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Stress Test Results
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Stress Test Results

Hello Everyone,

I'm a healthy 40 yr old woman with no health issue.  I had mild chest pains and went in for an EKG with my regular doc and it came back abnormal.  Family doc sent me to cardiologist and who had me do the nuclear stress test.  I got my results today and a little confused....

The EKG shows mild depression and the doc said he thinks it's fine and couldn't really give me an answer as to why it was abnormal.

The stress test findings were:

The overall quaility of the study is good.  The rotating raw images reveal breast attenuation.  The right ventricle appears normal.

Stress images demonstrates a small perfusion abnormality in the anterior wall.  Rest images demonstrate a small perfusion abnormaility of mild intensity in teh anterior wall.

Ejection Fraction of 72%.

Mypocardial perfusion imaging is probably normal.  The images reveal no ischemia.  There is a small area of infarction in the anterior wall.  Left ventricular function is normal without regional wall motion abnormalities.  Findings are consistent with breast attenutation.

So, I'm so confused!  It sounds like I've had a heart attack(infarction in wall) but then they say it could be breast tissue!  Does that sound right?  The doc said the test was good.  Just wanted a second opinion.

Thanks to all!
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30 Comments Post a Comment
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159619_tn?1318997813
Sounds like the images were affected by breast tissue and your doctor has determined that the infarction see is a false positive as a result. He has looked at several things to make this determination including your EKG during your stress tests as well as you great EF%. He most likely also had information about your wall motion and saw no abnormalities.

To me it sounds like a normal stress test, but I'm not a doctor. I would trust what you're being told.

Congrats!

Jon
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Avatar_m_tn
Thanks Jon - any idea what this means?

Stress images demonstrates a small perfusion abnormality in the anterior wall.  Rest images demonstrate a small perfusion abnormaility of mild intensity in the anterior wall.
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159619_tn?1318997813
This is saying that the anterior wall (back)  of your heart showed a reduced uptake of the tracer when stressed and at rest based on the images usually due to blockages in the arteries. This is what your doctor is saying is really the result of the image being blocked to some degree by breast tissue. By saying your test is normal, he has determined that these do not in fact exist.
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159619_tn?1318997813
Sorry, got that backwards AGAIN, it's the front of your heart, not the back. Still, good results for you so you can relax. Take care of your heart going forward as you have a good starting point.
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367994_tn?1304957193
To put your experience in perspective and based on what you stated in your post, you had chest pains and the doctor wanted to rule out a heart condition so there was an EKG test.

The EKG showed an ST segment depression (you just state mild depression).  Reading between the lines you must be referring to ST segment.  ST segment depression can be caused by ischemia (occluded vessels), digitalis (medication), rapid heart rate, and temperature or electrolyte abnormality (blood test can rule out). ST depression can also be seen in infarction (scar tissue from prior heart attack).  Your doctor comments  he didn't know the underlying cause so to rule out ischemia (vessel blockage) causing your chest pain you were given a perfusion stress test.

"The perfusion stress test' finding is images demonstrates a small perfusion abnormality in the anterior wall.  Rest images demonstrate a small perfusion abnormaility of mild intensity in teh anterior wall".

>>>> Perfusion abnormality indicates normal blood flow to the heart cells are compromised....with exertion there is higher demand for oxygenated blood and the blockage prevents an adequate supply, consequently, there is chest pain.  But with rest there is less demand for oxygenated blood and the blood flows adequately to the heart cells and no chest pains (angina pectoris). Because  "rest" images don't show return to normal and there remains some ischemia is usually not a mild condition....do you have chest pains with exertion, and chest pain at rest? The finding of lack of perfusion with stress and rest supports the finding of scar tissue. However, the left ventricular function is normal without regional wall motion abnormalities so your doctor considers it medically insignificant and the positive test regarding abnormal perfusion is an artifact.

What also should alert the cariologist is that your EF is slightly above normal range.  Normal is 50 to 70% and if the EF is higher than the normal range that could indicate the vascular system maybe overcompensating. However, the EF is an estimate and is not a static parameter and may not be an issue unless it is consistently higher than normal with some regularity.  

I can see why you have some quesitons...Do you still have chest pains?
Thanks for sharing, and if you have any further questions or comments you are welcome to respond.  Take care,

Ken
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159619_tn?1318997813
What Ken says is all basically correct. The bottom line is simple, we are not doctors. Yours has requested the test you underwent and has determined that the results were good. That's really all that matters. Every finding has a normal variant which your doctor has reviewed and determined everything to be within normal results.

Remember, as I said none of us on this board are doctors and are in no way qualified to second guess what you have been told by yours. Your doctor has committed to many years of education and residency and deals with issues like yours every day. If you feel you can not trust your doctor you should seek a second professional opinion.

I think if I was feeling good, free of symptoms that have not been explained by my doctor, I would be very happy with these results! There are many causes for chest pain, not all are related to the heart. Again, seek a second doctor's opinion if you feel the results do not match what you're feeling.

Good luck!

Jon
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367994_tn?1304957193
I hope you are not accussing me or anyone else on the HD forum of trying to be a doctor when answering a post and addressing the concerns of an individual's health concerns. I suggested the evidence as given by tests and chattycat's symptoms of chest pain does or could be pathological. Chest pain and a lesion is consistent with scarring or negrotic heart cells (defects).  That is not giving medical advice!

I believe as does chattycat something is left unexplained. Chattycat has his health concerns and has right for some answers based on the doctor's ambiguity.    Because the doc said the test was good....what does that mean? "COULD" be heart tissue for an irregulatity seen?

"There are many causes for chest pain":, true.  But an EKG indicted a lesion  so there was givien an EKG,  and there was an abnormal results (reliability for an EKG is about 70% as well as selectivity so it is not without some reliability. Based on that evidence there was a stress test to evaluate the perfusion of blood through the vessels  with exertion and rest and that showed some blockage with exercision and rest....that to me indicates a lesion (defect) and not necessarily a blockage. I think it would be a scar tissue if anything and that would be consistent with the other tests and symptoms,  and that is not giving medical advice....etc, etc. Frankly, telling someone to believe their doctor, and then suggesting a second opinion is providing advice!  I interpreted the given information and its signficance as I almost always do...no advice.

Thank you for your comments,

Ken
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Avatar_m_tn
Thanks Ken!  I appreciate your posts!

Could the brest attenutation be the cause of the stress and rest images to show the perfusion?  That might be a silly question but I am just learning.  I guess I'm just hoping for no past heart attacks!

Thanks
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159619_tn?1318997813
Ken,

I don't think any of us are in a position to second guess a doctor. You are not a doctor nor am I. Your comment; " I interpreted the given information and its signficance" would suggest that you have all the facts and are making a medical judgement which is contrary to what he has been told by a trained medical professional based on your knowledge from the Internet. His doctor has already done that and determined that his test results are fine based on the OP's COMPLETE history along with the documentation of the test results as well as the actual images, all information you and I do not have access to. My point is only this, if he is not comfortable with what he has been told, he may want to consider a second opinion. I am not pointing out the obvious, for example; "What also should alert the cardiologist is that your EF is slightly above normal range", do you really think a trained cardiologist of even a family doctor does not know this and has not considered it? Why would you put that doubt out there? Do you base that on your educated medical opinion or from what was read on the Internet? Again, you are second guessing his doctor. I am not singling you out, I think this is the danger of most Internet forums.

To the OP, yes breast tissue attenuation can cause the images to show a problem that is not really there. I have had a few nuclear stress tests and my first one read almost the same as yours. Two years later after losing 70 pounds I had another and it no longer showed any breast tissue attenuation. The important thing is how do you feel? If you are having chest pain still your doctor can do a cath to be sure, but it is invasive. Again, I would put my faith in the doctor's opinion unless you have reason to doubt it. If you do, reach out to another.

Good luck!

Jon
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367994_tn?1304957193
Q: Could the brest attenutation be the cause of the stress and rest images to show the perfusion?  That might be a silly question but I am just learning.  I guess I'm just hoping for no past heart attacks!

>>>>>>I understand completely what you are reading. Report: Mypocardial (sic) perfusion imaging is probably normal.  The images reveal no ischemia......THERE IS a small area of INFARCTION the anterior wall.  Left ventricular function is normal without regional wall motion abnormalities.  Findings are consistent with breast attenutation.

Meaning of test artifact: An artifact is usually an image artifact ... which is essentially a distortion in the picture of the heart in the imaging equipment.
Now occasionally an artifact is simply a small "something" which is not recognizable (but infarct was recognized), but most artifacts seen in an image, particularly of the heart are image artifacts and probably don't mean anything, since the heart is a moving entity.

Sourced:
>>>>1.  Info on breast attenuation: Breast attenuation generates apparent hipoperfusion of the anterior wall and can be seen not only in women with large breasts but also in those with relatively small but dense breasts.

>>>>2.  Shifting breast attenuation: Shifting breast attenuation can be caused by different position of the breast in the stress and rest acquisitions. Such differences will result in attenuation artifacts that affect different portions of the left ventricle in the stress and rest images and thereby simulate stress-induced ischemia and/or reverse distribution. (For instance a position may impede normal blood flow of a vessel to an area of interest).

>>>>>3.  Localized diaphragmatic attenuation generally creates a fixed inferior defect. Unlike the breast, the position of the left hemidiaphragm is relatively stable and therefore, shifting attenuation artifacts are relatively rare.


>>>>>4.   Then there is soft tissue attenuation: The effect of soft tissue attenuation may be generalized or localized. Generalized attenuation, encountered in obese patients and in individuals with a large chest circumference, results in decreased counts density and poor image quality. More frequent are fixed, localized soft tissue attenuation artifacts secondary to the left hemidiaphragm, large abdomen, the left breast, and lateral chest wall fat, usually mimic myocardial scarring....is your body type consistent with the description?

There may be a clerical error regarding the statement small area of infarction?! ...

Thanks for your response, and if you have any further questions or comments you are welcome to respond. Take care,

Ken


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Avatar_m_tn
I don't believe my body size is consistent with that desc...I am 5'2" 120 lbs...so that just further confuses me.

I have made an appt for a second opinion next week and I'm very anxious to hear his take on the results.  Will be a long wait until next Wednesday.  This has really taken a toll on me.
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159619_tn?1318997813
Hang in there, knowledge is power over your life. I suspect everything will turn out just fine so try to relax. The hard part is done, now you just need to get the test result looked at again. Enjoy the weekend, do what makes you happy and don't get too worked up, it just won't make any difference about what happens on Wednesday!

Jon
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367994_tn?1304957193
I have responded to serveral posts where breast attenuation was an issue and it always pertained to women with large breasts...doesn't mean men cannot have large breast!  Attenuation literally means loss of strength and for instance a large breast will weaken an image.

I don't mean to step in on another's response, but it appeared to me you have some understanding and you were focussed on the correct issue. Some members although well intended and motivated to help do not have any personal experience and don't have specific knowledge of the issues. For some passing interest the EF is on the upper outside the normal range and may have some significance if when/or considering a possible syndrome.

You are commended for taking an active role and interest in your own health.  That is what I did 7 years ago after having a heart attack and congested heart failure.  The initial cardiologist who was on duty when I was in emergency made himself the treating doctor  
with my permission (time constraint).  Test showed I had a blockage in the RCA (98%) and the ICX (72%) and heart failure (EF below 30%).  He implanted a stent in the RCA
and I was told my EF would not improve....I posted a question on this forum 7 years ago and another forum and was told correctly my EF  could be improved and evidenced by a current calculation of 59% so I was confused at the time, and thought I had a few months to live...the doctor was not helpful with any information with the question of longivity his response was non-verbal and pointed to the sky...no bedside manner :).  

The initial cardiologist a month after the RCA implant wanted to now stent the ICX...I had no symptoms, felt well with the medication, etc. and when asked the doctor could not adequately reply to my question why the ICX was not done at the time of the RCA implant?  Before I could make up my mind the cardiologist moved out of state.  My current cardiologist who is not an interventional cardiologist (doesn't do stent implants) has treated my symptoms with medication and has never recommended a stent implant. The first cardiologist did not speak and possibly understand the English language so I will give him the benefit of the doubt for his motivation. Some people may not be so generous in the evaluation of the doctor's motivation and may claim the doctor was more interested in the money for another implant, don't know?!  

However, worst case scenario you do not appear to have a very serious health issue, and there may be a communication problem, etc... ...again you are making the correct decison, you are in control, the doctor's work for you, and doctors are not always right for whatever the reason. I would be interested in the statistics for a seconded opinion!  I know insurance underwriters do not object to paying for second opinions...so the probability most have some significance.

Thanks for your response.  Take care, and your health is not seriously impaired according to your posted information, and if there is a problem you can be successfully treated..

Ken
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159619_tn?1318997813
Not trying to be too well meaning here but from the Cleveland Clinic Web Site;

"What is ejection fraction?

Ejection fraction (EF) is the measurement of how much blood is being pumped out of the left ventricle of the heart. It is reported as a percentage. Healthy hearts have an EF of 60-75%."


This would suggest to me that an EF% of 72% is pretty good. Also, as explained to me during my days of testing when gaining my personal experience due to issues I was experiencing as well as members of my family, breast attenuation could also be the result of dense muscular pectoral muscles as well so body size is not always the determining factor.

Again, I see no significance in an EF% of 72 as did the OP's doctor. It is within the normal range.
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976897_tn?1379171202
I learned something today which rather surprised me. The European Society of Cardiology (ESC) say that 50% of patients with heart failure have a normal EF. They say this causes overwhelming challenges in diagnosis and new methods for catching HF are being sought.

If the heart is pumping a normal volume of blood, how is this heart failure? Does this mean that heart failure is not simply an inability to supply the body's needs? The ESC say the outcome regarding mortality and morbidity is as severe as those with low EF.

So I think I'm stuck in confused.com on this one..
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Avatar_m_tn
I thought about your confusion regarding HF and cardiac output and did a few searches and this quote comes from a medical dictionary site via wikipedia.... I don't know it this information is useful? It makes sense but as a compensatory mechanism cannot be maintained forever.


"the failing heart attempts to maintain a normal output of blood by enlarging its pumping chambers so that they are capable of holding a greater volume of blood. This increases the amount of blood ejected from the heart, but it also leads to fluid overload within the blood vessels and excessive accumulation of body fluids in all of the fluid compartments."
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159619_tn?1318997813
I wonder how blood pressure plays into this. Does low cardiac output equal low blood pressure? I know when a heart enlarges to compensate, it usually has a higher resting heart rate and has difficulty keeping up with exertion which is when the symptoms kick in.
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976897_tn?1379171202
Very interesting and it seems to say that heart failure is not necessarily just the stage where its output cannot meet demands.
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367994_tn?1304957193
There is no exact range for of the ejection fraction.  I have read reports were the doctor considered anything over 65 as being in the compensation category.  What is important is whether or not the heart is beginning to overcompensate, and if and when it overcompensates the heart will enlarge and eventually cause heart failure if not treated.  

When the EF is high that can be due to a dilated left ventricle or possibly anxiety. I can go into detail and have on many occasions.  It is related to the Frank/Starling law of physics.  And I have used as an example a handspring....when stretched it recoils with more force, but overstretch the spring becomes flaccid...same with the heart muscles that have specialized heart cells (myocites) that elongate and return to size when appropriate.  This happens normally within the range of the EF to help maintani a balance of blood flow between the left and right side of the heart as does the heart rate, and blood pressure.

The OP had an EF that was estimated to be over the usual standard for some cardiologists. Is there a problem?  Facts as given by the OP are chest pains and a high EF and a test that stated possible scar tissue that inhibits blood flow with exertion and rest.  Possible scenario, a marginally dilated EF (over 70) that has occurred due to prior heart attack.  The chest pains are related to ischemia has not been ruled out according to any information provided by the OP.


Q: I wonder how blood pressure plays into this. Does low cardiac output equal low blood pressure? I know when a heart enlarges to compensate, it usually has a higher resting heart rate and has difficulty keeping up with exertion which is when the symptoms kick in.

>>>>I am not highly educated in human system anatomy and physiology, but I as I understand it low cardiac output will INCREASE the blood pressure, but there is an exception when in a very serious condtion and near death the blood pressure will drop and uncorrected the blood pressure will flat line.

High blood pressure is also a compensating mechanism.  When the cardiac output drops the endothelium cells that line the inner layer of the blood vessel senses the decrease and a signal to the CNS has the kidneys to produce an agent that constricts blood vessels.  Constricted blood vessels increase the volume of blood providing, hopefully, enough blood to the vital organs...The system is reacting to a condition of severe blood loss, and it cannot distinguish low cardiac output from loss/losing blood.  

Comment:The European Society of Cardiology (ESC) say that 50% of patients with heart failure have a normal EF. They say this causes overwhelming challenges in diagnosis and new methods for catching HF are being sought. If the heart is pumping a normal volume of blood, how is this heart failure?

>>>>>Ed's research is correct but the heart is not pumping sufficient oxygenated blood. For instance, if there is a diastolic dysfunction (filling phase) the hf is due to insufficient blood filling capacity due to thickened heart walls, and that reduces amount of blood available to be pumped into circulation.  The blood backs up into the lungs and body system and that causes fluid to leak into the vessels (edema).from the lungs to the left ventricle. Also, there can be right side heart failure (less blood to the lungs). The same percent of the blood is pumped out (EF) of the LV, but there is a reduction in the cardiac output due to low input, and if severe that can cause heart failure as the heart tissues are not receiving enough blood (hypoxia).

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159619_tn?1318997813
>>>>>High blood pressure is also a compensating mechanism.  When the cardiac output drops the endothelium cells that line the inner layer of the blood vessel senses the decrease and a signal to the CNS has the kidneys to produce an agent that constricts blood vessels.  Constricted blood vessels increase the volume of blood providing, hopefully, enough blood to the vital organs...The system is reacting to a condition of severe blood loss, and it cannot distinguish low cardiac output from loss/losing blood.<<<<<

That makes sense, thanks.

Jon  

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