For KenKeith and Ed34 to help me understand

[Roster17]

Can both of you please give your opinion of what this report means in laymen terms.

EKG response to stress:
Baseline EKG: Normal sinus rhythm with frequent apc's
Peak exercise: there was 1-2 mm additional horizontal st segment depression in the inferolateral leads that met criteria for ischemia.

of note:  At approx 5 min of recovery, patient developed tachycardia with a cycle length of 280 milliseconds which transitioned from wide complex to narrow complex without change in cycle length and appears to be a sort rp tachycardia. (Can you explain what this really means). I had no symptoms except fast hb from treadmill exercise.

Imaging results:  Tomographic images of the heart demonstrate a very small defect of moderate intensity in the mid to distal inferior wall which is predominantly reversible in the redistribution images. Gated spect imaging of the heart demonstrates normal wall motion with a left ventricular ej fraction at 72% and an end diastolic volume of 54 mI.

Conclusions: Likely nornal stress thallium imaging of the heart consistent with diaphragmatic attenuation artifact, although a small area of ischemia in the territory of the rt coronary artery cannot be excluded.  Also patient's tachycardia likely represents atrioventricular nodal reentrant tachycardia with an episode of abberant conduction, altough atrial tachycardia and less  orthodromic reciprocating tachycardia cannot be excluded. Clinical correlation is suggested.

Results of treadmill exercise:  Average exercise tolerance for age & sex.  (74-F)
                                            Achieved 100% target hr. Duration 5 min.
                                            There was a normal bp & hr response to exercise.
                                            There was 1-2 mm additional horizontal st segment depression in leads 2,3,
                                            v4-v6 that met criteria for ischemia.

Conclusion: Positiver exercise ekg stress test for ischemia.

Do the results sound really bad. Cardio wants to do Cath. I'm undecided. Also wants me to see an EP

I know this is long, but I would appreciate your input. I already have a DES 4 yrs ago and doing everything right. Eating right foods. taking rt meds, brisk walking 1 hr everyday, no smoking.
Thank you.
                              

[erijon]

Thanks for the update, please keep us informed. It sounds like your doctor is being very cautious, that's great.

Hope all goes well!

Jon

[Roster17]

Thank you all for responding. I spoke with my cardio today and  decided to have the Cath done to play it safe. It's scheduled for 2/22. I will let you know the results.

erijon, after I had the stent put in, my cardio advised I have a stress test every year. I passed it every year except for this one.
Thanks again

[kenkeith]

Treat with medication for stable angina... treat with a stent for unstable angina (chest pain at rest).  It has alway been that way.  The trouble is that many individuals are stented with a blockage below the recommended guidelines and no angina!  

There has always been silent ischemia for a few individuals (diabetics, older patients), but that doesn't justify a stent implant when suspected with an EKG (elevated or depressed ST segment)...it was 1-2mm that at best is margina...should be 2mm or greater.  Before going forward with just some unrelaibe evidence from EKG for ischemia there should be symptoms and other signs.  A stress perfusion (monitors dye in the blood flow) test would be the next test for suspected occlusion of coronary vessels

Q:....but if an echo showed me ischemia at rest, that would result in tissue damage, something which can possibly be avoided by stenting".

>>>>You may have confused an issue.  An echo DOES not show ischemia.  An echo can determine heart wall impairment (echo report will state hypokinesis or akinesis) and provide information of the area. It will not tell anything about ischemia.  At best, it will tell you if any areas have been infarcted (IRREVERSIBLE damage to heart tissue).  That condition would be termed akinesis (cell necrosis).

You may be thinking of  a perfusion test that monitors blood flow at rest and during exertion.  That would be a more appropriate test for suspected ischemia rather than intervention with a cath angiogram.  

[ed34]

I agree, you shouldn't have a stent if you don't need one, but nobody said that is the case. I said that I would have the angioGRAM to see the state of affairs. If the blockage is sufficient to cause ischemia with exertion but not at rest, then I would have a go with meds. However, if the ischemia occurs at rest then I would probably want a stent, regardless of whether I had symptoms or not. We know symptoms are not a reliable factor, but if an echo showed me ischemia at rest, that would result in tissue damage, something which can possibly be avoided by stenting.

[kenkeith]

My opinion regarding interventional is consistant and not take a possible risk without some regard to benefit.. I see no benefit in a cath procedure without good cause. For instance what would a stent do for your physiological vascular health with at the present time you have no symptoms.  Also, one should keep in mind the risk of stent implant, migration, collapse, incorrect size, restenosis and the medication recommended after the intervention.  

You may discuss your options for treatment if any with your cardiologist.  I don't believe adding hardware to one's vessels without good cause and that would be to abate chest pain that medication can't resolve.  I have had both medical therapy and stent implant...

[ed34]

The other guys have really said it all I think. Your heart is in good shape to achieve 72% EF on the left side. There is just some mild ischemia somewhere on the right side, which they want to investigate further. I would go for the angiogram to be on the safe side, but it seems like it will be a small restriction. The EKG seems to confirm ischaemia.
Don't be concerned about this with regards to your regime of no smoking, healthy diet etc. You have done well to have such a small problem in 4 years. Many people end up with more stents well before now.

[kenkeith]

Your report indicates your heart is functioning normally, and you have normal exercise tolerance for your age.

The issues that may have some medical significance is a fast heart rate while in the resting phase of you stress test.  And there may be a small area of ischemia in the territory of the rt coronary artery cannot be excluded. The EP recommendation is for an Electrophysiological correct diagnosis as it is unclear after analysis of available ECG tracings and for whom knowledge of the correct diagnosis is necessary for patient care. It is not possible to give you an answer from the electrphysiolgical viewpoint.  The fault can be due to an extra pathway for electrical impulses to conduct, there is a fast and slow pathway that should be considered, etc. that can cause arrythmia.  

There appears to be a small area of ischemia (lack of blood flow) that may or may not be significant.  If you don't have any symptoms (angina,chest pain), there may be no need for a cath. The ECG indicates ischemia but it is not a very good source for a dx of ischemia as there can be other benign causes for a depressed ST interval. You didn't have any symptoms with your stress indicates the ischemia is of little medical significance.

Hope this helps and thanks for sharing.  If you have any further questions or comments you are welcome to respond. Take care.

Ken

[erijon]

I'm sure Ken Ed will be along, but if I may offer a few points.

First, your doctor is being cautious as your stress test was positive and he wants to rule out any issues. The test you took has an accuracy rate of 65% whereas a cath is 100%, which I'm sure you know since you already have a stent. The fact that you already have a stent means you have some CAD present and oving on to a cath is normal protocol.

Also, since you do have CAD, and EP study makes sense as all rhythm issues should be explored when CAD is present, again normal protocol.

If I can ask, why was the stress test done? Were you experiencing symptoms? If so, I wouldn't hesitate to go forward with the Cath and EP study. You need to be there to take care of that little poodle, I have two and would hate to not be there for them:) (you can see them in my profile)

Good luck, I'm sure Ken and Ed will be along.

Jon