EXTRA COPY — ECG Blog #543: A 24-Hour Holter was Done- EXTRA COPY

The ECG in Figure-1 was obtained from a previously healthy elderly woman — who presented with dizzyness and fatigue, but no CP (Chest Pain).

• Details of the timing of this patient's symptoms with respect to when the ECG in Figure-1 was recorded are uncertain.

QUESTIONS:

With the above history in mind: 

• How do YOU interpret today's initial ECG?
• Clinically — What would you do?

Figure-1: The initial ECG in today's case.

My Thoughts:

The ECG in Figure-1 shows sinus bradycardia at a rate of ~50/minute.

• The QRS is narrow — the PR interval is normal — and the QTc is probably not increased given the slow rate. 
• There may be small U waves in the mid-chest leads (which sometimes occurs in association with bradycardia).
• There is a slight leftward axis — though not negative enough to qualify as LAHB (The QRS is slightly more negative than positive in lead aVF — but mainly positive in lead aVL — which puts the axis at about -15 degrees).
• There may be voltage for LVH (Hard to say for sure if the R in aVL ≥12 mm — given overlap of this R wave with the S wave in lead aVR).

Regarding Q-R-S-T Wave Changes:

• The narrow Q waves in leads I,aVL are probably not abnormal given fairly tall R wave amplitude in these leads.
• R wave progression — looks normal, with transition (where the R wave becomes taller than the S wave is deep) occurring normally beween leads V2-V3.
• There are subtle ST-T wave abnormalities in a number of leads. As shown in lead III and in leads V1,V2,V3 — there is ST segment coving but really no elevation, followed by T wave inversion (the RED arrows in these leads).
• BLUE question marks in a number of other leads highlight ST-T wave segments of uncertain significance — especially given the different ST-T wave appearance between the only 2 complexes that we see in leads aVL and aVL — and our inability to fully see the ST-T wave of the 2nd complex in leads V4,V5,V6 (? what is real vs artifact). That said — there appears to at least be ST segment flattening in lead II, with slight ST depression in leads V4,V5,V6.

Impression: In view of the brief history we were given, but without "being there" — it's hard to know what to think of the above described ECG changes shown in Figure-2.

• It is clearly possible that this elderly woman at some point in time (possibly recently) — had inferior and anterior infarction. That said — the lack of a history of preceding chest pain (and uncertainty about the time of this elderly patient's "dizzyness and fatigue" ) — make it difficult to know whether she may have had a "silent" MI with "chest pain equivalent" symptoms? And if so — when this may have happened? (See ECG Blog #228 — for more on "Silent" MI).
• Without a preceding history of CP that then resolved — this case does not fit criteria for "Wellens' Syndrome". That said — ECG #1 certainly could be the result of infero-antero infarction at some point in time, possibly recent (See ECG Blog #320 and ECG Blog #350 — for more on what Wellens Syndrome is, and what it is not).

Figure-2: I've labeled ECG findings in the initial ECG.

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The CASE Continues:

This elderly woman up until now had not sought out medical care. She lived alone and functioned completely independently. Although she reported dizziness and fatigue as the reason for her ED (Emergency Department) visit — the medical care provider who treated the patient thought she looked remarkably well. As a result — ACS (Acute Coronary Syndrome) was not considered:

• Of note, the patient did not have medical insurance, and she had financial limitation. As a result — she did not want an extensive diagnostic work-up, especially given that she felt good enough to return to her independent living situation at home. 
• Troponin was not ordered.
• Instead, a 24-hour ambulatory Holter monitor was placed — and the patient went home. Follow-up was scheduled for her to return the next day.

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The Patient's Holter Monitor . . .

As you think about the challenging limitations for managing this case — what follows below in Figures-3 -thru-9 are non-sequential rhythm strips from this patient's 24-hour ambulatory Holter moniter that was reviewed the next day.

• NOTE: Each of the 6 non-sequential Holter rhythm strips that are shown below manifest 6 leads — including 1 limb lead (lead aVR) — and 5 chest leads (leads V1-thru-V5).
• As you review these 6-lead rhythm strips — Keep in mind that the only symptoms this elderly woman reported when she was seen several hours earlier, were some "dizzyness" and "mild fatigue" — but no chest pain.
• For ease of comparison in Figure-3 — I've reproduced this patient's initial ECG that was shown above in Figure-2.

Figure-3: Comparison between the initial ECG — and Holter-A, recorded several hours later after the patient had returned home (at 11:16 pm — while the patient was sleeping).

My Thoughts on Holter-A:

Keeping in mind the inevitable slight differences in lead placement with 6-lead Holter monitoring vs the patient's 12-lead — I did not perceive any significant different between these 2 tracings in Figure-3.

13 Minutes Later ...

Figure-4: Holter-B — recorded 13 minutes later (at 11:29 pm) while the patient was still sleeping.

Subsequent Recordings during Sleep ...

Figure-5: Holter-C — recorded ~2 hours later (at 1:23 am).

Figure-6: Holter-D — recorded at 7:30 am the next morning.

Figure-7: A closer look at Holter-D — in which I've labeled regular-occurring P waves that are no longer upright in lead aVF. The vertical RED line marks the end point of the now widened QRS complex in these 6 simultaneously-recorded leads — with the ST segment beginning to the right of this vertical RED line.

Figure-8: 10 minutes after Holter D — We now see a markedly widened agonal rhythm without atrial activity.

Figure-9: 12 minutes later a flat line is seen ...

Editorial Comment:

Today's case is difficult. This elderly woman who lived alone, died at home in her sleep. These Holter tracings were only retrieved afterward.

• Presumably — the initial ECG in Figure-2 did represent recent LAD occlusion and infarction in the form of a "silent" MI in this elderly woman with minimal "CP-equivalent" symptoms, who otherwise looked good — and who wanted to go home.
• Presumably, the reason this patient's initial ECG did not show acute ST elevation — is that there was spontaneous reperfusion of her recent MI, with resolution of what must have been ST elevation several hours earlier. The RED arrows in leads III; V1,V2,V3 — as well as the Blue question marks in her initial ECG represented reperfusion T waves.
• 
  
• I have "been there". As a family medicine Attending and faculty physician for 30 years — we would periodically see elderly patients present a day or more later after some form of symptoms with ECGs similar to that seen in Figure-2. While clearly — hospitalization for a day or two to ensure nothing active is still ongoing would be ideally recommended (and depending on case specifics — serial tracings, Troponins and potentially cardiac catheterization) — but with full informed consent, that is not always the path chosen.

I have also "been there" in the eerie situation of interpreting a Holter monitor on one of our serivce patients who was admitted to the hospital and seemingly doing well on a telemetry-monitored floor. I was downstairs in the hospital ECG station, reviewing the patient's 24-hour Holter recording that had just been placed into my in-box for interpretation. XXXXXXX

I have been there. I'll never forget

Editorial Note:

I have had this same experience myself — that I'll never forget 

Watanabe et al — Heart Rhythm 8:18-25, 2014
https://pubmed.ncbi.nlm.nih.gov/24793460/

Nikolic et al — Circulation 66(1):218-225, 1982
https://www.ahajournals.org/doi/10.1161/01.CIR.66.1.218?doi=10.1161/01.CIR.66.1.218

XXXXXXX

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Acknowledgment: My appreciation to Passang Jinpa (from Guayaquil, Ecuador) — for allowing me to use this case and this tracing.

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pful ...

In retrospect — the only thing I could say is that subtle change in symptoms (ie, development of some new "fatigue" in recent days in an older person with the initial ECG that you show is suggestive that a recent MI may have occurred, and that we are now seeing reperfusion T waves. What to do with this IF the patient otherwise "seems well" is a difficult question and "Ya gotta be there!" because there is NO certain answer.

In my capacity as hospital Attending for 3-4 months each year — I would read all of our service ECGs and I'd see the Holter Monitors. I will NEVER forget reading ECGs one day — and seeing a Holter monitor of a hospitalized patient, when I suddenly saw on the Holter that the rhythm was getting slower and slower — and then stopped. So I ran up to the floor where this patient was — only to find everyone at the bedside treating her cardiac arrest. It was an EERIE feeling seeing that Holter, and then seeing the patient (just like the eerie feeling that I'm sure you have when you saw these tracings!).

The above said — YES, this is rare to catch this — but I'm not sure you have best exposure by writing an article. Instead — I propose that you let me write an ECG Blog Case that I will publish within a couple weeks. I will show the 12 lead ECG that you sent me and ask the reader how they will interpret this?

There is no right or wrong answer — but the fact that you are soul searching events is sign that YOU are truly a good, caring physician doing the best you can given limited resources for the best you can do for your patients. Many clinicians would not give this case a second thought ....

Is it OK with you that I write this case up as an ECG Blog? I would be happy to acknowledge you if you like? — or the case can be anonymous — JUST LET ME KNOW. It will be published as a Blog post on-line, so it can be referenced by a link to my Blog.