Cardiovascular Disease Prevention Expert Forum
S-T depression making me anxious
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S-T depression making me anxious

Hi,

I am a 36 year old male - 1 risk factor (smoking). Cholesterol is excellent, no family history.

2 years ago I started getting chest and back pains.  Stress test came out positive with 1.5mm S-T depression, (onset @120BPM) - this was a submaximal test; Modified Bruce, max HR of 165 BPM, max exercise T=7min.  Given the protocol, I think this is about 5 METS (?)

Since, I have exercise-phobia…

A follow-on nuclear perfusion stress test was done - S-T depression of 1.5mm, T=8min, 165 BPM, sub-maximal modified Bruce.  Resting Echo OK.  

The cardiologist deemed this a "false-positive", as imaging showed no abnormalities, and the ejection fraction was ok.  Symptoms disappeared for over a year.

When symptoms re-appeared, a new FP sent me over for another round of tests.  

1: Ex. Test, normal Bruce, maximal test: 9.5 min, 184 BPM, and the following note "there was an S-T depression, but it did not exceed >0.9mm.  No evidence of myocardial ischemia".  The nurse performing the test, said S-T changes appeared early, at 140 BPM, and disappeared within seconds of stopping.

2: resting echocardiogram: normal, EF 63%

3. Ex. echo, Bruce pr., maximal: 10+ min (11METS), 188BPM, again the note "there was an S-T depression, but it did not exceed >0.9mm.  No evidence of myocardial ischemia".  The echo part came out ok (no abnormal wall movement); EF was not specified.

It bothers me that S-T depression is showing up, time after time.  So:

- Can S-T depression decrease over 2 years from 1.5mm @ 5 METS/165BPM to "less than 0.9mm" @11 METS/188BPM?

- if the results say "less than 0.9mm" does it typically mean between 0.8mm to 0.9mm, or could it mean 0.5mm (I saw two numbers on the test display - one was showing "max 0.5" the other "max 1.1")

- what about "early onset" of S-T depression even if the max is less than 1mm?

- could the S-T be caused by something else? (I do not have MVP, but my K+ is 3.6 mmol/L)

Thank you
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Your question raises several important points. First what is your lifestyle including exercise, weight and dietary habits. Clearly smoking is a significant risk factor for heart attack, stroke, limb loss and lung cancer. The current gold standard for identifying a coronary stenosis that would be responsible for the nuclear perfusion finding is a cardiac cath. This could easily be done to dispel any question of the validity of the indirect finding on the stress test. But then what?.... Coronary bypass is the gold standard for revascularization of blocked coronaries. Bypass has the best durability but even most bypasses ultimately fail due to scar tissue or progression of the atheroclerotic process. Angioplasty and stenting is a minimally invasive treatment with shorter durability.

My point is that instead of fretting over .5, .9mm and all of these other indicators-I would use your apparent anxiety to motivate yourself to pursue a healthier lifestyle. At this point, think you are utilizing the "hope" strategy without any meaningful health improving actions.

The bottom line is that the stress test does not have 100% sensitivity and specificity and furthermore, many people who have heart attacks would have had a negative stress test within 5 years because "hot" lesions are a result of inflammation that causes spontaneous plaque rupture in a relative quiescent and benign appearing blood vessel. The inflammation comes from smoking, cholesterol, diet and genetics.

Best of health
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