Your Heart: Insights on ECG, Holter Monitoring, and Exercise Tests

Inquiry about the results of the electrocardiogram (ECG), 24-hour Holter monitor, and exercise stress test?

Hello, Doctor.
After staying up late for three consecutive nights at the beginning of November 2021, I started experiencing a tight feeling in my heart that occurs intermittently throughout the day.
I visited the hospital where the doctor performed an electrocardiogram (ECG), a 24-hour Holter monitor, and an exercise stress test.
The doctor mentioned that there might be vascular obstruction, but also noted that at my age, the likelihood is generally low.
They scheduled a myocardial perfusion scan for two months later.
Since the doctor’s explanation was not very clear at the time, and I have to wait a long time for the next examination, I am quite worried.
I hope you can help me assess whether the test results indicate a serious condition and the likelihood of myocardial ischemia.
Thank you very much! (My test results are as follows; I do not smoke or drink alcohol, and I do not have hypertension, diabetes, or hyperlipidemia; my blood pressure is around 125-130.)
Exercise Stress Test Results:
Phase Name: PRETEST
- Standing: 01:42, Speed: 1.00 mph, Grade: 0.00%, HR: 86 bpm, BP: 127/73 mmHg
Exercise Stages:
- Stage 1: 03:00, Speed: 1.70 mph, Grade: 10.00%, HR: 92 bpm, BP: 132/73 mmHg
- Stage 2: 03:00, Speed: 2.50 mph, Grade: 12.00%, HR: 100 bpm, BP: 168/74 mmHg
- Stage 3: 03:00, Speed: 3.40 mph, Grade: 14.00%, HR: 129 bpm, BP: 184/69 mmHg
- Stage 4: 03:00, Speed: 4.20 mph, Grade: 16.00%, HR: 171 bpm, BP: 157/49 mmHg
- Stage 5: 00:04, Speed: 5.00 mph, Grade: 18.00%, HR: 171 bpm
Recovery:
- 03:00, Speed: 0.00 mph, Grade: 0.00%, HR: 115 bpm, BP: 182/62 mmHg
- 02:49, Speed: 0.00 mph, Grade: 0.00%, HR: 104 bpm, BP: 161/65 mmHg
The patient exercised according to the BRUCE protocol for 12:04 minutes, achieving a maximum MET level of 13.70.
The resting heart rate of 72 bpm increased to a maximum heart rate of 173 bpm, which represents 89% of the age-predicted maximum heart rate.
The resting blood pressure of 127/73 mmHg rose to a maximum of 184/69 mmHg.
The exercise test was stopped due to shortness of breath and leg discomfort.
There was abnormal ST segment depression.
Conclusion: The exercise tolerance test (TET) is positive for myocardial ischemia.
There is horizontal ST depression of 2-3 mm in leads III and AVF, strongly suggestive of ischemia.
24-Hour Holter Monitoring Results:
The 24-hour Holter recording was examined due to frequent presyncope and syncope episodes, chest tightness during exertion and at rest, and severe palpitations for more than one month.
The total recording time was 21 hours and 45 minutes, with a basic rhythm of sinus rhythm.
The heart rate peaked at 107 bpm at 7:56 AM, indicating sinus tachycardia with ST depression reaching 3 mm in lead I, suggestive of ischemia, and a minimum heart rate of 34 bpm at 3:22 AM, indicating sinus bradycardia.
The daytime minimum heart rate was 43 bpm at 4:00 PM and 5:00 PM.
There were 0 premature ventricular contractions (PVCs) and 327 premature atrial contractions (PACs), with a day-to-night ratio of 116:211, and no pairs or runs.
There were 1946 long pauses, all occurring at midnight, with the longest RR interval being 1.9 seconds, indicating sinus bradyarrhythmia, with a heart rate of 35 bpm at 3:15 AM.
There were 10 episodes of tachycardia, all sinus tachycardias during the daytime.
There were 59 episodes of bradycardia, with a day-to-night ratio of 1:58, all being sinus bradycardia/bradyarrhythmia, with only one episode during the daytime.
Conclusions: Frequent sinus bradycardia/bradyarrhythmia with long pauses, more prevalent at midnight (minimum heart rate 34 bpm, longest RR interval 1.9 seconds).
Occasional PACs, day-to-night ratio of 1:2, with no pairs or runs.
Rare sinus tachycardia, more prevalent during the daytime.
Suspected ischemic heart disease.
ECG Results: Sinus rhythm with RSR (QR) in V1/V2 consistent with right ventricular conduction delay.

Yoi, 20~29 year old female. Ask Date: 2021/02/03

Dr. He Dongjin reply Cardiology

Hello, you have no risk factors, and the probability is indeed low.
However, a positive exercise electrocardiogram may be a false positive due to variations in your baseline ECG.
You should be fine, so don't worry.
If you still feel uneasy, you can consider getting a CT scan at your own expense.
Changhua Hospital cares about you.

Reply Date: 2021/02/03

More Info

Understanding your heart health through various cardiac tests, such as ECG, Holter monitoring, and exercise tests, is crucial for diagnosing potential issues like ischemic heart disease. Based on the information you've provided, let's break down the findings and their implications.

1. Exercise Stress Test (TET) Findings:
Your exercise stress test indicated a positive result for myocardial ischemia, characterized by horizontal ST segment depression of 2-3 mm in leads III and AVF. This suggests that during physical exertion, your heart is not receiving enough oxygen, which can be indicative of coronary artery disease (CAD). The test showed that you achieved a maximum heart rate of 173 bpm, which is 89% of the predicted maximum for your age, and you experienced shortness of breath (SOB) and leg discomfort, leading to the termination of the test.

2. Holter Monitor Results:
The 24-hour Holter monitor recorded sinus rhythm with significant fluctuations in heart rate, including episodes of sinus bradycardia (minimum heart rate of 34 bpm) and sinus tachycardia (maximum heart rate of 107 bpm). The presence of ST depression during periods of tachycardia further supports the suspicion of ischemia. Additionally, the report noted frequent premature atrial contractions (PACs) but no premature ventricular contractions (PVCs), which is generally a reassuring sign.

3. ECG Findings:
Your ECG showed sinus rhythm with a right ventricular conduction delay, which may not be directly related to ischemia but could indicate other underlying conditions. The overall sinus rhythm is a positive sign, but the presence of ST segment changes during exertion raises concerns.

4. Clinical Implications:
Given your symptoms of chest tightness, SOB, and the test results, there is a reasonable concern for ischemic heart disease, especially considering your age and lifestyle factors (non-smoker, no alcohol, and no hypertension). The combination of exercise-induced ST segment depression and Holter findings suggests that your heart may be under stress, particularly during exertion.

5. Next Steps:
Your physician's recommendation for a myocardial perfusion imaging (MPI) study is appropriate. This test will provide more detailed information about blood flow to the heart muscle and help assess the severity of any ischemia. It can also help differentiate between reversible and fixed perfusion defects, which is crucial for determining the best management strategy.

6. Other Considerations:
While waiting for your next appointment, it’s essential to monitor your symptoms closely. If you experience increased frequency or severity of chest tightness, SOB, or any new symptoms like dizziness or syncope, seek immediate medical attention. Lifestyle modifications, including a heart-healthy diet and regular exercise (as tolerated), can also be beneficial.

Conclusion:
In summary, while your test results indicate some concerning signs related to myocardial ischemia, the full clinical picture will depend on further testing and evaluation. It’s understandable to feel anxious about these findings, but proactive management and follow-up with your healthcare provider will be key in addressing any potential heart issues. Always feel free to ask your doctor for clarification on your results and the implications for your health.

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