Should I pursue further testing?

I am a young man in my early 20's. After a cocaine overdose two years ago, resulting in a mildly elevated troponin level, I have been dealing with shortness of breath and chest tightness. I have underwent numerous EKG's, holter monitors, an echo, stress echo, and a CT angiogram. Everything has come back normal. Lately, during extremely intense physical activity I have been feeling a painful sensation directly beneath my sternum. I do not get any arm or jaw pain with this. Resting for 30 seconds or so relieves this pain. I am concerned this pain is angina.I have also been extremely out of breath during this activity, and am being outperformed by individuals much older and in worse physical shape than I am in. At one point yesterday I had to stop and was unable to participate due to extreme shortness of breath. I called my physician today and he prescribed me an inhaler in the belief that it is exercised induced asthma. Although this may indeed be the problem, I am unconvinced my heart is 100%. Would a nuclear stress test pick up anything the other tests might have missed, or do I have all of my bases covered?

[rockcityaudiouk]

Hello,hope you feel better soon.Actually you had the same tests as me and exactly the same symptoms,except I had the nuclear stress test before my CT angiography.

My cardio said that the only reason they gave me the CT angiography was because I had a mild positive nuclear stress test showing mild ischemia and the CT would show for sure if my arteries were clear or not.So according to my cardiologist Dr. Simon Woldman MD FRCP (Glas) FRCP FESC whom is also President of the British Nuclear Cardiology Society my arteries are clear!despite the positive nuclear stress test first!.by the way I still feel ****!.
but hope this helps!.....
cheers jon.

[ed34]

A nuclear test will show which parts of the heart are using oxygen and which parts are not. The parts not showing up on the scan conclude dead tissue. The injected isotope
attaches itself to red blood vessels and is exposed as a cell uses the oxygen. So, each
cell in the heart muscle using oxygen will glow on the image. Dark areas are a bad sign.
If an area is very dull, but not dark, then the cells are classed as dormant, just about receiving enough oxygen to stay alive resulting in a suspected blocked coronary artery.

However, saying all that, many times the scan is not conclusive enough. In many scans
a heart looks healthy but the coronary arteries are a mess. It isn't really known why this
is and so good cardiologists will only use the scan to inform about muscle condition.
To get a clear image of the arteries, you need a CT or angiogram. Most hospitals have
just one CT scanner in the UK due to the high cost and there are normally 3-4 Cath labs which means the waiting lists tend to be shorter. The beauty of the Angiogram is that
if they spot a nasty blockage, they can usually treat it there and then. This is obviously
not possible with a CT scan and a further appointment will be necessary.

So to summarise, one test shows one thing and another shows something else. No test
shows everything.

[CubbieBlue]

Had a clean CT Angio, what I am concerned with is if a nuclear scam is necessary to detect any tissue/muscle damage, or if my other clean tests would have ruled this out. My concern comes from substernal pain instigated from intense exercise that lasts less than one minute, and goes away with rest.

[kenkeith]

The ct-scan should have provided some evidence regarding the health of your coronary arteries.  My ct scan calculated a calcium score and an analysis and this should be
adequate in conjuction with all your other tests.

An angiogram (non-intervention) and cath is an interventional angiogram.  Both tests can determine blockage in the lumen, but the ct scan-64 slice can visualize the entire anatomy of the vessel and image any soft plaque between the layers of the vessel.  It is this soft plaque that increases a risk of a heart attack.  The soft plaque ruptures into the lumen and a clot forms and this can cause an infarct.  

The plaque in the lumen can cause ischemia but not as great of a risk for a heart attack as the soft plaque rupture.  Also, the soft plaque can cause stenosis (narrowing...bulge of the inner lining into the lumen) and ischemia.

[ed34]

What happens is the fat lining the artery gradually hardens as it oxidises into plaque, which is more brittle like a chalky substance. When the atherosclerosis starts, the
fatty substance is soft and moves quite easily with the artery. As the fat oxidises it hardens the fat from the outside working its way in. As the Artery expands and contracts
with each heart beat, the brittle plaque is prone to fracturing and this triggers the platelets into believing that there has been serious damage and they form a clot.

Sometimes a piece of plaque can break away completely and travel through the artery,
eventually finding its way to the filtering process of the kidneys, or becoming trapped in
a smaller vessel in the heart/brain causing a heart attack MI or stroke. This causes a
double whammy as it is known by cardiologists because not only is there a blockage
caused by the plaque, but also a clot will form where the plaque broke free.

It still isn't fully understood why cholesterol is stripped in the arteries by the immune
system to reveal the fat and there are many hypothesis'. Even if cholesterol is low,
there will still be enough lipids for the immune system to strip open. It is also apparent
that certain cultures seem to develop Atherosclerosis far more commonly than others.
Personally I put it down to stressful societies where people constantly have worries. With
these societies having existed for so long, we have lost the ability to even realise we are
stressed. When you tell some people to completely relax, they find it hard to relax all
their muscles because they are so used to keeping them tense all the time.

[CubbieBlue]

So should I pursue further cardiac testing?

[rockcityaudiouk]

I think I answered your question about further testing?.
what tests are left for you to have anyway?.a nuclear stress test?your 64 slice CT angiography would or should have made that test unessential.(and the need of exposing yourself to further radiation).OR
A cath test?,again exposing yourself to a potential death risk or risk of serious complication. (yes its small, but however small its a documented risk).what doctor(in his right mind) would give you a cath test anyway based on your previous tests?.

However there is a new CT with very low levels of radiation.its called the Aquilion ONE.it slashes radiation dose compared to other cardiac imaging modalities including 64-slice CT and nuclear stress studies. A 64-slice CT study at Piedmont exposes the patient to 15 to 25 millisieverts (mSv) of radiation, and a nuclear stress test exposes the patient to a radiation dose of 15 to 28 mSv. On the Aquilion ONE, on the other hand, the radiation dose is between 3 and 6 mSv in most routine patient exams.here is the link for your information. www.cardiovascularbusiness.com

[rockcityaudiouk]

Re:your slightly raised troponin.
yes cocaine could raise trop value or of course cause heart trauma which would raise it also.
Current guidelines for the diagnosis of non-ST-segment elevation myocardial infarction are largely based on an elevated troponin level. While this rapid and sensitive blood test is certainly valuable in the appropriate setting, its widespread use in a variety of clinical scenarios may lead to the detection of troponin elevation in the absence of thrombotic acute coronary syndromes. Many diseases, such as sepsis, hypovolemia, atrial fibrillation, congestive heart failure, pulmonary embolism, myocarditis, myocardial contusion, and renal failure, can be associated with an increase in troponin level. These elevations may arise from various causes other than thrombotic coronary artery occlusion. Given the lack of any supportive data at present, patients with nonthrombotic troponin elevation should not be treated with antithrombotic and antiplatelet agents. Rather, the underlying cause of the troponin elevation should be targeted. However, troponin elevation in the absence of thrombotic acute coronary syndromes still retains prognostic value. Thus, cardiac troponin elevations are common in numerous disease states and do not necessarily indicate the presence of a thrombotic acute coronary syndrome. While troponin is a sensitive biomarker to "rule out" non-ST-segment elevation myocardial infarction, it is less useful to "rule in" this event because it may lack specificity for acute coronary syndromes.

[CubbieBlue]

As far as further testing, perhaps a nuclear stress test to evaluate if all of my heart muscle is functioning properly. Here's the thing, if this sub-sternal pain during exercise is angina, something has to be causing it, and whatever this something is, hasn't been detected yet in any of my previous tests.

If it is not my heart, what else is causing my shortness of breath and exercise intolerance? It's not asthma, so I am at a loss.

[rockcityaudiouk]

Hi..ok hang on a minute we are going backwards here.
you had a stress test but I just looked up your first post,that was a stress echo?.
why don't you take a treadmill test first,of all the tests the tredmill and to some degree the nuclear stress test will show something if indeed it is there.your still very young to show signs of angina although I'm thinking you may have some degree of heart muscle damage from your previous cocaine overdose,which may have caused scarring to a very tiny portion of your heart.(I mean tiny!) I did think this from the start and because you seem very insistent I'm only mentioning it now.So go for the treadmill test first and really go for it....get your heart rate up to your max for your age.(220 MINUS YOUR AGE)

If that test shows something worthwhile,then maybe go for the nuclear stress test,as really there are very few options left available to you as you really have exhausted all external tests.but please consider carefully and seriously before going for a cath....your far too young to take risks.As an update for you with my story,my new cardiologist told me to stop measuring my BP and lock it away(the machine) somewhere(he thinks I'm a nut basically) and I have Exactly the same symptoms and tests! that you describe and have had,although I was positive(mildly)on a nuclear stress test.very frustrating!!!
I know how you feel....:o(
keep me posted. jon.

[CubbieBlue]

Stress echo is the same as a typical stress test on a treadmill, except in addition to the EKG they perform an echo immediately after your test. Basically it is an echo of your heart pumping its hardest.

If my previous overdose indeed did cause any damage it should have showed up on one of my numerous EKG's or tests, especially my CT scan. Also, there is no reason I would get a cath, I have had a ct angiography, which is a newer (and non-invasive) version of the traditional cath.

Also, the majority of what I have read says the nuclear stress tests very often show false positives, so that is most likely why yours said you had some mild damage, but no other test did.

Regardless, I visited my primary care today and he wants to do one more stress echo where I give it my all. If that comes back negative he wants me to get the Nissen surgery for GERD as he believes my acid reflux may be the cause behind my symptoms....and most everything else has been ruled out.

[rockcityaudiouk]

Hi,Ive listed and answered your points to avoid any confusion.

Stress echo is the same as a typical stress test on a treadmill, except in addition to the EKG they perform an echo immediately after your test. Basically it is an echo of your heart pumping its hardest.A: Accepted,but the reason I said to have another Echo or a treadmill mill test was to see if indeed your EF(ejection fraction had gone down)since your last one Or indeed if the pain came on(sometimes during one test it may not)for whatever reason,say you did not really go hard on the treadmill.

If my previous overdose indeed did cause any damage it should have showed up on one of my numerous EKG's or tests, especially my CT scan. Also, there is no reason I would get a cath, I have had a ct angiography, which is a newer (and non-invasive) version of the traditional cath. Not always.It depends.The cath is still accepted as"the gold standard".
CT is getting there but like I said the cath is still accepted as the gold standard.

Also, the majority of what I have read says the nuclear stress tests very often show false positives, so that is most likely why yours said you had some mild damage, but no other test did.A: Agreed.possibly Approximately 10%.Only if I retake the test I will know for sure and I don't want to have further radiation exposure.(at least for a few years);o)

Regardless, I visited my primary care today and he wants to do one more stress echo where I give it my all. If that comes back negative he wants me to get the Nissen surgery for GERD as he believes my acid reflux may be the cause behind my symptoms....and most everything else has been ruled out.A:Very good point.I too have GERD and that can indeed stimulate the vagus nerve which may cause problems.
Do you take proton pump inhibitors?.
Cheers Jon.

[CubbieBlue]

Yes I do but they do not seem to help. I  take two 30 mgs of prevacid a day.

[rockcityaudiouk]

I'm in the same boat with Lanzoprazole!...but what helped me a lot was cutting way back on bad Carbs!..now I eat chicken and fish salads,no bread,cakes(only when I cheat)and drink whey shakes.Actually when I went on a kind of Atkins diet(but my version hahaha)just fish and chicken with complex carbs mainly veggies it really helped.I also cut right back on chocolate,coffee,tea and all diet drinks.I went from really fat to not so fat.The cardiologist was impressed. I've lost over 1 stone.(14 pounds)in a few weeks.body fat is down to 28%
from 32 %.I eat no carbs at all after 4pm.
jon.