What tests to request from new cardiologist?

I have a phone appointment with a new cardiologist in 2 days. Would like to make the most of it and see if I can get some him to order some tests of inflammatory markers, electrolytes, glucose(?) and other things that will help me as I try to design my own best approach for managing (maybe ending) afib with diet, some supplements etc.

I'm in British Columbia, so may not have access to all tests available in US. Like I don't know where I would get intracellular magnesium here or if it is even possible.

I am thinking of requesting:

*hsCRP (any other inflammatory markers I should ask for?)
*red blood cell magnesium
*potassium (is serum potassium good enough, or does that require a better test?)
*glucose (does this need to be glucose fasting?)
*full thyroid panel

Can anyone think of other important tests? Or are these important? He will have seen an echo from back in January. Should I try to get a new one?

He will probably just want to talk about getting me on pills, since that is all they seem to want to do for AF. But I am going to try to get more out of this appointment - information and labs that could help me as I try to design my own plan.

kim

I don't think you're going to have much luck giving a doctor a list of tests you want, especially not in a managed care system. You're going to have to be quite the diplomat to convince them to follow the orders you want instead of the orders their training and the health care system's guidelines tells them you need. But if you're going to give it a shot, here's what I think about the tests you listed:

I'm not sure when or why CRP became a thing here lately, but I've never heard of it being a useful test in AF. Okay, so the test says you have high inflammation levels or you have low levels. What would either result tell a doctor to do next as far as AF is concerned? The answer is nothing.

Intracellular magnesium levels just isn't a test the doctor is going to run. You'll have to find a private practice doc who will order it for you and pay both that doc and the lab company out of your own pocket.

An electrolyte panel is what you need if you want to know your potassium levels. The doc might be willing to do that because it's so routine, but keep in mind that seeing your potassium levels from a single test is a snapshot in time and I promise you your levels won't be far out of normal because you'd have obvious symptoms if they were. And whatever your K levels are when tested can be significantly different just a few hours later, so it's unlikely to tell you anything useful.

Glucose will be dismissed instantly as irrelevant unless there's reason to suspect diabetes.

A thyroid panel is reasonable, but if you have no symptoms of thyroid problems, I doubt the doc will do that one either.

Remember, the doc works for the health care system and has guidelines they have to follow. If they order a bunch of non-standard tests for you, they're going to have to explain that to their superiors.

The trouble is, doctors follow evidence-based medicine. If there's no good evidence to support doing this test or that, they're simply not going to do it. But what you read here is a whole lot of theory and speculation that has little or no clinical evidence to support it, so as credible as the things you read may sound, theories that sound good aren't going to greeted with open arms by most doctors, and especially not doctors working in a managed care system.

Honestly, I think you're going to have to find a willing private practice doc and get your credit card out if you want to pursue these metabolic theories. Metabolic issues can certainly exacerbate or reduce AF, but virtually no one in medicine believes they cause or can cure AF.

Thank you for the detailed reply Carey. I think my interest in CRP was to have a baseline so that as I pursue anti-inflammatory strategies, I could see if it goes down. But for all I know it may already be okay. The only past one of mine I could find is from 2 years ago, shortly after I completed chemo-radiation for a cancer, and it was 0.3 at the time. The machine doesn't measure lower (at least that's what the test result said). So I guess I wondered if it has maybe gone up since then. I have chronic lymphocytic leukemia and am currently on treatment for it. So systemic inflammation always possible with any cancer, and I would like to gauge the degree of that with a test somehow.

Am wondering whether my "mild atrial dilation" seen on echo has resulted in fibrosis. And I gather from reading here in last couple of days that that depends a lot on level of inflammation and inflammatory chemicals released by body. So all of that sparked my interest in the CRP.

I thought checking for thyroid issues and diabetes or pre-diabetes would be relevant to rule out, since either could be cause of afib. So that didn't seem so off base to me.

I do have an integrative & functional medicine doctor I have used in past who I am sure would order these tests, for a price of course. So I guess I will see how it goes in my Friday appointment with the cardio. And if I still feel I need any of these tests after that, and if he isn't inclined to order them, I can go to my functional med dr.

Thanks for the feedback!

Mild atrial dilation is something you'll find on almost everyone with AF. As long as it remains mild and doesn't increase it's not likely causing significant fibrosis. If you really want to know how much fibrosis is present, you need an MRI with delayed enhancement. That's an expensive test involving infusing contrast media. I've had one and it means upwards of 45 minutes in an MRI tube.

Diabetes doesn't cause AF, it just increases your risk of stroke and a host of other ailments.

I think if you want almost any of these tests you're going to have to ask your I&F doc for them. The only ones I can see a Canadian doc ordering (or an American one, for that matter) are maybe the thyroid, electrolyte panel, and a metabolic panel (to check blood sugar, but that's not something cardiologists usually order).

If you have high CRP then consider OSA and CPAP ( Dr. Natale asks about this both times when I saw him. It's like a stock question and the only question repeated on both visits.)

Get fasting insulin, A1c and calculate HOMA IR - if they are high - consider low carb diet.

PS - water fast only for 13 hours to get most accurate results

Lots of research on CRP and AF

[www.google.com]

And diabetes and fibrosis and resulting AF

[www.google.com]

[www.google.com]

Thank you Carey and NLAMA for the further info. I will be checking out those links NLAMA.

kim

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NotLyingAboutMyAfib
If you have high CRP then consider OSA and CPAP ( Dr. Natale asks about this both times when I saw him. It's like a stock question and the only question repeated on both visits.)

Sleep apnea is always worth investigating if you've got AF, but all those links are the theoretical things I mentioned in my previous post. It's a lot of interesting research that might guide treatment someday, but it's not accepted clinical guidelines her doctor can hang his hat on today. None of that will change her treatment.

Is it possible to get a sleep apnea test in one's own home/bed, I wonder? In this time of covid, I would not really want to sleep anywhere else. Plus I can't imagine how I would fall asleep in some sleep lab somewhere. I have a lot of insomnia.

I had three home studies. They mailed me the box with instructions and I called up ups to pick up the next day. Once the medical supplier sent a delivery guy and he came back the next day.

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susan.d
I had three home studies. They mailed me the box with instructions and I called up ups to pick up the next day. Once the medical supplier sent a delivery guy and he came back the next day.

That's good to know. I may try to do it this way. Did you turn out to have sleep apnea? And is there any way to know in advance? (I live alone, so cannot consult another party re: snoring)

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PoetKim Did you turn out to have sleep apnea? And is there any way to know in advance? (I live alone, so cannot consult another party re: snoring)[/quote

Yes I was diagnosed years ago but I needed another test for Medicare. I have a very great pulmonary doctor. I scheduled the first sleep study at the facility. It was the evening of the day I returned from a 22 hour flight. I was so jet lagged I could not sleep at all and obviously failed because I was wide awake. I’ve been at that sleep lab eight years back so out of the three bedrooms, one had the perfect temperature. The other two you can hang meat it was so cold with the AC running like a wind machine. Sleep lab test #two they gave me the meat locker room and ran out of all blankets. Only a sheet and a thin cover. Again I could not sleep. Test number 3 I did sleep but the tech woke me up and said I didn’t have 15 sleep apnea episodes so he couldn’t let me wear a mask so I might as well go home. FYI, if you qualify for certain conditions, you only need 5.

So my pulmonary doctor let me have the 1st home study without a mask to see if I had more than 5 episodes Per hour. The diagnosis was nocturnal hypoxia without the mask. Sleep home sleep study #2 was when wearing a mask. I didn’t get nocturnal hypoxia with a mask. Home study #3 was for testing the mask at a certain pressure to get less apnea episodes per hour.

When my mom died last spring I took 3 months off wearing the mask. It was during this time my af returned. I wear it now but I must have lost facial bone because it keeps me up hissing and leaking air. I’ve tried many brands and styles. A full mask is my favorite. However many are made of silicone which I am allergic. I now wear the most comfortable “air comfort mask”. It’s made of foam around the perimeter.

Have you audio recorded yourself to listen if you snore or gasping for air after holding off snoring/breathing?

The advantage of a lab in house study is that the tech custom adjusts the pressure to get the right low and high for the Rx. In house they hook up wires to your scalp for Rem, and you are really wired up with a video camera watching you sleep, while my home study I wore a belt around my chest and a nasal gadget. Home study was a fraction of the cost.



Edited 1 time(s). Last edit at 08/06/2020 11:49PM by susan.d.

Thank you for this detailed reply, Susan! I had no idea what was involved in a sleep study. It might be easier/cheaper for me to start by just trying to audio-record myself one night somehow with some gadget. I suppose a noise-activated recorder would be best. I don't have a smartphone or tablet or anything I could bring into my bedroom (no wireless devices in my home). But I will hunt around for some way to do this.

Kim,

Get one of these from Amazon. Charge it up and wear it 3 nights in a row. If you're below 90% O2 - then you have a problem. It's as simple as that.

[www.amazon.com]

You can buy a CPAP directly (at least pre-covid) for about $500. I've helped several people with this since doing it for myself.

I've seen very thin people with deadly sleep apnea (in the 70s at times!) the majority of the night. And I've seem fat people that stay above 90 with a few dips but avg 92%.

NLAMA - How do I get the stored data off that overnight oxygen saturation tracker? Do I press a button the next morning and it displays low reading(s) or something? I do have a fingertip pulse oximeter, but of course have to be awake to use it. lol!

If it requires an app and smart phone (or similar device) like a Kardia does... I don't own any wireless devices (by choice).



Edited 2 time(s). Last edit at 08/07/2020 02:35PM by PoetKim.

Yes - it goes to an app on the cell phone.

Some of the medium SpO2 meters have an alarm that you can set - if it keeps waking you up then you might want to get a sleep study.

The ring I use can be set for hi and lo O2 and HR so it's been helpful on many occasions on top of helping others.

If you have a voice activated recorder that could also be helpful to record the sounds overnight - or just ask your partner if you snore.

But the gold standard is hypoxia and IMHO sleep studies are almost designed to fail you via bad nights sleep and are a waste of insurance $$ - this isn't rocket science.

I agree about sleep studies being designed to fail. I can't see how I would get a typical night's sleep (and maybe no sleep at all) on a sleep study.

I also think I would never fall asleep if I thought an alarm was going to go off on some SpO2 monitor while I slept. I have a lot of problems with insomnia - even with sedative!

[hdmusa.com]

My favorite when traveling. I believe you need a Rx and to get a rx you need a doctor to write the parameters of low and high pressure settings. I find ebay a good source to sell without a rx . You can then download the clinical manual to set your pressure.

That looks very neat. And small! Thanks, Susan.

But you need a mask and tubing. The unit is very small. I pack it in a tiny carry on bag with room to spare.

After years of trying out masks, I like the following: resmed airtouch f20 cushion full face mask. You need to buy the frame and adjustable headgear.



Edited 2 time(s). Last edit at 08/07/2020 06:28PM by susan.d.

Hey, Kim.
Don’t know much about how medical care is provided in Canada. Here in the states, my GP — not my EP — orders labs for me: A1C, electrolyte panel, etc.
Not knowing anything about you, a calcium scan may be appropriate and useful.

/L

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LarryG
Hey, Kim.
Don’t know much about how medical care is provided in Canada. Here in the states, my GP — not my EP — orders labs for me: A1C, electrolyte panel, etc.
Not knowing anything about you, a calcium scan may be appropriate and useful.
/L

By calcium scan - do you mean blood test for calcium?

Part of my problem with these tests is I don't have a GP. There is a huge GP shortage in Canada in certain cities and regions. In my area alone (Nanaimo-Parksville) there are 20,000 people without a GP (called family physician) and no hope really of ever getting one. We use walk-in clinics and see a GP on a one-off basis. It's difficult to ask a GP to requisition all sorts of tests in that situation where there is no follow-up with the same doctor. So I have gotten in habit of leaning on specialists for things that would be more typically done by GP. It's a crazy problem because that is not the best use of health care dollars or the specialist's time for me to be getting these tests through the specialist. Canada's health care system is good apart from this one yawning gap that has developed and that no one seems able to remedy. No one wants to be GP anymore.

Pretty sure CAC was intended - I am one of those that think everyone should have at least one and if there is an issue then follow up the same as you would for colonoscopy.

No more radiation than a flight across the Atlantic.

One of my dearest friends was just over 40 when he died from colon cancer. It was part of my wake up to how dangerous the grain, sugar and fructose based diet is.

They found/removed numerous significant growths and in post op - I asked MD "guess this means no more BBQ" he said "nope - no more Krispy Kreme"

Sugar (in all of its forms) was and is the problem.

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NotLyingAboutMyAfib
Pretty sure CAC was intended - I am one of those that think everyone should have at least one and if there is an issue then follow up the same as you would for colonoscopy.

I see. I just looked up CAC. I wasn't aware of that test. Thanks!

I had a CT angiogram
[www.uofmhealth.org]

Insurance picked up the cost. Non invasive, nothing snaked up your veins like the typical angiogram. I don’t know how it compares in accuracy with CAC but it detected the percentage of plaque in my heart and heart structure my local EP cardiologist and Natale wanted the CD to view which I was told by his NP that he put up on the monitor of the cath lab during the ablation.

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susan.d
I had a CT angiogram
[www.uofmhealth.org]

Insurance picked up the cost. Non invasive, nothing snaked up your veins like the typical angiogram. I don’t know how it compares in accuracy with CAC but it detected the percentage of plaque in my heart and heart structure my local EP cardiologist and Natale wanted the CD to view which I was told by his NP that he put up on the monitor of the cath lab during the ablation.

That option is good to know about. Thanks!

Yes, Kim. Our fellow afibbers steered you right... a calcium heart scan.

All the best!

/L