"Normal" Ejection fraction rate?

Hello:  
I’m a healthy 55-year-old male who until last week had never been hospitalized. I’m 6’ 2” tall and weigh 195lbs and I walk five miles per day. My heart rate is about 50 beats per minute at rest. (Probably due to the fact that I ran 50 miles per week for 18 years. I blew my knee out four years ago and now I just walk.) Last week, about 1:30 A.M. I struggled to get out of bed (sciatic nerve pain in lower back was excruciating that evening) in order to urinate. While urinating I experienced dizziness, blurred vision, and broke out in a cold sweat.

Two minutes later I was fine (except for the sciatica) but my wife insisted I go to the ER. I was there for five hours and all tests (including EKG) showed nothing amiss. The ER doctor diagnosed my episode as a “meticulous syncope” and advised me to see my family physician. The next day I saw my doctor and he ordered: 1) Doppler of carotid artery; 2) Echocardiogram; 3) and the wearing of a holter monitor for 24 hours.

The 24 holter EKG recorded one instance (during my sleep) in which my heart rate dropped to 24 beats per minute. Other than that there were no other abnormalities. The echocardiogram revealed an ejection fraction rate of 50.

Two questions: I’ve read that a pacemaker is not the proper treatment in my case (since there was only the one incident and it happened during sleep). Is this correct? If so, what treatment is suitable? Also, my family doctor’s nurse told me that an EF of 50 is “abnormal.” However, subsequent to being told that, I was informed by a cardiac nurse that an EF of 50 is normal, especially for someone my age. Which nurse is correct?

[Michael J. McWilliams, M.D.]

I’ve read that a pacemaker is not the proper treatment in my case (since there was only the one incident and it happened during sleep). Is this correct?

When a patient stands up in the middle of the night to urinate (standing) and has syncope or near syncope, it is almost always micturation syncope (syncope from increased vagal tone from urination) or orthostatic hypotension (low blood pressure from standing to quickly).  In this setting with those test, I would not even consider a pacemaker in one of my patients.


If so, what treatment is suitable?

Unless there is something that i am missing, I would tell you to stand up more slowly and considering sitting down to urinate at night.  This is a very common cause of syncope in healthy people.

Also, my family doctor’s nurse told me that an EF of 50 is “abnormal.” However, subsequent to being told that, I was informed by a cardiac nurse that an EF of 50 is normal, especially for someone my age. Which nurse is correct?

An EF of 50% is technically "abnormal" but remember that these studies have a +/- 5% error margin so it could be 55%.  Reading an echo on a normal healthy adult (especially one in good condition) can be very difficult.  I have read many echo's for similar patients where the EF is what I thought was low normal (around 50%).  I look at the big picture and consider that is generally a normal finding in this situation.  I would consider re evaluating your heart function in a year or so to make sure that it is stable.


I hope this helps.

[Regmac]

Dr. McWilliams:

Thanks for your quick reply. But what about the fact that my 24 hour EKG Holter Monitor recorded one instance in my sleep when my heart rate dropped to 24 beats per minute? Should that fact be of concern to me? Could this have been a false reading?