Stress Test

I am 61 years old and had a massive heart attack and triple by-pass at age 41.  The past 20 years have fortunately been uneventful and I have had no symptoms or problems.  I just switched to a new cardiologist who is very promient and in whom I have a great deal of faith.  On a recent echo stress test, I went for 13 minutes achieving 15 METS.  The echo seemed to indicate that my ejection fraction was in the mid forties; however, my new cardiologist did not think that was reliable and recommended and RVG nuclear medicine test.  The RVG results were rather alarming, indicating an ejection fraction fo between 25 and 30. (Previous RVGs from many years ago were about 36.)   My cardiologist has recommended that I consider a pacemaker.    I have been on Altace for many years and on Coreg for a few years.  My cardiologist has also recommended that I double the Coreg dosage. Do you have any recommendations?  Are there any other treatments that could help?  Any experimental treatments available?   Most disconcerting to me is that I have been very optimistic through the years because I have always done exceptionally well on my stress tests and have no limitations or other problems.  However, these recent results seem to indicate that my heart is worsening and I am now very concerned.

[Michael J. McWilliams, M.D.]

Do you have any recommendations?  

15 METS on a stress test for 61 years old is great. It sounds like you are exceptionally fit and essentially without symptoms.  Ejection fraction does correlate with risk of long term cardiovascular outcomes, but it is important to consider that you do not have symptoms and have an excellent exercise capacity.  These are good indicators.

For my patients with ischemic cardiomypathies, I titrate their ACEI and beta blockers to the maximum tolerated dose.  The maximum dose of coreg is 25 mg daily and the maximum dose of altace is 10 mg. It is also important that risk factors are contorlled --no smoking, diabetes, high blood pressure, cholesterol.  If your choleserol is slightly elevated, I would start a statin medication.

If you ejection fraction is less than 30%, you doctor is probably recommending that you consider a single chamber ICD.  An ICD is a pacemaker that monitors your heart rhythm for dangerous heart rhythms and terminates them with a success rate of around 98%, sometimes requiring a shock.  If you have an ejection fraction less than 30%, this is a reasonable option.  The highest risk of death for someone with your history is a dangerous arrhythmia.


Are there any other treatments that could help?  

what I mentioned above, maximum doses of ACEI (ALTACE), maximum dose of Coreg, statin medications like liptor (liptor), simvastatin (zocor), etc, and aspirin 81 mg daily.  Watch your diet and continue to exercise.

Any experimental treatments available?  

There are no experimental therapies that I know of for you -- but I am not sure that you need them.  It sounds like you are doing well, just continue to maximize your medications, live healthy, and consider an ICD.

I hope this helps. Thanks for posting.