Please Help Me Decide -- Heart Scans

[Hank]

Hi,



I'm a very long time lurker and occasional poster but not in a long time. The information about investing that I garnered from this site 2 decades ago really helped me and I thank everyone. The forum section I never read in the past is now -- unfortunately -- my go-to -- Health!


Anyway, I failed a recent EKG and was referred to a cardio specialist. My EKG had some extra beats and 2 mild ST Depressions for non-specific reasons. Because of that I was given an echo cardiogram stress test which also showed similar problems but the doc couldn't figure out why. My max heart rate was good, valves were good and I have/had no symptoms. The cardio doc put me on baby aspirin and 20mg of Crestor. My cholesterol was high this most recent blood test but in the past has always been very good. My family history is bad. Father died at 58 from heart disease and my brother has had 2 strokes in his 60s. I'm 62 and lived a much healthier life than my father or brother but genetics might rule here. Uncle also had a bypass when he was in his 60s but lived into his 80s. So I don't think I can just ignore this...

For next steps the doctor gave me three options:

1) Nuclear Stress Test - (doc owns the diagnostic lab)


2) Conventional Angiogram -- catheter

3) Coronary CT Angiogram -- non invasive, easy, very accurate


Which choice is best? How should I decide?


My thought is that doing either the CCTA or the Conventional Angiogram is best. If I have blockages and do the Conventional Angiogram they might be able to fix some problems at that time (I think) . Stopping me from having to have a second procedure and dose of radiation. If I have the CCTA and they find blockage then they still do the Conventional Angiogram. I'm concerned about the radiation because I will likely have more CT scans in the near future for an unrelated issue. But since they all contain about the same amount of radiation then I am leaning toward the CCTA because it is easier and my situation is not an emergency and I think there is a good chance that I don't have blockages. So I figure why not try this non-invasive option first.


It is difficult for me to get a second opinion in a timely manner but I wish i could be even more sure that I need these tests.

Any thoughts from those who have been down this path would be appreciated.

 

[razztazz]

It might sound like getting"extra" tests but I'd go for the CT scan or nuclear stress test first . I'd be leery of getting the angiogram up-front. They are not risk free. (sticking something in there ain't nuthin', it's somethin') If they get in there and do not see any blockages you've assumed risk you didn't need. IF you have blockages THEN they can get in there and deal with that.

 

[braumeister]

Anyway, I failed a recent EKG and was referred to a cardio specialist. My EKG had some extra beats and 2 mild ST Depressions for non-specific reasons. Because of that I was given an echo cardiogram stress test which also showed similar problems but the doc couldn't figure out why.

I'm not sure how you "fail" an EKG; it's just a diagnostic tool.

But the "doc couldn't figure out why" part is what got my attention.

In your shoes I would probably consider taking the EKG and stress echo results to a different cardiologist for another opinion. Of course, if you have confidence in the one you're seeing that advice probably doesn't apply. Just something to consider.

 

[OldShooter]

I think it's pretty crazy that a heart expert wants his patient to specify the next test, particularly where none of the alternatives looks to be especially dangerous.

I would look for a second opinion, either by asking your doc's office to help expedite or by asking your insurance provider to help. Or even just cold-call some cardiac docs and plead your case to the scheduler. ALL docs keep a few appointments open for emergencies and surprises.

 

[Tom57]

Been there, done that

Yes, Angiograms add radiation to your body, along with X-rays, airplane flights, CT scans, etc. Hank, you did not state your age in your post so it is impossible for me to quantify the possible effect of radiation on your longevity.
My first Angiogram was in 4/2009, my CABG was in 10/2009, my second Angiogram was in 3/2010, my third Angiogram was in 7/2016, my cardiac arrest was 7/2016, followed by 6 CT scans all with contrast in 7/2016. My creatinine test (for kidney health) shot up to 2.49 in 7/2016 and I went to a Nephrologist (kidney specialist). He told me 1. my creatinine test score was starting to go down and 2. even if the contrast permanently damaged my kidneys, dialysis would keep me alive and that the risk of possible dialysis was a better choice than death.
Back to radiation...you are 100% correct, exposure to radiation can kill you if the levels are high enough and the exposure happens frequently. Almost every lifestyle choice has the long-term possibility to kill you and yet we choose certain lifestyle choices for various reasons.
From 1/2009 to 4/2009 I had an EKG, Echocardiogram, nuclear stress test and Angiogram to diagnose 3 cardiac vessels with blockages. That is why the CABG happened. I am currently 73 and a 5 year 8 month survivor of cardiac arrest. Medical statistics say fewer than 3% of cardiac arrest patients survive more than 4 years. My Cardiologist helps me stay alive and maintain a good quality of life.
Summary, trust your Cardiologist or get another Cardiologist.

 

[Starsky]

I've done the stress tests, both on the treadmill and chemical, and maybe they're better now; but my treadmill test caught a bundle branch electrical block, and totally missed the 98% physical blockage in multiple primary coronary arteries in my heart which led to a near-fatal attack a year and a half later. Because of that experience I feel like the stress tests are good for electrical (i.e. arrhythmia} issues, but don't give enough information on the heart's physical condition (i.e. blockages).

I wish I had done a CCTA instead of the stress test and think it would have caught my situation immediately before it was a life-threatening emergency. I've had friends who did these imaging tests and based on the results were sent into surgery for preventative stents within 24 hours - thus avoiding a potential future heart attack.

The conventional angiogram would be my last choice because of the catheterization. It's an unnecessary health risk compared to the alternatives; and doesn't sound like it is a better quality test than the CT version.

If your hereditary medical history revolved around blockages, I'd go CCTA just to rule out any blockage issues, since having blood supply issues is so immediately dangerous and can kill your heart muscle irreparably. I hesitate to say that it's best for you if your hereditary issues are electrical, so asking your MD which alternative would give the most data for analyzing your particular health situation would be my next question.

 

[Hank]

Hi, I'm 62, male. Thanks to everyone who responded. It really
helps. I guess I have to take this one step at a time and go from there. I'm in Canada and I am finding out what people mean about long waiting times and scheduling tests.



Oldshooter -- I am also very disturbed that the cardiologist didn't want to offer his opinion until I offered mine. It's a huge red flag. He doesn't like my questions.



I want to find a another cardiologist to work with but will probably schedule the test through the Dr. I have now not to lose my "place in line".

 

[OldShooter]

... Oldshooter -- I am also very disturbed that the cardiologist didn't want to offer his opinion until I offered mine. It's a huge red flag. He doesn't like my questions.

I want to find a another cardiologist to work with ...

Wise decision. This guy is a problem, actually hazardous to your health. Is there an ombudsman function in your health system? Maybe try that to get a faster switch?

 

[schenbew]

Hank,

I've made improving my health a primary focus before and now in retirement. I would recommend the CCTA - this should give the cardiologist a comprehensive view of your current cardiovascular situation to inform future treatment and lifestyle decisions.



I'd also look at the following:

1. Consider seeking out the help of a functional medicine doctor who can assist in trying to more thoroughly look at your labs and determine what lifestyle, diet and genetic factors may be contributing to your symptoms once you're past this current concern.

2. Consider having either your cardiologist, or your functional medicine doctor, order an NMR Lipoprofile test along with a Precision Health Report. Too much to go into in this post, but the standard cholesterol tests are too crude to really help you determine what's going on with your metabolism. The NMR Lipoprofile test will report on the # of cholesterol particles, not just the total quantity, in your blood.

This link will explain more about the Precision Health Report and NMR Liporofile test:

https://precisionhealthreports.com/

3. Consider having a test to determine your Lp(a) level...recent research indicates high levels are much more predictive of cardiovascular disease than simple LDL measurements. Also measure your C reactive protein (cRP) as well....if elevated, your risk for heart disease is significantly higher. Both can be done in conjunction with the NMR Lipoprofile.

4. Exercise. Whatever you're doing now, do more, especially strength training and walking, so long as your doctor gives you the go ahead.

5. Consider supplementing with magnesium. Some heart conditions can arise due to low magnesium levels. Be sure to use magnesium supplements the body can absorb...consider magnesium malate since it's very bio available. Consider having your magnesium levels checked to see if they are low.

Always coordinate closely with your current cardiologist as you move forward with any and all actions.

Good luck!

 

[Hank]

This is definitely something I will research. I've been walking and cycling forever and I don't even drive. I'm not very overweight (maybe 5-10). Don't eat meat. However, I sleep poorly and have a lot of mental stress. Doc said not to exercise yet other than walking slowly. No jogging, running or biking. I think I'll do the CCTA while looking for another cardio doc. I have to trust whoever I'm working with.

 

[Aerides]

My EKG had some extra beats and 2 mild ST Depressions for non-specific reasons. Because of that I was given an echo cardiogram stress test which also showed similar problems but the doc couldn't figure out why.

Did the doc say he couldn't figure out why, or that there's no smoking gun in your Echo? Hearing the former from a doc would not give me a lot of confidence. (I have some extra beats, as does my Dad, no underlying issues or specific cause for either of us).

Either way, I think it's a good idea to proceed with the extra tests while looking for a Cardio you can trust. Even if they seem smart you want to feel heard and not managed. For something like heart issues, I would want to find a doctor I would feel comfortable talking to from my hospital bed, and also explaining things to my loved ones in that situation.

 

[ivinsfan]

Wise decision. This guy is a problem, actually hazardous to your health. Is there an ombudsman function in your health system? Maybe try that to get a faster switch?

My goodness that's a broad statement. You would look for an ombudsman to complain about a doctor that actually offered someone a choice of options?


We're getting a quick and dirty summary of what is probably several office visits and tests from someone who is understandably concerned about a possible heart problem.



I would first tell the OP, have someone with you at all office appointments. This makes a tremendous difference because having an extra set of ears is pretty important.



Since this appears to be a heart ryhthm issue, I would see if your practice has access to an EP cardio who specializes in heart ryhthm issues.


The OP's issues as I see is he keeps jumping ahead to the what if's, and the posters on this thread who are aghast that the doc didn't just "solve" this issue pronto are pretty unrealistic.


OP got a couple things going on since he seems bothered by the fact the doc has an interest in the stress cardio lab...OP did you ask the doc directly what would you do if I was your Dad?

 

[ivinsfan]

Did the doc say he couldn't figure out why, or that there's no smoking gun in your Echo? Hearing the former from a doc would not give me a lot of confidence. (I have some extra beats, as does my Dad, no underlying issues or specific cause for either of us).

Either way, I think it's a good idea to proceed with the extra tests while looking for a Cardio you can trust. Even if they seem smart you want to feel heard and not managed. For something like heart issues, I would want to find a doctor I would feel comfortable talking to from my hospital bed, and also explaining things to my loved ones in that situation.

Hearts are funny that way, for myself I'd rather have a doc that says I'm not certain at this point I need more info, then one who says there is nothing wrong or who picks a diagnosis that "might" be correct.

 

[ivinsfan]

This is definitely something I will research. I've been walking and cycling forever and I don't even drive. I'm not very overweight (maybe 5-10). Don't eat meat. However, I sleep poorly and have a lot of mental stress. Doc said not to exercise yet other than walking slowly. No jogging, running or biking. I think I'll do the CCTA while looking for another cardio doc. I have to trust whoever I'm working with.

Take someone with you all appointments preferably the same person. Mental stress and comprehensive listening get worse when in a stressful situation like that. Frankly it might be you and not the doctor.



In your shoes I'd go with the NSS which can reveal a lot more since your doc has told you not to do hard exercise. Are you vegan? You might have low iron levels and/or vitamin B issues with can cause your type problems.



The fact your brother has strokes at a young age could mean a AFIB type issue which can cause clots and strokes.

 

[Aerides]

Hearts are funny that way, for myself I'd rather have a doc that says I'm not certain at this point I need more info, then one who says there is nothing wrong or who picks a diagnosis that "might" be correct.

Exactly, and we're hearing a characterization, not what the doc might actually have said. What one hears vs. what is said are often not the same thing, especially in a stressful situation.

Still, taking the OP at face value, if my doc said "I can't figure it out", vs. "inconclusive, needs more tests, not sure yet" - the former is not cool, the 2nd is totally normal. The lack of a "yet.." makes all the difference in this thread.

 

[ivinsfan]

Exactly, and we're hearing a characterization, not what the doc might actually have said. What one hears vs. what is said are often not the same thing, especially in a stressful situation.

Still, taking the OP at face value, if my doc said "I can't figure it out", vs. "inconclusive, needs more tests, not sure yet" - the former is not cool, the 2nd is totally normal. The lack of a "yet.." makes all the difference in this thread.

I have been with my DH to every single one of his cardio appts even the ones considered routine or minor and this is the reason why. I often remember something a doc said when he has no recollection of the comment.

 

[jollystomper]

I am not a doctor, nor did I sleep at a Holiday Inn last night . I'll just share what related tests I went through based on my heart condition.

In my early 40s I had my first electrocardiogram (it was offered free at a health clinic at my gym). It detected I had an enlarged heart. I was not too surprised, as my father also had this condition (but that is not what was his cause of death). My family physician took an EKG, it was normal based on my ethnic background, but he referred me to a cardiologist.

My cardiologist recommend a cardiac MRI instead of a CT scan. It is radiation free. Of course, it also requires no ferromagnetic objects in the body, so not everyone can have one. I ended up getting 2 MRIs. After I had the first one, they called later that day and asked me to return for a second one, as they need more clarification on something they saw in the first one. Since no radiation is involved, frequency is not an issue. The net result was a hole in my heart (ASD), which was successfully patched and returned my heart to normal size.

Since that operation I go to annual visits to my cardiologist. My heart has returned to normal size, but since then I have had 3 nuclear stress tests when I thought I had issues, the last one this past fall. My cardiologist has a nuclear stress testing facility in his offices but I never got the feeling he was doing this for that reason. He gave me the choice for them. I found the test itself to be a piece of cake, with no issues or side effects. That might be why your doctor is recommending it first.


Edited to add: sometimes the view of "indecisiveness" can be based on the doctor's bedside manner. For example, my cardiologist will use whiteboards, pictures, a model of the heart, etc. to explain what might be going on, what he thinks is going on, and what the options are. He is focused on giving his patients as much understanding as possible, and is honest enough to say "I am not sure, but here is a plan of attack...". Personally I like that.

 

[OldShooter]

My goodness that's a broad statement....

Fully justified IMO by the OP's comment:

... I am also very disturbed that the cardiologist didn't want to offer his opinion until I offered mine. It's a huge red flag. He doesn't like my questions. ...

Doctors are basically skilled tradesmen. If one is not satisfactory, move on to the next.

You would look for an ombudsman to complain about a doctor that actually offered someone a choice of options?

Re-read what I wrote, please. I suggested the ombudsman as a possible way to cut the waiting time to get a second opinion. It is up to the OP whether he also wants to complain about the doc or not. I made no suggestion.

 

[Hank]

Thanks for all the feedback. It is very helpful and I am grateful.



For those of you suggesting I bring someone to my appointments, I agree, however during covid it is not allowed. It's bad enough with crowded waiting rooms and people huffing and puffing on the treadmills. But I agree that you are only getting one side of the story and that I am stressed.

Exactly, and we're hearing a characterization, not what the doc might actually have said. What one hears vs. what is said are often not the same thing, especially in a stressful situation.


I agree that you guys are only hearing a characterization and the doctors point of view might be different. The doctor didn't say he "couldn't figure it out". That's my characterization. He actually said something very close to, if not verbatim to, "I can't make a diagnosis with this test. It's too crude....but you have lots of options to choose from. We have to get to get the bottom of this. You can't just let it go." He then explained the 3 tests and I responded asking him which he thought was best. His answer was," I'm going to let you decide but you have to let me know by the end of the week." Come back on Thursday and tell me. This didn't sit well with me and needlessly put even more pressure on me. How could a guy who is supposed to be an an expert and ordering the test not have an opinion worth sharing with his patient



The doctor sees an abnormal ekg and some irregularities on the echo stress test. He's worried it can be something serious but isn't sure so he wants more tests. I feel the same way since I can't really ignore this just because I don't particularly 'click' with this doctor. Tomorrow I am going to tell him I want the CCTA and go from there. He said he will want to order some more blood test as well. Maybe it's the more advanced lipid testing that one poster mentioned.





I'll post after my appointment tomorrow .... best regards to everyone and thank again.

 

[ivinsfan]

That's right you are in Canada, that's a shame you have to go solo. Even with Covid restrictions I have been able to go to all my DH's appts.



Good Luck with your appt tomorrow.

 

[Hank]

Fully justified IMO by the OP's comment:


Doctors are basically skilled tradesmen. If one is not satisfactory, move on to the next.

This is my thinking as well.

 

[ivinsfan]

It's possible this doc senses you are nervous and stressed and wants to include you in the treatment plan as a way of relaxing you a little. It seems like any of the 3 options would be OK to start with and he is asking which one seems easier or less stressful to you. I don't see anything wrong with that, except instead of empowering you it's cause you more stress.



Due to hospital stays and various other things such as retirements I bet I've interacted with over a dozen cardio docs and surgeons. They are all different just as we are all different. They all have different personalities and ways of talking to people. However maybe I'm lucky but not one of them was ego driven. What kind of trademen do you know that deals with humans and their families dozens of times a day. Not too many trademens have 14 years of training to be board certified.



I don't know what you mean by clicking but if you attempt to switch docs you might ask yourself what you expectations are in finding a new one. I've had docs and surgeons sit and hold my hand and a couple of them would always place their hands on my DH's leg or shoulder when he was in the hospital room also had some that came in said this is going on and left the room.



The surgeon that literally saved my DH's life in the OR brushed off my DH's expressions of gratitude and told him, you did the hard work now go and enjoy your life. They are human just like we are, imperfect humans that want to help others.


Perhaps I am be naive about cardio docs as a new survey ranked the hospital where my DH gets his care as one of the top 55 in the entire country and the cardio dept even higher. Maybe I have rose colored glasses.

 

[Chuckanut]

Here's an interesting article on calcium scores and their ability to predict or aid in heart disease. The two quotes below are interesting, but I'll let people read it and come to their own conclusions.

https://www.peoplespharmacy.com/articles/how-well-do-cac-scores-predict-heart-attack-risk?

Although CACS appears to add some further discrimination to standard CVD [cardiovascular disease] risk calculators, no evidence suggests that this provides clinical benefit.”

That is stuffy doctor talk. What they are trying to say is that CAC scores are not very helpful in predicting or preventing heart attacks. They go on to add that any modest gain from a heart scan may “often be outweighed by costs, rates of incidental findings, and radiation risks.”

In the future, cardiologists will need to learn why both intense exercise and statin therapy appear to accelerate calcified plaque progression. After all, both presumably protect patients from heart attacks. These findings suggest that the coronary artery calcium scan might not be the best way to predict cardiovascular complications.

 

[Katsmeow]

Here's an interesting article on calcium scores and their ability to predict or aid in heart disease. The two quotes below are interesting, but I'll let people read it and come to their own conclusions.

https://www.peoplespharmacy.com/articles/how-well-do-cac-scores-predict-heart-attack-risk?

I looked at this a bit when DH was referred to a cardiologist. What I found indicated that doing a calcium scan will find some people who are completely symptomatic and will tell them they should go see a cardiologist to figure out what is going on. The ideal person for the scan is someone at higher risk of cardiac disease due to age, heredity, etc. but who has no symptoms.

On the other hand, once you have been sent to a cardiologist who is investigating whether you have a cardiac problem then the scan doesn't give you any real benefit as there are specific tests that are more helpful.

DH is an ex-smoker who quit over 30 years ago. Periodically his doctor has him do a low dose CT scan of his lungs just to check on things. This year the scan was fine but the radiologist flagged that he had coronary artery disease which was absolutely news to him. He had no symptoms and the previous year's lung scan didn't find this. DH does have family history of heart disease.

So he went to a cardiologist. They did the new kind of stress test (no treadmill) and I think an echocardiogram. Basically they found plaque which was interesting because his cholesterol levels are completely normal. But doctor says the plaque is caused by cholesterol. So now he takes medication and sees the doctor regularly.

 

[Hank]

Sorry I haven't been able to give you an update sooner. When I follow health threads I like to learn their conclusion. Sometimes they end suddenly and I never like the feel of that.


So anyway, since I last posted I've taken anther EKG and echo cardiogram at a different cardio center and have a meeting with a new cardiologist at the end of June. I could have seen a different cardiologist sooner but I wanted to find one associated with the better hospitals here. I did that. So they took the new echo cardiograd and EKG and I haven't heard anything from them. This was last month. They said they would review the test immediately though then only call me if it was an emergency. So hopefully they reviewed them and things are not dire. The test was about 3 weeks ago.



The first cardiologist sent me for a blood test and scheduled me for a CT scan but it's not until Jan. 2023. So I figured in the meantime I can find another cardiologist and get a second opinion because this sounds nutty to wait this long. Also, the old cardiologist told me to take a baby asprin which I subsequently learned is no long recommended for people over 60 who have not already had a heart attack or stroke. They say the benefits don't outweigh the risks. When I asked the doctor why he prescribed the aspirin since the recommended rules say don't, he wouldn't answer the question. He just said, " then don't take it". That was enough for me to get motivated to find another doctor. Also, I think his hands may have been shaking. Can't be sure. I was his first appointment that morning so maybe he still had a hang over.



In the midst of all this I had a cancer scare which so far seems to be just a scare. But because I have that off my mind, now I can concentrate on my heart situation and advocate for myself better.



I found that taking magnesium stopped my heart palpitations and my sleep is better. i think worrying about my biopsy and some other health issues just gave me so much anxiety that the ekg was off. In any case, I'll get it all checked out.