In Which You Maybe Learn Some Stuff About Hearts

On Tuesday, a cardiologist and her happy minion tried to kill me and then assessed how close they came. Fortunately for me, not close enough. *Buzzer sound* Sorry. Try again next year.

The stress test was the least irritating of all the parts of this appointment, but that’s part and parcel with doctors. You wait in the waiting room for 60+ minutes (which is why you’re called a patient) and, when you leave, they’ve said a lot of words but haven’t really actually told you anything.

Travis, the Stress Test Tech Person, was delightful, actually. He called me “baby” a lot, but somehow it wasn’t creepy. Sort of like how diner waitresses call you “hon,” whether you’re three or 103, and whether they’re 55 or…

Wait. They’re actually all 55.

Anyway.

Travis was telling me what he was doing all along. He did an echocardiogram first, propping my back against his in a totally clinical way to position me where he wanted me so he could get the images he needed, and explaining very nonchalantly why I really couldn’t keep craning my neck to see the picture on the screen. (“Look, see what happens? The picture gets fuzzy.”) He also told me that he was super-annoyed that he kept getting 30- and 40-somethings for stress tests that day. “If one more person has to walk for 15 minutes before we get them to their target heart rate, I’m jumping out a window,” he said.

It took me 11 minutes. You’re welcome, Travis. I shaved four minutes off that last guy’s time. What’s that you say? That’s not a good thing?  The last guy is 58 and had a heart attack at 41 and is, from a fitness perspective, the lifespan equivalent of four minutes’ better endurance multiplied by a differential of 21 years and mitigated by one heart attack better off than I am? Well, what of it? You want to get your schedule back on track, right? That’s what I thought.

Travis is a very put-you-at-ease person. My blood pressure was 100/62, and he didn’t like it, because it meant I’d have to walk longer, but it was a testament to his calming presence. (At the beginning of my first appointment, two weeks ago, my BP was 120/80).

Happily, they did not make me run. They just made me walk faster by three-minute increments on a steadily increasing incline to get to the required target heart rate (220 minus age and multiplied by 0.90, or, in my case, 165.).

I basically still have no official comprehensive diagnosis, because doctors are annoying, but here’s what I’ve been able to figure out so far:

I have what’s called a 2nd degree Type 1 Wenckebach block. Wenckebach is pronounced WENK-ee-bock, which sounds really silly and is difficult to take seriously as a heart condition, but I guess that’s okay, because it’s not necessarily a serious heart condition, and Germans have funny names sometimes.

The two days I was beeping from the waist on the Holter monitor, minus the ten total hours required to be off-telemetry so the highly advanced cell-phone-cum-science-gadget could charge, resulted in the revelation that my heart skipped 3,842 beats during the other 38 hours. Which is considered “frequent” in a seemingly half-assed, three-sentence report of said monitoring.  The Wenckebach block is the reason for the dropped beats. It’s an electrical impulse disruption between the atria and the ventricles, in which the length of time in milliseconds between the electrical signal that contracts the atria and the one that contracts the ventricles gets progressively longer until it gets long enough that the whole heart skips a beat. Because it’s Type 1, it’s benign and generally, on its own, does not require treatment. If it were to be Type 2, they’d have to consider some options—pacemaker, etc.

It looks kind of like this on an ECG:

Wenckewonky.

Wenckewonky.

 

You’re looking at a series of waves, cleverly named P, Q, R, S and T. The P wave is the bump just before the spike. The Q wave is the lowest point just preceding the spike. The R wave is the tip of the spike. The S wave is the trailing low point of the spike. And the T wave is the bump right after the spike. A 2nd degree Type 1 Wenckebach block results in that flat line you see between the second T wave in the image and the next P wave. You see it happen again three beats later, on the right side of the image. That longer flat line is where the heart skips a beat entirely because the time between the P wave and the R wave (for some reason, the Q wave doesn’t matter to Wenckebach) got long enough that the heart said, “Eff it. Start over.”

This is where it gets fuzzy: This is not considered an arrhythmia. An arrhythmia happens when there’s a premature beat in either chamber of the heart, independent of the electrical signal conduction we’re talking about here. (It’s fuzzy because it’s still an irregularity and both of them are results of electricity within the heart, but different kinds of electrical conduction. MY thing is not considered “abnormal.” Even though it surely seems abnormal to drop 100 beats per hour on average and not even be a hip-hop star.) I have no actual arrhythmia. Apparently, that’s remarkable. I don’t know why, but the doctor said so. I win.

So, the block shows up on the ECG. Fine. The stress test is to see whether the block is consistent even when exertion makes my heart work faster and harder. Adrenaline naturally forces the heart to function more efficiently, so they were looking for correspondence. Excellent news: my heart does what it’s supposed to when I’m walking a stupidly significant incline at a rather good clip for 11 minutes.

Somewhat less excellent is that, after that, during what a normal person would call either a “cool-down” or a “Jesus, let me sit down for a minute,” and which cardiology types call “recovery,” they pulled me back over by my telemetry straps to the table, flopped me down all sweaty and heavy-breathing on it, and put their hands up my gown. It was the least awesome time that has ever happened.

This is when they do the second echo, to compare heart appearance and function under “stress” to the first, relaxed echo.

The echocardiogram revealed that, structurally, everything appears normal. This means it is not heart failure, cardiomyopathy or disease in the valves or arteries apparent in the ultrasound. Huzzah! Mac and cheese for everyone!

However, while I was lying there all schvitzy, the rhythms went wonky – I could feel and see on the monitor the way my heart tends to trip over itself, even when I’m not doing anything but sitting on my couch watching Orange Is the New Black. This essentially looked like the lines were trying to draw the Rocky Mountains instead of the usual rhythms. I have tried to find an image of this, but it’s tough to do a Google image search for “electrocardiogram that looks like Rocky Mountains.” To the best of my memory, it looked a lot like this highly technical medical thing I drew:

WTF wave

WTF wave

I got no explanation of what this Rocky Mountain Wonkiness was and, as strange as it sounds, couldn’t ask, because in those few moments, I wasn’t allowed to talk, and afterward, the doc who administered the test (different from the one I saw two weeks ago, because he was on hospital rounds) had another patient waiting and had already explained the block and the difference between the dropped beats and the arrhythmia and basically told me she had to go.

I did get to talk to my other doc the next day, and while he hadn’t seen everything at that point, I did manage to get him to look at the report and he said the Rockies were about the “P wave getting buried in the QRS complex.”

I hate it when that happens.

Basically, he’s a little surprised by the frequency of the dropped beats, and he says the fact that I drop them in recovery is “not quite normal.” Clearly, he doesn’t know me well yet, or he would realize that everyone knows I’m not quite normal. The upshot of these two surprises is that he and I will have a standing annual date to make sure things don’t get any more caddywompus. Because that’s possible, and then we’d have to discuss pacemakers or what-have-you.

Remember how half the reason I called the cardiologist with my hair on fire a month ago tomorrow was that I was swelling inexplicably? Yeah, we still don’t know what that’s about. But since my Lyme titer definitely, definitely says I may or may not have had Lyme Disease one time in the last 37 years, I might be able to pursue the 341 other possibilities for swelling with my general physician when I see her tomorrow to find out how many tests and dollars it will take to rule out the Lyme Disease thing.

So. Current diagnosis: Heart-wonk. Treatment: Eh. We’ll see. Recommendation: annual check-up. Follow up with general physician to find 27 other things that might or might not be a problem.

Ah, medical practice. Twenty-four hundred years after its beginnings, it still hasn’t made perfect.

 

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15 thoughts on “In Which You Maybe Learn Some Stuff About Hearts

  1. How aggressively this is pursued will probably be up to you. At least that’s been my experience. Patients who don’t question and insist get nowhere.

    • I’m pretty aggressive about health stuff when there’s health stuff to be aggressive about. Just back from the GP appointment. Six blood tests in my future: two for Lyme, four for anemia/kidney function/liver function/general blood counts. Then it’s back to the cardio guy for a summation and a couple more questions… after his vacation in New Hampshire. (Again: nothing alarming going on, so it can wait.)

  2. Well, that sounds like pretty good news, as news things go. At least you have some sort of diagnosis, which is better than being in the dark. And knowing is half the battle, right? Hopefully you will get some more answers to your many questions when those blood tests come back. But damn, science is such an imperfect art, no?

    • I do know some stuff. I’m waiting to know more stuff. When all the blood work comes back and they say, “We definitely did NOT accidentally find out you have lymphoma,” then I’ll be all set!

  3. Fascinating! Looks like the block happens pretty frequently; something is impeding the conduction system somewhere. Do you live anywhere near a medical school with a good reputation?
    mistyslaws, Science is not so imperfect, just subject to error. Medicine, however, is only half science and half art, and it certainly is quite imperfect. That’s partly because most of what’s wrong with us lies out of sight and is hard to evaluate, even with the sophisticated diagnostic tools at our disposal.

    • I like the academic angle of things, too, Joanne. Yes, I do live near a strong medical school, and my doc practices there. What intrigues me about the block is that it’s a function (or dysfunction) of the Vagus nerve. Now I’m curious to find correlating Vagus nerve interruptions, if any. How can it affect the electrical condition between atria and ventricles and not affect anything else?

      Because I need to look up medical science in my spare time.

  4. More fascinating! This is something I haven’t heard of. I have heard of vasovagal syncope, or fainting, in response to emotional distress (or dehydration). Are you drinking enough water? The Vagus (CNX, which stands for Cranial Nerve ten), otherwise known as “the wanderer,” carries parasympathetic fibers to the heart, among very many other organs in the thorax and abdomen. Its neurotransmitter is acetylcholine, which may be dampening signals from the pacemakers. Parasympathetic nervous stimulation (the rest-and-digest mode) is generally antagonistic to sympathetic nervous stimulation (norepinephrine, fight or flight mode); the latter increases heart rate.

    • I drink 64 oz of water a day, and have since I was a teenager. Nervous stimulation doesn’t cause any problems for me; my heart actually works better with norepinepherine/adrenaline. But what surprised the doc was that the vagus nerve and adrenaline don’t resolve as quickly as he thought they would in recovery. Hence the dropped beats right after the exercise.

  5. With panic attacks that pretend to be heart attacks or blanking out on my bike and crashing into a parked car, I’ve been through most of those tests. There was a time 30 years ago, I set the record for how long it took me to get my heart rate up to the target. These days, I can hit the target rate by looking at the treadmill (rimshot, please). After all the tests, by the way, they really haven’t a clue why I passed out. Possible heat stroke, they said. I also have a heart murmur, harmless but peculiar looking enough on and EKG that my cardiologist has me carry a copy of my EKG in my wallet in case so in case I end up in a hospital unconscious, they’ll know what’s normal for me.

    I’m glad you’re getting things looked at … it’s amazing how many people avoid the doctor because they are afraid of bad news. And while your heart isn’t normal, at least it sounds like things are stable. Hang in there and keep us informed … and laughing.

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