Angiogram

[green_been]

I went for my EKG stress test and a nuclear stress test. The tests indicated a blockage. I am now waiting for an angiogram. They put me on drugs after the test. I am on 1.25mg Monocor, 5mg Norvasc, 10mg Crestor as well as ASA 81mg - one per day. Now I wait for Angiogram. I am quite freaked out. So I am scheduled for an angiogram on Feb 5th. They tell me there are risks in this test. The risk is 1 in 1000 people die, stroke or have a heart attack during this proceedure. My question is this, Should I get a 64-slice Coronary CT Angiograph​y? This machine has no risk and will give them the same answers. This test is not covered by our health care insurance. It will cost me $1300. I am not opposed to paying that extra money to eliminate risk. What are your opinions? .

[ed34]

There is no such thing as no risk, even with ct angiography. You could react from the dye for example. The thing is, they have to give a risk quotation for any procedure to cover themselves. I was told this by a cardiologist, and I have met cardiologists who have performed thousands of procedures over 30 years and never had a patient come close to death. Yes you could have a stroke or heart attack and die, but the chances of that are so slim that it's unbelievable. Plus, if they dislodge plaque and you start to have a heart attack, they are already in your arteries and can sort it out. The other thing to realise is that ct angiography is not an intervention method, it's just analysis. If they find a blockage, you will need angioplasty anyway. Let them go in and sort it out with one procedure. I've lost count how many angiograms ive had now, and I can tell you they are painless and nothing to worry about. I have one just a few weeks ago and I was having discussions with the cardiologist during the procedure.

[green_been]

Here are some of my results from the tests I have had. I do not understand the numbers but I have googled some of this stuff and I think it says my numbers are normal but I do not really know. Tell me what you think of these numbers if you know anything about them at all.

Thanks    LVEF stress 55%.  LVEF REST 53%,  Post Stress EDV 150ml, Post stress ESV 67 ml

[Jerry_NJ]

I go about 50/50 with failing nuclear stress tests and I have twice had angiograms that showed I had no blockage. So for starters I think you can be hopeful you don't have blockage.  If you do we're starting to talk about higher risks.  I have also had open heart surgery for a valve problem and survived that just fine.

I would take another angiogram if my doctor recommended it and not have a second thought about the risk... I think one in a thousand serious/death is too high. No I don't have another number but I don't consider myself unusually unlucky - well having a bad heart valve isn't exactly good luck but it worked unaided until I was  67, so not so bad at that.

[Flycaster305]

An angiogram will give you and your health professionals an up close and accurate view of your heart. Like Ed, I've lost count of the number of angiograms I've had, I think about 15, the last one literally saved my life.  

You will go in and be prepped for the procedure, and given a cocktail before the procedure that will relax you.  Let them know you have anxiety, and they will give you additional meds.  The most difficult part of the procedure is staying still for about 4-6 hours afterwards, you will want to be up and about.  

I'd suggest you should feel very fortunate to live in time frame where angiograms are perfected.  You will be fine, and if you need a stent, it will happen, which probably will save your life.  

[ed34]

You may not have to lay still for hours, they may use the more modern approach and go through the radial artery, through the wrist. This lowers risks even further. Of course, we mustn't overlook the fact that your nuclear scan backs up your stress test.

[ed34]

The numbers you have posted are not really relevant to a blockage in all cases. For example, my LVEF is always 70% but it doesn't mean there is no ischemia. What is often observed as a giveaway is how slow the heart muscles is at relaxing each time it has pumped. I assume you have had some sort of symptom to prompt the tests?

[green_been]

My 1st post was this in the angia community. This is what prompted the tests

I get chest pain while using the eliptical machine in the gym. I go slow and after about 8 minutes I get burning pain in my middle chest. I hang in there for a full 15 minutes. Then I start my weight lifting routine. I work out very hard and heavy for about 1.5 hours. I use very heavy weights. I start with 300 lbs for bench press and do 5 reps, then drop 20 lbs and do 280 for 5 reps. I drop another 20lbs and do another 5 reps. This goes on for about ten sets of bench. I take very little rest between sets and I have no chest pain during this. I continue my workout doing other exersises for other body parts. No matter what work out I do it is very heavy and very high intensity work out and no chest pain. After the weight training I go back to the eliptical machine and do the same thing I did at the start and I get no pain. Is it possible I have a heart problem. This just started 3 weeks ago. I am baffled about this and worried. The next day I will do this again and start with elipticle again and the same thing will happen. I will get burning pain in my chest again. Has anyone ever heard of something like this? .

[Jerry_NJ]

I have read bad things relative to the heart for "power lifting"... also for "extreme athletes" I don't have any exact limits on exercise to avoid these risks but it sound like you are close or there.  Have you discussed this with your doctors?

[Flycaster305]

I used to power lift, and think Jerry_NJ gives your good thoughts.  I wasn't in your class, I was happy to press my weight but worked some very heavy weights with legs.  I stopped when I had my first coronary event at age 59 and simply did low weights/more reps and mixed in a lot of cardio. It was explained to me that sudden bursts of heavy activity is about the worst thing you can do if you have a blockage.
I'd far rather have a heart cath than risk a heart attack with sudden physical activity.  Things like shoveling snow, lifting heavy items, heavy stress are risky, far more than a heart cath.  I'd suggest you talk to your doctor about your fears, exercise, and simply let things happen so you can get more information.

[Occupant]

I don't think a 64-slice CT-A is good enough to remove all doubt as to were you are as far as your heart is concerned plus you will be out $1,300,  however, an Angiogram will. Below is what I found on a web site. That ought to tell you something.
"If the CT scan is normal or only mildly abnormal, it makes the likelihood of a severe blockage of the coronary arteries extraordinarily small. Conversely, if the CT scan is significantly abnormal, cardiac catheterization and angiography are then indicated, to see if angioplasty, stenting, or coronary bypass surgery may be indicated."

[ed34]

The trouble is, heart issues can be so very confusing, even for cardiologists at times until the appropriate tests are performed. Even then they can be inconclusive, but an angiogram is the best way for looking at the coronary arteries. When my heart started to give issues I was only affected if I breathed cold air and this caused a throat discomfort. For nearly two years it was blamed on my stomach. I've had angina come on quickly, but after resting a few seconds I continue with exertion and the problem doesn't come back unless I rest for quite a while. It's almost as if the heart is adapting in some way, opening extra vessels. With angina I've always found that standing still and using my arms has given no problems. Angina has always been associated with leg work for me, and I have no idea why. Perhaps because it's easier to circulate blood in the arms compared to the legs. As my disease progressed, it was eating which brought about attacks. Digestion needs a lot of blood and the heart has to work harder.

[green_been]

Thanks for all the advice from all. I am still interested if anyone can comment on any of these numbers

LVEF stress 55%. LVEF REST 53%, Post Stress EDV 150ml, Post stress ESV 67 ml .

[ed34]

Well the ejection fraction is ok, normal is 50-75%. The end diastolic volume could be classed as fine because the normal range is huge, something like 65-240ml but the average is about 120ml. The normal end systolic volume is something like 20-140ml with average being around 50ml.
So looking at the average numbers, your left chamber has a larger capacity than most, @ 150ml compared to 120ml. This could be contributed to many things, genetic makeup, fitness or enlargement. Your volume after the chamber has contracted is 67ml which is higher than average. So although you have more than average blood in the left chamber, you are pumping less than average, suggesting lower efficiency.

[green_been]

So I think what this means is when my heart is full it has 150ml and after the pump is has 67ml remaining. Is this correct?

[ed34]

Yes

[ed34]

Just to make even clearer, You start with 150ml and end with 67ml, which means 55% of the 150ml is ejected out of the heart with each beat. This 55% is your ejection fraction.

[green_been]

Thanks for the info. You have told me so much more than my doctor ever told me after my 2 minute appointment with him after the test. So here is another question if your up to it. The result of my treadmill test are this. I ran for 10.5 minutes and acheived 14 METS which they tell me is  the equivalent of running 10 MPH at a 5 degree grade. I could have gone harder and longer since the intensity level of this test was less than my normal workout. They had to keep increasing the speed to get my heart beat up to the required BPM. I have been training very hard leading up to this test. I did not get any chest pain during this test. They stopped the test because I acheived the required BPM and they did the isotope injection and I had a 3 mm of ST segement depression. My blood pressure before starting the test was 142/90 which was higher than my normal I think because of my worrying and lack of sleep leading up to the test. My blood pressure during the peak of the test was 194/88. I have googled a lot of these results and found that everything seems to be good except the segment depression. What do you think?

[ed34]

Yes the st segment depression certainly warrants investigation, and is more common than many people think being asymptomatic. Causes can be a few things such as ischemia, bundle branch blocks or effects from medications. It can also of course be a case of a bad contact with one of the leads on the skin.

[green_been]

Thanks for all your answers. So now I understand some things about my test results. My heart is a little larger than average which is consistant with an athelete that has trained for years. My ejection factor is normal so my heart is working properly. During my stress test I had to work up to 14 MET's to acheive the proper BPM. I had no chest pain during the test. My diastolic blood pressure did not rise during my stress test. I have read if it does rise it indicates a blockage. It did not rise. I got 3 mm of segment depression which could also indicate bad contact with one of the leads. So is it really wise to do a risky angiogram or would it be money well spent to do the  64-slice Coronary CT Angiograph​y?

[ed34]

If you want my truthful opinion, I would go for the angiogram. This is because of two things. First the there are risks, but driving a car carries risks, as does crossing the road. Life is full of risk. However, the risk for Angiogram is tiny. Let's say you go for the CT-64 slice, which my Cardiologists have all hated, and they find that there is a blockage which warrants further investigation, you will still need an angiogram after. If anything is found, all paths will send you back to the angiogram. Even if nothing is found during the angiogram, you will know with absolute certainty that there is nothing wrong. All cardiologists have told be they have had cases where the ct has missed something and this will haunt you for years, especially if you develop symptoms. Doctors will argue there is no blockage, you will believe there is one and a huge battle starts in your mind. Now, from personal experience, I can tell you that a CT can be next to useless. I went into hospital with severe Angina, and I mean severe. I honestly thought I was having a heart attack and blood tests showed my Trroponin markers were very elevated. During the Angiogram everything looked normal, there was no new blockage and blood was reaching all areas of the heart. The cardiologist then did FFR which is a tiny sensor on the tip of the catheter. You start at the top of each coronary artery, take a base reading of blood flow, then gradually descend it down the artery looking for drop offs in flow rate. Halfway down my circumflex the drop off was more than half and yet there was nothing to be seen. The artery looked the same diameter all the way down. He put a stent in the area and the flow increased to normal. However, below the stent the flow rate dropped off again, so another stent was put in place. This cured it and all my angina stopped and my troponin started decreasing. There is no way in a million years that this could be spotted in a CT. They can also check for vasospasm during an angiogram, which could be a cause of the ischemia. To be truthful, I could probably write a book as to why the angiogram is a much better choice. On a last, but important note. It is becoming the norm to do an angiogram through the radial artery in the wrist now. This reduces complications because you can't bleed to death from the wrist, not like you can from the femoral artery in the leg. You are up and about virtually straight after the procedure.

[green_been]

Thanks again

[leejosepho]

I agree with having the angiogram, and I had one just a few weeks ago.  However, I would also have a clear discussion with the cardiologist beforehand as to what will or will not also be done at that time.  My angiogram led the cardiologist to say I need coronary bypass surgery, but neither surgery nor stents actually treat any cause of coronary artery disease.  So before having stents to simply reduce angina, learn the things no cardiologist will tell you and consider an oil-free plant-based diet.

[ed34]

I get so confused about the so called causes of heart disease. I've heard it's smoking, lack of exercise, bad diet, stress and many other things. I do believe stress is a major contributor though. However, until a cardiologist answers my one question satisfactorily, then I will always be a big sceptic about causes. My question is "I've had scans all over my body, head, legs, abdomen, arms and no other vessels show any signs of disease, yet my coronary arteries are a mess. So, what is it that says 'let's just attack 3 vessels out of the miles of vessels in the body?' Doesn't it seem just a bit odd to anyone else that just three arteries in my body would be affected? It would suggest that cigarette smoke is intelligent or food is intelligent to attack just those.

[leejosepho]

My own blockages are much less in places other than around my heart, so my guess would be that the never-get-a-break arteries around the heart are more sensitive or subject to endothelial dysfunction brought on by poor diet even when said diet is allegedly "heart-healthy".