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What Do The Following Stress Thallium Test And CT Angiogram Reports Indicate?
Question: My stress thallium test on 16.6.2014 had this report: 1. Adequate exercise (88% THR achieved) 2.Good effort tolerance (MRTS 7.1) 3. Normal resting LVEF noted. 4. There is a moderate area of inducible ischemia invol V ing the apical and mid anterior wall (LAD territory)5. Rest of the myocardium shows normal perfusion at rest and stress. Tyen CT Angiogram done three days later i.e. on 19.6.2014 reported 1) Total calcium score =[0] using the AJ-130 method. This score suggest low peobability of significant coronary artery disease. 2) Right coronary artery dominance. 3) Distal Ld is diffusely thin and terminates before the apex. 4) No other significant abnormality is seen. HOW DO YOU EVALUATE MY HEART CONDITION. DO THESE REPORTS SUGGEST BLOCKADE IN ANY ARTERY? I DONT EXPERIENCE ANY CHEST PAIN BUT OCCASIONAL CHEST DISCOMFORT - MAY BE GASTIC TYPE. DO YOU SUGGEST INVASIVE ANGIOGRAPHY?
Brief Answer:
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Detailed Answer:
Dear Sir
1. Since the reports are nearly an year old, the scenario may have changed by now. However I will discuss them considering this limitation and will elaborate on your current clinical condition.
2. The thallium report suggests presence of blockage in coronary arteries. Inducible ischemia means that there is some obstruction which decreases the blood supply to heart muscle at time of exercise. However The coronary CT angiogram does not reveal any such thing in particular. The only explanation could be that this distal part of LAD is diffusely diseased and behaves like a narrowing; not allowing enough blood at time of exercise. This scenario does not warrant conventional angiography on the basis of these reports. But this was one year back.
3. We normally do not advise coronary angiogram in such scenarios straight away. If the chest pain always comes on exercise/ exertion, yes we do investigate such cases by ECHO followed by stress testing. If stress testing is high risk positive we do go for angiogram (conventional not CT). If the pain comes at anytime irrespective of exercise, then we get a stress test done depending upon clinical findings.
Hope this clarifies the issue. Feel free to discuss further.
Sincerely
Sukhvinder
please see details
Detailed Answer:
Dear Sir
1. Since the reports are nearly an year old, the scenario may have changed by now. However I will discuss them considering this limitation and will elaborate on your current clinical condition.
2. The thallium report suggests presence of blockage in coronary arteries. Inducible ischemia means that there is some obstruction which decreases the blood supply to heart muscle at time of exercise. However The coronary CT angiogram does not reveal any such thing in particular. The only explanation could be that this distal part of LAD is diffusely diseased and behaves like a narrowing; not allowing enough blood at time of exercise. This scenario does not warrant conventional angiography on the basis of these reports. But this was one year back.
3. We normally do not advise coronary angiogram in such scenarios straight away. If the chest pain always comes on exercise/ exertion, yes we do investigate such cases by ECHO followed by stress testing. If stress testing is high risk positive we do go for angiogram (conventional not CT). If the pain comes at anytime irrespective of exercise, then we get a stress test done depending upon clinical findings.
Hope this clarifies the issue. Feel free to discuss further.
Sincerely
Sukhvinder
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Does the term "diffusedly diseased and behaves like a narrowing" suggest that the distal LAD artery is not blocked. If it is so. Can the problem be treated conservatively. Though the reports are one year old, my only query was whether it warranted further angiography at that time and th what extent the CT Angio is reliable.
Brief Answer:
please see details.
Detailed Answer:
Dear Sir
1. If a stress test, be it TMT, stress ECHO or stress Thallium comes out to be positive for provocable myocardial ischemia. The next step is conventional angiogram and not CT angiogram as was done in your case. As per current literature, a positive stress test should be followed by conventional angiogram and not CT angiogram. Hope this answers your query that what should be done with a positive stress thallium test.
2. A diffuse thinning of distal LAD was a narrowing due to disease is only an assumption. The actual scenario can be best explained by the person who performed and reported CT angiogram. Being a relativity new modality, the terminology being used in CT angiogram is variable as yet.
3. Reliability of CT angiogram depends upon the person, the equipment and the experience in a given single case. otherwise in large population CT angiogram has a pick up rate of ~96% (that means it will not detect disease in 4% cases where disease is actually present.) and has specificity of 86% (that means it will be wrong in telling that disease is there when actually no disease is present in 14% cases).
4. If the problem can be treated conservatively? I will go for a coronary angiogram for ant positive stress thallium. hence can not comment definitely in this scenario. However I treat my patients conservatively if there is not a proximal large vessel disease (in early part of vessel) on angiogram and symptoms can be controlled with medicines and patient has good quality of life.
Hope this provides more insight into the issue. Feel free to discuss further.
Sincerely
Sukhvinder
please see details.
Detailed Answer:
Dear Sir
1. If a stress test, be it TMT, stress ECHO or stress Thallium comes out to be positive for provocable myocardial ischemia. The next step is conventional angiogram and not CT angiogram as was done in your case. As per current literature, a positive stress test should be followed by conventional angiogram and not CT angiogram. Hope this answers your query that what should be done with a positive stress thallium test.
2. A diffuse thinning of distal LAD was a narrowing due to disease is only an assumption. The actual scenario can be best explained by the person who performed and reported CT angiogram. Being a relativity new modality, the terminology being used in CT angiogram is variable as yet.
3. Reliability of CT angiogram depends upon the person, the equipment and the experience in a given single case. otherwise in large population CT angiogram has a pick up rate of ~96% (that means it will not detect disease in 4% cases where disease is actually present.) and has specificity of 86% (that means it will be wrong in telling that disease is there when actually no disease is present in 14% cases).
4. If the problem can be treated conservatively? I will go for a coronary angiogram for ant positive stress thallium. hence can not comment definitely in this scenario. However I treat my patients conservatively if there is not a proximal large vessel disease (in early part of vessel) on angiogram and symptoms can be controlled with medicines and patient has good quality of life.
Hope this provides more insight into the issue. Feel free to discuss further.
Sincerely
Sukhvinder
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Let me add that a stress thallium done in July 1999 at XXXXXXX New XXXXXXX showed: 1. Mixed lesion in inferior region and 2. Scarred myocardium in the antero septal region. I presume that, though I donot specifically know, this test too, was positive. But an Angiography done at XXXXXXX in year 2003 was normal. In view of this also, do you recommend another Angiography after last year's stress thallium? As I understand, the problem in my case, perhaps, is not that serious. So, if it so, can I defer any further revascularisation if some significant blockade is detected dueing the course of a formal invasive angiography because, although I may get angiography done at XXXXXXX but I would like to have further treatment in XXXXXXX due to better expertise available there.
Brief Answer:
please see details.
Detailed Answer:
Dear Sir
1. A mixed lesion in inferior region, means that there is presence of ischemia (low supply on demand) as well as dead tissue (died because of possible heart attack). Scarred myocardium again means dead tissue. If the angiogram was totally normal in such a scenario then it concludes that thallium was false positive. If once a test comes out to be false positive, we should not do the same test again. As the reliability of test will always be questionable.
2. Why did you get the second thallium done? Was there any symptoms?
3. First and foremost thing is if you get any symptoms on exertion/ exercise. If there are no symptoms and you have good exercise capacity like using 2-3 flight of stairs without symptoms, the problem is not likely to be serious. If you have symptoms on exertion or you have low exercise capacity, meet your cardiologist and a stress test (beside stress thallium) may be planned. Direct angiogram is planed only in small number of cases.
4. All angiograms are done with the intent of fixing a lesion in the coronary tree which is causing symptoms. Hope this makes things simple for you. No symptoms- no angiogram. No lesion- No angioplasty or revascularization. There is no point in getting angiogram done if there are no symptoms or stress test is not truly positive or we do not intend to fix the lesion. As per literature , fixing of such lesions , even if you have symptoms of exertional angina, neither prolongs life nor it saves from future heart attack. Hence angiogram should not be used as a test of XXXXXXX status like hemoglobin or cholesterol. Neither all lesions which are seen on angiogram are important.
I would recommend you to meet a good cardiologist preferably at a medical college with all your records and get your self clinically evaluated. One should not take a decision of undergoing angiogram or revascularization only on basis of internet based discussion. Rather, it should be used judiciously to enhance your understanding of disease process and management.
Sincerely
Sukhvinder
please see details.
Detailed Answer:
Dear Sir
1. A mixed lesion in inferior region, means that there is presence of ischemia (low supply on demand) as well as dead tissue (died because of possible heart attack). Scarred myocardium again means dead tissue. If the angiogram was totally normal in such a scenario then it concludes that thallium was false positive. If once a test comes out to be false positive, we should not do the same test again. As the reliability of test will always be questionable.
2. Why did you get the second thallium done? Was there any symptoms?
3. First and foremost thing is if you get any symptoms on exertion/ exercise. If there are no symptoms and you have good exercise capacity like using 2-3 flight of stairs without symptoms, the problem is not likely to be serious. If you have symptoms on exertion or you have low exercise capacity, meet your cardiologist and a stress test (beside stress thallium) may be planned. Direct angiogram is planed only in small number of cases.
4. All angiograms are done with the intent of fixing a lesion in the coronary tree which is causing symptoms. Hope this makes things simple for you. No symptoms- no angiogram. No lesion- No angioplasty or revascularization. There is no point in getting angiogram done if there are no symptoms or stress test is not truly positive or we do not intend to fix the lesion. As per literature , fixing of such lesions , even if you have symptoms of exertional angina, neither prolongs life nor it saves from future heart attack. Hence angiogram should not be used as a test of XXXXXXX status like hemoglobin or cholesterol. Neither all lesions which are seen on angiogram are important.
I would recommend you to meet a good cardiologist preferably at a medical college with all your records and get your self clinically evaluated. One should not take a decision of undergoing angiogram or revascularization only on basis of internet based discussion. Rather, it should be used judiciously to enhance your understanding of disease process and management.
Sincerely
Sukhvinder
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thanks for a detailed reply. The Angiography done at XXXXXXX following the stress thallium test was "LV-Normal and Coronaries-Normal". The clinical diagnosis was Atypical chest pain, TMT +ve and St. Th.+ve. This Atypical chest pain continued and again in year 2002, the Stress Thallium was repeated at XXXXXXX followed by Angiography in 2003. Stress Thallium showed: Stress induced reversible ischemia in the anteroseptal region (moderate) but the Angiography found:LMCA:Normal, LAD:Normal, RAMUS:Normal, LCX (Dom/NonDom):Normal, OM:Normal, RCA (Dom/NonDom):Normal. Incidentally this last Angiography was done/supervised by the famous Cardiologist Prof K.K. Talwar. Does this strengthen your view that again, the stress thallium was false positive. Interestingly another Angiography done in year 2000 at GB Pant by Prof. XXXXXXX XXXXXXX was also Normal. Now why the stress thallium was done in year 2014, let me try to explain the genesis behind it. As a part of our inservice annual medical examination, TMT is also done. TMT done in April 2013 at XXXXXXX was found to be qve for RI and the Cardiologist advised me forna Stress ECHO. Before I coukd go for that I was transferred to XXXXXXX Our part time Cardiologist there remarked that the TmT was Negative for RI (though reported +ve earlier). Again in April, 2014 I underwent the annual TMT by this very parttime Cardiologist who termed the result as Negative for RI at the ACHIEVED STRESS. Incidentally in all my TMT tests so far I have achieved the THR without any pain or trouble. I can climb flights of stairs and walk 3-4 KMs without ant chest pain. BUT occasionally I do feel some sort of discomfort/tightening in the chest especially during rest at nights. One more aspect may be worth mentioning. During a prostratectomy at Fortis, XXXXXXX in October, 2013, the Urologist observed A.F. he stopped the operation but when the F stabilized without any medicine or intervention of any kind, the surgery was successfully carried out there and then. Later I was put on 24'hr Hokter monitoring also but no AF observed. The Fortis Cardiologist was having a different view on my TMT and said that it could be interpreted either way. He, therefore, advised stress thallium. Upon the stress thallium report, there was divided opinion whether to go for interventional Angiography or CT Angio. It was then that CT Angio was done and all the results are before you. Of course, as advised by you I intend to consult PGI XXXXXXX before going for another angiograohy test. But now that I have fully explained my past medical history/genesis, what is your tale on my present condition. Thanks.
Brief Answer:
please see details below
Detailed Answer:
Respected Sir
1. It seems everyone tried to over-investigate you possibly because of some social reason or too much of symptoms on your part or your social standing. It is really not explainable that why repeatedly you were subjected to TMT or stress thallium when it is proven beyond doubt that these results are repeatedly coming false positive. Unfortunately, it is a practice in some of the institutions in our country to advise same test for annual check up without considering the previous results.
2. If one of my patients has normal exercise capacity on treadmill test and has no symptoms after achieving adequate heart rate and good exercise capacity, I will never subject him to angiogram. We treat patients and not reports. Especially when we know, doing any angioplasty in such a patient will not change the prognosis or future outcome in any favorable manner.
3. If the current ECHO of a patient (60 years male) is normal and he can do treadmill for 7 minutes on XXXXXXX protocol by achieving a heart rate of at least 136 beats per minute, without any symptoms, I will consider him to have a healthy heart currently. I will not investigate him further (for a cardiac cause) for any chest pain which does not come up on exertion. There is no test available with medical sciences currently which assures that a given subject will not have heart attack/ sudden cardiac death tomorrow morning. Neither TMT, stress thallium nor coronary angiogram provides this assurance.
4. The technical lacunae in interpretation of your last CT coronary angiogram is that interpretation lacks a clear mention if the distal LAD is diffusely diseased and thin or it is thin naturally without evidence of atherosclerotic plaque. This could be compared with the videos of your last conventional angiogram too. By any means, there is no lesion mentioned in your last CT angiogram report which can be fixed by stenting or surgically.
5. I hope the above facts and the previous discussions provide you a good estimate of where do you stand currently.
Sincerely
Sukhvinder
please see details below
Detailed Answer:
Respected Sir
1. It seems everyone tried to over-investigate you possibly because of some social reason or too much of symptoms on your part or your social standing. It is really not explainable that why repeatedly you were subjected to TMT or stress thallium when it is proven beyond doubt that these results are repeatedly coming false positive. Unfortunately, it is a practice in some of the institutions in our country to advise same test for annual check up without considering the previous results.
2. If one of my patients has normal exercise capacity on treadmill test and has no symptoms after achieving adequate heart rate and good exercise capacity, I will never subject him to angiogram. We treat patients and not reports. Especially when we know, doing any angioplasty in such a patient will not change the prognosis or future outcome in any favorable manner.
3. If the current ECHO of a patient (60 years male) is normal and he can do treadmill for 7 minutes on XXXXXXX protocol by achieving a heart rate of at least 136 beats per minute, without any symptoms, I will consider him to have a healthy heart currently. I will not investigate him further (for a cardiac cause) for any chest pain which does not come up on exertion. There is no test available with medical sciences currently which assures that a given subject will not have heart attack/ sudden cardiac death tomorrow morning. Neither TMT, stress thallium nor coronary angiogram provides this assurance.
4. The technical lacunae in interpretation of your last CT coronary angiogram is that interpretation lacks a clear mention if the distal LAD is diffusely diseased and thin or it is thin naturally without evidence of atherosclerotic plaque. This could be compared with the videos of your last conventional angiogram too. By any means, there is no lesion mentioned in your last CT angiogram report which can be fixed by stenting or surgically.
5. I hope the above facts and the previous discussions provide you a good estimate of where do you stand currently.
Sincerely
Sukhvinder
Note: For further queries related to coronary artery disease and prevention, click here.
Above answer was peer-reviewed by :
Dr. Yogesh D
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