On The Treadmill Longstanding Exercise Stress Test Remains Valuable Tool In Diagnosing Heart Disease
More exhausted than usual after a day’s work, Princetta Snow came home one night 15 years ago feeling feverish and nauseated.
She thought she had the flu.
“I thought it was something I had eaten that day, that my stomach was doing a number on me,” said Snow, now 39, of Los Angeles. “I had a little pain, like a pinpoint prick in the middle of my chest.”
When her discomfort wouldn’t subside, she went to the hospital’s emergency room. After three hours, physicians finally came up with a diagnosis: She was having a heart attack.
“I nearly flipped out. I said, ‘You guys are crazy. I didn’t have a heart attack,”’ Snow said. “I just hit the ceiling when they started talking pacemaker because, you know, at age 24, I couldn’t imagine that happening to me.”
Would anyone have thought to check a seemingly healthy 24-year-old woman for cardiac disease?
And should they have?
Such questions are posed even today in the wake of the death of Sergei Grinkov, an Olympic pairs ice skater who suffered a fatal heart attack Nov. 20 while practicing with his wife in New York. He was 28.
Doctors say Grinkov, whose father died of a heart attack at 52, could have taken preventive measures had he taken a stress test that determines how the heart functions during exercise. An autopsy revealed that two of Grinkov’s coronary arteries, including one called “the widowmaker,” were almost completely blocked.
“I think, had the skater had a treadmill (test) before the event, it would have picked up the abnormality and could have been addressed before he died,” said Dr. John Hess, a Thousand Oaks, Calif., cardiologist and past president of the Las Virgenes affiliate of the American Heart Association.
In a stress test, patients step onto a specially programmed treadmill while being hooked up to electrodes that monitor heart rate and rhythm, and blood pressure. Cardiologists watch the patient for symptoms during exercise, particularly angina, a drop in blood pressure, critical electrocardiogram changes or lightheadedness. If any appear, the test stops. Stress tests range from $400 to $1,200 and are covered by most insurance companies when ordered by a doctor.
“It’s one of those tests that carry so much validity about such an important disease, it’s rarely turned down for the appropriate indications,” Hess said.
Still, cardiologists don’t routinely prescribe stress tests to patients in their 20s, particularly those who are athletes. Even the American Heart Association does not recommend them for routine screening, even if they’re a good method of checking for coronary artery disease.
So who would benefit most from the test?
Stress tests are commonly used on patients known to have heart disease, said Gregg Fonarow, assistant professor at the University of California, Los Angeles, School of Medicine and associate director of the cardiomyopathy program.
Cardiologists also order stress tests for patients who have a family history of heart disease, especially if the parents died young from a heart attack or if they have high blood pressure, diabetes or are smokers.
“If you try to screen individuals who have no symptoms … you do a tremendous number of tests to find a very small number of individuals,” he said. “You could spend millions of dollars trying to identify a small number of individuals at risk.”
And plenty of people are at risk. Coronary heart disease is the No. 1 killer of men and women, causing 480,200 deaths in this country in 1992, the latest statistics available.
This year, the American Heart Association predicts, 1.5 million Americans will have heart attacks, 500,000 of which will be fatal.
Based on the ongoing Framingham Heart Study in Massachusetts, only 5 percent of all heart attacks occur in people under 40, while 45 percent occur in people under 65. The Framingham study has followed 10,000 residents of a small Massachusetts town for the past 40 years and is credited with shaping modern notions about cardiovascular disease.
To screen for heart disease, doctors are more likely to start with cholesterol tests. A desirable cholesterol level is below 200.
“Everybody gets at least one cholesterol test between the ages of 20 and 40,” said Dr. Cydney Stewart, a cardiologist at Kaiser-Permanente Hospital in Woodland Hills. “They need to have at least one. If it’s normal, it doesn’t have to be repeated until they’re older.”
Some must make stress tests a regular part of their lives.
Snow, who was given a pacemaker at 24 and a defibrillator at 38, now takes a stress test every six months. After her heart attack, Snow realized she had two crucial risk factors: She smoked, and her mother and grandfather died of heart disease.
She had a leg injury a few years ago, slowing down her activity, but she is walking with other women in her apartment building for exercise.
“I really do not have any restrictions per se. I come and go as I please, as much as my body will allow me,” Snow said.
Robert Carey, 64, of Westlake Village, must have an annual stress test because of a repair to one of his valves and a coronary bypass procedure two years ago. During a recent stress test in Hess’ office, Carey walked briskly on the treadmill with no shortness of breath.
Carey’s heart rate was taken up to 90 percent of his suggested maximum heart rate for his age (calculated by subtracting his age from 220, and then taking 90 percent of that figure).
“He really kicks on the treadmill,” said Hess. “He aced it.
“He went far beyond what you would expect for his age group. He went nine minutes, 31 seconds.”
Carey has exercised all his life, and now that’s he’s retired from sales, has more time for walking.
“I do it on a religious basis,” he said.
Cardiologists will acknowledge, however, that there are several cases in which a patient undergoes a stress test with positive results but then suffers a heart attack weeks or months later.
Essam Amarragy, 34, of West Covina, Calif., had a stress test two years ago but suffered a heart attack last June.
He decided to go for the complete checkup in 1993 because his father died of a heart attack at 53. A drafting technician for the city of Los Angeles, Amarragy knew he had high cholesterol but was told by his doctor at the time that no other abnormalities were found during his stress test.
In June, Amarragy felt severe pain in his shoulder and elbows but no chest pain. He went to the hospital, where cardiologists found one artery completely blocked and another partially blocked.
Amarragy’s arteries had deteriorated in the two years since he received the stress test. His clogged arteries were opened with balloon angioplasty, but the procedure had to be repeated a few months later.
“I never thought I’d go through all of this,” said Amarragy, who is married and has two young children.
Dr. David Cannom, Amarragy’s cardiologist, is not surprised that Amarragy’s previous stress test didn’t pick up any abnormalities.
“A two-year stress test is ancient history,” said Cannom, medical director of cardiology at Good Samaritan Hospital in Los Angeles. “Typically a stress test is good for nine months to a year,” Cannom said. “He had a lot going on two years earlier. We just didn’t pick it up because the tests weren’t sensitive enough.
“We’re going to do (stress tests) every three months (for the first year). We don’t want anything to happen to him in the early phase after he had all this fancy work done.”
While researchers are constantly looking for new testing devices, the decades-old stress tests have not been rendered obsolete. Even with the increase of rapid CT scanning to examine the heart, which can find evidence of arteriosclerosis before the arteries are clogged, Hess still believes in the stress test.
“The number of testing modalities has increased,” Hess observed. “However, what’s interesting is that none of these has really put treadmill testing aside. It’s still an important testing tool.”