pay out of pocket for Holter electrocardiogram monitor?
February 12, 2016 3:12 PM Subscribe
How do I ask my physician for a (not medically necessary) wearable electrocardiogram study?
I still get really mild (but worrying) chest pain during all-out cycling efforts. I've had a stress test with this result:
"Patient exercised for 10 min and 04 sec on a standard Bruce
protocol, achieving a maximum HR of 154 bpm (89% MPHR) and 12.8
METs, consistent with very good exercise capacity. Patient did
not experience any chest discomfort during the procedure, and
stopped due to dyspnea. Normal blood pressure and heart rate
response to exercise. No ischemic ST changes noted at rest or
with exertion. Isolated single PAC's noted."
So, yeah, I ran out of breath (dyspnea). I smoked a pack a day for 10 years & it's only when cycling familiar roads that I can pace myself to run my heart and legs at max effort without running out of breath. I offered to bring in a bicycle & trainer for the in-office electrocardiogram, but the protocol on the stress test calls for particular durations at various inclines.
In light of that, I looked at either buying a dodgy "USB EKG" or building something: there's a whole DIY community that also teaches each other how to read the results. Then, if I found something, I could show my Dr. & ask for legit testing.
But it's been 2 1/2 years and I still haven't done anything about it. I also haven't had a heart attack. I'm 48, cholesterol and blood pressure are OK and I'm just a bit overweight.
So, should I ask the Dr. for a 24 or 48 hour study with a wearable Holter monitor ECG so I can go induce my symptoms? I saw someone mention a price of ~$500 (but 10 years ago) which is totally worth it for peace of mind. That might have been the cost just for gathering the data, not including the analysis.
How does one ask a medical professional for something they don't think is justified without being a jerk?
I still get really mild (but worrying) chest pain during all-out cycling efforts. I've had a stress test with this result:
"Patient exercised for 10 min and 04 sec on a standard Bruce
protocol, achieving a maximum HR of 154 bpm (89% MPHR) and 12.8
METs, consistent with very good exercise capacity. Patient did
not experience any chest discomfort during the procedure, and
stopped due to dyspnea. Normal blood pressure and heart rate
response to exercise. No ischemic ST changes noted at rest or
with exertion. Isolated single PAC's noted."
So, yeah, I ran out of breath (dyspnea). I smoked a pack a day for 10 years & it's only when cycling familiar roads that I can pace myself to run my heart and legs at max effort without running out of breath. I offered to bring in a bicycle & trainer for the in-office electrocardiogram, but the protocol on the stress test calls for particular durations at various inclines.
In light of that, I looked at either buying a dodgy "USB EKG" or building something: there's a whole DIY community that also teaches each other how to read the results. Then, if I found something, I could show my Dr. & ask for legit testing.
But it's been 2 1/2 years and I still haven't done anything about it. I also haven't had a heart attack. I'm 48, cholesterol and blood pressure are OK and I'm just a bit overweight.
So, should I ask the Dr. for a 24 or 48 hour study with a wearable Holter monitor ECG so I can go induce my symptoms? I saw someone mention a price of ~$500 (but 10 years ago) which is totally worth it for peace of mind. That might have been the cost just for gathering the data, not including the analysis.
How does one ask a medical professional for something they don't think is justified without being a jerk?
i think the first step is to realise that you're not a jerk. you're concerned, willing to pay your way, and not doing anything unethical.
posted by andrewcooke at 3:38 PM on February 12, 2016
i get pain that i was unable to reproduce in the lab study. this is a problem: it worries me and it's affecting how much exercise i take. if i pay for a monitor myself to wear, and cycle to reproduce the pain, could you then look at the results? if not, i am going to continue to be worried about this.(more generally - i say this as someone with a chronic illness - managing your doctor, and building a relationship with them, is important and can really produce useful results. play nice. be a good patient however you can. thank them. pay attention. smile. ask about their kids. etc etc.)
posted by andrewcooke at 3:38 PM on February 12, 2016
Is your physician remotely reasonable? I don't know why they'd say no as long as you're up-front about your willingness to pay whatever this test costs. I recently asked my physician for a sleep apnea test despite not having really any of the symptoms (except being tired all the time), and she told me she doubted I had sleep apnea but the test could certainly rule it out. And then I paid my co-pay and had the test, which ruled out sleep apnea. Just list your symptoms and ask!
posted by jabes at 3:42 PM on February 12, 2016
posted by jabes at 3:42 PM on February 12, 2016
Just ask. The entire point of 24 or 48 hours outpatient monitoring is to try and capture cardiac events that didn't occur in hospital.
You requesting a very reasonable test for yourself, there's no reason anyone would say no.
posted by Silentgoldfish at 4:48 PM on February 12, 2016 [1 favorite]
You requesting a very reasonable test for yourself, there's no reason anyone would say no.
posted by Silentgoldfish at 4:48 PM on February 12, 2016 [1 favorite]
Best answer: You really need to go talk to your doctor about this.
IANYD but here are a few things you should know to start with.
#1 and most important, please do not get a black market EKG!! I can't think of a worse idea - I wish you hadn't told me there are communities of people out there trying to read their own EKGs. It's difficult enough for doctors to have a tough time with it. Lay people trying to read their own gives me palpitations!
- A treadmill stress test evaluates for ischemic heart disease, meaning blockages in blood vessels. The idea is that when your heart is working hard, a partial blockage will cause part of your heart not to receive enough oxygen through that particular blood vessel and it will be seen on the tracing. Your stress test was normal, which would suggest that you have no such blockage. You should not obsess about the fact that you got short of breath. The whole idea of the test is to achieve close to your maximal predicted heart rate, meaning have you exercise as hard as possible, that was the point. Your heart rate was adequate for interpretation of the test - anything above 85% of predicted is adequate.
- A Holter monitor is not the same as a stress test, it isn't looking for the same problems. A Holter monitor watches the rhythm of your heart to look for electrical problems - arrhythmias - it does not evaluate for blockages in blood vessels.
- There are other types of testing that might be reasonable, depending on your specific situation, such as an echocardiogram (that looks at your heart function and valves), or even a cardiac catheterization (only done if felt truly necessary as this is invasive).
- The bottom line is, it's been over 2 years since you had your stress test. That test is no longer applicable now because it cannot predict what's going on with your heart currently.
- You don't need to try to guess what you need now and go to your doctor with some kind of menu order that you're willing to pay cash for! All you need is to go in there and say "I'm still having worrying chest pain with exertion. What else can we do to figure out what the reason for this is?" And voila, your doctor will tell you what the medically indicated testing is, and your workup should be covered by insurance.
This is editorializing but I feel like with the prevalence of "Dr. Google", people feel like if they don't "do their research" before going to the doctor and try to figure out what their problem is or what tests they need, then they've failed in some way. I'm not saying don't educate yourself on diagnoses or tests, but at the same time, going to the doctor with a pre-conceived idea of what you need done is problematic for a whole bunch of reasons.
This is easier than you think. Go to discuss your problem, and talk to them about what you need. It's what you're paying them for. If you don't have a doctor who will talk to you about your problem and explain it to you adequately, get a new doctor or a second opinion.
posted by treehorn+bunny at 5:28 PM on February 12, 2016 [11 favorites]
IANYD but here are a few things you should know to start with.
#1 and most important, please do not get a black market EKG!! I can't think of a worse idea - I wish you hadn't told me there are communities of people out there trying to read their own EKGs. It's difficult enough for doctors to have a tough time with it. Lay people trying to read their own gives me palpitations!
- A treadmill stress test evaluates for ischemic heart disease, meaning blockages in blood vessels. The idea is that when your heart is working hard, a partial blockage will cause part of your heart not to receive enough oxygen through that particular blood vessel and it will be seen on the tracing. Your stress test was normal, which would suggest that you have no such blockage. You should not obsess about the fact that you got short of breath. The whole idea of the test is to achieve close to your maximal predicted heart rate, meaning have you exercise as hard as possible, that was the point. Your heart rate was adequate for interpretation of the test - anything above 85% of predicted is adequate.
- A Holter monitor is not the same as a stress test, it isn't looking for the same problems. A Holter monitor watches the rhythm of your heart to look for electrical problems - arrhythmias - it does not evaluate for blockages in blood vessels.
- There are other types of testing that might be reasonable, depending on your specific situation, such as an echocardiogram (that looks at your heart function and valves), or even a cardiac catheterization (only done if felt truly necessary as this is invasive).
- The bottom line is, it's been over 2 years since you had your stress test. That test is no longer applicable now because it cannot predict what's going on with your heart currently.
- You don't need to try to guess what you need now and go to your doctor with some kind of menu order that you're willing to pay cash for! All you need is to go in there and say "I'm still having worrying chest pain with exertion. What else can we do to figure out what the reason for this is?" And voila, your doctor will tell you what the medically indicated testing is, and your workup should be covered by insurance.
This is editorializing but I feel like with the prevalence of "Dr. Google", people feel like if they don't "do their research" before going to the doctor and try to figure out what their problem is or what tests they need, then they've failed in some way. I'm not saying don't educate yourself on diagnoses or tests, but at the same time, going to the doctor with a pre-conceived idea of what you need done is problematic for a whole bunch of reasons.
This is easier than you think. Go to discuss your problem, and talk to them about what you need. It's what you're paying them for. If you don't have a doctor who will talk to you about your problem and explain it to you adequately, get a new doctor or a second opinion.
posted by treehorn+bunny at 5:28 PM on February 12, 2016 [11 favorites]
Best answer: Coming in to agree with Treehorn+bunny (IAAD, IANACardiologist - have we got any cardiologists on here? Haven't spotted any so far)
The reason that strapping on a Holter and going for a bike ride will not tell you if you have significant coronary heart disease is that you can induce ECG changes in anyone and everyone, regardless of the state of their coronary arteries, if you stress their hearts hard enough and for long enough. I have seen plenty of previously-healthy twentysomethings in ITU who have had "heart attacks" in the context of multi-organ failure. That is not coronary artery disease.
Are you using a heart rate monitor when you get the chest pain? Are you by any chance way outside of your target HR when you get this chest pain? I have 20yr old friends (oh ok it was me a few years ago) who get chest tightness when they push their heart rate over 200 doing intervals. That isn't coronary artery disease either; it's being too tachycardic to adequately fill your coronaries between beats (they fill during diastole).
The Bruce and modified-Bruce protocols are used because they are standardised and extensively validated - an abnormal Bruce test shows inducible ischaemia which in turn has a sensitivity of 73-90% for clinically significant coronary artery disease (but a specificity of only 50-74%). Equally a normal test does not exclude all coronary artery disease - you can have mild atheroma, or even some types of complete (and thus irreversible) coronary artery occlusion, without inducible ECG changes. You need to understand the limitations of the test).
There are other tests available - a myocardial perfusion scan will use drugs to get your heart rate up to the required level, and then look for inducible ischaemia. It will also show "dead" bits of unperfused myocardium. It won't completely exclude coronary artery disease though, just disease severe enough to cause perfusion defects.
An angiogram will show the state of your arteries, but it is very invasive, and comes with its own risks (bleeding is very common, and I see a few patients a year who have been pushed onto dialysis by either cholestrol emboli or by contrast nephropathy). One would only stent a lesion causing a significant, ie >70%, occlusion, and given your zero risk factors and to be honest completely non-anginal-sounding symptoms, I doubt you would be able to persuade anybody that the benefits of doing an angiogram outweighed the risks in your case unless there was something else to suggest an underlying heart problem.
Talk to your cardiologist about this. They can look at the whole clinical picture, will actually have the benefit of examining you and being able to see your resting ECGs, can go into your symptoms in more detail and work out what IS causing the pain if it isn't angina. You aren't remotely being a jerk to be worried about chest pain - it is strongly associated with heart attacks in popular culture, and that would worry anyone. But there are lots of other possible reasons for your symptoms which are equally if not more likely than coronary artery disease given your young age, the long duration of symptoms, previously normal treatmill test and lack of other risk factors.
posted by tinkletown at 7:02 PM on February 12, 2016 [1 favorite]
The reason that strapping on a Holter and going for a bike ride will not tell you if you have significant coronary heart disease is that you can induce ECG changes in anyone and everyone, regardless of the state of their coronary arteries, if you stress their hearts hard enough and for long enough. I have seen plenty of previously-healthy twentysomethings in ITU who have had "heart attacks" in the context of multi-organ failure. That is not coronary artery disease.
Are you using a heart rate monitor when you get the chest pain? Are you by any chance way outside of your target HR when you get this chest pain? I have 20yr old friends (oh ok it was me a few years ago) who get chest tightness when they push their heart rate over 200 doing intervals. That isn't coronary artery disease either; it's being too tachycardic to adequately fill your coronaries between beats (they fill during diastole).
The Bruce and modified-Bruce protocols are used because they are standardised and extensively validated - an abnormal Bruce test shows inducible ischaemia which in turn has a sensitivity of 73-90% for clinically significant coronary artery disease (but a specificity of only 50-74%). Equally a normal test does not exclude all coronary artery disease - you can have mild atheroma, or even some types of complete (and thus irreversible) coronary artery occlusion, without inducible ECG changes. You need to understand the limitations of the test).
There are other tests available - a myocardial perfusion scan will use drugs to get your heart rate up to the required level, and then look for inducible ischaemia. It will also show "dead" bits of unperfused myocardium. It won't completely exclude coronary artery disease though, just disease severe enough to cause perfusion defects.
An angiogram will show the state of your arteries, but it is very invasive, and comes with its own risks (bleeding is very common, and I see a few patients a year who have been pushed onto dialysis by either cholestrol emboli or by contrast nephropathy). One would only stent a lesion causing a significant, ie >70%, occlusion, and given your zero risk factors and to be honest completely non-anginal-sounding symptoms, I doubt you would be able to persuade anybody that the benefits of doing an angiogram outweighed the risks in your case unless there was something else to suggest an underlying heart problem.
Talk to your cardiologist about this. They can look at the whole clinical picture, will actually have the benefit of examining you and being able to see your resting ECGs, can go into your symptoms in more detail and work out what IS causing the pain if it isn't angina. You aren't remotely being a jerk to be worried about chest pain - it is strongly associated with heart attacks in popular culture, and that would worry anyone. But there are lots of other possible reasons for your symptoms which are equally if not more likely than coronary artery disease given your young age, the long duration of symptoms, previously normal treatmill test and lack of other risk factors.
posted by tinkletown at 7:02 PM on February 12, 2016 [1 favorite]
Response by poster: > Are you using a heart rate monitor when you get the chest pain? Are you by any chance way outside of your target HR when you get this chest pain?
I wasn't using a monitor, but did today and hit only 152 bpm (1)(2) while feeling some discomfort. I noticed Strava thinks my max heart rate is 190, which seems crazy high. My stress test max of 154 claiming 89% of MHR means their max is 173 which was the simple (220 - age).
I had no idea that a Holter wasn't just a simplified ECG (because I'm not a cardiologist & now see that playing one on the internet is not helping). I'll go see the Dr. with my concern & continue to collect heart rate info in the meantime.
posted by morganw at 2:42 PM on February 28, 2016
I wasn't using a monitor, but did today and hit only 152 bpm (1)(2) while feeling some discomfort. I noticed Strava thinks my max heart rate is 190, which seems crazy high. My stress test max of 154 claiming 89% of MHR means their max is 173 which was the simple (220 - age).
I had no idea that a Holter wasn't just a simplified ECG (because I'm not a cardiologist & now see that playing one on the internet is not helping). I'll go see the Dr. with my concern & continue to collect heart rate info in the meantime.
posted by morganw at 2:42 PM on February 28, 2016
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I also complained of pain in my chest area but he seemed not too concerned because like you I am a little overweight. I work a sedentary job in IT (sitting at a desk/computer all day) and don't get much physical exercise.
Chest pain like pressure and difficulty breathing is more concerning. Any reason why you can't pitch this as a preventative measure?
A cardiac holter monitor is what I think you're looking for. It will monitor you for whoever long the doctor decides it should. Could be 24-48 hours, could be longer. In my father's case he wore it for 30 days.
Have you looked at something like this from AliveCor? AliveCor Mobile ECG or from QardioCore? I don't have experience with either one but searched for portable EKG. I read an article a couple of weeks ago about how the writer's wife's life was saved because they used the AlivCor ECG when she was having chest pain at home.
I suspect your doctor may take the easy (or lazy) route and just say that you're out of shape and to change your diet and exercise more but it's really up to you to advocate for yourself and insist (politely). If not then you can always go to another doctor. They work for you, remember that. Maybe you do have an issue but it will give you great piece of minds if you don't.
Good luck.
posted by eatcake at 3:34 PM on February 12, 2016