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TMT test showed ischemia. Done with lipid profile and cholesterol. What should be the next step?

Jan 2013
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Internal Medicine Specialist
Practicing since : 2003
Answered : 1658 Questions
I am 36 year old Indian male, 181 cms height, 84 Kg weight. I did my TMT few days back with good effort tolerance, Normal BP response level but TMT tested positive for inducible ischemia. I ran around 16 minutes on TMT without any exertion or heaviness and had XXXXXXX heart rate – 164 bpm{89% of target heart rate 184 bpm }, XXXXXXX Blood pressure – 150/92 mmHg, XXXXXXX work load – 20.00 METS. I also had LIPID profile with Serum Cholesterol – 220, HDL Cholesterol – 43, Serum Triglycerides – 266, LDL Cholesterol – 124. Currently, I am not taking any medicine and didn’t consult the cardiologist yet post TMT.
What is inducible ischemia and with all these parameters, what should be the next step?. Do I need to worry much considering the age factor and doing 30 minutes walk daily from last 1 month?.
Kindly advice.
Posted Sun, 10 Feb 2013 in X-ray, Lab tests and Scans
Answered by Dr. Mayank Bhargava 31 minutes later
Welcome to XXXXXXX forum.

Let me explain your query one by one.

Your TMT performance is good with 16 minute running span.
A TMT is considered as valid if a person achieves 85% of target heart rate and you have achieved 89%.
Maximum systolic blood pressure should not be > 200 mm Hg otherwise TMT must be stopped immediately. You have achieved only 150/92mm Hg.
Maximum work load 20 METS is also a good parameter.
Inducible ischemia means downward slopping ST segment is concerned leads tracing while performing TMT. This is a significant change and it indicates that inadequate blood supply to heart during increased physical activity (when we perform increased physical activity, heart also has to work briskly to match increased body activity).
You should go for coronary angiography and 2 D echo and if needed, then you should also go for coronary angioplasty (requirement is decided by angiography).

Treatment of Dyslipidemia (deranged lipid profile) is decided by presence / absence of risk factors.
Are you a smoke and an alcoholic?
Do you have positive family history of early heart disease? (Early heart disease is considered in female <65 years and in male <55 years and you have mentioned only family history of heart disease).
Do you have an active or sedentary life?

Smoking, age > 45 years, sedentary life, first degree relative with positive early heart disease 140/90 mm Hg, Diabetes are considered as risk factors.

Normal BMI is between 18.5 -25.
Your BMI (Basal metabolic rate) is 25.64; which is slightly higher and you will be categorized in overweight.
You have one risk factor (overweight).

Treatment of Dyslipidemia is decided by LDL level and should read ATP III guidelines.
If < 2 risk factors are present then LDL should be < 160 mg%.
If > 2 risk factors with 10 year risk of developing heart disease is <20% then LDL should be <130 mg%.
If > 2 risk factors with 10 year risk of developing heart disease is >20%, diabetes then LDL should be <100 mg%.
You can download calculator from following site: WWW.WWWW.WW For very high risk patients, LDL should be < 70 mg%.

As you have only one risk factor, your LDL must be below 160 mg%.
Your LDL is 124 mg% and as such there is no need of anti lipid lowering medicines.
Total cholesterol should be < 200 mg% (your value is 220 mg%) and triglycerides should be < 150 mg% (your value is 266 mg%).

As you are overweight with slight derangements of lipid profile, you should reduce your weight.
Life style modifications are required in your case.
You should take low fat diet and live physically active life.
You should continue brisk exercise 30 minutes per day, at least 5 days in a week.
You should continue life style modifications for 3-4 months and should go for repeat lipid profile and observe the improvements.

Your liver function test is also deranged with increased bilirubin and enzymes level.
You should also go for ultrasound imaging to rule out hepato-biliary pathology.

You should consult with XXXXXXX medicine specialist/ cardiologist and should remain in touch.

Hope that helps.
Let me know if I can address any more concerns.
Take care,
Dr. Mayank Bhargava
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