ST depression

[Unregistered]

I had some strong palpitations over xgiving, and measured my BP using an Omron home machne, 140/40, which I thought to be crazy numbers and called my GP the following Monday.

They got 152/50 in their office, he ordered bloods for total blood count, Mg, K, and inflamation, all negative. He also ordered an echo which came back normal. At that point he refered me to a cardio.

Cardio checks me out and orders a Halter monitor and a standard Bruce stress test. Halter shows nothing abnormal. I make it to stage 5 on stress test (I'm a runner), but attending cardio reading the tape notes I have a 2mm ST depression.

My Cardio then orders a Nuclear stress test, but the insurance company has denied that test. Cardio is now going to set up another office visit to discuss where we go from here.

I still have the palpitations, and they are not only felt in my chest, but I can feel the pulse beat in various parts of my body at different times. I always feel them in my sinus area, and not only can I feel them, but at times it's downright painful. I also sometimes get small disturbances in my vision in time with my heartbeat.

Health history synopsis:

I am otherwise in great health, 6'2", 172#, last choleseterol (June) was low 150's total with high good, low bad. BP in June was 128/70. All other bloodwork has been great but for homocysteine, which has run 18 or so all thru my 40's.

I've had a few palpitations over the years but they normally last a few hours and then go away for a few months. These current palpitations have been steady of varying strength since xgiving.

There is some family history, my father had a septuple bypass in his mid-50's, and his father passed away of a heart attack in his mid-50's. BTW, cancer, not cardio problems, took my Dad when he was in his mid-70's. I'm 50.

So, is ST depression something to worry about? I'm more worried about the BP, I've been home measuring and still get 100 or greater pulse pressure, and I'm worried about what this BP is doing to my body.

I hope this isn't too rambling, just looking to both vent a little and for advice. Thanks!

 

[bbchien]

I can't give you healthcare advice here. Only certification advice.

But you seem to have the attitude of "anything but healthcare" and that will not serve you well. GET some healthcare! NOW!

 

[flyingron]

The first thing I'd like to rule out (and smack the technician/cardiologist if he hasn't already done this) is any of the non-medical artifacts on the stress test readings. ST depression can be caused by poor electrode contact (especially problematic when you're moving around like on a treadmill, especially for those who have to really get moving to get the heart rate up like ld runners). Was this a 12-lead? What leads was the depression found on? I assume since this was the only thing mentioned that there were not any other things noticed like Q wave abnormality or winds of bundle branch conductive issues.

The not-run nukie test would look for ischemia , but there are other things to look for with regard to things like mitral valve prolapse. You say you're a runner. How much (especially in the vicinity of these tests). Any chance you're electrolyte deficient (especially Potassium) when the test was run?

I'd definitely be looking for a doctor whose willing to lay out the differential diagnoses and reasonable ways to explore them rather than one who just orders tests randomly to see shat the insurer will pay for.

 

[Unregistered]

But you seem to have the attitude of "anything but healthcare" and that will not serve you well. GET some healthcare! NOW!

Untrue, I know something is wrong, and very much want to find the cause and fix/repair. The original consult with the cardio was unsat in my book, the guy had the personality of a doorstop barely talked, other than ordering the Bruce treadmill. I'm now in wait mode to consult again with him. If the next consult does not go well, do I walk and try to find another guy?

 

[Unregistered]

The first thing I'd like to rule out (and smack the technician/cardiologist if he hasn't already done this) is any of the non-medical artifacts on the stress test readings. ST depression can be caused by poor electrode contact (especially problematic when you're moving around like on a treadmill, especially for those who have to really get moving to get the heart rate up like ld runners). Was this a 12-lead? What leads was the depression found on? I assume since this was the only thing mentioned that there were not any other things noticed like Q wave abnormality or winds of bundle branch conductive issues.

The not-run nukie test would look for ischemia , but there are other things to look for with regard to things like mitral valve prolapse. You say you're a runner. How much (especially in the vicinity of these tests). Any chance you're electrolyte deficient (especially Potassium) when the test was run?

I'd definitely be looking for a doctor whose willing to lay out the differential diagnoses and reasonable ways to explore them rather than one who just orders tests randomly to see shat the insurer will pay for.

Ron, thanks for these talking points, I will print and ask of the cardio. I believe it was a 12 lead test but do not know which leads, etc. My last run (or any exercise) was 2.5 weeks prior to the Bruce test.

The Dr I was refered to has good credentials (I would suppose, intern, res, and fellowship at Mayo) but is not big on talking about these things.

How does one shop for a cardiologist?

 

[AggieMike88]

Untrue, I know something is wrong, and very much want to find the cause and fix/repair. The original consult with the cardio was unsat in my book, the guy had the personality of a doorstop barely talked, other than ordering the Bruce treadmill. I'm now in wait mode to consult again with him. If the next consult does not go well, do I walk and try to find another guy?

Keep in mind that Dr. Bruce comes across lots of airmen who express higher interest in how to game the FAA system in their favor to obtain/retain a medical rather finding out the core health issue that's "killing them" and fixing it.

And wile he can provide advice/guidance on how to proceed as you work with your doctors (aka "for a XXXX condition, you need these items, and a report from the doctor that describes _____ and covers these bullet points), he cannot conduct an examination via the interwebz, he cannot provide direct medical advice on what a board poster's condition is or isn't. Unfortunately, the wording of your post sounded like the latter.

So I can definitely appreciate his frustration that gets expressed every once and while. Airmen need to remember that it always must be "Health First, Fly Later"


To find a good cardiac doctor, www.Healthgrades.com is one site that provides a review mechanism for some doctors. The only other way that I can think of is to ask people in your social circle and network outward from them.

 

[comanchepilot]

I believe I read that the days with the highest death rates from coronary thrombosis is Thanksgiving Weekend, Christmas Eve and Day and Super Bowl Sunday, because people do not want to rock the boat and go to the ER . . . . keep that in mind that you waited 4 days to see the doc. . . .

Obviously there are real symptoms here so its not likely a lead problem -

 

[Unregistered]

Keep in mind that Dr. Bruce comes across lots of airmen who express higher interest in how to game the FAA system in their favor to obtain/retain a medical rather finding out the core health issue that's "killing them" and fixing it.

I am not here to game the system, I am just trying to gain more understanding as to what is going on with my health. I'm also not here to pull one over on Dr Bruce, I've met and chatted with him at several POA flyins, I know he's a good guy.

I'm done with this thread, moving on.

 

[Gary F]

I believe I read that the days with the highest death rates from coronary thrombosis is Thanksgiving Weekend, Christmas Eve and Day and Super Bowl Sunday, because people do not want to rock the boat and go to the ER . . . . keep that in mind that you waited 4 days to see the doc. . . .

Obviously there are real symptoms here so its not likely a lead problem -

Around here it is the beginning of deer hunting season and the first really big snowfall.

I can make some general comments on the OP's original question later when I have the time. Unfortunately I'm post call and very busy.

 

[Gary F]

For those of you who can't wait, here is some interesting background material. http://circ.ahajournals.org/content/98/16/1622.full

 

[bbchien]

For those of you who can't wait, here is some interesting background material. http://circ.ahajournals.org/content/98/16/1622.full

Quothe he, the BIBLE.

 

[Unregistered]

Quothe he, the BIBLE.

Yes, I've seen this and similar studies in my online research and I don't like what I see. The attending cardio told me he considered me to be moderate risk. What I don't understand is why the insurance company rejected the nuclear test. As I understand it, this test is necessary to determine if I need to go to the cath lab. I see my original cardio tomorrow afternoon, hopefully I can get some answers to the questions I have regarding this issue.

 

[Gary F]

Yes, I've seen this and similar studies in my online research and I don't like what I see. The attending cardio told me he considered me to be moderate risk. What I don't understand is why the insurance company rejected the nuclear test. As I understand it, this test is necessary to determine if I need to go to the cath lab. I see my original cardio tomorrow afternoon, hopefully I can get some answers to the questions I have regarding this issue.

There are multiple issues raised here including diagnostic strategies, limitations of various tests, predicting coronary risk, treatment options if CAD is diagnosed and of course FAA medical department policies. Nothing here should be construed as medical advice. This is general medical information.

If a person has symptoms consistent with possible coronary artery disease an abnormal stress test (including a simple GXT) should be sufficient to justify a coronary angiogram. It is usual for somebody who "flunks" a simple treadmill to undergo some type of imaging study including nuclear perfusion, stress echo, cardiac CT or invasive angiogram. I don't understand why the insurance company is denying further noninvasive testing, perhaps they want to go straight to the cath lab. Some people may elect to be treated for presumed CAD medically without further testing. The decision is based on many factors and physician biases. CMS and insurers generally want someone to fail medical therapy with 2 or more antianginal drugs before performing coronary artery revascularization (stents) in patients without high risk findings.

 

[comanchepilot]

Can you complete the Bruce protocol without significant effort [heart rate not to 90% of max because the protocol cannot get your heart rate up] and still be at risk of CAD?

I'm curious if people can be in good cardiovascular condition such that the Bruce protocol cannot reach 90% of max, but still be at risk . . . guess without a cardiogram at the same time as doing the test its meaningless . . . .

 

[Gary F]

Can you complete the Bruce protocol without significant effort [heart rate not to 90% of max because the protocol cannot get your heart rate up] and still be at risk of CAD?

I'm curious if people can be in good cardiovascular condition such that the Bruce protocol cannot reach 90% of max, but still be at risk . . . guess without a cardiogram at the same time as doing the test its meaningless . . . .

Anybody who can complete the Bruce protocol would need to run 21 minutes, the last 3 minutes at 6 mph on a 22% grade and achieve 20 METS. That is amazing athleticism. For anybody else it depends on how long they walked and the heart rate and blood pressure response. Another issue is why the person could not achieve target heart rate.

 

[Unregistered]

Anybody who can complete the Bruce protocol would need to run 21 minutes, the last 3 minutes at 6 mph on a 22% grade and achieve 20 METS. That is amazing athleticism. For anybody else it depends on how long they walked and the heart rate and blood pressure response. Another issue is why the person could not achieve target heart rate.

My target was 145, which I achieved at the beginning of stage five. The tech told me to continue running until I was tired, I quit at 155. That said, I still have the 2mm depression.

We've all known, or known of, that guy who was in super physical shape, maybe a runner or cyclist, who died of a heart attach out of the blue. I don't want to be that guy.

 

[Gary F]

My target was 145, which I achieved at the beginning of stage five. The tech told me to continue running until I was tired, I quit at 155. That said, I still have the 2mm depression.

We've all known, or known of, that guy who was in super physical shape, maybe a runner or cyclist, who died of a heart attach out of the blue. I don't want to be that guy.

Anybody who makes it to stage 5 then has completed at least 12 minutes of exercise and that level of performance predicts a low risk for a cardiac event in the next year. Anybody with a beating heart is at risk for a heart attack and sudden death. The risk varies considerably based on a number of factors. The traditional risk factors including hypertension, tobacco use, diabetes, genetics, and advanced age and lipids have been known for years. A good physician should be able to determine the risk for cardiac events over a moderate time period, typically 10 years.

Here is a tool for predicting risk. http://cvdrisk.nhlbi.nih.gov/

 

[Henning]

My method for finding a doc worked well for finding a neurosurgeon to take care of my back. If I was looking for a cardio guy I'd go into the cardio-thoracic ward of the best hospital in the area and ask 10 nurses, "If you were going to send your brother/son/husband to a doc for <insert condition here> who would you send them to?" You'll find the majority of them will name one person, that's who I would go to.

 

[Gary F]

My method for finding a doc worked well for finding a neurosurgeon to take care of my back. If I was looking for a cardio guy I'd go into the cardio-thoracic ward of the best hospital in the area and ask 10 nurses, "If you were going to send your brother/son/husband to a doc for <insert condition here> who would you send them to?" You'll find the majority of them will name one person, that's who I would go to.

That might work if you are looking for a surgeon to do your bypass or heart valve surgery but getting on to the ward or intensive care unit and asking questions might prove challenging. You might also be able to find the best interventional cardiologist to place a coronary stent by asking nurses. The downside is that when you are a hammer everything looks like a nail. Some interventional cardiologists have been known to be too aggressive in placing stents. Stents do not improve longevity when used in most cases of stable coronary artery disease.

 

[PaulS]

That might work if you are looking for a surgeon to do your bypass or heart valve surgery but getting on to the ward or intensive care unit and asking questions might prove challenging. You might also be able to find the best interventional cardiologist to place a coronary stent by asking nurses. The downside is that when you are a hammer everything looks like a nail. Some interventional cardiologists have been known to be too aggressive in placing stents. Stents do not improve longevity when used in most cases of stable coronary artery disease.

How do you determine if a blockage is stable? My understanding is that some blockages can burst??? causing a clot going from a small blockage to 99% clot very quickly. What differentiates that type from stable disease. Just wondering.

 

[Gary F]

How do you determine if a blockage is stable? My understanding is that some blockages can burst??? causing a clot going from a small blockage to 99% clot very quickly. What differentiates that type from stable disease. Just wondering.

This is known as the vulnerable plaque. At this time there is no way to identify which plaques are at high risk for rupture. They have looked at using intravascular ultrasound and sensitive temperature sensing equipment to identify which lesions are at high risk for rupture. Unstable lesions are slightly warmer than the surrounding tissue.

Your best strategy to protect yourself is aggressive management of coronary artery disease risk factors (diet, exercise, BP and diabetic control) and appropriate medications including anti-platlet agents (aspirin and/or clopridogrel) and statins as appropriate. Smoking cessation and abstinence of all forms of tobacco and nicotine is very important. See your physician before starting an exercise program if you have been sedentary. Seek medical care for chest discomfort as this may be a warning of a pending heart attack.

Here is a paper on the subject. I have not yet had a chance to read the entire paper but I will review it when I get the chance. http://atvb.ahajournals.org/content/30/7/1282.

 

[Unregistered]

OP here, he scheduled me for a coronary angiogram tomorrow.

 

[Gary F]

OP here, he scheduled me for a coronary angiogram tomorrow.

A reasonable option. I would not be surprised if they found something and I would not be surprised if it is OK.

 

[PaulS]

This is known as the vulnerable plaque. At this time there is no way to identify which plaques are at high risk for rupture. They have looked at using intravascular ultrasound and sensitive temperature sensing equipment to identify which lesions are at high risk for rupture. Unstable lesions are slightly warmer than the surrounding tissue.

Your best strategy to protect yourself is aggressive management of coronary artery disease risk factors (diet, exercise, BP and diabetic control) and appropriate medications including anti-platlet agents (aspirin and/or clopridogrel) and statins as appropriate. Smoking cessation and abstinence of all forms of tobacco and nicotine is very important. See your physician before starting an exercise program if you have been sedentary. Seek medical care for chest discomfort as this may be a warning of a pending heart attack.

Here is a paper on the subject. I have not yet had a chance to read the entire paper but I will review it when I get the chance. http://atvb.ahajournals.org/content/30/7/1282.

Thanks Gary, I've bought into what you prescribe, pretty much get my own "stress test" 3 to 4 times a week, plus statin and good BP control plus yearly A1C. It's scary stuff, hopefully the prediction tools will become better in the coming years.

 

[dtuuri]

Here is a tool for predicting risk. http://cvdrisk.nhlbi.nih.gov/

I put in my numbers and clicked "Calculate your ten-year risk". Then it tells me my cholesterol is below the range, so I upped it to the minimum value and tried again. This time it tells me I have a 10% risk and to find out how to lower it, I should go to the link "High blood cholesterol--what you need to know."

dtuuri

 

[BrianR]

OP, as to your original question, 2 mm ST depression is certainly something the FAA would worry about. You are not certifiable without further cardiovascular evaluation. I doubt the agency would be satisfied with anything less than a negative angiogram (or revascularization, should it prove indicated). Of course, false positive treadmill stress tests are far from uncommon.

I had a similar issue when preparing for my initial third class...2-3 mm ST depression in multiple leads. Nuclear stress test was inconclusive (which Dr. Bruce predicted would be the case). Fortunately for me, angiogram was completely negative.

My insurance company also argued, as I was asymptomatic. But I did have several risk factors for CAD, so they acquiesced.

Hope everything turns out fine. But if not, get it addressed, then worry about the aviation implications.

 

[Gary F]

OP, as to your original question, 2 mm ST depression is certainly something the FAA would worry about. You are not certifiable without further cardiovascular evaluation. I doubt the agency would be satisfied with anything less than a negative angiogram (or revascularization, should it prove indicated). Of course, false positive treadmill stress tests are far from uncommon.

I had a similar issue when preparing for my initial third class...2-3 mm ST depression in multiple leads. Nuclear stress test was inconclusive (which Dr. Bruce predicted would be the case). Fortunately for me, angiogram was completely negative.

My insurance company also argued, as I was asymptomatic. But I did have several risk factors for CAD, so they acquiesced.

Hope everything turns out fine. But if not, get it addressed, then worry about the aviation implications.

If I think a stress test is really a false positive I have on occasion ordered a cardiac CT angiogram. In most cases I was able to exclude significant disease. Unfortunately some CT angiograms are uninterpretable. I believe that Dr Bruce has indicated previously that the FAA does not recognize the results of this test. Too bad since for properly selected patients it is safer, less uncomfortable and cheaper.

 

[Unregistered]

OP here again. Procedure was piece of cake. Results are good news/bad news.

Good news is the arteries are clear, no blockage.

Bad news my aortic valve is in moderate to severe failure. More tests to come but open heart surgery to replace is likely by end of January.

 

[Henning]

OP here again. Procedure was piece of cake. Results are good news/bad news.

Good news is the arteries are clear, no blockage.

Bad news my aortic valve is in moderate to severe failure. More tests to come but open heart surgery to replace is likely by end of January.

Well, glad you found the problem, good luck.

 

[Gary F]

They got 152/50 in their office, he ordered bloods for total blood count, Mg, K, and inflamation, all negative. He also ordered an echo which came back normal. At that point he refered me to a cardio.

Cardio checks me out and orders a Halter monitor and a standard Bruce stress test. Halter shows nothing abnormal. I make it to stage 5 on stress test (I'm a runner), but attending cardio reading the tape notes I have a 2mm ST depression.

OP here again. Procedure was piece of cake. Results are good news/bad news.

Good news is the arteries are clear, no blockage.

Bad news my aortic valve is in moderate to severe failure. More tests to come but open heart surgery to replace is likely by end of January.

Wait a minute. Are these posts from the same person? Aortic valve stenosis or insufficiency? I thought the echo was normal. This should have shown if there was a problem with any of the heart valves. If you can complete 4 stages on a Bruce protocol it is very unlikely you have hemodynamically significant aortic stenosis. I would get a second opinion before having aortic valve surgery. Something here does not make sense.

 

[Unregistered]

Wait a minute. Are these posts from the same person? Aortic valve stenosis or insufficiency? I thought the echo was normal. This should have shown if there was a problem with any of the heart valves. If you can complete 4 stages on a Bruce protocol it is very unlikely you have hemodynamically significant aortic stenosis. I would get a second opinion before having aortic valve surgery. Something here does not make sense.

I will get a second opinion. However, the set of symptoms do line up.

Palpitations
High pulse pressure
Flashing on fingernail pinch test
Large displacement of leg with pulse when legs crossed
Night sweats

The big mystery is the echo. I think another echo by a different group is warranted. A ct scan is the next test.

 

[Gary F]

I will get a second opinion. However, the set of symptoms do line up.

Palpitations
High pulse pressure
Flashing on fingernail pinch test
Large displacement of leg with pulse when legs crossed
Night sweats

The big mystery is the echo. I think another echo by a different group is warranted. A ct scan is the next test.

Sound more like aortic insufficiency (regurgitation) than aortic stenosis. Either of these problems should be blatantly obvious on the echo. The criteria for surgery for aortic valve insufficiency is based primarily on the echocardiogram anyway. This is a big deal so a second opinion by an unbiased independent cardiologist is highly recommended. I would ask my primary physician for a referral to a respected university medical center or Mayo or Cleveland clinic cardiologist.

 

[Gary F]

Some reading on aortic insufficiency. It's a little dated but the basic principles still apply. http://circ.ahajournals.org/content/106/21/2637.full

 

[Unregistered]

Resolution was Re: ST depression

Wait a minute. Are these posts from the same person? Aortic valve stenosis or insufficiency? I thought the echo was normal. This should have shown if there was a problem with any of the heart valves. If you can complete 4 stages on a Bruce protocol it is very unlikely you have hemodynamically significant aortic stenosis. I would get a second opinion before having aortic valve surgery. Something here does not make sense.

Consult with cath doctor showed 4+ aortic insufficiency.

An echo last Monday confirmed the cath, major leakage of the aortic valve. Jet was not centric, it was asymmetrical. This of course contradicts 1st echo.

Had surgey yesterday, aortic valve and part of upper aorta replaced with human tissue. Doc said the valve was terrible, thin and stretched, and one of the petals had a perforation (hole) in it. The other two were solid but in bad condition. That explains the non centric jet. Doctor figures the perforation opened up sometime during the three weeks between the echos. In his opinion the valve would have failed totally in the next 2-4 weeks. He took pictures of the valve, it looks terrible. He found no evidence of infection or calcification. His best estimate is connective tissue disorder possibly congenital.

Bp before operation was 152/50, today one day after op 117/67. Doctors say pumping action is excellent.

Happy to be alive and glad I went to the docs when I did. I am blessed that I was refered to the best guy in the city.

Dr b I will contact you after healing to find out how to get my 3rd class.

Merry Christmas to all!

 

[Gary F]

Re: Resolution was Re: ST depression

Consult with cath doctor showed 4+ aortic insufficiency.

An echo last Monday confirmed the cath, major leakage of the aortic valve. Jet was not centric, it was asymmetrical. This of course contradicts 1st echo.

That is very scary. I find it incomprehensible that the first echo did not show the problem. The decision to replace the valve is almost always based on the echo findings. A heart cath is usually done after the decision to proceed with surgery to determine if coronary artery bypass grafting is needed at the time of valve replacement. It seems that either the first echo was of exceptionally poor quality or misread.

Had surgey yesterday, aortic valve and part of upper aorta replaced with human tissue. Doc said the valve was terrible, thin and stretched, and one of the petals had a perforation (hole) in it. The other two were solid but in bad condition. That explains the non centric jet. Doctor figures the perforation opened up sometime during the three weeks between the echos. In his opinion the valve would have failed totally in the next 2-4 weeks. He took pictures of the valve, it looks terrible. He found no evidence of infection or calcification. His best estimate is connective tissue disorder possibly congenital.

Bp before operation was 152/50, today one day after op 117/67. Doctors say pumping action is excellent.

Happy to be alive and glad I went to the docs when I did. I am blessed that I was refered to the best guy in the city.

Dr b I will contact you after healing to find out how to get my 3rd class.

Merry Christmas to all!

I'm glad that your surgery turned out OK.

 

[Unregistered]

At home recovering, great to be out of the hospital. Good days and bad days as we all know. Happy new year to all.

 

[Everskyward]

At home recovering, great to be out of the hospital. Good days and bad days as we all know. Happy new year to all.

Glad to hear that! Happy New Year to you too.

 

[Berol]

Having this sort of reactions is natural according to me but the thing is we gotta take care of stuff that causes inapproproate things to our mental wellness,Staying away from that all that has a bad impact on our mental well being.


physical therapy