Monday, July 02, 2007
To Stress, Or Not to Stress?
Our story thus far: As I reported in a previous post, three years ago I had a stress-echo test after some months of mild chest pain. I was told that the test was normal and that I had a very healthy heart; the chest pain, we all decided, was GERD. I've recently started having the chest pain again, and I figured it was GERD (a logical assumption, since I went off my GERD meds after a study showing that they increase the risk of osteoporosis, which I'm at risk for anyway), but this time it's been combined with fatigue, a classic cardiac symptom in women . . . but also a classic sign of depression, allergies, and sleep disorder, all of which I also have.
But I went to my doctor for a checkup and mentioned all of this, and she said, "Let's do a stress echo," and I told her I'd had one and it was normal, and she looked at the results and said, "No, it wasn't normal. You had some ST-segment depression" -- which can indicate narrowing of arteries -- "but they decided it wasn't significant because your exercise tolerance was so good."
So I had another stress echo this morning, after paying my *cough, cough* $416.60 copay.
Note: I'm a healthy weight, have good cholesterol levels, have never had high blood pressure, don't smoke or drink, and exercise six days a week. However, my mother's had a stroke and my father's had quadruple bypass, so my risk is increased because of family history.
This time, my EKG was evidently pretty wonky. The PA was using words like "profound" and "globalized." The ST depression was 2-3 millimeters; T waves were "flipped." I'm not sure exactly what any of that means, but I gather it's not great. There was other stuff going on that I was even less able to follow; the PA and the two techs -- all of us crowded into a tiny room with an examining table, the ultrasound machine, the treadmill, and the EKG cart -- kept pointing things out to each other and muttering. The PA would gesture to something on the EKG, say, "What worries me is," and then go off into incomprehensible medicalese. I'm better at med-speak than many laypeople, since I volunteer at a hospital, but I can't follow arcane cardiac lingo. Occasionally he lapsed into plain English of the "Wow, look at that!" variety, which isn't the kind of plain English you want to hear during a medical exam.
The PA and both techs had responded with eye-rolling and/or raised eyebrows when I said that I hadn't been told about the ST depression last time. "Well," said one of the techs, "every doctor has his own way of doing things," but I could tell that she was being diplomatic and thought I should have been informed.
Mind you, I still didn't have any chest pain or shortness of breath on the treadmill; one of the corollaries of Murphy's Law is that all medical symptoms vanish in the doctor's office. (I've never had SOB, but the pain does sometimes start pinging during a workout.) The ultrasound tech said my heart looked absolutely fine, although she hadn't been able to get good pictures of one portion of the heart before the treadmill test. And the PA told me that 30% of women have false positives on this test.
But given my symptoms -- especially the fatigue -- and the family history, the PA clearly thought I needed more testing. When I asked him what would happen next, he said that the cardiologist would decide that, but that I'd probably be sent for a cardiac work-up, or maybe for a thalium stress test to get a better picture than the ultrasound had provided. And he said that given the family history, the cardiologist might even decide to "cut to the chase" and send me to the cath lab.
I said, "Can you compare this test to the one three years ago to see if it's worse?"
One of the techs said, "Oh, no, we don't have it," and then, "Oh, well, I guess we could get it out of storage." But no one responded to that with any urgency.
Wouldn't a comparison be useful? What am I missing here?
So I got dressed, and the PA went to find the cardiologist. And then the PA came back and said, "Well, he says it's probably a false positive and you should go home. But he'll append a note to the report saying that if you or your primary are still concerned, you might want to consider the thalium test."
I don't get it. How can the PA and the cardiologist have such different takes on the same results? I'm also frustrated by the fact that the decision of what to do next was handed back to me and my primary: hey, guys, I was sent here because you're the experts, okay? I guess my primary has the result of the earlier test and can do the comparison, but wouldn't a cardiologist be better at that?
So I have a call in to my primary, who'll call back, I'm sure, sometime this century. Meanwhile, my gut instinct is that I should probably have the thalium test just to be safe; the PA even said, "Look, if you're nervous, press for it." But we'll see what my doctor says.
I have a long history of having vaguely alarming symptoms, and then having tests which produce vaguely alarming results, and then having gobs and gobs of ever-more-expensive tests which show that there's nothing wrong. This isn't how I want to spend my summer. But if something's wrong with my heart, I want to know about it.
On the plus side, watching an ultrasound of your own heart is seriously cool. The ultrasound tech agreed with me; she said, "This stuff blows me away." It's nice to be around people who love their work!