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Called "hostile patient" by cardiologist when I turned down stress test

SDSue

Southeast
Messages
1,066
Reviving this thread.

I’ve been asked to do a stress test. Ugghh. My last trip to the cardio, just for an office visit, left me bed bound for nearly 3 weeks.

Is it worth it? Could they instead do a Holter monitor? Seems it would be important to see what my heart does during sleep and ADL’s. Just what I need - telling a cardio what to do.

Any one with experience of stress test and/or Holter? Advice? Thanks.
 

Sushi

Moderation Resource Albuquerque
Messages
19,935
Location
Albuquerque
I’ve been asked to do a stress test. Ugghh. My last trip to the cardio, just for an office visit, left me bed bound for nearly 3 weeks.
Is it worth it? Could they instead do a Holter monitor? Seems it would be important to see what my heart does during sleep and ADL’s. Just what I need - telling a cardio what to do.
Any one with experience of stress test and/or Holter?
Can you ask him what he hopes to learn from a stress test? And whether he could learn similar valuable information from a Holter or a Holterish test that lasts more than one day?

I think "stress test" is sort of a knee-jerk recommendation and cardios don't realize the consequences it would have for some of us. That said, I've done a variety of them and don't think anything useful came out of any of them.
 

Gingergrrl

Senior Member
Messages
16,171
@SDSue did not read thread (only your post) but IMO the Zio Patch if available is light years beyond what a regular holter monitor can provide and you can google to find website.

As far as stress test, I would want to know what info they think it will add b/c it will not show the data that a two day CPET test can provide. I did the treadmill stress test with my former cardio last Sept 2014 and since I have no arm strength it was incredibly difficult to hold treadmill and I was in pain for weeks afterwards.

I also was told on phone by former cardio that results were "perfect" but when a copy was sent to my new cardio, the results showed ischemia during the treadmill portion (but not the echo portion) which she felt was a "false positive" but I am not so sure about that.

So for me, that test was useless.
 

SOC

Senior Member
Messages
7,849
Can you ask him what he hopes to learn from a stress test? And whether he could learn similar valuable information from a Holter or a Holterish test that lasts more than one day?

I think "stress test" is sort of a knee-jerk recommendation and cardios don't realize the consequences it would have for some of us. That said, I've done a variety of them and don't think anything useful came out of any of them.
I'm inclined to agree with this. Unless the cardio has some purpose that would be of clear benefit to you (as in resulting in necessary disability documentation or significant treatment), I suspect it will not be worth the consequences. He probably doesn't understand the consequences to you of the test and so doesn't think it's a big deal to run the test "just in case".

The Holter tests I've had simply involved wearing the monitor all day doing my normal activities except that I was asked to walk up one flight of stairs during the day so the consequences could be recorded. That one might be worth doing if he's not expecting any extra physical activity as part of the test.
 

Sushi

Moderation Resource Albuquerque
Messages
19,935
Location
Albuquerque
Did the Holter or Zio find anything useful?
They claimed not but it is also known that docs skim through these things and miss a lot. When patients look at the results themselves they find things!
Also, what was Randy Thompson’s opinion on all this, if you know. thx!
He wasn't in favor of killing his patients! He never sent me for one but then I already had a sheaf-full of results.
 

Gingergrrl

Senior Member
Messages
16,171
@SOC @Sushi @Gingergrrl Did the Holter or Zio find anything useful? Also, what was Randy Thompson’s opinion on all this, if you know. thx!

@SDSue For me the Zio Patch was useful, easy to use and accurate. I did it three separate years through mid 2014 and each time they captured multiple episodes of tachycardia in the 160's and 170's but every single one (whether in my sleep, POTS episode or random was all sinus tachy) so the test showed I was having inappropriate sinus tachycardia (IST) vs. an arrhythmia of any kind.

This helped determine that I did not require an anti-arrhythmia medication beyond a beta blocker and was a relief for me to know that the episodes were sinus rhythm.

The treadmill test is another story that I do not recommend unless for a really clear purpose. I would be too ill to do it now and would have to decline if it was me!
 

SOC

Senior Member
Messages
7,849
@SOC @Sushi @Gingergrrl Did the Holter or Zio find anything useful? Also, what was Randy Thompson’s opinion on all this, if you know. thx!
My guess is that your cardiologist is looking for non-ME cardiac reasons for your symptoms, so he wants to run tests to look for structural/functional cardiac problems. If you have heart problems independent of ME/CFS, the tests will help to find them and you may get some useful treatment. If your symptoms are ME-related then the standard cardiac tests are not likely to be grossly abnormal. That doesn't mean there aren't problems the cardio can't help with, just that he might not look in the right places to find them.

The Holter didn't change my treatment plan, but confirmed CFS in Dr Lerner's evaluation
A. Abnormal Holter Monitoring

Abnormal T-wave flattenings and inversions are found in patients with the US Centers for Disease Control defined CFS. This finding has been tested statistically, and we can now say that 90% of patients with CFS have abnormal 24-hour monitoring. This is a biomarker. The absence of abnormal Holter monitoring leads us to believe that CFS as the cause of fatigue is less likely. The T-wave of the electrocardiogram records repolarization (electrical recovery) of the left ventricle after every heartbeat in preparation for the next heartbeat. The normal T-wave is upright. With increased heart rates the abnormal T-waves occur. Abnormal oscillating T-waves occur with exercise. The symptoms of CFS are worsened by exercise, a striking coincidence.
http://www.treatmentcenterforcfs.com/faq/index.html

I'd say the reason to do a Holter test is to find out if you have arrhythmias that could be causing your symptoms independent of ME/CFS. I didn't, but I did have the T-wave flattening and the abnormal oscillating T-waves walking up a flight of steps (iirc) that Lerner finds in ME/CFS patients. I think a cardiologist would not consider either of those things significant, however.

Bottom line: There's probably no harm in doing a 24- or 48-hour Holter test just in case you have arrhythmia. It's probably more a rule-it-out test than anything that's likely to lead to treatment, but you don't know until you do the test.

If your cardiologist is a civilized human being, you could show him these couple paragraphs from the ME/CFS Primer for Clinical Practitioners:
3:5 Autonomic/Cardiovascular Disturbances
Autonomic dysfunction, if present, is manifested by an inability to maintain an upright posture or feeling faint or weak upon standing (orthostatic intolerance). In such cases, tilt table testing may show neurally mediated hypotension (NMH) or postural orthostatic tachycardia syndrome (POTS). Some patients with ME/CFS may complain of heart palpitations and show a persistent tachycardia at rest. Holter monitoring may reveal benign cardiac rhythm disturbances and non-specific T wave changes such as repetitive oscillating T-wave inversions and/or T-wave flattening. 54 Suspected diastolic dysfunction has been documented in some patients with ME/CFS using echocardiography. This diastolic dysfunction (improper ventricular filling) may be due to a lack of energy at the cellular level. 55 Low blood volume has also been found in some patients with ME/CFS. 56
It may encourage him to do a TTT (if he hasn't already) or treat for low blood volume (or test for it, at least).
 

Little Bluestem

All Good Things Must Come to an End
Messages
4,930
Dr. Lerner says
The normal T-wave is upright. With increased heart rates the abnormal T-waves occur. Abnormal oscillating T-waves occur with exercise.
I am assuming that if the normal T-waves are upright, the abnormal ones must be less upright, which could also be called flattened.

Yet the ME/CFS Primer says
Holter monitoring may reveal benign cardiac rhythm disturbances and non-specific T wave changes such as repetitive oscillating T-wave inversions and/or T-wave flattening.
 
Messages
92
I had the same experience last year, @SDSue after doing the Tilt Table Test. The cardio who did the TTT seemed familiar with but cynical about dysautonomia, which was dismaying, as he had been one of the people who had apparently developed the test.

I made it very clear to him when he asked me to come back for a follow-up test treadmill test that I wasn't going to risk PEM. I started the test but stopped after about 2 minutes. He was very patronizing and dismissive, telling me he was "disappointed in me" (!) and that I was just deconditioned. I didn't get PEM, and was very glad I'd stuck to my instincts. He also couldn't tell me why he wanted the test in a way that made sense to me--see above @SOC 's comments.

I did get 3 days of mild PEM after a very brief/slow bout on a treadmill a few months later to find my anaerobic limit. Still also considering the 2-day CPET test...
 

Sidereal

Senior Member
Messages
4,856
I did a treadmill cardiac stress test 10+ years ago because my cardiologist at the time knew nothing about dysautonomia or ME/CFS. The price of a doctor practising CYA medicine to rule out ischemic heart disease is high to an ME patient since we are harmed by exertion. I wasn't able to finish the test, almost collapsed on the treadmill. The nurse and cardio stared at me in disbelief and said I was deconditioned, had to get a grip on myself etc.

This test yields no useful information to an ME patient unless you have heart disease.

I had major difficulty getting home, walking from the car to the elevator was a major problem. Stayed in bed for days after the test and felt on the verge of death with PEM although at the time I had no idea what PEM was.

At the time I was nowhere near as sick as I am now.

I've done Holter a couple of times. It showed that every time I did anything my heart was in sinus tachycardia, 140-160 bpm. This was interpreted as "normal".

I don't think cardiology is a useful referral for our cardiac problems and is usually quite damaging in terms of tests they do and psychobabbly explanations offered for findings they don't understand.
 

SDSue

Southeast
Messages
1,066
I've done Holter a couple of times. It showed that every time I did anything my heart was in sinus tachycardia, 140-160 bpm. This was interpreted as "normal".
It’s amazing how many abnormal findings, along with our overall clinical picture, are dismissed as “normal”. Add them all up and suddenly we aren’t so normal after all. But then, that would take a diagnostician. Sigh.
 

Gingergrrl

Senior Member
Messages
16,171
In general I agree with @Sidereal but in my case, the Zio Patch studies were helpful and my HR in 170's was considered abnormal but ruled out other arrhythmias like afib so I found it a relief to know it was all sinus tachy.

I tried two BB's, a calcium channel blocker, Florinef and all kinds of crap before finding the right BB that controls the tachy pretty well. But otherwise cardio pretty useless and a treadmill test would kill me at this point and I would refuse it at all cost.

Am no longer seeing cardio b/c nothing more to offer me and he stopped taking my insurance but have him if needed in some kind of true emergency.
 

Sidereal

Senior Member
Messages
4,856
In general I agree with @Sidereal but in my case, the Zio Patch studies were helpful and my HR in 170's was considered abnormal but ruled out other arrhythmias like afib so I found it a relief to know it was all sinus tachy.

I agree, by all means rule out arrhythmia. There are less destructive ways than a stress test though. If you wear a 24-hour monitor you can "exert" yourself by walking up the stairs or whatever you feel you're able for.

Cardiologists have no idea what stress tests do to us. I have met people who have had permanent worsening of ME symptoms because of it.