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Checking for Heart Disease? Experts: Skip the Stress Test
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.
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.
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