Re: Cardiologist too conservative?

On May 29, 11:30 am, "Zen Cohen" <atu...@[EMAIL PROTECTED]
> wrote:
> I had to take a treadmill stress test yesterday because I had minor
> right-side chest pain a couple weeks after a 40% spontaneous
pneumothorax in
> my right lung. I suspect the test was overkill but I wasn't going to
defy my
> doc's advice.
>
> He said he'd calculate 220 minus my age (49) so limited the test to 171
bpm.
> I told him that I sometimes approach 180 when exercising and that I'd
like
> to see if there are any problems when my heart reaches that range. Also
said
> I'd heard the 220-minus-age formula was arbitrary, He agreed but said it
was
> a good rule of thumb and summarily dismissed my request by pronouncing I
> just shouldn't exercise above my 220-minus-age. I realize that there is
some
> additional risk by exercising at higher heart rates but I'm willing to
take
> some measure of risk because I like to push myself and better my
> performance. Nonetheless he stopped me right at 171. I feel like the
doctor
> didn't do me a service because he didn't provide a sufficient reason for
> this and it seems his refusing to let me go further may have left him in
the
> dark about potential problems that could develop in these higher ranges
if I
> don't follow his advice.
>
> I get the impression this cardiologist knows plenty about counseling and
> treating sedentary or ill patients but has no interest in advising
fitter
> patients who want to push their endurance without undue risk. Has anyone
had
> experience with cardiologists who are more fitness-friendly? What have
they
> said about the risks of exercising at or near max HR?
>
> BTW, it took me 15:30 to reach my "max" HR. He said his patients
normally
> don't last longer than 11 minutes but heard of some accomplished
athletes
> going over 20 minutes. I might've gone another minute or so but nowhere
near
> 20 (with the speed/incline increases every minute). If you've done this
> test, how long did you go?

Hi Zen, A couple of years ago I used to do a day of treadmills once a
week. Most of the patients did a standard Bruce protocol which is the
increase grade and speed at intervals. The idea is to complete a
certain amount of stages based on the patient's age. While the patient
is exercising, I am watching the EKG tracing for abnormalities and
watching the patient for signs of discomfort or fatigue.

The results of the exercise treadmill test (ETT) can help to diagnose
causes of chest pain and can help to predict if there are existing,
fixed atheroscl*****c narrowing s to the coronary arteries.

In your case, the pretest likelihood of you having coronary artery
disease as a cause of your atypical, right-sided chest pain was small.
It was most likely pleuritic pain due to the pneumothorax. But since
an ETT is an easy to perform, noninvasive test of function it was
worthwhile to order.

I can't tell from your description exactly which protocol was used,
and it doesn't matter. For explanation sake I'll discuss a Bruce
protocol. It consists of four 3-minute stages and involves changes in
both grade of incline and speed of treadmill. Stage 1 is 1.7 mph and
10% grade, stage 2 is 2.5 mph and 12% grade, stage 3 is 3.4 mph and
14% grade and stage 4 is 4.2 mph and 16% grade.

Once you have completed a Bruce protocol, you've completed the ETT.
The heart rate is another parameter that can be monitored. I want to
see a patient get to the minimum predicted exercise heart range. I may
stop the test on a patient who appears fatigued, winded and has
reached higher than the average predicted maximal heart rate.

In your case, if you felt fine I would have let you keep going even if
you had passed the predicted maximal heart rate limit. It's only an
average and a guideline. OTOH, if you had already exercised 15:30
without any worrisome symptoms or changes on your EKG, you had already
passed the test if a Bruce protocol was used. No further information
would be gained by continuing to exercise or pu****ng your heart rate
higher. The question, "was this atypical right-sided chest pain due to
a fixed blockage of a coronary artery or are there any other
significant existing blockages at this time?" was answered, and the
answer is, "no."