Are these tests necessary?

Hi All,
I just went to my cardiologist after four years. I have been AFIB free for over two years but had a relapse after the norovirus. The AFIB is diminishing again after two months. The only medication I am on is to take metoprolol to lessen AFIB symptoms. I am rarely in AFIB longer than an hour so I don't use it much. All I wanted to do is get a new prescription for metoprolol since my original bottle is 4 years old and to start seeing an EP instead of a cardiologist (in case things ever go south).

My consult lasted five minutes. He did not recommend a blood thinner and renewed my prescription for metoprolol. I asked him if he could give me a referral to an EP. He said no and that he could treat me?

However he wanted me to do an echocardiogram and a nuclear stress test. I told him I do moderate exercise every day and once a week I ride my bike up a steep hill taking my heart rate to ~90% for a short time. I have no chest pain or discomfort, quite the contrary I feel great!

I can't think of one reason to have these tests. If I feel great, have no symptoms of anything except for an occasional 10 min run of AFIB every couple of weeks, do I need these tests? I am 69, Mediterranean diet, normal blood test, low blood pressure, and bmi of 20. I am an ex-endurance exercise guy.

As an aside, I got a bill for $442. I saw that he charged $642 for the consult and my insurance only paid $200. Is this normal?
I am thinking of cancelling the tests and finding a new doctor.

Any thoughts about the echo and stress test, I would appreciate it.

That consultation sounds excessively costly, especially when you add in the costs of what he proposes. I have had two MIBI stress tests, neither of which turned out to be necessary in view of both my history as a runner/cyclist and due to my lack of ischemia. Also, other diagnostics like Doppler ultrasound of my carotid arteries showed minor deposition at my then-age of 67.An angiogram ordered by my EP showed 'minor deposits.' MRI and chest X-rays were all clear.

I would get a second opinion, and it should involve a referral to an EP. The EP might think that you're okay for now on pill-in-pocket treatment with metoprolol, and you probably should be on a direct-acting oral anti-coagulant if you are even occasionally in short runs of AF. Although, some research I saw just a few weeks ago suggests that extended runs of AF are more problematic when it comes to the threat of strokes than are the much shorter runs.

Whether you should be on an anticoagulant depends on your CHADS-Vasc score.

As for that bill, I'm not surprised at the amount but I am surprised at the amount your insurance paid. Does your deductible explain why they only paid $200? If not, are you sure he's in-network with your insurance?

I have a chads score of 1 for being over 65. The doctor said "if I were you I would not be on the anti coagulant."

I do have a large deductible, he is in my network. But the bill says my bluecross/blue shield is only paying $201.98 out of $645. I might give them a call tomorrow.

I am not a big fan of tests with no symptoms; I also don't like the anxiety of false positives. What could the echo tell me that would change anything I am doing? If I had a bad leaky valve, he should have heard it with the stethoscope?

As for the stress test, Google AI says:
"This test can help diagnose heart conditions like coronary artery disease, heart failure, and heart attack."
Again, I have no symptoms and the results won't change anything I am doing.

Am I missing something?

Hi MikeN
I would suggest you begin to monitor your heart rhythms 3-4 times a day, 30 seconds each for a total of 2 minutes of your day. You may discover you are having asymptomatic AF even when u feel good. You will need an APP called Kardia to see your EKGs which are interpreted. Alternatively you can do it on an Apple Watch with an iPhone.
My background is I am a physician, not a cardiologist but I have considerable experience with AF as I am also affected with it. If interested read my BIO

Hugheart

Hugging,
Thanks for the reply. I do have a kardia, and am very symptomatic. When I am in AFIB the feeling is so intense I can't lay down. The metoprolol helps make the symptoms livable. So far I have never recorded AFIB on the Kardia when I did not feel the symptoms. So I am almost 100% sure I am not in AFIB other than when I feel it. Also, I am pretty good at feeling my pulse and detecting AFIB as well.

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MikeN
Also, I am pretty good at feeling my pulse and detecting AFIB as well.

Good for you! I've been preaching for years that afib is trivially easy to diagnose from nothing more than palpating your pulse, but everyone prefers to buy expensive devices to do it for them. A Kardia is nice to get a recording you can show your doc, but it's not necessary to answer the question: Am I in afib right now?

How about just doing the Echocardiogram, and not the Nuclear Stress test? I have heard the Nuclear test is expensive, and is a money maker for the Cardiology Centers. Have you had an Angiogram done recently? that would make the Nuclear test less important. Also an exercise stress test could be used in place of the Nuclear test.