VTs -- which causes/symptoms do you treat?

[Tigger716]

Hi Doctor,

I’ve written to you a few times over the past few months, and I appreciate your calm, thoughtful responses.  So now that I have a little more information, I’d like to put my case to you again.

I've been taking lithium since 1993.  Last spring, my primary care physician discovered that I was hypothyroid.  He prescribed Synthroid.  A few months later, my psychiatrist ordered a routine electrocardiogram, which revealed some PVCs.  I'd never had these before, so I consulted a cardiologist.  He ordered an echocardiogram, a Holter monitor, and a stress test.  The stress test picked up some benign ventricular tachycardias.  Now the cardiologist is thinking, possibly, of performing a catheter ablation on my heart.  But he’s convinced there’s no present danger, so he’s in no hurry about this.

My response is “Whoa!”  Wouldn’t it be easier just to adjust or switch the lithium and/or levothyroxine treatments so that we avoid the preconditions for symptomatic VTs?  Of course, that chain of cause, effect, and treatment is just my guess.  What I'd really like is for the cardiologist, the internist, and the psychiatrist to have a 15-minute conference call to straighten this all out!

Thanks.

[Michael J. McWilliams, M.D.]

Do you notice the VT?  If you have a structurally normal heart (echo, ekg, stress test) and asymptomatic non sustained VT, the treatment is beta blocker and sometimes no treatment at all.  If you have sustained VT (by definition, this means long runs of VT usually greater than 30 seconds), a VT ablation might be a reasonable option.  

Seeing the VT and knowing the possible locations would is very important in making these decisions.  Right ventricular outflow tract VT is easily accessible, left ventricular VT is a more complex procedure.

I think the most important point is do you have symptoms and is it dangerous.  If you have a structurally normal heart, it is not dangerous.  If it is infrequent and does not causes symptoms, medical management is a good approach.

Believe it or not, a conference would not solve much. If I did not think this was a dangerous VT, I would not stop the lithium or the synthroid.  If I thought the VT was dangerous, I would recommend stopping the lithium and trying a different drug.  The conference wouldn't change the way I viewed the VT problem.  I do agree that communicating the recommendations is very important and I will call the doctors to discuss treatment plans when appropriate, otherwise, letters are the usual way to communicate (emails if you are in a group or academic practice).

I would consider a second opinion before proceeding with an ablation.

I hope this helps. Thanks for posting.