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!


  1. Anonymous1:15 PM

    Doctors are only human, you know, as complicated as the rest of us! Best wishes, crossed fingers and prayers that nothing is amiss (or if it is, they diagnose it rsn)


  2. One thing I've learned this summer is that EKGs aren't really as useful as you'd think. They're very useful if you're experiencing the pain at the moment the EKG is being done. Depending on what shows up, they're significantly less useful other times.

    For example: flipped T waves. They can be any of the following: due to stress, pharmacological agents, natural variations, cardiac (ventricular) hypertrophy, ischemia, and a few more that I can't remember. That's a huge spectrum of possibilities. Classic ischemia-related inverted T-waves are symmetrical, but that's not a 100% thing. The shape of the T-waves can change everything in the interpretation (sharp? round? biphasic? and so on - they each have different meanings). Most of my "quizzes" have included "non-specific T-wave abnormalities" and use some odd variations to teach about rare diseases.

    If it's going to make you more stressed not to know, then that's not good, and I'd push for a full work-up (as long as you don't have a biphasic T-wave, but I think you'd have gotten a large "oh wow" in that case), but if your doctors don't think it's indicated otherwise, then you're probably good to go. But I'd definitely push for a full explanation as to why the T-wave inversion and ST depression isn't important (if only because the underlying rationale might make you feel more secure).

  3. Thanks to both of you! M: I appreciate the prayers. A: That's very helpful info, although the gap between the PA's reaction and the doctor's still puzzles me. (Particularly since the doctor didn't talk to me, only to the PA.)

  4. Susan, I'm sorry you aren't getting clear and positive results. It has got to be hugely frustrating. I'll keep you in my prayers about this.

    In the mean time, knowing nothing about Thallium tests I went and looked it up. Now I'm wondering if there is some way that Susan is going to turn a Thallium test into another circulatory system (CS?) Jesus. (g)

    Peace, Hope & Joy

  5. Dear Lord, none of this is a surprise to you. Please help the medical people to tell Susan what she needs to know, and not to confuse her, or be confused themselves. Work this out for her good and your glory.


  6. Anonymous4:42 AM

    The gap between the PA and the cardiologist is probably due to something fairly innocuous: the PA, simply doesn't have the kind of background to make a complicated reading. PA school is two years, and most additional training is done on the job, which means the knowledge of the PA can vary considerably based on a) how much they pay attention on a daily basis, b) how long out of school they are (time = knowledge) and c) how long they've been working in this particular field. Some PAs are only a step behind the doctor when it comes to highly specific fields. Some are equivalent to Dr. Google.

    So while the PA probably knows all the big danger readings and a good deal of the mediums (again: knowledge will vary widely), the doctor's extra years of medical school, residency, and presumably fellowship allowed him to make a more informed call about what your EKG meant.

  7. Oh, Susan, this whole thing sounds stressful!! It seems very unfortunate that the PA was allowed to natter on in your actual presence. This isn't very professional and perhaps the cardiologist would be interested in knowing that her/his staff are scaring the patients half silly. Then again, perhaps they don't care. Any way you can speak to the cardiologist in person? You must be left with a million questions. BTW I *have* seen flipped T-waves--on an Irish Wolfhound recovering from emergency surgery and massive blood loss--and the vets and techs all were mightily impressed, and I said, CALL THE CARDIOLOGIST. (It was my dog and I was freaking out. Turned out to be all the stress and drugs and he made it through, but I know how horrifying all that Oh-ing and Ah-ing can be.)Sure hope you are OK. They may have GIVEN you the flipped T-waves with all that hand-flapping.

  8. Lee, Martin, Anon, and Terri -- Thanks! All info and good wishes appreciated.

    Terri: Speaking to the cardiologist would be, well, awkward. I know his name and practice, but I'm sure he doesn't want to be pestered with calls from hospital patients. My primary is supposed to call me when her office gets the results (I spoke to her assistant today and emphasized that I had questions), so I'll wait to see what she says before I do anything else. In the meantime, I've been reading up on women's heart disease (especially the WISE study, although I'm sure all my doctors are familiar with it too), and I've located a female cardiologist in town who specializes in women's heart disease. (Of course, she's probably swamped with patients and not accepting anyone new.)


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