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Forum Name: Cardiology Symptoms

Question: Positive Stress Test with Negative Angiogram


 fearuvhorses - Tue Jun 10, 2003 8:07 pm

I was admitted to ICU 6 weeks ago with new unstable angina. Cholesterol was 650 and blood pressure 189/109. Was placed on IV nitro for angina, and given LOADS of drugs. Stablized and sent for angiogram which revealed a 40% blockage, deemed not significant. Have had to discontinue Lipitor, Altace, Atenolol and Aspirin due to side affects. BP is down but heart rate still resting 90-105. Had another positive stress test today and physician said he would have sent me for an angiogram based on this stress test if I had not already had the one 6 six weeks ago. So, can a 40% blockage go to a more significant blockage in just six weeks. Also, what other causes for angina, shortness of breath, rapid heart rate (180 during stress test and still at 130 10 minutes after the test), elevated blood pressure if not a blocked artery?
 Dr. Yasser Mokhtar - Wed Jun 11, 2003 10:22 pm

User avatar Dear Fearuvhorses,

Thank you very much for using our website.

You have to tell me more about yourself. Male or female? How old? Smoking or not? Family history of coronary disease at a young age? Do you exercise or lead a sedentary life?

If you had an angiogram that showed that you do not need anything except medications, why did you have a stress test. The angiogram overrides the stress test and it was already done, so i do not know why did you have the stress test.

What do you mean by a positive stress test? What kind of stress test was it? Did you walk on a treadmill? Did you have chest pain while walking? How long were you able to go on the treadmill (if you had a treadmill test) before you had to stop or have the chest pain?

Were there any ekg changes? Was a radioactive substance injected? Lots of questions to answer.

In which artery is the 40% blockage? Can the lesion change in 6 weeks, sure it can. But any significant change will be so dramatic that it will result in a heart attack most probably.

The standard of care in your case is to take aspirin indefinitely, beta blockers (for heart protection and hypertension), lipitor (or any medication that lowers your cholesterol) because they were found to have other beneficial functions (to the arteries) besides lowering the cholesterol and it should be the bad cholesterol (ldl) and not the total cholesterol that should be followed (should be less than 100 according to the last guidelines). Altace and the like medications are used if you had a heart attack and for high blood pressure. i do not know the kinds of side effects that you had but if these side effects were tolerable, then it is better that you go back to these medications or let you doctor find an alternative for them.

About your last question, angina is usually caused by a blocked artery. Shortness of breath has lots of causes begining at not being physically fit and ending with severe heart and lung diseases. Rapid heart rate can also has many causes.

Once more, thank you very much for using our website http://doctorslounge.com and hope that this information helped and waiting for your reply.

Yasser Mokhtar, M.D.
 fearuvhorses - Sun Jun 22, 2003 10:28 pm

In reply: I am a 42-year old, non-smoking, caucasian female. Family history includes my father with a 1st heart attack at 40 and 1 subsequent at approx. 55ish (??). My paternal grandparents were 1st cousins, following a pattern of several generations of intermarriage between two clans. Both died of heart attacks. Grandmother at an early age and grandfather at 60ish. Of my father's 12 siblings, 1 died in infancy, 8 died of heart attack or stroke and his remaining 3 living siblings have all had either heart attack or stroke. One cousin died of heart attack at 37, 1 of aneurism at 42. One cousin had a child died of heart failure at 22. My brother had a stroke at age 45. All are diabetic. I am glucose intolerant. Most aunts had fatal 1st heart attacks before 55. I do not live a totally sedentary lifestyle but neither am I athletic. I am overweight. I walk, when able, most days for 20-40 minutes.

Angiogram showed 40% blockage (early April) and was deemed not to be significant. I had to discontinue Lipitor due to muscle cramps and something to do with what showed up in blood tests (liver??). I have re-started the Atenolol and have found that by splitting the doseage into half in the morning and half in the evening that I have minimized the side affects significantly. I can take aspirin every 2nd day and still get red spots (like little bursted blood vessels) but do not get daily nosebleeds.

The stress test involved walking on a treadmill. I developed chest pain and shortness of breath in less than a minute. As this is usual during daily activity I elected to finish the test and actually insisted on doing so. My report stated "2.20 horizontal to downsloping ST segment depression". I have no idea what this means and would appreciate further clarification. The test was ordered because of continuing chest pain. An exercise MIBI has been booked for further investigation.

Angina continues to worsen, with more episodes occurring at night and several that have instantly dropped me to my knees with pain and lightheadedness so extreme I come close to passing out. These can last up to 10 minutes and usually are a result of unusual excitement or physical activity.

Thank you. Any further information would certainly be appreicated.
 Dr. Yasser Mokhtar - Mon Jun 23, 2003 1:02 am

User avatar Dear Fearuvhorses,

Thank you very much for using our website.

Your family history is definitely one that has lots of cornary disease.

Glucose intolerance is an old term now it is called prediabetes (before diabetes), so you are going to develop diabetes at a certain point (if you really were glucose intolerant). Putting this fact in mind. You have to try to modify your life style the best way you can in addition to try to control your health problems (like high blood pressure and high cholesterol) the best you can.

Like i said, you have to take the asa, very good that you are taking the atenolol. There are other medications that could control your cholesterol in addition to losing weight and exercise although with the numbers, these will not be enough and you will have to take medications (they do not have to be of the lipitor family), there are other medications that can lower the cholesterol that you can use if you had the muscle problems with the lipitor and its family (no need to take any risk).

About your stress test. Although i was not in agreement with doing the test but stoping the test after one minute together with the ekc changes that you mentionned will give us no valuable information (putting in mind that we know the results of the angiogram). Unless there was a dramatic change in your lesion and if this is the case especially with the kind of symptoms you described at the end of your message (night time angina) my advice is to go ahead and repeat the angiogram immediately.

Once more, thank you very much for using our website http://doctorslounge.com and hope that this information helped and waiting for your reply.

Yasser Mokhtar, M.D.
 fearuvhorses - Mon Jun 23, 2003 1:49 pm

Even though I experienced chest pain and shortness of breath at one minute, I insisted on continuing and was taken off at 4 minutes. As I said, the physician's report stated "2.20 horizontal to downsloping ST segment depression". I would like some clarification of what this means. Is this finding what indicates a positive stress test, how positive? Or is it the shortnes of breath and chest pain, which I felt was manageable and believed I could have continued. Thank you.
 Dr. Yasser Mokhtar - Tue Jun 24, 2003 10:17 am

User avatar Dear Fearuvhorses,

Thank you very much for using our website.

A positive stress test is indicated by many things of which are chest pain, shortness of breath and ekg changes. The ekg changes could be st depression (should be more than 1 mm in leads that correlate with heart territories supplied by the same coronory artery) and could be in the form of st elevation (in case of coronary artery spasm).

In general stress tets are only 70-75% sensitive and in women, stress tests are less sensitive than in men even, that's why most of the time, the test is complemented with injection of a radioactive material that shows the blood supply of the heart (through certain pictures). So, let's say the patient gets chest pain during the stress test and the ekg shows changes and then the radioactive material pictures show that the blood supply to the area where the ekg changes happened then we know that this is a positive stress test.

Stress tests are used to know whether a patient has coronary disease or not. If a patient comes with symptoms strongly suggestive of coronary disease like typical central chest pain during exercise, relieved by rest, pressure in nature, all the typical charateristics, does this person need to have a stress test? The answer is no, because most probably the stress test will be positive (and even if it comes back negative), this patient needs an angiogram, so a stress test usually is not done in these circumstances and angiography is immediately done.

In my opinion, in your case, repeating a stress test after an angiogram is not going to help much because we know that you have a 40% lesion which if your symptoms have changes since the angiogram could mean that the lesion has worsenned but usually the change is so dramatic that the result is usually a heart attack or in rare cases onset of severe symptoms.

Once more, thank you very much for using our website http://doctorslounge.com and hope that this information helped and waiting for your reply.

Yasser Mokhtar, M.D.

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