Dr. Sagar Ramesh Makode
Cardiology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello doctor,
What is the risk of SCD in a patient with LVH and history of PVCs and possible NSVT? Will simply treating BP reverse any risk? All I have read about this indicates the prognosis is unclear but I am very worried and hope you can shed some light on my situation. I have not had confirmed NSVT but I have felt longer fluttering sensations and have had PVCs for 10 years off and on. I am 23 years old. My stress test was normal. I am on Zio patch now. My echo showed apparent LVH and aortic root dilation 3.8. If I have LVH, does that predispose me to arrhythmias like a hypertrophic cardiomyopathy would, and can it be reversed if I control my blood pressure, which is higher than normal?
Hello,
Welcome to icliniq.com.
Firstly, how bad are your hypertension and hypertrophy? Can your hypertrophy be explained by your hypertension? If yes, then it is likely hypertension induced. Hypertrophic cardiomyopathy may cause hypertrophy in young age, but it usually causes severe hypertrophy, with thickness usually more than 15 mm, and can be detected in the echo. Please attach echo report if possible. Also, let me know how much maximum was the BP reading? You have mentioned 145/90 which is mildly elevated. Next, Compared with those without VPCs (ventricular premature complexes), patients with VPCs had significantly higher all cardiovascular mortality, somewhere between 1.5 to 2 times. But, the majority of patients do well and lead a normal life. Also, your stress test is negative ruling out coronary artery disease which additionally contributes to mortality. Also, you should have a treatment for hypertension which should remain under control and strict BP control may reverse hypertrophy and ectopics to some extent but not completely usually. However, you should ask for beta blockers containing medicines like Metoprolol for BP so it will also control ectopics. So overall, the majority of patients do well and there is no need to worry much about it.
Patient's Query
Hello doctor,
Thank you for some piece of mind. My echo report is attached here for you to see. You can see my septum is mildly dilated. Is this concerning? My main concern are the studies that show NSVT and VPC with LVH significantly increases chance of sustained arrhythmia. Like I said my NSVT was unconfirmed, but I do have ectopic beats. My blood pressure has read up to 155/95 mmHg, but that was only a few times. My usual reading is somewhere between 135/85 mmHg and 148/90 mmHg. Also, you may see the diastolic dysfunction. BP management would reverse this as well? Why do I have this at age 23? Any additional reassurances would be helpful because I am very worried.
Hello,
Welcome back to icliniq.com.
I have gone through the report (attachment removed to protect patient identity). Firstly, it is unlikely to be hypertrophic cardiomyopathy. The LVH (left ventricular hypertrophy) is mild. We consider concentric LVH as more than 12 mm and your septum is 13 mm, so just LVH. This must be due to slightly elevated BP which you have. Since this is mild, this may reverse with time if BP is strictly under control and you achieve some weight loss. Your elevated BP is likely a result of being overweight. You should have a healthy lifestyle like avoiding fatty, oily, and high-calorie diet. Have a low salt diet and monitor blood pressure regularly thrice a day for one week then once or twice a week. If BP is persistently more than 140/90 mmHg, then you should be on medicines for it. Regular exercises like brisk walking, jogging, according to your capacity at least 30 minutes a day and five days a week. Avoid smoking and alcohol, if any. Get your lipid profile and sugars tested once. Aortic root is also mildly dilated, for which you just need to keep watch for progression with yearly or two yearly echoes. Overall, I do not think you need to worry about it. As I mentioned these ectopics are benign and not worrisome, the majority of individuals do excellent. You should get started on beta blockers like Metoprolol which would control BP and suppress these ectopics.
Patient's Query
Hello doctor,
Thank you for your reply.
I just wanted to update you on my condition. I have continued to see my regular cardiologist, and I get an echocardiogram every 6-months at his office. I have attached both recent echocardiograms for you to review. I also have seen an electrophysiologist for my PVCs, where I received one EKG. I have attached this EKG as well, along with an EKG I received at my cardiologist's office. I am currently on Irbesartan 150 mg 1 up from 75 mg since we last talked. I have not added any additional medication besides once daily COQ10 200 mg. My blood pressure is controlled at this time averaging 110/65 mmHg to 130/85 mmHg depending on if I am up, seated, or stressed. I have measured standing up and it does increase to over 140/90 mmHg. My electrophysiologist examined my EKGs and rhythm strips and determined my PVCs are originating from the right-outflow tract, and are benign. I occasionally have 2 to 3 or more beats in succession (NSVT), she said that this was benign. My cardiologist has examined my echocardiograms and would like to do a cardiac MRI on me to determine what is causing the left ventricle to grow in size. I have elected not to do the MRI at this time due to contrast agent concerns, but he said this MRI was not urgent and could wait. I wanted to get a second opinion on what he is looking for specifically with a cardiac MRI and whether you think this is needed in my situation. I also would like to know what you think may be causing my hypertrophy and if you think any other research or insight you have. I am concerned about my heart, but I do exercise almost every day at moderate intensity. I notice my heart does tend to increase in BPM quickly when exercising, but I do not notice any SOB, chest pain, or dizziness. I do not notice frequent PVCs when exercising. So, in your judgment, what should I do at this point? I am a 24-year-old male with a family history of hypertension and a congenital heart defect on my mother's side. My father's side has had atrial fibrillation, and my grandfather may have died from either a malignant arrhythmia or a MI, unknown of which. He was a smoker. I do not smoke or drink and eat a healthy diet full of olive oil, low carbs, proteins, fish, and dark chocolate. I am attempting to lose about 60 to 100 pounds. My current weight is 612 pounds. I am 6' 2" with a large body frame and shoulders. My muscle mass is also heavy. If you need me to resend the older documents, please let me know.
Hello,
Welcome back to icliniq.com.
I have gone through your reports (attachment removed to protect the patient's identity). I think you should have MRI (magnetic resonance imaging), because of the NSVT (nonsustained ventricular tachycardia) runs, J notch. It is better to rule out the possibility of structural heart disease like ARVC (arrhythmogenic right ventricular cardiomyopathy). All these are likely to be benign as the echo shows normal LV (left ventricular) and RV (right ventricular) function, but MRI detects subtle changes if any over and above the echo and will give additional peace of mind to you as well as the doctor.
LVH (left ventricular hypertrophy) can be explained by hypertension. So, it is not a reason for MRI. LA appears a bit enlarged as compared to the previous echo, but it may be a measurement variation. And we should confirm this enlargement on the next echo. Losing weight may help in the resolution of these issues.
Hope this helps you get back if you have any doubts.
Patient's Query
Hello doctor,
So you are saying to rule out ARVD specifically I should get the cardiac MRI? Can you think of any other reason why he would order the MRI? I have talked to him and all he has told me is to see why my left ventricle is becoming larger. Also, I have already been seen by an electrophysiologist and she deemed my (unconfirmed) NSVT runs and J notch to be benign. Are you saying she could have overlooked any changes caused by ARVD, or would she know the difference? I have been exercising frequently, sometimes at peak intensity for me. Could this be causing my atrium to get bigger? The reason why I wanted to forego the MRI is because of gadolinium deposition in the brain (recent studies). I know you must have contrast injected to see any infiltrate in the heart muscle. My cardiologist said this was not urgent and can wait, but what do you think?
Hello,
Welcome back to icliniq.com.
Yes, it is mainly for ARVD or other right ventricular dysplasias. A mild increase in size may even be related to your heavy activities. I do not think it is absolutely necessary for left ventricular part. Your left ventricular size still is within normal limits. If the electrophysiologist is well convinced that NSVT runs are benign then may wait for MRI. LA size increment may be related to exercising. Also, you may have diastolic dysfunction which is either not checked or not mentioned.
I hope this has helped you. Thank you.
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Cardiology
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