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Abnormal Stress Test
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Abnormal Stress Test

Never had any symptoms of heart problems.  Just had a Thallium Stress Test as a precautionary measure due to family medical history.  The stress test results showed an evidence of ischemia of basal septal wall.  Cardiologist is recommending catheterization.  

Is it necessary?  Some doctors say absolutely not.  Use aggressive medical treatments to control cholesterol and blood pressure with 80 mg. aspirin daily.

Since doctors opinion is mixed on catheterization, I am not sure whether to have catheterization done or not.  Please let me know what you guys think.  Medical profession has become a business and many tests are unwarranted but performed to generate revenue.
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976897_tn?1379171202
It depends if the affected heart tissue is dead or not. If it's dead, then some doctors fail to see the point in getting oxygen to the area if it isnt going to be used. Others tend to
believe that revascularization will improve matters in the area.
Personally I would opt for the catheter, here's why....

A cardiologist saw my nuclear scan results and discharged me from hospital when I had severe angina. He said "there is nothing wrong with your heart and you are as fit as an ox". The following day I was called back to hospital because he looked at the images from an angiogram. The two show very different stories. The Angiogram showed 100%
very long occlusion in LAD and severe disease in the RCA. So, the nuclear scan can only tell PART of the story and should only be used as a guide to tissue health, nothing more.
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63984_tn?1385441539
I'm wondering if you are confusing the process of receiving stents to open up blocked arteries with catherization .Certainly, it is the gold standard used to not only determine where blockages are located but the entent of the blockage.  During the angiogram (catherization) if it is determined a heart needs a stent, it is done at that time, depending on the agreement you have with the doctor.  

An angiogram is considered least invasive yet most informative method of determining if there are blockages in the heart arteries, and I would by all means recommend you proceed with the procedure with the greatest of confidence.  I've had seven or eight of them, in some instances I needed stents, in some I did not.  

If a blockage is found, during the catherization, there are several outcomes.  It is possible you will need aggressive medications only, you may need a stent as well as medications, or even need a bypass. It is also possible that the stress test was a false positive, and nothing is needed.  However, none of those options is open to you unless more information is gathered, and a angiogram is the gold standard for information and minimally invasive.

Keep us informed.  

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976897_tn?1379171202
No I wasn't confused, to put it simpler, I was saying that an Angiogram gives far different information to a nuclear scan and in reality a cardiologist requires BOTH to have an accurate detailed picture of what's going on. One is no good without the other.

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367994_tn?1304957193
I agree with Flycaster's reasoning: QUOTE: " If a blockage is found, during the catherization, there are several outcomes.  It is possible you will need aggressive medications only, you may need a stent as well as medications, or even need a bypass. It is also possible that the stress test was a false positive, and nothing is needed.  However, none of those options is open to you unless more information is gathered, and a angiogram  is the gold standard for information and minimally invasive".

The cath procedure would be the approach of an interventional cardiologist, but a non-inteventional cardiologist may wish to avoid and may not believe an interventional  procedure (cath) is necessary.  The non-interventional  cardiologist may proceed with CT scan 64 slice (angiogram) that provides an anatomy of the entrie vessel that will include any soft plaque between the layers of the vessel (it is the soft plaque that rutures causing a clot that leads to stroke or heart attack....the hard plaque seen by the cath usually causes ischemia not the heart attacks).

Also a non-interventional cardiologist will treat with medication, and if symptoms are relieved no further action required.  Medication, stent, and by-pass only treat the symptoms not the disease.  If medication does not effectively relieve the symptoms, then stent implants may be necessary.  A bypass may necessary if the lesions are located at a site in appropriate for stent, or the lesion is too long, too many, etc.  and if there is an emergency, a by-pass may be required in a matter of life or death.  The different ttreatments does not increase longivity...the COURAGE study concludes.

QUOTE sp47: "Since doctors opinion is mixed on catheterization, I am not sure whether to have catheterization done or not.  Please let me know what you guys think.  Medical profession has become a business and many tests are unwarranted but performed to generate revenue."  I agree I have a totally blocked LAD and circumflex is 72% occluded and I am adequately served with medication for more than 5 years.  If you are asymptomatic, there should be no need to stent unless special circumstances.

Apparently, the other poster is symptomatic (angina) and if meds do not relieve the angina, then stents would be appropriate.
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63984_tn?1385441539
You hit the nail on the head, Kenkeith.  I'm very symptomatic and when I was having a very active CAD period, blockages caused a lot of chest pain and and even more shortness of breath, which reduces the quality of one's life.  I'm also a volunteer at at cardiac trauma center where stents are routinely inserted and  problems with the procedure are extremely rare.  However, they do occur...
Interesting post, sp47.

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Avatar_m_tn
Ok I posted this esewhere.  kenkeith commented on my post, but I am still confused.

I had a negative chemical stress test a week ago.  When I saw the cardiologist this week, he said that I should have a catheterization done to check it out ( blockage ).  He said the stress test  showed blockage to a portion of my heart ( on the bottom ) that showed during the stress part of the test. He said it did not show up during the relax part of the test. He then said, that since I have no insurance we could put it off, and treat it with medication.  None of this is making any sense to me.  I have had no pain, or shortness of breath. The stress test was ordered, because I was on medication for Afib. That was what had put me in the hospital.  Even then I had no chest pain, only a feeling of flutter.

I don't know what to think.  The local hospital, is a for profit hospital.( HCA ) as are hospitals in this area. They had said that further admittance was dependent upon my ability to pay, or medical insurance.  I had been dropped, for a pre-existing condition.
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367994_tn?1304957193
I'm surprised you were given a stress test without some basis other than family history.  I can tell you that an insurance policy will not cover the test without some objective evidence for the procedure.  A better test would be a CT scan 64 slice if there is a family history.

The scan will image the entire anatomy of the vessel including between the layers of the vesssel (cannot be seen with a cath examining only the lumen).  Between the layers of a vessel soft plaque can be a high risk to rupture causing a heart attack.  The plaque in lumen has much less risk for a heart attack but can cause ischemia (lack of blood flow) and angina.  The CT scan also views the lumen.

There is a possibility you have stenosis (narrowing of the vessel due to a bulge from the inner lining into the lumen of the vessel) and the lumen appears clean.

If you don't have symptoms, insurance will not cover!  You should be concerned about the condition of your heart just based on family history.  What should be done is avoid all risk factors: control blood pressure, proper diet and exercise, not stress your heart with unnecessary negative thoughts, etc.
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Avatar_m_tn
At age 62, I've been type 1 diabetic for 50 yrs., no major complications until now, not overweight, exercise regularly, and eat moderately.  I went to doc with mild "tightening" in chest, only with max exercise. Did all the nuke stress stuff, and the treadmill said no problem.  The nuke pics showed blockage in lower part, actually two parts on right side. He said was not real bad but bad enough.  A positive is that my heart functions good.  He recommended cath, but said latest and best research (one being Courage study) shows meds, diet, exercise to be as good as stints, and that he would recommend the regimen over stint if cath verifies what he sees on nuke, and he's 99% certain on that.  He told me most, if not all, cardios in this area would do stints, but he would not.  When I asked what he would say if I opted for non-invasive for time being and monitoring carefully, he said that's fine.  When asked how he felt about second opinion, was fine with that.  Unlike some, I can readily do the diet and exercise. In fact, tightening has become rare with more exercise - am just starting on statin - Crestor - Am thinking about second opinion from more cutting edge place than local, and wondering if legal exposure is another reason why so many go with cath. as well as stints.  Any thoughts/info. about any of this will be appreciated.
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Avatar_f_tn
Just to let you know... I am a 25 ur old female and I had a thallium stress which showed a largely positive blockage in my lad. My dr in ny told me to get a second opinion because that result didn't sound right. I am glad I did!! I went to duke and saw a cardio who did a cardiac MRI(pretty new tech) and it came back completely neg for any blockages. The dr did not recommend a cath. So the test could be wrong. You can always get a second test that is better than thallium stress.
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Avatar_m_tn
Thanks - Very interesting post - esp. since Duke is top-notch.  The new tech cardiac MRI interests me.  Any idea how to get more info. on that other than standard search?  I'm in AL, and am considering 2nd from UAB specialist which is probably top-notch in this area.  An additional note on my situation is that doc said I probably generated new collateral blood vessels that explain strength of function.  It's all as fascinating as it is mysterious and humbling - in my experience.
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Avatar_f_tn
I went to see the cardio in duke when I got those positive stress test results. The dr at duke recommended the cardiac MRI, so I googled it and that is how I found more info on it. You might be able to get a cta too... I couldn't because of my anxiety and they couldn't get my heart rate down. But the MRI is just as good and doesn't ecspose you to radiation. I actually got a cardiac stress MRI, where they inject you with meds to make your heart race and that further cks for blockages. I would suggest to get a 2nd opinion in the university hospital...just to be sure.
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367994_tn?1304957193
The latest CT scanners 128 slice are now available and the procedure is in 3D and the very best for an angiogram.  Can be performed on patients with arrhythmia and very fast heartbeats without the need for beta blockers. Given is the skinny on the new innovation and introduction of the 128 slice.  I had a CTA scan about a year ago, and a beta blocker was able to reduce my hr below 60.  I was somewhat surprised by the amount of soft plaque...calcium score is calculated and given a numerical value for evaluation with the general heart-disorder populations' artery health.

SOURCE: Zwanger-Pesiri Radiology has been providing the Long Island community with state-of-the-art radiologic services for over 55 years. We now have eight convenient locations in Nassau and Suffolk counties.

The 128 slice is ground breaking technology that leads to the most accurate and confident diagnoses with significantly shorter exam times. We also perform CTAs (Computer Tomography Angiography) for a more accurate diagnosis of arterial blockages, aortic dissections, and pulmonary embolisms by using unprecedented resolution and speed. Prior to this, cardiac catheterization was the primary solution to study coronary arteries. This more invasive procedure can now be avoided by the revolutionary 64 and 128 slice CT scanners.

The Siemens Definition performs Cardiac CTAs at a full 128 slices, faster than three revolutions per second, producing approximately 400 ultra-thin slices per second. Therefore, Cardiac CTA can be performed on patients with arrhythmia and with very fast heart rates without the need for cardiac-slowing beta-blocker medications. With this new revolution in CT technology, we can provide vital information, like detecting soft plaque in the coronary arteries, in a scan that can be performed in a single breath hold.
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Avatar_m_tn

The Courage study concludes:
In summary, our trial compared optimal medical therapy alone or in combination with PCI as an initial management strategy in patients with stable coronary artery disease. Although the addition of PCI to optimal medical therapy reduced the prevalence of angina, it did not reduce long-term rates of death, nonfatal myocardial infarction, and hospitalization for acute coronary syndromes.

So why would anyone  with 'stable' CAD even think about catheters and stents? What's the point? I'd really appreciate your opinion
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367994_tn?1304957193
It is true therapy (meds, stent implant and CABG)for coronary vessel occlusion only treats the symptoms as the COURAGE study concludes.  You ask the right question, who would want interventional therapy (CABG or stent implant) if medication effectively treats angina?  Also, stents and by-pass eliminate the probability of collateral vessel development...a natural by-pass of an occlusion.  I have a totally blocked LAD (collateral vessels) and 72% circumflex occlusion for at least 5 years and med (nitrate) prevents angina when I go to the gym for a workout.

A stent implant may be appropriate for individuals that can not tolerate a nitrate (some people experience a severe headaches.  Or for some reason a nitrate is not effective.

A by-pass may be appropriate if stent implants are contraindicated.  Such as a very long lesion, too many lesions, stent not possible due to location of blockage, i.e. irregularly shaped or small vessel , an emergency, etc.




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Avatar_m_tn
Your posts have been big help, Ken - thank you.  I have three questions related to non-interventional and non-cath approach:  

1.  If have 50% blockage and on meds, exercise, diet with stable CAD, I can't see using nitro to thwart mild angina.  If pain is not too bad, would it be better to endure that and even not to hesitate inducing it through strenuous exercise?  

2.  Related question:  Is the nitro constructive in some way other than cessation of pain?
  
3.  Per product info. posted on Siemans website, I see they now have a 128-slice CT.  I have only had the nuke stress test and am not going with the cath, but considering CT consultation at more cutting edge place for that.  What advantage would there be in following the nuke with most advanced CT?  I'm not thinking about confirmation of CAD so much as extent on the walls and what it would mean to get take on the more big event factor of soft plaque inside.  My cardiol says he doesn't see how it would make a difference in treatment.  By the way, I run all considerations by him on this stuff, and will not hesitate to get second medical opinion as well.
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Avatar_m_tn
I've been on medication for five days now and look forward hopefully to see if it could put off surgery.. One thing my cardios ask repeatedly is if I have  angina. I say NO, I haven't. Breathless? Yes, but intermittently.  But I feel this doesn't register with them nor with this group either. (In brief: an injected stress test showed 'suspected' trifascular disease).  Is anyone else with no angina being unwillingly pointed towards eventual stents and/or bypass?
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367994_tn?1304957193
Quote:1. " If have 50% blockage and on meds, exercise, diet with stable CAD, I can't see using nitro to thwart mild angina.  If pain is not too bad, would it be better to endure that and even not to hesitate inducing it through strenuous exercise?"

>>>Whenever there is angina that indicates the heart cells are not receiving an optimum blood supply.  To be conservative in view, it may not be a very good idea to not provide heart cells to a good supply of blood/oxygen.  Oxygen fuels heart cells as calories fuel skeletal muscle cells.  For some people it is a good idea to burn calories from the reserve of excessive calories in fat tissues, but the heart does not have a reserve of oxygen to burn. When the heart requires more blood/oxygen, it takes away from other parts, and when that isn't sufficient there is angina.  However, heart cells are very resilient.

Quote: "2.  Related question:  Is the nitro constructive in some way other than cessation of pain?"
>>>>Its helpful for some types of esophegeal distress.  Not aware of any other circumstances.

Quote: "3.  Per product info. posted on Siemans website, I see they now have a 128-slice CT....."  

>>>Over a five year period I have a stress test, echocardiograms, CTscan 64 slice (recently hospital has installed 128 slice scan.  It is 4 dimensional, and reports state the images are  almost or as good as surgeon's view during surgery.  Also, one doesn't need to have there heart rate below 60bpm nor hold their breath for a very long time (difficult for some individuals).  The CT scan views the anatomy of the vessels for any soft plaque between the layers of the vessel.  It is this soft plaque that causes most heart attacks, as the soft plaque can rupture the lining into the lumen and clot.

I believe you are referring to calcium score with a ct scan.  There is an algorithm that numerically calculates the degree of soft plaque for each coronary artery and the combined total.  The algorithm compares the score with known data, etc. and predicts the probability of a heart event within a year.  A total score over 1000 Indicates the probability of a heart event at 25% per year. ..the higher the score the greater the probability...I remember the 1000 because my total is greater than 1000.

It probably wouldn't make any difference in treatment if one is already on choles. lower medication, but it does provide a basis for subsequent tests, and provides the general health of your arteries rather than just whether there is any plaque within the lumen viewed by a cath.  However, there can be ultra sound attached to a cath and that can view the entire anatomy of the artery.
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Avatar_m_tn
I had an abnormal chemical stress test. Results were blockage during rest and stress. Also scaring in both pulmonary arteries and backflow. Cardiologist ordered a heart cath. Results were NOTHING! No scars,no blockage and no back flow. All that money for what?
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