Preparing for a doctor appointment
June 17, 2009 3:36 PM   Subscribe

When, if ever, is it reasonable to ask for a preemptive test? Given a family history of congestive heart failure I'm wondering how reasonable it is to reguest a MUGA or echocardiogram just to allay (or confirm) my own worries. I'm definitely already going to see a doctor, so I'm not asking for medical advice. I guess I am asking for perspective to help me frame my request with my physician.

I'm 53 and have an upcoming appt with my internist regarding a different matter. Since I made that appointment my slightly older brother died a few weeks ago of sudden cardiac arrest at age 56. Apparently he had been seeing a doctor for congestive heart failure for a while. My other brother (age 59) received a stent some years ago while being diagnosed with diabetes and some degree of congestive heart failure. My mother died at age 66 of -- you guessed it -- congestive heart failure. Until my younger-older brother died, I was aware that my family history was not great, but his death has catapulted the issue of CHF to top-of-mind, to say the least. Yet...

I have what I assume to be the usual litany of complaints about getting older, but I tend to think of them as not really rising to the level of needing to be addressed. I received a good bill of health at my physical last year, along with the usual lifestyle warnings. (Salt, alcohol, maybe I should do some strength work in addition to walking, etc.) I just don't feel I have any acute physical complaints that would justify tests that are probably kind of expensive.

For anyone with perspective from the US health care community, am I one of those "walking worried" patients driving up costs for everyone, or would it be reasonable to push hard for a test to rule early CHF in or out?
posted by anonymous to Health & Fitness (12 answers total)
With your age and family history it is definitely reasonable to think about a cardiac workup. However you want to consider your own health also. Are you an overweight/high cholesterol/diabetes type of person, or did you just finish running your n-th marathon last week? Do you now or have you ever had a history of heart problems or symptoms (chest pain, difficulty breathing, palpitations, etc)?

Being aware of your heart's health is a smart thing to do, but I wouldn't jump to a MUGA or Echo right away. Depending on your activity level, a regular old ECG and a exercise stress test would probably come first. I'd also check your triglycerides and cholesterol levels. (MeFi internists/cardiologists correct me if I'm wrong here.)

However, the most important thing you can do is ask your internist about this when you meet. If he decides not to do any cardiac testing on you at this point, make sure you are crystal clear about why not and when he eventually will (at your next yearly physical at least).
posted by ruwan at 3:49 PM on June 17, 2009

Preventive care is always less expensive than after-the-fact care. I can't see any HMO's balking at stuff you're asking for.

If you had a heart attack (and survived it), it would be a lot more expensive to care for you.

These days, it's my understanding that, if you get adequate care, there is no reason to die of heart disease. I could be wrong.

But I would encourage you to get whatever preventative care you feel you would benefit from.
posted by Danf at 3:50 PM on June 17, 2009

I'm 51 and your medical genealogy is almost as bad as mine. It would be absurd not to do any testing. I've done stress and echo in 2005, and I exceeded the target for my age limit. They patted me on the back and told me to come back in five years or so.

Get it done. No responsible provider would deny it.
posted by jgirl at 4:28 PM on June 17, 2009

You have had multiple members of your family die from complications in the same area, at an age not much above where you are. It wouldn't matter what area this is, asking for extensive testing is more than fair. Exceptionally so since it's your heart.

I can't think of a single doctor who would hear your family history and even raise an eyebrow at you asking for complete testing. Ask for whatever testing you want. Your HMO might whine and complain a little, but looking at your family history, I think they'd find it to be a worthwhile investment considering the risk.

If an HMO would consider it worthwhile on the basis of profit, I'd dare say with your life in consideration, it's worth asking for.
posted by Saydur at 5:46 PM on June 17, 2009

By all means, get whatever tests will reveal what is going on with your circulatory system.

A 51 year old friend of mine, very fit, with great health habits and exemplary cholesterol levels, but also with heavy-duty heart disease in her family (both of her parents died in their 60s of it), just suffered two strokes. She'd been having intermittent symptoms of disorientation, strange vision events, etc., and was trying to find out why. But apparently her doctor failed to order for her the tests she needed to find the problem. Turns out her carotid artery was 95% blocked on one side, 30% on the other. She was given one stent, and is now recovering, thank God.

You have to push for the tests you need to know what's going on.

So sorry for the sudden loss of your brother, and the earlier loss of your mother.

Good health to you.
posted by sparrowdance at 6:56 PM on June 17, 2009

I think that you'll do better instead of coming in with a list "I want XYZ done" to ask "What kind of primary prevention can I do to reduce my risk heart failure? What's the path to heart failure that I can prevent? What do we need to watch for?"

MD will probably do a stress test, think about beta blockers if your BP looks sideways at her.
posted by a robot made out of meat at 7:00 PM on June 17, 2009

I don't see a problem with asking for a cardio workup when you have this sort of family history. Hell, I had a stress test and echo last year, and I'm 34 (due to suddenly high bp and family history of heart disease). Just mention your family history, say you are concerned and want to get an idea of your heart health so you can get a better idea of your risks and what to do for prevention. Your health care provider should be happy to take a closer look, given your family history.
posted by bedhead at 8:10 PM on June 17, 2009

Don't just get some horses ass stress test done -- have these folks take a serious peek inside, shoot that dye in or whatever it is they do. Voice of experience -- I died three times July 6 2004, a genetic 'gift' from my mothers side of the family; how nice! And I knew I had something going on, I thought again and again as I'd run or swim or whatever "Jesus, I'm dying!" and I went to my doc, scared, and he found nothing, he referred me to The Austin Heart Hospital, they found nothing because they didn't really look. Or maybe they just didn't have the tests available that they have now; you want them to watch your heart work, in real time, check for any blockages, any problems.

You don't need to be diabetic or overweight or have high cholesterol or anything of the sort; I was running and biking and swimming and eating organic vegetarian, etc and etc and etc. Had they done the correct tests they'd have seen the problem immediately, jammed a stent into my poor old heart and sent me home. But because they didn't test deeply enough I croaked, it's only because of the spectacular methods in use now that I am alive, typing this note here.

They also told me (I have of course gone and met each and every one involved, and thanked them, and my cardiologist is just a great guy also, younger than I am but runs the cardiology department at Brackenridge hospital; I see him next month, my yearly checkup, I always bust his balls about being a kid and stuff -- the guy rocks, we really have a time. I'm his favorite 'save', no one has been further out, and damn sure no one has come back as far as I have, either -- it's a hoot.) they told me that they thought I was much younger than I was -- I was 49 but with my hair cut short and without a beard I look like I'm 11 or 12 -- and also I was clearly in very good shape. They gave me their all. I owe them my life.

That said, I was wearing my favorite jeans when I showed up there, and they cut the son-of-a-bitching things off of me -- wtf is that all about? Dicks...

Anyways. I've insisted that all my brothers and sisters get every test there is. I was the only one, other than my mother, who had the exact same heart attack in the exact same location almost one year to the day after I had mine. But it so happened that she was in the hospital for some other testing; they popped into her vein or artery or whatever it is that they pop into, put in a stent in the same place mine is, and all was well.

Believe me. Take my word. This thing is so sweet, we are so lucky to get to be here. (Unless maybe you live in LA, in which case you may as well bag it.) Get every test you can. You just watched your brother pass from the scene, he left the game in the early innings. Life is so goddamned beautiful. Don't lose your life, don't let it slide because some mope doesn't want to run this test or that, or because you want to save a few grand or whatever; you've got a history, find out all you can about your current cardiac health and fix whatever needs fixing and then enjoy this thing, go buy a hat, an ice cream cone, a new car maybe, flirt with a pretty girl, tell her that you need her and stuff, go eat an apple.
posted by dancestoblue at 8:52 PM on June 17, 2009 [2 favorites]

Don't just get some horses ass stress test done -- have these folks take a serious peek inside, shoot that dye in or whatever it is they do.

Forgive me, but this is abjectly terrible advice that you have no business giving regardless of whatever did or didn't happen in your case. "Get every test you can" is complete non-sense, and may place the OP at risk for needless harm. "Shooting that dye" is an invasive procedure with a small but significant risk of major, life-threatening complications.

OP, talk to your doctor about this. It's perfectly reasonable to outline and get an idea of your risk of heart problems after a complete history and physical, and in your case if for nothing other than peace of mind, maybe a less invasive test might be warranted. I don't think you're being overly presumptuous at all.
posted by drpynchon at 10:01 PM on June 17, 2009

drpynchon -- when was the last time you were dead?

I do have business giving the advice, all the business in the world. I want to live. I'm assuming that the OP does also. My physician missed the problem but he's a GP, he listened to my heart, listened to my story, did an EKG, found nothing. And I'm healthy as a horse, aside from a genetic fumble on Dear Sweet Moms side of my tree, easy to see how he'd think maybe there was nothing there.

But the physicians at the heart hospital should have caught it. The fact that they didn't caused me unbelievable problems, cost me my life, truth be told. Only because of the spectacular setup at Brackenridge am I alive today.

I'm glad you are here to tell this man what he might need to catch that which might kill him if it is not caught. I'm glad you told him not to take a test that could possibly hurt him. Except that you are prescribing over the internet, same as I am. You don't know the whole story. His doctor may call for that test.

You're a doc, you're perhaps -- I don't know, of course, but perhaps -- inured to the fact that people die. When I died, because I was not tested thoroughly, and was not told what was wrong with me, do you think that those docs at Austin Heart Hospital lost any sleep about it? I don't think that they did. My family did. My friends did. I bet the OP would be unhappy about it if he died in a way that could have been avoided, my guess is he'll want to know all that he can.

I'm glad you're here, drpynchon. I have ultimate respect for people who are able to do what you can do, and, quite frankly, I think that they -- you -- are some the coolest people on the planet. You can help the OP in ways that I cannot.

But I can help him in ways that you cannot. I can, and will -- it is my business to do so -- tell him that he'd do best to make sure that he's got every chance to find anything that is going on in his body.

Doctor, if I have been offensive to you in any way, please know that I do not wish to, that is not why I'm writing here. Thank you for doing the work that you do; I truly appreciate it.
posted by dancestoblue at 10:51 PM on June 17, 2009 [1 favorite]

I watched a 38 year old man with chest pain die on the cath lab table because of an error. Procedures have risks; "doing everything" exposes you to lots of them. Imperfect tests will give you false positives and expose you to more.

You doctors could have done that one test in only you and it would have been fine, but they don't get to see the future. If they did the battery to all the people that look like you did, on the whole, they'd hurt more than they helped. These tests aren't held back to keep them mysterious or because MDs don't know about them. Your MD would make more money by ordering them more often. They hold them back because they're bad for you.
posted by a robot made out of meat at 6:25 AM on June 18, 2009

I understand the concerns drpynchon and others have voiced, and those are legitimate concerns. However, dancestoblue has a point. Patients are increasingly - and rightly - partners in their healthcare. Once upon a time, it was unseemly for a patient to question the doctor. Thank goodness, we got over that. The flip side of that is that you as a patient have an obligation to educate yourself. There are a lot of resources available online and at libraries. Read up and be prepared, so that you are in a position to ask questions, and are equipped to understand the answers. If for whatever reason, you are not convinced the doctor is doing all he can, change doctors and get a second, third, forth or tenth opinion. Sadly, there are other considerations than just your health at play - the doctors have time/resources constraints and insurance companies impact this equation too. I have changed doctors more than once, when they dragged their feet on tests I requested. It's a partnership - either party can quit it. A doctor may decide you are not a good patient for him - that's fine. And the other way around. It's your health, you have a say in your treatment. Too often have I heard and seen stories like dancetoblue's play out. The heck with that jazz. You are in charge. And finally I stress again - with power comes responsibility - if you defy your doctor, be prepared for the consequences in case you did not educate yourself properly and force the doc to do something that's suboptimal. To sum up: prepare extensively before your visit, be ready to question the doctor, don't get browbeaten into a process you disagree with.
posted by VikingSword at 11:03 AM on June 18, 2009

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