positive stress test

[kriswillems]

Since 2 or 3 months I have this constant feeling of pressure in my chest, around the area where my heart is.

It happens especially early in the morning or late in the evening and it it a long lasting pain/pressure (can take up to an hours or longer).

I would describe more like a pressure that a pain.

When I am tired of work hard, the pain gets more serious, I sweat more that before and feel dizzy.

My blood pressure is normal. I an 41.

First I thought I was imagining things or it was just a muscle, so I didn't go to see a doctor. But I guessed 3 months is too long for a muscle that hurts, so I went to see a doctor.

Today I went to see a heart specialist at phyathai.

They did a normal EKG in rest, which didn't show anything.

They made an x-ray of lungs, which didn't show anything.

Then test decided to do a stress test, which just means they let you run at variable speeds and check your heart under stress.

This is the observation of the doctor:

Baseline EKG showed no significant abnormalities.

EST with Bruce protocol was applied

98% maximal predicted HR with total exercise time of 8:59 minutes

and METs = 10.1 were achieved, with 1-2 mm horizontal ST

depression in II, III, AVF, V3-V6.

The test was terminated due to dyspnea, without chest pain.

Recovery symptoms, BP and EKG gradually returned to nearly baseline.

This is the conclusion:

Positive EST ; by EKG, without chest pain.

The doctor always asked me if I had chest-pain, but besides the feeling of pressure/pain that is there for 2 or 3 months I didn't feel any extra pain during the test. So, I said no.

I did feel dizzy after the test, starting from the moment he stopped the machine.

Now. The doctor suggested to do further test (the test today costed 5500 baht) which would be much more expensive.

I have full health insurance in my country, but don't have an insurance in Thailand.

I have been reading around on the internet and found that with a MET between 10 to 12 and no angina it's very likely that the test is a false positive or that there's no problem.

The doctors interpretation was that the chance that I have no problem or not very serious/urgent heart problem is higher than a than I have an urgent problem (that needs operation). He estimated all 3 chances to about 33%.

The doctor advised to take one aspirine a day.

What would you do in my case?

Any advice where to further tests?

Is that website I found right?

http://drsvenkatesan.wordpress.com/2009/06/26/should-all-patients-with-positive-stress-undergo-coronary-angiogram/

Is a positive EST a result of a mathematical calculation or an interpretation from the doctor?

What to do next? Acoording to the doctor there are 2 possibilities, a CT-scan or an X-ray of colored blood. Which would you advice?

Do you think it's better to take a holiday in my country and get a check there?

Edited September 2, 2013 by kriswillems

[jrtmedic]

The symptoms described are to an extent atypical (which is not unusual! )

The significant finding is

"with 1-2 mm horizontal ST

depression in II, III, AVF, V3-V6."

Which may be suggestive of a degree of myocardial ischemia but may also be an artefact.

The dyspnea (shortness of breath) which terminated the test may just be a reflection of your general level of fitness.

The next stage of investigation will most probably be be coronary angiography.

If you are generally well and able to return home for futher investigation that might be a good plan.

Best wishes

[lopburi3]

From my own positive EST experience believe CT may be normal recommendation for next step if indications are not extreme (but I can only go by the doctor report of 1 in 3 chance of severe). Mine were all sensors indicating issues so doctor advised CT would likely be a waste of time as it would almost certainly have to be following by angioplasty sooner than later. Mine was without symptoms but EKG indicated issues so EST was performed.

[Sheryl]

1-2 mm horizontal ST depression in multiple leads, toegther with a clinical history of a feeling of "pressure" in the chest are is indeed suggestive of coronary artery disease.

This article gives an idea of the predictive value of your EST findings:

http://onlinelibrary.wiley.com/doi/10.1002/clc.4960020408/pdf

You will note that for an ST depression of 1 mm, 73% had confirmed coronary artery disease on angiogram. For 1-2 mm, figure a little higher. In other words, while it is possible the finding was just an "artifact", the odds favor there in fact being a problem.

The wisest course would be to return to your home country where you are fully insured and undergo a coronary angiography during which, if indicated based on the findings, they can immediately insert stents to open up blockage.

[kriswillems]

Ok, thanks for your advice.

All this medical stuff is way behind my understanding.

I found this on wikipedia:

.....while an exercise stress test requires an ST depression of at least 2 mm to significantly indicate reversible ischaemia

Now the graph of the ST value is always less that 2mm, except on the very last point, with the highest heartbeat it reached 2 mm.

It linearly increases with my heartbeat until 2mm at the very last point.

Maybe that's why the doctor was not sure about the severity?

Sheryl, Is that 1 mm the value on a normal EKG, not a stresstest?

[Sheryl]

No, the 1 mm is during exercise, and is specifically 1m horizontal ST depression.

[tolsti]

Stop relying on Wikipedia as a diagnostic tool. You have been given serious advice by Sheryl and jrtmedic. If you have the ability to return to a country where you have free cover then do so. Even if it is just a weeks holiday and you come back with all tests done and the Dr says your fine... its worth it. Do it.

Remember.... you're a long time dead.

[kriswillems]

Thanks you very much Sheryl. I am not sure how to interpret that paper.

It says that the group of >1 mm includes also those in the groups >2mm, >3mm, >4mm, >5mm, so groups to which I don't belong.

So, I assume it's not correct to say I have a 73% chance on a coronary disease, because I know I am for sure not a member of those more severe groups,right?

The group of >1mm were 65 people of which only 90 - 66 = 24 people were between 1 and 2 mm.

Specific Information about these 24 people (that seem to represent me) seems not be available in the document.

Edited September 2, 2013 by kriswillems

[kriswillems]

ok, I am trying to do some mathematics here.

the group >2 mm has 52 out of 66 people with a problem.

the group >1mm has 63 out of 90 people with a problem.

So the group 1mm to 2mm has 90-66 = 24 people of which 63-52= 11 people had a problem.

So, the chance I have a coronary disease is 11/24 = 45.8 %

I think this is why wikipedia talks about 2mm to be significant.

Anyway, 45.8% is enough chance for me and I'll go back to my home country.

[meatboy]

1-2 mm horizontal ST depression in multiple leads, toegther with a clinical history of a feeling of "pressure" in the chest are is indeed suggestive of coronary artery disease.

This article gives an idea of the predictive value of your EST findings:

http://onlinelibrary.wiley.com/doi/10.1002/clc.4960020408/pdf

You will note that for an ST depression of 1 mm, 73% had confirmed coronary artery disease on angiogram. For 1-2 mm, figure a little higher. In other words, while it is possible the finding was just an "artifact", the odds favor there in fact being a problem.

The wisest course would be to return to your home country where you are fully insured and undergo a coronary angiography during which, if indicated based on the findings, they can immediately insert stents to open up blockage.

what sheryl has posted and what could be the problem is almost what i was experiancing,lack of breath,tight chest,[presure] but no pain,i did have that presure feeling in my left arm and also after food i was limited to what i could do.

the tests ecg.was ok.echo gram showed a valve problem with my heart but the same symptoms that you are getting revealed

coronary blockage[had a double by-pass.and a valve replacement.

do you smoke,have hbp,or high cholestrol.i had 2 out of 3 but never smoked in my life.

as its been said take a holiday.

[canman]

Statistics are just numbers, your young and any indication there may be coronary disease needs looking at sooner rather than later, good advice given above by those who are qualified. Go get a coronary angiogram.

[kriswillems]

No, I don't smoke and have never smoked.

I am allergic to alcohol (overreaction), so I don't drink at all.

My cholesterol values area normal.

I don't have diabetes.

But my life style is bad - I sleep not much, often work 15 hours per day and skip meals (up to 2 meals). I eat at random times (not fixed). I never almost never take a day off. When I eat I eat too much at once. We don't have time to cook at home, so that leaves street-food and restaurants. So, I eat (very) unhealthy. I am fat too.

So, the first thing I'll do know is taking my daily aspirin and cook healthy food at home.

I am looking for a cheap place to do further tests, but such a place doesn't seem to exist.

Today I waited the whole day in the government hospital in Sri Racha only to find out they can't help me (no knowledge, no experience, no equipment). Strange, because in my opinion it's by far the biggest hospital around here.

[Sheryl]

You are going to need an angiogram and the usual procedure is to insert stents, if required, at the same time as the initial angio. Otherwise, you have to go through the angio procedure twice. The costs of stents is quite high....around 300,000 baht (angio + single stent placement) at a private hospital.

An angio alone, about 125,000 at a private hospital. But then you will have to have it done all over again for stent placement if indicated.

[bunnaag]

1-2 mm horizontal ST depression in multiple leads, toegther with a clinical history of a feeling of "pressure" in the chest are is indeed suggestive of coronary artery disease.

This article gives an idea of the predictive value of your EST findings:

http://onlinelibrary.wiley.com/doi/10.1002/clc.4960020408/pdf

You will note that for an ST depression of 1 mm, 73% had confirmed coronary artery disease on angiogram. For 1-2 mm, figure a little higher. In other words, while it is possible the finding was just an "artifact", the odds favor there in fact being a problem.

The wisest course would be to return to your home country where you are fully insured and undergo a coronary angiography during which, if indicated based on the findings, they can immediately insert stents to open up blockage.

what sheryl has posted and what could be the problem is almost what i was experiancing,lack of breath,tight chest,[presure] but no pain,i did have that presure feeling in my left arm and also after food i was limited to what i could do.

the tests ecg.was ok.echo gram showed a valve problem with my heart but the same symptoms that you are getting revealed

coronary blockage[had a double by-pass.and a valve replacement.

do you smoke,have hbp,or high cholestrol.i had 2 out of 3 but never smoked in my life.

as its been said take a holiday.

was the operation performed in Thailand?If yes where and what did youn have to pay?

[kriswillems]

Actually the price I got from Phayathai sriracha is:

40000 to 50000 B for angio only and about 150K for something with balloons. The doctor in Phayathai didn't talk about stents.

The doctor in somdej said today the treatment with balloons is much less good than stents.

Anyway, that means I got a good price from Phayathai, but still it's probably better to go back to my country.

(Somdej is a very cheap hospital and I have very good experiences with them. I waited the whole day, but in the end I paid 50B for consulting the doctor. Too bad they don't do angio. I don't mind waiting because I live close to the hospital and can go back home while waiting or even do some work in the waiting room.)

[meatboy]

1-2 mm horizontal ST depression in multiple leads, toegther with a clinical history of a feeling of "pressure" in the chest are is indeed suggestive of coronary artery disease.

This article gives an idea of the predictive value of your EST findings:

http://onlinelibrary.wiley.com/doi/10.1002/clc.4960020408/pdf

You will note that for an ST depression of 1 mm, 73% had confirmed coronary artery disease on angiogram. For 1-2 mm, figure a little higher. In other words, while it is possible the finding was just an "artifact", the odds favor there in fact being a problem.

The wisest course would be to return to your home country where you are fully insured and undergo a coronary angiography during which, if indicated based on the findings, they can immediately insert stents to open up blockage.

what sheryl has posted and what could be the problem is almost what i was experiancing,lack of breath,tight chest,[presure] but no pain,i did have that presure feeling in my left arm and also after food i was limited to what i could do.

the tests ecg.was ok.echo gram showed a valve problem with my heart but the same symptoms that you are getting revealed

coronary blockage[had a double by-pass.and a valve replacement.

do you smoke,have hbp,or high cholestrol.i had 2 out of 3 but never smoked in my life.

as its been said take a holiday.

was the operation performed in Thailand?If yes where and what did youn have to pay?

it was done in the uk.i also suffered with stress although i didnt know what stress was,long working hrs.big meals,i was looking after celebs.so i used to worry that all was in order.

untill i had a bad night,room going round,flashing lights and sweating then i went to the docs.thats when they started the tests

but it took 5yrs.of suffering before i had the surgery.

after it i realized how bad i had been,i feel as if i am a different man.

i was told what i had done if i went private uk.it would have been around 40k-50k gbp.

oh nearly forgot i liked a drop cider.

[lopburi3]

Actually the price I got from Phayathai sriracha is:

40000 to 50000 B for angio only and about 150K for something with balloons. The doctor in Phayathai didn't talk about stents.

The doctor in somdej said today the treatment with balloons is much less good than stents.

Anyway, that means I got a good price from Phayathai, but still it's probably better to go back to my country.

(Somdej is a very cheap hospital and I have very good experiences with them. I waited the whole day, but in the end I paid 50B for consulting the doctor. Too bad they don't do angio. I don't mind waiting because I live close to the hospital and can go back home while waiting or even do some work in the waiting room.)

Actually it is a three step process in my experience (if required) and is easily done in one visit. You are awake and comfortable during entire time and nothing more than missed heartbeat type feeling (wrist access normally used here) but may require an overnight in CCU to reduce pressure bandage and monitor vitals.

First angiogram to check what condition is - then if needed opening blockages with balloon tip Angioplasty and for more than about 70% blockage perhaps recommendation of stents. But current thinking of my doctor and from what have read is excess stents is counter indicated and suspect that would be more so for a young man (41). But this can be done as the 3rd stage of same procedure if needed.

[kriswillems]

Last night I didn't feel good at all. I was tired because I had look for the paperwork the whole day because the passport of my wife and child are expired and I went for a reentry-permit. Because of this reason my wife and son can't fly back together with me.

I was dizzy so I decided to lie down. I suddenly got very cold hands and arms, feet and legs. Especially my right hand was ice cold. I was shaking because I felt cold. I didn't imagine this because my wife could feel too my hands were ice cold. I felt bad for half an hour and got better. My body temperature was normal all the time. I didn't feel any extra pain around my heart.

Tomorrow I have to go to BKK to arrange more paper work. I don't know if I should risk this. Would it be OK to take a taxi from door to door? It's a 2 hours drive, one way.

I woke up now (at night) because of pain around my heart again and probably because I worry.

I fly back on the night between Thursday and Friday. I have an appointment with a specialist on Monday.

Any advice is welcome.

Edited September 10, 2013 by kriswillems

[Sheryl]

I am frankly not sure what is going on with you. But the most likely is either just anxiety or a significant drop in blood pressure.

Suggest you check your blood pressure today- if you don't have a device for that, many pharmacies can do it for you.

If normal and otherwise feeling OK, go ahead but do take taxi door to door, that way you can if necessary re-route to a hospital.

If this recurs, first of all try to control your breathing so that it is slow, steady and deep; if the cold extremities is due to hyperventilation (common in anxiety) that will relieve it. Then go to an Emergency Room.

[kriswillems]

Ok, I feel stupid.

I felt cold because my wife put the air much colder when I asked her to put it less cold. She confirmed me several times it was on 27, while it was set much colder. I thought I was getting mad, I felt so cold and was getting colder all the time.

It was dark, so she didn't see the display.

So, I felt very cold because it was very cold.

Edited September 11, 2013 by kriswillems

[Sheryl]

One mystery solved!

[kriswillems]

Ok, yesterday they checked my coronary vains. They are perfectly normal. I am one of the few people with a false positive stress test.

So, they went to look into my gullet and stomach. I have an infection of the gullet near my heart which was causing spasm. So it felt like I had a heart problem. It will go away with some simple pills.

[Sheryl]

Thanks for the feedback and glad all is well.

Gastritis can indeed mimic heart problems.

I assume they will have tested for the presence of h. pylorii, if positive then a combo of pills to eradicate it otherwise such something to reduce the acidity.

[kriswillems]

Thanks for the feedback and glad all is well.

Gastritis can indeed mimic heart problems.

I assume they will have tested for the presence of h. pylorii, if positive then a combo of pills to eradicate it otherwise such something to reduce the acidity.

They took tissue samples. It will take 5 days to test. For now I just take something simple to reduce acidity (pantomed 40 mg), later, when they have the lab results I might need to take additional medicines. They saw a light infection on the camera.

I have no doubt now that this combined with a bit too much work was the reason for my problems.

Just want to say the coronary was one of the easiest checkups I ever had, even checking the gullet/stomach was more scary than this.

I was on the wrong track from the beginning because of this false positive stress test.

I'll be back in Thailand soon.

Thanks Sheryl, for your support.