What else causes ST depression in a 28-year old female?

[obsidian12]

Hi there,

I'm a 28-year-old female who has had dyspnea on exertion for about four years now (sudden onset). After initially being told it was stress (when I was an active person at a healthy weight), I was unable to exercise and gained weight (but the severity of the shortness of breath did not change) - and my previous doctor attributed it to the weight gain.

I recently had a series of EKGs, stress tests, and a myocardial perfusion scan. Resting EKG shows inverted and/or flat t-waves in Leads III and aVF. Stress tests, I reached my maximum heart rate at 178 on level 2 of the Bruce protocol, with non-specific ST-T changes (but I wasn't feeling short of breath at this heart rate). Myocardial perfusion, my cardiologist pushed me until I was symptomatic at the end of level 3 of the Bruce protocol, reaching a HR of 198. ST depression was noted, and the cardiologist says there is a strong indication that I have coronary artery disease. I'm not sure what the scan itself showed...

I'm slated to go for an angiogram within the next month, but I'm petrified. The thought of having CAD starting as early as the age of 24 is absolutely frightening. I've never smoked, although I was exposed to second-hand smoke during my childhood. My diet isn't awful (I avoid take-out and processed foods where possible, but do occasionally indulge like most other 20-somethings I know - maybe about once a month if that), and my exercise as of the past 4 years has been almost non-existent as I sometimes end up feeling really dizzy and short of breath on walks (we live in a very hilly area, and this is torture for me now). Before 4 years ago, I used to power-walk *everywhere* (I don't drive), no problems.

I was just wondering is CAD the only potential cause of my dyspnea and ST changes? Can exercise-induced asthma cause ST changes? POTS? What about congenital abnormalities? I'm just looking for someone to explain the situation a bit. This has been really stressful.

Thanks in advance!! This may help me sleep at night... :)

[obsidian12]

Hi, I'm happy to post that after having an angiogram (after some very strong positive test results), my coronary arteries are clear.

I did a series of pulmonary function tests, and it was found out that for the past three years of experiencing severe shortness of breath upon any type of exertion, I've been dealing with undiagnosed/untreated asthma. I'm now on inhalers and feel amazing. I was able to resume my old level of activity fairly immediately (at least when it came to normal stuff like being able to run up the stairs). Running on the treadmill is a bit more of a challenge due to deconditioning, but this type of shortness of breath was different from the kick-me-in-the-gut type of shortness of breath I was experiencing before.

I really hope you have the same good fortune! At this point, I guess it's safer/better to rule out the heart stuff first, and then take it from there.

Wishing you well! :)

[brooknoe]

So....I googled and found your page. I am having the EXACT same S/S as you. I am a RN so I knew something wasn't right MONTHS ago but ignored it. (I know...not so smart) I saw my PCP yesterday and was placed on a holter. He reviewed it right away (the advantage of working with him) and I have ST depressions. My echo was good. Labs were good.

I am having the SOB, dizzy, my BP is extremely low at times when I have the episodes..... Please let us know what you have found out. Thanks & good luck!

[is_something_wrong]

To answer the last question first - Holter tests are very unlikely to discover any ischemia (lack of blood supply), and they are often inaccurate regarding the ST segment. They may be, but in that case the electrodes must be placed differently (channel V5, etc). Usually, they place the electrodes where it's easiest to diagnose rhythm abnormalities (supraventricular tachycardia differensiation, PACs with wide complex vs PVCs, etc). Honestly I'm not sure if channel 1, 2 and 3 represent the resting EKG lead I, II and III counterparts, I doubt that, but I'm not sure. I'm not a doctor :)

The other questions leave me without any good answers, I'm sorry. From your background and risk factors, CAD would be extremely unlikely. However, you have a (or more) positive stress test results, you have some suspicious (though fairly atypical, but in females that's more common) symptoms, so I would suggest you follow your cardiologist's advice.

And please, keep us updated on the results. Good luck!!!!! I hope you will be OK!

[obsidian12]

Hi there,

Thanks for your reply as well. That helped a lot. Thank you!!

To answer your questions:

1. My BP during one of my stress tests (though I was not symptomatic during this one, but I reached my target heart rate quickly) was 160/80 (at rest that day it was 118/80). I have no idea what it was on the perfusion stress test where I was actually highly symptomatic. I know it wasn't low though.

2. Cholesterol has always been right in the middle of the normal range. Have never been high or borderline (even since I've gained 80 lbs in under a year - starting about 4 months after my symptoms began. I'm 5'4" and weighed 140 when my problems began, but I'd always weighed that with the exception of my very early 20s when I was 120 lbs; I'm now 200 lbs, but reached as high as 220 - we think that was purely endocrine because it happened sooooo quickly and I'm unable to take the weight off. We're waiting on my blood tests to be a bit more revealing). Obesity right now is my one and only risk factor that I know of, but again, that happened after my symptoms began.

3. No diabetes. Blood sugars are always perfectly fine, same with insulin levels.

4. Resting BP was 107/78 when I was 140 lbs; now has since been 120/80. Still have moments when it's about 110/75 occasionally, but it's not the norm anymore.

5. Radiation yes, but not due to cancer treatment. I had a benign teratoma (germ cell tumor) (hooray for rarities - sigh) removed from my thymus gland that had been attached to my right lung and right pericardium. I've had at least 15 chest x-rays in my lifetime, as well as 4 CT scans of my chest (not including 1 CT of my abdomen, a radioactive tilt test, and the 2 doses of radiation from this perfusion study). I guess that's a substantial amount though...

Now what's interesting is I actually had a holter monitor done before any of this started. I was complaining about the sensation of skipped beats (which of course never happened while the holter monitor was on) early in 2008. I got a copy of those holter monitor results last year to see what they were because I was told they were normal. Anyway, (asymptomatic) my heart rate had reached 160-ish and there were notable ST depressions (3 mm or greater) in channels 1, 2, and 3. 20 episodes in ch.1, 15 episodes in ch.2, and 9 episodes in ch.3. No one told me about these (but I guess if you are asymptomatic it is not a big deal).

Would that be potentially indicative of what you were saying about being born with smaller arteries? Also, my ST depressions on the stress test are pretty diffuse during activity, and I am not sure if that would be suggestive of CAD either.

Thanks again for your help!!

[is_something_wrong]

You should follow your doctor's advice and take the angiogram, but I also have a feeling that it CAN be clean. There may be a lot of causes for ST depression but it's slightly concerning that it happens at high heart rate. A virus affecting the heart would usually cause diffuse ST elevations during rest (I think) and probably a lot of PVCs during exercise.

Important questions:
How high were you able to push your systolic BP during the stress test (in this case, high is actually not bad..)?
How high is your cholesterol?
Do you have diabetes?
How is your resting BP?
Is your chest exposed to radiation, as in cancer treatment?

I assume the T wave is flat in avF and inverted in III (as the lead avF is a combination of II and III). This doesn't necessarily mean anything but should be interpreted by your cardiologist. Nonspecific ST-T changes at high heart rate can also be a sign of "anything and nothing".

Some people are born with abnormal coronary arteries, making insufficient blood supply more likely. Such things will be seen on the angiogram.

If you do have CAD, it is fixable with a stent or bypass surgery. If the cause of your CAD also is treated, you can live a normal life again. It's not the end of the world. But CAD, as narrowed coronary arteries, in a 28 year old female with no risk factors, would almost be a sensation.

Stress tests may have a lot of false positives, but as you had symptoms as well, you could definitely benefit from getting this further examined.

Good luck, and keep us updated!

[obsidian12]

Hi Michelle,

Thanks so much for the great answer!

Yeah, I have had a few echos done, but was told everything was normal. The only thing that was found were mildly leaky mitral and tricuspid valves, which are noted on some (not all) of my echos.

I don't really pass out, just feel dizzy and short of breath when I walk or go up the stairs (usually walking normally, sometimes I am able to jog up the stairs though). I notice my heart rate jumps up when I stand by about 20-30 bpm. My resting rate is about 77 bpm.

I'm a little (read very) afraid of the angiogram, so I really do hope it's nothing. I'm meeting with my interventionist within the next two weeks, so hopefully he can help abate some of my fears. I don't have a huge history of cardiac issues that I know of, though my grandfather (paternal) apparently had heart failure. I know my great-grandmother (my paternal grandmother's mom) also had heart failure, but my grandmother never did. I hope this worry is all for not because I want to have a family and things like that, and I just figure CAD would make that prospect considerably more difficult...

[MichelleP_3811]

It is odd for someone your age to have coronary artery disease but I am sure it is not unheard of if you have a family history of heart disease.  That said, you are right it could be something else.  Have you had an echo done to evaluate how your heart is functioning?  I see a stress test but you didn't mention an echo.  I would push for one of those if you haven't had one.  I would also get a full blood panel to rule out any electrolyte issues.  Do you only pas out when you stand?  If so I would look into dysautonmia because I believe that is a symptom of that disorder.  And the only other thing I can think is possibly you had some sort of flu or virus that affected your heart but again an echo should be able to rule that out.  Well good luck with the angiogram.  From what I understand they aren't that bad and at least you will know.  I kind of have a feeling you will come back clean but I am not a doctor so it is good you are seeing one of them to get properly diagnosed. If one is concerned enough to order a test they are ordering it for a reason.  So follow his advice. : )  

In any event, hopefully someone will jump on who can better explain the EKG readings but I will say if you do exercise make sure you stay hydrated.  If your BP is low and you are dehydrated it can cause your bp to go super low making you feel as though you might pass out.  I know if I don't get enough sodium in my diet I get all woozy.  Not sure if there are any ST irregularities that happen when I am feeling that way but you could have a low sodium/bp issue as well.  In any event, keep getting properly evaluated by your doctor.  I am sure the angiogram will be no big deal but keep us posted on how it went and how you are doing.  Take care.