Debating EP Study

Hello,

I have an EP study scheduled for Friday, but I've been thinking about cancelling quite simply because I'm feeling good.

The reason for the EP study is as follows. My two day holter picked up:

1) 185 bpm SVT while exercising. This happened when I was riding my bike at full speed (equivalent to a full on sprint), so I kind of expected the rate to be this high. I didn't have any symptoms as this was happening. I didn't even realize that anything was wrong because I just kept riding.

2) 7 beat NSVT while sleeping. Heart rate was 65, looked perfectly normal, then bam 7 beats of v-tach at 125 bpm. This was followed by a brief return to normal rhythm, then another 3 beats of v-tach. I was asleep during this so I didn't notice any symptoms.

Now obviously #2 concerns me. I've had low pottasium in the past (2.9) but I have since increased it to the 3.5-3.6 range. Still on the low side, but within range.

My heart is structurally normal according to an echo. My EP said that the v-tach could've been caused by a pottasium deficiency, even though bloodwork around the time said that I was within range (albeit borderline). He also said it was unlikely that he'd be able to reproduce it, but he would at least try.

As for #1, If I really did have SVT during exercise as the holter suggests, then I'm thinking that maybe I had it my whole life and just didn't realize it. Is this really a concern and is this really EP study worthy? I certainly don't want to be afraid to exercise.

I since continued to drink more OJ and eat more bananas, especially before falling asleep at night. I feel like I've been returning to normal, and haven't had any major racing heart episodes for over a month now. It's been a few months since the holter and I've had another one since, which didn't show any v-tach but it did show 120-130 bpm at one point when I was simply walking around a store.

Should I still go through with the EP study? My EP said that it was a "no brainer" and my primary care doctor tends to agree. But then again my EP also said that he would mainly be doing it for the SVT which again was asymptomatic. So should I really care about that? I'm more concerned about the v-tach returning.

What do you guys think? I appreciate any input. Thanks!

[michellepetkus]

Doing an EP study and ablation is a big decision.  The procedure itself is quite expensive though that shouldn't be a reason not to do it but expect to pay your full out of pocket for the year to do it.  Mine was $4,000.  Did your doctor say what type of svt you had?  I had an svt called avnrt and you would not mistake this for simple sinus tachycardia even at rates of 180 which I have gotten up to.  My type of svt would start and stop on a dime and reach rates in the 200s.  Now I have heard that WPW might present at a lower rate and they can sometimes tell the difference based on how the heart beat looks on the monitor.  It might be worth doing the ablation if they are leaning towards wpw or afib because those carry a higher risk to the patient then my avnrt did.  I also agree it is very unlikely your EP will be able to invoke any vt but I might ask the doctor what type of svt he really thinks you have before agreeing to do the ablation.  Though is isn't really all that big a deal while going through it, you can click on my name and read my journal entry to learn about it.  I was terrified to do it but once said and done it really was a piece of cake.  That said, if you aren't frequent it might be hard to even induce the svt.  And the revving up of the heart they do to try and invoke the arrhythmias can aggravate the heart which may take a few months to settle down.  So I can really see your hesitation.  That said, 2 doctors gave you a recommendation to do it so that should hold some weight but ultimately it is your body and if you are not in any real physical danger from your svt then it really is an elective procedure.  The best advice I can give you is to listen to your gut.  One choice will feel like the better choice than the other.  For me one may feel more calm or the other might make me feel a little more agitated and so I go for the choice that gives me the most peace.  Even though I was really initially terrified to do the ablation I had an underlying sense of calm and peace that it was the right choice for me but I was having almost weekly episodes that were starting to last hours so my health may have been compromised down the road if I didn't do anything.  As for you, you aren't even sure you have a true svt so I would try to really meditate so to speak on your 2 choices and opt for the one that gives you the most sense of well being.  But definitely call the doctor to try and find out what type they think you have.  Take care.  I wish you the best of luck whatever you decide to do and do keep us posted.

[Stay_Frosty]

Thank you Michelle. That helps a lot.

I actually ended up cancelling my appointment since I've been pretty normal and you wouldn't believe that today, the day my appointment was supposed to be, my heart started acting up again. If that's not a sign I don't know what is. So I rescheduled and now I feel stupid for cancelling in the first place.

I can't live my life getting these random tachycardias worrying that it could be VT. I also get these nasty feelings in my chest that kind of travel up my throat/neck. It's quick, over within 1-2 seconds. Maybe it's a PVC? I've been told I get those occasionally, but I never knew what they actually feel like.

[Jerry_NJ]

As your EP said, he may not be able to stimulate during the EP study.  I have never had one, but I'll comment anyway.  

First I do not argue with anything Michelle told you, in fact I didn't read it carefully as I wanted to comment just on the 185 HR during exercise.  I can say I used to run up to 165 when running and that was when I was in my late 50s, so if you are in physical condition I'd say 185 isn't too high if you are able to handle... I always considered my ability to breath hard enough more important that my HR.  One test was can I still say a simple sentence without gasping for air.

I'm now on Medicare, so my biggest concern is finding a great doctor who will work for those low wages.  As for my private coverage it has something like a $2K out of pocket before it starts to pay 80%, and a $5K before it pays in full - again assuming in-network.  For us old folks that is Medicare rates, which are way down even compared with the large private insurance in-network rates.  Sorry for the distraction, I also felt a need to add comments on the cost subject too.  Where this all goes in the future is anyone's guess... I doubt that it will be better.  I had no idea a EP study was $4K, that may be the "list price" or "rack rate" : )

[Marz1808]

I'm only 16 years old, I had an ep study done which at the time I felt was unnecessary as id only collapsed and thought it was a once off. I was so wrong, turned out the abolition saved my life as I had a severe case of WPW, my advice would be to go ahead with the ep study it could be worth the two or three days of discomfort.

[Stay_Frosty]

Well, my procedure is scheduled for Monday but I'm having second thoughts after reading various posts on this board. It seems like a lot of people with NSVT in structurally normal hearts have doctors that tell them not to worry unless it becomes frequent. In my case, I only have one documented case of it.

Now I know that I was feeling PVCs the last time that I made a post here, and that's very unusual for me. There have also been some times where I have woken up in the middle of the night in an absolute panic, as if my heart had stopped. And during these panics I could sometimes feel PVCs (which makes me think that maybe it's NSVT that wakes me up). All I know is that once I wake up I seem to return to normal fairly quickly.

I'm not so sure why my doctors are so quick to rush me to an EP study based on a single recording while other recordings have shown no such thing.

My main problem over the past few months has been chest pain. I get some really nasty jolts in the sternum area. Sometimes it's obvious that it's non-cardiac. Like I can push on my sternum during the pain and make it worse. Other times I feel I get deeper pain, like heart spasms. And other times I get lightning bolt through the chest sensations. Some pains have been so severe that they force me to stand up and panic, because I think my aorta is about to erupt or something. But the pains are always over within a few seconds. Other days I have a lingering "funniness" underneath my sternum. It's like a light clamp around my heart or esophagus or something. It feels like something is in there that doesn't belong. This is especially prevalent when I get up from my chair and  start walking around. One idea I had was hiatal hernia. So that might be my next investigation.

That's been my life for the past 6 months or so. It's been terrible, and I still get some nasty sensations and funniness in my chest at times. I haven't been able to correlate any of the pains with physical activity, and none of my doctors even want to consider a blockage because of my age and lack of risk factors.

All of this hit me at the same time so I feel it's all related. For example, I never had (or at least never felt) PVCs or NSVT or any kind of arrhythmia at all in the past. I never had nasty chest holts and pains on a daily basis. 27 years of my life my heart was perfect then all of a sudden I turn 28 and I have all of these chest symptoms? It's just so bizarre and none of my doctors seem to be able to help.

But going back to my original debate, I'm not so sure if I should continue with the EP study because in terms of rhythm, I feel I've been pretty normal for the past couple of months. And from reading this board, it seems that everyone who goes to an EP for NSVT is unable to have it induced during the study. So what's the point? Especially in my case since NSVT seems to be a rarity.

Appreciate any thoughts. My EP is going to kill me if I cancel again. :(

[DeltaDawn23]

You need to be at peace about this.  Find a doctor you trust and turn it over to him or her.  Sounds like 2 doctors have said you need the study.  Third opinion?  Good luck whatever you decide.

[tom_h]

While I'm a proponent of the ablation procedure, I don't believe a single event warrants it. If you're still not sure why your physicians are rushing you into this, consider what they stand to gain monetarily.  They'll be compensated whether or not your SVT can be provoked.  I'm actually surprised your insurance company has approved the procedure.

[michellepetkus]

I am with DeltaDawn, you need to be confident this is the right thing for you.  I would say the jolts and odd things you are feeling are pvcs.  The fact that they hurt means your heart is a bit irritated at this time for some reason maybe partly due to stressing about what is going on.  Or possiblyu because of some svt.  My heart was getting fairly irritated from my svt episodes before my ablation to the point I felt pain of some sort in my heart everyday.  Now that I am out of the svt for a year and a half the pvcs I do feel do not have the pain associated with them so it is possible some svt is irritating the heart causing your pain or since you state you could press the area and feel pain it is possible you strained something at some point and that is why the pvcs are hurting.  However as uncomfortable as they are they are not a threat.  I would say do your best to give your heart as much rest as possible to see if that helps the pvcs hurt less.  Are you sure they are even intending to do an ablation for the vt because a seven beat run that converts on its own that isn't causing you serious symptoms like passing out isn't necessarily a reason for an ablation so I might question what it is they plan to try and ablate.  As for doing the ablation follow your gut and you can't go wrong.  I wish you the best whatever you decide to do.

[littlegreenman1]

Here's the overall mantra for all things...

It's not a problem, until it's a problem.

If the SVT doesn't bother you... don't get it ablated. 7 beats of SVT == BFD.
If you find yourself having troubles with it... fix it.

[DeltaDawn23]

I just recalled when I had a stress test that showed a short, non-sustained run of VT, no one suggested an ablation to me.  This was after my first episode of Afib when they were running tests to see if there was an underlying problem.  I did, however, end up having a heart cath to rule blockages.  This was in 2003.  I was told they probably would not do that today. Hoping maybe some of this will be useful to you.  

[Stay_Frosty]

I cancelled for two reasons.

1) Still have that doubt and will definitely be seeking a second opinion ASAP.

2) I live with my nephew and he brought home a stomach virus from school. He was up all last night throwing up :( I'm not going to take the risk of having to throw up while I'm on the table or during recovery when I have to lay still.

My EP probably hates me at this point. But I need to get more opinions for peace of mind.

You guys are awesome, thanks so much for the input!

[littlegreenman1]

Who's opinion do you need beyond your own?

[DeltaDawn23]

Don't worry about the EP.  It is his job to take care of your mind as well as your body.  If you are not mentally ready for this, it is okay to change your mind.  Your body, your money, you live with the outcome.  Keep us posted.

[itdood]

I didn't read the whole thread so I may have missed it.  What type of SVT was it?  SVT encompasses many types of tachycardia originating in the top part of the heart including ones that are completely appropriate, like when we exercise.  I'd be looking for some type of reentry issue.  

On the NSVT, the key is finding out where it originated from (within the ventricles).  Certain origins are known to be less benign than others.  For instance, NSVT originating in the right ventricular outflow tract (RVOT) is generally considered benign and very ablatable.  There's another type of NSVT that originate in the bottom of the left ventricle that can be more troublesome and is usually addressed.  NSVT is also evaluated in the context in which it occurs.  For instance, exercise NSVT throws a red flag.

So to evaluate the episode of NSVT further consider its origin and context.  The EP might be able to tell the general area the NSVT originated from by the holter strip.  I get a high load of PVCs sometimes, and they 100% originate in the RVOT for me...

[Stay_Frosty]

I never actually found out what kind of SVT it was. I'll ask my cardiologist next time I see him.

The interesting thing is that the holter software reported "No SVT detected" and yet my doc says that the 185 bpm while riding my bike was SVT. Could he or the holter be mistaken? I feel that when I go full sprint I can always get myself up to that rate, so does that mean I'm having SVT every time and just don't realize it? I certainly don't become sustained @ 185. Once I stop my heart rate starts slowing as it should.

My second holter report did actually report some SVT, but only 7.2 seconds out of two days, and when I was sleeping no less! There was also a time when I was out shopping and it showed my heart rate between 108 and 126 for the hour - just walking around the store. It didn't say that it was SVT though, just tachy. I wonder again - Can that be SVT and the holter software just isn't catching it? Or do I just have IST at times?

[itdood]

SVT is a bucket term, what is causing the SVT is what should be discussed.  Your 185 was being caused by exercise, so that's normal.  The 108-126 while walking around is normal and healthy!

[tom_h]

I agree. The rates you note are quite normal for the activities you mention.  On a treadmill test just before my ablation, I started throwing salvos of SVT that were almost the same rate as my sinus pulse at the time, 195 bpm.

[Stay_Frosty]

Just as an update, I went to a new cardiologist, because my current one thinks that MRI's have radiation. After I requested a cardiac MRI, he said "you don't want all that radiation". I wish I was joking.

New cardiologist seems a lot smarter. He immediately ordered me a cardiac MRI and an echo stress test.

I also showed him my holter results and he looked at the 185 bpm that I had during the bike ride. I told him that my other cardiologist (and the EP) said that it was SVT. He looked at me wide eyed and said "you were riding a bike!" as if the holter recording was completely normal. He also mentioned that it was too quick to even tell if it was SVT. And I tend to agree with him because 1) the holter software said no SVT detected 2) I had no symptoms at all and 3) The holter shows my heart slowing down once I slowed down with the pedaling. So that made me very happy.

My second holter did detect some SVT, in which the software clearly labeled it SVT. A very minimal 7 or so seconds of SVT out of 48 hours. And it all occurred as I was sleeping.

I'm glad that I'm getting more tests. I still think that something serious is going on in terms of chest pain at times, like maybe a brief coronary spasm or something. I just hope it's not clogged arteries at age 28. That would suck.

Thanks again for the support. You guys are the best!

[itdood]

"you don't want all that radiation"  just wow  :(

2nd doc is on the ball.  Like I mentioned above, SVT us a very broad term, it can mean all sorts of stuff including exercise, which is a completely normal response.

[Stay_Frosty]

Does $1,234 sound right for EP study pre-testing? All they did was an EKG and take some blood. Just got the bill today. My jaw dropped.

[tom_h]

Yup, that sounds about right.  Your EP study with ablation will probably run from $75K to $100K, perhaps more.

[tom_h]

I re-read the thread.  So you're going for it?  When's the date?

[wmac]

I have had three ep studies.. Not one of them cost 75k-100k! The average price was aroundt 20,000.00 then of course my insurance has their allowable price.. I also feel your first doctor was very quick to jump to an ep study. I wore monitor after monitor from 2002-2005 before they ever decided to do the study. I have nsvt, svt, pacs, pvcs. They never were able to induce my nsvt nor my svt. I even had a loop recorder implanted in me for 10 months. Medication made my nsvt worse. Dont be afraid of the ep study there could be complications as with everything but I would do it again if there was a chance I could be fixed.. Good luck keep us posted.

[tom_h]

Here's a breakdown of my charges; over $76,000 in 2010.  I've seen others on here with charges over $100,000.  I'm not pulling these figures out of the air!  These are documented posts from other members.

http://www.medhelp.org/user_journals/show/257573/Post-Ablation-Observations

[Stay_Frosty]

I'm not having the EP study. The bill is from the pre-testing that they did a few days before the study was scheduled. I then went ahead and cancelled the study after I had already went through pre-testing. Bad timing on my part.

I'm done with my stress echo and cardiac MRI. Stress echo was unremarkable. My doctor mentioned mild MVP but just shrugged it off saying that it's nothing to worry about. Had the cardiac MRI yesterday so I'm still waiting for results on that. Going to call my doc today.

I had another blood test which showed my potassium at 3.7. I was hoping for better than that considering I've been proactive in making sure to eat potassium rich foods. I think I'm going to start the supplements that my doctor prescribed. My Vitamin D was also really low at 16. So I need to start supplementing that. Otherwise everything looks normal.

[tom_h]

Good!  Keep an eye on it to gauge if your episodes increase.  I hope the supplements work for you.

[littlegreenman1]

My ablation was in the $65-85,000 range.
This is part of the rationale behind my previous comments of "it's not a problem, until it's a problem."

If you have standard (USA style) Deductible + 80/20 type in surance, then you will pay the Max OUT OF POCKET for an ablation. If you have HMO and it's $250 Outpatient co-pay, I think you are morally obligated to objective about your spending impact to your peers.

So back to a case of: "I get SVT twice a year for 30 seconds..." Live with it and die of old age.

$1200 for an EKG and blood. Yep. I'd suppose there is a negotiated discount in there too. (my $65k was AFTER discounts - it was  ~$100K before).

[DeltaDawn23]

WOW!!!  

[wmac]

That is absoultly crazy!!! Where did you go for your EP study? None of mine were that much!! Ha maybe thats why im not fixed yet! I went to the University Of Utah twice and the Utah heart clinic the third time. My last study was in 2011 my total out of my own pocket was around 2,000.00

[tom_h]

I had mine done at UMass Medical Center in Worcester, MA.

[wmac]

tom_h, did you get an ablation during your ep study? Also are you fixed now?

[michellepetkus]

I had mine done in the Chicago area and it cost a total of $50,000 though my out of pocket was only $4,000.  I set it high so I did not have to pay as high premiums monthly since I pay for my insurance on my own.  So the fact you paid $2,000 only means that is what you paid not what your insurance paid.  it is likely your insurance paid somewhere around the $50,000 at least.  Accessory pathway ablations are a little cheaper than afib ablations which run $75,000 - 100,000.  Though your area may be a little less expensive than a big city it is very highly likely your actual ablation costs exceeded $2,000.  That was likely just your contribution unless they gave you the ablations probono.  But out of pocket was established to keep people from going broke from medical care but it does not mean that is all that was paid out for your care during a one year period.  The sad part is the rest of the world is probably in line with the $2,000-3,000 mark.  We are crazy off course in the states when it comes to medical care.