Angina Pectoris

[Unregistered]

I was on a long drive last week, at night. I had slept 2 hours in the 48 hours prior, and was keeping myself awake with Monster Energy Drink (about 48 oz. in three hours). A late night traffic jam got me annoyed, plus a call from my ex led to some shouting, and then I felt pressure, more than pain, in my chest. It increased for about a minute. I took an aspirin (always keep them in the cab for headaches) and a swig of the Monster juice, and the pressure went away. Total time about five minutes.

Went to the doc, and he did some tests (blood test, EKG) and told me I most likely have Angina Pectoris. I also have high cholesterol, he prescribed mevacor.

He also told me lose weight, lay off the caffeine (I was drinking 4+ big cups of coffee a day, plus the energy drinks), sleep better, quit smoking, and don't talk to the ex (well, actually, to stop getting upset. same thing.)

My new medical insurance doesn't kick in for a month, so we're going to wait on that for the rest of the tests he wants to do. In the meantime, he told me not to fly, obviosuly. Not that I would, anyway, but it's official.

Now here's my question. I fly SP, so I use my DL as my medical. What I want to know is what kind of tests, and what kinds of test results, should my doc be looking at for the flying decision, when the time comes?

Thanks

 

[bbchien]

Stress treadmill run, 9 monitored minutes. There might be an echo or a nuclear-thallium heart scan at the end, it depends on their setup.

 

[twdeckard]

<I am not a physician>

You could also inquire about a CT Angiogram. There is a lot of debate about using this test for wide spread screening. Getting it covered by insurance can be challenging and depends on your carrier.

Our POTUS had one recently as part of his presidential physical.

At an academic hospital, performing the exam regulary, it can provide insights that the functional exams do not.

The stress/imaging exam that Dr. Bruce suggested is the well accepted practice and you should feel confident with this if your personal cardiologist has never heard of me and does not recommend CCTA :wink2:

 

[Unregistered]

Okay, thanks. Much appreciated.

 

[Doggtyred]

The stress/imaging exam that Dr. Bruce suggested is the well accepted practice and you should feel confident with this if your personal cardiologist has never heard of me and does not recommend CCTA :wink2:

A little additional blurb.. The stress test has about a 20% false positive rate. What that means is.. if you are NEGATIVE, you are NEGATIVE for signs of significantly narrowed vessels and what they call "ischemia" (decreased blood flow).

When its positive, there is still a 20% chance that there isn't significant disease present. Most of these tests that fall in the 20% are the ones with marginal or questionable changes on the findings.. "eh.. its just slightly different from normal". Somewhat subjective..

Why do the stress test then? Because its cheaper, less invasive and less complication prone than the next diagnostic step, a cardiac catheterization and angiography.

The CT Angiogram mentioned does provide imaging of the vessels, but it usually is not able to show if there is clinically significant disease or not, where the stress test may. The CT Angiogram is a resting test, whereas the stress test puts your heart under a workload to see how it handles it. (what that means is... many of us have some disease in our blood vessels, but that its not to the point of causing a problem.... you can have chest pain, have vascular disease, and the symptoms not be caused by the vascular disease... that's where the judgment of the physician comes into play)

 

[bbchien]

<I am not a physician>

You could also inquire about a CT Angiogram. There is a lot of debate about using this test for wide spread screening. Getting it covered by insurance can be challenging and depends on your carrier.

Negative on that. There are, per the Federal Air Surgeon, still not enough slices nor resolution to exclude a diagnosis of CAD. Only enough to make a diagnosis if a slice happens to hit a lesion just right.

Therefore, the FAS has taken the position that these cannot be used to rule out Coronary Disease. The reason that it's used on the POTUS and on celebs is that there is zero risk to the Doctor. Think about that.

 

[Jeanie]

Also, in regards to changing your diet you might look up: www.drmcdougall.com for very good info on how to reverse heart disease - yes, reverse it ... and also, there is a good book by Dr. Carl Esslestyn on that same subject.
Changing what you eat - drasticly I suppose to some - versus expensive, potentially invasive and not alway successful medical care is a good thing in my perspective
Heart stuff runs in my family - so I'm conscientious about it and I cut my cholesterol from 306 to 134 with diet only - no drugs.

 

[twdeckard]

Negative on that.

I'll try to make Gaston's next year and I can lobby you on CCTA! Again, not a physican but I have a very smart part in helping develop this technology and so I am a zealous advocate.

Stress tests generally only evidence moderate to severe stenosis, yet 40% of heart attacks are believed to be caused by lesions which are positively remodeled (bulge outward). Even conventional catherization is a simple lumingram and cannot pick up these without the esoteric IVUS or OCT. Some day we will have the technology to actually recognize these "vulnerable" lesions but admitedly the science is not there yet.

With a modern (64+) slice CT scanner it is not a matter of "getting lucky" and capturing the lesion but rather that the facility has a good protocol, is comfortable beta blocking and so forth.

In general CCTA is an excellent for the equivocal presentation and moderate risk. If you very likely suspect a problem then go to the angio suite. But its the person you are not confident sending home for which you now have another powerful tool.

The larger debate is using this to screen the asymptomatic population. A very modern scanner can capture a single volume image of the heart
about diastoyle for under a millisievert (in a relatively normal body habitus). Thats like moving to Denver. Yet it is ionizing radiation and it is a very expensive specialized test and does use iodinated contrast. For an older male who has presented with some suspicion the cost/benefit on the radiation risk is very arguable. For a younger woman, perhaps not so.

You are correct that the case has not been fully made at the CMS but there are small to medium size trials underway now to compare CT to conventional XA and a very large trial being piloted to compare CT to nuclear scanning. I might even have some trial results under my arm next year!

(Now for folks with mild angina or a fear about heart disease, again the advice from your cardiologist trumps anything I have offered on the internet -- just be sure to always be candid and inquisitive with your doctor)

Todd

 

[RJM62]

....

Stress tests generally only evidence moderate to severe stenosis, yet 40% of heart attacks are believed to be caused by lesions which are positively remodeled (bulge outward). Even conventional catherization is a simple lumingram and cannot pick up these without the esoteric IVUS or OCT. Some day we will have the technology to actually recognize these "vulnerable" lesions but admitedly the science is not there yet.

....

The larger debate is using this to screen the asymptomatic population. A very modern scanner can capture a single volume image of the heart
about diastoyle for under a millisievert (in a relatively normal body habitus). Thats like moving to Denver. Yet it is ionizing radiation and it is a very expensive specialized test and does use iodinated contrast.

....

I was thinking the exact same thing...

 

[twdeckard]

I was thinking the exact same thing...

yes this was a very un-aviation related post. Rather than ramble on, I should have made a note to pick Dr. Chien out of the crowd at Gaston's and introduce myself! Nothing I posted is of real value to a real pilot/patient seeking advice.

Its a topic I have spent a lot of time immersed in.

Todd

 

[RJM62]

yes this was a very un-aviation related post. Rather than ramble on, I should have made a note to pick Dr. Chien out of the crowd at Gaston's and introduce myself! Nothing I posted is of real value to a real pilot/patient seeking advice.

Its a topic I have spent a lot of time immersed in.

Todd

I was joking, Todd. Don't sweat it, lol.

-Rich

 

[twdeckard]

I'm the one laughing. I am starting to realize why folks avoid me at cocktail parties.

imaging physics is even more boring than pilot stories!

 

[RJM62]

I'm the one laughing. I am starting to realize why folks avoid me at cocktail parties.

imaging physics is even more boring than pilot stories!

But not more than some of my recent theological treatises.

 

[bbchien]

Our POTUS had one recently as part of his presidential physical.

I think, Todd, when you make a post such as this you might hint of your commercial relation to CCTA.

It leaves a very bad taste. I was watching how this thread would turn out....

Like all the faculty members, we await vaild, prosepctive trials compared to angiography. When there are good data, we'll be able to embrace this. But right now, please avoid "sly" solicitation. In the end that's why those that do science avoid the relationships of commerce.

The original poster will now get what other have suggested:

There is nothing that knowing you have early Coronary Disease can do for you unless that knowledge is what prompts you to do what you should, anyway:

Not get fat.
Exercise
Control hypertension and cholesterol
And, if you are concerned, a medically monitored Bruce Protocol Stress Treadmill. If you go 9 minutes to the proper heart rates, a negative run is assurative of a less than 1% frequency of a coronary event in the following five years.

CCTA doesn't have that predictive value; it MAY in the future, but right now doing the "heartCheck America" thing for cash, is medical puffery. If you choose to have it done, for the time being, it ought to be on a research protocol, with full disclosure.

 

[Unregistered]

I think, Todd, when you make a post such as this you might hint of your commercial relation to CCTA.

It leaves a very bad taste. I was watching how this thread would turn out....

Like all the faculty members, we await vaild, prosepctive trials compared to angiography. When there are good data, we'll be able to embrace this. But right now, please avoid "sly" solicitation. In the end that's why those that do science avoid the relationships of commerce.

The original poster will now get what other have suggested:

There is nothing that knowing you have early Coronary Disease can do for you unless that knowledge is what prompts you to do what you should, anyway:

Not get fat.
Exercise
Control hypertension and cholesterol
And, if you are concerned, a medically monitored Bruce Protocol Stress Treadmill. If you go 9 minutes to the proper heart rates, a negative run is assurative of a less than 1% frequency of a coronary event in the following five years.

CCTA doesn't have that predictive value; it MAY in the future, but right now doing the "heartCheck America" thing for cash, is medical puffery. If you choose to have it done, for the time being, it ought to be on a research protocol, with full disclosure.

Thanks again doc.

I barely smoked before the event, so stopping comepletely is no problem. Also keeping a lid on the stress thing, that's real important too. Getting enough sleep so I'm not mainlining cafeeine to stay awake, and exercising more, starting by walking to places I would usually drive. My friend is a chemist and he said drinking that much energy drink in three hours is incredibly dangerous. That I was doing it every day made it even worse. So I'm limiting caffeine to a couple of cups a day. The withdrawal is giving me a headache, but I can deal with that.

I don't have high blood pressure, but he tells me that my sugar is a little high. But he doesn't want to treat it yet. He told me losing weight and exercising will probably be enough to bring it back in line, and the sugar's not at a level that's dangerous yet. I'm about 30 pounds overweight.

He also wants me to take an aspirin every other day, and some vitamin supplements every day (fish oil, co-q-10, garlic, cinammon, and a multivitamin). Easy enough. Oh, and a glass of red wine at night.

Thanks again doc.

OP

 

[bbchien]

Folks, I don't know the rules on this board as to matters of commercial interests, but I need to disclose here that one of the posters in the string "carries the banner" for CT evaluation of Coronary Disease. Translation: he promotes it.

The status of this technology is that it MAY WELL in the next five years, find enough data to be validated as a good noninvasive tool to evaluate the coronaries. However, good scientific data are lacking currently. The poster's statement that getting "insurance coverage may be challenging" is an understatement. None of the majors will pay for it until it has good scientific vetting.

Personally I would like to see this technology develop to the point of good scientific vetting. But to suggest that someone should get it because the President had one, without disclosing the cmomercial interest, is disgenuous at best, and might be worse. It, as he has accused me privately, "takes the cake".

To this individual: if I did not disclose my interests in University Review Committee matters, the regent would remove me from my post. Charlie Rangel is experiencing the same thing. YOU should be more forthcoming.

Caveat Emptor!

Mods, feel free to take this down is inappropriate. It is aviation medicine related, but not strictly about aviation.

 

[Doggtyred]

I'll try to make Gaston's next year and I can lobby you on CCTA! Again, not a physican but I have a very smart part in helping develop this technology and so I am a zealous advocate.

Todd

Its not Doc you need to convert, its boss flight surgeon in OKC..


Good luck with your efforts. In the community hospital cath lab I just left, we had 4 labs and about 10 cardiologists total and we hammered out angiograms day in and day out. Most of the outpatients were screened Nuclear Stress Tests. One cardiologist actually HAS the CT scanner in his office and uses it for screening patients who are referred to him (for symptoms). His words were he wished he hadn't bought it. More than several cases the findings on CT didn't match what we saw with multiple views angiographically. This empirical, of course, but not much buy in, even from folks who'd bought into the technology.

I'm in the process of moving into a major medical center with a dozen rooms, and cutting edge practice (stem cells, LVAD's going in down the hall in CVOR).. So I will see what the academic folks think. (again.. empirical, but a top ranked place..)

You are right about most heart attacks not being the result of progressively worsening and narrowing vessels, that then cause angina and finally clog off.

They are usually being caused by light to moderate plaques rupturing (with no previous symptoms).. These same light to moderate plaques would not be severe enough to treat with stents or angioplasty since they aren't significantly occluding flow.. until they rupture.

So.. how you detect the ticking time bomb that you are gonna treat with pills (rather than with stents, etc) really is a matter of semantics. ALL use radiation of some kind. and ALL have some strong points and some not so good points.

 

[wby0nder]

\
You are right about most heart attacks not being the result of progressively worsening and narrowing vessels, that then cause angina and finally clog off.

They are usually being caused by light to moderate plaques rupturing (with no previous symptoms).. These same light to moderate plaques would not be severe enough to treat with stents or angioplasty since they aren't significantly occluding flow.. until they rupture.

\

This leaves me, a perfectly healthy, athletic, middle aged male with family history and some mild BP and cholesterol risk factors, feeling like I'm walking around with a loaded gun to my head.

 

[TMetzinger]

This leaves me, a perfectly healthy, athletic, middle aged male with family history and some mild BP and cholesterol risk factors, feeling like I'm walking around with a loaded gun to my head.

Driving on the beltway gives me the same feeling. The trick is to control what you can, and not worry about what you can't control, or why you can't control it.

 

[Doggtyred]

This leaves me, a perfectly healthy, athletic, middle aged male with family history and some mild BP and cholesterol risk factors, feeling like I'm walking around with a loaded gun to my head.

Yea... its not too common but every once in a while we get people in their 30's who do this.

Just like some people have little aneurysms in their head that one day just let go.

Some things you can adjust for. Some things you cant. Lifes not fair.
Worry about the things you can control, and dont obsess over what you cant control.

Live life like every day is your last, and you nor your family will have any regrets.

 

[wby0nder]

Yea... its not too common but every once in a while we get people in their 30's who do this.

Just like some people have little aneurysms in their head that one day just let go.

Some things you can adjust for. Some things you cant. Lifes not fair.
Worry about the things you can control, and dont obsess over what you cant control.

Live life like every day is your last, and you nor your family will have any regrets.

I think I'll work on controlling the things I CAN control and worry about the things I can't.

 

[Steve Foley]

There are, per the Federal Air Surgeon, still not enough slices nor resolution to exclude a diagnosis of CAD. Only enough to make a diagnosis if a slice happens to hit a lesion just right.

Therefore, the FAS has taken the position that these cannot be used to rule out Coronary Disease. The reason that it's used on the POTUS and on celebs is that there is zero risk to the Doctor. Think about that.

This seems a little inconsistent. The OP is flying under the sport pilot category, using his driver's license in lieu of an FAA medical. Does the Federal Air Surgeon have any say over the issuance of a driver's license?

 

[steingar]

Geeze, the OP needs a couple MDs and a rambling thread just to figure out he should lay off the caffeine and whatever it is they put in the energy drinks, stop smoking,loose some weight, get some exercise and avoid stress. Seems like simple common sense to me. Oh, maybe I'm some sort of genius. If so, why don't I have more money.

Full disclosure: This overly sarcastic rant is brought to you by someone with no commercial interests in much of anything. Sarcasm is a service freely offered here.

 

[Dean]

This seems a little inconsistent. The OP is flying under the sport pilot category, using his driver's license in lieu of an FAA medical. Does the Federal Air Surgeon have any say over the issuance of a driver's license?

No, but the rule states:

"... if a pilot knows or has reason to know of any medical condition that would affect his or her ability to operate a light sport aircraft, then the pilot should refrain from acting as a pilot in command".

So if you crash and turn in an insurance claim, most likely it will be denied.

 

[steingar]

No, but the rule states:

"... if a pilot knows or has reason to know of any medical condition that would affect his or her ability to operate a light sport aircraft, then the pilot should refrain from acting as a pilot in command".

So if you crash and turn in an insurance claim, most likely it will be denied.

I've read this before, and I'm wondering if an insurance company has ever denied a claim on this basis? I honestly doubt it, but could just be stupid about it.

 

[Dean]

I've read this before, and I'm wondering if an insurance company has ever denied a claim on this basis? I honestly doubt it, but could just be stupid about it.

Not paying attention to dates: An insurance company can deny coverage if your medical was expired or bi-annual review was not current. This might seem minor, but the insured is in violation of the policy and your insurance claim could be denied.

Knowing insurance companies, I would say they would jump at the chance to deny a claim. So if they can prove you had a medical condition that would have kept you from being PIC, I am sure they would deny the claim.

 

[steingar]

Not paying attention to dates: An insurance company can deny coverage if your medical was expired or bi-annual review was not current. This might seem minor, but the insured is in violation of the policy and your insurance claim could be denied.

Knowing insurance companies, I would say they would jump at the chance to deny a claim. So if they can prove you had a medical condition that would have kept you from being PIC, I am sure they would deny the claim.

Just because and insurance company can doesn't mean it will. Pilots are often well heeled and well lawyered, making me somewhat skeptical. So once again, does anyone have any first hand knowledge of an insurance company denying a claim because someone broke a FAR?

 

[jesse]

Just because and insurance company can doesn't mean it will. Pilots are often well heeled and well lawyered, making me somewhat skeptical. So once again, does anyone have any first hand knowledge of an insurance company denying a claim because someone broke a FAR?

I've never heard of an instance of it.

 

[TMetzinger]

I've never heard of an instance of it.

Only time I've heard of it is when someone used the airplane for commercial purposes when it wasn't insured for such, nor was the pilot rated for such. And that was a clear exclusion in the policy language itself.

Otherwise, whether it's been a gear-up, or a no-fuel, or other pilot error, I've never seen an insurance company not cover it. Now I have seen the airplane insurer sue the maintenance organization who clearly did a substandard job which led to an accident, but they made the aircraft owner whole first.

 

[Pilot150]

Of all of the things listed, lack of sleep seems to be the cause of much of your problems. I developed an arrhythmia out of nowhere. I was about to lose my job and I haded’t slept for a full night in weeks. Because of this, I also drank tons of coffee. Get awesome sleep. I went through all of the tests and everything was fine except for the “skipped beet”. Then, just as quickly as it appeared, it went away. Just passed my first class medical with EKG. Heart rate as dependable as a Swiss clock.

 

[wilkersk]

I'm a CT tech. I do CT angiograms all day long. And, I'd rather have the stress test than a CT angiogram. Needles, radiation, and X-ray contrast are great for guys that come into the ER with chest pain and shortness of breath. But, they are not necessary to confirm what your doctor is already telling you.

 

[azure]

Classic necropost...

But whatever, I agree with @wilkersk. And if you need an imaging study to go with the stress test, I would take (and have taken) the stress echo over the nuclear stress test any day, given the choice. The nuclear stress test involves a radiation exposure comparable to a CT scan or invasive angiogram. The echo involves none at all.

 

[wilkersk]

Classic necropost... ...

Egads! I've been had....

 

[Lindberg]

Since we're all here, and it's been more than five years since Dr. Chien said maybe in five years, who was right?

 

[bbchien]

Since we're all here, and it's been more than five years since Dr. Chien said maybe in five years, who was right?

Federal policy remains the same. Ultraslice CT can only GIVE you the diagnosis. It can't remove it.

 

[Warmi]

No, but the rule states:

"... if a pilot knows or has reason to know of any medical condition that would affect his or her ability to operate a light sport aircraft, then the pilot should refrain from acting as a pilot in command".

So if you crash and turn in an insurance claim, most likely it will be denied.

This is such vague statement it is meaningless ... what does it mean to be affected by something and how do you quantify it ... yes, having a heart attack and attempting to fly a few months after would probably qualify but how about 5 years after without any further symtoms ..or with high blood pressure ... or with controlled diabetes etc etc ... my take on it is , you got the driver license and your doctors deems you safe to drive , you can fly your light sport or whatever it is.