Ask a doctor on the topic of Internal medicine

Changes in EKG and Long-term EKG findings

October 2, 2012 | 15,00 EUR | answered by Dr. med. Kathrin Hamann

Hello,

I am 24 years old, male, a smoker. I have Hashimoto's disease, known reflux, chronic gastritis, enlarged lymph nodes and unknown nodules in the chest, as well as a known carpal tunnel syndrome.

About a year ago, an ECG abnormality was accidentally discovered in me. It is described as follows:

Indifferent type, sinus rhythm, HR 74/min., elevated J-point descent in leads II, III, aVF, V5 and V6 by 0.1 - 0.2 mV.

It was initially thought to be a heart attack, and I was kept in the cardiology ward for 2 weeks. In addition to a cardiac MRI, an ultrasound, multiple ECGs with consistent findings, and a stress test were performed. All these tests did not show any signs of disease, except for a slightly enlarged heart in the MRI.

After that, I was discharged and regularly went for follow-up appointments with the cardiologist. The abnormality is still visible, but no cause was ever found.

In the last six months, I have felt heart palpitations for the first time, initially sporadically, but more frequently recently. Therefore, a Holter monitor was arranged. I had it done by an internist. Unfortunately, this woman does not seem particularly competent to me, which is why I would like to seek a second opinion.

The Holter monitor results showed:

Total QRS: 99,368
PVCs: 71
Pause: 00:43 3%
Max HR: 124
Mean HR: 71
Min HR: 55
SVPCs: 8
Max/HR: 2
Isolated PVCs: 68
Max/HR: 22
Multiform: YES
Premature beats: 3
Tachycardia: 6
Max HR: 124

I have attached some images of the ECG excerpts to the post.

Now to my questions:

Are multiform PVCs always a sign of heart disease? Given my ECG abnormality, this does worry me a bit. This really concerns me as I only noticed it later and the doctor did not comment on it.

The doctor did not even look at the individual ECG excerpts. As far as I know, it is necessary to determine if the premature beats are potentially dangerous, right? After all, this is just a computer printout and not a manual analysis.

Could Brugada syndrome be possible with this ECG image?

Lastly, I should mention that the premature beats I feel always occur at rest. At most, I felt a premature beat once after physical exertion. How would you assess this Holter monitor report? Thank you for your efforts.
Sincerely.

Dr. med. Kathrin Hamann

Hello,

I am happy to help you further.

Based on the expressions, one can suspect the origin of the ventricular extrasystole, due to its width at the base. Supraventricular extrasystoles are much narrower.

Extrasystoles are often found in athletes and in young hearts, so they don't mean anything serious. But you describe a muscular bridge and a known unilateral heart enlargement. The electrical axis of the heart shows an indifferent type, so I cannot say which side of the heart is affected. In this case, I would recommend presenting the 1-channel long-term ECG evaluation to a cardiologist. You are quite right: multiple VES (ventricular extrasystoles) for almost 24 hours) are quite common. SVES (supraventricular extrasystoles) also occur frequently in your case. This can manifest as palpitations.

You mention Brugada syndrome, a rare genetic disease that affects the ion channels in the heart muscle cell, leading to changes in electrophysiological processes. To diagnose whether this is present, a 12-channel ECG is necessary. Often, a kind of incomplete right bundle branch block is seen in V1-V3. However, this diagnosis cannot be made based solely on the long-term ECG or only one printout of a 12-channel ECG. This should be handled by a cardiological center. Especially since the heart rate values are altered, which I cannot see in your case. I would suggest showing this to your cardiologist, as I have mentioned before.

Most extrasystoles are harmless, but the frequency of multiple VES in the presence of a known heart condition is concerning, and I recommend an in-depth electrophysiological examination (EPU).

Do you have any questions about this? I am happy to help you further.

All the best and a speedy recovery.

Best regards,

Dr. K. Hamann