chest pain and hard to breathe, I need some help here

[Cruisin Home]

Awesome news as I said in my PM to you.

EF is a measure of your Heart' ability to pump, usually a low score indicates a valve problem as some of the blood ends up pumping backwards if a valve does not close tightly. would be good to review your cardiac SPECT scan to make sure no damage was done to your heart muscle due to poor perfusion (blood flow). Send to me if you like. A rule of thumb, which is not always how it goes, is that you can usually suffer up to 70% occlusion of a blood vessel before it begins to become a problem. Your RCA was probably greater than 90%. Now is a good time to ask the question why and what should I be concerned in future. What I see with people your age that suffer this problem is that it is going on throughout your body. Would really be good to get an appointment with a vascular specialist. You really want to get your coratid arteries (in neck, provide most of the blood flow to brain) because where they bifurcate (fork) in your neck is another very common place for blockage. Would probably start by doing a doppler ultrasound of your neck on both sides and then maybe followed by a CT angiogram (CTA).

Happy Holidays!!!

 

[TSandM]

Cruisin Home has a very good point, that vascular disease is a whole-body phenomenon, and if your insurance will pay for screening, it would certainly be reasonable to do what's called ankle-arm indices, and perhaps carotid screening as well, although if a Doppler is negative, I certainly wouldn't go on to a CT angio.

But I will take issue with the idea that a low EF most commonly indicates valve problems. A low EF is FAR more commonly related to issues with the heart muscle itself, either as a result of past infarctions, or ischemia, or cardiomyopathy due to any of a number of causes. I WISH low EF were most commonly valve-related, because valves can be fixed or replaced. Aging or damaged heart muscle, at this point, cannot.

 

[Cruisin Home]

sorry, as TS&M so pointed out I didnt mean to imply that a leaky valve is the only explanation for low ejection fraction. just a nice example i use when trying to analogize the heart to a ordinary pump when talking to layperson.

Wow TS&M you really dont like CT scans, kinda like last resort to you! Well as the inventor of the modern multi slice CT scanner I am surely biased but I also see so many people avoid future problems by getting one. Particularly mid life. Let me give you an example: My Radiation Physicist, as most RP's are, was against getting CTs unless absolutely necessary due to accumulated radiation exposure. But then he went 6 months ago for ordinary CT scan re kidney stones. Incidental to his kidney we saw a pancreatic tumor which has since been resected and found to be malignant. As many of you may know Pancreatic cancer is associated with very poor outcome, normally due to late diagnosis. This guy is now one of the lucky. Ask him what he thinks of having a CT scan now! Now he is a preacher to everyone he can find about the benefits for someone to get a "Wellness" scan in midlife.

Granted some institutions use it for everything and thus just increasing medical costs but when a someone you know is symptomatic or in a high risk group for a disease I see it as a great precaution. You can bet your life that if I was in Retnav's shoes that I would get a CTA even if it came out of my pocket,(which I am fortunate to own my own CT scanner).

Nonetheless TSM I respect you as a very dedicated professional to this site and your advice is normally very prudent. You should rejoice in helping to hit a home run in this case. Divers helping divers, I really like it.

Happy holidays to you all!

 

[Cruisin Home]

BTW retnav, they should have calculated your EF with your SPECT scan which is one of the gold standards for measuring. Again its the VA so anything goes, but I bet it was within normal limits. Its really under stress that is when we would want to do measurements in your case because you were getting enough blood to perfuse the muscle when at rest, it was only during exertion that the muscle was now "complaining". I seem to remember taht your stress scan/test was botched in someway but perhaps that was in a PM?

Again my advice to you is to be more proactive this time and get evaluated by a vascular specialist. Kind of like in diving to really do a thourough maintenace of your gear. Especially when you have a warning that there is something maybe wrong with your gear ahead of time. Lot better than waiting for something to break and then try to resolve. You were very lucky in this case, you were on the edge of a MI for probably months. My employee recently only lasted two days after his warning sign (which was misdiagnosed and ingnored). In case of an event with your carotids you could suffer a stroke (lack of blood flow to your brain)with permanent disability and/or death with little or no warning. Get it checked now, do your maintenance. There are many ways to correct now such as stent, etc.

Godspeed.

 

[TSandM]

No, Cruisin Home, I DO like CT scans. They allow me to diagnose any number of things quickly and accurately . . . but if there is a non-radiation-based method for getting an equivalent amount of information, I'll use that instead. We are really being warned, nowadays, about the epidemic of scanning, and the cancer risks we are creating in our patients, by the indiscriminate use of CT.

I think, in a patient who has had no TIA symptoms and who only has coronary artery disease as an indication, a Doppler of the carotids would be very reasonable. But if it is negative, I don't think arterial disease in another site is enough basis on which to recommend proceeding to CT angio. If the patient has had symptoms, that would be a different story. I do not SCREEN with CT, and I don't believe it is warranted in the vast majority of cases. Screening tests should be sensitive, inexpensive, and extremely low-risk, because the majority of people screened will not prove to have the problem being sought.

 

[Cruisin Home]

Welcome to the real world, where screening tests are not : inexpensive, sensitive, and without risk. That doesnot mean that inventors like myself are not trying to aim towards those goals.

But lets take Colon cancer as an example, something I happen to know alot about because CT is on forefront of doing Virtual colonoscopy. But lets talk conventional endoscopic screening, its considerably expensive, not toally specific, and is not without risk (if you check the incidence of perforated colon you may be very surprised. Yet it is the number 2 cancer killer. Early detection can result in a very good outcome percentage. Probably one of the biggest homeruns we could hit as a nation, short of outlawing cigarettes. Now you add a high risk to family history. Thats me. You can bet I get SCREENED. When you personalize medicine you think differently. This country spends very little on prevention but fortunes on treatment. do you know that 80% of costs are due to 20% of patients and with a huge amount of that in the last 60 days of life? They probably blew $100k of costs on my father in law these past two months prior to his death. Would have been nicer, and much less expensive, to get a correct diagnosis 10 months earlier.

Lets expand to breast and lung cancer where there are great new data re screening.

I get it, you're not a SCREENER.

Lot of news articles re radiation/cancer link but virtually no scientific studies. This scare was introduced 2 years ago re some crackpots saying a scan was like standing a mile away from epicenter of hiroshima( totally nonsense) but media loved it. Tel me why myself and other radiation professionals that recieve 10 times the radiation dose as the ordinary public do not have higher cancer incidents? Why dont pilots/stewardess? Why dont populations at high altitude? In fact a paper at this years Radiological socity of North America has now shown this scare to be way overblown. Yet there are now people refusing a CT scan. crazy.

In this case we are talking about here this man may decide for himself to be screened, thats his decision. but let it be said that I also suggested doppler u/s first.

 

[Dhboner]

I have to say that I teared up a little reading this thread. The amount of care and attention to the OP's issues are inspiring. You are all guardian angels since I shudder to think of the outcome if the good doctors of ScubaBoard had not intervened. Kudos to you all!

Bob (Toronto)

 

[retnav7696]

I will talk to my doctor on the 3rd of Jan about getting a CT scan. Should I ask for a whole body scan so that it can show any damage to my heart or possible blockage in my neck area? Let me know what I should ask for. I'm not really worried about the radiation exposure. When I was active duty I spent alot of time doing jobs in the reactor compartment and I don't think what I will pick up by having a CT scan can compare with what I got in the Navy.

 

[TSandM]

retnav, I don't think you should ask for a CT scan.

Damage to your heart could be identified by an echocardiogram, which would look at wall motion, and discern whether it's normal . . . but the cardiac catheterization you had would have alerted the doctors to any major issue with contractile function. You got revascularized BEFORE you had damage -- that was the whole point of pushing for the cath before you actually had a heart attack.

Yes, it is possible that you have vascular disease elsewhere in your body, given that you have it in your heart. A screening carotid doppler is a VERY reasonable test. It will give your physicians a lot of information about whether there is any narrowing, or any turbulent flow in those arteries. If they see anything that concerns them, they may order a CT angio. If the Doppler is normal (and it may well be) you will avoid radiation you won't receive any significant benefit from.

Measuring ankle-arm indices may be reasonable as well. But if you have no symptoms of leg pain or excessive cramping, the results are likely to be normal, or at least close enough to normal to require no intervention. And narrowing of the arteries into the legs isn't a life-threatening problem -- there is plenty of time to investigate symptoms and proceed to therapy.

I don't think you should be overly frightened, and no matter what anybody else tells you, CT is NOT an appropriate screening modality for vascular disease. You got the big, life-threatening problem taken care of. If you want my advice, I'd turn your attention to lifestyle alterations at this point -- would it benefit you to stop smoking? Lose weight? Change your diet to lower your cholesterol? Get more exercise? All of these interventions will improve ANY vascular issues you have, or at least stabilize them.

 

[DocVikingo]

Hi retnav7696,

I think TSandM makes some good points.

Given the facts provided to date, a carotid ultrasound test appears to be a more appropriate procedure than CT angiography. This procedure is safe, reliable and informative, and, unlike CT angio, is relatively inexpensive and involves no exposure to ionizing radiation or to a possibly claustrophobia-inducing environment. And at this point in the diagnostic workup, IMHO it does not seem at all sensible to even consider paying out of pocket for a CT angio.

The ankle-brachial assessment mentioned by TSandM arguably is a lower priority, but is simple, inexpensive, and essentially risk-free.

Regards,

DocVikingo

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual and should not be construed as such.