Question about MIBI scan

<[email hidden]> wrote in message
news:[email hidden]...

Quoted message said:

I just a mibi done. I'm in my early 40's, get only the minority of
chest pain which sometimes I wonder if it's GI related. It's fleeting
and usually very specific to what I would say is my PMI area. I also
have mildly elevated chol and have normal BP. I used to smoke but
quit 15 years ago. There is cardiac history in my family but only in
the 70's.

My Mibi shows an "area of concern." My doctor sent me at my request
because I wanted a stress test before I start exercising again since
it's been a few years.

My main question is, how accurate are these? I really don't want to
have a cath which I assume is the next step.

Thanks

The "sensitivity" of nuclear cardiology scans is above 90%. That is how
likely we're able to detect a problem.
The "specificity" is said to be above 90% as well. That is how likely
something we detect is actually a real problem.

There are false-positives (scan looks bad, heart is actually good) and false
negatives (scan looks good, heart is actually bad).

The accuracy of the scan can depend on the technical factors and physician's
interpretation. I'm not a doctor, I'm a technologist, but "area of concern"
sounds quite vague to me. What else does it say on the report? What does
your cardiologist think about it?

Andrew

Quoted message said:

I just a mibi done. I'm in my early 40's, get only the minority of
chest pain which sometimes I wonder if it's GI related. It's fleeting
and usually very specific to what I would say is my PMI area. I also
have mildly elevated chol and have normal BP. I used to smoke but
quit 15 years ago. There is cardiac history in my family but only in
the 70's.

My Mibi shows an "area of concern." My doctor sent me at my request
because I wanted a stress test before I start exercising again since
it's been a few years.

My main question is, how accurate are these?

Specificity is around 85-90%.

Quoted message said:

I really don't want to
have a cath which I assume is the next step.

Then discuss your concerns with your cardiologist. S/he should go over
the decision tree with you. Ultimately, it is your decision whether to
have the procedure.

Quoted message said:

Thanks

You are very welcome.

Humbly,

Andrew

--
Dr. Andrew B. Chung, MD/PhD
Board-Certified Cardiologist
http://www.heartmdphd.com

MD/PhD said:

Quoted message said:

I just a mibi done. I'm in my early 40's, get only the minority of
chest pain which sometimes I wonder if it's GI related. It's fleeting
and usually very specific to what I would say is my PMI area. I also
have mildly elevated chol and have normal BP. I used to smoke but
quit 15 years ago. There is cardiac history in my family but only in
the 70's.

My Mibi shows an "area of concern." My doctor sent me at my request
because I wanted a stress test before I start exercising again since
it's been a few years.

My main question is, how accurate are these?

Specificity is around 85-90%.

And this is for coronary flow obstruction only, which is a late
manifestation of atherosclerosis. MIBI scans cannot detect non-intrusive
atherosclerosis which is often the cause of an acute coronary syndrome. I
would encourage you to find out more specifically what "area of concern"
really means by asking your doctor for more information, or send your
report to me and I'll give you my 2 cents worth.

Quoted message said:

Quoted message said:

I really don't want to
have a cath which I assume is the next step.

you are correct, and unfortunately it is often the next step regardless of
the outcome of the nuclear scan.

Quoted message said:

Then discuss your concerns with your cardiologist. S/he should go over
the decision tree with you. Ultimately, it is your decision whether to
have the procedure.

As to risk of the procedure, seek them out. You might be suprised. MIBI
scans require an intravenous dose of radioactive dye. There is no safe dose
of radiation, no matter how low the exposure.

A heart cath carries even more risk for complications. I remember quite
well a patient of mine, 45 years of age, with chest discomfort, underwent
the course of evaluation you are pursuing now. I met her while serving as
the attending resident on the stroke rehab unit. She is now in a nursing
home and cannot converse with her children. Her heart, however, was just
fine.

Quoted message said:

Andrew

--
Dr. Andrew B. Chung, MD/PhD
Board-Certified Cardiologist
http://www.heartmdphd.com

--
~~~
Patrick Blanchard, M.D., A.B.F.P.
Board Certified in Family Practice
http://www.familydoctor.org/blanchard
~~~
SonoScore
Winning against heart attack and stroke
http://www.sonoscore.com

Patrick Blanchard said:

MD/PhD said:

Quoted message said:

I just a mibi done. I'm in my early 40's, get only the minority of
chest pain which sometimes I wonder if it's GI related. It's fleeting
and usually very specific to what I would say is my PMI area. I also
have mildly elevated chol and have normal BP. I used to smoke but
quit 15 years ago. There is cardiac history in my family but only in
the 70's.

My Mibi shows an "area of concern." My doctor sent me at my request
because I wanted a stress test before I start exercising again since
it's been a few years.

My main question is, how accurate are these?

Specificity is around 85-90%.

And this is for coronary flow obstruction only, which is a late
manifestation of atherosclerosis.

Patrick,

Aren't you confusing sensitivity with specificity here?

When we talk about sensitivity, we are describing a test's ability to detect
something. Here you would be correct that the "mibi" only detects ischemia or
infarcted myocardium. This would indicate advanced atherosclerosis. However,
imho, the late manifestation of atherosclerosis is death and not ischemia.

Otoh, when we talk about specificity, we are describing what it means when a
test is positive (i.e. the likelihood it is a true positive result). This has
nothing to do with the tests ability to detect non-occlusive (less advanced)
atherosclerosis.

Quoted message said:

MIBI scans cannot detect non-intrusive
atherosclerosis

You probably mean non-occlusive.

Quoted message said:

which is often the cause of an acute coronary syndrome.

During ACS, the disease is no longer non-occlusive.

Quoted message said:

I
would encourage you to find out more specifically what "area of concern"
really means by asking your doctor for more information, or send your
report to me and I'll give you my 2 cents worth.

Or the report can be described and discussed here for more than 2 cents of
information.

Quoted message said:

Quoted message said:

Quoted message said:

I really don't want to
have a cath which I assume is the next step.

you are correct, and unfortunately it is often the next step regardless of
the outcome of the nuclear scan.

Why is this unfortunate, Patrick?

And why would a normal mibi scan lead to a heart catherization in your
community? (it doesn't in mine)

Quoted message said:

Quoted message said:

Then discuss your concerns with your cardiologist. S/he should go over
the decision tree with you. Ultimately, it is your decision whether to
have the procedure.

As to risk of the procedure, seek them out.

These should be enumerated on the informed consent form that one signs giving
the cardiologist permission to perform the procedure. One can ask to review
this form a few days or more before the procedure, if one wish.

Quoted message said:

You might be suprised.

Why would I be surprised by the risks?

You probably are referring to the original poster (Why aren't you responding to
that post instead?)

Quoted message said:

MIBI
scans require an intravenous dose of radioactive dye.

Correct.

Quoted message said:

There is no safe dose
of radiation, no matter how low the exposure.

Depends on your definition of "safe"

Quoted message said:

A heart cath carries even more risk for complications.

It does.

Quoted message said:

I remember quite
well a patient of mine, 45 years of age, with chest discomfort, underwent
the course of evaluation you are pursuing now.

You probably are trying to respond to the original poster.

Quoted message said:

I met her while serving as
the attending resident on the stroke rehab unit. She is now in a nursing
home and cannot converse with her children. Her heart, however, was just
fine.

Strokes should be listed as a possible complication of a heart cath albeit a
rare one.

Humbly,

Andrew

--
Dr. Andrew B. Chung, MD/PhD
Board-Certified Cardiologist
http://www.heartmdphd.com

Welcome back Patrick
KC

"Patrick Blanchard, M.D." <blanchard@sonoscore_nospam.com> wrote in message
news:[email hidden]...

Quoted message said:

MD/PhD said:

Quoted message said:

I just a mibi done. I'm in my early 40's, get only the minority of
chest pain which sometimes I wonder if it's GI related. It's fleeting
and usually very specific to what I would say is my PMI area. I also
have mildly elevated chol and have normal BP. I used to smoke but
quit 15 years ago. There is cardiac history in my family but only in
the 70's.

My Mibi shows an "area of concern." My doctor sent me at my request
because I wanted a stress test before I start exercising again since
it's been a few years.

My main question is, how accurate are these?

Specificity is around 85-90%.

And this is for coronary flow obstruction only, which is a late
manifestation of atherosclerosis. MIBI scans cannot detect non-intrusive
atherosclerosis which is often the cause of an acute coronary syndrome. I
would encourage you to find out more specifically what "area of concern"
really means by asking your doctor for more information, or send your
report to me and I'll give you my 2 cents worth.

Quoted message said:

Quoted message said:

I really don't want to
have a cath which I assume is the next step.

you are correct, and unfortunately it is often the next step regardless of
the outcome of the nuclear scan.

Quoted message said:

Then discuss your concerns with your cardiologist. S/he should go over
the decision tree with you. Ultimately, it is your decision whether to
have the procedure.

As to risk of the procedure, seek them out. You might be suprised. MIBI
scans require an intravenous dose of radioactive dye. There is no safe

dose

Quoted message said:

of radiation, no matter how low the exposure.

A heart cath carries even more risk for complications. I remember quite
well a patient of mine, 45 years of age, with chest discomfort, underwent
the course of evaluation you are pursuing now. I met her while serving as
the attending resident on the stroke rehab unit. She is now in a nursing
home and cannot converse with her children. Her heart, however, was just
fine.

Quoted message said:

Andrew

--
Dr. Andrew B. Chung, MD/PhD
Board-Certified Cardiologist
http://www.heartmdphd.com

--
~~~
Patrick Blanchard, M.D., A.B.F.P.
Board Certified in Family Practice
http://www.familydoctor.org/blanchard
~~~
SonoScore
Winning against heart attack and stroke
http://www.sonoscore.com

MD/PhD said:

Patrick Blanchard said:

MD/PhD said:

[email hidden] wrote:

> I just a mibi done. I'm in my early 40's, get only the minority of
> chest pain which sometimes I wonder if it's GI related. It's

fleeting

Quoted message said:

> and usually very specific to what I would say is my PMI area. I also
> have mildly elevated chol and have normal BP. I used to smoke but
> quit 15 years ago. There is cardiac history in my family but only in
> the 70's.
>
> My Mibi shows an "area of concern." My doctor sent me at my request
> because I wanted a stress test before I start exercising again since
> it's been a few years.
>
> My main question is, how accurate are these?

Specificity is around 85-90%.

And this is for coronary flow obstruction only, which is a late
manifestation of atherosclerosis.

Patrick,

Aren't you confusing sensitivity with specificity here?

Assuming that coronary flow obstruction is causing myocardial ischemia
which in turn is causing [email hidden]'s chest pain, no.

Quoted message said:

When we talk about sensitivity, we are describing a test's ability to
detect
something.

A very high sensitivity, when negative, rules out disease. The disease a
MIBI nuclear perfusion scan rules out is myocardial ischemia from any
cause.

Quoted message said:

Here you would be correct that the "mibi" only detects ischemia or
infarcted myocardium. This would indicate advanced atherosclerosis.

yes, but again, we both are assuming the myocardial ischemia is from
atherosclerosis.

Quoted message said:

However,
imho, the late manifestation of atherosclerosis is death and not
ischemia.

we must agree to disagree here, as we have many times before about the
definition of atherosclerosis.

Quoted message said:

Otoh, when we talk about specificity, we are describing what it means
when a
test is positive (i.e. the likelihood it is a true positive result).

Yes, you are correct about specificity. It has everything to do with
ischemia but not necessarily occlusive atherosclerosis. A very specific
test, when positive, rules in disease. For a MIBI nuclear perfusion scan
the test is for myocardial ischemia. Most often myocardial ischemia is
caused by flow limiting atherosclerosis and not, say, trauma.

Quoted message said:

This has
nothing to do with the tests ability to detect non-occlusive (less
advanced)
atherosclerosis.

yes, a MIBI scan is not used to detect non-occlusive disease.

Quoted message said:

Quoted message said:

MIBI scans cannot detect non-intrusive
atherosclerosis

You probably mean non-occlusive.

No, I mean non-intrusive, assuming that there is no plaque vulnerability
upstream of ischemic myocardium. Non-intrusive atherosclerosis will not
result in occlusion unless vulnerable plaque triggers thromboembolic
episodes. For silent non-intrusive atherosclerosis, a MIBI nuclear scan
will be negative; MIBI scans cannot detect (silent) non-intrusive
atherosclerosis.

Non-intrusive is found with positive remodeling of the artery; an atheroma
is present, can be vulnerable, but does not intrude into the arterial
lumen. Non-intrusive positive remodeling continues for quite some time in
non-diabetics.

http://tinyurl.com/xs30

The carotid IMT of 75 patients with multiple complex coronary plaques was
significantly larger than that of 50 patients with solitary plaques (p <
0.0003). CONCLUSIONS: In acute coronary syndrome, multiple complex coronary
plaques are associated with positive carotid remodeling, suggesting that
plaque vulnerability may be a systemic phenomenon.

http://tinyurl.com/xs40

RESULTS: Soft plaque was observed more frequently in acute than in stable
coronary syndrome (59% vs 31%), whereas hard plaque was more common in
stable coronary syndrome (69% vs 41%) (P = 0.03). The EEM CSA (15.11 +/-
2.89 mm(2) vs 13.25 +/-3.10 mm(2), P = 0.019) and plaque CSA (10.83 +/-2.62
mm(2) vs 9.30 +/-2.84 mm(2), P = 0.035) were significantly greater at
target lesions in patients with acute rather than stable coronary syndrome,
while lumen CSA and percent area stenosis were similar in both groups. RI
was significantly higher (1.08 +/-0.16 vs 0.95 +/-0.14, P = 0.002) and
positive remodeling was more frequent in acute coronary syndrome (53% vs
23%, P = 0.019), whereas negative remodeling was more common in stable
coronary syndrome (58% vs 24%, P = 0.007).

Quoted message said:

Quoted message said:

which is often the cause of an acute coronary syndrome.

During ACS, the disease is no longer non-occlusive.

ahem...
http://tinyurl.com/xs40

RESULTS: Soft plaque was observed more frequently in acute than in stable
coronary syndrome (59% vs 31%), whereas hard plaque was more common in
stable coronary syndrome (69% vs 41%) (P = 0.03).

The mechanism of occlusion in acute coronary syndrome results from
thromboembolism, not from the actual atherosclerosis. Thrombosis, although
associated with atherosclerosis, is a triggered event of platelet
aggregation. Occlusion can occur without thrombosis, albeit much slower,
but can occur exclusively from atheroma growth without thrombosis and with
an intact fibrous cap. In other words, someone can have a non-occlusive
vulnerable atheroma giving rise to acute coronary syndrome. In fact, non-
occlusive atheromas, or vulnerable plaques, are the primary cause of ACS.

Quoted message said:

Quoted message said:

I
would encourage you to find out more specifically what "area of concern"
really means by asking your doctor for more information, or send your
report to me and I'll give you my 2 cents worth.

Or the report can be described and discussed here for more than 2 cents
of
information.

Quoted message said:

Quoted message said:

> I really don't want to
> have a cath which I assume is the next step.
>

you are correct, and unfortunately it is often the next step regardless
of
the outcome of the nuclear scan.

Why is this unfortunate, Patrick?

And why would a normal mibi scan lead to a heart catherization in your
community? (it doesn't in mine)

Often is the key word. Not always, but often.

In this study, 15% of the time.

http://tinyurl.com/xred

The study population consisted of 334 patients. Their mean age was 56 +/-10
years, and 80% were men. Of the patients, 30% were asymptomatic, 29% had
angina, and only 6% had recent acute myocardial infarction or unstable
angina. Fifty-one patients (fifteen percent) were subsequently referred for
coronary angiography.

I would consider 15% "often" considering the risk of coronary angiography
and its kissing cousin, angioplasty. http://tinyurl.com/xrwg

The author of the original post, [email hidden], was told "an area
of concern" was identified on his MIBI scan. This is really a euphemism for
"let's warm up the cath lab".

Quoted message said:

Quoted message said:

Quoted message said:

Then discuss your concerns with your cardiologist. S/he should go

over

Quoted message said:

the decision tree with you. Ultimately, it is your decision whether

to

Quoted message said:

have the procedure.

As to risk of the procedure, seek them out.

These should be enumerated on the informed consent form that one signs
giving
the cardiologist permission to perform the procedure. One can ask to
review
this form a few days or more before the procedure, if one wish.

Quoted message said:

You might be suprised.

Why would I be surprised by the risks?

You probably are referring to the original poster (Why aren't you
responding to
that post instead?)

Yes, I should have posted this elsewhere; it was not directed at you.

Quoted message said:

Quoted message said:

MIBI
scans require an intravenous dose of radioactive dye.

Correct.

Quoted message said:

There is no safe dose
of radiation, no matter how low the exposure.

Depends on your definition of "safe"

There is no safe dose.

Quoted message said:

Quoted message said:

A heart cath carries even more risk for complications.

It does.

Quoted message said:

I remember quite
well a patient of mine, 45 years of age, with chest discomfort,
underwent
the course of evaluation you are pursuing now.

You probably are trying to respond to the original poster.

yes.

Quoted message said:

Quoted message said:

I met her while serving as
the attending resident on the stroke rehab unit. She is now in a nursing
home and cannot converse with her children. Her heart, however, was just
fine.

Strokes should be listed as a possible complication of a heart cath
albeit a
rare one.

http://tinyurl.com/xrxy

....and quite tragic.

Quoted message said:

Humbly,

Andrew

--
Dr. Andrew B. Chung, MD/PhD
Board-Certified Cardiologist
http://www.heartmdphd.com

Regards,

--
~~~
Patrick Blanchard, M.D., A.B.F.P.
Board Certified in Family Practice
http://www.familydoctor.org/blanchard
~~~
SonoScore
Winning against heart attack and stroke
http://www.sonoscore.com

Patrick Blanchard said:

MD/PhD said:

Patrick Blanchard said:

On Thu, 04 Dec 2003 04:20:56 GMT, Dr. Andrew B. Chung, MD/PhD
<[email hidden]> wrote:

> [email hidden] wrote:
>
>> I just a mibi done. I'm in my early 40's, get only the minority of
>> chest pain which sometimes I wonder if it's GI related. It's
fleeting
>> and usually very specific to what I would say is my PMI area. I also
>> have mildly elevated chol and have normal BP. I used to smoke but
>> quit 15 years ago. There is cardiac history in my family but only in
>> the 70's.
>>
>> My Mibi shows an "area of concern." My doctor sent me at my request
>> because I wanted a stress test before I start exercising again since
>> it's been a few years.
>>
>> My main question is, how accurate are these?
>
> Specificity is around 85-90%.

And this is for coronary flow obstruction only, which is a late
manifestation of atherosclerosis.

Patrick,

Aren't you confusing sensitivity with specificity here?

Assuming that coronary flow obstruction is causing myocardial ischemia
which in turn is causing [email hidden]'s chest pain, no.

Quoted message said:

When we talk about sensitivity, we are describing a test's ability to
detect
something.

A very high sensitivity, when negative, rules out disease. The disease a
MIBI nuclear perfusion scan rules out is myocardial ischemia from any
cause.

Correct. The most common cause of inducible ischemia (typically 99%) is
occlusive coronary atherosclerosis.

Quoted message said:

Quoted message said:

Here you would be correct that the "mibi" only detects ischemia or
infarcted myocardium. This would indicate advanced atherosclerosis.

yes, but again, we both are assuming the myocardial ischemia is from
atherosclerosis.

If not occlusive atherosclerosis, then endothelial dysfunction which is highly
associated with non-occlusive atherosclerosis.

Quoted message said:

Quoted message said:

However,
imho, the late manifestation of atherosclerosis is death and not
ischemia.

we must agree to disagree here, as we have many times before about the
definition of atherosclerosis.

Here we seem to be disagreeing on the definition of "late."

Quoted message said:

Quoted message said:

Otoh, when we talk about specificity, we are describing what it means
when a
test is positive (i.e. the likelihood it is a true positive result).

Yes, you are correct about specificity. It has everything to do with
ischemia but not necessarily occlusive atherosclerosis.

The latter would be factored into lowering the specificity. As you should be
well aware, the gold standard for determining both sensitivity and specificity
is the cardiac cath (ie coronary angiography).

Quoted message said:

A very specific
test, when positive, rules in disease. For a MIBI nuclear perfusion scan
the test is for myocardial ischemia. Most often myocardial ischemia is
caused by flow limiting atherosclerosis and not, say, trauma.

It is not clear to me why you brought up trauma. Nonetheless, a defect on a
"mibi" could mean either ischemia or myocardial scar. The scar would be from
past infarction.

Quoted message said:

Quoted message said:

This has
nothing to do with the tests ability to detect non-occlusive (less
advanced)
atherosclerosis.

yes, a MIBI scan is not used to detect non-occlusive disease.

Quoted message said:

Quoted message said:

MIBI scans cannot detect non-intrusive
atherosclerosis

You probably mean non-occlusive.

No, I mean non-intrusive,

I have never seen this terminology you are using. Is this term "non-intrusive
atherosclerosis" your invention?

Quoted message said:

assuming that there is no plaque vulnerability
upstream of ischemic myocardium.

Is this ever the case?

There is such as a thing as decreased plaque vulnerability but is there really
such a thing a *no* plaque vulnerability? Or is this another invention of
your?

Quoted message said:

Non-intrusive atherosclerosis will not
result in occlusion unless vulnerable plaque triggers thromboembolic
episodes.

Reading between the lines, are you defining non-intrusive atherosclerosis to
mean atherosclerosis that has no chance of rupturing (ie plaques but
*invulnerable* ones)?

Quoted message said:

For silent non-intrusive atherosclerosis, a MIBI nuclear scan
will be negative;

Not if there is flow-limiting occlusion (ie occlusive coronary disease).

Quoted message said:

MIBI scans cannot detect (silent) non-intrusive
atherosclerosis.

Are you confusing silent ischemia with non-occlusive coronary disease?

Quoted message said:

Non-intrusive is found with positive remodeling of the artery; an atheroma
is present, can be vulnerable, but does not intrude into the arterial
lumen. Non-intrusive positive remodeling continues for quite some time in
non-diabetics.

http://tinyurl.com/xs30

Your reference is about the carotid as an indirect way of assessing what may be
going on in the coronary arteries during the ACS. The authors don't define
your term "non-intrusive atherosclerosis."

Quoted message said:

The carotid IMT of 75 patients with multiple complex coronary plaques was
significantly larger than that of 50 patients with solitary plaques (p <
0.0003). CONCLUSIONS: In acute coronary syndrome, multiple complex coronary
plaques are associated with positive carotid remodeling, suggesting that
plaque vulnerability may be a systemic phenomenon.

http://tinyurl.com/xs40

RESULTS: Soft plaque was observed more frequently in acute than in stable
coronary syndrome (59% vs 31%), whereas hard plaque was more common in
stable coronary syndrome (69% vs 41%) (P = 0.03). The EEM CSA (15.11 +/-
2.89 mm(2) vs 13.25 +/-3.10 mm(2), P = 0.019) and plaque CSA (10.83 +/-2.62
mm(2) vs 9.30 +/-2.84 mm(2), P = 0.035) were significantly greater at
target lesions in patients with acute rather than stable coronary syndrome,
while lumen CSA and percent area stenosis were similar in both groups. RI
was significantly higher (1.08 +/-0.16 vs 0.95 +/-0.14, P = 0.002) and
positive remodeling was more frequent in acute coronary syndrome (53% vs
23%, P = 0.019), whereas negative remodeling was more common in stable
coronary syndrome (58% vs 24%, P = 0.007).

Still don't see where you get the terminology you are using.

Quoted message said:

Quoted message said:

Quoted message said:

which is often the cause of an acute coronary syndrome.

During ACS, the disease is no longer non-occlusive.

ahem...
http://tinyurl.com/xs40

RESULTS: Soft plaque was observed more frequently in acute than in stable
coronary syndrome (59% vs 31%), whereas hard plaque was more common in
stable coronary syndrome (69% vs 41%) (P = 0.03).

The mechanism of occlusion in acute coronary syndrome results from
thromboembolism, not from the actual atherosclerosis.

Nonetheless, we call this occlusive coronary disease at this point.

Quoted message said:

Thrombosis, although
associated with atherosclerosis, is a triggered event of platelet
aggregation. Occlusion can occur without thrombosis, albeit much slower,
but can occur exclusively from atheroma growth without thrombosis and with
an intact fibrous cap. In other words, someone can have a non-occlusive
vulnerable atheroma giving rise to acute coronary syndrome. In fact, non-
occlusive atheromas, or vulnerable plaques, are the primary cause of ACS.

Quoted message said:

Quoted message said:

I
would encourage you to find out more specifically what "area of concern"
really means by asking your doctor for more information, or send your
report to me and I'll give you my 2 cents worth.

Or the report can be described and discussed here for more than 2 cents
of
information.

Quoted message said:

>
>> I really don't want to
>> have a cath which I assume is the next step.
>>

you are correct, and unfortunately it is often the next step regardless
of
the outcome of the nuclear scan.

Why is this unfortunate, Patrick?

And why would a normal mibi scan lead to a heart catherization in your
community? (it doesn't in mine)

Often is the key word. Not always, but often.

In this study, 15% of the time.

http://tinyurl.com/xred

The study population consisted of 334 patients. Their mean age was 56 +/-10
years, and 80% were men. Of the patients, 30% were asymptomatic, 29% had
angina, and only 6% had recent acute myocardial infarction or unstable
angina. Fifty-one patients (fifteen percent) were subsequently referred for
coronary angiography.

Ok, 15% had a "positive" myocardial imaging result in this Lebanese cardiac
center. This is hardly surprising since 6% had a heart attack and 29% had
angina.

Quoted message said:

I would consider 15% "often" considering the risk of coronary angiography
and its kissing cousin, angioplasty. http://tinyurl.com/xrwg

Your reference does not say 15% of "normal" myocardial perfusion imaging
results lead to heart catheterizations, now does it?

Quoted message said:

The author of the original post, [email hidden], was told "an area
of concern" was identified on his MIBI scan. This is really a euphemism for
"let's warm up the cath lab".

Does it really? <raised eyebrow>

Quoted message said:

Quoted message said:

Quoted message said:

Quoted message said:

>
> Then discuss your concerns with your cardiologist. S/he should go
over
> the decision tree with you. Ultimately, it is your decision whether
to
> have the procedure.
>

As to risk of the procedure, seek them out.

These should be enumerated on the informed consent form that one signs
giving
the cardiologist permission to perform the procedure. One can ask to
review
this form a few days or more before the procedure, if one wish.

Quoted message said:

You might be suprised.

Why would I be surprised by the risks?

You probably are referring to the original poster (Why aren't you
responding to
that post instead?)

Yes, I should have posted this elsewhere; it was not directed at you.

Quoted message said:

Quoted message said:

MIBI
scans require an intravenous dose of radioactive dye.

Correct.

Quoted message said:

There is no safe dose
of radiation, no matter how low the exposure.

Depends on your definition of "safe"

There is no safe dose.

As you are reading this, you are getting a dose of radiation. If you truly
believed that no amount of radiation is safe, why are you using your computer?

Quoted message said:

Quoted message said:

Quoted message said:

A heart cath carries even more risk for complications.

It does.

Quoted message said:

I remember quite
well a patient of mine, 45 years of age, with chest discomfort,
underwent
the course of evaluation you are pursuing now.

You probably are trying to respond to the original poster.

yes.

Quoted message said:

Quoted message said:

I met her while serving as
the attending resident on the stroke rehab unit. She is now in a nursing
home and cannot converse with her children. Her heart, however, was just
fine.

Strokes should be listed as a possible complication of a heart cath
albeit a
rare one.

http://tinyurl.com/xrxy

...and quite tragic.

Your reference describes the overall complication rate as being very low.

Humbly,

Andrew

--
Dr. Andrew B. Chung, MD/PhD
Board-Certified Cardiologist
http://www.heartmdphd.com

Here's a follow up to my message. Sorry for the delay, I was at work.
I have read all the comments so far and very much appreciate them.

Here are the main highlights:

Exercise to 12 minutes, bruce 4 to 12.9 METS. HR from 62 to 169 at
peak. BP from 120/100 to 170/106 at peak. 2.5 mm flat ST depression
in 2,3,avf starting 7 minutes and lasting 1 minute into recovery. 1.5
mm flat ST depression in v5 and v6 starting at 10 minutes lasting 1
minute into recovery. Everything was normal with the perfusion except
a "small" reversible inferoseptal defect EF was 60%

I would like to point out that I am usually not hypertensive but must
have been nervous. I have had my wife who's an RN check since then.
I am more in the range of 110/80.

To try and describe my "chest pain" better, it is in fact more like an
occasional sensation of something wrong. Such as a grain of sand on
the left either below or lateral to the nipple. It is very slight and
pain is probably not even the word to describe it. I only feel it at
rest but not if I do any heavy manual house work or occasional
exercise or during every day activity. I have a history of heart burn
and sometimes it seems GI related but at other times not. On a second
note however, there was one time about 3 or 4 years ago where I was
running on my treadmill and felt a momentary tear like substernal
sensation which lasted for a few seconds. It caused me to stop
running out of surprise but never occurred after that with a run
again. I was relatively athletic at that time.

Back to the MIBI. I had no chest pain during the exercise but did
feel quite winded during the last 25% of it. I am out of shape at
present and am about 40 pounds overweight. What was difficult about
the exam was just getting enough air for the run. The test mentions
my heart rate to be 169 at max but I observed it into the high 180's
during the test.

This is kind of a wild question, but from a respiratory standpoint I
had reached my max, can this somehow effect the ST changes?

I'm also curious, do the ST changes shown correlate with the
inferoseptal defect on scan?

Overall, does my cardiac picture look bad? Is this something you
would find on an otherwise healthy 43 year old, the ones who just
never had the test done in the first place?

If it is suggested do you think I should follow up with a cath or just
toss it up as being a false positive and check again in 10 years?

I have not been able to either speak to my doctor directly because
he's away but do have a cardiologist appointment set for next week.

I appreciate any replies.

Quoted message said:

<[email hidden]> wrote in message
news:[email hidden]...

Quoted message said:

I just a mibi done. I'm in my early 40's, get only the minority of
chest pain which sometimes I wonder if it's GI related. It's fleeting
and usually very specific to what I would say is my PMI area. I also
have mildly elevated chol and have normal BP. I used to smoke but
quit 15 years ago. There is cardiac history in my family but only in
the 70's.

My Mibi shows an "area of concern." My doctor sent me at my request
because I wanted a stress test before I start exercising again since
it's been a few years.

My main question is, how accurate are these? I really don't want to
have a cath which I assume is the next step.

Thanks

Quoted message said:

Here's a follow up to my message. Sorry for the delay, I was at work.
I have read all the comments so far and very much appreciate them.

Here are the main highlights:

Exercise to 12 minutes, bruce 4 to 12.9 METS. HR from 62 to 169 at
peak. BP from 120/100 to 170/106 at peak. 2.5 mm flat ST depression
in 2,3,avf starting 7 minutes and lasting 1 minute into recovery. 1.5
mm flat ST depression in v5 and v6 starting at 10 minutes lasting 1
minute into recovery. Everything was normal with the perfusion except
a "small" reversible inferoseptal defect EF was 60%

http://tinyurl.com/xw5e

CONCLUSION: Of 270 consecutive patients, 41 (15%) referred to coronary
angiography due to reversible MIBI uptake defects showed coronary artery
stenoses < 50%. Twenty-six (10%) of these presented angiographically normal
coronary arteries. The significantly higher proportion of left ventricular
hypertrophy and LAFB in patients with reversible MIBI uptake defects
without significant CAD suggest microvascular disease, angiographically
underestimated CAD, and conduction abnormalities as underlying mechanisms.

In other words, you might consider an echocardiogram to identify your left
ventricular size. However, ecocardiograms are risk free and give a
tremendous amount of information about left ventricular size and is very
well validated. You should also be screened for diabetes.

Quoted message said:

I would like to point out that I am usually not hypertensive but must
have been nervous. I have had my wife who's an RN check since then.
I am more in the range of 110/80.

To try and describe my "chest pain" better, it is in fact more like an
occasional sensation of something wrong. Such as a grain of sand on
the left either below or lateral to the nipple. It is very slight and
pain is probably not even the word to describe it. I only feel it at
rest but not if I do any heavy manual house work or occasional
exercise or during every day activity. I have a history of heart burn
and sometimes it seems GI related but at other times not. On a second
note however, there was one time about 3 or 4 years ago where I was
running on my treadmill and felt a momentary tear like substernal
sensation which lasted for a few seconds. It caused me to stop
running out of surprise but never occurred after that with a run
again. I was relatively athletic at that time.

I would not consider you pain to be cardiogenic, but musculoskeletal.

Quoted message said:

Back to the MIBI. I had no chest pain during the exercise but did
feel quite winded during the last 25% of it. I am out of shape at
present and am about 40 pounds overweight. What was difficult about
the exam was just getting enough air for the run. The test mentions
my heart rate to be 169 at max but I observed it into the high 180's
during the test.

This is kind of a wild question, but from a respiratory standpoint I
had reached my max, can this somehow effect the ST changes?

It is not a wild question. Hyperventilation can effect ST segment. Before
all exercise treadmill test I supervise, I expect the technician to perform
supine, standing, and standing hyperventilation ECGs to ensure there is no
ST changes from these positions and with hyperventilation.

Quoted message said:

I'm also curious, do the ST changes shown correlate with the
inferoseptal defect on scan?

inferior, but I would defer to Dr. Chung.

Quoted message said:

Overall, does my cardiac picture look bad? Is this something you
would find on an otherwise healthy 43 year old, the ones who just
never had the test done in the first place?

First of all, do not panic. Do not make a hasty decision. Learn about your
options first.

Quoted message said:

If it is suggested do you think I should follow up with a cath or just
toss it up as being a false positive and check again in 10 years?

Neither.

Quoted message said:

I have not been able to either speak to my doctor directly because
he's away but do have a cardiologist appointment set for next week.

I appreciate any replies.

Quoted message said:

<[email hidden]> wrote in message
news:[email hidden]...

Quoted message said:

I just a mibi done. I'm in my early 40's, get only the minority of
chest pain which sometimes I wonder if it's GI related. It's fleeting
and usually very specific to what I would say is my PMI area. I also
have mildly elevated chol and have normal BP. I used to smoke but
quit 15 years ago. There is cardiac history in my family but only in
the 70's.

My Mibi shows an "area of concern." My doctor sent me at my request
because I wanted a stress test before I start exercising again since
it's been a few years.

My main question is, how accurate are these? I really don't want to
have a cath which I assume is the next step.

Thanks

Hope this helps.

--
~~~
Patrick Blanchard, M.D., A.B.F.P.
Board Certified in Family Practice
http://www.familydoctor.org/blanchard
~~~
SonoScore
Winning against heart attack and stroke
http://www.sonoscore.com

Quoted message said:

Here's a follow up to my message. Sorry for the delay, I was at work.
I have read all the comments so far and very much appreciate them.

Here are the main highlights:

Exercise to 12 minutes, bruce 4 to 12.9 METS. HR from 62 to 169 at
peak. BP from 120/100 to 170/106 at peak. 2.5 mm flat ST depression
in 2,3,avf starting 7 minutes and lasting 1 minute into recovery. 1.5
mm flat ST depression in v5 and v6 starting at 10 minutes lasting 1
minute into recovery. Everything was normal with the perfusion except
a "small" reversible inferoseptal defect EF was 60%

I would like to point out that I am usually not hypertensive but must
have been nervous. I have had my wife who's an RN check since then.
I am more in the range of 110/80.

To try and describe my "chest pain" better, it is in fact more like an
occasional sensation of something wrong. Such as a grain of sand on
the left either below or lateral to the nipple. It is very slight and
pain is probably not even the word to describe it. I only feel it at
rest but not if I do any heavy manual house work or occasional
exercise or during every day activity. I have a history of heart burn
and sometimes it seems GI related but at other times not. On a second
note however, there was one time about 3 or 4 years ago where I was
running on my treadmill and felt a momentary tear like substernal
sensation which lasted for a few seconds. It caused me to stop
running out of surprise but never occurred after that with a run
again. I was relatively athletic at that time.

Back to the MIBI. I had no chest pain during the exercise but did
feel quite winded during the last 25% of it. I am out of shape at
present and am about 40 pounds overweight.

Not good. Your hsCRP is probably high as a consequence of the latter.

Quoted message said:

What was difficult about
the exam was just getting enough air for the run. The test mentions
my heart rate to be 169 at max but I observed it into the high 180's
during the test.

This is kind of a wild question, but from a respiratory standpoint I
had reached my max, can this somehow effect the ST changes?

No.

Quoted message said:

I'm also curious, do the ST changes shown correlate with the
inferoseptal defect on scan?

Yes.

Quoted message said:

Overall, does my cardiac picture look bad?

The EF of 60% is a bright spot.

Quoted message said:

Is this something you
would find on an otherwise healthy 43 year old, the ones who just
never had the test done in the first place?

No.

Quoted message said:

If it is suggested do you think I should follow up with a cath or just
toss it up as being a false positive and check again in 10 years?

It is not a false positive. However, a case can be made for foregoing the
cath and trying lifestyle changes +/- medical therapy to reverse your
disease.

Quoted message said:

I have not been able to either speak to my doctor directly because
he's away but do have a cardiologist appointment set for next week.

I appreciate any replies.

You are welcome.

Humbly,

Andrew

--
Dr. Andrew B. Chung, MD/PhD
Board-Certified Cardiologist
http://www.heartmdphd.com/

Patrick Blanchard said:

Quoted message said:

Here's a follow up to my message. Sorry for the delay, I was at work.
I have read all the comments so far and very much appreciate them.

Here are the main highlights:

Exercise to 12 minutes, bruce 4 to 12.9 METS. HR from 62 to 169 at
peak. BP from 120/100 to 170/106 at peak. 2.5 mm flat ST depression
in 2,3,avf starting 7 minutes and lasting 1 minute into recovery. 1.5
mm flat ST depression in v5 and v6 starting at 10 minutes lasting 1
minute into recovery. Everything was normal with the perfusion except
a "small" reversible inferoseptal defect EF was 60%

http://tinyurl.com/xw5e

CONCLUSION: Of 270 consecutive patients, 41 (15%) referred to coronary
angiography due to reversible MIBI uptake defects showed coronary artery
stenoses < 50%. Twenty-six (10%) of these presented angiographically normal
coronary arteries. The significantly higher proportion of left ventricular
hypertrophy and LAFB in patients with reversible MIBI uptake defects
without significant CAD suggest microvascular disease, angiographically
underestimated CAD, and conduction abnormalities as underlying mechanisms.

In other words, you might consider an echocardiogram to identify your left
ventricular size. However, ecocardiograms are risk free and give a
tremendous amount of information about left ventricular size and is very
well validated.

Left ventricular size is not going to guide management here, Patrick.

Quoted message said:

You should also be screened for diabetes.

I would be very surprised if this hasn't been done already.

Quoted message said:

Quoted message said:

I would like to point out that I am usually not hypertensive but must
have been nervous. I have had my wife who's an RN check since then.
I am more in the range of 110/80.

To try and describe my "chest pain" better, it is in fact more like an
occasional sensation of something wrong. Such as a grain of sand on
the left either below or lateral to the nipple. It is very slight and
pain is probably not even the word to describe it. I only feel it at
rest but not if I do any heavy manual house work or occasional
exercise or during every day activity. I have a history of heart burn
and sometimes it seems GI related but at other times not. On a second
note however, there was one time about 3 or 4 years ago where I was
running on my treadmill and felt a momentary tear like substernal
sensation which lasted for a few seconds. It caused me to stop
running out of surprise but never occurred after that with a run
again. I was relatively athletic at that time.

I would not consider you pain to be cardiogenic, but musculoskeletal.

Chest pain is tricky to diagnose. You are correct in describing the symptoms
as atypical chest pain or atypical for angina. Could still be variant angina,
however.

Quoted message said:

Quoted message said:

Back to the MIBI. I had no chest pain during the exercise but did
feel quite winded during the last 25% of it. I am out of shape at
present and am about 40 pounds overweight. What was difficult about
the exam was just getting enough air for the run. The test mentions
my heart rate to be 169 at max but I observed it into the high 180's
during the test.

This is kind of a wild question, but from a respiratory standpoint I
had reached my max, can this somehow effect the ST changes?

It is not a wild question. Hyperventilation can effect ST segment. Before
all exercise treadmill test I supervise, I expect the technician to perform
supine, standing, and standing hyperventilation ECGs to ensure there is no
ST changes from these positions and with hyperventilation.

That would be standard procedure.

Quoted message said:

Quoted message said:

I'm also curious, do the ST changes shown correlate with the
inferoseptal defect on scan?

inferior, but I would defer to Dr. Chung.

I have already responded that there could be a correlation.

Quoted message said:

Quoted message said:

Overall, does my cardiac picture look bad? Is this something you
would find on an otherwise healthy 43 year old, the ones who just
never had the test done in the first place?

First of all, do not panic. Do not make a hasty decision. Learn about your
options first.

Good advice.

Quoted message said:

Quoted message said:

If it is suggested do you think I should follow up with a cath or just
toss it up as being a false positive and check again in 10 years?

Neither.

Discuss it with your doctor.

Humbly,

Andrew
--
Dr. Andrew B. Chung, MD/PhD
Board-Certified Cardiologist
http://www.heartmdphd.com/

MD/PhD said:

Patrick Blanchard said:

Quoted message said:

Here's a follow up to my message. Sorry for the delay, I was at work.
I have read all the comments so far and very much appreciate them.

Here are the main highlights:

Exercise to 12 minutes, bruce 4 to 12.9 METS. HR from 62 to 169 at
peak. BP from 120/100 to 170/106 at peak. 2.5 mm flat ST depression
in 2,3,avf starting 7 minutes and lasting 1 minute into recovery. 1.5
mm flat ST depression in v5 and v6 starting at 10 minutes lasting 1
minute into recovery. Everything was normal with the perfusion except
a "small" reversible inferoseptal defect EF was 60%

http://tinyurl.com/xw5e

CONCLUSION: Of 270 consecutive patients, 41 (15%) referred to coronary
angiography due to reversible MIBI uptake defects showed coronary artery
stenoses < 50%. Twenty-six (10%) of these presented angiographically
normal
coronary arteries. The significantly higher proportion of left
ventricular
hypertrophy and LAFB in patients with reversible MIBI uptake defects
without significant CAD suggest microvascular disease, angiographically
underestimated CAD, and conduction abnormalities as underlying
mechanisms.

In other words, you might consider an echocardiogram to identify your
left
ventricular size. However, ecocardiograms are risk free and give a
tremendous amount of information about left ventricular size and is very
well validated.

Left ventricular size is not going to guide management here, Patrick.

I disagree. It may help identify a false positive for macrovascular
atherosclerosis on his scan.

Quoted message said:

Quoted message said:

You should also be screened for diabetes.

I would be very surprised if this hasn't been done already.

Quoted message said:

Quoted message said:

I would like to point out that I am usually not hypertensive but must
have been nervous. I have had my wife who's an RN check since then.
I am more in the range of 110/80.

To try and describe my "chest pain" better, it is in fact more like an
occasional sensation of something wrong. Such as a grain of sand on
the left either below or lateral to the nipple. It is very slight and
pain is probably not even the word to describe it. I only feel it at
rest but not if I do any heavy manual house work or occasional
exercise or during every day activity. I have a history of heart burn
and sometimes it seems GI related but at other times not. On a second
note however, there was one time about 3 or 4 years ago where I was
running on my treadmill and felt a momentary tear like substernal
sensation which lasted for a few seconds. It caused me to stop
running out of surprise but never occurred after that with a run
again. I was relatively athletic at that time.

I would not consider you pain to be cardiogenic, but musculoskeletal.

Chest pain is tricky to diagnose. You are correct in describing the
symptoms
as atypical chest pain or atypical for angina. Could still be variant
angina,
however.

Quoted message said:

Quoted message said:

Back to the MIBI. I had no chest pain during the exercise but did
feel quite winded during the last 25% of it. I am out of shape at
present and am about 40 pounds overweight. What was difficult about
the exam was just getting enough air for the run. The test mentions
my heart rate to be 169 at max but I observed it into the high 180's
during the test.

This is kind of a wild question, but from a respiratory standpoint I
had reached my max, can this somehow effect the ST changes?

It is not a wild question. Hyperventilation can effect ST segment.
Before
all exercise treadmill test I supervise, I expect the technician to
perform
supine, standing, and standing hyperventilation ECGs to ensure there is
no
ST changes from these positions and with hyperventilation.

That would be standard procedure.

If he did not have a pre exercise hyperventialtion ecg, then there is a
quality concern about the technical accuracy of the scan itself.

Quoted message said:

Quoted message said:

Quoted message said:

I'm also curious, do the ST changes shown correlate with the
inferoseptal defect on scan?

inferior, but I would defer to Dr. Chung.

I have already responded that there could be a correlation.

2,3 aVf are isolated for the inferior wall, but I am not certain what leads
would become involved with the septum.

Quoted message said:

Quoted message said:

Quoted message said:

Overall, does my cardiac picture look bad? Is this something you
would find on an otherwise healthy 43 year old, the ones who just
never had the test done in the first place?

First of all, do not panic. Do not make a hasty decision. Learn about
your
options first.

Good advice.

Quoted message said:

Quoted message said:

If it is suggested do you think I should follow up with a cath or just
toss it up as being a false positive and check again in 10 years?

Neither.

Discuss it with your doctor.

Or with us.

Quoted message said:

Humbly,

Andrew
--
Dr. Andrew B. Chung, MD/PhD
Board-Certified Cardiologist
http://www.heartmdphd.com/

Regards

--
~~~
Patrick Blanchard, M.D., A.B.F.P.
Board Certified in Family Practice
http://www.familydoctor.org/blanchard
~~~
SonoScore
Winning against heart attack and stroke
http://www.sonoscore.com

Thanks for the additional replies!

I actually only had a supine and exercise ekg. Not with
hyperventilation unfortunately. I will raise this and maybe it will
be easy to do without heading to the cath lab.

I don't have diabetes and my crp's have been normal.

The idea about doing an echo is new also but wouldn't this come up on
ekg?

I would of course consider lifestyle changes. The only measures I
really know of would be to adopt the dean ornish diet, exercise like
hell and go on statins. However I don't ever remember coming across
anything saying that things can be reversed to any considerable
extent.

By the way, ironically, the reason I wanted the stress test after all
was that I wanted to resume rigorous exercise but now I'm not certain
I can do that part due to safety.

Thanks

MD/PhD said:

Quoted message said:

Here's a follow up to my message. Sorry for the delay, I was at work.
I have read all the comments so far and very much appreciate them.

Here are the main highlights:

Exercise to 12 minutes, bruce 4 to 12.9 METS. HR from 62 to 169 at
peak. BP from 120/100 to 170/106 at peak. 2.5 mm flat ST depression
in 2,3,avf starting 7 minutes and lasting 1 minute into recovery. 1.5
mm flat ST depression in v5 and v6 starting at 10 minutes lasting 1
minute into recovery. Everything was normal with the perfusion except
a "small" reversible inferoseptal defect EF was 60%

I would like to point out that I am usually not hypertensive but must
have been nervous. I have had my wife who's an RN check since then.
I am more in the range of 110/80.

To try and describe my "chest pain" better, it is in fact more like an
occasional sensation of something wrong. Such as a grain of sand on
the left either below or lateral to the nipple. It is very slight and
pain is probably not even the word to describe it. I only feel it at
rest but not if I do any heavy manual house work or occasional
exercise or during every day activity. I have a history of heart burn
and sometimes it seems GI related but at other times not. On a second
note however, there was one time about 3 or 4 years ago where I was
running on my treadmill and felt a momentary tear like substernal
sensation which lasted for a few seconds. It caused me to stop
running out of surprise but never occurred after that with a run
again. I was relatively athletic at that time.

Back to the MIBI. I had no chest pain during the exercise but did
feel quite winded during the last 25% of it. I am out of shape at
present and am about 40 pounds overweight.

Not good. Your hsCRP is probably high as a consequence of the latter.

Quoted message said:

What was difficult about
the exam was just getting enough air for the run. The test mentions
my heart rate to be 169 at max but I observed it into the high 180's
during the test.

This is kind of a wild question, but from a respiratory standpoint I
had reached my max, can this somehow effect the ST changes?

No.

Quoted message said:

I'm also curious, do the ST changes shown correlate with the
inferoseptal defect on scan?

Yes.

Quoted message said:

Overall, does my cardiac picture look bad?

The EF of 60% is a bright spot.

Quoted message said:

Is this something you
would find on an otherwise healthy 43 year old, the ones who just
never had the test done in the first place?

No.

Quoted message said:

If it is suggested do you think I should follow up with a cath or just
toss it up as being a false positive and check again in 10 years?

It is not a false positive. However, a case can be made for foregoing the
cath and trying lifestyle changes +/- medical therapy to reverse your
disease.

Quoted message said:

I have not been able to either speak to my doctor directly because
he's away but do have a cardiologist appointment set for next week.

I appreciate any replies.

You are welcome.

Humbly,

Andrew

Quoted message said:

Thanks for the additional replies!

I actually only had a supine and exercise ekg. Not with
hyperventilation unfortunately. I will raise this and maybe it will
be easy to do without heading to the cath lab.

I don't have diabetes and my crp's have been normal.

The idea about doing an echo is new also but wouldn't this come up on
ekg?

sometimes, but echocardiography is your best option since it will throw the
questionable MIBI scan into a whole new light. If you do not have LVH, then
you must also consider the absence of a standing hyperventilation ecg as
being an important missing part of the scan. I suspect however, that the
poor protocol of the study will be downplayed by those involved with it.

Quoted message said:

I would of course consider lifestyle changes. The only measures I
really know of would be to adopt the dean ornish diet, exercise like
hell and go on statins.

This is one of many, many options.

Quoted message said:

However I don't ever remember coming across
anything saying that things can be reversed to any considerable
extent.

Then we have a whole bunch to talk about.

Quoted message said:

By the way, ironically, the reason I wanted the stress test after all
was that I wanted to resume rigorous exercise but now I'm not certain
I can do that part due to safety.

It is my opinion that you can engage in mild exercise for the time being,
but it is also important to know what medications you are currently taking.
Please include all supplements and over the counter as needed medications.

--
~~~
Patrick Blanchard, M.D., A.B.F.P.
Board Certified in Family Practice
http://www.familydoctor.org/blanchard
~~~
SonoScore
Winning against heart attack and stroke
http://www.sonoscore.com

"Patrick Blanchard, M.D." <blanchard@sonoscore_nospam.com> wrote in message
news:[email hidden]...

Quoted message said:

On Fri, 05 Dec 2003 22:44:05 GMT, <[email hidden]> wrote:

sometimes, but echocardiography is your best option since it will throw

the

Quoted message said:

questionable MIBI scan into a whole new light. If you do not have LVH,

then

Quoted message said:

you must also consider the absence of a standing hyperventilation ecg as
being an important missing part of the scan. I suspect however, that the
poor protocol of the study will be downplayed by those involved with it.

How do you think a standing hyperventilation ecg would affect the scan
quality, since the tracer is not injected until peak exercise?

I can see a hyperventilation ecg affecting the interpretation of the stress
ecg (if ST changes are noted on both, for instance), but how would it affect
the images?

Quoted message said:

~~~
Patrick Blanchard, M.D., A.B.F.P.
Board Certified in Family Practice
http://www.familydoctor.org/blanchard

Andrew Kerr M.R.T.(N.)

Patrick Blanchard said:

<snip>

Quoted message said:

Left ventricular size is not going to guide management here, Patrick.

I disagree. It may help identify a false positive for macrovascular
atherosclerosis on his scan.

The "mibi" has already identified normal LVEF so one should not be expecting
increased LV dimensions, anyway.

Quoted message said:

<snip> 2,3 aVf are isolated for the inferior wall, but I am not certain what
leads
would become involved with the septum.

Precordial V4, V5, and/or V6 for the inferior septum depending on actual lead
placement and heart position.

Quoted message said:

Quoted message said:

Quoted message said:

>
> Overall, does my cardiac picture look bad? Is this something you
> would find on an otherwise healthy 43 year old, the ones who just
> never had the test done in the first place?

First of all, do not panic. Do not make a hasty decision. Learn about
your
options first.

Good advice.

Quoted message said:

>
> If it is suggested do you think I should follow up with a cath or just
> toss it up as being a false positive and check again in 10 years?

Neither.

Discuss it with your doctor.

Or with us.

We aren't his doctors, Patrick.

Humbly,

Andrew
--
Dr. Andrew B. Chung, MD/PhD
Board-Certified Cardiologist
http://www.heartmdphd.com/

Quoted message said:

Thanks for the additional replies!

I actually only had a supine and exercise ekg. Not with
hyperventilation unfortunately. I will raise this and maybe it will
be easy to do without heading to the cath lab.

I don't have diabetes and my crp's have been normal.

hsCRP is not the same as the routine CRP. Which did you have and what was it?

Quoted message said:

The idea about doing an echo is new also but wouldn't this come up on
ekg?

Imho, there is not really an indication for the echo.

Quoted message said:

I would of course consider lifestyle changes. The only measures I
really know of would be to adopt the dean ornish diet, exercise like
hell and go on statins. However I don't ever remember coming across
anything saying that things can be reversed to any considerable
extent.

There can be reversal. Achieving ideal body weight is very important in this
regard.

For weight loss consider:

http://www.heartmdphd.com/wtloss.asp

Quoted message said:

By the way, ironically, the reason I wanted the stress test after all
was that I wanted to resume rigorous exercise but now I'm not certain
I can do that part due to safety.

If there are no symptoms (and your EF is normal by your report), it is
reasonable to try lifestyle changes first (imho, weight loss is very
important).

Quoted message said:

Thanks

You are very welcome :-)

Humbly,

Andrew
--
Dr. Andrew B. Chung, MD/PhD
Board-Certified Cardiologist
http://www.heartmdphd.com/

Andrew Kerr said:

"Patrick Blanchard, M.D." <blanchard@sonoscore_nospam.com> wrote in
message
news:[email hidden]...

Quoted message said:

On Fri, 05 Dec 2003 22:44:05 GMT, <[email hidden]> wrote:

sometimes, but echocardiography is your best option since it will throw

the

Quoted message said:

questionable MIBI scan into a whole new light. If you do not have LVH,

then

Quoted message said:

you must also consider the absence of a standing hyperventilation ecg as
being an important missing part of the scan. I suspect however, that the
poor protocol of the study will be downplayed by those involved with it.

How do you think a standing hyperventilation ecg would affect the scan
quality, since the tracer is not injected until peak exercise?

I can see a hyperventilation ecg affecting the interpretation of the
stress
ecg (if ST changes are noted on both, for instance), but how would it
affect
the images?

Andrew Kerr M.R.T.(N.)

Hyperventilation can induce coronary vasospasm. Coronary vasospasm is not
always due from atherosclerosis, and is often the achilles' heel of
coronary angiography.

http://tinyurl.com/xy75

We are discussing the 'scan' and not just the 'images'. The 'scan' includes
the images and the ecg interpretation together. A finding on one can
influence the interpretation of the other. Because of this, it would be
interesting to have the ecg strips and the perfusion images read
independently by different doctors, and see if indeed the two still
correlate.

--
~~~
Patrick Blanchard, M.D., A.B.F.P.
Board Certified in Family Practice
http://www.familydoctor.org/blanchard
~~~
SonoScore
Winning against heart attack and stroke
http://www.sonoscore.com

MD/PhD said:

Patrick Blanchard said:

<snip>

Quoted message said:

Left ventricular size is not going to guide management here, Patrick.

I disagree. It may help identify a false positive for macrovascular
atherosclerosis on his scan.

The "mibi" has already identified normal LVEF so one should not be
expecting
increased LV dimensions, anyway.

OK, I'm leaving my terra firma, but I would like you to clarify this for me
in the perspective of Starling's law. LVEF is a reflection of contractility
of the heart, and not the size of the myocardium. LVH is a reflection of
the myocardial size, and not of contractility.

Quoted message said:

Quoted message said:

<snip> 2,3 aVf are isolated for the inferior wall, but I am not certain
what
leads
would become involved with the septum.

Precordial V4, V5, and/or V6 for the inferior septum depending on actual
lead
placement and heart position.

Quoted message said:

Quoted message said:

>
> >
> > Overall, does my cardiac picture look bad? Is this something you
> > would find on an otherwise healthy 43 year old, the ones who just
> > never had the test done in the first place?
>
> First of all, do not panic. Do not make a hasty decision. Learn about
> your
> options first.
>

Good advice.

>
> >
> > If it is suggested do you think I should follow up with a cath or

just

Quoted message said:

> > toss it up as being a false positive and check again in 10 years?
>
> Neither.
>

Discuss it with your doctor.

Or with us.

We aren't his doctors, Patrick.

No we are not, and I should have stated "and with us at SMC" instead. Thank
you for clarifying this; it is quite important.

Regards,

--
~~~
Patrick Blanchard, M.D., A.B.F.P.
Board Certified in Family Practice
http://www.familydoctor.org/blanchard
~~~
SonoScore
Winning against heart attack and stroke
http://www.sonoscore.com