Friday, April 25, 2008

The Cause of the Pause

Reading Holters today, I can across this:

A 46 year-old man who drives trucks for a living submitted a Holter with a diary that was blank (no symptoms). Here's his starting rhythm - not too exciting:

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A bit later, we see this:

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Then we see this!

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So you check the rate histogram of all of the beats for 24 hours and find this:

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So what's the diagnosis? Does he need a pacemaker?



Ian Furst said...

pause from valsalva related to sleep apnea? Needs CPAP?

Anonymous said...

I don't know, thats a big sinus pause even if it is at night mostly. I'd think you call that a sick sinus and slap in a pacemaker for sure but thats why we pay you cardiologists the big bucks :).

The Happy Hospitalist said...

my guess is sleep apnea or the lead fell off. That seems like a pretty long arrest not to get a pacer even if it was asymptomatic. Three secs i remember is a class Ia indication if symptomatic, if i remember correctly. Maybe a pacer will help the apnea I suppose. I've never met a non smoking trucker without apnea

Eric, AKA The Pragmatic Caregiver said...

The timing sure has elements of sleep disturbance. How big is his neck? Is it possible that he takes a beta blocker at bedtime for HTN?


The Happy Hospitalist said...

I forgot to ask what meds he's on. Also why was the holter ordered in the first place? Also, maybe he has a sensitive carotid body that compresses when he lays his head on one side or the other causing the Brady/pauses

DrWes said...

This man was on no medications, but was recently with diagnosed diabetes and yes, now newly-diagnosed sleep apnea. Sleep apnea can occur in obstructive (mechanical) or central (neurologic) forms. Any form of hypoxia (no necessarily from Valsalva) can cause sinus slowing or even sinus arrest. His treatment should be to treat the underlying sleep disordered breathing, rather than a pacemaker, as the first step.

Unknown said...

Asymptomatic patient with high vagal tone (occurred during night hours and no patient-triggered events on Holter), however the patient must have been having some kind of symptoms in order to get the event monitor in the first place. The pause seems unduly long to just cross it off to "high vagal tone"-- I'd put in the pacemaker before the SSS occurs at an awake time.

Anonymous said...

He obviously has a highly fragmented hard drive, and possible spyware infection. He should defrag his hard drive and run ad-aware and hijack this. If that doesn't fix it, he should consider re-imaging his system and starting afresh.

Then again, I'm a software developer, not one of you high-falutin' doc types. I have a hammer, so all my challenges look like nails =P.

Love your posts, though, Doc.

Parenthetically, I'd love to improve the healthcare process through software. If anyone has any thoughts on the topic, let me know, woudja?

The Happy Hospitalist said...

danimal. The best thing anyone could do to improve the delivery process of medical care is to shadow doctors for one month. Experience all of the inefficiencies first hand and really understand how our jobs are bogged down by incongruent technology. There are so many different ways technology could improve flow but nobody seems to understand how doctors think and create actionable events

Anonymous said...

Danimal - can you design software that will somehow force people to make better decisions about their own health care and lifestyle habits? 'Cause that would help a lot. :)