I mentioned earlier that I had a Holter monitor test because I had drop-kicked atenolol out of my life. Well, today I got the results. I have had five Holters done total in the last twenty years and have been given copies of three of them, two of them from the cardiologist at a leading teaching hospital, one from a cardiologist in private practice. So I know what a Holter report is supposed to look like. It took almost two weeks to get the results from my latest one, done at a private lab run by cardiologists. KMH Labs.
At first I thought the fax machine had eaten most of the report. You see, these reports used to be like a phone book, then technology made them more efficient so they were only several pages long. This one was one page.
Well, OK. Maybe this one page is as comprehensive as those bigger reports were. Uh, no.
It gave the range of heart rate (and boy, does mine vary, nothing new there), and I looked for the times associated with the lowest and highest rates like on the previous reports. Not there.
Unlike previous reports, this one didn’t give the QRS total (the total number of heartbeats in 24 hours). It means nothing to me, but it should mean something to my GP. So how can he do his job properly when this is missing? I assume it’s on all the other reports because it’s, like, oh I don’t know, important!
On the good side, the average heart rate over 24 hours is noted. And it’s lower than it used to be! But, uh, what was my average at night and average at day? Never mind, the tabular hourly report will allow for that kind of calculation. Uh, no, wait, the report is just one page. No tabular report. OK, well, then — scanning, scanning — it should say here the time of the fastest heart rate and slowest one. Nope. Not even the longest duration of tachycardia or bradycardia. Oh brother. Who are these people? Never mind. On to the next paragraph.
It said there were five ventricular premature beats (no big deal) and one ventricular couplet. But — I flip fax over to see if by some miracle the info is printed there, nope — no times given either for each one or for the exact time they appeared most frequently, not like it matters in my case, but details are always better — and critical — than vague sometime-in-24-hours-we’re-not-going-to-tell-you-when-this-happened kind of information. Same for atrial premature beats and atrial couplet (never had a couplet before, but one is no biggie). Previous reports gave the time of these events down to the second.
On to the next sloppy part: “no significant ST depression.” For a medical report, this is vague speak. This is like when the doctor pats the patient on the head and says, “don’t worry,” except in this case it’s the cardiology lab telling the GP “don’t worry.” Unreal. In my previous reports, measurements are given as in “No episodes of ST depression (defined as < -1.0 mm or more) were noted in channel 1.” Wait a sec, channel 1? I check my other reports again and see that the number of channels is noted; some results are given by channel. This report doesn’t bother to note how many channels were analysed in the first place and so no results are noted in correlation to them. Guess this is more pat-on-the-head BS.
Symptoms are mentioned and what they are correlated with. This is good. Usually the symptoms are mentioned elsewhere in the report or written in by hand and so are incomprehensible. So, for example, I know that the one episode of fluttering was when I had that one atrial couplet. Great. Uh, what time? Was I exercising? Was I using one of my gizmos? I did write those down in my diary for a reason, you know. How come I go to the trouble of recording when I exercised, and nothing is mentioned about that? There are no times given in relation to my symptoms or heart rate. Ridiculous.
Time! people. It’s important!
Time is so important that Holter reports usually include a tabular teport, showing in the left column the hour (e.g, 08:00, 09:00, etc.) and in a line across for each hour, the minimum heart rate, the average, and the maximum; total number of QRS; number of each kind of ventricular episodes (mine are usually a bunch of zeroes, with a 1 thrown in here and there); runs; and the same for supraventricular events. This report has, well, no tabular report because it’s just one page.
A tabular report is really useful not only to see the timing of events, but also for someone like me with a fast heart rate, to see if it does go down at night, to see when it’s fastest, to see if bradycardia events are only at night when in bed or asleep, and when tachycardia is most prevalent. With no tabular report, how the hell will I know if my heart is behaving itself in the less-stressful condition of sleep and slows down like it’s supposed to do? For someone with a brain injury whose system is on overdrive, it’s important to see what events and what times are the worst and the best so that the doctor can tell them… Oh wait, doctors don’t know yet that brain injuries cause problems with regulation of the heart. So, OK, for the rest of us, this information would give us precise feedback on what makes our hearts happier and what makes them speed up, whether exercise helps and for how many hours, whether the gizmos work in a noticeable fashion and again for how many hours. At the moment, I can take my pulse — if I remember, which I usually don’t — before and after I exercise or use one of my gizmos; I can take a guess based on how I feel. But nothing beats precise information. And this report is effing useless in that way.
In the beginning, Holter reports were huge because they included the readings of the QRS or heartbeats. All of them. The one I had back in 2008 shrunk the number of pages by printing out only those times when either symptoms or the incidences they noted occurred, like a ventricular premature beat. They noted heart rate and exact time, down to the second, of each reading. The GP could actually see the QRS of the heart beat and make their own judgement. If they had previous results, they could even compare: is it better? Is it worse? Is there no change? Well, this pat-on-the-head report clearly says you don’t need to know that! C’mon. We’re the experts, you leave reading QRS to us. How disrespectful. But I also wonder: can GPs do basic things like read QRS, at least well enough to put them into the total context of their patient’s health?
Previous reports came with graphical analysis. In one glance, you can see visually whether the heart rate drops at night, when events occur along the timeline, how each channel looks. Fast and effective. But this report is one page. So no graphical analysis. Because you know, stress being such a big problem in North America, and a worse one for those with brain injuries, information giving stress-related feedback is not needed, right? That’s what that stress test is for, the one that gives a snapshot, while you walk or run on a treadmill, not a 24- to 48-hour picture that includes everything from anxiety-inducing events to running (or walking).
I got mad. I didn’t velcro my chest to receive this kind of garbage report. So I called up my GP’s office and complained. They said they’d call the lab and get what I asked for. It may take a week. So far, I have received three pages of QRS readings. I can now see the exact time when my fastest heart rate and slowest one occurred and that they used a 2-channel Holter. I don’t know if a 2-channel Holter is the same, better, or worse than 3-channel; my GP ought to know. But I got curious so went Googling. I found a dog Holter website, which explains that all they need for a Holter report is one clean channel; the other channels are essentially backup. Given how the second channel looks on my report — bouncing off the page here and there — I’d say the backup failed! The top channel looks peachy though. Anyway, with no tabular report and no graphical analysis, I still don’t know if overall my heart rate drops at night and into normal territory, rate-wise. I’m guessing it does; but hard evidence would be good…
You know, this report was more critical than my last one because I am off the beta blocker now, whereas I was on it for the previous one. How does my heart work all on its own, with no drug helping it along? Getting details on that is important.
This all makes me wonder: How many patients are going to call up their doc and complain about the piss-poor quality of their test reports? How many will even get or ask for copies? Yet unless a patient becomes an active participant in the management and understanding of their own health, this kind of garbage will proliferate and it’s us who will suffer. And we won’t know why.
So while we complain about the lack of health care dollars, basic health information that used to be given is now being withheld. If I hadn’t had doctors who used to hand me these reports, whether I wanted them or not, I wouldn’t have known how inadequate KMH’s report is. If I hadn’t developed the habit of gathering all my health information because either specialists disappeared (aka died) or because of all my insurance lawsuits, I wouldn’t have known how variable cardiac care is. If I hadn’t studied physiology in university, I wouldn’t have even a rudimentary understanding of some of this information. It must all look like gobbledygook to most people; but it shouldn’t to the GP. The GP needs to have a complete picture of their patient. That means they need complete reports.
This reminds me of the stress test I did a couple of years ago at a lab in one of the teaching hospitals (that reminds me of a desert). The cardiologist read out the report to me. I didn’t get a copy and was not well enough to ask for it. I noticed that the techs had “forgotten” to mention why the test stopped prematurely. So, not even the cardiologist gets a complete report in today’s health care system. And people wonder why heart disease remains the number one killer.