[NP-Clinical] Incidental asymptomatic cardiac finding

[Andy Craig]

I'd be cautious about teaching the patient to do carotid sinus massage on
themselves, lest they code.  Consider that if the underlying rhythm is slow,
then those might not be "PVCs"--they might be ventricular escape beats.  The
sinus node is supposed to be the primary pacemaker and it fires at 60-100
bpm; the AV node is the second line pacemaker (i.e. it takes over if the SA
node fails or is too slow) and it's supposed to fire at 40-60 bpm; if all
that fails, the ventricles will kick in themselves (i.e. "idioventricular
rhythm") with an intrinsic rate of 20-40 bpm.  So if the heart is beating
slow enough that the ventricles decide to kick in a little extra help, and
then you try to shut all that down with carotid sinus massage or lidocaine,
then what you may do is get rid of the underlying rhythm, which will leave
you with---idioventricular rhythm at 20-40 bpm.  Or you might shut
everything down and go into Vfib or asystole.  That's why in ACLS they teach
to treat (symptomatic) bradycardic PVCs with atropine, not lidocaine.
 
I throw these every now and then because my underlying rhythm is 40-50 bpm
since I went back in the service and started running regularly.  The slowest
it's been is 38, and I typically go into junctional bradycardia when that
happens.  I had a stress echo and did fine; my cardiologist told me to drink
plenty of caffeine (I had been trying to wean off when all this happened
last year), and he reassured me that as I get "older and more decrepit", the
vagal tone will decrease and my rate will speed back up on it's own.  
 
If it's asymptomatic, I'd leave it alone.  Don't fix it if it ain't broke!
I agree with having the cardiologist take a look at her, but if she's not
having a problem I'd wait and see what cards has to say before giving her
stuff to do about it.
 
Andy Craig, NP
Charlotte, NC

-----Original Message-----
From: np-clinical-bounces at nurse.net [mailto:np-clinical-bounces at nurse.net]
On Behalf Of Priscilla Merrill
Sent: Sunday, January 14, 2007 6:07 AM
To: 'NP Clinical'
Subject: RE: [NP-Clinical] Incidental asymptomatic cardiac finding



Thanks, Mary.  This was very helpful and reassuring.  Her Lyme was neg and
TSH 2.1. CMP was noncontributory.  I'm seeing her for fu this week.  Her
Holter showed what you described below, many PVC's but none regularly and a
few runs of bigemini and trigemini.  I'm having her see cardio to CYA as I'd
bet they'd do an echo?  I think she'll be just fine.  I'll tell her about
the carotid massage.  Is that better than Valsalva?

 

Priscilla Merrill FNP

 


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From: np-clinical-bounces at nurse.net [mailto:np-clinical-bounces at nurse.net]
On Behalf Of mary.beck
Sent: Saturday, January 13, 2007 9:55 PM
To: NP Clinical
Subject: Re: [NP-Clinical] Incidental asymptomatic cardiac finding

 

Hi Priscilla,

  I am a healthy 48 year old who has almost daily episodes of bigeminy. I
first noted this years ago when I was working in ICU. One day as I felt
palpitations I hooked myself up to a cardiac monitor and saw bigeminal PVCs
on the screen with a palpable pulse in the 50s-60s. I still have PVCs almost
daily. I can convert myself to a regular sinus rhythm by a 10 second carotid
massage. Might be related to an extra cup of coffee each day, but not
always. No other symptoms. 

 

  I saw a well 60 year old woman for a physical the other day and she had an
irregular pulse. EKG showed multiformed PVCs, as many as 10/minute. Good BP,
asymptomatic. Chem panel, TSH, CBC normal. My collaboarating doc thought no
further w/u needed.

 

Just a few more irritable ventricles to ease your mind.

 

Mary Beck, NP

 

 

----- Original Message ----- 

From: Priscilla Merrill <mailto:prispunnyfnp at metrocast.net>  

To: 'NP  <mailto:np-clinical at nurse.net> Clinical' 

Sent: Saturday, January 06, 2007 4:49 PM

Subject: [NP-Clinical] Incidental asymptomatic cardiac finding

 

One of my 10 minute "quick sicks" this week was a 30ish healthy woman
presenting w/ c/o sinusitis.  No cardiac hx.  She admitted to some usual
fatigue attributed to her sinusitis.  No cardiac sx's.  When I was checking
her HR while listening to her lungs, I was amazed at the pauses.  I got a
routine EKG with her permission and she was in trigeminy.  No hx Lyme or
anything at all.  You might say my heart skipped a beat!

I scheduled her with a Holter and cardiac consult but wondered if any of
your cardiac gurus had run into this before?  Totally asymptomatic
trigeminy.  I got a lab panel including Lyme and TSH, CBC and CMP.  My
colleague FP doc felt this was enough workup where asymptomatic but thought
she should see cardiac where insured.  Normal weight and past lipids ,etc.

Thanks for any thoughts.

Priscilla Merrill FNP

 

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