EP Study Indicated?

[medic58]

I am a 27 y/o male, pretty healthy.  I have had an occasional palpitation since the age of 20.  This brings me to my current situation.  About 4 months ago or so I had a week of frequent palpitations (skipped beats, normal rate).  This happened mostly in the early mornings and at night.  I saw my primary care giver for a physical and mentioned this to him durring it.  He told me that he wanted me to see an electrophysiologist so I did.  I was given a thirty day monitor and wore it for most of the time without much.  I did have a couple mornings where it caught several couplets and PVC's.  My ECG shows what he calls an incomplete RBBB, but most Dr.s I have seen have called it a non specific conduction delay.  I do have a B.S. in Emergency Medical Care so have some knowledge of what they are talking about.  After being told by the PA at the office that everything was probably o.k., I received a phone call about a week later after they got a copy of my stress test from work last month (no premature beats at all on it).  They said that everything looked great, but because of the couplets and my wide QRS pattern that he was slightly concerned and wanted another ECHO and possibly an EP study (the echo they had was from 2006 when I was sent to investigate LVH on my 12-lead which was nothing).  The echo was totally normal I was told, but since I have the RBBB and the couplets he is concerned.  He says that it is in my best interest to have a EP study to which I agreed, but am scared.

If you had a patient like me, do you think you would advise the same thing.  Do you think the risk is justified? (for your patient of course)

Thanks!

[kyfan]

A related discussion, Palpitations was started.

[LukeL]

A Incomplete RBBB is a very common finding in the adult population and is usually an incidental finding. Do you know if the PVCs were monomorphic or polymorphic? Also most cardiologist agree that it is HIGHLY unlikely in a structurally normal heart for someone to go into V-Tach.  

[medic58]

You have cerntainly given me something to think about.  They keep saying that it is due to the RBBB and the morphology of the PVC's.  They tell me that they need to make sure I can't go into V-tach.  I perhaps should not say this, but my Dr. is in the same town you are.  Perhaps I will make you my second opinion.  At the very least I think I should pin him down for some further answers.

It is hard when you are faced with a decision like this.  He says he feels very strong this is what is best for me and I just don't know.

Thanks,

[Michael J. McWilliams, M.D.]

I am not sure that i understand the reason for the EP study yet.  PVCs by are not an indication for an EP study.  Based on the information you provided, I would not recommend an EP study.  If I were in your position, I would gather all the records from your current EP including the stress test strips that show the couplets and the echo cardiogram and request a second opinion.  I cannot say that an EP study is not indicated, but based on the information you provided above, I don't see the indication.

The risks of an EP study are pretty low, but they should only been for appropriate indications nonetheless.  "A picture is worth a thousand words" so I may be missing the big picture because I can't see the couplets or your baseline EKG.  You should have someone that can review your studies do this.

I realize this only a partial answer but it is the best I can do.  I hope it helps.