Should I Seek Further Evaluation for Heart Issues After Tests?

Is further examination necessary?

Since November 2nd, I have experienced chest tightness and an increased heart rate.
I went to a clinic where an electrocardiogram (ECG) indicated a heart issue, leading to a referral to the emergency department.
However, blood tests, X-rays, and ECGs showed no abnormalities, and I was scheduled for an outpatient exercise stress test (TET No: 1102361).

1.
Testing Method: Bruce protocol;
2.
Reason for not completing the full duration: Target heart rate achieved;
3.
Results:
1.
Resting ECG: Normal sinus rhythm.
Predicted maximum heart rate (MHR) = Peak HR/Age predicted MHR = 157/177 = 89%.
Modified Time Index = MBP * HR * (10^-2) = 140 * 157/100 = 220 units.

2.
Exercise duration: 6 minutes and 31 seconds.

3.
Blood pressure response:
- Stage 0: BP 107/65
- Stage 1: BP 126/72
- Stage 2: BP 140/73
- Stage 3: BP 140/73
- Stage 4: BP 138/71
- Stage 5: BP 127/71
- Stage 6: BP 111/71
- Stage 7 to 13: BP readings were taken at various intervals.

4.
ECG Changes:
a.
ST Segment abnormalities: ST segment elevation of 1 mm in V5-6 beginning at 3 minutes of exercise and lasting for 3 minutes into recovery.

b.
T or U wave changes: Normal.

c.
QRS complex changes: Normal.

5.
Arrhythmia: None.

6.
Chest Pain: None.

Interpretation: Positive for ischemia.

Further, a myocardial perfusion study was conducted under a standardized dipyridamole stress test, which indicated:
1.
No significant inducible ischemia in the myocardium.

2.
Adequate left ventricular (LV) systolic function.

Study: 26025B Stress & redistribution myocardial perfusion study with SPECT.

INDICATION: Diagnosis of coronary artery disease, rule out myocardial ischemia.

CLINICAL HISTORY: 43-year-old male with chest tightness and tachycardia.
Smoking history.
TET: Positive for ischemia.
UCG: Adequate LV systolic function (LVEF: 57.9%), no obvious regional wall abnormalities.

NUCLEAR MEDICINE STUDY: Thallium-201 myocardial perfusion imaging (MPI) with dipyridamole and resting state.

RADIOPHARMACEUTICAL: Thallium-201, 3 mCi intravenous.

SCINTIGRAPHIC FINDINGS: Thallium-201 myocardial perfusion imaging was performed after standardized dipyridamole stress protocol (dipyridamole: 0.56 mg/kg, continuous IV infusion over 4 minutes) and resting state.
The initial and 4-hour delayed images showed no definite perfusion defect in the myocardium.

1.
Post-stress LVEF = 71%, resting LVEF = 79%.

2.
Wall motion: No obvious regional wall motion abnormalities.

IMPRESSION: Under standardized dipyridamole stress test,
1.
No significant inducible ischemia in the myocardium.

2.
Adequate LV systolic function.

Comment: The mean sensitivities and specificities of vasodilator SPECT for detecting coronary artery disease (greater than or equal to 50% stenosis) are 86% and 73%, respectively.
(Reference: J Am Coll Cardiol 2003;42:1318-33.)
Based on the report, the doctor stated that there were no abnormalities.
Should I consider seeing a psychiatrist?

Yang, 40~49 year old female. Ask Date: 2021/12/26

Dr. Wu Xueming reply Cardiology

The myocardial perfusion scan results show no signs of hypoxia, indicating a very low likelihood of coronary artery disease.

Reply Date: 2021/12/26

More Info

Based on the information provided, it appears that you have undergone a series of cardiac evaluations due to symptoms such as chest tightness and tachycardia. The tests included an exercise stress test (TET) and a myocardial perfusion study using Thallium-201, which are both important for assessing coronary artery disease (CAD) and myocardial ischemia.

Summary of Findings:
1. Exercise Stress Test (TET): Your test results indicated a positive finding for ischemia, which means that there were changes in the EKG during exercise that could suggest reduced blood flow to the heart muscle. Specifically, you experienced ST segment elevation, which can be a sign of myocardial ischemia.

2. Myocardial Perfusion Study: The subsequent Thallium-201 myocardial perfusion imaging showed no significant inducible ischemia in the myocardium, and your left ventricular (LV) systolic function was adequate. This suggests that while there may have been some concerns during the exercise test, the perfusion study did not confirm significant ischemia at rest or under stress.

Interpretation:
The conflicting results between the exercise stress test and the myocardial perfusion study can be confusing. The exercise test indicated potential ischemia, while the perfusion study did not show significant abnormalities. This could suggest that the ischemia observed during the exercise test may be transient or related to other factors, such as increased heart rate or blood pressure during exertion.

Recommendations:
1. Further Evaluation: Given the positive exercise test and the subsequent normal perfusion study, it may be prudent to seek further evaluation. This could include:
- Coronary Angiography: This is an invasive procedure that can provide detailed images of the coronary arteries and help determine if there are blockages that could be causing your symptoms.

- Holter Monitor: If you continue to experience symptoms, a 24-hour Holter monitor may help capture any arrhythmias or other abnormalities that occur during daily activities.

2. Consultation with a Cardiologist: It is essential to discuss these findings with a cardiologist who can interpret the results in the context of your symptoms and overall health. They can help determine the best course of action, whether that involves further testing or starting a treatment plan.

3. Lifestyle Modifications: Regardless of the test results, adopting a heart-healthy lifestyle is crucial. This includes:
- Regular cardiovascular exercise (as tolerated).

- A balanced diet low in saturated fats, cholesterol, and sodium.

- Smoking cessation if applicable.

- Stress management techniques, as stress can exacerbate heart symptoms.

4. Mental Health Consideration: If you are experiencing anxiety or stress related to your heart symptoms, it may also be beneficial to consult with a mental health professional. Sometimes, psychological factors can contribute to physical symptoms, and addressing these can improve your overall well-being.

Conclusion:
While your myocardial perfusion study did not show significant abnormalities, the positive exercise test indicates that further evaluation may be warranted to rule out any underlying coronary artery disease. It is essential to work closely with your healthcare provider to monitor your symptoms and adjust your treatment plan as necessary. Remember, proactive management of your heart health is key to preventing future issues.

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