Passing Out

When I had my annual visit to my cardiologist last week, he recommended that I have another stress test as it as been three years since my last one. The purpose of the stress test is to see if there are any issues with blocked or partially blocked arteries in the heart that need checking into (i.e., before you have a heart attack from them). The type of stress test he prescribed is known as a non-exercise nuclear stress test. Let me give a brief description of what this involves (see this article for more details).

Description of Nuclear Stress Test

This test takes 3-4 hours to complete. There are three phases involved. After checking in and taking some baseline statistics (heart rate, blood pressure, etc.) the nurse/technician inserts an IV into your arm/hand for the administration of various drugs. In the first phase they take pictures of the heart while resting to establish a baseline. The second phase is to stress the heart. And the third is a repeat of the first phase after stress to see what changes can be observed.

The first (and third) phase is done through the injection of a radioactive substance (via IV). You then just sit and wait (30-45 minutes) for that substance to circulate through the blood stream. One of the places that absorbs the radioactive material is the heart. This material has a fairly short half-life so it does not remain in the body very long. You then are positioned in front of a gamma camera which takes a series of pictures of the radiating area. (It’s no more dangerous than getting an x-ray, except that instead of having the rays be shot through your body and captured on film on the far side, the origin of the rays is actually inside the body.)

When I had this done not too long after my heart attack back in 2005 (see here for details), and when I did again a few years ago, I was lying on a table and the gamma camera rotated above me. For the one last week, I was sitting in a machine with arms resting on a platform at head level (to keep them out of the pictures) and the “chair” rotated in front of the camera(s). Either way works fine. It takes less than 10 minutes to complete the rotation and for the camera to capture all the necessary images.

(A side note – I joked to the nurse/technician that I was now radioactive, and her response was, “yes, you’re ‘hot’!” Her joke was better than mine!)

The images captured give vital information about the heart, including: the size of the heart chambers, how well the heart is pumping, whether there is any damage, and if there are any blockages or narrowing of the coronary arteries. And by comparing the images taken in the first (resting) phase with those taken in the third (post-stress) phase they can gather additional information. (Any blocked or narrowed arteries limit the absorption of the radioactive material into the heart and create “cold” spots in the gamma images.)

The second phase is to put the heart under stress. First, the technician/nurse connects you to an EKG (attaching 10 different stickers to different areas of the chest/side, clipping a lead onto each, and the whole thing connected to the EKG machine). But unlike a typical EKG which only takes a minute or two of measurements, this one will record the results throughout the stress period.

When done with exercise (which I did many years ago), you get on a treadmill. It starts slowly, then picks up speed and increases the incline until you are doing the equivalent of a brisk walk up a steep hill. You’re breathing hard, your heart is pounding, you are sweating, and all the while the EKG machine is collecting measurements. The test is ended either when the technician watching the EKG notes that your heart has reached the amount of stress that you should have, or when you call out, “I’m done!” as you feel ready to collapse from the workout. They then immediately inject another dose of the radioactive material and you start phase three.

If the patient cannot do this type of physical activity (which I cannot because of continuing problems with my foot that limit the ability to walk), they instead inject medications (through that same IV) that either speed up the heart or dilate the arteries. The body responds to these medications with the same sort of stress reactions as the extreme exercise – your heart rate increases, you begin sweating, etc. And, like the exercise, you feel like you are working, even though you’re sitting in a chair (and connected to the EKG machine).

What happened this time?

So, why was this most recent test different? And why the title of this blog?

I had prepared for the test as instructed. This included (1) no caffeine for 24 hours [I often have a diet Mountain Dew during the day, but abstained as directed], (2) no aspirin for 48 hours [I usually have a baby aspirin as part of my medication regimen], and (3) only a light breakfast with no milk that morning [just dry cereal and a glass of water!] I also took my morning insulin shot (something I had just recently started) but this was ok per the instructions they had given me.

When taking the initial measurements of my blood pressure, the nurse asked if my blood pressure was usually this low. It was 115/65. I have fairly good records of all the times that I’ve had my blood pressure measured. My systolic ranges from 115 to 140, with the lower readings often an indication that I’m pretty relaxed. And my diastolic ranges from 60-70. So, while at the lower end of my “normal”, I did not think it was out of line and I told her so. But in retrospect, perhaps I should have been concerned.

The first phase went as planned, except that this time I was seated in a gamma camera machine instead of lying down. It was a bit uncomfortable, but only because I had to have my arms up at head level and my right shoulder gives me some level of pain whenever I try to raise it sideways to more than 90 degrees. But I tolerated it.

It was in the second phase that things “went south”. As the above article notes, there are some possible side effects. One of these is “fall in blood pressure during or after exercise, possibly leading to dizziness or faintness”. This is the one that got me!

I was doing ok, which meant that my body was reacting to the stress-inducing medication and I was starting to sweat, could feel my heart beating faster, etc. I was not feeling any particular pain, was not nauseous, etc. But then, possibly because I had started out at the lower end of my “normal” blood pressure, it fell too far and I got lightheaded.

There were two other people in the room when it started – one observing the EKG and one administering the medication through the IV. I don’t know how long I passed out, but I suddenly became aware that there was another nurse in the room who was shaking me and shouting, “Mr. Russell, Mr. Russell, are you ok?” I lifted my head back up and tried to shake it off.

But my blood pressure was still too low and I couldn’t keep my head up. Over the next few minutes, I passed out at least two more times. Before it was all over, they had given me an “antidote” through my IV which counteracted the one causing the stress (and drop in blood pressure), and the team working on me had expanded to include another tech (a large muscular male who could help support me) as well as my cardiologist who had been summoned from his office down the hall. Once I was stable enough, they had gotten a litter from elsewhere in the office and the male tech and my cardiologist had supported me to get out into the hall (it was a small room) where I could lay down on the litter and recover in that horizontal position.

The tech connected a bag of saline solution to my IV (to help increase my fluids and get my blood pressure back up) and offered me a glass of coke as well (once I felt well enough to sit up). As I was now going into the third phase and waiting for the second dose of radioactive material to take effect (they give that about the same time as the stress-inducing medication so it can be absorbed during the “exercise”). I was then allowed to go back to the waiting room where I could also use the restroom.

I discovered in the restroom that I had also lost partial control of my bladder during my period of unconsciousness and so my underwear was wet. And the small glass of coke only caused a bit of nausea (another of the listed side effects), so it ended up down the front of my shirt and on the floor (fortunately I had a dark-colored non-absorbent fabric shirt so it didn’t show), and there was a box of tissues in the waiting room that I took advantage of to clean up. So, I needed a change of clothes when I went home afterwards!

I’m happy to report that despite all the drama, I was able to successfully complete the three phases of the test. The EKG had been hooked up during all the drama and had captured the actions of my heart. And the phase one/three images were just fine. But I was slightly embarrassed by the fuss I caused – even though the staff did not observe the issues with my clothing. My cardiologist commented as he was assisting, “Well, we won’t do this type of test again,” [on me].

As I’ve gotten older and had more medical issues to deal with, I’ve gotten used to some of this type of thing and am no longer as embarrassed as I would have been when younger. It’s all just a part of growing older and nothing to be ashamed about. I’d rather that these not happen, but they do. So, I have no problem with sharing them in my blog. I’m not looking for sympathy, rather I hope that by sharing I can help others as they deal with similar issues.