Tag Archives: stress echocardiography

A Patient’s Confusing Journey Into The Quagmire Of Cardiac Imaging: A Cautionary Tale

Mary-Ann, a reader from the north,  provides today’s post. Her story illustrates how easily medical care can veer off the rails while it is simultaneously railroading patients.  It is a cautionary tale with wisdom that can help most patients.

In this post I’ll just present Mary-Ann’s perspective and solicit responses.  Down the line I’ll provide some perspective on the processes, the problems and the solutions.


It started innocently enough. I showed up for a regular visit with my cardiac provider, a mid-level professional. She noted I was flushed and had a high pulse — about 100. 

Starbucks, I explained, and I flush easily — always have. She looked skeptical.

That is how I went from a half-caf Americano to a 48-hour holter monitor.

I went back for results — the usual ectopic beats but nothing scary or new. But again, she noted I had a fast heart rate and I was flushed.

And once again I explained: Starbucks — it is right down the street and okay, I might have a problem.

That is the short — but highly accurate — version of how I wound up getting a stress echo. 

I showed up for the results of the echo and that is where the runaway train started down the tracks.

“…possible inferoapical wall hypokinesis with lack of augmentation of systolic function, which are abnormal findings and may be indicative of ischemia due to underlying coronary artery disease. EF was 56% at rest and 40-50% at stress.” 

Wait — what?!

I was marched down the hall and scheduled for a cardiac angiography — and told not to run any marathons in the intervening two days. 

Marathon?! I was terrified I was going to drop dead at any moment. I contemplated just sitting the waiting room for 48 hours — just to be safe.

Then I started reading the professional literature and things were not adding up. An EF at stress of 40 – 50% is not good — in fact, it can be heading into heart failure land.

But I was active and fine — it did not make any sense.

I called the office; my provider was not available. I explained that I was worried there was a mistake. Oh no, I was assured, they are very careful to not make mistakes.

I wrote my will. I cried a lot. 

And when the person called to remind me of the procedure (like I could forget!?) I once again explained that I was worried there had been a mistake, and once again — reassurance. No mistake.

Nevertheless, she (aka me) persisted!

I sat on the hospital bed in nothing but a gown and handed the nurse my two-page letter; it started like this:

“I am reminded that what is normal and ordinary for a professional is never that for a patient. I am terrified.

First, I want to be really sure that there is not any chance of a mix-up in the stress echo test results. This is not simple denial or wishful thinking…” 

And that nurse paid attention, which is how I wound up not having a cardiac angiography. 

The cardiologist scheduled to do the procedure — we shall call him Doc #2 — wrote: 

“She has some concerns regarding the results of the stress echo study … I reviewed the most recent stress echo and it appears to me that the results for the resting versus the stress echo ejection fractions have been transposed…”

Translation: A Typo.

I was elated! Jubilant! We went to Starbucks to celebrate.

The giddy joy quickly turned to something along the lines of WTH just happened here? I read the original echo report written by Doc #1 — that lit the tinder. There were two different values for EF at stress documented in the report, and another sentence that was repeated. 

The professorial side of me was deeply affronted — in a subsequent meeting with hospital administrators I confess to saying that someone who is making hundreds of thousands of dollars a year doesn’t get to write such a sloppy ass report — and about someone’s heart, no less! 

But the best part of that meeting was learning that Doc #1 denied there was a typo — he stood by his findings. 

Oh dear.

And Doc #2 stood by his findings as well. And Doc #3 got involved somewhere along the way and he agreed with Doc #2. And the mid-level Provider also agreed with Doc #2.

The majority rule seems like an odd way to make health care decisions — wouldn’t you think all those smart people could talk among themselves and agree?

Apparently not.

That first meeting with the hospital folks included all manner of solicitous apologies and an attitude of collaboration. Of course, they said, we can send the echo to an outside cardiologist — at our expense — and get an answer.

And then I made the unthinkable mistake — and I blame the Skeptical Cardiologist for this — of asking informed questions.

“Are the cardiologists involved in reading my echo Level III echo specialists?”

“I understand that there can be variance in estimated EF between cardiologists — what level of variance is considered acceptable?”

The hospital team responded to my questions by calling a meeting — and the tone had changed considerably (Thanks a lot, Corporate Legal).

The offer to pay for an outside opinion was off the table — after all, they said, you would not have a patient-provider relationship with the cardiologist reading the echo. Ahem, I noted — I have zero relationship with the first cardiologist who read the echo and would not know him if I bumped into him at Starbucks. And you all did offer to pay for that outside opinion…

Oh never mind those minor details. No outside opinion on their dime. They would do a Lexiscan at their expense as a tie breaker. Final Offer.

Tiebreaker — really?! Is this a soccer game?

And seriously — should I have to have an invasive test to settle THEIR disagreement?! [Note: If it involves needles, it is invasive.]

Because there were not enough cardiologists involved already, I saw yet another one — from a different practice. He offered that the EF at stress looked more like 55%, placing his bet smack in the middle, and recommending a CT Angiography Coronary Arteries with Contrast as the tiebreaker.

Tiebreaker. That word implies both sides are equivalent or equal. However, my heart is not actually a game and the two teams cannot both be right — there is no equivalency in play here. What we are really trying to do involves accuracy — not breaking a tie score.

But I digress.

It doesn’t seem like you should have to make a chart to keep track of what cardiologists say about the same echo but in this case, it seemed necessary.

 And in the meantime, yet another cardiologist weighed in that the quality of the echo was poor — and no wonder they could not agree.

Deep breaths.

And so, for the past four months I have tried to navigate all this, and to understand what this actually means about cardiology and medicine and so many things. My confidence and my mind have been blown. Resources – and time – have been wasted. 

Ectopic heartbeats are typically benign in a structurally normal heart — I thought I was safe. But I have not felt safe since that day when I learned that Doc #1 and Docs #2, 3, and so on had decided to have a stand-off at the OK Corral that is my heart.

Except, I do not know if it is okay. And that is the problem. 


Unfortunately, Mary-Anne’s tale is not uncommon. It touches on many of the areas that patient’s should be aware of including

-Undergoing diagnostic imaging testing when you are free of symptoms

-Inadequate quality control in diagnostic imaging and how that leads to false positive results

-Variance in imaging performance and interpretation-how the same test can be read as normal by one doctor and markedly abnormal by another.

-The tendency of some cardiologists to recommend invasive testing when it is inappropriate and likely to cause more harm than good

-The importance of second opinions, especially if invasive testing is recommended

-The importance of patient’s doing their own research and asking good questions based on that research.

Transparently Yours,

-ACP

Are Your Palpitations Due to Benign PVCs?

If you feel your heart flip-flopping, then you are experiencing palpitations: a sensation that the heart is racing, fluttering, pounding, skipping beats or beating irregularly.

Often, this common symptom is due to an abnormal heart rhythm or arrhythmia.

The arrhythmias that cause palpitations range from common and benign to rare and lethal, and since most individuals cannot easily sort out whether they have a dangerous or a benign problem, they often end up getting cardiac testing or cardiology consultation.

The most common cause of palpitations, in my experience, is the premature ventricular contraction, or PVC (less commonly known as the ventricular ectopic beat or VEB).

Premature Ventricular Contractions-Electrical Tissue Gone Rogue

The PVC occurs when the ventricles of the heart (the muscular chambers responsible for pumping blood out to the body) are activated prematurely.

This video shows the normal sequence of electrical and subsequent mechanical activation of the chambers of the heart.

To get an efficient contraction, the electrical signal and contraction begins in the upper chambers, the atria, and then proceeds through special electrical fibers to activate the left and right ventricles.

Sometimes this normal sequence is disrupted because a rogue cell in one of the ventricles becomes electrically activated prior to getting orders from above. In this situation, the electrical signal spreads out from the rogue cell and the ventricles contract out of sequence or prematurely.

This results in a Premature Ventricle Contraction.

labeled-pvc
p waves represent depolarization and activation of the atria which are followed normally after120 to 200 milliseconds by the QRS complex which represents activation of the ventricles. The PVC (inside red circle) is wider and weirder and disrupts the regular interval between beats (green lines).

I recorded the above AliveCor tracing in my office on a patient who suffers palpitations due to PVCs (we’ll call her Janet).

The wider, earlier beat (circled in red) in the sequence is the PVC. The prematurity of the PVC means that the heart has not had the appropriate time to fill up properly. As a result, the PVC beat pumps very little blood and may not even be felt in the peripheral pulse. Patients with a lot of PVCs, say ocurring every other beat in what is termed a bigeminal pattern, often record an abnormally slow heart rate because only one-half of the heart’s contractions are being counted.

While recording this, every time Janet felt one of her typical “flip-flops,” we could see that she had a corresponding PVC and the cause of her symptoms was made clear.

There is a pause after the PVC because the normal pacemaker of the heart up in the right  atrium (the sinus node) is reset by electrical impulses triggered by the PVC.. The beat after the PVC is more forceful due to a more prolonged time for the ventricles to fill and  Consequently, most  patients feel this pause after the PVC rather than the PVC itself,

PVCs are common and most often benign. I have patients who have

ECG from 70 year very vigrous man who had 20 thousand PVCs in 24 hours. Every third beat is a PVC (green arrow)
ECG from 70 year old very vigorous man who had 20 thousand PVCs in 24 hours. Every third beat is a PVC (green arrow PVC, blue arrow normal QRS.)This patient feels nothing with his frequent PVCs. He has had them probably lifelong and definitely for the last 10 years without any adverse consequences.

thousands of them in a 24-hour period and feel nothing. On the other hand, some of my patients suffer disabling palpitations from very infrequent PVCs. From an electrical or physiologic standpoint, there seems to be neither rhyme nor reason to why some patients are exquisitely sensitive to premature beats.

How Do I Know If My PVCs Are Benign?

My patient, Janet, is a great example of how PVCs can present and how inappropriate or inaccurate heart tests done to evaluate PVCs can lead to anxiety and unnecessary and dangerous subsequent testing.

A year ago,  Janet began experiencing a sensation of fluttering in her chest that appeared to be random. Her general practitioner noted an irregular pulse and obtained an ECG, which showed PVCS. He ordered two cardiac tests for evaluation of the palpitations: a Holter monitor and a stress echo.

A Holter monitor consists of a device the size of a cell phone connected to two sensors or electrodes that are stuck to the skin of the chest area. The electrical activity of the heart is recorded for 24 or 48 hours, and a technician then scans the entire recording looking for arrhythmias while trying to correlate any symptoms the patient recorded with arrhythmias. The Holter allows us to quantitate the PVCs and calculate the total number of PVCs occurring either singly or strung together as couplets (two  in a row), or triplets (three in a row.)

Janet’s Holter monitor showed that over 24 hours her heart beat  around 100,000 times with around 2500 PVCs during the recording.  Unfortunately, the report did not mention symptoms, so it was not possible to tell from the Holter if the PVCs were the cause of her palpitations.

A stress echocardiogram combines ultrasound imaging of the heart before and after exercise with a standard treadmill ECG. It is a very reasonable test to order in a patient with palpitations and PVCs, as it allows us to assess for any significant problems with the heart muscle, valves or blood supply and to see if any more dangerous rhythms like ventricular tachycardia occur with exercise. If it is normal, we can state with high certainty that the PVCs are benign.

Benign, in this context, means the patient is not at increased risk of stroke, heart attack, or death due to the PVCs.

In the right hands, a stress echocardiogram is superior to a stress nuclear test for these kinds of assessments for three reasons:

-Reduced rate of false positives (test is called abnormal, but the coronary arteries have no significant blockages)

-No radiation involved (which adds to costs and cancer risk)

-The echocardiogram allows assessment of the entire anatomy of the heart, thus detecting any thickening (hypertrophy), enlargement  or weakness of the heart muscle, that would mean the PVCs are potentially dangerous.

Unfortunately, my patient’s stress echo (done at another medical center) was botched and read as showing evidence for a blockage when there was none.  An invasive and potentially life-threatening procedure, a cardiac catheterization was recommended.  Similar to the situation I’ve pointed out with the performance and interpretation of echocardiograms (see here),  there is no guarantee that your stress echo will be performed or interpreted by someone who actually knows what they are doing.  So, although the stress echo in published studies or in the hands of someone who is truly expert in interpretation, has a low yield of false positives, in clinical practice the situation is not always the same.

Given that Janet was very active without any symptoms, she balked at getting the catheterization and came to me for a second opinion. I felt the stress echo was a false positive and did not feel the catheterization was warranted. We discussed alternatives, and because Janet needed more reassurance of the normality of her heart (partially because her father had died suddenly in his sixties) and thus the benignity of her palpitations/PVCs, she underwent a coronary CT angiogram instead. This noninvasive exam (which involves IV contrast administration, and is different from a coronary calcium scan), showed that her coronary arteries were totally normal.

lad-ccta
Images from Janet’s coronary CT angiogram showing the left anterior descending (LAD) coronary artery coming off the aorta. The LAD (and her other coronaries) were totally free of any plaque build-up.)

Benign PVCs-Treatment Options

Once we have demonstrated that the heart is structurally normal, reassurance is often the only treatment that is needed.  Now that the patient understands exactly what is going on with the heart and that it is common and not dangerous, they are less likely to become anxious when the PVCs come on.

PVCS can create a vicious cycle because the anxiety they provoke can cause  an increase in neurohormonal factors (catecholamines/adrenalin) that may increase heart rate , make the heart beat stronger and increase the  frequency of the PVCs.

Some patients, find their PVCs are triggered by caffeine (tea, soda, coffee, chocolate) or stress, and reducing or eliminating those triggers helps greatly. Others, like Janet, have already eliminated caffeine, and are not under significant stress.

Since I’m already over a thousand words in this post, I’ll discuss treatment options for these patients with benign PVCs who continue to have troubling symptoms after reassurance and caffeine reduction in a subsequent post.

Prematurely Yours,

-ACP