Harvard Heart Letter

Ask the doctor: How could I have a heart attack after a normal exercise test?

Q. I had a nuclear exercise test last fall, and it was perfectly normal. Imagine my surprise this spring when I developed burning chest pain that turned out to be a heart attack on the bottom part of my heart. Did the doctors mess up the reading of my exercise test?

A. Without having seen the results of your test, it's difficult to comment on it. But the likelihood is that it really was fine last fall. Here's the most probable scenario for what happened: You had a moderately sized atherosclerotic plaque in the inner wall of the right coronary artery, the artery that runs down to the bottom of your heart. That plaque probably wasn't big enough to compromise blood flow and thus cause angina, or to make a worrisome signal appear on your nuclear exercise scan. But even a small plaque can rupture and, when it did, it caused a blood clot to form that blocked off the artery, causing your heart attack.

I know this scenario is scary, because it means a heart attack can occur in anyone at any time, even someone able to run miles the day before. While true, your chances of having a heart attack are much lower than average if you can exercise without symptoms or if you have a negative exercise test, as you did.

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