Hahah..I know I know!!!mmarshall said:woman!!!....stop stressin'....lol everything is going to be ok and you will be on here tuesday saying that everything went well and it was not bad at all.
I am such a worrier - it's just my nature..lol.
Stress Test - When is it risky?
- Thread starter Ashley
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I am such a worrier - it's just my nature..lol.
Ashley.
I bet Bob H will check in here shortly. He has some great points to make about stress tests.
I had a few of them over the decades while they were watching for aortic regurgitation to worsen, but a few years ago my cardio halted one rather than going through with it due to concerns about my stenosis worsening. Then came my surgery last February. Then, just two months later, the cardio said I would have to have a stress test before enrolling in cardiac rehab. I said no, that's ridiculous so soon after surgery, and got to start the rehab anyway. I suppose he wanted to see how much improved my heart function is after the surgery, but I side with those (Boss Ross and others)who say there are other tests that involve less risk.
As an aside... August, loved your quip about the "chemical stress tests" of collegiate days. Takes me back to fraternity keg parties of many years ago. I'm sure Ross will explain, but one alternative to treadmill stress tests is being shot up with drugs that stress your heart. Actually that sounds even scarier to me than doing a treadmill til winded!
I bet Bob H will check in here shortly. He has some great points to make about stress tests.
I had a few of them over the decades while they were watching for aortic regurgitation to worsen, but a few years ago my cardio halted one rather than going through with it due to concerns about my stenosis worsening. Then came my surgery last February. Then, just two months later, the cardio said I would have to have a stress test before enrolling in cardiac rehab. I said no, that's ridiculous so soon after surgery, and got to start the rehab anyway. I suppose he wanted to see how much improved my heart function is after the surgery, but I side with those (Boss Ross and others)who say there are other tests that involve less risk.
As an aside... August, loved your quip about the "chemical stress tests" of collegiate days. Takes me back to fraternity keg parties of many years ago. I'm sure Ross will explain, but one alternative to treadmill stress tests is being shot up with drugs that stress your heart. Actually that sounds even scarier to me than doing a treadmill til winded!
Stress Tests in Stenotic Valve Patients
Stress Tests in Stenotic Valve Patients
Click here for an earlier thread on Stress Tests: http://www.valvereplacement.com/forums/showthread.php?t=8350&highlight=stress
From the American College of Cardiologists/American Heart Association Guidelines for the Management of Patients With Valvular Heart Disease (bolding mine):
"ACC/AHA Guidelines for the Management of Patients With Valvular Heart Disease" and is found in "4. Management of the Asymptomatic Patient," under "a. Initial Evaluation," third paragraph.
The quote above was from the segment for asymptomatic (nonsymptomatic) patients, and I only highlighted the one line about symptomatic patients for others who may be reading. If I can find and read this as an enthusiastic non-medical professional, I think a cardiologist should be able to, even required to...
Regardless, patients have a right to refuse tests. Doctors know there is usually more than one way to skin a cat, and will find a more acceptable test if pressed to. If the stenosis is advanced enough to be symptomatic, it is beyond the point of needing further clarification by a stress test, especially in light of both the risk to the patient and the lack of accuracy pointed out in the ACC/AHA quote.
Frequently, people who have gone through with this have come back with the answer that the results were "inconclusive." Not much payback for the risk. There have been several who have posted with bad or near-fatal experiences during the testing.
The fact that someone would be there to try to revive you if you have a heart attack or go into dangerous arrythmias is hardly reassuring. And for a patient with an enlarged aorta, an immediate open heart surgery would be the only available response to a dissection caused by the effort, if it could be accomplished in time (remember, you're with a cardiologist for this test, not a cardiothoracic surgeon).
Based on the ACC/AHA guidelines and common sense, it would certainly seem to press the definition of reckless endangerment to order an exercise stress test for a symptomatic, stenotic aortic valve patient with an aortic aneurism. It would seem likewise both pointless and dangerous on a symptomatic aortic stenosis patient without an aortic aneurism, or a non-symptomatic stenosis patient, for the same reasons given in the guidelines.
Stress tests can have their place in heart problem diagnosis, but it's not in aortic stenosis, and probably not in basic valve issues in general. Mary was right, I really don't have much patience for this cardiologists' cash cow.
Best wishes,
Stress Tests in Stenotic Valve Patients
Click here for an earlier thread on Stress Tests: http://www.valvereplacement.com/forums/showthread.php?t=8350&highlight=stress
From the American College of Cardiologists/American Heart Association Guidelines for the Management of Patients With Valvular Heart Disease (bolding mine):
The quote is from the American College of Cardiology Foundation (ACC) Site, http://www.acc.org/clinical/guidelines/valvular/jac5929fla16.htm#A4
"ACC/AHA Guidelines for the Management of Patients With Valvular Heart Disease" and is found in "4. Management of the Asymptomatic Patient," under "a. Initial Evaluation," third paragraph.
The quote above was from the segment for asymptomatic (nonsymptomatic) patients, and I only highlighted the one line about symptomatic patients for others who may be reading. If I can find and read this as an enthusiastic non-medical professional, I think a cardiologist should be able to, even required to...
Regardless, patients have a right to refuse tests. Doctors know there is usually more than one way to skin a cat, and will find a more acceptable test if pressed to. If the stenosis is advanced enough to be symptomatic, it is beyond the point of needing further clarification by a stress test, especially in light of both the risk to the patient and the lack of accuracy pointed out in the ACC/AHA quote.
Frequently, people who have gone through with this have come back with the answer that the results were "inconclusive." Not much payback for the risk. There have been several who have posted with bad or near-fatal experiences during the testing.
The fact that someone would be there to try to revive you if you have a heart attack or go into dangerous arrythmias is hardly reassuring. And for a patient with an enlarged aorta, an immediate open heart surgery would be the only available response to a dissection caused by the effort, if it could be accomplished in time (remember, you're with a cardiologist for this test, not a cardiothoracic surgeon).
Based on the ACC/AHA guidelines and common sense, it would certainly seem to press the definition of reckless endangerment to order an exercise stress test for a symptomatic, stenotic aortic valve patient with an aortic aneurism. It would seem likewise both pointless and dangerous on a symptomatic aortic stenosis patient without an aortic aneurism, or a non-symptomatic stenosis patient, for the same reasons given in the guidelines.
Stress tests can have their place in heart problem diagnosis, but it's not in aortic stenosis, and probably not in basic valve issues in general. Mary was right, I really don't have much patience for this cardiologists' cash cow.
Best wishes,
mmarshall
Well-known member
Ashley said:Hahah..I know I know!!!
lol...it's natural...but i really would not worry about the sudden death issue. you are not having symptoms and according to your cardio...you are in the monitoring stage. but looking back on my stress test...i would have to agree with a lot of the posts here....the stress test just seems like it does not have to be done and i'm not sure what it is really going to accomplish. i know for me, the echo and ekg told it all. then once they saw that and we started talking surgery...then the ct scan was ordered. i would think that should give them enough info to go on. although i guess if you are still wanting to play soccer and stuff...this type of test may give them some kind of read on whether or not you can do that again. i would ask your cardio why she want's to do the test and then decide on whether you want to do it or not.
G
Guest
Ashley said:
*rolls eyes*
You mean I'm not the only worrier? Good night shirt tail ... sometimes, the worrying is worse than whatever it is I'm worrying about. Heh.
I've learned to lessen the worries, though, by relaxing more and trying to have more fun. Sometimes it works, sometimes it doesn't.
*shrugs*
Cort, "Mr MC" / "Mr Road Trip", 31swm/pig valve/pacemaker
'72,6,9/'81,7.hobbies.chdQB = http://www.chevyasylum.com/cort/
MC Guide = http://www.chevyasylum.com/mcspotter/main.html
"Are we having fun yet?" ... Nickelback ... 'This Is How You Remind Me'
ALCapshaw2
Well-known member
NOT all patients with valve disease show symptoms before they reach the 'Serious' stage. This seems to be especially true for patients who are in good physical condition, i.e., they have conditioned their bodies to be more efficient which means they can do more with less (oxygen, blood circulation, etc.) Remember the basketball and football players who DROP DEAD on the court or field? OK, it's not common, but it does happen.
Do you really want to run that RISK?
SHOW the AAFP and AHA Guidelines to your Cardiologist and ASK him/her WHY s/he does not choose to follow them!
'AL Capshaw'
Do you really want to run that RISK?
SHOW the AAFP and AHA Guidelines to your Cardiologist and ASK him/her WHY s/he does not choose to follow them!
'AL Capshaw'
K
KimC
Ashley,
I was hospitalized at age 36 in '03 with chest pain. I was also six-months postpartum, recovering from mild peripartum cardiomyopathy (which I was told had improved signficantly since the birth of my son). I do not have severe valve disease.
Because my HR and other vitals were markedly abnormal, the cardio ordered a thallium stress test to check for worsening aortic disease, CAD, etc.
I've been athletic all of my life, sometimes to the extreme. The morning of the stress test, I walked onto the treadmill and joked with the cardiologist that he would have to "pump it up" because I was in such "great" shape.
He did, and I almost collapsed. It was so unexpected. They hit the red emergency button, and pulled me off the treadmill. No prolonged cardiac arrest, but for seconds I had no blood flow, and I felt like a train had hit my chest.
I echo Bob's comments. Your cardio has the numbers; surgery is indicated. Why push it? You have the answer. In addition to the potential physical danger, consider the possible emotional toll. How would you -- an active young woman -- feel if they had to push the panic button? It's not a memory I cherish, let me tell you.
Bottom line, this is a decision between you, your family and doctors. I hope we've helped, and not created undue anxiety.
Blessings,
I was hospitalized at age 36 in '03 with chest pain. I was also six-months postpartum, recovering from mild peripartum cardiomyopathy (which I was told had improved signficantly since the birth of my son). I do not have severe valve disease.
Because my HR and other vitals were markedly abnormal, the cardio ordered a thallium stress test to check for worsening aortic disease, CAD, etc.
I've been athletic all of my life, sometimes to the extreme. The morning of the stress test, I walked onto the treadmill and joked with the cardiologist that he would have to "pump it up" because I was in such "great" shape.
He did, and I almost collapsed. It was so unexpected. They hit the red emergency button, and pulled me off the treadmill. No prolonged cardiac arrest, but for seconds I had no blood flow, and I felt like a train had hit my chest.
I echo Bob's comments. Your cardio has the numbers; surgery is indicated. Why push it? You have the answer. In addition to the potential physical danger, consider the possible emotional toll. How would you -- an active young woman -- feel if they had to push the panic button? It's not a memory I cherish, let me tell you.
Bottom line, this is a decision between you, your family and doctors. I hope we've helped, and not created undue anxiety.
Blessings,
Well, I rescheduled for July 22
Well, I rescheduled for July 22
Thanks everyone for your help with making my decision. I cancelled the appointment for the stress test (exercise) that was scheduled for yesterday. I met with my cardiologist yesterday - told her my reasons for cancelling the test - which she understood. However, we decided together that it is still in my best interest to do the test. My valve is actually at 1 cm2 or better (not sure what "better" means), so they intend to monitor me every 6 mos. They want to use the stress test as another marker for the valve worsening. I agree that it valuable, so I have rescheduled the test for July 22. I'm not in as bad shape as I initially thought, so I feel comfortable with the test at this point. It will also give me confidence with other exercise (still no soccer, but they say light jogging, swimming etc. is okay.) So again, thanks for all the thoughts and opinions! So much appreciated!!!
Well, I rescheduled for July 22
Thanks everyone for your help with making my decision. I cancelled the appointment for the stress test (exercise) that was scheduled for yesterday. I met with my cardiologist yesterday - told her my reasons for cancelling the test - which she understood. However, we decided together that it is still in my best interest to do the test. My valve is actually at 1 cm2 or better (not sure what "better" means), so they intend to monitor me every 6 mos. They want to use the stress test as another marker for the valve worsening. I agree that it valuable, so I have rescheduled the test for July 22. I'm not in as bad shape as I initially thought, so I feel comfortable with the test at this point. It will also give me confidence with other exercise (still no soccer, but they say light jogging, swimming etc. is okay.) So again, thanks for all the thoughts and opinions! So much appreciated!!!
You must do what you feel is right for you.
Just some further thoughts:
- The ACC guidelines point out that one main problem with stress tests for patients with AS is that they are simply not accurate.
- There are no related ACC-AHA guidelines stipulating what indices from a stress test would be acceptable evidence that valve surgery is needed. This would go hand-in-hand with the conclusion by the ACC and the AHA that stress tests on AS patients "have limited diagnostic accuracy."
- Accepted measures for valve surgery include a combination of heart enlargement, degree of stenosis (in fact, just under your 1 cm² size in some cases), ejection fraction, degree of regurgitation (may also be termed "insufficiency"), and presence of symptoms. The above can be determined with a standard echo, a trans-esophogeal echo (TEE), and/or a catheter angiogram. A magnetic resonance angiogram (MRA) may also be used to develop part of that information.
- There is no measure for stress test results vs surgery readiness included in any documentation I have seen. Perhaps it is intended to provoke symptoms, but symptoms are not actually a requirement to indicate the need for surgery. Some patients just never do develop symptoms, although their stenosis may become frighteningly advanced (.4cm²). Because of this, some never come to realize realize they have AS, and experience sudden death on the basketball court or shovelling snow. (That's not an indication that I think you're likely to come to permanent grief from your stress test. It's just a statement of something that does happen, and sometimes makes the news.)
Best wishes,
Just some further thoughts:
- The ACC guidelines point out that one main problem with stress tests for patients with AS is that they are simply not accurate.
- There are no related ACC-AHA guidelines stipulating what indices from a stress test would be acceptable evidence that valve surgery is needed. This would go hand-in-hand with the conclusion by the ACC and the AHA that stress tests on AS patients "have limited diagnostic accuracy."
- Accepted measures for valve surgery include a combination of heart enlargement, degree of stenosis (in fact, just under your 1 cm² size in some cases), ejection fraction, degree of regurgitation (may also be termed "insufficiency"), and presence of symptoms. The above can be determined with a standard echo, a trans-esophogeal echo (TEE), and/or a catheter angiogram. A magnetic resonance angiogram (MRA) may also be used to develop part of that information.
- There is no measure for stress test results vs surgery readiness included in any documentation I have seen. Perhaps it is intended to provoke symptoms, but symptoms are not actually a requirement to indicate the need for surgery. Some patients just never do develop symptoms, although their stenosis may become frighteningly advanced (.4cm²). Because of this, some never come to realize realize they have AS, and experience sudden death on the basketball court or shovelling snow. (That's not an indication that I think you're likely to come to permanent grief from your stress test. It's just a statement of something that does happen, and sometimes makes the news.)
Best wishes,
tobagotwo said:
Bob,
Thanks so much for the info - I really appreciate your help
I think for me, the test feels like the right thing to do at this point. I can see however that it doesn't necessarily provide clear answers - but I guess compiled with the other info, it might be helpful (let's hope!). Any thoughts on what test is the most conclusive? I have never had a TEE - is that something that is usually done? I recently had an angiogram and echo though. Thanks!
Ashley
Testing Overkill?
Testing Overkill?
In my informal reading of posts (and for my own VR), it appears most "simple" AVRs are done on the basis of a series of standard echoes, followed by one angiogram (heart catheterization) performed a day or a few days before surgery. If the person has had indications or family history of CAD or arterial blockage, it's more likely previous angiograms or MRAs may have been done.
Obviously, not everyone fits that, but I believe it to be the most common scenario.
More often now, there are posts about TEEs, MRAs, and an occasional CAT scan procedure (and stress tests, ACC/AHA notwithstanding), but from a nonprofessional point of view, I don't really see anything that shows that these are of more value overall to the goal of determining the proper time for AVR. The use of multiple catheterizations to double-check echo results also seems contrived (get a better tech, or better equipment). Perhaps with the new 3D Doppler echocardiograms that are starting to be used, the perceived need for the other tests will wane. The real answer that all these tests aspire to reach is when must surgery be done to avoid permanent heart damage.
Having more, or even more accurate tests does not really seem of great value toward this. The proper timing for OHVS is an inexact science, and is apt to vary greatly from person to person, heart to heart. So there is limited intuitive value to the distressing and intrusive overtesting of an individual in the name of exactitude. It more serves malpractice insurance companies, for explaining why the patient was sent for surgery, should something go wrong.
Putting the patient through unpleasant, but extremely accurate testing of the criteria (versus the usual, nominally accurate testing) amounts to developing a very steady aim for a moving target. What is the enhanced value of that fine tuning, and how close is it reasonable to shave it, when the risk is permanent cardiac damage?
A TEE (TOE in the UK) is generally considered more acurate than a standard echo, as it is done through the throat, and there are no bones in the way. Still, unless there are unusual standard echo readings, previous surgical concerns, or suspected congenital issues (other than "basic" bicuspid valve), it usually seems to be overkill, because it's intrusive and stressful for most people, and rarely varies significantly enough from results of a series of standard echoes to cause a gross change of plans regarding valve surgery. A TEE is usually done while you're asleep during surgery to determine proper functioning of the valve in place before closing up.
Best wishes,
Testing Overkill?
In my informal reading of posts (and for my own VR), it appears most "simple" AVRs are done on the basis of a series of standard echoes, followed by one angiogram (heart catheterization) performed a day or a few days before surgery. If the person has had indications or family history of CAD or arterial blockage, it's more likely previous angiograms or MRAs may have been done.
Obviously, not everyone fits that, but I believe it to be the most common scenario.
More often now, there are posts about TEEs, MRAs, and an occasional CAT scan procedure (and stress tests, ACC/AHA notwithstanding), but from a nonprofessional point of view, I don't really see anything that shows that these are of more value overall to the goal of determining the proper time for AVR. The use of multiple catheterizations to double-check echo results also seems contrived (get a better tech, or better equipment). Perhaps with the new 3D Doppler echocardiograms that are starting to be used, the perceived need for the other tests will wane. The real answer that all these tests aspire to reach is when must surgery be done to avoid permanent heart damage.
Having more, or even more accurate tests does not really seem of great value toward this. The proper timing for OHVS is an inexact science, and is apt to vary greatly from person to person, heart to heart. So there is limited intuitive value to the distressing and intrusive overtesting of an individual in the name of exactitude. It more serves malpractice insurance companies, for explaining why the patient was sent for surgery, should something go wrong.
Putting the patient through unpleasant, but extremely accurate testing of the criteria (versus the usual, nominally accurate testing) amounts to developing a very steady aim for a moving target. What is the enhanced value of that fine tuning, and how close is it reasonable to shave it, when the risk is permanent cardiac damage?
A TEE (TOE in the UK) is generally considered more acurate than a standard echo, as it is done through the throat, and there are no bones in the way. Still, unless there are unusual standard echo readings, previous surgical concerns, or suspected congenital issues (other than "basic" bicuspid valve), it usually seems to be overkill, because it's intrusive and stressful for most people, and rarely varies significantly enough from results of a series of standard echoes to cause a gross change of plans regarding valve surgery. A TEE is usually done while you're asleep during surgery to determine proper functioning of the valve in place before closing up.
Best wishes,
