"but I feel fine!"

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Spartacus

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49yo male, non-smoker, non-drinker, not diabetic, not fat. I eat well and run 2-5 miles somewhat regularly. On hctz/amlodipine for low grade hypertension.

I went in for peace-of-mind cardiac checkup, assuming it would be boring. We're all young and healthy, right?

Survey says:
* EKG: Some ST depression.
* stress test: heart seemed "irritated" (doc's words) on the treadmill, with some extra beats when under stress.
* Calcium CT score = 0.
* 3 day Holter was unremarkable.
* 9:14 on Bruce protocol. I could have gone longer, but the doc said I hit my target heart rate and he got the data he needed and did not need me to go until failure. It's an awkward speed between walking and running and I just wanted it to be over so I could get a cup of coffee. Maybe next time I'll see how far I can go.
* "abnormal" nuclear imaging.

Next up: CT angiography & echocardiogram.

Get those tickers checked...
 
I agree with getting it done. My best friend was not the type to check on these things and passed unexpectedly from a heart attack. So, I recently had this done with similar results - ST Depression. After CTA Echo I ended up getting an FFR, which is much more accurate.

The first Doc didn't explain any of it all, and he never followed up with me. I found a second opinion and they explained that the EKG Stress Test is not that accurate. He went into great detail on all the test results to conclude the FFR was showing good heart flow and not to worry.

In the weeks between, my head was all over the place.
 
llewtrah- he's in a high prevalance group. Pred. Value is going to have but a small false positive rate. False negatives are a tad bit larger than small, but still small. At least he didn't get a Cor CT and end up in the same place (rads). And if you can get a FFR-CT where you are, that counts federally as a CATH. That's where, if you have to, you want to substitute for a diagnositc heart cath if/when that comes up.

Trouble is, "I fell fine" until...."I don't feel fine any longer!". The alternative is to do a postmortem exam (AKA) "Autopsy".
 
Many years ago, a friend was driving to work, and had some chest pain.

DC General Hospital was brand new, and just 2 blocks off his route, so he made a stop "Just to get checked out". Soon, he was diagnosed as having a heart attack, images called for a multiple bypass operation. Before he went to surgery, he called his boss for sick leave.

A week or so later, he was released, and found that the tendency to get tired often had disappeared. His surgeon told him that if he had had been in an accident, it likely would have triggered a fatal attack.

Sometimes it is very important to check things out, even if it ends your flying career.

He was not a pilot, but another 20 years working made a huge difference in the benefits his family would receive when he retired, more the 3 times what his wife and teen age children would have had if he died.

All of life is a series of trade offs, and we make the best of those choices that we can.
 
bbchien said:
llewtrah- he's in a high prevalance group
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You’re the one in active practice and I’m not, but I’m not sure I see that: 49yo non-smoker, non-drinker, non-diabetic, active, controlled hypertension, no mention of lipid issues or family history who “…went in for peace-of-mind cardiac checkup” which prompted the EKG , ETT, and “Calcium CT score” (zero, incidentally). The EKG triggered the ETT which triggered the Holter which led to an “abnormal’ nuclear imaging” (nature unstated) and “next up CT angiography and echocardiogram” for unstated reasons.

Generically, and with the limited info first presented, I think a pilot should be cautious about getting too many tests from a “peace of mind cardiac checkup”.

While not trying to be argumentative, as presented (anonymously), I’m not sure I’d make the broad recommendation he did to the crowd to do likewise, primarily because of false positives for many of the things listed - all of which require follow-up plus documentation at the next physical, as needed.
 
llewtrah381 said:
I think a pilot should be cautious about getting too many tests from a “peace of mind cardiac checkup”.
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I sure agree with that part: that crowd represents fertile ground for corporate medical explitation with a lousy ROC. ONE can dilute ANYTHING for $s...and it appears to be the "american way"....and the coronary CT represents EXACTLY that. The scattergram on that test is TERRIBLE which is why for YEARS I have been saying "don't do that" (and it was for cash back then). If you have to have an evaluation at least do a real Bruce TMT whose ROC is known.
 
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Llewtrah381 said:
“abnormal’ nuclear imaging” (nature unstated)
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Nuclear imaging showed (only in the VLA series) some darker areas after stress compared to at rest, which could be explained by 1) poor blood flow to the heart muscle or 2) imaging artifacts. Dr. stated that one could confirm or refute with CTA or cath, with CTA being more appropriate for an otherwise low risk patient.
 
Your doc needs to find you a CT-FFR. From the primary CT + contrast data digital stream, they can actually calculate where the narrowings are and how narrow. This has been validated, and is now being accepted in lieu of diagnostic recath prior to 1st/2nd class return to service after stenting. If he doens' thave access to this your hospital is a smidge "behind the curve". And it costs less than a cath. And as for Risks: no danger of a catheter dislodging an atheroma in the aortic arch.
 
Spartacus said:
Nuclear imaging showed (only in the VLA series) some darker areas after stress compared to at rest, which could be explained by 1) poor blood flow to the heart muscle or 2) imaging artifacts. Dr. stated that one could confirm or refute with CTA or cath, with CTA being more appropriate for an otherwise low risk patient.
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This. It feels like you’re chasing one false positive after another, especially being “…an otherwise low risk patient”. Then if it gets to a cath which ends up normal but there’s a procedural mishap, not good. Let alone this isn’t cheap
 
AMEN to that.....Do NOT have a procedural mishap as he spends your Insurance benefit.
If he insists then teh way to go is CT-FFR.

Whether or not you're in a higher risk group depends on:
Smoking
Family history
Obesity (overweight)
Hypertension and control
.....only your Caretaking MD is going to have the tools to assess that. And it wouiwld apper that ll you have is hypertension (asusmedly controlled) and that I didn't read the first post carefully.

Got a Family history of CAD?
 
I would be surprised if Hopkins did not have FFRCT.

An uncle on dad's side checked out early due to an aneurysm, an uncle on mom's side has had at least one MI and a stroke; both were/are smokers.
 
Spartacus said:
49yo male, non-smoker, non-drinker, not diabetic, not fat. I eat well and run 2-5 miles somewhat regularly. On hctz/amlodipine for low grade hypertension.

I went in for peace-of-mind cardiac checkup, assuming it would be boring. We're all young and healthy, right?

Survey says:
* EKG: Some ST depression.
* stress test: heart seemed "irritated" (doc's words) on the treadmill, with some extra beats when under stress.
* Calcium CT score = 0.
* 3 day Holter was unremarkable.
* 9:14 on Bruce protocol. I could have gone longer, but the doc said I hit my target heart rate and he got the data he needed and did not need me to go until failure. It's an awkward speed between walking and running and I just wanted it to be over so I could get a cup of coffee. Maybe next time I'll see how far I can go.
* "abnormal" nuclear imaging.

Next up: CT angiography & echocardiogram.

Get those tickers checked...
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IMHO, you need a second opinion. Way overdone. A calcium score of 0 negates all followup testing for blockages.
 
mryan75 said:
They can also reveal serious medical conditions. I applaud someone who chooses to be proactive.
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100% agree. I’ve been totally behind evidence-based screenings all of my medical career.

And if one wants to get it fully on their dime, have at it. I just don’t like me paying for someone else’s random screening (via my insurance premiums) - and especially their treatment for unforced-error “misadventures” when, say, a cardiac cath goes bad.

Men get breast cancer. You had your mammogram yet?;)
 
I agree that "preventative maintenance" is a good idea! The challenge I think when you're in aviation is that sometimes you say the wrong thing to your AME and all of a sudden it's thousands of dollars in tests for what is really a non-issue, but the FAA has such archaic and opaque policies.
 
AeronautCanuk said:
I agree that "preventative maintenance" is a good idea!
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Performing oil analysis, using a borescope to look through the spark plug holes, etc. is reasonable, and equivalent to a physical exam, lab work, and ekg.

Pulling cylinders off to examine the cam just for "peace of mind," when the engine is running well and making good power, is unreasonable, and equivalent to doing a heart cath just to check things out.

Maintenance-induced failure is a real thing, both in aviation and in medicine.
 
Add: the fact this is posted by a “guest” suggests they are aware of the potential risk to their Medical of this game, IMHO
 
This is why health insurance is so expensive in this country. Because we actually do have access to great care and people expect to get it on demand, even if it's completely unnecessary.

Of course all of this testing will have to be disclosed on the next medxpress application. And the FAA may or may not agree that the OP has reached the end of testing.
 
First, my standard disclaimer-None of this is to be construed as medical advice...

From the history, it seems low risk. If you can run regularly, and you can hit your target heart rate on a treadmill without chest pain, you are very, very unlikely to have significant flow limiting coronary blockage. Your calcium score was O. While cases of coronary artery blockage have been reported with zero calcium in the plaque, this is stunningly rare.

Perhaps the doc's "layman's terms" weren't very good, but nonspecific ST changes on a baseline EKG can mean nothing. You can get nonspecific ST depression from eating a meal. Yes some patterns look worrisome, but your description is pretty indeterminate. Now you get a stress test that has a few extra beats, again, not really classically abnormal, but could be. (depends exactly what was seen). Then, the nuclear scan was not conclusive. Sigh...

What we have here is a low risk individual, no symptoms and a good exercise tolerance with basically indeterminate tests.

If you want to keep your medical, you're stuck, you'll probably need a CTA FFR.

But, if you don't need your medical, do you need a CT FFR or angiogram?

Hmmm. Here is the problem. CTA (or CTA FFR) both give you a pretty good radiation dose. Congratulations, you've now increased your lifetime cancer risk. "good news, your arteries are clear, bad news is, you're getting lymphoma in 20 years from the radiation." I mean, maybe. But your statistical chance of having meaningful cardiac disease is very, very low. You can lower your statistical risk some more by getting the CTA FFR, but you'll have to accept increasing your future cancer risk ever so slightly to find out. The FAA doesn't care about your future cancer risk, so it will likely want more tests...

It's even worse with a coronary angiogram. This has much higher real world risks. "good news, your coronaries are clean...bad news, you had a small embolic stroke from the procedure. It's a known risk. You signed a consent. Kinda a downer. Hope rehab works out for you..."

"I want to be proactive," and "I want to know," are all very laudable goals. But every procedure you have going forward has some nonzero downside personal risk to you, apart from all the money that is spent...

Knowing when not to order or have a test done is perhaps the most important decision of all.
 
Mark K said:
"I want to be proactive," and "I want to know," are all very laudable goals. But every procedure you have going forward has some nonzero downside personal risk to you, apart from all the money that is spent...
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The issue is that the money is not spent by the consumer. Ironically, much of medical care in this country would actually cost less if we had to pay for it.
 
Someone suggested I get a calcium score. I asked my doc about it. He said you're low risk, but it wouldn't hurt to know the score. I asked him what was the likelihood of getting diagnostically useful information vs. getting ambiguous results that make the FAA ask more questions? He changed his answer to don't have the test.
 
Llewtrah381 said:
100% agree. I’ve been totally behind evidence-based screenings all of my medical career.

And if one wants to get it fully on their dime, have at it. I just don’t like me paying for someone else’s random screening (via my insurance premiums) - and especially their treatment for unforced-error “misadventures” when, say, a cardiac cath goes bad.

Men get breast cancer. You had your mammogram yet?;)
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Yeah I mean you can extrapolate out, but what is the cost of a late diagnosis? We pay for more for people who don’t have insurance than for people who do.
 
Lindberg said:
Someone suggested I get a calcium score. I asked my doc about it. He said you're low risk, but it wouldn't hurt to know the score. I asked him what was the likelihood of getting diagnostically useful information vs. getting ambiguous results that make the FAA ask more questions? He changed his answer to don't have the test.
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Getting mine in April, don’t really care one way or the other what the FAA has to say about it. I’ll deal with that if I have to.
 
Half Fast said:
Performing oil analysis, using a borescope to look through the spark plug holes, etc. is reasonable, and equivalent to a physical exam, lab work, and ekg.

Pulling cylinders off to examine the cam just for "peace of mind," when the engine is running well and making good power, is unreasonable, and equivalent to doing a heart cath just to check things out.

Maintenance-induced failure is a real thing, both in aviation and in medicine.
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Truer words have never been spoken! "Maintenance-induced failure is a real thing, both in aviation and in medicine."
 
mryan75 said:
Getting mine in April, don’t really care one way or the other what the FAA has to say about it. I’ll deal with that if I have to.
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Well, just know that coronary calcium scans drift up with age. 25% of men who are 57 will have a value of 100 or more. By the time you get to 67, you have a 50% chance of having a score of 100 or more.

Does that mean you have a 25 or 50% chance of having clinically meaningful heart disease. No, likely your doctor will just recommend a statin if your value is over 100 in the absence of other risk factors or symptoms.

However, if you have a class three or higher medical, it does indeed mean that you will have 50% chance of needing an SI and maybe paying for additional tests on your own dime (or having the rest of us pay though our premiums!) IIRC, any score over 99 means deferral/SI...
 
CTA revealed no CAD.

They plan to roll out new software in the coming months; the dataset acquired today can be run through the FFR analysis later, if so desired.

OKC is no factor. Thanks, BasicMed/MOSAIC!

Insurance engaged outside counsel / hatchetmen (rhymes with EvilCorp); upon review, they found the claims to be medically appropriate.
 
Spartacus said:
CTA revealed no CAD.

They plan to roll out new software in the coming months; the dataset acquired today can be run through the FFR analysis later, if so desired.

OKC is no factor. Thanks, BasicMed/MOSAIC!

Insurance engaged outside counsel / hatchetmen (rhymes with EvilCorp); upon review, they found the claims to be medically appropriate.
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How much did you get the insurance company to spend to confirm that a healthy, low-risk individual does not, in fact, have a disease that he had no indications of having?
 
I have to agree this was likely mostly a waste of money. One of the few reasons to do a coronary calcium scan is to believe the data that says if you have a zero score on your $100 calcium scan, and you have no symptoms, and you have no meaningful risk factors, you have a negligible risk of significant coronary artery disease and the workup should probably have stopped there.

So yeah, the other $2500 or so that was spent...and then everyone moans about their health care premium...this is why.
 
bbchien said:
Your doc needs to find you a CT-FFR.
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I had not heard of this test until reading your post.

I googled it.
As I understand it, they first do a CT coronary angiogram, then use sophisticated software to determine bloodflow pressures upstream and then downstream of any blockages?

Where Do I find out who performs these?
Google didn’t offer much on that question.
 
FFR is just a software upgrade that is tacked on to a coronary CT angiogram. Whether or not someone needs one is a complex question best discussed by you and your cardiologist if someone has known coronary disease and inconclusive CT angiogram results, or a few other scenarios best discussed in conjunction with your cardiologist. It hasn't become the standard to run it on every CT angiogram. It's still relatively novel and the data is evolving. I'm still not clear in my mind who needs one and who doesn't.

However, this is America and yes, you can just pay for one yourself...

So you want to pay for FFR?

Note I am in no way advocating for MDSave, have no financial interest in them or any imaging or laboratory corp and am not giving any sort of medical advice. Just really pointing out you can buy anything in the US, whether or not you need it...
 
When i read such discussions i am reminded of an enjoyable book by dr Norton Hadler called “Worried Sick”. I think it does a good job delving into the actaul statistics of many medical problems.

Here are ssome of his thoughts on cardiac crap: https://www.discovermagazine.com/discover-dialogue-physician-nortin-hadler-15524

He has a few other good books.

I bet that over a 22 year RN career I drew blood from >1000 patients testing for a heart attack, none were positive. I think my much longer career spouse had two positive and one of those it was really known without blood tests. Such a waste of time and resources!

The OP needs a shrink for peace of mind. Spartacus in name only
 
4RNB said:
I bet that over a 22 year RN career I drew blood from >1000 patients testing for a heart attack, none were positive. I think my much longer career spouse had two positive and one of those it was really known without blood tests. Such a waste of time and resources!
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That's what you get with a medicolegal system which opens up clinicians to potentially devastating lawsuits if they don't order the test and it later turns out there was an MI which was missed. With little downside to ordering screening tests and a potentially major cost if they don't order the test, many (most?) clinicians will choose to order. Thus does "defensive medicine" drive up medical costs.
 
The echocardiogram was also unremarkable.

Aside from routine checkups, I have not consumed much in the way of healthcare in my 49 years to date. I am not the type who runs to the doctor for every cough or ache or hangnail; if anything, the opposite. The suggestion that I should feel guilty because I am spending other people's money on preventative care is mildly entertaining. In the event that insurance didn't cover the tests, I was prepared to pay out of pocket. Due to ever-increasing deductibles, it may work out that way anyway; I'm sure the statements will start rolling in after a few months, after the opaque random number generators decide how much to bill me.

I have seen enough people delegate/abdicate responsibility for their own health to their PCP, usually with poor outcomes. Maybe they make bad decisions, maybe they have mediocre providers, maybe both. In any case, I don't want to be one of them.

To use an aviation analogy, a good A&P is necessary but not sufficient; a proactive owner helps to complete the picture.

To use another aviation analogy, I view this like a mid-time engine that's been running well, but hasn't been borescoped or had an oil analysis; I don't think it's a bad idea to take a non-invasive look to establish a baseline, particularly when heart disease is the #1 killer.

Now I just need to avoid cars and ladders for the rest of my life.
 
Spartacus said:
The suggestion that I should feel guilty because I am spending other people's money on preventative care is mildly entertaining.
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Except, you're not engaging in preventative care. Preventative care would be to set a goal over the next 6 months of doubling your weekly running mileage, or some other physical activity. I know you mentioned that you eat well, but in 30 years of medical practice, I can say that "I eat well," comes out of virtually every patient's mouth. Which seems disconnected from the reality I see when I go to Costco or Safeway and see what the majority of folks are cramming into their shopping carts.

As far as tests, things like cholesterol, A1c/blood glucose, colon/prostate/breast cancer screening. Those are preventative tests. So preventative care is counseling on lifestyle and a limited number of tests. That's it.

An FFR is not preventative care. It's a specialized test that is only useful in certain scenarios. The problem is that, unfortunately, you don't have a good handle on what these tests tell us and don't tell us.

What do we know? We know you don't have symptomatic cardiac disease and you run regularly. So, your pretest probability of having a significant blockage, although not zero, is low. We know your coronary CT scan was zero. So your post test probability is now markedly lower. We know your CTA was normal, which now makes your chance of significant obstructive CAD vanishingly low.

To get into a little more detail, typically an FFR is done where there is a question about the severity of blockage shown on a CTA, as excess calcium often interferes with the ability of a CTA to accurately assess that blockage. But we know you don't have any calcium, since your calcium score was zero!!! So your CTA, even without FFR, is likely highly accurate in confirming you don't have any blockages. FFR would likely offer no meaningful post test reduction in your probability of significant cardiac disease.

None of this should be construed as medical advice specific to your situation. You should ask your cardiologist, "how good were the images on the CTA," and , "in your opinion, is there any value to an FFR?" Dang, that's why you pay your cardiologist 500k/year. To answer those questions. (Assuming he doesn't have a financial interest in the imaging center, er, that' a whole different bag of worms...)

The aircraft analogy is as follows.

Your engine is running fine, but, for "peace of mind, you"
-Check the compression, and it's normal on all cylinders.
-You have a boroscope exam, and it's totally normal.
-But, you hear about a higher resolution, "4k HDR" boroscope exam that some mechanic on the other side of the country is offering.

So for peace of mind, you fly out to the other coast and have this done.

And, you sure wouldn't mind if someone else would pay for it
 
Mark K said:
As far as tests, things like cholesterol, A1c/blood glucose, colon/prostate/breast cancer screening. Those are preventative tests.
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I'm not sure how things work in the medical profession, but in the engineering world we wouldn't call a test a "preventative test." Tests don't prevent anything; they merely inform. That information might then be used to take a preventative action, but the test itself is not preventative.
 
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