What is a stress test going to show??

[watson524]

Hi all,

My mom had her follow up with her local cardio today after the 1/3/11 MV replacement surgery in Cleveland Clinic was canceled (http://www.valvereplacement.org/for...k-from-Clevelandand-not-going-back-in-January!!).

I planned to go with her but I am just getting over a wicked cold (thank GOD she wasn't having surgery) and I didn't want to risk infecting folks so I stayed home.

Anyway, she asked him about the difference in the echo readings and he said about with the catherization, she'd be on sedatives and it's not surprising it was lower but then she said their regular echo also showed PAP about 15mmHg lower than his (he hadn't seen the regular echo results from CCF). I guess he didn't have any real good answer for the vast difference then. Anyway, he wants her to have a stress test (I don't know what kind) since she's never had one. My question to her was "why?" She said he didn't tell her what it would show that something in Cleveland didn't so I'm wondering if anyone might know. She told him that if he puts her on a treadmill and raises and speed or incline, of course she'll be out of breath, we all know that. So I'm wondering what the point of this test is? In Cleveland, the surgeon and cardiologist had her do pulmonary testing, vascular testing, blood work, echos, catherization, etc..... what is this stress test going to show for pete's sake that we don't already know? I told her I'm a bit annoyed with her local cardio and she understands but she's also been going to him for 30 years so I understand that too.

But really.... this seems like a wasted test to me at this point all because this is the second time (first was 2000) that he said it was time to replace the valve and we went to CCF and they said nope, go home.

 

[escargome]

Well having been the primary advocate for my mom, I too know what it is like to a get an mature person to change doctor's or even challenge what the doctor might say. Maybe you could call her cardiologist and have him explain his reasoning. Cause I tend to agree with you. Why submit your mom to more testing (dye injection) than is truly necessary. I wish you and your mommy the best.

 

[TXWildflower]

Well from my own experience over a year ago when they 'thought' it was time, my cardio ordered a stress test. He said it was because what he was seeing on the echo wasn't consistent with my symptoms - which at the time were pretty much non-existent. Then we did a heart cath - which showed my valve area to be larger than the echo did - so surgery postponed. Anyway, to make a long story short when I had my consultant appts with my possible surgeons, and I mentioned the concern they had over my stress tests (stopped it early). He said anyone with aortic stenosis is going to show symptoms on a stress test. So I think I am inclined to agree with you that it seems like a waste of time. It is certainly your mother's and your's right to ask more questions.

 

[normofthenorth]

My stress tests generally showed the opposite of the ones you folks have mentioned. All my echos etc. had shown serious BAV stenosis (<<1cm2) and also significant AV regurg. But I always did fine on the treadmill, in the stress echos. For quite a while it was actually a source of tension between me and my Cardiologist, because he was suggesting AVR surgery sooner, and then I'd take 9-ish minutes to get to my target heart rate, no rhythm abnormalities or anything, certainly no premature ending of the stress echo. At one point, right after one of my last pre-op stress-echo cardiograms (while I was still postponing surgery), he told me through clenched unhappy teeth "There's no question that this is a VERY good test!

My impression of the test is that it's sort of 3 loosely-connected tests:
1) First they lie you down, wire you up, and do a complete 12-lead EKG plus an echo cardiogram.
2) Then while you're still wired up, they get you walking then jogging on the gradually accelerating and gradually inclining treadmill, while they mostly monitor your HR and compare it to their pre-defined target HR.
3) Then they instantly lie you down and repeat a lot of the #1 test, basically seeing how well and how quickly your heart recovers back to its resting state.

In my case, it was interesting because I had no symptoms but my Cardio thought I SHOULD, and the stress-echo was a chance to show them and "feel" them (except I didn't). In your mother's case, I don't think I see a real purpose for it.

Also, I found that every time a different medical/technical team did an echo or a stress-echo on me, they came up with different numbers. My Cardio had one (contract) technician who always seemed to calculate larger effective areas, and the Cardio never trusted him or his numbers. It looks like science and technology, but there seems to be a lot of art and judgment involved.

 

[ALCapshaw2]

Be sure to ask the Cardio about the RISK of performing a Stress Echo on a Valve Patient.
(you may also want to ask one of the CC Doc's who examined your mother,
along with asking what he thinks of performing a stress echo on her).

 

[Lily]

It's only my personal non-professional opinion but I know they can be dangerous and maybe they're often unnecessary.

 

[watson524]

The more I sit here reading and thinking, the more irate I get over this whole thing. I talked to my mom again Friday nite about this. Apparently the cardio set the test up for the 13th and she said no, I have to decide and talk to my GP so they scheduled it tentatively for the 18th knowing she might cancel it. She goes to her GP on the 11th and I plan to go with her. I've looked at all kinds of information as far as what a stress test can tell you and I just don't get it. I did say to my mom that if it was a necessary test, I'm pretty darn sure the surgeon or cardiologist in Cleveland would have had it done given how thorough they were with all the other tests and she agreed. I think I will put a call in to her cardiologist in Cleveland and see what he thinks. Then we'll meet with the local GP and even if they all say have it, there's nothing to say we can't still go with our gut and not do it.

 

[skeptic49]

I realize that stress testing for valve disease patients is controversial around here, but I think the cardios are just going by the book.

From the 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease

2.1.6. Exercise Testing
Exercise testing can provide valuable information in patients with valvular heart disease, especially in those whose symptoms are difficult to assess. It can be combined with echocardiography, radionuclide angiography, and cardiac catheterization. It has a proven track record of safety, even among asymptomatic patients with severe AS. Exercise testing has generally been underutilized in this patient population and should constitute an important component of the evaluation process.

 

[TXWildflower]

My stress tests generally showed the opposite of the ones you folks have mentioned. All my echos etc. had shown serious BAV stenosis (<<1cm2) and also significant AV regurg. But I always did fine on the treadmill, in the stress echos. For quite a while it was actually a source of tension between me and my Cardiologist, because he was suggesting AVR surgery sooner, and then I'd take 9-ish minutes to get to my target heart rate, no rhythm abnormalities or anything, certainly no premature ending of the stress echo. At one point, right after one of my last pre-op stress-echo cardiograms (while I was still postponing surgery), he told me through clenched unhappy teeth "There's no question that this is a VERY good test!

My impression of the test is that it's sort of 3 loosely-connected tests:
1) First they lie you down, wire you up, and do a complete 12-lead EKG plus an echo cardiogram.
2) Then while you're still wired up, they get you walking then jogging on the gradually accelerating and gradually inclining treadmill, while they mostly monitor your HR and compare it to their pre-defined target HR.
3) Then they instantly lie you down and repeat a lot of the #1 test, basically seeing how well and how quickly your heart recovers back to its resting state.

In my case, it was interesting because I had no symptoms but my Cardio thought I SHOULD, and the stress-echo was a chance to show them and "feel" them (except I didn't). In your mother's case, I don't think I see a real purpose for it.

Also, I found that every time a different medical/technical team did an echo or a stress-echo on me, they came up with different numbers. My Cardio had one (contract) technician who always seemed to calculate larger effective areas, and the Cardio never trusted him or his numbers. It looks like science and technology, but there seems to be a lot of art and judgment involved.

Now this is interesting. We had the stress test for the same reasons - but mine showed symptoms and yours didn't. I agree wholeheartedly that you can get different results from the same test given by different technicians. There is a skill involved in doing them right.

 

[scott.eitman]

I have to think that this test is picked due to symptoms or lack of symptoms from a patient. For me, my cardio switched to stress-echos because I did not have symptoms yet my echo said I should. The stess-echo enabled me to prove I was not lieing and then when I started lieing (actually just not noticing) the stress-echo picked it up. Would an echo only have picked it up, I will never know.

 

[normofthenorth]

I think the last couple of comments are the key to the main "value-added" from the stress test. Everything about the Echo seems to be based on the interpretation of the Tech and the Cardio, but how long you can keep slogging on the treadmill before you hit your target heart rate is a FACT, not somebody's interpretation of a sound or a shape-in-a-cloud on a computer screen.

But I think that's about all that the "stress" test adds to the "echo" -- it tells you whether or not you have CV symptoms that limit your CV fitness level. It seems to me that Watson's Mom already knows that she's very symptomatic, so it looks like a long shot (to me) that the "stress echo" will add new info that all the other tests didn't already produce. And if it DOES produce new info, it will still be in that "interpretive" part of the evidence -- e.g., the echo tech will SUGGEST that her recovery from the treadmill was unusually slow, or one of the valves showed ____ while it was stressed.

I think I'd still skip it in favor of the other kinds of tests. The angio (catherization) and the TEE and maybe the chest CT were the tests that seemed most important to my surgical team -- until they actually examined my Aortic Root. (I think it was only THEN that they made a final decision about whether or not to do a Bentall and replace my AR with a Dacron sleeve! They did not, they left it alone, after taking a small "tuck" to make it a bit smaller.)

 

[watson524]

Hi all,

Mom and I met with her GP today just to talk about things since her surgery was canceled. It was interesting because she's been a bit concerned that if she didn't have the stress test, her cardio would tell her to find a new doctor. I said "if he gets his shorts in that much of a bunch than you SHOULD find a new doctor" and her GP agreed. She mentioned to the GP right off the bat that her cardio said he wanted her to have a stress test and he said "why? you just had a catherization, we know you'll get out of breath on an incline, what else is to show?" Basically he said look, doctors don't always have to agree, your cardio still thinks you need to have a valve replacement now and disagrees with the doctors in Cleveland. He said that's why you get second opinions, it's not that one is necessarily right or wrong. He said he just doesn't see a need for a stress test at this point in time given all the other testing she had done. He said he suspects it's because the cardio is hearing that my mom isn't having symptoms and given the numbers on her tests, he thinks she should be..... ok great, but that doesn't change the course for right now (go to Cleveland again in 6 months for another evaluation, or go sooner if need be - i.e. if she feels worse).

So in that respect, I think it was a good conversation with the GP. My mom is going to call the Cardio and just respectfully decline the stress test for now. She's a bit nervous about what her cardio will say but again, if he pitches a fit, out come the yellow pages.