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