What is a stress test like?

[Rosemary349]

Hi everyone

I have told my doctor that i want a battery of tests run on me because of what happened to my father last week.  The doctor asked me what type of test i wanted!  I don't know!  Maybe you can advise?

He's arranged for me to have a stress test.  What am i to expect with that?  Are there any dangers with that test?

I really just want a set of tests that will measure whether there is any heart disease or heart problems (i've had an irregular heartbeat although that seems to have resolved by about 95% since my thyroxine medication has increased).

Thanks for any advice you can give.  The doctor said he wouldn't recommend an angiogram because it can be dangerous.......thoughts?

[kenkeith]

Should be price on verticle axis and quantity on horizontal.  An increase in inventory shifts the supply curve to the right...higher quantity, lower price!  In a competitive market!  

[kenkeith]

by kenkeith, Oct 16, 2009 04:35PM
Quote ed: "My Cardiologist told me that bare metal stents are a nuisance. Scarred tissue grows quicker than normal tissue to try and repair a vessel asap, and bare metal stents dont prevent this".

My response,>>>Sales figures for manufacturing are up for BMS and decreasing for DES indicating, if you will, a decrease in the medical communities' acceptability of DES to reduce restenosis when comparing the risk of clots with DES.
My point is/was doctors are voting with their dollars indicated by up for BMS, down for DES.
_________________________________________________________

Ed's response QUOTE:  "The explosion of DES usage over the last few years has been incredible and this is partly due to them replacing the older BMS type in most applications, and it is also due to the fact that CAD is increasing dramatically, including in countries which previously had low occurrences of the disease. In 2005 alone 6billion dollars was spent in purchasing stents for the US, so worldwide the figure must be staggering. This is virtually double what the cost would total if BMS were exlusively used".

((There has been a simple question asked for you to produce your source for the explosion of DES usage!))
_____________________________________________________
My source regarding decrease in DES sales is 'theheart.org'.  DES sales plummet: Stent thrombosis, COURAGE study & competition.   I think I said an increase in demand for BMS will increase the price (demand pull, not cost push). The decrease of demand for DES (at least the generation of production referred to) will decrease price.  Have you recently seen graphic models...To read the graphic output is the supply (upsloping) and demand curves (down sloping) with price on the horizontal axis and the vertical axis is output....   When you bring cost into the equation you have revenue and cost equalibrium graphic models...not supply and demand!  I'll help you...what don't you understand?

[ed34]

" Please stay focused with why there is an increase in BMS and a decrease in DES...show your source! "

I presume this was aimed at Kenkeith because this was his statement.

With regards to economics, everyone knows the underlying basics are supply and demand. No demand means cheap cost. I.E. DES no longer used will result in huge stockpiles going very cheap to try and shift them at least with some cost. How you think the cost will rise is beyond me, perhaps economics works differently where you come from and has caused the worldwide recession. If something is in great demand then the supply has to be greater. However, this doesn't necessarily mean higher cost either because it all depends on the 'competition'. Do you remember how the clever Japanese brough about cheap production and knocked the electronics market for six. So, we have the new factor of availability. If I had the only stent available in the world, then of course I would let it go to the highest bidder and it would be worth a fortune.

[Max_123]

What is your source that "The explosion of DES usage over the last few years has been incredible and this is partly due to them replacing the older BMS type in most applications, and it is also due to the fact that CAD is increasing dramatically, including in countries which previously had low occurrences of the disease"...wouldn't that show an increase in DES sales and not a decrease?

What is your source that DES isn't correlated to not having a higher statistic for clots?  Is the plavix recommended by cardiologist for a year post DES implant and not the same for bare metal stents relying on a false premise?

We already know that clots can occur with either stent, and that is not the issue, as the medical medical community relies on statistics...I don't know your country's system, it may rely on cost!  If the demand for BMS is increased, that wouldn't cause the price of DES to increase?  You don't understand simple economics or your health system is not a free-market economy for health care?!

Show your stats that there is an increase for DES over BMS.  We all know there is an increase in CAD, restenosis, etc., but that is irrelevant as that does not change the CAD population to favor DES (as you state) when the underlying reason has not changed....    Please stay focused with why there is an increase in BMS and a decrease in DES...show your source!  The statistic may have changed as well as more current information as I am relying on information from a year or so ago..  

[ed34]

"Sales figures for manufacturing are up for BMS and decreasing for DES indicating, if you will, a decrease in the medical communities' acceptability of DES to reduce restenosis when comparing the risk of clots with DES"

Well I'm not surprised at seeing this war going on because the cost has far exceeded that expected by anyone. Of course clotting can occur in any stent, whether bare or whether DES. The explosion of DES usage over the last few years has been incredible and this is partly due to them replacing the older BMS type in most applications, and it is also due to the fact that CAD is increasing dramatically, including in countries which previously had low occurrences of the disease. In 2005 alone 6billion dollars was spent in purchasing stents for the US, so worldwide the figure must be staggering. This is virtually double what the cost would total if BMS were exlusively used.
I'm afraid that statistics do not really accurately point to DES as being a cause of more clotting problems and so we have to read between the lines and see what is happening behind closed doors. I remember last year in the UK there was a huge battle that went on between health ministers and Cardiologists. Costs had to be reduced and it was insisted that cheaper BMS were to be used and perhaps DES should be banned. Cardiologists strongly disagreed and the battle was eventually won to keep DES.
Both stents are identicle apart from the chemical coatins the DES. The BMS and DES are fitted in the same way, have the same physical properties and both carry a risk of
clotting which is why anti-platelet agents are always prescribed to CAD Patients. Clotting
of either BMS or DES is rare and is a risk associated with both types. With the use of stents becoming a booming industry, and a drain on medical insurances, I'm sure we will see a few regulations for usage appear in the near future.

[Rosemary349]

Thanks for your reply.  I think you are right.  I will consider writing in future.

Of course the question is how far do you go with things.  Like for me, because the stress test was ok this time.....I would feel daft if i pursued anything further.......but should i (feel daft that is, they'd certainly try to make me feel that way if the cardiologist is anyone to go by)?

I realise there are finite resources in the health system and i wouldn't want to push for tests that are unnecessary.

Equally I can see a need for people to have more tests than they currently do so that people like my dad would be picked up before the even happened (where possible).

[Rosemary349]

I hasten to add that my personal doctor was not at fault here in that he was not involved in what happened....he has only spoke about it retrospectively....

Also i have no real issue with the cardiologist i saw because he was only doing his job.  It's the nurse who i was on the phone to that i'm wondering about and the system in general that is not picking up on cases until it's too late.

[Rosemary349]

Yes i guess that stress test got me stressed!  LOL!

seriously i'm just angry because my father didn't make time to go to the doctor's.....but what really makes me angry is that he would have done if he'd realised what could happen.

I'm angry at the person on the health helpline who i feel overly reassured us that it was just indigestion.  I don't understand why she didn't say that we should get help immediately.  If i were a trained nurse on a telephone i would say they should get help immediately - based on my experience now.

My doctor told me that my father didn't have classic symptoms.  He did but they were at the end when it was too late.  However leading up to this two days before he had indigestion with bloating.  The doctor now tells me that some heart attacks present like that.  Why is no one told this?????  Surely the nurse on the phone should have realised that 12 hours of indigestion is too long?  

All the while i have people telling me i over worry, so i'm listening to people and following their advice and trying not to worry when i was right all along.

The cardiologist said to me that what has happened is in the past now and i am getting nowhere wondering about it all.  How convenient.  I asked him if my father would have had problems on that stress test a week before he died......he hesitated and then said something like well it's supposed to show up problems so we would hope that it would.....but most people don't get to have that test unless they have symptoms......such a simple test....doesn't take up much time.....why?

Heart disease is the biggest killer in this country.  There shouldn't be any complacency.  I'm almost getting the impression that it's acceptable for men to die and leave their wives widows.  Surely by now there should be far more checks in place and as i say there should be invitations for men of a certain age to be checked.  and i ask the question WHY isn't there?

How much would it cost for a man to be checked say once every five years after the age of 40?  Checked either with the scan that kenkeith mentioned or even just a simple stress test?  What reasons would there be for not doing this?

[kenkeith]

Quote ed: "My Cardiologist told me that bare metal stents are a nuisance. Scarred tissue grows quicker than normal tissue to try and repair a vessel asap, and bare metal stents dont prevent this".

>>>Sales figures for manufacturing are up for BMS and decreasing for DES indicating, if you will, a decrease in the medical communities' acceptability of DES to reduce restenosis when comparing the risk of clots with DES.

[ed34]

Rosemary I live in the UK and there are two important things to do. Firstly, if you want to know anything which your cardiologist hasn't told you, write to him/her asking the questions. If you are unhappy with any comments they made in your meeting, include that in the letters also. Always send a copy to your GP. This soon makes them change their opinion about you and treat you with respect. You see, if you put something in writing such as you don't believe they are taking you seriously or you believe they are overlooking certain things and you become ill over the next few weeks, they are in serious trouble. Not many people write to their cardiologist as they are intimidated by them and scared of them. Here's an example of a conversation I had with a cardiologist last year.....

Dr "I have been told off by hospital management for spending too much time on your case. I don't see anybody else once a week, so you are really lucky"
Me "Well I want the name of the manager concerned because I pay my national insurance and I'm entitled by law to receive treatment. I will take this to a good solicitor"
Dr "well there's really no need because I told him I would continue to see you due to your case being very difficult"
Me "I wouldn't have to come and see you every week if you could make up your mind as to which plan of action is best and we can begin. Each week you have a different opinion and seem to contradict yourself from statements made the week before. I really don't see the point in coming here each week because we simply talk for 5 mins and nothing moves forward. I feel the same now as I did months ago. Perhaps I should have that managers name and take this situation to court"
Dr "Really there's no need for drastic action, I will have a plan of action ready for next week, that's a definite"

I'm sure he was telling lies about the manager and I was not going to be told how lucky I was to be making a journey every week which was a total waste of time. You have to stand your ground, make noise and tell them what you want. I regularly wrote to my GP keeping her informed so if I needed backup, she was there.

[erijon]

Wow, they got you a little worked up it sounds like to me........ Congrats on the stress test results, that's the important thing, glad it came out good for you. I know what you mean, some doctors don't always give you the time you need. I always schedule a appointment and make them explain the hard copy of the report to me, sometimes it's the only way to get the info you need.

Congrats again,

Jon

[Rosemary349]

Also...

(Ok i'm on a roll)

I told him that when i wore the heart monitor previously i didn't feel any ectopic beats take place.  He just laughed as if he thought people lied about it.  He said he hears that all the time, that they don't occur when the monitor is on.

Interestingly mine have stopped a great deal after i requested that my thyroxine treatment was increased.  I certainly wasn't lying about them

[Rosemary349]

Oh they saw a few ectopic beats on my stress test but said that ectopics are normal and that they can come on during exercise ......or go away during exercise and come on at rest.....

I'm not convinced

[Rosemary349]

I've no doubt it all comes down to cost.....

but people should be educated on how important it is and then maybe they would invest in that sort of testing themselves.

Dad didn't know.  No one told him.  and there will be many other's like him.

Sorry, guess i'm still grieving!

Thanks everyone once again for your advice - i'm keeping hold of it for now

[Rosemary349]

I was told i passed the stress test and they had no concerns.

I'm beginning to get a bit fed up with people though, the doctor was like 'why are you here?' and he was asking it in a way like he thought i needn't have been there.  I hate the monopoly that doctors have on medical information, they don't share everything with you and if you question too much then you have an 'anxiety disorder' or something.

There are plenty of intelligent people in the world who could handle medical knowledge even if they haven't been to medical school!

and i'm amazed that here in England there aren't routine tests for people for heart disease considering it's the biggest killer in our country.  They check women for cervical cancer.....but there isn't any routine testing or invitations for it for heart problems.  My father never went to the doctor's but had he been invited for a routine check that other men his age got he would have gone along.

[ed34]

My Cardiologist told me that bare metal stents are a nuisance. Scarred tissue grows quicker than normal tissue to try and repair a vessel asap, and bare metal stents dont prevent this. DES were manufactured with a chemical coating to inhibit scar tissue growth. This allows the slower growing normal tissue time to form over the stent, providing a much smoother surface along the inner lining. Bare metal stents are much cheaper and are still used when felt they can get away with them. Plavix along with aspirin simply stop platelet activity against the stent, preventing a thrombus. Restenosis
involving fats/plaque can form on any stent, DES or bare metal which is why people have their blood pressure controlled through medication and why cholesterol is lowered.

[Rosemary349]

Hi everyone

Thanks for your posts on this thread.  I am reading every post but it's been a bit technical so i haven't responded.....be sure i'm taking it all in though.  It's just difficult at the moment with everything that's happened.....my father's funeral was yesterday.

I am really, really grateful for all the advice given here and all the different information.  I have my stress test tomorrow and i will ask about the availability of other tests.

Thanks again, it's really appreciated

[kenkeith]

QUOTE: "I have a question on the 128 slice ct scan i asked my cardio dr if i could get one and he said since i already have stents there is no reason for one. is this true or should i get another opinion. and would it show anything that they havent seen on other tests. im curious thx"

I may have misinterpretated your question.  Your doctor may have thought you were asking to have a ct scan to look for any occlusions, and his response was there is no reason to have a scan as the stents have taken care of your occlusions...and that is a correct decision for you at this time.  But if you have a major heart event, a ct scan can within minutes determine the underlying cause with minutes that used to take hours and sometimes days.

With the ct scan 156 slice requires one to be able to hold their breath for about 30 seconds and also the heart rate should be below 60 bpm.  But the new 256 slice doesn't have those strict requirments.  It can measure subtle changes in blood flow or minute blockages forming in blood vessels no bigger than the average width of a toothpick (1.5 millimeters) in the heart and brain.

Johns Hopkins cardiologist João Lima, M.D., who will lead all cardiovascular testing, says the 256 slice scanner’s strength means it can find the earliest signs of restricted blood flow, long before symptoms appear (helpful for individuals with family history but no occlusions) or an organ becomes permanently damaged.  My doctor's hospital has the new 256 slice scanner so I have been given related information.
  

[kenkeith]

If you have a stent, one is still vulnerable for soft plaque accumulation going forward, or a rupture from the buildup of plaque aready in place at the site of the stent.   In fact, when there is a stent implant,  that may injure the intima (inner lining) and the site is acceptable to stent thrombosis up to about a year or until there is new growth.

Recent reports have indicated that there may be an increased risk of late stent thrombosis (clots) with use of drug-eluting stents, as compared with bare-metal stents up to about 12 months...but DES reduces revascularization (growth of new tissue) that could cause the artery to clog again.  That's my understanding.

[cblmn7]

I have a question on the 128 slice ct scan i asked my cardio dr if i could get one and he said since i already have stents there is no reason for one. is this true or should i get another opinion. and would it show anything that they havent seen on other tests. im curious thx

[kenkeith]

There is another option not discused by Jon and Ed  and may be more appropriate for you. Because you want to establish a base of your cardiovascular health and not looking specifically for lumen blockage, I would recommend a CT  scan, 128 slice if available.  The scan images the entire anatomy of the major vessels and establishes a calcium score based on the degree of calcium deposits (soft plaque) within the artery walls.  The calcium score has some validity to predict a future heart event.  This soft plaque usually does not cause stenosis (narrowing of the vessel) so it is not observed with a stress test.  Also, soft plaque is much more likely to cause a heart attack as any cardiologist will tell you, as it is the soft plaque that ruptures and causes a clot within the lumen (inner channel) and a heart attack. Stenosis is more,likely to cause chest pain and heart failurre.  I have had the test and I consider it informative, but didn't like the results :)  Stress test only observes stenosis within the lumen based on perfusion images and correleate with the individual's exercise tolerance. It can be utilized for post heart attack patients to establish exercise tolerance for heart rehabilitation as well.

Consensus statements from the American Heart Association, the American College of Cardiology, and other organizations have discussed the application of the coronary calcium score. These documents concur that coronary artery calcification is part of the development of atherosclerosis, occurs exclusively in atherosclerotic arteries, and is absent in normal vessel walls. Much better test for you or anyone with a family history of CAD or sudden death events from a heart attack with no prior symptoms..

For more detail: "A dedicated computer program identifies calcifications meeting the scoring criteria throughout the images. The person performing the analysis then identifies those calcified plaques in the epicardial coronary arteries and identifies the location of the plaque by the coronary vessel. The computer software sums the amount of calcification per lesion and per artery simply by adding up the pixel values and adjusting for the slice width (Figure 2). Pixel values are then converted to an Agatston score, plaque volume, or plaque mass. Each provides essentially the same information: The amount of calcified plaque in the coronary arteries. Currently, in clinical practice, Agatston scoring is used almost exclusively and has come to be known as the "coronary calcium score." The other scoring systems have various merits but have yet to be implemented into clinical practice in a meaningful way".

[cblmn7]

Everyone pretty much said it all on the nuc stress test the only thing they left out was you may taste metal when they inject you i did and it is a awful taste. so dont be alarmed the test is not that bad i was very nervous before my first one. but i still hate them though.lol

[erijon]

ed is correct, but bottom line is you'll know more than you would with a normal exercise test so it's worth doing. Also, the accuracy is much better;

Treadmill test: sensitivity of 67%, specificity of 70%
Nuclear test: sensitivity of 81%, specificity of 85-95%

The definition of specificity is;

"The proportion of persons without a disease who are correctly identified by a test. The specificity is the number of true negative results divided by the sum of the numbers of true negative plus false positive results."

To me, I would want the higher accuracy level if I'm taking a stress test anyways!

Good luck!

Jon

[ed34]

Well yes and no. Do you know what type of nuclear scan you are having because there are a few types. Most people assume there is only one but it depends which type your cardiologist has requested. Different scans actually focus on different issues.
Let me give you just two examples.
A nuclear perfusion scan is for determining whether blood is reaching all areas of the heart tissue and gives an estimate as to how much. It is used as a guide, a kind of map by cardiologists to guide them to which areas could be of concern. Our tiny blood vessels in heart tissue are not all mapped the same, which would be handy, but they are quite different. It is not possible for a cardiologist to know if there are problems with tiny blood vessels by looking with an angiogram, hence the nuclear scan. Everywhere the radioactive substance flows causes a glow on the image which shows blood is getting there. Whether it is enough is down to the judgement of the examiner of the scans.
A nuclear viability scan aims at focusing on tissue condition, showing if there is any tissue damage in the heart from a previous heart attack or infection etc. So the scans are totally different and give different information depending on the request made.
These are just two of many different types.