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What to do if tested positive for induced ischemia?

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Practicing since : 1998
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Dear doctor, my father 65 years age undergone executive health check up in a corporate hospital, BIOCHEMISTRY REPORT : CHOLESTEROL-SERUM/PLASMA -211, HDL CHOLESTEROL - SERUM / PLASMA - 50, TOTAL CHOLESTEROL / HDL CHOLESTEROL RATIO - 4.2, TRIGLYCERIDES - SERUM - 146, LDL CHOLESTEROL - SERUM / PLASMA - 132, and TMT Test Report - The patient exercised according to the XXXXXXX for 5.04 mins, achieving a work level of XXXXXXX METS: 7.00 resting heart rate of 61 bpm XXXXXXX to a maximal heart rate of 142 bpm. The value represented 91% of the maximal, age-predicted heart rate. The resting blood pressure of 120/80 mm Hg, XXXXXXX to a maximum blood pressure of 200/90 mmHg. The exercise test was stopped due to Fatigue / SOB. TMT CONCLUSIONS: 1) SYSTOLIC HIGH BP RESPONSE 2) NO CHEST PAIN / ARRHYTHMIA 3) AVERAGE EFFORT TOLERANCE 4)TEST IS POSITIVE FOR INDUCIBLE ISCHAEMIA. Based on the above reports 1) What do it mean, test is positive for inducible ischaemia 2) What should be my next step ?
Posted Wed, 11 Dec 2013 in Hypertension and Heart Disease
Answered by Dr. Sukhvinder Singh 27 minutes later
Brief Answer: please see details. Detailed Answer: Dear Sir 1. "Positive for inducible ischemia" implies that there was significant ECG changes ( ST depression) during the exercise which suggests that there exists a blockade in the blood vessels of the heart which is significant enough to restrict blood flow to heart muscles. The tests has a pick-up rate of ~68% and it is correct up to 76%. 2. When a patient has positive TMT test but does not develop symptoms, we usually recommend an imaging based stress test (stress ECHO or stress thallium). Sometime the ECG changes are too striking and we recommend angiography straightaway. If you can upload the TMT ECGs, I will be able to guide you in a much better way. Please also tell if he is a smoker or diabetic? If there is any other medical illness. waiting for the ECGs of TMT. Sincerely Sukhvinder
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Follow-up: What to do if tested positive for induced ischemia? 43 hours later
Thanks doctor for your reply, sending complete TMT reports as attachment. In past my father is a smoker and stopped ten years back and not diabetic. 1) Based on the reports do they have clearly indicate the problem in heart , where and in which page they are indicating. Doctor can you be detailed. 2) As a doctor , what would be your final impression on report , suggestions and advise to patient. Regards, XXXXXXX
Answered by Dr. Sukhvinder Singh 4 hours later
Brief Answer: please see details. Detailed Answer: Dear Sir 1. The TMT is positive for provocable myocardial ischemia. Page number 6 of TMT has most striking "down-slopping" ST depression in leads II, V3 and V4, which qualifies for a positive test. Page 7 also has some of these changes. The test is positive in recovery and carries same value as of a test which is positive during exercise. Since the test was stopped due to shortness of breath, The exercise capacity is also sub-optimal. These two findings warrant further evaluation. 2. In such cases, A plain ECHO to look for any structural heart disease should be done and an angiogram should be planned for further risk stratification. The final decision is best taken after the Echocardiogram. 3. A qualified cardiologist's opinion should be taken on priority. Hope this clarifies the issue. Sincerely Sukhvinder
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Follow-up: What to do if tested positive for induced ischemia? 1 hour later
Thanks Doctor for your reply and valuable suggestions, now i am coming to final point. My father took health checkup in Apollo , Hyderabad on 18/07/2011 and Consultant doctor said everything is fine based on reports and on 19th ,he moved to his native place and 19th evening 6pm , he felt pain and uneasy , my father thought reports are fine and took gastric medicines, as he well educated and Retd Professor , went to local doctor and they took ECG , next minute they put a tablet under tongue , they asked us to move Vijayawada to visit cardiologist,its on 20th.This all happened within 30 hours after health checkup. I purely think this as medical negligence . Please see final impression given by Apollo doctor - Consultant Internal Medicine. So we filed a case in Andhra Pradesh State Consumer Forum. We need Doctors advise. Report by Vijayawada Emergency Doctor:This is to certify that Dr.D XXXXXXX XXXXXXX aged 65 years , was admitted in our hospital on 20/07/2011 with a diagnosis of Acute inferoposterior wall M1, Killips C1.11, Mild to Moderate LV Systolic Dysfunction, HTN. He underwent coronary angiogram on 20/07/2011 which revealed double vessel disease with RCA 100% blocked in the mid segment and Primary PCI with stent to Mid RCA on 20/07/2011. He was discharged on 24/07/2011. We delayed nearly 6-8 hours, after pain. By god Grace he is well, if anything would have happen, we are the suffers. Reports shows TMT Positive and final impression shows TMT Negative given by Apollo doctor. 1) That's why doctor every time , i been insisting you , what would you do based on reports , if you were in that place. 2) Do you think its purely medical Negligence or not. Do i have sufficient evidence, to fight. 3)Needed valuable suggestions and advise, it will be great helpful to us, to fight. Regards, XXXXXXX
Answered by Dr. Sukhvinder Singh 20 minutes later
Brief Answer: please see details Detailed Answer: Dear Sir 1. The TMT report has clearly written that it is positive. The final report writes TMT-negative. Hence There is a mis-match. This can be a typographical error too. 2. I have already told you about my opinion in similar circumstances and similar patients. 3. The technical point is that the positive TMT and occurrence of heart attack are not entirely linked pathophysiologically. A person with a positive TMT may not have heart attack for years together and a person with negative TMT may have an attack the same evening. This is so because "for TMT to be positive there has to be a significant obstruction (usually more than 70%) but heart attack can occur on any degree of obstruction". In fact most of heart attacks occur on pre-existing obstructions which are less than 70%. Hence the occurrence of heart attack can not be directly attributed to missing the correct TMT report, though , it is evident that the correct report was missed. 4. I hope the above paragraph explains the medical concept behind the total case. Regarding legal aspect you have to consult a lawyer or an expert in medical jurisprudence. Sincerely Sukhvinder
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Follow-up: What to do if tested positive for induced ischemia? 55 minutes later
Thanks doctor for your valuable suggestions, whether they are convincing or not, its a different matter. I felt , i will get a supportive answer and some hopeful evidence. As a doctor you have given , your expertise and advise. So Thankful to you ,and for spending your valuable time. Closing my discussion. Regards, XXXXXXX
Answered by Dr. Sukhvinder Singh 8 hours later
Brief Answer: please see details. Detailed Answer: Dear Sir 1. The matter of fact is that to prove any negligence, conclusively, a direct cause and effect relationship is required. The only element of "dereliction of duty" without convincing "cause and effect" relationship may not yield the desired results. Sincerely Sukhvinder
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