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Case 255

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A female patient, 60-year-old, sought care by a cardiologist requesting release for physical activity. Sedentary, asymptomatic, presented with hypercholesterolemia for 5 years, controlled with Enalapril, Hydrochlorothiazide and Simvastatin. Positive family history for coronary artery disease (CAD). Physical examination: good general condition, overweight (BMI: 25.6), BP: 140/80 mmHg, HR: 88 bpm, regular heart rate, normal heart sounds, no murmurs. Exercise testing was then required. Pre-test score for CAD - Morise = 12 (intermediate probability).

Based on the clinical history and the presented image (electrocardiographic tracings), what is the alteration presented by the patient and the best approach to be taken?

a) Occasional ventricular extrasystoles, contraindicating the immediate practice of physical activities

25%

b) Occasional ventricular extrasystoles, and the patient can be released for physical activities

25%

c) Supraventricular tachycardia, contraindicating the immediate practice of physical activities

25%

d) Supraventricular tachycardia, and the patient can be released for physical activities

25%
   

Image analysis

 

Image 1: Treadmill test.

Resting electrocardiogram: regular sinus rhythm, HR: 88bpm, constant and normal PR interval.

Electrocardiogram in the peak phase: sinus tachycardia (HR between 100 and 230, P-QRS link, narrow QRS complex, constant and normal PR interval), with isolated ventricular extrasystole (premature and wide QRS, ST segment and T wave are altered, with opposite polarity to the QRS). Infringement of the J points accompanied by ascending ST segments (normal response to exercise - see Image 2).

Electrocardiogram at the 1st minute of the recovery phase: sinus tachycardia (HR between 100 and 230, P-QRS binding, narrow QRS complex, constant and normal PR interval). Absence of extrasystoles;

Electrocardiogram at the 3rd minute of the recovery phase: sinus tachycardia (HR between 100 and 230, P-QRS binding, narrow QRS complex, constant and normal PR interval). Absence of extrasystoles.

 

 

Image 2: Normal electrocardiographic changes during exercise.

With the increase in heart rate, we observed that the P wave becomes more apiculate, without changing its axis and the PR and QT intervals decrease. Q waves tend to deepen, becoming more negative, and R waves progressively decrease in amplitude throughout the exercise. The S waves increase in amplitude, becoming deeper in the lateral derivations, probably due to the change of the electric axis. The J point usually becomes negative, occurring its depression, which persists even a few minutes after the end of the exercise. With the effort, the ST segment is ascending, the slope of the ST ramp being variable according to the observed shunt and the magnitude of the J point depression. This aspect is extremely important in the evaluation of ischemic patients, since the slope With horizontal, descending or ascending morphology is one of the most suggestive electrocardiographic findings of effort-induced ischemia.

Source: Electrocardiography - 1st Ed. - Chapter 38 - Electrocardiographic changes in the Ergometer Test.

 

 

Image 3: Most frequent abnormal electrocardiographic changes during exercise.

A) Normal ST segment response, with rapid return to the baseline; B) Slow upward slope of ST; C) Horizontal level of ST; D) Downward slope of ST, measured from point J; E) ST elevation.

Source: Brazilian Consensus of Ergometry - Arq Bras Cardiol Volume 65, (nº 2), 1995

Highlights

- Pre-participation clinical assessment for physical-sports activities seeks to identify cardiovascular diseases that are incompatible with physical activities;

- The initial evaluation should consist of complete history, physical examination and 12-lead ECG for all individuals before beginning sports practice;

- If there are no contraindications, the exercise test should always be performed in the pre-participation clinical assessment;

- Asymptomatic individuals with no cardiovascular risk factors can be released without the need for treadmill test, in the specific condition of leisure activities of mild/moderate intensities;

- In the case of positivity for CAD at initial screening, tomographic myocardial scintigraphy or Doppler echocardiogram should be performed for complete evaluation of the condition;

  • - Ventricular extrasystoles, alone, do not justify greater limitation to physical activities in asymptomatic individuals.

References

- Morise, A., Haddad, W. and Beckner, D. (1997). Development and Validation of a Clinical Score to Estimate the Probability of Coronary Artery Disease in Men and Women Presenting with Suspected Coronary Disease. The American Journal of Medicine, 102(4), pp.350-356.

- Nau, G. and Lopez, J. (2003). Comisión de extrasistolia ventricular aislada y agrupada. Revista Argentina de Cardiologia, 71(2).

- Germiani, H. Extra-sistolia ventricular: quando e como tratar. Revista Latino-Americana de Marcapasso e Arritmia. 2001.;

- N Ghorayeb et al. Diretriz em cardiologia do esporte e do exercício da sociedade brasileira de cardiologia e da sociedade brasileira de medicina do esporte. Arq Bras Cardiol 100 (1 Suppl 2), 1-41. 1 2013;

- D. Akinpelu et al. Treadmill Stress Testing: Background, Indications and Contraindications, Technical Considerations [Internet]. Emedicine.medscape.com. 2016 [cited 7 November 2016]. Available from: http://emedicine.medscape.com/article/1827089-overview#a5;

- P. Goldwasser G. Eletrocardiograma orientado para o clínico. 2nd ed. Rio de Janeiro: Livraria e Editora Revinter Ltda; 2002.

Author

Lucas Augusto Carvalho Raso, 5th year medical student at Universidade de Minas Gerais School of Medicine

E-mail: lucasraso[at]hotmail.com

Supervisor

Marconi Gomes da Silva, medical specialist in Cardiology and Sports Medicine, former president of the Mining and Exercise Medicine Society of Minas Gerais - SMEXE

E-mail: sportifmarconi[at]gmail.com

Reviewers

Juliana Albano, Luísa Bernardino and professor Viviane Parisotto.

Translated by

Giovanna Vieira Moreira, 5th year medical student at Universidade Federal de Minas Gerais.

E-mail: giovieiramoreira[at]gmail.com

 

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