Myocardial Ischemia: Insights from ECG and Echocardiogram Results

Myocardial ischemia, exercise electrocardiogram?

Hello Doctor, I have noticed significant differences in the test results from a clinic and a large hospital, and I hope you can assist in interpreting them.
Thank you!
[Clinic A]
1.
24-Hour Holter Monitor:
- 402.10 HYPERTENSIVE HEART DISEASE, BENIGN WITHOUT CONGESTIVE HEART FAILURE
- 414.8 OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE
- 427.9 CARDIAC DYSRHYTHMIA, UNSPECIFIED
- 427.0-2 PAT 790.6 OTHER ABNORMAL BLOOD CHEMISTRY
- 424.0 MITRAL VALVE DISORDERS
- Recording from: August 15, 2022, 12:28:49
- Duration: 24 hours
- Recorder type: FD4 (3 channels)
- Analyzed retrospectively
- Analyst: Release: 12.0
- Preference: CCH
Findings:
1.
Sinus rhythm.
2.
Total 24-hour heart rate of 117,143 beats.
3.
Intermittent ST depression, T wave inversion, myocardial ischemia.
2.
Echocardiogram:
- Purpose:
- 402.10 HYPERTENSIVE HEART DISEASE, BENIGN WITHOUT CONGESTIVE HEART FAILURE
- 414.8 OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE
- 427.9 CARDIAC DYSRHYTHMIA, UNSPECIFIED
- 786.50 CHEST PAIN, UNSPECIFIED
- 424.0 MITRAL VALVE DISORDERS
- 780.50 SLEEP DISTURBANCES, UNSPECIFIED
- M-Mode, TWO DIMENSIONAL & DOPPLER STUDIES
- Right Ventricular Diameter (RVD): 1.9 (0.7-2.3)
- Mitral Valve Structure: REGURGITATION VELOCITY
- Left Ventricular Diastolic Diameter (LVDD): 4.5 (3.5-5.5)
- Ejection Fraction (EF): 57% (normal range: 50-70%)
Interpretation:
1.
Normal chamber size & wall thickness.
2.
Mild Mitral Regurgitation (MR).
3.
Mild Tricuspid Regurgitation (TR); Trivial Aortic Regurgitation (AR) & Pulmonary Regurgitation (PR).
4.
E/A ratio > 1.
5.
Estimated Pulmonary Artery Pressure (PAP) = 30.2 mmHg.
6.
Mild to moderate Hypokinesia: Interventricular Septum (IVS), Anterior wall; Mild Hypokinesia: Inferior wall & LV apex.
7.
Normal LV systolic & diastolic function, LVEF = 57%.
[Hospital B]
1.
Exercise Stress Test:
- The patient exercised according to the BRUCE protocol for 10:43 minutes, achieving a maximum MET level of 12.90.
- Resting heart rate of 86 bpm increased to a maximum heart rate of 190 bpm, representing 100% of the age-predicted maximum heart rate.
- Resting blood pressure of 108/72 mmHg rose to a maximum of 152/52 mmHg.
- The exercise test was stopped due to fatigue.
- Interpretation:
- Adequate blood pressure response without angina and no ST segment changes during the exercise test.
- Conclusion: Negative.
2.
Echocardiogram:
- Date: 08/18
- Weight: 69 kg, Height: 171.00 cm, Body Surface Area: 1.81 m²
- Clinical Impression: Chest pain
- Aortic Root Measurements:
- Aortic annulus diameter: 22.30 mm
- Sinus Valsalva diameter: 33.30 mm
- Ascending aorta diameter: 29.80 mm
- Left Ventricle Measurements:
- Ejection Fraction (EF): 67.90%
- Good LV systolic function.
Impression:
1.
No chamber dilation.
2.
Good LV systolic function, estimated LVEF: 69%.
3.
Normal RV systolic function.
4.
Mild TR, PG: 18 mmHg, estimated RVSP: 26 mmHg.
Summary:
The doctor at Clinic A has consistently indicated that I have myocardial ischemia, but I do not have hypertension (my blood pressure sometimes reaches 130, which other doctors do not consider high).
The doctor at Clinic A suggested that without hypertension, it could be a congenital vascular anomaly and recommended a cardiac CT scan.
Consequently, I went to Hospital B (which has a cardiovascular center), where the doctor arranged for an exercise stress test and echocardiogram.
The findings from Hospital B differ significantly from those of Clinic A.
I have a history of anxiety disorder and ankylosing spondylitis, which often makes me feel unwell.
Recently (after these tests), I occasionally experience palpitations, a feeling of tightness in my chest, and frequent involuntary deep breaths.
Wearing a mask often feels suffocating.
However, after moving heavy objects (over 20 kg) up and down stairs about ten times, I only experienced shortness of breath and muscle soreness without other symptoms.
The doctor at Hospital B also indicated that the likelihood of myocardial ischemia is low and suggested that my chest tightness and palpitations are more likely related to gastroesophageal reflux (I undergo gastroscopy annually, which consistently shows esophageal burns and relaxation).
However, if the symptoms persist, he can arrange for further tests, though he believes the probability is indeed low.
I apologize for the lengthy message, and I appreciate your patience in reading it.
I would be grateful for your clarification on this matter.
Thank you, Doctor!

Xi, 30~39 year old female. Ask Date: 2022/11/01

Dr. He Dongjin reply Cardiology

Hello, I trust large hospitals.
I cannot make a judgment without seeing the relevant images, but I believe it is better to observe first.
Changhua Hospital cares about you.

Reply Date: 2022/11/01

More Info

Understanding myocardial ischemia is crucial for assessing cardiovascular health, especially when interpreting results from various diagnostic tests such as ECGs and echocardiograms. The discrepancies between the findings from the two medical facilities you visited highlight the complexity of diagnosing cardiac conditions.

Overview of Myocardial Ischemia
Myocardial ischemia occurs when blood flow to the heart muscle is reduced, preventing it from receiving enough oxygen. This condition can lead to chest pain (angina) and, if severe or prolonged, can result in a heart attack. The assessment of myocardial ischemia typically involves a combination of clinical history, physical examination, and diagnostic tests, including ECGs, echocardiograms, and stress tests.

Analysis of Your Reports
#
A Clinic Findings
1. 24-Hour ECG: The report indicates sinus rhythm with intermittent ST depression and T-wave inversion, which are suggestive of myocardial ischemia. The presence of these changes during periods of stress or exertion can indicate that the heart is not receiving adequate blood flow.

2. Echocardiogram: The findings suggest mild mitral regurgitation and mild to moderate hypokinesia in certain areas of the left ventricle, which could be indicative of underlying ischemic heart disease. The left ventricular ejection fraction (LVEF) of 57% is on the lower side of normal, suggesting some degree of left ventricular dysfunction.

#
B Hospital Findings
1. Exercise ECG: The exercise test showed that you achieved a maximum heart rate of 190 bpm without any significant ST changes or angina, which is a reassuring sign. The adequate blood pressure response during exercise further supports the absence of significant ischemia.

2. Echocardiogram: The results indicated good left ventricular systolic function with an LVEF of 69%. This is a positive finding, suggesting that the heart is functioning well despite the symptoms you are experiencing.

Discrepancies and Clinical Correlation
The differences between the two reports can be attributed to several factors:
- Variability in Testing Conditions: The conditions under which the tests were performed, including the patient's state of health, stress levels, and even the specific protocols used, can lead to different interpretations.

- Interpretation of Results: Different physicians may interpret the same data differently based on their clinical experience and the context of the patient's overall health.

- Underlying Conditions: Your history of anxiety, ankylosing spondylitis, and gastroesophageal reflux disease (GERD) may contribute to symptoms like palpitations and chest discomfort, which can sometimes mimic cardiac issues.

Recommendations
1. Follow-Up: Given the conflicting results, it is essential to maintain regular follow-ups with your healthcare provider. Continuous monitoring of your symptoms and periodic re-evaluation of your cardiac status is crucial.

2. Lifestyle Modifications: Engage in heart-healthy lifestyle changes, including a balanced diet, regular exercise (as tolerated), and smoking cessation if applicable. Managing stress and anxiety through relaxation techniques or therapy may also help alleviate some of your symptoms.

3. Further Testing: If symptoms persist or worsen, further diagnostic testing, such as a coronary angiogram or advanced imaging techniques, may be warranted to rule out significant coronary artery disease.

4. Gastroenterological Evaluation: Since GERD can cause chest pain and discomfort, it may be beneficial to continue managing this condition with your gastroenterologist, as effective treatment may alleviate some of your cardiac-like symptoms.

Conclusion
In summary, while the findings from A Clinic suggest potential myocardial ischemia, the results from B Hospital indicate a more stable cardiac condition. It is essential to consider both sets of results in the context of your overall health and symptoms. Regular follow-up with your healthcare providers and a comprehensive approach to managing your health will be key in addressing your concerns and ensuring optimal cardiac health.

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