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Undiagnosed hear enlargement
I recently got diagnosed with a midly enlarged heart. I'm 35, male, non-smoker, drink moderately, exercise regularly, eat healthily. I had gone to the doctor to complain of back pain between my shoulder blades and he suggested it didn't sound like my heart but out of due diligence I should have a stress echo done. The exercise part of the test was fine - normal response to exercise, as expected because I cycle, had been lifting weights and used to do a lot of kickboxing. The backpain subsequently disappeared after a couple of manipulations by the chiropractor.
It was the resting echo part of the test that suggested the enlargement of the left ventricle, The LV is about 6.3cm when relaxed. It said that systolic function was preserved despite enlargement with the ejection fraction at 55%..
When I saw my GP after the tests he suggested I consult the cardilogist that wrote the reports. The cardiologist saw me within the week and suggested the size was around the upper limits of normal for my height and weight (I'm 188cm tall and weigh 92kg) and that it was probably nothing to worry about. However he then reviewed some of the images and there was one image (that he called the biplane measurement) that showed an ejection fraction of 43% in the left ventricle. I asked why the report had said 55% snd he said they measure from several different angles when they do an echo and the reported number was from a different method (alhough I'm not sure which) but that biplane was 'more accurate'. He therefore had another echo done that day, biplane method only, using the same machine but a different operator and that came back as biplane meaurement 50-55% - effectively an increase of up to 13% in a week wthout any medication (not that medication would achive those results in that timeframe anyway). He then prescribed me 2.5mg Ramipril to see if affected the size of the ventricle.
A follow up echo, two months later, showed no change in size, despite meds, and the ejection fraction was still at the 55% level. He upped the dosage to 5mg per day of Ramipril and ordered an MRI. The MRI happened a few weeks later and showed the mild enlargement is actually global and symmetrical and the EF is at 60%.
All through this time I have been exercising without issue (I cycled for two hours yesterday with my heart rate up at about 75-85% of maximum) and I have not been suffering any of the symptoms that are related to heart disease - fatigue, shortness of breath, swelling. The only thing I have had is a sustained period where I kept getting skipped heartbeats, that have now gone away, but could have been down to anxiety over the whole thing as I did feel very scared, anxious and obsessed with this for a while. When it first happened, I was scared I'd be dead within the year and it was very traumatic.
The cardilologist has told me to keep taking the Ramipril and has scheduled to see me for another echo in a year. My concern is that the first echo biplane measurement seems to have been a bit of a mistake, as all measurements since then have been in the normal range (including a week after the first with no medication involved) and am I taking this stuff for no reason?
I have always been active and my cardiologist did discuss athletes heart as a potential, but I am dubious of this. My resting heart rate is about 55bpm for sure, but I simply don't do enough strenuous exercise to warrant this. I cycle to and from work about three to four times a week (15 mins each way) and I cycle once a week for about two hours. I used to do weights and kickboxing but not for the last year or two. Even if I did have athletes heart the amount of time I have not been actively lifting weights or kickboxing it would have regressed, like any muscle.
The cardio thinks I have been born with it.
I would be interested to hear from other people that may have experienced similar or any other cardiolotgists that may have an opinion on the findings. For reference, the results of the MRI are below - for each finding the results are listed one under the other (parameter, value, normal, units)
Many thanks
CARDIAC MRI
FINDINGS
1. Mild V enlargement – no cause defined. The RV is similarly enlarged. This may be at the limits of normal volume if an active athlete.
2. Normal biventricular systolic function.
3. No regional wall motion abnormality.
4. No evidence of prior infarction, inflammation or infection.
COMMENT:
The enlargement of his ventricles is very symmetrical and when normalized, reside not far from the top limits of normal for his size and weight. This would be even closer to normal if he were an active athlete. It may be prudent to repeat some form of imaging (echo or MRI) in a year or two to add a further datapoint.
CLINICAL NOTES
LV enlargement. Palpitations and atypical discomfort. Symptoms improved on Ramipril.
FINDINGS (Images available on WebPAX)
Mild right atrial enlargement. The interatrial septum is intact. The tricuspid valve is normally situated. Trace TR. The right ventricle shows normal volume and systolic function.
Parameter
Value
Normal
Units
LV EF
60.2
56-78
%
LV EDV
215.9
77-195
ml
LV EDV (INDEXED)
99.7
47-92
ml/m²
LV ESV
86.0
19-72
ml
LV ESV (INDEXED)
39.7
12.75-30
ml/m²
STROKE VOLUME
129.9
51-133
ml/beat
CARDIAC OUTPUT
7.79
2.82-8.82
l/min
CARDIAC INDEX
3.60
1.74-4.20
l/min/m²
The left atrium is of normal size. No left atrial appendage thrombus. Normal mitral valve. Trace MR.
The LV is enlarged. LVEDD of 6.3cm, ASWT of 09cm, PSWT of 0.8cm. Normal global systolic LV function. There are no regional wall motion abnormalities. No intracavitary thrombus is seen. The estimated LV ejection fraction was 60%.
No abnormality on delayed hyperenhancement images. No evidence of infarction or inflammation.
Dr Lawrence Dembo
It was the resting echo part of the test that suggested the enlargement of the left ventricle, The LV is about 6.3cm when relaxed. It said that systolic function was preserved despite enlargement with the ejection fraction at 55%..
When I saw my GP after the tests he suggested I consult the cardilogist that wrote the reports. The cardiologist saw me within the week and suggested the size was around the upper limits of normal for my height and weight (I'm 188cm tall and weigh 92kg) and that it was probably nothing to worry about. However he then reviewed some of the images and there was one image (that he called the biplane measurement) that showed an ejection fraction of 43% in the left ventricle. I asked why the report had said 55% snd he said they measure from several different angles when they do an echo and the reported number was from a different method (alhough I'm not sure which) but that biplane was 'more accurate'. He therefore had another echo done that day, biplane method only, using the same machine but a different operator and that came back as biplane meaurement 50-55% - effectively an increase of up to 13% in a week wthout any medication (not that medication would achive those results in that timeframe anyway). He then prescribed me 2.5mg Ramipril to see if affected the size of the ventricle.
A follow up echo, two months later, showed no change in size, despite meds, and the ejection fraction was still at the 55% level. He upped the dosage to 5mg per day of Ramipril and ordered an MRI. The MRI happened a few weeks later and showed the mild enlargement is actually global and symmetrical and the EF is at 60%.
All through this time I have been exercising without issue (I cycled for two hours yesterday with my heart rate up at about 75-85% of maximum) and I have not been suffering any of the symptoms that are related to heart disease - fatigue, shortness of breath, swelling. The only thing I have had is a sustained period where I kept getting skipped heartbeats, that have now gone away, but could have been down to anxiety over the whole thing as I did feel very scared, anxious and obsessed with this for a while. When it first happened, I was scared I'd be dead within the year and it was very traumatic.
The cardilologist has told me to keep taking the Ramipril and has scheduled to see me for another echo in a year. My concern is that the first echo biplane measurement seems to have been a bit of a mistake, as all measurements since then have been in the normal range (including a week after the first with no medication involved) and am I taking this stuff for no reason?
I have always been active and my cardiologist did discuss athletes heart as a potential, but I am dubious of this. My resting heart rate is about 55bpm for sure, but I simply don't do enough strenuous exercise to warrant this. I cycle to and from work about three to four times a week (15 mins each way) and I cycle once a week for about two hours. I used to do weights and kickboxing but not for the last year or two. Even if I did have athletes heart the amount of time I have not been actively lifting weights or kickboxing it would have regressed, like any muscle.
The cardio thinks I have been born with it.
I would be interested to hear from other people that may have experienced similar or any other cardiolotgists that may have an opinion on the findings. For reference, the results of the MRI are below - for each finding the results are listed one under the other (parameter, value, normal, units)
Many thanks
CARDIAC MRI
FINDINGS
1. Mild V enlargement – no cause defined. The RV is similarly enlarged. This may be at the limits of normal volume if an active athlete.
2. Normal biventricular systolic function.
3. No regional wall motion abnormality.
4. No evidence of prior infarction, inflammation or infection.
COMMENT:
The enlargement of his ventricles is very symmetrical and when normalized, reside not far from the top limits of normal for his size and weight. This would be even closer to normal if he were an active athlete. It may be prudent to repeat some form of imaging (echo or MRI) in a year or two to add a further datapoint.
CLINICAL NOTES
LV enlargement. Palpitations and atypical discomfort. Symptoms improved on Ramipril.
FINDINGS (Images available on WebPAX)
Mild right atrial enlargement. The interatrial septum is intact. The tricuspid valve is normally situated. Trace TR. The right ventricle shows normal volume and systolic function.
Parameter
Value
Normal
Units
LV EF
60.2
56-78
%
LV EDV
215.9
77-195
ml
LV EDV (INDEXED)
99.7
47-92
ml/m²
LV ESV
86.0
19-72
ml
LV ESV (INDEXED)
39.7
12.75-30
ml/m²
STROKE VOLUME
129.9
51-133
ml/beat
CARDIAC OUTPUT
7.79
2.82-8.82
l/min
CARDIAC INDEX
3.60
1.74-4.20
l/min/m²
The left atrium is of normal size. No left atrial appendage thrombus. Normal mitral valve. Trace MR.
The LV is enlarged. LVEDD of 6.3cm, ASWT of 09cm, PSWT of 0.8cm. Normal global systolic LV function. There are no regional wall motion abnormalities. No intracavitary thrombus is seen. The estimated LV ejection fraction was 60%.
No abnormality on delayed hyperenhancement images. No evidence of infarction or inflammation.
Dr Lawrence Dembo
Well, I finally got round to my follow up with a second cardiologist.
He was equally undecided as to what the cause of the enlargement was and agreed with the first cardiologist that I should have a repeat scan in a year. He did however say he didn't think I needed the ramipril. So I came off it.
That was a few weeks ago and sicne then I've been generally ok, but I do have periods when I'm extremely tired,sort of dizzy and I still get the mid back pain and also some upper abdominal discomfort.
According to some websites, these can be very early symptoms of cardiomyopathy. They could also be off something else. Do, the jury is out. When I feel bad I try and forget about it and wait to feel better again. I've made an appointment to see an osteopath on the advice of a friend. And the investigation continues......
He was equally undecided as to what the cause of the enlargement was and agreed with the first cardiologist that I should have a repeat scan in a year. He did however say he didn't think I needed the ramipril. So I came off it.
That was a few weeks ago and sicne then I've been generally ok, but I do have periods when I'm extremely tired,sort of dizzy and I still get the mid back pain and also some upper abdominal discomfort.
According to some websites, these can be very early symptoms of cardiomyopathy. They could also be off something else. Do, the jury is out. When I feel bad I try and forget about it and wait to feel better again. I've made an appointment to see an osteopath on the advice of a friend. And the investigation continues......
You may want to consider seeing a GI doctor as well; pain in the back as well as in the front is sometimes caused by esophogus issues.
This whole thing just got weirder. Sunday night I developed jaw and neck pain. Came and went over a couple of days - at times quite painful. Tuesday night I went for a run and had to stop halfway because of pain between my shoulder blades and across my shoulders. Went away quite quickly after I stopped. Wednesday morning I flew to a mine site (work) and whilst I was being driven round the pit on an inspection (in an airconditioned four wheel drive) I suddenly felt dizzy, lightheaded, out-of-this-worldly, mildly sick and could not stop yawning (wasn't tired). Had back pain and chest tightness. This stayed with me on and off all day and I rang my GP. He recommended I get to a hospital as soon as I landed back in civilisation, which I did.
The hospital naturally suspected heart attack. But the tests came back negative on that - BP and pulse all ok, AS I had a negative stress test a few months ago, I would have been amazed by a heart attack. But I did get an abnormal ECG which has gone to the cardio for review. Other than that, everything was perfectly fine. The emergency ward doctor suggested coming off the ramipril for a while and my cardio was sympathetic to that.
Today I feel heaps better. No jaw pain (yet), no chest discomfort and back on planet earth. Still have mild back pain - but I am managing this wth paracetemol. My cardio is supposed to be calling me this week to set up another appointment.
This is all very strange. Especially the pain when running and the jaw pain.
The hospital naturally suspected heart attack. But the tests came back negative on that - BP and pulse all ok, AS I had a negative stress test a few months ago, I would have been amazed by a heart attack. But I did get an abnormal ECG which has gone to the cardio for review. Other than that, everything was perfectly fine. The emergency ward doctor suggested coming off the ramipril for a while and my cardio was sympathetic to that.
Today I feel heaps better. No jaw pain (yet), no chest discomfort and back on planet earth. Still have mild back pain - but I am managing this wth paracetemol. My cardio is supposed to be calling me this week to set up another appointment.
This is all very strange. Especially the pain when running and the jaw pain.
You would have to have a cardiologist who was from a different plant treating aliens if he does not recognize the relatioship between anxiety and palpitations!! Anxiety cause the release of catacholamines into the bloodstream. That form of adreline helps all of us in our "fight or flight" response. Your right, a second opinion is important.
No the drug can't be the cause. The palpitations did stop after I started taking the drug. Naturally the cardio seems to the think the drug is the cause of the stop therefore. I'm just questioning the causal relationship between the two given there seems no evidence that Ramipril actually does stop or even reduce palpitations from what I can find. As I say, there is evidence that they can cause them, but in my case not, as the papitations started before I took the drug. To me there is an argument that my palpitations were anxiety-driven, but I think my cardio does not recognize 'anxiety' as a condition that can manifest itself physically.
I really don't know, so this second opinion will be most useful.
I really don't know, so this second opinion will be most useful.
Import....this is going to be interesting finding out what you end being told. I would be curious why they even mentioned Athlete's Heart (wwhich would give you thinkened walls) and why any doctor would think you were born with this (which generally means HCM or thickened walls). If memory serves me right 1cm. is the size of a grown man's heart wall thickness which would put you just about right. So if this is all the case, then what is everyone's concern? As far as the palpitations go, call the cardiologist and tell him this is a problem and that the drug may be the cause.
My heart wall are normal thickness by all accounts. The left ventricle posterior wall is about 1.1cm. So, although the ventricle is bigger than normal, it is neither thick nor thin (at this stage).
My current cardio seems to think the Ramipril stopped my palpitations but I have looked around and cannot find any documented evidence that Ramipril does that. Other drugs are prescribed for that purpose. If anything, palpitations are noted as a possible side effect of the drug itself - even says it on the paper slip in the box!
I'll be very interested to hear what the other cardiologist has to say. In the meantime, as a precaution, I'm still taking the drug and have stopped drinking alcohol (although I only ever really drank once or twice a week anyway - i.e sharing a bottle of wine with fiance over dinner or something) as alcohol is the only substance that I consume that could be contributing to it - no drugs, non-smoker, good diet, etc
My current cardio seems to think the Ramipril stopped my palpitations but I have looked around and cannot find any documented evidence that Ramipril does that. Other drugs are prescribed for that purpose. If anything, palpitations are noted as a possible side effect of the drug itself - even says it on the paper slip in the box!
I'll be very interested to hear what the other cardiologist has to say. In the meantime, as a precaution, I'm still taking the drug and have stopped drinking alcohol (although I only ever really drank once or twice a week anyway - i.e sharing a bottle of wine with fiance over dinner or something) as alcohol is the only substance that I consume that could be contributing to it - no drugs, non-smoker, good diet, etc
There are some things that don't make a heck of a lot of sense here, Import. If your doctor is even considering Athletes heart that could be be mistaken for HCM, not DCM. In HCM the muscle of the heart wall thickens; just like an athlete's body muscle thickens. In DCM, the exact opposite happens, the walls become too thin. When the heart walls thicken in the ventricles, the atrium chambers can become enlarged as a result of the amount of blood being pumped into them. In DCM that usually doesn't happen because the ventricular chambers are too big allowing a lot of blood to remain in those chambers. Blood clots can form as a result of blood not being able to completely leave the chamber. The progression you are speaking about, doesn't happen that fast, so I would question the tech's ability to run the scan correctly.
Apparently they are experts in current thinking around both HCM and DCM. One of the doctors lectures in both conditions. My current cardio, out of the two, favours a DCM diagnosis. Although seeing as my left ventricular size didn't respond to the 2.5mg Ramipril now he's not so sure - hence the increased dosage to have another pop at it apparently. I'm so new to this kind of thing I wouldn't have a clue either way to be honest.
The other thing that concerns me is that although the left ventricle appears to be staying the same size the series of scans seem to suggest the other chambers are enlarging as well. The first echo had a normal-sized left atrium (3.8mm) and the second (three months later) showed mild dilation (4.4cm). The MRI then showed dilation of the right side also, but interestingly said the left atrium was normal size - but then went on to say mild global enlargement. I don't know whether this is just margin for error in the scans or an actual progressive enlargement - the current cardio thinks it hasn't changed in the time I've had my scans, so I guess I have to assume it's margin for error. I take solace from the fact I feel ok. Time will tell I suppose.
Sorry ed43, didn't know what to make of the comment, glad I didn't offend.you with something I said..
The other thing that concerns me is that although the left ventricle appears to be staying the same size the series of scans seem to suggest the other chambers are enlarging as well. The first echo had a normal-sized left atrium (3.8mm) and the second (three months later) showed mild dilation (4.4cm). The MRI then showed dilation of the right side also, but interestingly said the left atrium was normal size - but then went on to say mild global enlargement. I don't know whether this is just margin for error in the scans or an actual progressive enlargement - the current cardio thinks it hasn't changed in the time I've had my scans, so I guess I have to assume it's margin for error. I take solace from the fact I feel ok. Time will tell I suppose.
Sorry ed43, didn't know what to make of the comment, glad I didn't offend.you with something I said..
I would be curious as to what they tell you as well. The only concern I would have with this new 'group' is whether on not they have a specialty in HCM. As far as the doctor goes who told you your heart rate was too high for Athlete's heart......he's not looking at the WHOLE picture, which would certainly include your 'white coat syndrome' as you call it.
Sarcasm? no way. I am genuinely very interested to know the outcome and hope you will report back with the verdict of the second opinion.
I really don't know what to make of that comment ed34. It sounded like sarcasm and obviously if I've said something to upset you, then I'm sorry.
Thanks for the comments guys, I have asked my GP for a second opinion and he has referred me to a separate outfit. A private clinic that has many doctors that are at the forefront of up to date knowledge about this kind of thing. My GP agrees that the rogue 43% ejection fraction reading was probably just that - rogue and down to operator error, so he thinks a second opinion is a good thing.
I did do a stress test, it was one of my first tests I did and that came back negative...heart reponse to exercise was completely normal. I exceeded my maximum heart rate, which is apparently good in such tests.
My cardio ruled out ahtletes heart on the basis my resting heart rate was too high when I came to see him. I do suffer a bit from 'white coat syndrome' - my heart rate goes up (and my bp) when I'm sitting in a clinic talking to a doctor about my heart, so that's probably not a true reflection of resting, but I'll wait and see what this other guy thinks of it all.
Here's hoping. I have the appointment end of next month.
I did do a stress test, it was one of my first tests I did and that came back negative...heart reponse to exercise was completely normal. I exceeded my maximum heart rate, which is apparently good in such tests.
My cardio ruled out ahtletes heart on the basis my resting heart rate was too high when I came to see him. I do suffer a bit from 'white coat syndrome' - my heart rate goes up (and my bp) when I'm sitting in a clinic talking to a doctor about my heart, so that's probably not a true reflection of resting, but I'll wait and see what this other guy thinks of it all.
Here's hoping. I have the appointment end of next month.
I would have to totally agree with grendslori. It is worth having a stress echo because you really want to see your heart at both rest and when racing. If those tests find no problems, I would just take this as a good thing and get on with life. I know you lose muscle mass over time if you don't exercise, but even now you are doing more exercise than mr average.
If I were you, I would get a second opinion from someone not related with the carddiologist or the hospital he is associated with; I'm talking about a TOTALLY different doctor and hospital. This definitaly sounds like it could be a form of "Athlete's Heart" The reason I'm saying this is actually for several reasons: Your resting is abit low (although certainly in the normal range) and your EF%s are certainly normal. (50%-70%) People who have Athlete's heart have enlargement in most of the areas of the heart while with HCM (the other possibility) usually only one wall is affected. People with Athlete's heart don't have symptoms of heart problems while people with HCM certainly do and would not be able to do the things you are saying you can do. Based on what you have written on here, this could be Athete's heart. I understand that you have not done some of the more strenous exercises, but you are still doing alot ofexercise and while you are right that you will lose some of the muscle mass, including heart muscle mass, you don't know that you have not lost some of that mass because you have no tests to show that loss. It takes time to build up muscle mass, it takes time to lose it. Usually, when HCM is present at birth, the child, obviously has to grow....well so does the heart disease. For example, my daughter was born with HCM which was discovered as a fluck when she was hospitalized at the age of 6 years; by that point, her ventricular walls were already the thickness of a full grown man; it got A LOT worse through her teen years and at 22 she had to have a heart transplant. Transplantation is rare even in this disease, so please don't think that's the road I'm telling you you are headed down! If you are really serious about finding out exactly what is going on you may want to visit the Mayo Clinic or the Cleveland Clinic. Also most University Hospital where transplants take place would be able to diagnose you as far as whether you actually have HCM or not. Take care
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