Category Archives: Echocardiograms

The Skeptical Cardiologist Answers Good Questions: Retesting For Symptomatic Benign PVCs?

One of the many things I enjoy about writing this blog is the interesting comments and questions that readers post. Many of them stimulate me to better answer and inform my patients.

Here’s one such question (about premature ventricular contractions):

Wondering your opinion on retesting. I’ve had PVCs since I was 15 (63 now) and they have come and gone over the years, attributed to hormones, low potassium, stress, and dehydration/bad diet. Recently they started again and are driving me insane and none of the usual fixes are working. Two ER visits with normal EKGs and my cardiologist all say no worries. I’m thinking maybe I should have another ultrasound, buy MD doesn’t think it’s necessary. I had a perfectly normal cath in 2015 but no tests since. Your thoughts? Thank you.

This was the response I typed off the top of my head:

Good question. I consider retesting for patients who have not had documentation of “structurally normal heart” for some time and who have a significant change in their symptoms. You would qualify since no testing in 3 years and worsened symptoms.
Typically I would order a stress echocardiogram which allows a reassessment of both LV structure and function and for any blockage in the coronary arteries and I would consider some kind of monitor-a 24 hour Holter would be fine if you are having daily symptoms.
You might also consider acquiring an AliveCor device to monitor your rhythm with symptoms. I’ve written a lot about this elsewhere on this site. Unfortunately AliveCor does not identify PVCs but if you connect via KardiaPro with your physician your recordings can be viewed and interpreted by him/her.

The answer reflects my clinical practice, which is based on 30 years of experience taking care of patients with PVCs, in conjunction with regularly reading papers, reviews and guidelines in this area.

Periodically, both for specific patient problems and for blog questions, I will search the medical/scientific literature and review guideline publications to see if there is any new information that I am unaware of to ensure that my recommendations are scientifically grounded.

In this case, a more prolonged search of the literature did not yield precise guidance on the frequency of retesting of patients with benign PVCs.

This 2014 guideline comments briefly on the evaluation and treatment of PVCs without structural heart disease (SHD):

In the absence of SHD, the most common indication for treating PVCs remains the presence of symptoms that are not improved by explanation of their benign nature and reassurance from the physician.

In addition, some patients may require treatment for frequent asymptomatic PVCs if longitudinal imaging surveillance reveals an interval decline in LV systolic function or an increase in chamber volume.

For patients with  >10,000 PVCs/24 h, follow-up with repeat echocardiography and Holter monitoring should be considered.

In patients with fewer PVCs, further investigation is only necessary should symptoms increase.

It should also be recognized that PVC burden often fluctuates over time.

This initial testing approach corresponds closely to what I wrote in my post on benign PVCs here.

Retesting with echocardiography and Holter monitoring is advised for those few patients who have lots of PVCs, but the frequency of this retesting is not specified and cardiologists have to use their best judgement, balancing the cost (to patient and to society) and patient safety.  Most cardiologists will err on the side of more frequent repeat testing for a variety of reasons.

Personally, I will advise an annual echocardiogram to such patients since they are at a higher risk of developing a cardiomyopathy.

In the absence of really frequent PVCs (>10,000 per 24 hours is a nice round number, but the precise cut-off is debatable), we should probably only repeat testing if the patient recognizes a significant change in their symptoms.

The reader clearly fits into that category, and retesting in her will provide reassurance that all is still good with her heart. This, in turn, should help with managing symptoms and preventing recurrent ER visits.

The final question (and the toughest) that we could pose related to retesting is “What is the time interval that one should wait before retesting in a patient with worsened symptoms?”

For example, if the reader had a normal echocardiogram 6 months ago should we repeat it when symptoms worsen? My reflex answer would be no, but at some time interval depending on the individual characteristics of the case-patient risks for heart disease, patient anxiety levels, patient symptom severity and frequency, the answer would become yes.

Cardiologists have to answer dozens of questions like this daily.  There is no science to inform a precise answer, consequently the answers will vary wildly from one cardiologist to another depending on a variety of factors specific to the cardiologist.

Those cardiologist-specific factors are complex and sometimes controversial. Part of this makes up the art of medicine and part reflects the business of medicine. They are definitely worthy of another post when time permits.

Questioningly Yours,

-ACP

N.B. The Eternal Fiancee’ (my layperson surrogate) expressed surprise that one could have 10 000 PVCs per day. I told her that if your heart beats roughly once per second (6o beats per minute) since there are  60 x 60 x 24 = 86400 seconds in a day, your heart beats almost 90 000 times in 24 hours.

Thus, roughly  1 in 9 beats is a PVC.

Most Echocardiograms Done In the UK Are Free But Not Read By Cardiologists

In the course of researching a previous post on the cost of an echocardiogram, the skeptical cardiologist discovered a website in the UK ((HeartScan)) that offered a “private” echo at a cost of around $400.

Subsequently,  Antoinette Kenny, the creator of HeartScan, was kind enough to answer some questions I had about echocardiography in the UK.

 

From the HeartScan website. I presume this is Dr. Kenny, herself, performing an echocardiogram on a patient.

 

First she provided me with some background on her career. (Green text below from Dr. Kenny)

As you will know from HeartScan’s website (redesign of which is almost complete and will be launched next month) I am a cardiologist in the UK. I am still a fulltime NHS (UK’s public health service) cardiologist at one of the leading heart centres in the UK, the Freeman Hospital, Newcastle upon Tyne. I am Head of the Regional Echocardiography Department there providing TTE, TEE, stress echo, 3D etc. My career has also been heavily involved with the British Society of Echocardiography (BSE) which is affiliated with British Cardiovascular Society and promotes standards of practice for echocardiography in the UK including accreditation programmes for individuals and departments/private services.

Dr. Kenny is clearly well-trained and dedicated to providing high quality echocardiography.

And according to  HeartScan’s FAQs

At HeartScan you are secure in the knowledge that your Echo will be performed to the highest standards laid down by the British Society of Echocardiography. HeartScan is to date the only private provider in the UK to be awarded British Society of Echocardiography Departmental Advanced Accreditation.

Are Echos Free In The Uk?

You are correct, echocardiograms are free of charge through the NHS in the UK. However, there are waiting times involved for elective referrals and typically patients may have to wait for 6-12 weeks or longer in some geographical areas.  So some patients will chose to have their echocardiogram privately and self-fund.  Other patients are covered by health care insurance and will have their echo reimbursed by their health insurance provider

It would be unusual for someone to wait for more than 1-2 weeks for an echocardiogram in the US. I suspect the longer UK waiting time does not cause worse outcomes.

Hopefully, patients presenting with some conditions (acute heart failure  comes to mind)  are moved up in the queue.

How Does Dr. Kenny Determine What To Charge For Her Private Echocardiograms?

My services are very competitively priced and I chose this price point to be competitive with other private echo services but also add value to the patient in that the echo is reported by a cardiologist who is an echo specialist.  Other local private hospitals provide an echo privately at a higher cost (approx. £380-480 for a sonographer reported echo).

So £295 is the cost of what I believe is a very high quality echo with a high quality  report.  I guess I have tried to make private echo reported by an echocardiologist as available as I can.  Whilst we are a small clinic I do get patients who travel great distances for an echo as they tell me they trust the service (as they know it’s reported by a specialist) and find the pricing better than they can attain locally.

A Marked Difference In The Practice of Echocardiography Between In The US Compared To The UK

One of the main differences between the UK and US I think is that imaging cardiologists are very much in the minority here so that in a smaller hospital there may be no cardiologist who has echo expertise.  Therefore the Echo service is almost completely physiologist delivered.  In larger teaching hospitals over the last decade or so there has been an increased awareness of the importance of imaging and thus an increased training and appointment of imaging cardiologists.  However numbers are small in relation to the service load. For instance in my unit we perform almost 18,000 TTEs annually but there are only 1.5 Echo consultants (and we both do general cardiology also).  So the TTE service is physiologist reported with myself and my colleague running ongoing education and  QA programmes for the physiologists.  We only report a small percentage of TTE cases that are flagged up by the physiologists but we perform the TOE (TEE!) and DSE’s etc. Echo is a relatively small sub-specialty in the UK so echo cardiologists tend to know each other and lecture on each other’s teaching courses etc. But there are many hospitals with no cardiologist echo expertise.

I was amazed by this. In the US, sonographers record the examination and make measurements. In some (typically academic) centers the sonographers create a preliminary reports, however, an echo trained physician signs off on all reports.

I was curious what training and reimbursement these physiologists receive  as they doing, in essence,  what a cardiologist does in the US.

Salary and Training of Physiologists in UK

Yes, our cardiac physiologists have considerable responsibility!

Their training is changing with a programme of ” modernising scientific careers” that’s underway but I will send you on info regarding their training. In essence the previous model was to complete a university course and then train in the hospital in various disciplines. For those in cardiology they train in the cath lab, cardiac rhythm management and Echo so have a very broad base before then specialising in Echo ( or cardiac rhythm etc).

Salaries depend on experience and seniority but the salary for a cardiac physiologist who has attained BSE accreditation and reports independently is up to £42,000 a year.

I’m fascinated by this fundamental difference in the way echocardiography happens in the US versus the UK. I wonder how it impacts either clinical outcomes or the cost of medical care in the two countries.

I’ll be posting information on the training that UK physiologists go through in the near future.

I welcome comments from any UK readers on their experience with private or NHS echocardiograms, either good or bad.

I remain Anglophilically yours,

-ACP

 

N.B.  For your further edification, I’ve copied Dr. Kenny’s About Page from the HeartScan web page.

Perhaps Dr. Kenny can tell us what all those initials after her name mean.

About Dr Kenny

Dr. Antoinette Kenny, Director of HeartScan Ltd.
MB BCh BAO MD FRCP FRCPI

Dr. Antoinette Kenny is a full time Consultant Cardiologist and Specialist in Echocardiography (ultrasound heart scans) at the Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne.  She is also an expert in cardiac screening for individuals involved in sport.

Dr. Kenny qualified in medicine in Dublin in 1983 and trained in clinical cardiology at St. James’s Hospital Dublin and Papworth Hospital Cambridge. She was awarded the Grimshaw-Parkinson  Fellowship from Cambridge University for her research towards an MD thesis in echocardiography at Papworth Hospital. She was made a Fellow of the Royal College of Physicians, London, in 1998 and of the Royal College of Physicians, Ireland, in 1999.

Following her clinical cardiology training and MD thesis she was appointed Fellow in Echocardiography at the Oregon Health Sciences University, Portland, Oregon, USA.  There she undertook training in advanced echocardiography, including three-dimensional echo techniques, with Professor David Sahn the internationally renowned specialist in echocardiography. In 1993, at the relatively young age of 33, she was appointed Consultant Cardiologist and Clinical Head of Echocardiography at The Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne.  At that time only 19 (<5%) of consultant cardiologists in the UK were female and an even smaller percentage of cardiologists had achieved consultant status by the age of 33, facts which serve to highlight Dr. Kenny’s postgraduate career achievements.  (Source Royal College of Physicians Census).

Echo experience:
As Clinical Head of Echocardiography at Freeman Hospital for over 20 years, Dr. Kenny has gained a vast experience in assessing patients with heart failure, valve disorders and inherited cardiomyopathies.  Her expertise includes evaluation and selection of patients for advanced valve replacement techniques such as TAVI (transcutaneous aortic valve implantation) and minimally invasive surgery.  She is a member of the Specialist Heart Valve Team at Freeman Hospital providing specialist echocardiographic expertise for the selection of patients for valve surgery.

Sports Cardiology experience:
Dr. Kenny is also a cardiology adviser to the Football Association (FA) and a member of the FA cardiology consensus panel producing guidelines for cardiac screening.  She has performed cardiac screening for the Football Association since this programme was introduced for young footballers in 1996.

Dr Kenny has also been involved with investigation and heart screening in premiership football players for the last decade and provides heart screening for Newcastle United FC, Sunderland AFC and Middlesbrough FC, including their first team players. Dr. Kenny has particular expertise in distinguishing between the normal changes produced by athletic training (athlete’s heart) that could be misinterpreted as abnormalities and abnormal cardiac conditions that can pose a serious health risk.

Achievements:
Dr Kenny holds full accreditation with the British Society of Echocardiography, the national benchmark of quality in performing and interpreting Echo scans.  As an elected council member of the British Society of Echocardiography she has been involved with standards and quality in delivery of national Echo services.  She also held the post of Chairman of the Scientific and Research Committee of the British Society of Echocardiography with responsibility for organisation of the annual meeting and educational sessions.

She is co-author of a well received textbook of echocardiography which has been translated into other languages. Dr. Kenny is also a leader in education in echocardiography, co-directing a national Echo course and invited to lecture at both national and international Echo conferences.

Dr. Kenny has developed and led research studies in advanced applications of echocardiography over the last two decades and has published widely in peer reviews journals.