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Checking for Heart Disease? Experts: Skip the Stress Test

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I often see patients who, despite being asymptomatic, have annual exercise stress tests to screen for heart disease. If the result is positive, an angioplasty is often done. Needless to say, stress testing is even more frequently performed in symptomatic patients to monitor progress.

More and more information indicates that this is inappropriate. New information released in BMC Cardiovascular Disorders found that using treadmill stress tests following an angioplasty had no value in determining if the implanted stent remained open. This further confirms the recommendation of the American Heart Association and the United States preventative task force that stress tests not be performed to routinely screen for heart disease.

In the long term, there is little evidence to support the value of stress testing in asymptomatic individuals or stable patients with proven heart disease. A groundbreaking report from the New England Journal of Medicine showed that in more than 2,000 symptomatic stable patients, an angioplasty offered no advantages over ideal medical management. Simply put, angioplasty did not reduce the risks of death or a recurrent heart attack.

Information is accumulating that a large fraction of angioplasties and even open-heart surgery are unnecessary and could be avoided. The older you are, the more likely this is to be the case. And yet, increasing numbers of invasive cardiac procedures are occurring in people 75 and older, in whom risks of side effects are substantially increased.

So what should be done to screen and treat heart disease? First, you must recognize that everyone over 50 is at risk of developing coronary artery disease. In addition, other risk factors include a strong family history of heart disease, high blood pressure, cigarette smoking, high cholesterol, a high-fat diet and a sedentary lifestyle. Increases in an amino acid in the blood called homocysteine and evidence of inflammation by finding an elevation of C reactive protein are also risk factors.

The best approach to heart disease is to make sure that as many of these risk factors as possible are removed either by medical treatment or lifestyle changes.

From age 50 onward, an annual medical checkup and an EKG every couple of years should be done. Screening for high blood pressure should be done annually at a much younger age, and cholesterol should be measured every five years from age 30 onward.

A routine stress test should be limited to those who require it for occupational purposes (such as an airline pilot) or when evaluating an individual with numerous risk factors. A stress test should be done if new symptoms develop that suggest coronary artery disease. These include atypical chest pain, increased shortness of breath and palpitations. In this case, the stress test can help make or exclude the diagnosis of coronary artery disease. If positive, an angiogram may be needed to identify the extent of the problem and determine if coronary artery bypass surgery or an angioplasty is needed.

For asymptomatic healthy individuals with no significant risk factors, a stress test is not needed. The same applies for stable patients with known coronary artery disease. While a stress test is not necessary, people with stable heart disease must still be managed medically to reduce the risk of worsening disease.

We now know that aggressive lowering of cholesterol in combination with diet and exercise could actually reverse coronary artery disease. Making sure the top, or systolic, blood pressure remains consistently below 130 in those under age 70 and below 140 in those over the age of 75 is critically important.

Sadly, many patients diagnosed with coronary artery disease are not on the appropriate medications. Unless there is a major contraindication, they should be on an aspirin, a beta-blocker, an ACE inhibitor and, if necessary, a statin to lower elevated cholesterol.

Remember, your coronary arteries are not like a car tailpipe. If blocked, the heart has the capacity to produce new blood vessels to bypass the blockages. While surgery and angioplasty definitely have a valuable place in modern medicine, we must strive to assure that these procedures are done only when absolutely needed. Be educated and empowered — just because a physician tells you a procedure is needed does not necessarily make it so. Ask questions and get a second opinion — every good physician will support you.

Dr. David Lipschitz is the author of the book "Breaking the Rules of Aging." To find out more about Dr. David Lipschitz, and read features by other Creators Syndicate writers and cartoonists, visit the Creators Syndicate Web page at www.creators.com. More information is available at www.drdavidhealth.com.

COPYRIGHT 2007 CREATORS SYNDICATE, INC.


Comments

5 Comments | Post Comment
I have been on BP and chol. meds for more than 10 years. About a year ago chest pains sent me to the ER followed by angiop. and 4 stents due to blockage in 3 arteries. Since then I have followed my cardiologist's and GP's instructions. I take my BP a number of times/day and log it down. It has been normal and even low at times. For some reason when I got for my cardio visit about every 2 months my BP is higher than normal, I assume due to "white coat". My Dr. seems to knee jerk and want to change the BP meds which ruins me for 2 or 3 weeks or more until I get used to them. I just finished my annual EKG, Echo, and stress test. I got a call about a week after the test saying the stress test was abnormal and I may have to have a cathederization.
I can't believe this. I am physically fit, excercise regularly, don't smoke, eat right am taking Crestor and Plavix and feel great. I will definitely seek a second opinion.
Comment: #1
Posted by: JFP
Tue Apr 6, 2010 8:06 AM
I just went to a new doctor due to pain in my right shoulder and arm. I was diagnosed several years ago with Fibromyalgia and also have spinal stenosis, spinal arthritis and sciatica. The dr. gave me a cortisone shot, put me on Prednisone and Naproxen, the took an exray, gave me an EKG, carotid ultrasound, bone density scan and an echocardiogram along with blood tests. After making an appointment for a Lexican Cardiolite stress test, he sent me home with a Halter Monitor. I have no symptoms of heart disease and though my parent's deaths were reported as congestive heart failure, they were 90 and 96 years old when passing.

I am concerned about the need (and side effects) of this stress test, but more so for the necessity. When I asked why all these tests were needed, my doctor informed me this was protocal now that I am 60 years old. Does anyone have any suggestions or feel I should go ahead and have this test?
Comment: #2
Posted by: Nancy
Sun Dec 19, 2010 1:35 PM
I had a stress test done in 2011 and again in 2013. In 2011 the test read "Conclusions: Small defect in the apex, which is not reversible, consistent with artifact. The stress test in 2013 read: Moderate defec. in the anterolateral wall; which is mildly reversible, consistent with chronic ischexia.. I was told "everything was ok with the stress test of 2013. Should I get a second opinion, and if so where or who will help me define the difference?
Thank you very much, hope you can be of help to me.
Creekyonder@aol.com
Comment: #3
Posted by: Anita Fama
Tue Oct 22, 2013 5:10 PM
I had a stress test done in 2011 and again in 2013. In 2011 the test read "Conclusions: Small defect in the apex, which is not reversible, consistent with artifact. The stress test in 2013 read: Moderate defec. in the anterolateral wall; which is mildly reversible, consistent with chronic ischexia.. I was told "everything was ok with the stress test of 2013. Should I get a second opinion, and if so where or who will help me define the difference?
Thank you very much, hope you can be of help to me.
Creekyonder@aol.com
Comment: #4
Posted by: Anita Fama
Tue Oct 22, 2013 5:10 PM
DEAR DR LIPSCHITZ
I AM 85 YR OLD FEMALE, ASYMTOMATIC. MY DR ORDERED ECHO & I AM WAITING FOR RESULTS.
HE ALSO ORDERED NUCLEAR STRESS TEST NEXT WEEK. I HAVE SHORTNESS OF BREATH & WANTS
TO SEE IF IT IS CARDIAC OR PULMONARY.
READ YOUR ARTICLE & READ THAT ECHO SHOULD BE DONE AFTER STRESS.
AM I A CANDIDATWE FOR STRESS TEST? YOUR HELP IS APPRECIATED
HELENE BLUM
3021 FALLSTAFF ROAD
BALTIMORE, MD 21209
410 764 0007 THANK YOU
Comment: #5
Posted by: HELENE BLUM
Mon Jan 6, 2014 8:38 PM
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