Atrium enlarged

Hi,  after visiting my doctor yesterday re pvc's we went over a test that was conducted a year ago which was an ultrasound of the heart.  Everything was classified as normal although noted that the left (I believe it was) atrium was slightly enlarged.  The doctor said nothing to worry about the normal number is 40 and mine was 43.    Is that significantly higher than the norm?  what is a number to worry about I guess would be the question.

[erijon]

You are within what is considered a normal variant. The actual numbers are as follows;

30 - 40 Normal
41 - 46 Mildly abnormal
47 - 52 Moderate abnormal
> 52    Severely abnormal

Also, an echo is not the most accurate way to measure the atrium. Remember, and echo is a single slice view of the atrium. Imagine a banana, if you cut it on a 90 degree angle it will look smaller than if you slice it at a 45 degree angle, this is the issue with echos and diagnosing atrial enlargement. Much depends on the angle of the slice and the axis of the heart. The best way is to measure atrial volume, but this is rarely done as an enlarged atrium is normally not a significant finding. The biggest issue is an increased risk for blood pooling in the atrium which can form a clot which may induce a stroke. When mine was diagnosed to be enlarged, my cardio said it may just be normal for me.

I hope this helps,

Jon

[erijon]

I should add that your doctor should work with you to find the underlying cause of the enlargement. It could be something as simple as high BP, but it should be dealt with. Once the underlying cause is resolved, the atrium can remodel itself back down to a normal size.

Jon

[kenkeith]

You haven't mentioned the PVC issue.  That could be an underlying cause..also the size of any chamber is not static because the intra chamber pressures change constantly.  You can probably safely apply a marginal error of 5-7% higher or lower. With the banana theory aside the measurement of any chamber is difficult because the shape of any of the 4 chambers are not spherical meaning from any fixed point the distance to other points is not equidistant. The margin of error will give a ballpark estimate.

I am providing a link that may help give you a perspective and yes a dilated left atrium could cause palpitations and PVCs. The treatment depends on the cause. It may be due to high blood pressure. Do you have high blood pressure?  If I understand, are the results of an echo you provide a year old, and you are having a heart rhythm issue currently?

http://www.medhelp.org/posts/Interventional-Cardiology/dilated-left-atrium/show/674947

Thanks for your question, and if you have any further questions or comments you are invited to respond.  Take care and I wish you well going forward.

Ken

[erijon]

You don't like the banana theory? Would it help if you knew it came from one of the MH docs here in a response to a question I asked? Here's their exact quote;

" You have to understand the limitations of echocardiography in assessing left atrial size: although they are telling you that it is dilated at 4.9 cm, and the upper limit of normal is 4 cm, it may actually not be dilated at all. This 4.9 cm was most likely obtained on a single 'slice' of the atrium and may not be representatitive of actual left atrial size. For instance if you slice a banana perpendicular to its long axis you may get a small value, but if you cut it at a 45 degreee angle you may get a larger value: simply because you were not perpendicular to its main axis. Often patients, especially patients who may have been heavier in the past ( you mention that you lost 60 pounds) does not have the standard  orientation in the chest and may be rotated to the left, causing the standard echocqardiographic views to be off axis and the consequent innacuracies in measurements. The most accurate way to measure the left atrial size is to report atrial volumes,  but this is difficult to assess in most patients, and in general has very little prognostic value in most patients. The exception are patient with atrial fibrillation whose likelyhood of responding to treatment depends on the left atrial size."

Hope this clears up the banana theory for you Ken :)

[foxkat]

Thank you very much all for your comments.   I have been taking metropolol 25 mg morning, 25 mg evening for about six years now to treat pvc's.  These pvc's went away up until a few weeks ago.   My BP is excellent 118/120 over 78/80 most times.  Last night was terrible, the pvc's only start around 7pm.  I was having one every 2-3 beats for about an hour.  I was petrified so I went to bed.  The only thing that has changed for me was going south in April taking Advil for a sore ear for 7 day straight (about 5 per day).  I normally do not take Advil.  When I got home I had severe stomach issues which they diagnosed as gastritis.  Prescribed stomach pill.    My GP says the stomach issue could trigger the pvc's.   He also has me on a list for a holter monitor.   I am scared to death which I am sure doesnt help things..  

[curmudgen]

First off  benign PVC's will not kill you even though they feel like they will.  Yes, stomach irritation can trigger PVC's as well as anxiety. My doc put me on OTC Prilosec for 14 days and that helped me.   metoprolol really doesn't treat PVC's.  See if you can get an event recorder...since your PVC's are intermittent...this allows you to record the PVC's when you feel them.
I get my PVC's mid-day (not every day) and they can last for minutes or hours...the ones that occur every other beat are the worst for me.  Relax, easy to say, and avoid NSAIDs.

[kenkeith]

I understand the point made, my explanation considers the chamber's geometry and the inherent difficulties to determine the area of an irregular shaped heart chamber. . Your banana illustration is an explanation from a technical perspective...its not wrong, but a shape of a heart chamber is not shaped as a banana and the two comments from a different perspective compliments not distract. Due to an irregular shaped chamber volume would be the better calculation to determine the area measurement rather than a metric...obviously.that is true as that would account fior any geometric irregularity (needless to say).

Foxkat, from my understanding sourced from a professional, Metoprolol is usually the first medication prescribed for PVCs, but some people that have frequent PVCs and  find them very bothersome cannot tolerate beta blockers.  For relief, one can also try an anti-arrythmic medication called propafenone (Rhythmol). This is only prescribed in someone with no history of coronary disease and a structurally normal heart. Your blood pressure is very good

You and your doctor may have to try different medication and dosage to find what is best for you.  Curmudgen offers some insight that may be helpful for you. I wish you well going forward.

Ken

[erijon]

Actually, Rythmol is not prescribe very often as it causes more rhythm issues in about 50% of the cases. It is usually only used for severe cases of A-Fib. I too can have runs of bigemey and trigeminy for an hour or two, it is very annoying but as stated above they will not kill you, but they area bother.

From; By Richard N. Fogoros, M.D., About.com Guide
Updated September 25, 2007


"Unfortunately, we don’t have antiarrhythmic drugs that fill these criteria. Most antiarrhythmic drugs are relatively poor at treating PVCs (though they often reduce their frequency.) And, all antiarrhythmic drugs can make dangerous arrhythmias more likely. In addition, each of these drugs has its own unique toxicity profile – some more ominous than others – that render these drugs, as a group, among the most toxic used in medicine.

Thus, both doctors and patients should always be very reluctant to treat PVCs with antiarrhythmic drugs."

The best way to control PVC's is by eliminating the triggers such as caffeine and stress. Beta Blockers only slow the heart rate down making the PVC's less noticeable but they do not stop them. They are a pain, I know personally, wish I had a sure fire way to help you get rid of them, I could be wealthy.

Good Luck,

Jon

[ed34]

Interesting point you made about the sliced banana, I can see how this would give an inaccurate measurement. Heres a picture, the one at the bottom with the LA traced, and you can see that the image has to be face on. If tilted in any way, the image will greatly distort the LA internal dimensions/volume. Good point.

https://www.stanford.edu/group/ccm_echocardio/cgi-bin/mediawiki/index.php/Left_atrium_dimensions

[kenkeith]

Good link: Sliced banana comment refers to imaging (I think?) and is not reliable because the atrium is not symmetrical meaning a fixed point (center of LA) is not equidistant for all lines to the outer perimeter...definition of irregularily shaped quadrants of the atrium.

LA size is measured at the end-systole, when the LA chamber is at its greatest dimension and usually that is the only measurement on a report....that is consistant with all echo reports that I have read.

Or the Simpson’s rule, similar to its application for LV measurements, which states that the volume of a geometric figure can be calculated from the sum of the volumes of smaller figures of similar shape. (not clear to me?)    

I believe the following refers to imaging with MRI or CT scan: "LA minor and major axis in apical 4 chamber view..You have to get a good apical 4 chamber view, with complete visualization of the atria, mitral and tricuspid valve, and both ventricles.

This method is not recommended, measurement of LA area and volumes are preferred".

My thought regarding LA measurement was to calculate the difference of volume before and after filling (EF).  Or fraction shortenting (FS) the measurement of dimension size before and after filling the same as ventricles. That would provide the dimension of the area with a margin of error of 5 to 7%.

I agree, Erijon is correct to say the sliced banana analogy would give an inaccurate measurement...2D or 3D echo is the perferred procedure.


  

[is_something_wrong]

Hi Ken!

What Jon means is just a picture, it doesn't have to be a banana, but it's a good description because the banana has peel and a soft core, which may be compared to the heart during M-mode echocardiography.

To do some math:
Say your heart has the following dimensions, when the probe is held towards the heart in a 90 degree angle towards the heart:
LVPWd: 1,0 cm
LVISd: 1,0 cm
LVIDd: 5,0 cm
(which is a fairly normal result)

In that case, your RWT would be 0,4 (normal), your LV mass would be 161g, also normal. Result: Normal LV geometry and no hypertrophy.

Say, the cardiologist hold the probe at a 45 degree angle (to use a drastic example).
According to the Pythagorean theorem, the results would be:

LVPWd: root(1^2 + 1^2) = 1,41 cm
LVISd: root(1^2 + 1^2) = 1,41 cm
LVIDd: root(5^2 + 5^2) = 7,07 cm

RWT would still be 0,4 but LV mass would be 454 g, in other words SEVERE hypertrophy and dilation.

This is just a calculated example, but it illustrates what happens if the cardiologist holds the probe wrong, or the heart is positioned otherwise than normal in the chest.

[foxkat]

Thanks again.   The doctor has given me Tecta to try to see if indeed an irritated stomach is the result of pvc's.  He has ordered a holter monitor but will be nine or so weeks.   Just to add I drink decaf coffee, do not smoke or consume alchol.   I eat very healthy so a couple of things going for me.  Other points that keep me thinking positive is when I walk at a very fast past or slight run there are no pvc's,  all day at work no pvc's.  The ones that come every 3-4 beats (last night) for a couple of hours scare the daylights out of me.    I might add I am a little more tired at night (earlier) which I would assume is to the extra beatings.  Your thoughts ....

[ed34]

"(not clear to me?)"

Isn't this the method usually used with odd geometric shapes? You basically fill it with tiny squares of a known size and count them. It is obviously an estimate, but not far off the correct answer. I'm not sure why you would do this if the outline is not far off being a square or rectangle.

[kenkeith]

Thanks for the response. That makes sense...small dots (pixels), whatever, can fill an odd shaped space and then count the dots. :)  There may some utility for this method as the filling of the LA chamber involves an E/A ratio and a volume measurement at a specific time can distinquish between the early filling phase from the later filling phase and analyze for some obscure reason??...possibly for restrictive cardiomyopathy...just speculation that would be the use.  From my understanding the E phase represents about 80% of the filling capacity, etc. Reverse of the E/A ratio would indicate restrictive cardiomyopathy.

Foxkat, on another board there was a thread where the same phenomonon was discussed.  Exercise reduced the individual's PVC's, and it was speculated the the heart was so tired it didn't produce PVC's later. So that may work for you!  Hope you can find some relief as it can be very troublesome.  Take care,

Ken