Arrhythmia or Myocardial Infarction: Your Heart Health Concerns

Arrhythmia or myocardial infarction?

Dear Dr.
He,
On September 6th, I went hiking and climbed about 400 meters of stairs.
While resting at noon, I suddenly lost consciousness and fainted for about 3-4 minutes.
At that moment, I did not feel any chest tightness, chest pain, or significant shortness of breath, and I don't think I experienced palpitations.
I had incontinence and my limbs were stiff.
I later woke up to my companions calling my name.

After fainting on September 7th, I felt soreness in my back, which gradually improved by September 9th.
I thought it was fine not to see a doctor.
However, on September 13th, while resting at home, I suddenly experienced palpitations (my heart was beating very hard) that lasted about 3-5 seconds, accompanied by slight dizziness.
I immediately went to see a family medicine doctor, and the next day I was referred to the cardiology department at Tzu Chi Hospital.
During this time, I also consulted a neurologist (I will know the EEG results on October 5th).

On September 14th, I had a chest X-ray and an electrocardiogram (ECG), which revealed arrhythmia.
I also underwent a 24-hour Holter monitor.
On September 15th, after reviewing the 24-hour Holter report, the doctor mentioned that there was an episode of ventricular tachycardia (the doctor said it lasted about 4 seconds with 12 beats before stopping).
On September 18th, I returned for a follow-up and had an echocardiogram (the heart generally looked fine, but one blood vessel had an unusual flow rate).
Consequently, I had blood tests done, and my high-sensitivity cardiac troponin level was 21.6 pg/ml.
The doctor concluded that my fainting on September 6th might have been due to a myocardial infarction.

The doctor prescribed antithrombotic medication, aspirin, and Concor (bisoprolol).
I felt very uncomfortable taking them.
During this time, on September 19th, I experienced some discomfort in my chest and went to the emergency department at National Taiwan University Hospital, where blood tests and an ECG were normal.
On September 21st, the doctor urged me to undergo a cardiac catheterization to check for any blockages.
I asked if we could start with medication treatment instead, and the doctor advised me to return for a follow-up in a week.
On September 22nd, I was referred to National Taiwan University Hospital, and on October 12th, I have an MRI scheduled, followed by cardiac catheterization to investigate the cause of the arrhythmia.
The doctor only prescribed Concor 1.25 mg to be taken once a day.
I would like to ask the doctor the following questions:
1.
The 24-hour Holter monitor detected my ventricular tachycardia with 12 beats in 4 seconds.
At that moment, I felt slightly disoriented.
If my blood pressure is normal, is this dangerous? Is this considered mild? Is it necessary to perform cardiac catheterization to provoke the arrhythmia? Could provoking it make it worse? Is it essential to have an ablation procedure, or can I just manage it with medication? Additionally, since taking Concor, I often feel like I have missed a heartbeat (about 5-6 times per minute, sometimes better), and my blood pressure has been lower than usual (around 90-100 systolic and 60-70 diastolic).
2.
Was my condition on September 6th a myocardial infarction? If so, are my blood vessels in a state of impending blockage? Is urgent intervention needed? Will my heart fail as a result? Since September 6th, I have not experienced significant discomfort in my chest (no widespread pain or shortness of breath), but sometimes I wonder if it is due to panic or anxiety, as I feel something is off with my body.
3.
I really want to understand the cause of my fainting but am afraid of overtreatment leading to unnecessary harm.
I appreciate your response to my concerns.
I have been feeling close to panic this month.
I cannot attach images, but I have the 24-hour Holter monitor and echocardiogram data available.
Thank you very much for your assistance.

Jinzhang Konghuang de Ren, 40~49 year old female. Ask Date: 2023/09/28

Dr. He Dongjin reply Cardiology

Hello, on September 6th, it should not be a myocardial infarction.
Myocardial infarction occurs when a blood vessel is blocked, which requires urgent intervention.
Whether there is a blockage or not can only be determined after examination.
Overall, it is recommended to proceed with cardiac catheterization: first for vascular examination and second for potential ablation.
If you have not experienced fainting before, such extensive measures may not be necessary.
However, since you have fainted previously, it is crucial to identify and resolve the underlying issue, as it is akin to carrying a ticking time bomb, which is dangerous.
Regardless of the approach taken, the goal is to ensure greater safety in the future.
While cardiac catheterization does carry risks, the risks of not proceeding are significantly higher.
There is concern about the possibility of fainting again, which is why proactive measures are needed.
Ventricular tachycardia is indeed dangerous and must be addressed promptly, especially since you have experienced fainting.
The physician will provide the most appropriate treatment for you, and there is no issue of overtreatment.
Changhua Hospital cares about your well-being.

Reply Date: 2023/09/28

More Info

It's understandable that you're feeling anxious given the symptoms you've experienced and the medical evaluations you've undergone. Let's break down your concerns regarding arrhythmia and the possibility of myocardial infarction (heart attack) based on the information you've provided.

Understanding Your Symptoms
1. Syncope (Fainting): The incident on September 6, where you fainted after climbing stairs, is concerning, especially since it was accompanied by loss of consciousness and some postictal symptoms (like stiffness and incontinence). Fainting can occur for various reasons, including dehydration, vasovagal syncope, or more serious cardiac issues. The fact that you did not experience chest pain or significant shortness of breath at that moment is somewhat reassuring, but it does not rule out a cardiac event.

2. Palpitations and Dizziness: The episodes of palpitations and dizziness you've experienced, particularly after the fainting episode, warrant further investigation. The fact that you had a documented episode of ventricular tachycardia (VT) during your 24-hour Holter monitor is significant. VT can be serious, especially if it leads to syncope or is sustained.

Evaluating the Risk of Myocardial Infarction
1. Troponin Levels: Your high-sensitivity troponin level of 21.6 pg/ml is a marker that can indicate myocardial injury. However, the interpretation of this value depends on the context, including your symptoms and other test results. If your doctor suspects a myocardial infarction, they may consider additional tests, including coronary angiography, to assess for blockages.

2. Heart Function: The echocardiogram results indicating that your heart is generally functioning well are a positive sign. However, the mention of an abnormal blood flow in one of the vessels suggests that there may be some underlying issue that needs to be monitored.

Addressing Your Concerns
1. Need for Further Testing: Given your history of syncope and the findings from your Holter monitor, it is prudent to follow through with the recommended coronary angiography. This procedure can help determine if there are any significant blockages in your coronary arteries that could lead to ischemia (lack of blood flow) or arrhythmias. While it may seem invasive, it is a standard procedure that can provide crucial information about your heart health.

2. Medication Management: You mentioned experiencing skipped beats after starting the medication (likely a beta-blocker). This is not uncommon, especially as your body adjusts to the medication. However, if these symptoms persist or worsen, you should discuss this with your cardiologist. They may need to adjust your medication or explore alternative treatments.

3. Anxiety and Panic: It’s important to recognize that anxiety can exacerbate physical symptoms, including palpitations and feelings of dizziness. Engaging in relaxation techniques, mindfulness, or even cognitive behavioral therapy may help manage these feelings.
4. Understanding Your Condition: It’s natural to worry about the implications of your symptoms. While there is a risk of serious conditions like myocardial infarction, your healthcare team is monitoring you closely. The absence of significant chest pain or shortness of breath is reassuring, but ongoing vigilance is necessary.

Conclusion
In summary, while your symptoms and test results warrant careful monitoring and possibly further investigation, there is no immediate indication of a life-threatening condition based on the information provided. It is crucial to maintain open communication with your healthcare providers, adhere to their recommendations, and address any new or worsening symptoms promptly. Remember, managing anxiety and understanding your health can significantly improve your quality of life. If you have further questions or concerns, don't hesitate to reach out to your healthcare team.

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