Stress Thallium or CT Angiogram

[nspower]

I am 50 yesr old male with history of MI in2007. LCx 100% blocked. LAD opened with a bare metal stent. RCA normal. Few other smaller artries are also bloked 50-80%. EF 30%. My LAD area of heart is damaged and haert is enlarged. Taking beta-blocker, ace-inhibitor, asprin, clopidogrel, digoxin, water pills and statin. Have an ICD.

For last few months I have started feeling mild to moderate pain in my left neck while walking, which disappears after 20 mimutes of slow walk followed by fullness in left ribcage for next 10 minutes of my 30 minute walk.  Im not SOB. The symptom of my MI was also throat pain, though at different location, no SOB. Not sure if this can be due to medicines. I am worried that I may end up with another MI. My cardiologist is not worried but has recommended Stress Thallium for my satisfaction.

My question is what will be a better option, a stress thallium or CT angiogram.  
Please advise.

Thanks in advance.

Note: Earlier I participated on this forum as tinu1959.

[erijon]

It seems to be that your condition is mostly unchanged, but I'm not n expert just some one who has researched my own test results. Once heart muscle is dead, it does not regenerate. There is a possibility that these heart cells have been shocked into hibernation and can become functional once again with the proper treatment, but I don't see that in your report I don't know enough about it to say. Perhaps some one more knowledgeable will post.

I wish the best possible outcome for you.

Jon

[nspower]

Thanks Jon.

I was just wondering if my current stress thallium is reporting lesser area as damaged due to MI.
The report mentions anterior and large apical walls as infarcted area. The last year's report states, anterior, apical and distal infrolateral walls as infarcted. The distal infolateral wall is absent in this year's report. Does it has any relevance?

What does this report for me. Is my heart condition stable or it is deteriorating with respect to last year??

Ed34, Thanks for the question. It may be very relevant in my case. May be someone can answer.

Thanks again.

[erijon]

Good questions, I have no earthly idea.................

[ed34]

When damaged heart tissue becomes scarred, does it tend to make the heart eventually change shape around it?  If I picture something like a balloon and draw a circle on the side, then imagine the balloon as active muscle except for the circle, then the circle is basically being pulled in by good muscle? rather than contracting by itself. I am wondering what happens to the tissue around the circle, does it strengthen to compensate?

[erijon]

Your results are fairly clear, you have damaged heart muscle most likely due to a previous heart attack as outlined;

"Features on SPECT myocardial perfusion scintigraphic study are consistent with myocardial infarction involving anterior and large apical walls with a few islands of residual peri-infarct ischemia"

This is a fairly broad area mentioned involving the walls separating the chambers of your heart. I'm not sure what "a few islands of residual peri-infarct ischemia" means, never seen that in a report before but it is defined as "ischemia that was adjacent to an infarcted area and was located in the same vessel territory" which makes me think there are areas of heart muscle adjacent to the damaged areas of your heart that have limited blood flow causing ischemia.

There are members more versed on this than myself that I'm sure will post as well.

Good luck,

Jon

[nspower]

Got my stress thallium test results today. Please help me in understanding. How is my test result as compared to same test one year back? The values of last year's results are within brackets.

Medicines: No medicines before test (betablocker three hours before test)
Date: 16NOV2009 (14NOV2008)
Workload METS: 6.4 (6.4)
HR Exercise, bpm: 146 (148); BP: 140/80 (130/70)
HR Recovery, bpm: 88 (89); BP: 120/84 (140/70)
SPECT Myocardial perfusion scintigraphy reveals:
1.  Nil significant lung uptake of radio pharmaceutical on a representative planer anterior projection scintigram. (same)
2.  Left ventricular cavity size = ++ on multiple coplanar arthogonal tomographic sections. (size=+/++)
3.  Post exentive imaging shows reduced radiopharmaceutical uptake in anterior and large apical walls. A rest injection imaging shows a few islands of refilling kinetics in the peripheral zones of above mentioned area. ('Fixed' reduced radiopharmaceutical uptake in anterior, apical and distal infrolateral walls during rest - stress MIBI as well as reinjection TI-201 imaging sequence)
IMPRESSIONS:
Features on SPECT myocardial perfusion scintigraphic study are consistent with myocardial infarction involving anterior and large apical walls with afew islands of residual peri-infarct ischemia. (Features on SPECT myocardial perfusion scintigraphic study are consistent with myocardial infarction involving apical, anterior and distal inferolateral walls. There is no definite evidence for ischemia)

Thanks

[nspower]

Thank you so much. After MI I try to relate every symptom with bp, pulse or pain in neck/throat, to my heart problem. Two years after MI I still get stressed every time I get one of the above parameters out of normal range, without my understanding the reason. I appreciate my cardiologist's pacience but I know there has to be a limit. Getting test done every time I have some symptom also does not make much sense.

This forum has been a great help and support. Thanks.

[NucmedTech]

ECG/EKGs are good to get, however; the littlest movement or connection problem can produce inaccurate readings. I have seen patients come in with abnormal EKGs and the next one was normal. (I am also an EKG tech). Your question with radiation: with having a 'thallium' stress test, you will receive more radiation exposure with the stress test vs. the CT. The CT camera gives off radiation. In the NucMed, the injections of thallium will produce the radiation (not the gamma camera itself). Thallium has a half-life of three days- every three days half of the tracer leaves your body: 80% through the GI tract and 20% urine. It has the potential to stay in your system for weeks. At my facility, we use a Technetium based isotope where half of the tracer leaves your body in 6 hours. In that case, my stress test is less exposure than the CT. So it depends on the type of isotope you receive during the stress test, but thallium does have a longer half-life. I would not be worried about the exposure. In health care, it is risk vs.benefit. I am pretty sure any heart complications would kill you before a little exposure to radiation! I hope that answered your questions.
**Your symptoms are odd. I do know that our doctors are always more concerned when symptoms present themselves at 'stress' more-so than at rest. Chest heaviness is also a big indicator that something more serious is going on. Also, I often see patients get treated for GERD (gastric reflex) when complaining of Chest pain/burning- esp. after eating. However, with your history- they probably won't try to pull that one. I am def. not a dr though! So I would just follow up :)

[nspower]

Thnks All for valuable feedback.

Which of the two test does more damage due to harmful rays/radiations? If stress thallium and ct angio are to be compared. We have a 180-185 slice ct machine which is supposed to have lower exposure as compared to earlier 64 slice ct machines. But I do not know the comparison between two tests in absolute terms.

As I write this mail I suddenly felt sharp locallized pain in left side of my neck lasting for about one minute with simultaneous heavyness in my head (a feeling of blood rushing into my head), pulse at rest rising from 70 to 100 bpm and bp rising from 105/70 to 130/75. It all normalized to original levels in next five minutes. It has happened ten minutes after I completed my dinner.This happened about a year back also with no changes in ECG or blood tests. I was then told that it could be spasm?? Does it sound like angina at rest? I had no heaviness in chest or any other pain.

Regards

[NucmedTech]

Hello. I am a Nuclear tech and I think the stress test is the better option at this point with your known history and symptoms- esp. since you are getting symptoms with exertion/exercise. Depending on your physical condition you can either get a chemical induced stress test or an exercise stress (which i'm sure you know), The exercise is the better of the two if you are able to reach your target heart rate. CT will give valuable information, but it sounds like you already know the info. it would provide. You have to watch your 30% EF. Another stress test will also give you a current EF that you can use for comparison. By comparing the rest and stress perfusion images from the stress test, you can see if the walls of the heart are filling in adequately. Good luck with everything.

[kenkeith]

There are biofeedback instruments that helps a person develop complete relaxation with mind control .  The instrument provides negative and positive feedback enabling a person to know when there is complete relaxation and the appropriate mindset related to the relaxation so as to sustain the relaxation mode.  Years ago I had sessions with the local community college.  Also, there were commercial enterprises that sold a mantra, alleging repeating the mantra provides mind/body benefits.  Nothing but a gimmick to make money although some people claimed benefits!  Probably nothing more than a placebo effect if they really were experiencing benefits.  That's my opinion.

[ed34]

However, adding to that. If you are lucky enough to find the cause of your CAD, which a few are, you can prevent it from becoming worse for a considerable amount of time. As we age, it appears that we all develop some level of atherosclerosis anyway. I lowered my cholesterol which for a year didnt slow it down. The next thing I tried was relaxation classes and understanding to recognise when I'm under stress. Controlling this seems to have halted the development of the disease over the last year, proved by 2 angiograms that are 12 months apart. Maybe it was a combination of statins and stress control, but I would have expected some difference with medication in the first year.

[kenkeith]

I agree with ED.  Considering your history and current symptoms the better test would  probably be the nuclear perfusion scan to see if any areas are being deprived of oxygen when under stress.

The CT scan will score your coronary vessels for soft plaque, etc. and provide a prognosis for the probability of a MI due to a rupture of the vessel.  Unfortunately, there isn't any corrective treatment, just the knowledge of how serious is your CAD.  That may induce anxiety for some individuals...my soft plaque score was over 1000 and the probability is about 25% I would/will have a major heart event within a year....that's 15 months ago, and I feel fine so I don't fall into the 25% population.

[nspower]

Thanks for the response. I am actually confused. It looks like both tests, CT angio and stress thallium have some advantages over each other. My case does not look like an emergency situation. I am experiencing some pain in throat (left side) while walking which dissapears after 20 minutes of walk. I had pain in my throat at the time of MI in 2007 but at different location (lower middle of throat). I am worried (but not my cardiologist). He has advised stress thallium due to my concern.

In this case which test is good? I just read today that stress thallium has exposure equivalant to 600 x-rays. About CT angio? I am not sure.

Stress thallium has some risks. I had one stress thallium exactly one year back, in Oct 2008.

What should be the consideration in choosing a test in my case.

Thanks for time and attention.

[kenkeith]

Hi tinu1959,
I remember some of your prior posts in the past regarding your lower than normal EF!  A ct scan 256 or 128 slice will provide the anatomy of the vessels with very good images.  The 256 slice is now in 4 dimensions (this shows heart movement as the 4th dimension)...doesn't require getting the heart rate below 60...I have had a ct-scan (128 slice) several months ago.

The scan will show degree of blockage within the lumen, also shows the soft plaque buildup between the layers of the vessel.  It is this soft plaque that puts the individuals at higher risk of an MI.  The soft plaque breaks through and ruptures into the lumen causing a clot that can/will cause MI.  Also, the scan views the lungs and ascending and descending aorta. I don't why the doctor would say there is no additional information available.  He may mean there is no additional information availble that can be acted on at the present time....The ct scan is best used when an individual  is admitted as an emergency patient with chest pain, etc.  The individual can be reliably diagnosed within 20 minutes for any heart disorder where in the past it would take hours and sometimes days.

[ed34]

Yes absolutely because it will also show up smaller arteries not really visible on an angiogram. As the tissue actually absorbs the blood, it gives an orange/yellow glow on the image showing which areas are deprived, if any. It would be invaluable map.

[nspower]

Ed34, thanks for explaining.
My concern is not to end up with another MI and loose my EF any further. At 30% it is already at heart failure limit. I would like to take preventive action to reduce chances of another MI by knowing if any of my artries require fixing. As per my cardiologist, the locations of blockagesf in my artries are already known from my angiogram at the time of stenting. Therefore, he feels that CT angiogram will not give any additional information. A stress thallium will tell us if any of the current blockages are increasing.

I assume your preference for stress thallium is also based on same logic?

Regards
nspower

[ed34]

I suppose it all depends on what information 'you' need to see to satisfy your own mind.
A Nuclear scan (perfusion) will give a map showing all areas of the heart receiving Oxygen and how much. A CT scan will really give more of a map of the coronary arteries, similar to the images of an angiogram. If the newer high resolution CT scanner is available at your hospital then much better results will be available and this will include accurate analysis of the complete heart. I'm not sure if the CT will show how much oxygen is getting to all tissue areas. If I was in your shoes, I would probably opt for the nuclear perfusion scan to see if any areas are being deprived of oxygen when under stress.