Exercise Test Negative, Angiogram still recommended?

[acp]

I had a exercise test last week, 10.5 min Bruce Protocol THR achieved. The exercise test showed no changes and the summary was Negative for Reversible Ischemic DIsease. The Stress Echo also was Negative for Heart disease.

I did have a MI 10 years ago and a stent in the LAD at the time. No angina since. Recently though (about 3 months ago) while travelling in Vietnam I started to experience some discomfort occaisonally while scuba diving and walking. The problem would usually clear itself up after some serious burping. As I work as an instructor, I was still able to complete all the tasks (including lifting tanks up and down steps, loading and unloading the boats etc).

The discomfort only happens during the exercise though I have a long history of burping, and occaisonal stomach discomfort. It appears that I have discomfort usually in the mornings only

My Cardiologist stress tested me and reported the findings as above. However he is now recommending an angiogram as well. During the test I was uncomfortable. I describe the pain as starting just under the sternum in the middle, moving as a sharp pain to the right side (first down and then up into the chest) and then involving the chest. DUring the test, the pain started at level 2 of the Bruce Protocol, however, I was able to complete the exercise. There is no shortness of breath, sweating etc. And the pain is not the same discomfort as I felt during the angioplasty ten years ago (which was a sensation like a band being tightened across the chest accompanied by difficulty in breatthing).

Please advise if possible.

[CCF-M.D.-MJM]

This is tough -- but after reading your descriptions I agree that you need a cath.  This is where medicine is an art, not a science.  Your stress test is negative but your symptoms sound like they could be anginal chest pains and we know that you have coronary disease.  If you were a 23 year old male with burping and chest pain only in the mornings, I would probably believe the stress test.  In someone with a previous MI and symptoms that might be consistent with angina, there are three choices in my opinion.  1. is to just cath you, 2. do a stress test to figure the distribution of the ischemia on stress test and then cath you.  The second option is important because if you have any subclinical stenosis that do not cause ischemia, the stress test may help us when deciding which vessels need a stent (if any).  3. medical management with beta blockers, aspirin, controlling blood pressure, and statin.  If you continue to have symptoms on a beta blocker, than cath you.  Sometimes stress tests can be wrong.  In your case it sounds like it is worth doing the cath.

I hope this helps.  Good luck and thanks for posting.

[acp]

Thanks for your inputs.

TO clarify point 2. Is there a form of the Stress test that identifies the distribution of Ischemia?

The Stress test that was done showed no abnormalities in the waves. This is consistent with a stress test done last year. In the 10 years since the MI, every doctor who has seen my EKG or stress test has commented that if I did not tell them I had had a MI, they could not read it in the charts.

A quick follow up. I am presently in India for some period of time. It appears the facilities here are quite good, I presume there is no need for me to wait (or hurry back) to the States to pursue the test. Your recommendation apparently is to do it with all deliberate speed -- and I should so go ahead and do so while I am here (visiting family members).

Thanks again.

[Mantels]

DO THE CATH!