the 2014 report are quite few (1-8 PVCs) during exercise stages; they are isolated, not associated with complex arrhythmias like atrial fibrillation or ventricular tachycardia. No PVCs are recorded during recovery phases.

Coming to this point, I would not consider those scarce PVCs as having any clinical significance.

So relax and don't worry to much about them!

Just, I encourage you to follow the diagnostic noninvasive steps we discussed earlier in order to further clarify the cause of those ectopic beats.

Hope to have been helpful to you!

Best wishes,

Dr. Iliri
Above answer was peer-reviewed by
 
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