Elderly patient lies in bed at night listening to ‘extra’ heart beats

+Clinical
In print
Heartbeat

Elderly patient lies in bed at night listening to ‘extra’ heart beats

Chris Ellis

Chris Ellis

Heart rate

Ectopic beats are frequently benign. Auckland cardiologist Chris Ellis considers how far to investigate the patient before reassurance can be provided

A 76-year-old retired nurse presents with concerns about “her heart”. She explains that for about three to four months she has been experiencing brief episodes of “palpitations” and “loud bangs” in her chest. Her usually regular heart beat seems to be “inter­rupted” by these episodes. Her symptoms last for a few seconds and then recur, several times a minute, and usu­ally last for about 15 to 20 minutes, and then stop. She is aware of them towards the end of the day, and often when she is lying in bed at night.

When the palpitations are more prolonged and fre­quent, she also feels short of breath, and they can make her “cough” and feel a little “light-headed”. She has not experienced chest pains or syncopal episodes.

Concerns are expressed about her family risk of “heart problems”; her mother died from a heart attack at 82 years of age, although her father reached 92 before dy­ing from prostate cancer. Her two younger sisters have no cardiac problems.

The patient can walk without difficulty, although she no longer walks regularly with her friends as she now looks after her husband, who has developed quite ad­vanced dementia. He would wander from home and get lost if she is not with him. She has no significant past history, except for mild hypertension, for which she has taken amlodipine 5mg daily for the last five years. She is a non-smoker and drinks alcohol rarely. She has a normal clinical examination, and an ECG is performed.

1. What does the ECG show?

2. What is the likely diagnosis?

3. Is this common?

4. How would you manage this situation?

5. What is the prognosis?

Discussion

1. The ECG shows normal sinus rhythm with one ven­tricular ectopic beat, which has a right bundle branch block (RBBB) pattern, hence a left-ventricular origin. The axis is normal (–17 degrees); the heart rate is 61 beats/minute.

2. Your patient is very likely to be describing episodes of benign ectopic beats, either supraventricular or ventricular in origin. These are recognised when she is at rest: a time of reflection, and a time she is able to “feel” the ectopic beats. Further, with her social stressors, she is likely to be more stressed and have higher levels of adrenaline, which increase the number of ectopic beats.

3. Patients presenting with, probably benign, ectopic beats are a common occurrence. These patients often take a lot more effort to evaluate, investigate and ulti­mately reassure, than do patients with more significant pathology. However, for many of these patients, their physical symptoms are remarkably disconcerting, and, if correctly assessed, diagnosed and treated from the be­ginning, the anxiety and concern about these episodes can be abated. For younger patients, ectopic beats are usually benign, but as patients age, there is something of a dilemma as to know how far to investigate the pa­tient to try to exclude the possibility the ectopy is not the first sign of an important cardiac problem, such as ischaemia.

Key to diagnosis is history

4. All doctors have a slightly different manner and ap­proach, and this is then tailored to a patient’s individual needs. The key to the diagnosis is in the history, and this may need to be reassessed on several occasions. Explaining that this condition is an “innocent” situation, but one certainly producing “physical” symptoms (ie, it’s not “all in your head”), is important. Investigations are designed to exclude more serious pathologies and allow reassurance for the patient (and doctor!). Some presen­tation histories, and some patients, will require more in-depth investigations.

a. Routine blood tests to check on electrolytes (low potas­sium?) and renal function, thyroid function (thyrotoxicity?), liver function, a full blood count (anaemia?) and C-reactive protein, and a fasting lipid profile and glucose measurement would be performed.

b. I would arrange for a 24-hour Holter monitor, a fairly basic test, to try to correlate symptoms with ectopic beats, which would be extremely reassuring for all par­ties. There is now also the option of using a device which can link up to a mobile phone to record an ECG rhythm strip, which can be of help.

c. In most patients, I would request an echocardiogram to ensure there is a structurally normal heart (particularly, to exclude mitral valve regurgitation), and a treadmill test to ensure there is a functionally normal heart with an appropriate heart-rate response to exercise, and no induc­ible arrhythmias. However, “my population” of patients with ectopic beats would be more at the severe end of the patient spectrum, having been sent by a colleague to a specialist clinic; many lesser cases may not warrant these extra tests.

d. Treatment is essentially with explanation, includ­ing the exacerbation of the ectopy with the “adrenaline rush” produced by stress. Patients are encouraged to accept having a slightly excitable heart and ignore the symptoms. More regular exercise and finding time to relax are also good ways of reducing stress, which can be the best treatment for many patients. As a last re­sort, a beta-blocker at a low dose, either as required (eg, propranolol) or once daily (eg, metoprolol CR), can settle some patients.

5. The prognosis is excellent provided time is invested into the patient’s problem. The insight into a person’s life, revealed with an indepth history, is helpful and assists with ongoing patient management. 

Chris Ellis is a consultant cardiologist at Auckland City Hospital, and at the Auckland Heart Group and Mercy Hospital, Auckland

Earn CPD points with ELearning

Go to ELearning for a downloadable pdf of this article and your RNZCGP reflective learning form. Click here

 

PreviousNext