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Stress Testing (Read 830 times)

    I believe it is important for people to have a better understanding of heart disease, because it is so prevalent and the medical community must continue to try to have patients understand what the disease is and how heart attacks and sudden death occur-so we can better prevent it and take the very best care of ourselves. There is a time and a place for testing-especially stress testing. Here is a link to what a stress test is and what it does. http://www.americanheart.org/presenter.jhtml?identifier=4568 I discuss risks and benefits with my patients every single day. Risks of taking medicine-risks of not taking medicine. Risks of choosing to live life one way or another... But, I try to get up on a pedestal only rarely, and I am concerned that there are some people who will believe that testing isn't a good choice simply based on opinion stated here and I've started this thread to enlighten everyone as much as I can. FTR, I have been practicing medicine for 14 years (cardiology for 11years) and I take care of patients. I practice evidence based medicine-which means that when studies have been shown to prove that doing a certain thing provides benefit more than not, I advise that specific treatment option. If taking aspirin is shown to benefit males who are 50+years old and have one risk factor for CAD, then I tell my patients that it would be advisable to do this. The choice is always the patient's-taking medicine or not; doing testing or not. We in the medical community preach living life as full and active as possible and testing as much as needed. We are all associated with numbers that carry risk-your blood pressure, your weight, your blood lipids, your blood sugar and your age are the most important. Some things you can change. One can live an active life and still have bad genetics and be at risk with elevated BP and cholesterol. Inactive and overweight people are more at risk than those that are active and lean body weight...but we cannot perfectly predict who will have an MI or who will die. I can tell you who is more at risk though. There are calculators that put in numbers and give people an idea of their inherant cardiac risk. I use this just about every day-it is in each of my office's in the patient exam rooms. You can plug in your numbers and assess your own risk. http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof Please understand that when someone has a risk of under 1%, that's low and probably doesn't require any extra attention. When risks are higher than 1%, we consider provocative testing to get a better idea of whether there may be an underlying problem-even in people who are fit and otherwise well. The usual test first test is an EKG. This is a simple way to screen people that is cheap, easy and risk-free. Some people come to me every day with an abnormal EKG. And unfortunately there are many reasons for a minimally abnormal EKG which are not a big deal, but occasionally there are serious reasons. Athlete's can have many minor abnormalities and it is not indicative of high risk. Any time we do a test and it comes out anything other than normal, there is anxiousness. I believe it is best that we choose tests appropriately and try to know what the limitations are of specific tests so that you can interpret the results best. Over the years, I've seen dozens of people who've had their life saved because of a test that was done in an otherwise aymptomatic and well patient. I have so many stories that I don't know where to begin... When the initial EKG screening is ok, there is sometimes a need to go to the next level of testing for heart disease, and that is the stress test. An exercise EKG treadmill test is a very good diagnostic test for underlying heart disease. We use statistics in medicine very often. The best example I can think of is Baye's theorum in which we try to decide whether the pretest probablilty is high or low. So when doing stress testing, it is important to choose the right test on the right person. The physician has to choose who to send for the stress test and know whether you are going to do anything else in terms of testing or have a treatment plan. There must be an assessment of risk factors ahead of time and this will help guide the people caring for the patient. Today we are talking about CAD. This is the most important killer in the US-number one in terms of causes of deaths. It's prevalence increases with age. So whether you are 40 or 80, it is the most likely cause of death. I do not take this lightly. Anyone over 35 years of age is 'at risk' to me until proven otherwise. When I see Mrs. Jones in the office, she doesn't care about the statistics, she wants to know what her specific risk is of dying and what she can do about it. If you want to lower your own risk, do the following: choose your parents carefully don't smoke check your BP/blood lipids/weight/blood sugar-and modify your lifestyle to lower your numbers to optimal with diet/exercise etc...if you cannot meet the goal, consider drug therapy and work with your doctor stay active consider testing for any symptom that is out of the ordinary like unusual pressure/pain in the chest-especially with exercise or activity which you wouldn't think should cause this; this includes becoming unusually breathless with activity too... As always, you should check with your own doctor about your individual risks, and consider tests when appropriate. A normal stress test often gives peace of mind that the risk is low-especially when used with a Duke scoring system. Low means, less than 1%/year. That is not zero. I've heard many stories of people who have had a 'normal' stress test and then had an MI several weeks later. I've had patients like that. The test just helps define risk and gives a pretty good idea of the possibility of CAD. There are other more costly/sophisticated noninvasive tests like exercise echocardiography or exercise nuclear stress testing which are up to 90+% sensitive for detecting CAD, but there is no ideal test and 'false' positives occur. (This means that we tell someone that the test may indicate a problem yet there really isn't. Usually further testing rules out the possibility of actual disease and everyone is reassured. Without doing the test often enough, we miss many people who do have the disease, so again it is important to pick the right people for testing.) Coronary angiography is still the gold standard for the diagnosis of CAD. It is an invasive test-involving placing a catheter into the leg artery and threading a wire backwards to the heart to direct the catheter to the arteries that feed the heart muscle itself it's blood and oxygen supply. Diagnostic caths are fairly safe, but still can have unusual complications, so I try not to do them unless absolutely necessary-ie the risk of not doing it and knowing/potentially treating is greater than not...These days, we can sometimes do balloon angioplasty-opening the artery that's clogged up critically, and leave a stent in the vessel to keep it open and not narrowing back up. The heart can do ok even if there are clogs everywhere up to 50%. As long as the vessel is not critically narrowed, people don't have symptoms of trouble. This is why it is a 'silent' disease. When a plaque in the vessel ruptures, a tiny blood clot can form and block the heart's blood supply. This can cause a heart attack or a fatal arrhythmia-sudden death. When this happens, only a small number of people survive. The patient has to have been lucky to have access to medical personnel quickly and often time to intervention is the biggest reason for survival. Use of bystander CPR and defibrillation (shocking a dangerous/fatal rhythm back to a normal one) is needed very quickly. The longer the patient goes without, the more likely they will not survive. (I'm quite glad for aamos's DH and Kevin50 who were both lucky enough to have early intervention) If someone has 'the disease', the standard of care if often treatment with medicines to make it less likely to have a heart attack or die. Treatment of the 'numbers' I talked about is done with more aggressive endpoints. Use of aspirin is advocated to make the blood a bit slippery and less likely to have those tiny clots forming within the heart arteries. Here is a prior 'lecture' re 'numbers' and treatment-back in '06 when I needed to get up on the pedestal. -------------------------------------------------------------------------------------- --Nowadays it is just silly not to know certain numbers that are associated with each of us... those include your: Blood lipids-including all 4 components Total Cholesterol, LDL ('bad' cholesterol), HDL ('good') and Triglycerides Blood pressure Blood Sugar-if at risk for diabetes or are overweight I tell all my patients that there are some things that are within their control, like dieting/exercising, taking your prescribed medicines and letting their doctors know if they develop any concerning symptoms. Some people need screening tests for certain diseases, like cardiac disease or cancer. But EVERYONE should know their cholesterol number and what their targets are for treatment, whether it be watchful waiting to see if it rises to a risky number, or keeping it at a target number thereby keeping their heart related risk lower. Men are more at risk for heart attacks and women are more at risk for strokes until later years. And aspirin can lower the risk in some/many people. You should talk to your own doctor if taking aspirin or taking a pill for your blood lipids/cholesterol is for you. Depending on what your risk factors for developing cardiac disease are, you should aim for certain numbers: Here is the reference link for the various guidelines-some of this information may be difficult to digest, but the guidelines are here and most cardiologists, and physicians in general, do follow guidelines based on evidence-based medicine... http://www.americanheart.org/presenter.jhtml?identifier=3004583 And here is a link to a patient page about cholesterol, which is very indepth. http://circ.ahajournals.org/cgi/content/full/111/21/e360?maxtoshow=&HITS=20&hits=20&RESULTFORMAT=&searchid=1&FIRSTINDEX=0&displaysectionid=Cardiology+Patient+Page&resourcetype=HWCIT A couple of points need to be made for those who do not want to go into the guidelines. Diabetes is considered equal to having coronary artery disease. That is because studies have shown that patients who have developed diabetes have similiar cardiac triple endpoints of Death/MI/Stroke equal to those patients who have ALREADY HAD AN MI!! So, we treat patients with diabetes as if they've already have been diagnosed with CAD (coronary artery disease). This means being treated with aspirin/statin +/-ACE inhibitors +/- BBlockers. Statin treatment should be given almost regardless of the LDL, but ideally should be pushed to a target LDL of ~70. We do not yet know what the 'ideal' LDL is, but less is certainly better, especially is you have CAD. If you just have risk factors for CAD, then a decision between you and your doctor must be made about what your 'goal numbers' are. Then you change your lifestyle over a period of time and recheck the numbers. If you are not at your 'goal', then drug therapy is needed. There are no plots by drug companies to decieve us into taking medicines. The option to take medicines or not is always up to the patient, but you should be educated about the risks and benefits of treatment options. So, in summary, you all should know your numbers and know what they should be to have as low as possible, heart risk-- (and I'd be careful about 'fudging' numbers by having blood tests after long runs...) Dale (aka D.Toce MD FACC) I'll entertain a small number of questions later in the thread... Brian, Low HDL is a risk factor. The ratio is important and the absolute LDL is very important, but the absolute HDL is also key. We just don't have any great treatments for raising it...yet. There is a very promising drug on the horizon-but it's several years away-and clinical trials are always enlightening of possible side effects, so we'll see. Here's a page specifically about the HDL. http://circ.ahajournals.org/cgi/content/full/111/5/e89 edited to add the better version to read... And I'd be willing to bet that almost anyone who has an HDL above 80 simply has great genetics. An elevated HDL is cardioprotective, btw. Running/activity, wine/alcohol, certain drugs have a very modest effect on this number. Don't stress over the numbers, just do what you can...as you are... [This message has been edited by dtoce (edited Oct-06-2006).] ------------------------------------------------------------------------------------- So, that's my interpretation of the 'statistics' of cardiology and testing, FWIW. I believe that it is all too often that 'seemingly well' people have problems. I read about them every day in the obituaries. I also argue with statistical neophytes regarding the utility of testing every day of my life-usually because of cost issues rather than risk issues. It is a tiresome chore but I must advocate for my patients...
    Mariposai


      What can I but a heart felt thanks for taking the time to enlighten us dtoce. I know that you did this posting to benefit us even when your schedule was overbooked. We are blessed to have you here. Muchas gracias mi amigo.

      "Champions are everywhereall you need is to train them properly..." ~Arthur Lydiard

        Well done, Doctor Dale! I think the thing that scares most of us is when we read things like Bobby Doyle dieing. Was he not paying attention? Were his Doctors not paying attention? He had known heredity risk factors and yet was taken down by them. Unfortunately in his case, he was far from immediate attention when it happened, like could happen to any of us with high risk factors. Keep up the good work! Fran
          Thanks Dale: We asked for it and you obliged with some great information. I have not gotten through it all yet, but will be doing so over the weekend. All of this stuff is just good to be reminded of for most of us and new runners or people entering a new stage of life, need to hear this information. Again....THANK YOU
          Vista
          coastwalker


            Hi Dale, Thanks so much for taking the time to share all this information with us! Since, as you said, decisions regarding our health are ultimately ours to make, we'd better become informed about the issues we need to deal with, and the options we have. Your post is very helpful in that regard. I have a question for you about stress testing, if you don't mind: Should a person in reasonably good health have a stress test on a regular basis, such as every few years or so? I'm 60, and haven't had a stress test since I was in my early-mid 40s. My annual physicals are usually pretty basic, and I'm wondering if I should demand more of my Dr. at them? On the other hand, nothing in those basic exams, fortunately, has raised any red flags. Thanks, Jay

            Without ice cream there would be darkness and chaos.


            King of PhotoShop

              You continue to be a great gift to us Dale. Thank you so much for this. As one who has some issues with the topics you covered, I need to hang onto this thread. Spareribs
                Doctor, Thank you for the in-service... will there be CEU's for this? (just kidding). This really helped me see how physicians practice "evidence based medicine". You really have a gift for writing in terms that non-medical people can understand without "talking down" to them. Excellent.
                LaVita
                seemomgo


                  Thank you for this excellent post...I come from a family full of heart disease, high cholesteral and non-exercising. This information is very important to me and I will save it and review it frequently. I have had a stress test, but never really understood the meanings, results or reasons....I do know that I am working hard to break the cycle! You took a lot of time to post this and it is very appreciated!
                    This thread couldn't have come at a more appropriate time for me and my husband. We spent 6 hours last Wednesday in the ER wondering if he was having a heart attack. He wasn't thankfully, but he underwent a stress test two days ago. Although the initial findings are that he's okay, I am looking forward to an actual appointment with the cardiologist regarding his risk factors, which I believe are high. He is on medication for both high blood pressure and cholesterol, is about 50-60 pounds overweight, and, except for his job where he stands all day, he lives a fairly sedentary lifestyle, and he's only 47. All of this is extremely hard for me to deal with, and over the years I have learned that it doesn't matter what I say or do, he has to make the decision on his own to do the necessary things to ensure a long, healthy life. So far, he hasn't been willing to do so. I can only hope that whatever was going on last week shook him up; however, I fear that the statement by whoever gave him the test that his heart is healthy will have the affect of him not doing anything to improve his health. And as some of you might be inclined to ask: No, my change of lifestyle over the last few years and the addition of my running two years ago has had absolutely no affect on him. It's frustrating.

                    Leslie
                    Living and Running Behind the Redwood Curtain
                    -------------

                    Trail Runner Nation

                    Sally McCrae-Choose Strong

                    Bare Performance

                     

                      Thanks for posting this, Dale. I was just 15 when I saw my father have a very serious heart attack at 50. 15 years later, he died of his 2nd attack. He was always pretty trim and athletic, but was a heavy smoker (up to his first attack) and in those days (the 50s and 60s) nobody paid any attention to cholesterol, fat intake, etc. These incidents, and losing my dad before I was 30, affected my psyche more than I knew. Being a male, I guess I always identified more with my dad than my mom (whose relatives all lived into their 80s and 90s), and when I reached my mid-40s I developed a bit of a fear of "something" happening before I was 50. In many ways it was a typical mid-life crisis. Anyway, it had three benefits: I started getting periodic complete physicals including stress testing; I adopted a much healthier diet and lifestyle; and I started running. My cholesterol could not be controlled with diet and neither could my BP, so I have been taking medication for both with good results. I had been gaining confidence in my likely longevity for a while when, surprisingly, my younger brother had a mild heart attack. He is not a runner, but is active and in his ideal weight range and even more into "natural" healthy food than we are, so this was quite a shock to me, and definitely brought my confidence level back down a notch. This is all just to verify that genetics do play a large role in one's lifespan, and I am not sure exactly how much I am extending my life with all this effort. However, there's no doubt that I will continue to just plain feel better for whatever years are left, and at least I'm not doing anything to significantly shorten my existence. I'm already looking forward to my next major physical checkup!

                      Doug, runnin' cycling in Rochester, MI

                      "Think blue, count two, and look for a red shoe"

                        Thanks, Dr. Dale. You explained everything so well.

                        "During a marathon, I run about two-thirds of the time. That's plenty." - Margaret Davis, 85 Ed Whitlock regarding his 2:54:48 marathon at age 73, "That was a good day. It was never a struggle."

                          Thanks for your post, DrDale. You explained things very well. I will have to reread your post and let things sink in more than they did the first time. It's great to have a resident expert who can help us understand the sort of things that can affect many of us. Your efforts are appreciated. TomS


                          Maniac 505

                            Dale: Thanks so much for taking the time to post this. My previous doctor did cholesterol, and blood sugar tests every year. even though I have cholesterol numbers people would kill for, (a couple years ago, on Cool Running, I won the fudge for the best cholesterol.) My parents did not bless me quite as well with blood pressure and blood sugar. A couple years ago, My insurance forced me to drop that doctor, and chose an HMO. For my last two annual physicals, the doctor didn't feel any tests were worth while. (except blood pressure) for a few hundred a year will be able to go back to the previous doctor in November. and I will. I think it will be well worthwhile dave
                              : Should a person in reasonably good health have a stress test on a regular basis, such as every few years or so? I'm 60, and haven't had a stress test since I was in my early-mid 40s. My annual physicals are usually pretty basic, and I'm wondering if I should demand more of my Dr. at them? On the other hand, nothing in those basic exams, fortunately, has raised any red flags. Thanks, Jay
                              This is a good question. The answer is: 'it depends'. You should bring up your concerns with your doctor. In the setting of any concern from the patient (or if I'm concerned at all), I err on the side of being aggressive. I'd rather do a stress test and be reassured by the fact that a normal exercise EKG treadmill stress test has prognostic value-meaning that if you do well and there are no abnormalities, we are generally reassured that your heart-related risk is low. The most important thing is actually visiting your PCP (or cardiologist) regularly to have a history and physical exam +/- EKG. --------------------------------------------------- Marposai/Nancy-de nada LaVita/Barb-no CEU's, but I have enough to submit for another 3 year 'certificate of excellence', but I just don't have the time to do paperwork for that stuff. My patients already know that I'm 'in the know'. fatozzig/Leslie-I hope that you convince your husband to take the proper care of himself. Unfortunately many people need to have a critical event before changing their lifestyle. And I've had to deliver that news to patients or families all too often. I am much happier seeing patients in my office prior to events so that I can advocate an active lifestyle with proper choices...but...anyway, good luck to you both. divechief/Dave-It is difficult to choose one's parents. Alas, my genetics are such that no male on my father's side lived past 50, until my father-who I made get a stress test in his late 40's and we found his totally occluded RCA...and now pushing mid 60's and doing ok. I thank him for kidney stones too...ha. It is important to have a good relationship with your doctor. If you are more comfortable with the care you had previously but it costs you a bit more, well...I say it's better to have the confidence that your MD is doing the best for you. I am hopeful that people do actually read this and have a better understanding of CAD and stress testing. I was definitely concerned and felt the need to deliver this message.
                                Thanks again, Dtoce/Dale! (Hee hee, I was hoping that you could grant me a few CEU's for this on-line inservice...maybe if you would have had a pre-test and a post-test, it would count?) Keep up the good work!
                                LaVita
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