April 30, 2015 general

Let’s call her Betty. She was excited about her planned trip to Florida to be with one of her daughters for Mother’s Day. That was until a 6 PM urgent call from her cardiologist’s office insisting on seeing her the next day. Of course, anxiety ensued and the flight to Florida was cancelled. Betty and her family started to hold their collective breath as they waited for the appointment the following afternoon. The reason given was to follow up on the results of a “nuclear stress test”. (The name sounds a bit as though they thought she’d visited the Fukushima meltdown.) It is actually a cardiac test procedure defined by the Mayo Clinic at this link where you can also learn the reasons given for its use. A monitored treadmill workout is a stress test commonly used to see how the heart performs. But, docs can also approximate that by injecting a radioactive indicator dye and a chemical to make the patient’s heart race.

Certainly there are serious situations where such a test is medically necessary. But, unless that is the case, knowing that the damage from radiation can accumulate forever, I am not keen on having that dye circulating thru my body (and brain). A heart-stressing drug is also not very appealing. Never mind any long-term concerns, the immediate risks of the nuclear stress test include heart attack and potentially fatal heart rhythm irregularities. (Irregular heartbeat is responsible for those sudden-death heart attacks in people who did not have any of what are considered the usual risk factors such as high cholesterol.*) They call those stress test effects “rare”, but they can’t predict who will have them. When something like that happens to you or a loved one, slim odds are not much comfort.

Flashback. Betty started having routine stress tests starting several years ago when had chest pains.* At the time, blood tests and an EKG did not show a heart attack, so perhaps we couldn’t blame the doc for exercising an “abundance of caution” and doing a stress test. The stress test also found nothing. But, Betty was now on a hamster wheel that she cannot easily get off of because routine tests are a legal safety net for doctors and the bread and butter income of cardiology. At an average cost of $3,800 (some as high as $10,900) the clinic has a powerful incentive to continue to recommend stress tests for years on end. (Health insurance coverage may blind us to these ridiculous costs, but they do increase our premiums.) We will not be told to stop testing because we are apparently healthy. The testing will continue until ultimately some sort of problem is identified.

It could be worth the worry, risk and expense if the nuclear stress tests are all that they are cracked up to be as a predictor of treatable heart disease and consistently saved lives. However, they may be no better than flipping a coin. According to this journal article, cardiology may be quietly moving away from the use of stress tests.

The truth is that most of us have something wrong that could be found if docs look hard enough–but that doesn’t mean it is a threat to our health. For example, detailed exams of the spines of folks who are pain-free and fully functional often reveal cracks in vertebrae and bulges in disks. They would likely never cause an issue. Overused diagnostic tests can not only themselves cause harm, but they also find things that aren’t there (false positives) or issues that don’t need to be fixed or that cannot be fixed or for which the treatment is worse than the disease. (…hence the debate over mammograms and PSA). Over–testing and over-treatment are major concerns of ethical experts in medicine today.

Return to the saga. Betty and three of her loving daughters (some took time off of work) arrived for the appointment. They waited an agonizing hour and a half, imagining the worst. If this appointment was so important that an immediate consultation was required, why didn’t the doctor see Betty? Instead a staff person did and asked “so what brings you in today?” It turns out that the “news” was just that the test showed a shadow of something…possibly a borderline scarring of the heart. But, it could have been a testing error and they weren’t sure, so Betty should keep coming back for more testing.
I want to know what in the heck they would have done if they had confirmed scarring of the heart. They certainly wouldn’t remove the scar because it is just healed tissue. Would they possibly blame the damage on “inflammation” and give her an anti-inflammatory drug to prevent more scarring?*
It seems we should give more thought to the question: “Are stress tests worth the cost and risk?” We probably should also read Sherry Rogers, MD’s book Is Your Cardiologist Killing You?

*Non-heart attack chest pains can be caused by severe indigestion or cramps in the pectoral muscles of the chest. The mineral magnesium relieves muscle cramps and it helps normalize irregular heartbeat (which is often found in conjunction with heart scarring). Magnesium is also anti-inflammatory. Most anti-inflammatory drugs on the other hand are hard on the GI Tract and often lead to prescriptions for an acid-blocker like Nexium. Those drugs in turn lower the body’s store of magnesium thereby increasing heart attack risk. If cardiologists want to save more lives, they should order red blood cell magnesium tests on their patients or go ahead and write a “prescription” for magnesium. Oops, that won’t pay the clinic’s rent.