Stress Echo Cardiogram

[Unregistered]

I figured this wouldn't be a problem but now that I have to renew my 3rd class, I'm beginning to get nervous. Here's the story...

My wife had an abnormal EKG during her annual physical and was referred to a Cardiologist. He performed a cardiac CT (calcium score) and a stress/echo cardiogram. She came out fine, no problems. I was fascinated watching the tests and, at age 62, though it might be a good idea to have the same thing to make sure everything was OK. I had no symptoms but family history was not good and I do take 5mg of Lisiniprol for mild hypertension. The doc said my results were wonderful and no problems were detected.

Will I need to bring anything extra to my AME or can I simply report the visit to the cardiologist and the results on the form? It seems like this should be treated as a routine procedure, similar to a colonoscopy.

 

[Gary F]

I figured this wouldn't be a problem but now that I have to renew my 3rd class, I'm beginning to get nervous. Here's the story...

My wife had an abnormal EKG during her annual physical and was referred to a Cardiologist. He performed a cardiac CT (calcium score) and a stress/echo cardiogram. She came out fine, no problems. I was fascinated watching the tests and, at age 62, though it might be a good idea to have the same thing to make sure everything was OK. I had no symptoms but family history was not good and I do take 5mg of Lisiniprol for mild hypertension. The doc said my results were wonderful and no problems were detected.

Will I need to bring anything extra to my AME or can I simply report the visit to the cardiologist and the results on the form? It seems like this should be treated as a routine procedure, similar to a colonoscopy.

I would get a copy of the results for my records. Dr. Bruce will tell you if you need to provide them to the FAA. My guess is yes.

It is usually not a good idea for an asymptomatic person to get an imaging stress test for screening purposes due to the possibility of a false positive result. This is generally less of a problem with stress echos than stress nuclear studies but still not a good idea. For men a simple treadmill stress test is more reasonable as long as the ECG is normal at rest, women will have a high rate of false positive results.

 

[frfly172]

If you requested the test and not your dr. There should be no problem,as it was a precautionary test,the test just rules out some heart problems.

 

[bbchien]

Bring a copy with you.
That was terrible judgement. I'm glad you had a low calcium score. Now that you do, are you really going to do anything else differently?

Eat right
don't get fat.
Exercise
Control your cholesterol
Avoid diabetes.
Don't smoke.

that's about it.

 

[Gary F]

If you requested the test and not your dr. There should be no problem,as it was a precautionary test,the test just rules out some heart problems.

So he is more qualified than his physician to decide what tests are necessary? The problem is that most people are clueless as to the usefulness and limitations of medical tests. Do you understand what happens if there is a false positive result and how that can complicate a medical evaluation and the FAA certification process? I don't think it matters if the test was "precautionary" or not, whatever that means.

 

[Unregistered]

Thanks, all, for the info. Guess I got lucky but I have to admit I do feel better knowing my heart is in good shape.

The cardiologist that performed the tests is well respected in the DFW area and it was he that convinced me I should do it. The fact that my insurance covered most of it was a factor, too. I was not aware of the high potential for false positives, I thought these tests would be conclusive...

Hopefully, others will learn something from this experience...

 

[Gary F]

Thanks, all, for the info. Guess I got lucky but I have to admit I do feel better knowing my heart is in good shape.

The cardiologist that performed the tests is well respected in the DFW area and it was he that convinced me I should do it. The fact that my insurance covered most of it was a factor, too. I was not aware of the high potential for false positives, I thought these tests would be conclusive...

Hopefully, others will learn something from this experience...

Few tests in medicine are conclusive, especially cardiac imaging tests. The good news for cardiologists is that false positive tests usually generate more lucrative (and risky and expensive) tests. This can be a problem for pilots when they try to get certified. Getting an imaging test for reassurance in an apparently healthy person with good exercise tolerance and no cardiac symptoms is almost never a good idea. That being said, my flying habit has been well funded by the fees I get for interpreting these tests. Many of these were ordered by well intentioned providers who don't understand the proper role of cardiac tests.

 

[frfly172]

Few tests in medicine are conclusive, especially cardiac imaging tests. The good news for cardiologists is that false positive tests usually generate more lucrative (and risky and expensive) tests. This can be a problem for pilots when they try to get certified. Getting an imaging test for reassurance in an apparently healthy person with good exercise tolerance and no cardiac symptoms is almost never a good idea. That being said, my flying habit has been well funded by the fees I get for interpreting these tests. Many of these were ordered by well intentioned providers who don't understand the proper role of cardiac tests.

Thanks for that info.

 

[Aztec Driver]

So what paperwork would a person need if they had a problem that their doctor recommended those tests for? Let's assume they had an abnormal rhythm or some such problem and their doctor ordered these tests and they turned out normal. Would it be sufficient to bring the results and the explanation to the next medical? Would it make a difference for class 3 or class 2? Doesn't class 1 already require an EKG?

 

[bbchien]

So what paperwork would a person need if they had a problem that their doctor recommended those tests for? Let's assume they had an abnormal rhythm or some such problem and their doctor ordered these tests and they turned out normal. Would it be sufficient to bring the results and the explanation to the next medical? Would it make a difference for class 3 or class 2? Doesn't class 1 already require an EKG?

It's all cases, Bryon. Not enough information here.....depends on what the rhythm, how the walls and valves look, the pressures, the dimensions........It's hard to believe that a guy would order up a bunch of stuff just to get normal and bill.

If that were the case, you'd be in the wrong office.

 

[mnewb1]

Few tests in medicine are conclusive, especially cardiac imaging tests. The good news for cardiologists is that false positive tests usually generate more lucrative (and risky and expensive) tests. This can be a problem for pilots when they try to get certified. Getting an imaging test for reassurance in an apparently healthy person with good exercise tolerance and no cardiac symptoms is almost never a good idea. That being said, my flying habit has been well funded by the fees I get for interpreting these tests. Many of these were ordered by well intentioned providers who don't understand the proper role of cardiac tests.

This...as a PCP I can't tell you how much time I spend trying to talk people out of unnecessary tests they are sure they need...

 

[bbchien]

BUT MY FAMILY DOCTOR WOULDN'T order the MRI!!!!!!
...sigh.....
actually.....
more of a whimper.....

 

[BrianR]

Thanks, all, for the info. Guess I got lucky but I have to admit I do feel better knowing my heart is in good shape.

The cardiologist that performed the tests is well respected in the DFW area and it was he that convinced me I should do it. The fact that my insurance covered most of it was a factor, too. I was not aware of the high potential for false positives, I thought these tests would be conclusive...

Hopefully, others will learn something from this experience...

Gary F has it spot on. Of course the local cardiologist convinced you you should do it. It's his bread and butter, his next mortgage payment, his....well, you get the idea.

False positives in cardiac imaging are prevalent. I'm a good example of that myself. My third class SI required a treadmill stress test. It was abnormal. I suspected a false positive because I was asymptomatic, even though I had some risk factors for coronary artery disease. Next, I underwent a nuclear stress test. It was positive. Again, I suspected falsely so. Of course, the only thing then acceptable to the FAA was a coronary angiogram, certainly NOT inexpensive or risk-free. Also, not necessary, according to my insurance company. Although they were correct, they (eventually) paid for most of it, based on my risk factors.

Of course, the angiogram was completely negative.

The cardiologist who performed my angiogram (also a pilot, and an AME, though not mine) commented that if not for FAA requirements, he'd never order even a stress test in a patient such as myself with no symptoms, because it can easily start in motion a cavalcade of increasingly risky and expensive tests.

 

[Aztec Driver]

It's all cases, Bryon. Not enough information here.....depends on what the rhythm, how the walls and valves look, the pressures, the dimensions........It's hard to believe that a guy would order up a bunch of stuff just to get normal and bill.

If that were the case, you'd be in the wrong office.

Sorry Bruce, I am not sure I understand the answer here.

Since the visit has now been done, I'll elaborate on my question.

Six months ago, I had an episode of what I can only refer to as " skipping or irregular heartbeat." I had gone for a significant time without proper rest and had consumed a fair amount of sweet tea and other sweets to keep me going. It lasted for about two days. After I had gotten some reasonable rest, it subsided completely and I chalked it up to the diet and rest problems and thought no more about it. I have always had the feelings of skipped beats here and there so it did not really feel any worse.

Last week, just as the Labor day weekend was beginning, I started to have the condition again. This time, the only thing at the time that I thought I could attribute it to were maybe my normal consumption of sweet tea and sweets, as I was on my regular sleep schedule. It felt odd in my chest, but no pain and no real pressure. I was not short of breath, but the sensation certainly made me want to breathe deeply. This was only at rest. I could not sleep well with it, as it kept me awake. It was a feeling of skipping or adding a slightly harder thump every 10 or 15 beats or so, all evening and night long, so long as I was not exerting myself. If I exerted myself, such as walking or exercising, the feeling would go away completely, but then return when resting. Since I did not have any other symptoms, and it did not keep me from doing anything, I did not believe it was anything to go to the ER for. On Monday, I made an appointment for my GP without giving any real details as to why I wanted to be there.

Unfortunately, as the week progressed, the symptoms subsided to almost nil by the time I saw him. He has done blood work and an EKG so far, which are normal. He has also scheduled a stress echocardiagram and a holter monitor. These are scheduled for tomorrow, hence my question.

Reading these posts has me concerned about the possible repercussions of these tests.

I think I may have found my own answer to the condition, but I'll ask you for the possibility. This time, at least, I am aware that, due to my usual seasonal allergies, my head and chest get considerably congested because of the constant post nasal drip. I try not to take anything, but after awhile it gets miserable. Just prior to the episode, I had let my head and chest get pretty well congested, and during and just after I had used some decongestant to clear things up. That's when it started to diminish. Is that a possibility?

And, since all of the tests are negative, and they even commented on my endurance in the test, and all symptoms have disappeared, what ramifications are there? Should I consider myself grounded until a definitive diagnosis is made? What if one never reveals itself?

This is the reason I hate to go unless my limbs are actually physically falling off.

 

[Gary F]

This...as a PCP I can't tell you how much time I spend trying to talk people out of unnecessary tests they are sure they need...

I did not mean to imply that all primary care providers have a tendency to order unnecessary tests. I practiced primary care for 7 years, four as a GMO in the Army and three as an internist. Tests are ordered inappropriately for a number of reasons, including but not limited to, patient demands, inexperience or lack of understanding or defensive medicine by medical providers. I've noticed a trend of replacing primary care physicians with inexperienced mid-levels (physician assistants and nurse practitioners). You might save $50 on the office visit charge but nervous mid levels have a tendency to over-test. It doesn't take too many $4,000 cardiac nuclear imaging tests to overwhelm any initial savings. Mid-levels can do an excellent job after they have attained sufficient experience as long as they work closely with supervising physicians. Specialists are a big part of the problem. Greed is alive and well in the world of fee for service and specialists have been known to have a low threshold for choosing the most lucrative diagnostic pathway or treatment options.

 

[mnewb1]

I did not mean to imply that all primary care providers have a tendency to order unnecessary tests. I practiced primary care for 7 years, four as a GMO in the Army and three as an internist. Tests are ordered inappropriately for a number of reasons, including but not limited to, patient demands, inexperience or lack of understanding or defensive medicine by medical providers. I've noticed a trend of replacing primary care physicians with inexperienced mid-levels (physician assistants and nurse practitioners). You might save $50 on the office visit charge but nervous mid levels have a tendency to over-test. It doesn't take too many $4,000 cardiac nuclear imaging tests to overwhelm any initial savings. Mid-levels can do an excellent job after they have attained sufficient experience as long as they work closely with supervising physicians. Specialists are a big part of the problem. Greed is alive and well in the world of fee for service and specialists have been known to have a low threshold for choosing the most lucrative diagnostic pathway or treatment options.

I didn't take any such implication, I like your take on the matter.

 

[Unregistered]

So, I guess I got lucky and dodged a bullet. I am surprised that the insurance paid for it without putting up a fuss.

 

[bbchien]

Byron:

So if there is an insurance record of an irregular heartbeat, you have two choices: try to get the doc to conclude it is psudoephedrine related, or do the treadmill, holter and echo. This is one of those areas where the family doc is superior to most high-billing cardiologists who want the higher level of evidence and the higher gross billing. Not all, but many......

You are permitted one extra beat on the whole flat x 1/2 x 11 EKG sheet. If that's all you have, it's a nonissue....if accompanied by a letter saying that he thinks your family history is such that CAD is unlikely to be an issue, you lack most of the risk factors, and that you have a clear association with pseudoephedrine.

I actually think that at age 50, if you have any risk factors a one time plain stress treadmill is a reasonable screening tool. If you have no risk factors, it sucks.

FAA's view: I'm working a case on a 48 y.o from Moline who went to the 80 y.o.+_ AME in Princeton, IL and he heard an extra beat. Deferral, Stress treadmill, Echo and Holter are spotless. I'll get him issued next week. What did he hear? He has atrial 3 beat tachycardias at a rate of 120. Big deal.

The proper approach for an AME: Listen carefully, do an EKG and try to catch it, and see what it is. If it's something like my guy from Moline, it's a big nothing. Issue the certificate.