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Diabetic. Borderline positive for reversible ischemia. On jalra m. Having chest pain. Suggested CT angiography

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Hi Doctor,
I recently did a TMT wherein I could 9 mins, test stopped due to target heart rate achieved.. results were borderline positive for reversible ischemia. a brief of my medical history
1 - I am diabetic with Hbac1 of 6.1 - 6.4
2- lipid levels have been stable and under control since over 1-2 yrs. ( yes couple of years back the lipid levels very high... (that was probably of undetected diabetes)
3- TMT exactly one year back was normal/ negative
4- TMT done about 3 years back was also normal/negative
5- vitamin d3 and b12 deficiency
6- no smoking, almost no red meat, no alcohol
a)Jalra M 50/500 twice a day
b) stanlip 145 one a day ( this has been changed couple of months back earlier it was atorvastatin 10 mg)
c) time to time calcium and vitamin deficiency doses
a) small irregular chest pain
b) overall muscle weakness... sometimes difficult to open a tight tap or a bottle cap
c) overall weakness etc

my questions are
1 - how is mine TMT results changed in one year wherein my HB and lipids have been under control and stable.
2- doc has advised me to do an angiography... can I choose to do a CT angiography instead of the invasive one
3- any recommendations for me ?
Posted Wed, 27 Mar 2013 in Hypertension and Heart Disease
Answered by Dr. Anantharamakrishnan 1 hour later
Hi friend,
Welcome to Health Care Magic

Diabetes it self is major risk factor for Coronary Artery Disease / with male sex and age add on / Lipids too – but controlled / family history is important / there are others like smoking – you didn't mention / there are other risk factors, which are less common and/or unusual - usually not investigated...

     With time, TMT can change. Simple ageing is a factor – when everything else is controlled.

     If TMT (Treadmill Exercise ECG) suggests ischemia, it is an indication for further work up – because at times, there may be false positive or false negatives. The next step is TMT with thallium isotope. It is the ideal non-invasive way to evaluate ischemia / to assess the PHYSIOLOGY (function) – to see whether the blood arriving at the heart muscle.
     If there is a suggestion, the next step is to see the ANATOMY (structure) – undergo catheterisation and coronary angiography with a view for possible intervention. It is the only way to directly ‘see’ the block, if any – and its location, extent, severity and so on. Coronary arteriography is invasive but it is the gold standard for this.

CT angio is non-invasive study for the anatomy.
If positive, you will need catheterisation, anyway.
The aim of any investigation is to modify the treatment, based on the result.
Intervention – dilatation with balloon and placing a stent (Angioplasty) - or CABG (Coronary Artery Bypass Graft) may be advised based on the results / it can be done only after angiography..

So the best option is to go for angiography

Take care
Wishing speedy recovery
God bless
Good luck
Above answer was peer-reviewed by
Follow-up: Diabetic. Borderline positive for reversible ischemia. On jalra m. Having chest pain. Suggested CT angiography 1 hour later
Dear Sir,
I did mention about me being non-smoking, under point no 6; lipids and HB too are under control. My dad doesn’t has any issues but my uncle and first cousin have been heart patients…The major fact I missed to mention is my age… I am 36 years old, keeping your view point I have follow up questions.
-     Can I avoid doing angiography? Like 6-12 months and does the TMT by any ways reflects the severity of the blocks assuming the TMT results are correct.
-     Considering my age are there any alternate therapies… I can check on instead of going the invasive way
-     Citing the age factor would you do any change in the hierarchy of the process I should follow?
Answered by Dr. Anantharamakrishnan 49 minutes later

Age is a factor but not the deciding criteria for diagnosis or management.
On the other hand, being young, the approach must be aggressive – to prevent complications / to prolong the quality and quantity f life.

TMT has no direct correlation to the location or severity.

Angiography is the gold standard. It cannot be avoided. One may plan to postpone the inevitable? Postponing may not be safe.
After all, it is a test / and the aim is to tailor the treatment based on the results.
If hesitant still, go for thallium scan and CT angio – the results will confirm or rule out the need. Better to see the result and be convinced than guess...
Do not be afraid - the risk is practically if not theoretically negligible.

Till it is done, it should be presumed to be and treated as CAD with beta-blockers, anti-platelet agents and so on.

Above answer was peer-reviewed by
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