Echos in the Waiting Room - how often???

[susieq14]

My 6 month appointment with the cardiologist is this Wednesday, December 6. Needless to say I?m on the edge of my seat so to speak. I?m especially anxious because my cardio did not schedule me for an echo prior to the visit. At my last visit in June he told me that I did not need to have a 6month echo ? a 1 year follow-up was sufficient.

A question for those in the waiting room or to those who remember being in the Waiting Room: How often do or did you have an echo?

I don?t understand how he can tell how things are just by listening to my heart, checking to see if my ankles are swollen and asking if I have been SOB? Do you think that is sufficient?

He told me once that the LV Systolic Dimension is supposed to be less than 3.5 and he would be worried if it got to 4.0. My numbers have been: 2.7 (July 04), 2.1 (Dec 04), 3.0 (Nov 05) and 3.3 (May 06 via a cardiac MRI). In June he was very pleased that the cardiac MRI showed I had normal heart function with mild leakiness and that my forward effective ejection fraction was good at 64%.

Also each of the above-mentioned tests showed pericardial effision. That was also seen on a recent chest CT done for another medical issue. Is that anything to be concerned about? He says no - it is only a trace.

Any opinions, suggestions etc?
Thank you!

 

[davidfortune]

Susie,

My opinion would be to call the cardio and request an echo before your appointment. Especially if I had increasing dimensions you mentioned in your post, I think it would be prudent to check it at 6 month intervals - which means an echo.

Talking with your cardio is virtually worthless unless you are experiencing symptoms that you can quantify. You are correct, he can't see what is going on without looking inside.

Just any FYI = my ejection fraction actually INCREASED as my left ventricle has increased in size. EF is NOT the sole determining factor in surgical timing. All cardiac dimensions should be taken into account but continued, consistent increases in LV diameters are a critical sign for surgical intervention.

There is also changing conventional wisdom in the cardiology community that earlier intervention is better than waiting.

Please recognize that many cardiologists are stereotypically conservative (read "Slow or late") to recommend surgery. This is a mechanical issue at the end of the day. It takes a mechanic (i.e. surgeon) to fix it. Late surgery can result in permanent damage. Appropriately timed surgical intervention is the key. "Appropriate" is changing to be earlier than it used to be.

I would strongly argue for the echo.

 

[Wise]

I can't advise you on what you should do. I have an echo done once a year. I would assume that my cardio would do it more often if my condition were deteriorating sufficiently to warrant it. Good luck with your appointment.

Wise

 

[yankeeman]

Similar situation with my cardiologist

Similar situation with my cardiologist

I am also scheduled for a six-month visit with my cardiologist in March.

This will be the first time I have a six-month appointment...previously they have been one-year appointments, for three or four years.

He also is not scheduling an echo prior to March. He said he does not think it is necessary.

I have drawn two conclusions: One, because I have started having symptoms (dizziness, shortness of breath, fatigue), he thinks they will be so obvious to me by March that the echo would be unnecessary. Two, he doesn't want to spend the money on an echo (I'm in an HMO) because he thinks the writing is on the wall and that my surgery will be next year.

I have a bicuspid aortic valve that's moderately stenotic.

 

[jbrown413]

for those wondering what symptoms might be like...

for those wondering what symptoms might be like...

the first ones i noticed about 11.4 years ago was findng myself awakening in the middle of the night, having trouble breathing. as a psychologist who specializes in anxiety, i thought my job was just making me too anxious. i would get out of bed at 3 am, go downstairs, smoke a cigarette, and feel better. actually, i think,the cigarette probably acted a lot like digoxin, in that in increased my heart rate, and led to feeling better (not that i'd recommend that as a treatment). my primary care doc thought i was developing asthma. my cardiologist, after reviewing an annual echo, said i had congestive heart failure. thus the new st jude valve on 12/12/95. next the new aorta, on 1/3/7. i figure by the time i get to 100, i'll have entirely new circulatory system. -- joe

 

[ALCapshaw2]

My cardio was concerned about having echo's too often and having the coverage denied by the insurance company.

SO, I asked my insurance company how often I could get Echo's. Their response was whenever it was deemed "Medically Necessary".

I believe the standard of care is once a year UNLESS you become more symptomatic or there are other indicators that you should be monitored more closely (i.e. your numbers have advanced to the "severe" range).

I even called before my 6 month checkup last spring and told the scheduler that without an echo, we wouldn't have much to talk about. DIDN'T phase them. NO ECHO.

When I started noticing minor changes in my symptoms and scheduled my second checkup for the year, an Echo was ordered before the appointment.

Hope this helps you to at least have a better 'feel' for 'how the game is played'.

'AL Capshaw'

 

[MrP]

Susieq14,
From your post, your LV dimensions decreased and then increased slightly over time but remain within normal averages. The margin of error in these measurements may explain the slight increase in LVd over the past several tests. You may want to request an echo for peace of mind. Costs for this test are relatively inexpensive. Try not to worry too much.
MrP.

 

[Marguerite53]

My cardiologist put me on an annual echo schedule from the first visit. However, since I'd known about my BAV for 25+ years, and she was chosen by me as the one to be my doctor with an estimated 1 to 5 years until AVR, I simply told her that I was not comfortable waiting a year between echoes. She said fine, let's schedule one in 6 months, she wrote whatever was necessary to get insurance coverage, and away we went. Intuitively I knew I wasn't going to "last" 5 years. It was 2 years, and I'm the one who pushed the final, telling echo closer by about 3 months.

You could call the cardio's office today, ask to be given an echo prior to the visit and see what they say. Generally, there is never a big hurry to get stenotic valves fixed..they ramble along deteriorating at a slow pace. But I was unable to accept waiting a whole year, emotionally, so I just voiced my concerns and was heard.

Use your doctor. Don't be afraid, shy, intimidated or silent! Check with your insurance, too. Find out what the necessity is. If your deductible is all paid up, why not get the echo done before the end of the year!!

That said, I do feel that the cardiologists can tell a lot just by listening. They have amazingly trained ears. If you don't get the go ahead on the echo, then be sure to ask these questions you've voiced here, of your cardiologist.

Good luck! Keep us posted.

Marguerite

 

[CathyK.]

The day I found out that I have a BAV with moderate to severe regurg I have been getting echos every 6 months until my last visit, they did a TEE and Cath and now I go back in Jan. which will be 3 months since last visit. I am getting close to surgery. Actually I will be setting a date when I go for my Jan. apt. Hope this helps!!

 

[susieq14]

Thank you all for taking the time to read my post and answer me so thoughtfully. I took little peeks during the day while at work to see my responses but was not able to respond back until tonite.

I did call my cardiologists's office today but was told that he would not be in until Wednesday and he did not order an echo so it was a no go - similar to what you were told Al. I did not pursue it and will just go in for my appointment and discuss my concerns with him in person.

You?re absolutely right Marguerite that I need to be more forthright when I talk with my cardio. I am learning the hard way that one must be their own advocate since no one else is going to do it for you. (Just an aside: I have a few other new medical issues that I?m dealing with and took a very big step in September and changed to a new GP because I was not getting what I needed from my old GP. One of the reasons I selected the new GP that I did was so that he could give me a referral to specialists at Brigham and Women?s in Boston. My former GP was not associated with them. Well it worked. Two weeks ago I saw my GP for a follow-up about some GI issues and when he told me that he wanted me to go back to see my GI doc, I said I did not want to see him and preferred to see someone else. We went back and forth until finally I he said okay I understand and gave me the referral to a B and W doc. I was so nervous that I was practically hyperventilating!)

Anyway hearing that some of you are on 1 year echos is somewhat of a relief but I do think that every 6 months would make me feel more secure especially after reading some of what you wrote.

David, I was surprised to hear how your EF increased at the same time that as the ventricle size increased. I will definitely ask him about that occurring especially since he was so excited about my good EF on the cardiac MRI in May. By the way ? best wishes as you prepare for your surgery next week.

I will also ask him straight out what he can tell w/o an echo and what he hears with hs stethoscope. He has been very thorough when he listens and practically turns himself and me upside down and inside out in the process.

Again, thank you all so much!
Susie

 

[afraidofsurgery]

Yup. Sounds familiar

Yup. Sounds familiar

I was on the same schedule while I was in the waiting room (for about 10 years). Once a year for the echo, doctors visits every 6 months. If the echo turned up something such as an increase in ventricle size, i'd come back in 3 months for a follow-up echo.

At times the LV dimension would increase slightly, then at the 3 month follow-up echo it would be back down. My doc and I finally agreed it was the variance about the mean value - I mean jeez, a beating heart measured by ultrasound by a human - can't be THAT exact. My cardio did (at my request) graph the echos over the years and the graph had a slightly positive slope, but you could only see the change when the long-term data was graphed.

What 'triggered' my surgery was the appearance of symptoms though. I wasn't scheduled for an echo at that visit, but of course they did one, and nothing really different showed up. But the appearance of symptoms is a very important indicator of the imminent need for surgery.

I've read a lot of journal articles about the recommendations for surgery for people in the waiting room, and seems it's not an exact science as much as we'd like it to be. I always thought the 'face time' for the 6 month visits was very important, especially since my doc bothered to find out enough about me to understand if I was telling him that something changed or not (meaning he could tell if I was lying).

If you don't like the plan, talk to your doc. I was perfectly OK with my plan at the time, seemed to make sense. But that doesn't mean it's OK with you.

Patty

 

[Adrienne]

Maybe you can ask your cardiologist Wednesday if your next appointment (with echo) could be in 3 months instead of 6 months.

 

[davidfortune]

Susie,

I would also ask your cardio why he doesn't do an echo every visit? Maybe he doesn't think necessary. Maybe he is worried about insurance. I'm sure he would explain his reasoning if you ask. If you agree with the reasoning, great. If you don't agree or don't feel comfortable waiting a year then press him for an echo earlier.

"Normal" is a estimate as far a size of heart measurements go. Smaller people have smaller hearts and bigger people have bigger hearts. You have an advantage in that you have a couple of years worth of history to help determine your normal sizes.

For me it was also reassuring to have a second opinion from another well respected cardio - especially since there was ambiguity regarding the timing for my surgery (until recently).

As Patty mentioned the decision for surgery varies somewhat significantly among the medical community. As MrP mentioned the sonogram techology used to measure the heart (i.e. a Trans Thoracic Echo) is not perfect. There is variation due to the skill of the technician, the skill of the doctor reading the echo, and the quality of the equipment. For both these reasons - I am always a fan of a second opinion.

 

[catwoman]

Susie:

One thing to remember: My cardiologist's practice now has to get insurance pre-certification before doing echoes.
My husband had an echo in September, I think it was, and when I went with him to see the cardiologist a week or two later, we learned that insurance companies were beginning to require precerts.
My husband is to have another echo next month (January 2007) and wants to see the cardiologist that same day. So, he needs enough lead time to get an OK from his insurer.

I had an echo in early 1990. Did not have a repeat until 4/15/03, when I began having symptoms. I had surgery 6/24/03.
My current cardiologist prefers to see valve replacement patients (dunno if that's restricted to mechanical, or mechanical AND tissue) every 6 months. I switched to him in May, had an echo then.
I had a recheck yesterday (12/4), no echo needed. A tech did an EKG. The cardiologist said my heart sounds great & to come back in 6 months for an echo & checkup.

Hindsight is great: If I were in the waiting room now, I would be under the care of a cardiologist and getting an echo at least every 2 years, if not annually, depending on whether there was any changes in numbers and any symptoms.
I strongly urge my friends with valve problems to get periodic echoes, frequency depending on any changes in results and whether they experience symptoms.