Is a 30-day Holter monitor useful for palpitations?

Question

Hi doctor,

I am a 30-year-old Caucasian woman, 5 feet and 11 inches, 195 pounds, and semi-active. My family has a history of heart problems. My mother, eldest brother, and father are all taking Metoprolol for heart arrhythmias and my maternal grandfather died of a heart attack at 55. My father also has a history of blood clots, though I tend to have the opposite problem with my blood not clotting easily at all, most likely due to a vitamin K deficiency. My HDL cholesterol tends to be in the 20s, and my LDL cholesterol tends to be in the 60s. I have had three different surgeries in my life. I have had a lateral release of the tendon on my left knee and my gallbladder removed, and two months ago, I had a cyst removed from my uterus.

My issue is that I have been having palpitations off and on for seven months. They began after a severe case of the flu. At first, it was just the heart racing, but after a few months, it has become more of a skipped beat. The episodes last anywhere from one to 20 minutes. At first, the doctor thought it might be anxiety, but after a visit to a psychologist who specialized in anxiety, it was determined that anxiety was not the cause. The palpitations are not constant, but I also have other symptoms of lightheadedness and pain in the chest on the left side (I'm not sure if this is musculoskeletal or not). I also have digestive issues, which may be a factor.

I have had an echocardiogram with the following results:

Left ventricle: The left ventricular size is normal. LV posterior wall thickness was normal. LV systolic function was hyperdynamic. Left ventricular ejection fraction, by visual estimation, is 65 to 70 percent. Spectral Doppler shows a normal pattern of LV diastolic filling.
Right ventricle: The right ventricular size is normal. RV wall thickness is mildly increased.
Left atrium: The left atrium is mildly dilated.
Right atrium: The right atrium is normal in size.
Aortic valve: Mid-aortic valve thickening is present.
Mitral valve: The anterior and posterior leaflets are mildly thickened. Trace mitral valve regurgitation is seen.
Tricuspid valve: Trace tricuspid regurgitation is visualized. The tricuspid regurgitant velocity predicts an estimated right ventricular systolic pressure of 27.7 mmHg with normal pulmonary pressure.
Pulmonic valve: The pulmonic valve was not well visualized. Trace pulmonic valve regurgitation.
Aorta: The aortic root and ascending aorta are structurally normal with no evidence of dilation.
Pulmonary artery: The pulmonary artery is not well seen.
Pericardium: There is no evidence of pericardial effusion.

I also had a 48-hour Holter monitor but was sick in bed the entire time. The results were Min HR: 50, Max HR: 160, Average HR: 82, Ventricular ectopic activity consisted of seven beats, of which six were single PVCs and one was a single VE. The supraventricular ectopic activity consisted of 210 beats, of which 10 were in atrial couplets, 125 were late beats, and 75 were single PACs. The longest R-R interval was 1.4 seconds. The longest N-N interval was 1.4 seconds.

I have also done an overnight pulse oximetry test, which came back as normal. I have also tried Metoprolol ER and non-extended release. I was only able to take it for a week, as the results fixed the racing and weird beats, but after about an hour I was barely able to walk to my bed and fell asleep for 10 hours without my husband being able to wake me up no matter how hard he tried.

The palpitations seem to be getting less frequent (especially since the pain from the cyst removed earlier in the year has subsided), but then I will have a week where I get them every day, a few times a day for about 20-minute increments. My husband wants me to get a 30-day heart monitor, but after working with my current cardiologist's office, we have been unable to get one after two and a half months of them saying they are sending it. My husband now wants me to go to a different cardiologist’s office, but the closest one is over three hours away. So, I wanted to get a different cardiologist's opinion.

Is there anything that I really need to worry about, or is my heart relatively normal, and is this just a case of something that I have just never experienced before?
Should I continue to push to get the 30-day Holter monitor or get a new cardiologist and make the trip?

Please advise.

Answer 1

Hi,

Welcome to icliniq.com.

I reviewed your reports, and the Holter monitor shows runs of ill-sustained supraventricular tachycardia, possible atrial tachycardia, and a few ventricular premature beats. Ideally, Metoprolol would be a good option for you; however, since you are unable to tolerate it, I suggest considering Diltiazem or Verapamil instead. The echocardiogram indicates that your heart is in good condition, so there is no need for undue worry.

A 30-day monitor may not serve much of a purpose, as it will primarily help determine whether these palpitations are sustained. I would recommend considering electrophysiology and ablation for the ectopic ventricular beats if they are particularly disabling and you are not satisfied with the pharmacological treatment. The only downside is that your palpitations need to be sustained for this procedure to be effective; otherwise, it may take a long time in the electrophysiologist's lab.

I hope this helps you.

Thank you.