Dr. Roach: Time to check lungs and blood for cause of shortness of breath

Keith Roach
To Your Health

Dear Dr. Roach: I am an 82-year-old male and started experiencing shortness of breath about 14 months ago. The condition continues to deteriorate. I’ve had an echo stress test, nuclear stress test, pulmonary test, chest X-ray and CT scans, all coming back negative. Recently, a cardiac CT scan showed blockage in two arteries: 70% in one and 80% in the other. The cardiologist who performed the procedure found the blockage was not enough to warrant stents. Any suggestions?

— M.S.

Dear M.S.: Many people tell me they don’t know what shortness of breath is. It’s very like the sensation you have after intense exertion, such as a sprint, when you just can’t get enough air in your lungs. Shortness of breath is a concerning symptom that requires thoughtful evaluation. Almost any heart or lung condition can have shortness of breath as a symptom. Other conditions include severe anemia, and many psychological disorders, especially anxiety. However, we often are unable to diagnose the cause, even after an extensive work-up.

Dr. Keith Roach

It might surprise you that the cardiologist does not want to open the blockages in your coronary arteries with balloon angioplasty (the stent keeps them open afterward). However, a CT scan shows anatomy, and a stress test reveals physiology — how blood flows to different areas of the heart at exertion and at rest. If there is no lack of blood flow to the affected region, then it is unlikely that opening the artery will relieve symptoms. And there is abundant evidence that in people with stable coronary artery disease, a stent does not reduce the risk of heart attack or death.

The situation is totally different in a person having a heart attack, where opening up a blocked blood vessel can have many benefits, including preventing death of heart cells.

It can sometimes be very difficult to tell whether shortness of breath is coming from the heart or from the lungs in a person who has conditions affecting both organs. In this case, pulmonary function testing or specialized cardiopulmonary stress testing can sometimes answer the question. It sounds like your cardiology evaluation has been very thorough. It might be time to revisit whether there is something else going on in your lungs or blood.

Dear Dr. Roach: I’m an 83-year-old man, and have been told by my urologist that I need surgery to remove bladder stones. I understand this is painful. Are there any alternatives, like sound waves used to break up kidney stones?

— M.L.

Dear M.L.: Bladder stones are most commonly found in an older man with an enlarged prostate. The urine never gets completely emptied due to the partial blockage at the prostate, leading to crystallization of the minerals in urine. There are other causes, such as a kidney stone too large to pass. Over time, bladder stones usually get bigger, so surgical removal is usually recommended.

The surgical procedure is normally minimally invasive. An instrument is inserted into the bladder through the urethra. The stones are broken up with laser or sound waves (through the instrument) and removed from the bladder. The procedure is usually done with local anesthetic and sedation. Most of my patients have tolerated the procedure well without too much pain.

There are some promising reports of using sound waves (called extracorporeal shockwave lithotripsy) for small bladder stones; it is usually used for kidney stones.

Bladder stones often come back if the underlying condition isn’t addressed, so be sure to talk to the urologist about preventing future stones.

Readers may email questions to ToYourGoodHealth@med.cornell.edu.