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Forum Name: Hypertension

Question: Slight Left ventricle enlargement


 dmbfan07c - Sun Apr 20, 2008 11:09 pm

I went to the ER one night a couple months ago because of a severe panic attack. At the ER they did an EKG and a Chest X-ray all of which were negative. They kept me for a little while and then about 4 hours later they did another EKG and some blood tests. Everything came out fine there as well. So I went home and a few days later I went to my doctor and he prescribed Prozac to me. About a week in taking the Prozac I went back to my doctor because I was having mild heart palpitations and dizziness. He did an EKG which showed slight Left Ventrical Enlargement but said everything else looked OK, so he sent me in to have a 24 hour Holter Monitor done just in case I was having "episodes" of something he didn't catch on the EKG. His nurse called about 5 days later and said I was fine according to the Holter. I did experience my palpitations and dizziness during the test so I know they were on there. She didn't offer any information on it at all though.

So my question is, do you think that is thorough enough? Also why did my left ventricle enlargement not show up in the ER after 2 EKG'S and a chest x-ray but showed up on the docs EKG a week later? If I have even slight left ventricle enlargement shouldn't I still be concerned? Why did the doctor just shrug it off? I suffer from severe anxiety and panic disorder and even mild agoraphobia and am now constantly focusing on my pulse rate and things like that. If I stand up my heart rate increases dramatically (I am in horrible shape as well) and sometimes I will feel pressure in my head along with a slower heart rate after standing up and feel like I may black out. But I never do. My insurance just ran out and I cannot afford any kind of tests at the doc because I am jobless and certainly cannot afford an ER visit unless it's life threatening.. What should I do? Should I trust my doc?
 John Kenyon, CNA - Sat Jul 19, 2008 1:17 pm

User avatar Hello dmbfan07c -

Since your left ventricular enlargement diagnosis has been made via EKG, and since this appeared very shortly after a negative finding on EKG, here are some observations that may help you feel better about this:

First, deep waves (high amplitude QRS complexes) on EKG are sometimes a first indicator of left ventricular enlargement. However, this is far from the Gold Standard for such a diagnosis, even if it happens to be regarded as not serious. An echocardiogram is the best (and, for some, the only) way to to determine if the left ventricle is enlarged or thickened, and this apparently was not performed.

Now then: you have acknowleged being a very anxious person. The recent "excitement" of an ER visit and the precipitating anxiety and panic preceding that may not have caused your cardiac output to become strong enough to cause "false" deep waves on your EKG, but that can often happen, and since by the time you saw the doctor in his office you'd had time to worry more about the potential problems you could have, this may have had you in a more agitated state (minus outright panic) and could account for the deep waves suggesting an enlarged left ventricle. At that time I would have hoped the doctor would have sent you for an echocardiogram in order to rule that in or out at once so you wouldn't have had it to worry about in the interim period.

So the thing that makes this a happy call is that you do not develop a true LV enlargement overnight. It takes a long time to develop, and there are almost always EKG indicators, not just off and on. So the odds are enormous that you do not have any enlargement of the LV. The palpitations and dizziness you experience are partly normal for the general population, and more common in the extremely anxious patient, who is aware not only of them, but of pretty much everything their hearts are doing at any given moment. This is not a criticism but an observation. It's not something you learned overnight, and you can't stop doing it overnight, but the good news is that generalized anxiety and panic disorder can be very well managed, which can usher in a whole new and far more satisfying life for you. It will require some work on your part, but it's worth it.

In the meantime, it is by far better to seek reasoned advice on things such as this concern about the enlarged LV, which of course nobody wants and would be a worrisome thing if there were any real evidence for it. The evidence you have provided actually argues against it. Your ER EKGs would have also shown the same findings as the EKG the doctor did separately. And without an echocardiogram the doctor has a very slim basis for his suspicion. Had he compared the two EKGs he would have seen this was not a consistent finding. Had he recognized your profound anxiety problems he would likely have couched his findings in more reassuring words.

Your description of the pressure in the back of your head and presyncope (feeling as though you might faint) are also very common in the general population (either as orthopedic hypotension or cardioneurogenic presyncope, both benign but annoying and common and best accommodated by standing slowly and waiting a moment to get your bearings). And to answer your posed question "...is this enough?" I would say generally yes, it is enough at least to convince me you are physically fine. It may not be enough for you, however, in which case you do have grounds to ask the doctor to refer you for an echocardiogram (or perform one himself) to once and for all rule out (for your peace of mind only) an enlarged LV, or, failing at that, to get a second opinion on the matter.

I see no way, given your detailed information, that you are likely to have an enlarged LV, and were it not for the ruminant thinking of anxious patients, I'd say that should be enough. However, I know it is likely you will be concerned until and unless you have an unequivocal clincal "no", so I'd push for the echo. Absent that, I do not think you have an enlarged LV at all, and would strongly recommend you find a good psychotherapist who works with anxiety and panic disorder, preferably one who specializes in fixed-term cognitive therapy, a discipine which is interactive, modifies behavior and reactivity, and has pretty good success at helping people to change their own "wiring" so as to improve their lives by getting free of the anxiety and panic attacks which can be so crippling to one's lifestyle.

I wish you all the best and hope this has been helpful to you.

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