What did the sawbones see?

April 3, 2012 5:50 PM

Internet strangers well-versed in cardiology, lend me your insight! My sister had a stress echocardiography / treadmill test today and is awaiting the results. The attending physician had some funny questions for her that made her wonder about a possible abnormal result.

She passed the running test with ultrasound just fine, but the doctor waited until everyone out of the room to ask if she'd ever been a cocaine user -- she hasn't ever used illegal drugs and told him so. Doctor apparently said he expected her heart to be "brighter" or "bigger" on the ultrasound. You are not her doctor, of course, but what could he be talking about?

She's early thirties, married, children. Has always been reasonably fit. Drinks in moderation, used to smoke. No real physical ailments other than 3 -4 migraines a month, until about a year ago, when a host of things started happening ( fatigue, strange mottled rashes, bouts of dizziness and confusion, sporadic muscle weakness, joint pain, and heart symptoms -- palpitations that wake her from sleep, for instance). MRI on brain came back clean - no signs of MS. RA factor blood test was negative.

TLDR - what would an MD see on a stress test that would lead them to think of cocaine usage, on a patient that's never used cocaine or any illicit substance?

posted by heigh-hothederryo to health & fitness (9 answers total)

Whether or not someone is or was a cocaine user is pertinent information for any young person undergoing a cardiology evaluation. He probably asks that question of everyone, and waited til everyone was out of the room for privacy.

I suspect there was a miscommunication. I am not a cardiologist (and IANYD) but hearts are always a standard brightness level on ultrasound (the "brightness level" or echogenicity of tissue with the density of muscle) and having your heart be bigger is not usually a good thing, because that would typically indicate some degree of heart dysfunction.
posted by treehorn+bunny at 6:33 PM on April 3, 2012

I am not a doctor, but yeah, betting that it was a standard question, or that it was related to her history of heart palpitations.

(Unsolicited comment: her symptoms, especially the rash/joint pain, sound like possible lupus, or celiac's disease. Is she working with an internist, rather than a general md?)
posted by shortyJBot at 6:59 PM on April 3, 2012

Anecdata: I also had an exercise stress test today (wheeee!) and I wasn't asked about illegal drugs or alcohol at all, just smoking. I had different symptoms than your sister that led to my stress test, though. I got my stress test results right away (everything looked normal). My echocardiogram was at a different time than the stress test, too.
posted by booksherpa at 7:11 PM on April 3, 2012

I had a exercise stress test and a nuclear stress test and I can say that if there was something immediately wrong that the doctor could identify, your sister would not have left the room without a plan to immediately address the issue. Cardiologists do not send patients home with abnormalities without knowing what that abnormality is. In my case, even having gone longer than the average person in my age, sex and physical condition category, I was sent directly to have an angioplasty that led to two stents. I wanted to go home and change and then have my then wife drive me to the other hospital and after much arguing and a conversation with a surgeon friend, I was in the back of a meat wagon; did not pass go, did not collect $200.

As part of the prep admittance work for the nuclear stress test, I was asked about smoking, illegal drug use, alcohol use and to list all medications I took in the last 2 years. Also asked detailed questions about immediate family and heart disease. I am sure that the question about the cocaine was asked as part of a routine questioning and Dr. wanted to give privacy and if there was an issue maybe a higher probability that your sister would 'fess up.
posted by JohnnyGunn at 7:45 PM on April 3, 2012

I don't think the doctor (necessarily) saw anything abnormal in your sister's echocardiogram, much to his surprise. He was obviously expecting increased echogenicity of cardiac muscle tissue ("brighter"), and an enlarged heart ("bigger"). He must have been basing his expectations on your sister's presenting history. What else?

When his expectations weren't met he's turned to questioning cocaine use. Your sister is in the right age group for cocaine-abused heart. Cocaine is rugged on the heart in acute and chronic ways.

I don't think your sister can draw any conclusions from her post-procedure interaction with the doctor. It's like he was reasoning aloud ... not at all informative.

It's possible: no abnormalities were detected.
posted by de at 9:45 PM on April 3, 2012

<3 you all. Thank you for your wisdom.

A few more details from the conversation - second-hand, so grain of salt, yes? -- sister's impression was of the doctor saying he was surprised because her heart did not look like what a reasonably fit, early 30-something heart should look like, and that he seemed embarrassed to be asking the coke question, but needed to because of the unexpected difference. She also didn't think he had any history on any of her other symptoms, just "referral re: palpitations."
posted by heigh-hothederryo at 10:43 PM on April 3, 2012

The weird assortment of symptoms could be due to Lyme disease. Standard tests for Lyme have high false negatives. I had what was probably undiagnosed Lyme (or something related) that got worse and worse and worse until I finally talked my doctor into giving me the proper antibiotics, because a friend's mother insisted I had Lyme. Within the week I felt so much better. My collection of symptoms there at the end sounds much like your sister's, with the exception of the rash. Lyme is frequently misdiagnosed and some (many?) doctors are not well educated on it. Even if your sister has already had tests for Lyme, it's worth seeing a Lyme specialist or Lyme-educated doctor to re-evaluate.
posted by parrot_person at 2:20 AM on April 4, 2012

I don't know about a grain of salt. The additional information does create a different impression.

The doctor was expecting a normal 30-something heart and witnessed some "smaller" and "less bright" cardiac structure than expected. It's reasonable to suspect some anomaly has been detected. Given the conversation, the result was clearly worthy of remark.

There really is no guessing. Valve? Chamber? Wall?

Encourage your sister to speak to her referring doctor before he or she disappears for easter. It seems a little unfair to keep your sister worried for herself when the results may already be written up.
posted by de at 7:17 AM on April 4, 2012

Now that I see your follow up, I think your question is really "what relevance does cocaine use have to cardiac health?" That, I can answer.

Cocaine causes coronary vasospasm, which is a fancy way of saying it causes the blood vessels in your heart to constrict. This can cause early heart attacks. When I see people in their 20s and 30s who have had heart attacks, the majority of the time, it's cocaine-related - even really horribly genetics don't usually get you a heart attack before 35.

I certainly don't mean to scare you about your sister's echo, and this could have nothing to do with what was seen, but if the heart was not beating quite as well as would be expected (i.e. what echocardiographers call "wall motion abnormalities" that usually indicate prior heart attack or overall decrease in cardiac function/cardiomyopathy) then that would prompt me to ask about cocaine use in a young person. I would also add though that that may have been a cardiology fellow if she was at a teaching hospital and perhaps the final reading would come from someone else who did not find anything unusual with the study. Things like wall motion abnormalities can sometimes be pretty subtle.
posted by treehorn+bunny at 3:43 AM on April 5, 2012 [1 favorite]