Correlation of EKG Stress test and potential for heart attack

[Gasry]

I have a copy of my treadmill test results. My ST was flat at about 0.9 out to about 90 BPM (V3), then dropped with a near constant slope to -0.9 at about 120 BPM and then dropped with a steeper slope to -3.8 at 142 BPM. The recovery line followed the test line to about 120 BPM and then recoved with a smaller slope to about -.1 at 80 BPM after 11 minutes of recovery time. I did not experience any angina during the test. The angiogram showed three blockages, two in one branch artery at 90 and 75% and the second in another branch artery at 75%. The two blockages are in a branch off of the LAD. The other is in a branch off of the RCA. The 90% block is right at the junction of the branch.  I tried to paste a picture showing the locations of the blockages, but would not work. The doctor put me on Amlodipine besylate and Metroprolol. The cardiologist said that my condition is not life threatening as long as I manage my lifestyle..  Can I infer a safe exercise level from the treadmill test results? I am 6' and 196 #. Up to the day of the treadmill I was exercising on a daily basis on the elliptical and rowing machine for 30-45 mintes with my heartrate at 125 to 130 BPM to lose weight and stay in shape.  I am coming back from 4 months of sedentary life recovering from a detached retinal requiring multiple procedures to fix. The cardiologist has said that we will reassess the need and benefit for a stent in about 3 weeks with another treadmill and nuclear. I have improved my diet, but can I really expect an improvement in the treadmill results with diet and drugs in one month? The doctor suggested that if I had continued to exercise at the higher BPM, it would have eventually led to a heart attack, suggesting a strong correlation between ST depression and death. If the blockages are addressed with stents, does that mean that mean that my ST depression will be mitigated? If so, does that mean that I can get back to a more rigorous exercise regimen? Thanks, Gary

[Lee Kirksey, MD]

Hello
My response was to highlight that current research is indicating that for patients with asymptomatic heart disease have similar life expectancy, risk of heart attack and death as those people who undergo angioplasty and stenting. This is largely because angioplasty and stenting does not "remove" blockages, it merely dilates the blockage. At some time within five years, the blockage is likely to occur.Furthermore stents can fail and cause complete obstruction of blood vessels and result in a heart attack. For this reason, the decision to place stents is not taken lightly. There are potential complications

Instead, in people with asymptomatic heart disease, the first line of treatment is control of risk factors like cholesterol, blood pressure, diet and exercise. Over time, the body generally creates collaterals which compensate for the blockages.

I believe that your doctors acted consistent with this prevailing philosophy that you would benefit from this trial of risk management. There is really no "risk free" magic procedure for the treatment of heart blockages. There is still a lot that we dont understand but it is becoming more accepted that heart attack is not caused by stable mild or moderate blockages but instead spontaneous rupture of these lesions. Control of your cholesterol, blood pressure and aspirin therapy appears to decrease this potential for spontaneous rupture.

If I were you, I would arrange a short discussion with your doc about the risk and benefits of treatment and the safety of beginning a graded exercise program that returns you to rigorous activity





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[Lee Kirksey, MD]

Hello Gary
What is your age. What are your risk factors including cholesterol etc. It would be helpful to know what if any symptoms prompted the stress test. Was it routine. Very compelling research is emerging that in the absence of symptomatic heart disease ie lack of shortness of breath or chest discomfort with exertion or  similar symptoms at rest- Medical management of the blockages with lifestyle management including diet, exercise and stress management along with control of your cholesterol, hypertension and other risk factors is just as effective as revascularization with a stent or open heart surgery. Additionally, evidence is emerging that stent placement does not have equivalent durability to open heart surgery

In your case, it sounds like you have been relatively sedentary because of your recent retina problems. If your cardiologist, deems it safe- a graded exercise program of swimming etc will be very helpful. Without knowing your cholesterol parameters, you should strive to reduce your body weight with a combination of diet and exercise.

You cannot infer a safe exercise tolerance from your stress test. Discuss this with your doctor. A stress test is just that-a test which is only one small part of all of the information that your cardiologist has about your condition

In my opinion, your focus should be less on improving your treadmill test results and more on committing to a gradual change in lifestyle which gets you to a low total fat of less than 25-30 gms per day and less than 12-15 gms of sat fat along with an omega 3 fish oil, coenzyme Q10 and Doxy ribose regimen. This regimen is invaluable for all heart patients who engage in a cardiac rehab regimen

The st depression is an indication that some layers of your heart muscle were receiving insufficient oxygen and blood flow. Use this as motivation to maintain your life style change

[Gasry]

I do appreciate your inputs.  I must admit that my confidence in the medical system has waned mightily over the past few years, primarily becasue of inaction by my primary physician.  This was compounded by the my impression that my cardiologist changed the orders at the last minute before the cath that eliminated the possibility for intervention for no apparent reason (there was the possibility that he had another procedure to do that pm).  And then there were the comments by the other personnel in the room after the cardiologist had left such as the 90% seemed like a no brainer and you are getting a second opinion.  This came from more than one person.  I have been active athletically all of my life with soccer, running (marathon, several half marathons and 10Ks) and biking.  After I got a TKR, I transitioned to tennis.  Since December 20th, when my I was told by my retinal specialist that I could exercise again, I have been working hard to increase my stamina, so it was frustrating for me to hear that I should limit my exercise to a walk.  I am committed to a healthier lifestyle (food) and I have the luxery of being able to pass the reins of my company on to the President, so I can take a leave (retire) and focus on getting back on track.  One problem is that I am goal oriented.  I actually have two cardiologists, on in the HMO and one on POS.  I could go back to the POS cardiologist and ask him to put together a plan, but then all of that could change on April 7 when I am scheduled for another EKG stress with nuclear enhancement.  My POS cardiologist is getting all test results.  I do have enough inputs now to at least believe that I have two possible scenarios for the path forward.  Thanks again, Gary

[Gasry]

I am 64 years old.  I was experiencing vision aberations, transient in nature that only occurred after I had been sitting for some time and then walked upstairs.  We postulated that the vision change might be due to a combination of higher than average intraocular pressure, which was the case, and a reduced flow of blood through the carotid artery.  My retinal specialist ordered a carotid ultrasound that confirmed blockage, but the 50% blockage was thought not sufficient to cause the problem.  That prompted me to ask my primary for a stress test.  Also my primary ordered a blood test that confirmed that my chlosterol is too high (240), so I am on 40 mg of Simvastatin.  I have experienced some neck and head pain at night turning over in bed, which seemed to start at the same time as I started the medication.  I have asthma, but well controlled with mouth and nasal inhalers.  After the angiogram, my cardiologist put me on Amlodipine besylate (0.25 mg) and Metoprolol Succ ER (50 mg).  My pulmonary specialist has ordered tests to verify that the beta blocker is not effecting my breathing.  I am still somewhat perplexed by your answer.  I must be missing something as far as the test data correlation with mortality.  It seems like removal of blockage would decrease the potential for a heart attack, if a heart attack is caused by reduced flow of blood to a region of the heart.  Are you saying that a combination of diet change and use of medications over time will enable me to get back to a rigorous exercise program with the same risk as having angioplasty and stents put in place?

[Lee Kirksey, MD]

PS
My book Your Guide to Optimal Health: Creating Your Personal Wellness Wheel includes several chapters on diet, exercise,stress management and the appropriate supplements to take for various illnesses including cardiovascular disease. See exerpts at www.personalwellnesswheel.com