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    Stress Testing Question
    sageherb posted:
    My husband is 64 with cardiac history with both his mother and father...he recently complained of some mild L arm pain with exertion, has had some shortness of breath and increased fatigue, but no chest pain, pressure, palpitations, etc...PCP did a resting EKG which was unchanged...he then had a plain stress test which resulted in him being able to achieve his target heart rate with mild shortness of breath and L shoulder discomfort at peak exercise...resting BP was 124/76...peak BP was 180/80...heart rate increase to a maximum of 136 beats/min...rate pressure product 24, ectopic beats or arrhythmias were peak exercise the ST-segments were isoelectric, however in the early recovery period he developed up to 1.5mm horizontal ST depression in leads II, III, aVF and V4 through V6 with ST-segments finally normalizing in the late recovery period...Conclusion indicated EKG changes reach criteria for mild-to-moderate ischemia in the inferolateral leads noted in the recovery period....the length of the test was 9 minutes 30 seconds.

    He was started on bisoprolol fumarate 5mg 1/2 tab @ HS and 6 days later had a nuclear stress test performed.(held the beta blocker the night before the test) with the following results: Baseline EKG: sinus rhythm at 55 beats/min, borderline left atrial enlargement...nonspecific T-wave abnormality in 3 and aVF...early transition point...early re-polarization pattern. The nuclear test was terminated at target heart rate (my husband said it took him longer to reach during this test and the time frame was 12 minutes 30 seconds)...he had no chest pain or left shoulder discomfort...resting BP was 114/72 with peak BP of 152/80...heart rate increased to a maximum of 133 beats/min (85% of age predicted maximal) rate pressure product was 20,216...several isolated PVC's complex ectopy or arrhythmia was peak stress there was up to 1 mm upsloping ST depression in II, III. aVF and V3-V6 which resolved in the early recovery period...there was normal homogenous radioisotope uptake in all left ventricular wall segments in both the stress and rest images (SSS = 1, SDS = 1)...Gated SPECT: Normal regional wall systolic motion and wall thickening. Rest LVEF stress LVEF 58%. TID, LHR and LVEDV are within normal limits...functional capacity increased by 12%...EKG changes no longer reached criteria for ischemia.

    My question is about the beta blocker and its effect on the nuclear stress test...could it be masking an existing issue? Should a cardiac catheterization be done? What about the ST-segment depression in the recovery phase on the plain stress test? Is that significant for CAD? I am a nurse, but not well experienced with cardiac testing...the current treatment was for my husband to return to all former activity and continue on the beta blocker with a follow-up in one month.

    Can you help us make sense of this as the cardiologist, who seemed quite concerned following the plain stress test, was rather unconcerned and brief with his explanation to us following the nuclear stress test.

    Thank you for any information you can provide.
    James Beckerman, MD, FACC responded:

    I think that the very low dose of beta-blocker (which was held) would be rather unlikely to result in a false negative test - it's possible, but very unlikely.

    Generally, the nuclear imaging is felt to have higher sensitivity and specificity than the ECG alone - so if the imaging was normal, cardiologists generally feel pretty comfortable with that.

    But it's important to remember that these tests aren't perfect. If you or the doctor have a high index of suspicion that this is coronary disease, further noninvasive testing (like a stress echo) or even an angiogram could be warranted.

    Thanks for posting!

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