Abnormal Nuclear Stress Test

[ashnar]

I have been having PVCs for the past 10-15 days and I went to see my primary care doctor to make sure that was not serious.  He did an EKG - said it looked abnormal and referred me to a Cardiologist (to see on the same day).  The cardiologist put me on a 24 hour portable EKG machine to monitor the palpitations and prescribed a Echocardiogram and Nuclear Stress Test to be done the same week.  I got both of them done last week.  He said the echo looked fine, but the EKG under stress was abnormal.  The pictures taken after the treadmill walk apparently also showed that some part (about 10%) of my heart was not receiving enough blood.  He thinks there is blockage in an artery (front right portion of the heart) and is recommending a Caronary Angiogram as next step.  He also asked me to start taking Baby Aspirin, Toprol and Lipitor.  He has not done any blood work so far -- so I do not know what the LDL levels are.

I am a 38 year old, active, non-smoking male with reasonably active lifestyle.  I work out about twice a week (cardio and weights) and play golf every week.  I have never had any attributable chest pain or discomfort so far other than the PVCs in the past two weeks.  I did have acid reflux which was treated with medications -- eventually got off the medications by altering lifestyle and diet.  However, I felt the reflux coming back in recent weeks because of bad eating habits.

All of this has been moving too fast for me -- the doc wants to do the catheterization tomorrow !!  Based on what I read on the internet, CA is an invasive procedure and I am not ready to go thro' that unless I really have to.  Am I at a risk here if I push the procedure for another 10 days so that I can get a second opinion.  Also, do I need to start on the Toprol and Lipitor right away even before knowing the results form the blood work that was done this morning?

Any comments, suggestions and advice will be greatly appreciated.

Thanks
A

[PA_C]

Get the cath. Based on your findings, the risk of the cath is so low compared to consequences.  If you do get a cath make sure you get it in a Hospital that can actually place stents.  Some hospitals have "diagnostic cath centers"  and if they find a problem you will have to be transferred to have a stent placed (same procedure twice).   Also I think it is best to have this procedure done in a hospital with cardiothoracic surgery back up just in case something goes wrong.

[ashnar]

I finally got my chart today and the cholesterol numbers don't look good !

Lab Results:

Total : 226 mg/dL
LDL: 165 mg/dL
HDL: 41 mg/dL
Triglycerides: 99 mg/dL

Stress Test Results:  (I have no idea what this means -- am simply typing the words as they are on the report)

Resting ECG:

The resting ECG showed Normal Sinus Rhythm; Old inferolateral MI, anterior T wave abnormality consistent with ischemia

Stress ECG:

The stress ECG showed Sinus Tachycardia; ST/T wave changes in leads aVF, II, III, V1, V2, V3, V4, V5, V6; Downsloping ST depression up to 2 mm.

Stress Study Impressions:

Abnormal exercise tolerance test die to diagnostic ST segment changes, without chest pain; Functional Class I; Normal incremental hemodynamic response to exercise; No exercise induced arterial desaturation; No significant induced arrhythmias

Profusion Summary:

Abnormal myocardial perfusion study; apical, apical wall ischemia

Any more thoughts/advice/suggestions based on this more precise information?

Thanks in advance.
A

[Cleveland Clinic]

It is not that hard to come off beta blockers, some of them have to be tapered over a period of a week or so, but not all, toprol does have to be tapered off.  

I think catheterization is very safe when done by an experience operator.  We do them here at the cleveland clinic with extremely low complication risk in all comers.  

Given that you are so young, there is a long terms risk of radiation exposure.  Because the procedure is relatively new, we don't really know what that risk is in the long term.  The risk of radiation exposure from catheterization is much lower.  

[ashnar]

Thank you for the feedback !

The last approach sounds logical to me.  I am definitely waiting to get a second opinion.  I will need to think about getting a CTA done and starting on the meds in the mean time.

The PVCs also have gone down considerably now -- have had only 3 or 4 in 7 days (Compared to 3 or 4 every hour the week before that).  I am hesitant to get on the beta blocker as I heard it's really hard to get off of it. Is there any truth to that? I am waiting on the lipid panel to see if I really need to get on Lipitor or not.  While I am concerned about the side effects of these medications, I will certianly start taking them if I was told my life is in danger !  I am just trying to get the facts right in the mean time so that I can make an informed decision.

Which procedure, in your opinion, is safer - CTA or Catheterization, considering the invasive nature of CA and radiation levels in CTA?

Thanks much
A

[Cleveland Clinic]

It is very unlikely that you have any significant blockages, making it more likely that the test is a false positive.  It probabaly should not have been done in the first place because the likelihood of CAD in some such as youself is very low.  Now, of course, we have to deal with the results of the test to make sure that we aren't missing anything.  One way to do it is to have a catheterization, the other is to have a CT angiogram (non-invasive procedure) and the third is given that the area of ischemia is only 10% to proceed with medical management.  I would start the ASA, beta blocker and the lipitor at least for now, and then get a second opinion.  Maybe you could have a CT angiogram done to rule out significant CAD at which point you won't have to be on the ASA or the lipitor.  I would stay on the beta blocker because it is likely to help you with the PVC's.  Finally, your reflux will probably get worse while on ASA.  Take it with food.