Need answers about cardiac....

mattcastens · Feb 21, 2002

Wow ... there's a lot of questions there. Let's start at the top. If you're having PVCs that last "an hour or more" they should be evaluated, especially if you're symptomatic (near syncopal episodes, arm pain). It sounds as if your EP doc is on the right track. It's quite typical to go with meds first, follwed by either an ablation or a pacer. Sometimes even a pacer/defibrillator if the arrythmias have lead to something potentially fatal (v-tach or v-fib). The one test you didn't mention that you might want to suggest is a Holter monitor. It's a portable heart monitor that you wear for at least twenty-four hours and it records all cardiac activity. You write how you feel and the time in a journal so that the recording can be related to symptoms. This can give the doc a better idea of what might be going on and what triggers there are. Personally, I think you should have been admitted and had EP studies immediately after you arrested.

As for pacers and defibrillators, yes there can be problems if placed incorrectly. As you know, though, nothing in medicine is without risks. The complications I've seen are 1) perforating the myocardium (very rare). If this were to happen, probably a pericardial drain would be placed for a day or two to prevent tamponade until the bleeding stopped and the myocardium healed. As I said, it's very rare. 2) Lead displacement, where the pacer lead dislodges from the myocardium and fails to work or over-fires. Also rare and preventable if you follow the activity restrictions post-procedure.

Mitral insufficiency will affect you with decreased cardiac output of varying degrees, depending on the severity. The arrythmias and the mitral insufficiency may be related if there is enough ventricular hypertrophy to irritate the ventricle (or atrial hypertrophy, for that matter, but the ectopy you report is more ventricular in nature). At its worst, mitral insufficiency can lead to CHF. Really the only other way mitral insufficiency might be linked to your arrythmias is if they are both related to a myocardial infarction.

Good luck with everything! I hope these answers helped. Keep us posted!

babsRN · Feb 22, 2002

Some additional considerations to Matts excellent remarks...you didn't mention whether or not you had ever been diagnosed with heart failure. I'd be curious about what your EF(ejection fraction) is. Have you had an ECHO or a stress ECHO?

One of the newer treatments for heart failure includes a biventricular pacemaker. This pacer has three leads, one in the atria, one in the right ventricle, and a third lead that is cannulated through the coronary sinus, ending up in the left ventricle. The two leads in the ventricles are synchronized so that the right fires just prior to the left one. An aside to this treatment is that there has been a decrease in ventricular arrhythmias observed in those heart failure patients treated with this technology. Some EPs are currently waiting until there is a biventricular pacer on the market that also has an internal defib. But there are probably an equal number of cardiologists who feel that the internal defib may not be needed since the treatment actually may decrease the arrhythmia.

Best of luck to you my friend. Let us know if you have more questions.

b

MickeymomRN · Feb 22, 2002

WOW! :eek:

I guess I did leave some info out. Yes, I had a holter done years ago. It freaked the internist who read it. He was desperately trying to reach me so that I can start meds right away. I think (but not real sure) that I had 144 PVCs in a 24 hour period. I had it repeated last year but of course, I had a good day. The dysrhythmia only happens once in awhile. I told the original card that and he didn't do anything else.

This EP doc that I am seeing is only treating me for the NCS. He says that I shouldn't be concerned about the chest pain or frequent PVCs. He's not the only one. But then I heard others tell their story about irregular HR and pretty much the same symptoms and how they were worked up and I remember my ACLS training and I feel like a big "story teller". I hear it a lot that I shouldn't be having any problems b/c I'm a female and young. I look a lot younger than I am. Some guess me to be 18 or in my early twenties. Thanks,mom!

An autopsy I watched last November was on a 31yo female who died of a heart attack. I'm 35! What do you think was going on in my head at that time.

Last Sept. I had a huge massive crushing sudden pain at night while my DH was out of town. I could barely move let alone call for my oldest son to help me get my nitro. While he helped me, he was asking me if he should call 9-1-1. I told him no that the nitro should help. But I've never had it hurt like that before or since. I was sweating ( I totally soaked my pjs) and breathing with difficulty, etc. He panicked and called. When EMS got there, all my vitals were elevated. They too said, "awe you're too young. You probably just have heart burn." Well, we all know that they tell that to the doc when they bring you in. and guess what they diagnosed me with. They didn't even do an ekg. They did place a nitro patch but that's about all. Another pt came in c/o chest pain and was male. Guess where everyone ran to help and left me. This ER was at a smaller hospital and wasn't even affiliated with the heart hospital in town. I was not happy. I've never had heartburn and never had "that" pain return.

Well, I think that was too much info. I really am scared about this. I hear that it's benign (the NCS). They tell me that the PVCs and mitral valve insufficiency (moderate regurg BTW) are all unrelated to each other and to the NCS. But my NCS has both components, decrease in pulse and b/p. Then they also said that if my brain doesn't get perfusion that it could send signals that will mess up my heart b/c of the NCS. I just know that I have already heard that 2 other people have died from this benign condition. (the NCS). I know from ACLS that a prolonged abnormal rhythm is not good. I don't know much about the mitral valve except what was said that it could lead to CHF. (And their telling me to increase my fluids for the NCS)

I've only had an ECHO done. Not a stress ECHO. I only had a stress nuclear scan.

I guess I just don't want to ignore my chest pain and wind up in the morgue. All last night and today I've had PVCs. Headache and chest pain with it. The pain's progressing and I don't want to go to the ER only to find out that "I'm too young and I'm female and I probably have heart burn." I haven't taken my pulse b/c I don't want to get worked up about it. I don't want to take my nitro b/c it just aggravates my NCS and messes up my body.

Basically I don't know what to do and where to turn. I don't want to push where my knowledge is pretty limited. But I don't want to just sit here either.

BTW, each time they do an EKG during my chest pains, I have elevated t-waves. Is that common in persons who aren't having a MI?

mattcastens · Feb 22, 2002

No, elevated t-waves aren't common in people who aren't having an MI, but they are possible.

I don't know ... after reading your latest post, it seems that you need to get a third and fourth opinion. Granted, it's unusual for a woman your age to have an MI, but it's possible and I've seen a couple personally. Your family history should be a huge red flag in this matter. Fortunately, many physicians are starting to take women's chest pain seriously, but there are idiots in every group.

That comment about "your brain not getting enough perfusion" and sending signals to "mess up your heart" is just stupid. Obviously, if your brain isn't getting enough perfusion, there's something already wrong with your heart. :rolleyes:

Keep getting this evaluated -- and keep going to the ED when you have pain. I know it sounds really cynical, but if you code in the ED, at least they would be convinced.

MickeymomRN · Feb 22, 2002

It's just good to know that I'm not a hypochondriac. Just seeing that I have elevated t-waves with chest pains is reassuring but the treament I get isn't. (They only drew baseline blood levels upon admission but didn't do any repeats to check cardiac enzymes. I even asked and they said that it wasn't ordered. Wouldn't you think as a nurse you would confirm that order with the doc if you had a observation pt for r/o chest pain?)

That comment about the perfusion didn't make sense to me either. But you know how some just want to impress you with their knowledge that they forget to focus on the pt.

I will try to keep strong when I go to the docs next Thurs. Maybe if I keep harping him about it, he'll look into my symptoms.

I did get a great tip from a fellow NCS, I'm keeping a detailed diary of my symptoms. Maybe then they can see how much this is affecting my life.

Thanks for your support! Knowing that I'm not the only one seeing things makes me feel better. I just don't want to become one of those that are shooed away only to have them find me dead on the street somewhere.

VickyRN, MSN, DNP, RN · Feb 23, 2002

Just thought I'd throw my $0.02 in with everyone elses' excellent replies. In the level one CICU in which I practice, we have onboard a wonderful female cardiologist who specializes in women's heart ailments. I once attended her lecture on "Women and Heart Disease," and my, was it an eye-opener! This knowledgeable and compassionate doctor stated that women with heart disease often receive inferior treatment because they are not taken as seriously as men with cardiac complaints nor treated as aggressively, that the death and disability rate for women with MI is higher than men, women experiencing MI often have presenting symptoms that differ from the typical male "clenched fist over the chest." Treatment options for women with heart disease should be different than those for men--different medications, dosages, etc. What often works with men will not work with women and vice-versa. Cardiac research in the past nearly always involved men only. Women's coronary arteries are much smaller than men's and more difficult to treat; vasospasm can be at play, not just blockages. Chauvinistic doctors will often minimize women with cardiac complaints, attributing their presenting complaints to mere "anxiety" (treat with Ativan or Valium), hyponchondriac, attention seeking, drug seeking (wants Morphine or Demerol). Sound familiar???????

Medications used to treat arrhythmias, especially the beta blockers, often have the side effect of fatigue. Sometimes the fatige can be absolutely debilitating. Perhaps an ablation, AICD (internal defibrillator-pacer) or the new biventricular pacer would be a better option for you. Yes, I have seen ST elevation with CP that was not an MI--this is a classic symptom of unstable angina, especially if the CP occurs in the early morning hours before daybreak, awakening one out of a sound sleep. Unstable angina is a serious condition and should be taken seriously. Often is a warning sign of an impending MI (as TIA is for CVA). And mitral valve regurge can cause ventricular dysrhythmias. As the left ventricle must work harder to accomodate an insufficient mitral valve, it hypertrophies, leading to changes in the flow of electricity across the stetched-out-ventricle. My advice to you is to find a doctor who is competent and who takes you seriously (preferably a FEMALE cardiologist). Are there situations in your life which are producing stress (other than NCS). Stress alone can exacerbate, even produce cardiac symptoms, arrhythmias. Try to reduce stress, even if it means cutting back hours at work, different shifts, stopping work altogether, etc. And of course, avoid caffeine, chocolate, nicotine. Co-enzyme Q-10 is a wonderful supplement that is great for the heart, as is vitamin E. Feel free to email me privately at any time.

MickeymomRN · Feb 25, 2002

Thanks Healing Touch! You have nailed my frustrations right on the head. I've read literature about how females are different than males. How come these cardiologists, ER nurses, EMTs and Paramedics don't see that? I did think that a female doc would make a difference. I tried one and all she did was ask me if I've had depression in the past. (I've only had PPD with one child but I don't think I've had depression any other time.) When she heard that I had PPD, she suggested that I was probably clinical depressed all the time and advised me to return to my PCP and get help. She was a - (sorry!) And to hurt even worse, I had to pay for that visit out of my own pocket b/c she wasn't in network but highly recommended. (Thought great rep, knowledge and being female would help me.)

Anyways, I know that the beta blockers drop my b/p even lower. Which is one of my components with NCS. So that's what puzzles me about the Rx. I also thought that the beta blockers would help me out with the PVCs. But not! (I've only had calcium channel blockers in the past that helped with the PVCs) The original cardiologist placed me on a beta blocker and then added proamitine. It really knocked me on my butt. I had trigeminy PVCs and bradycardia in the low 40s for days.I didn't even get out of bed. All he said was that they were the drugs of choice and that he had nothing else to give me. The proamitine was to elevate my b/p which was low from the beta blockers. I took the drugs for 5 days then thought "what am I doing?" That's when I decided to change to an EP doc. He's still trying different drugs but I'm still not functional. It's getting frustrating and my finances are really hitting bottom.

Everyone gave me great answers. I hope that I hear more. I'm especially troubled about the pacer. I know of some who have one and they still aren't functional either. I don't know if I want a pacer or not. Having been an RN in surgery before and called the "ICD" queen, I don't want to be on the other end of the defibillator. Although I do admit that was the fun part of the procedure from the RN view. ( I'm a sicko!) :rolleyes:

**canoehead, BSN, RN** · Feb 25, 2002

Isn't it scary how difficult it is to get a good physician who will listen when you are really sick? And some people don't have the knowledge to spot the inconsistencies you did or the energy when they are sick to do anything about it.

I'm really frightened of getting old and needing regular medical care.

MickeymomRN · Feb 27, 2002

Someone suggested that maybe my syncopal episodes are of me going into SVT? Any ideas? I'm so lost with the cardiology stuff.

VickyRN, MSN, DNP, RN · Feb 27, 2002

SVT is a common cause of syncope. The heart is racing, which is cutting down on diastole in each cardiac cycle. Cardiac filling occurs during diastole. Less blood in the ventricles, means less cardiac output, which means less oxygenation to the organs (especially the brain). Hence the syncopal episodes.

mattcastens · Feb 27, 2002

Healingtouch is right. The best way to catch these arrhythmias is with a holter monitor, as I mentioned before. Of course, if you're having a good day then it won't pick anything up. I don't think it would hurt to try it again.