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Q. My cousin has shortness of breath with sinus tachycardia and ST depression. Please help.

Answered by
Dr. Muhammad Zohaib Siddiq
and medically reviewed by Dr. Vinodhini. J
This is a premium question & answer published on Dec 13, 2020 and last reviewed on: Jan 08, 2021

Hello doctor,

My cousin has shortness of breath while climbing stairs for three months. We got a lipid profile where LDL is 210 and triglycerides were 320. He has elevated homocysteine levels as well. EKG showed sinus tachycardia and ST depression in 2, 3, AVF. 2D echo showed aortic sclerosis, normal LVEF 70%, and his HS CRP is 3.9 (normal < 1). He has been started on Aspirin, Rosuvastatin, vitamin B12.

What do you think is the reason for the shortness of breath? What is the diagnosis for him? What treatment does he need (water pill diuretic or Metoprolol to slow the heart), and does he need CAG for ST depression? He could not do TMT due to his shortness of breath. The remaining investigations, including LFT, RFT, and thyroid, are normal.

#

Hi,

Welcome to icliniq.com.

All the prescribed medicines are fine. Shortness of breath is not due to systolic heart failure as LVEF (left ventricular ejection fraction) is normal. Yes, there may be diastolic heart failure. Please send me a full echocardiography report so that I may comment on it. This report indicates diastolic dysfunction grade 1 (attachment removed to protect patient identity).

Shortness of breath can also be due to noncardiac causes such as chest infection, asthma, interstitial lung disease, etc. Does he smoke or ever smoked? Please have a chest x-ray done too.

What is his weight, BMI? Is he diabetic? Obesity also causes shortness of breath. A sedentary lifestyle leads to deconditioning of the heart and slight exertion raises heartrate and shortness of breath too.

Regarding ST depression, please send me ECG so that I may comment on it. If he had shortness of breath and ECG showed ST depressions, cardiac troponin I should have been done to diagnose non-ST elevation myocardial infarction (NSTEMI). If ECG is recent (within seven days), then still cardiac troponin I can be done.

CAG (coronary angiography) is not needed at this point just because of shortness of breath. A water pill may be needed, but the first assessment of the patient is essential. Metoprolol may not be needed as there is no benefit in normal LVEF. Another option is tablet Ivabradine 5 - 7.5 mg twice a day to control heart rate but only when all causes have been excluded from tachycardia.

Thank you doctor,

He is a nonsmoker, non-diabetic, and cardiac troponin was also done (trop T 0.05). I forgot to mention that he is obese and has obstructive sleep apnea as well. He does not have asthma or any lung infection and does not know about interstitial lung disease. What would be his diagnosis? ECG shows sinus tachycardia and ST depression, and T inversion in 2,3 AVF. The echo shows aortic valve sclerosis with normal diastolic function. What does elevated hs CRP indicate? Lastly, should he be on a diuretic or not?

#

Hello,

Welcome back to icliniq.com.

OSA (obstructive sleep apnea) itself is a cause of shortness of breath. He should lose weight to control OSA and its consequences.

T wave inversions in inferior leads suggest myocardial ischemia, but there was no heart attack as his troponin was normal. He should continue his medicines.

Regarding diuretics, on echocardiography only, diuretics are not needed, but clinically patient should be examined to see the fluid status.

Does he have chest pain? What was his hemoglobin level?

OSA should be controlled, as it has negative effects on the lungs and heart. CRP level is a nonspecific marker of inflammation in the body. Those with OSA will snore at night and cannot sleep properly, so they pass the whole day in somnolence. They feel sleepy the whole day.

Echocardiography also comments on pulmonary pressures, which are usually raised in patients with OSA.

Obese people have large body mass and surface area and are usually sedentary, so their heart becomes deconditioned, and heart has to pump more blood to the large body, and thus heart rate may rise on slight activity and same way respiratory rate may also rise to cope with oxygen demand of the large body. Moreover, the pressure exerted by abdominal fat and organs on the lower side of the lungs results in compression of lungs and cannot fully expand, and thus they have to increased respiratory rate. This is also a common cause of shortness of breath in obese peoples.

A confirmed diagnosis can only be made after a chest x-ray, spirometry, and calculation of lung volumes.


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