sure  just remove the obvious (?) andti spambot pieces of the (9letter prefix) email addy....;
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well thats a little weird...this time the display shows my original Long post from earlier this AM...hmmm...forget re-write PTII...;

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raildown,
Yes, I think this disuscussion would be best continued offline, if you have a way of getting me your E-mail.
Tom

rats...I typed in a Long post to you but it appear not to have 'taken'...I'll try again with a multiple part reply..I'll wait to see if each piece posts before adding..;

o w.r.t. BP meds in your case..addding a BB given the orthostatic effects (and rsting HR of 45 with Altace..waht was rest HR w/o Altace ?) of the Altace seems overdone even in view of your max exercise BPs...board had reference to CC study w.r.t. that situation..;

- what is the gradient of your treadmill BPs ?

- note that Cleveland Clinic Foundation recently published a study in the NEJM (Feb 27,2003) which suggests the use of EKG monitoring in the treadmill test recovery period; there was a NEJM 2 pgae editorial on the study as well;

did you get EKG during stress test recovery ?

- have you had an Ambulatory BP Monitor test ?

o your gene pool looks excellent...and since that cannot be changed, you have a leg up on many..;

o your chol #s look great w/statin;

- what is the statin and dosage ? any side effects ?

- what have you done w/ diet ?

o more in Pt II..;

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not sure about the prophylactic BP med usage...my cardio wants me on one for exercised induced diastolic response; my max exercise pressure is 180/90..the 180 is ok bt the 90 is 75th percentile and with the AAA of my father he would like to get the 90 diastolic down...;

- what is the gradient of your exercise induced BP profile...maybe if you notch back your exercise it might require less prohphylaxis ?

- what is your post exercise recovery profile ? there was NEJM study from Cleveland Clinic Feb  27,2003 about the importance of EKG monitoring in the recovery period of a treadmill exercise test not just during the exercise period of the test.  

- certainly adding a BB to the Altace (?) would likley exascerbate the orthorstatic BP and BB induce lethargy that affects ability to exercise...with your resting HR seems like driving tacks with sledgehammers;

o what is your statin and dosage ? any side-effects ?

chol #s look very good;

what is your diet ??

o I take the 4mg folic acid which pushed level from a very high 17.9 to a very good 7.7...not sure what the typical dosage response gradient is...my cardio didn't titrate the FA...I've only seen mention of 1 mg in some studies...my internis raised eyebrows at 4 mg but I've found no indication FA is toxic at 4 mg...until I found 800 mcg and 1 mg pills the 4 mg FA was a pain...lots of little pills;

o your gene pool looks excellent and many folks don't have that and you can't change it...;

o the 'inflammation' model is still developing...'inflammation' in this model may not mean the process result of infectious bacteria etc...but rather a misguided/vicious cycle immune system response (via monocytes ?) to (various) 'insults'/injury to the endothelial lining of the arteries...there has been some investigation of clymidia (STD) and CAD...;

the CRP 'marker' (there are Other inflammatory process proteins being investigated that may yield a more specific CAD marker..?) promoted recently by Dr Ridkers research is problematic at the clinical level because CRP is not a inflammatory process protein which is Specific to CAD...CRP levels can be volatile and require a half dozen readings (per Dr Ridker)...lab testing protocols still developing...;

o w.r.t 'extreme' exercise and CAD...and note that I've been a pretty active runner (10ks), sailboat racer, xcnty skiier over the years...persistent 'extreme' exercise (marathons, ultramarathons, triathalons may have some components of OCD...and there might be some underlying predisposition to high levels of cortisol and other anxiety related neurochemicals...Stress is thought to be a risk factor for CAD but it is hard to quantify w.r.t. lab testing etc...;

I remember reading Dr Ken Coopers work on aerobics in the 70s and IIRC he said that anything over 30 minutes/day was Competetion and not necessarily of additional benefit to general health...he now has sequed into a CAD clinic in Dallas...is a big proponenet of plant sterols (such as Take Control)...;

if you want to carry this discussion on off the board I'll post an email addy with the requisite antispambot gibberish imbedded..;

I read your message and left another for you back on the old thread.

Perhaps someone could explain to me why bypass surgery or even stents are needed if the vessal is well collateralized and there are no symptoms when exercising.  Seems to me you are fixing a problem that the body has already fixed.

Please comment....

Funny you would ask that question. I asked it of my cardiologist and surgeon and they both got a good laugh out of it. "Here's a guy with a 95% LAD lesion and he wants to know if he needs surgery! Yuk Yuk".
  Since my surgery I found a thread on this forum where a 48 year old heavy exerciser had a similar situation to mine and asked that question. The CCF forum doctor answered that if further testing showed normal left ventricular function, there may be no need for the surgery.
  I guess at the time I was so overwhelmed with the news that I would not be allowed to go home without surgery that I didn't press for a second opinion. Even if I had, I don't think you would find many cardiologists who would have voiced opposition to the first doctor, considering the potential danger of an LAD blockage (and risk of the legal ramifications had I dropped dead on the hospital steps.)
  In retrospect, I am happy that the bypass was done. I don't think I ever would have felt comfortable again pushing myself to near max knowing of the blockage. You really don't know ahead of time how much of the perfusion is being accomplished by the collaterals vs what is left of the native LAD flow.

Sorry - I misread your message -- I thought that you were still experiencing angina.

If I were in your shoes, I'm not sure that I would go for another catheterization either.  

My doctor always wants to do another one, but I ask him "What's the Point"?  I'm not going to take any invasive action anyway and because I use my legs to stay alive, I really don't want to take further chances on messing up my Femoral Artery.

The fact that you survived blockages in the past and your heart collateralized around them is testimony that you probably won't experience SCD even if you have some ischemia.

The risk would be that if you are experiencing silent ischemia and you continue with extreme aerobic activity you could eventually damage your left ventricle (LVH).

This is the balance that I am striving for.  Because I have severe un-bypassed CAD, I experience exertional angina, expecially during the first mile and after eating.  I love to walk up 3,000' or so a few times per week and I really have to pace myself to do it.  If I push too hard early, I pay for it later.  I don't want to end up in heart failure 10 years from now.

I think getting that second opinion will be worth while.

Best Regards.

you mention that you have none of the common risk factors; what is the purpose of the Altace and what is your BP ?

Also what is your target levels for TOT, LDL, HDL, TG after the statin use ?

w.r.t. 'less common' risk factors/'markers', there are a number of 'models' of the athrosclerotic process and statistically associated markers..the unresolved question is which are causitive and the how can the process be altered to mitigate/remove the bad effects;

hundreds of 'markers' have been investigated over the years...;

the homocysteine theory of Dr Kilmer McCully has been around since the 60s...f.w.i.w I had a level of 17.9 and reduced it to 7.7 using 4 mg/day;

father (smoker) had AAA at 58, maternal grandfater MI at 55/SCD at 75, Mom is 90 and fit as a fiddle (her Mom lived to 100)... I've (58/male) been diagnosed (Mar 2002) with mild diffuse CAD, no focal point occlusions, low HDL, high TG, slight ischemia, slight ST segment depression, 14 METS on treadmill,  slight diastolic elevation at max exercise...95 %  predicted max...aggressive 10 % LF dairy/vegie diet w/ plant sterols/Take Control, and Walnut Oil brought TOT to 155, LDL to 90, HDL stuck at 35, TG to 100...Tricor (fenofibrate) helps get (refractory) HDL to 45,TG to 60, LDL to 70 and TOT to 125...;

have you heard of the lipid sub-fractions tests by Berkeley Heart Lab and/or Athrotech's VAP test...they give levels of sub-fractions of LDL,HDL...as well as VLDL, IDL, lp(a)...and lipid particle sizes w.r.t. Patterns thought to be particularly athrogenic;

the 'inflammation' theory is proceeding and the (non-specific for CAD) inflammation marker CRP has been brought attenton by Dr Ridker but there still is work to be done with the model, clinical testing protocols etc...;

there is what we know, what we know we don't know, what we don't know we don't know...;

be well;

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Thanks for your comment.
   The reason for the Altace I think is that it is considered good practice for anyone with CAD based on the recent studies showing greatly improved survival. I know from reading some of the papers that that data was based on specific subsets of CAD patients which I may or may not belong to. In any event, I do seem to have exercise induced hypertension with BP reaching 220/110 at 13 or so METs. Resting BP has always been 120/80 or below at home. I do have "white coat hypertension" as my BP in Dr office is normally in 140/90 range.
   Prior to surgery, cholesterol was 210 tot with 59 HDL. With statin, this has gone down to 151 total, 63 LDL, HDL 58 and 49 Trig. I am under pressure from lipid specialist as well as cardio to start a beta blocker, but I resting HR of 45 could be problematic. I also suffer from some orthostatic hypotension with only the Altace.
   What has been your experience with folic acid dosage? My homocysteine dropped I presume from ? to 14.5 with 1 mg/day and a multiple vitamin. Do greater dosages result in greater reduction? My reading indicates that 14.5 is still way to high in light of data showing a steep graded response.
   I have always assumed that I would live to a ripe old age. Although my father died at 79 of cancer (he had bypass at 68 after heavy smoking for 40 years), his 4 siblings are in good shape at ages up to 90 and my mother and her 3 sisters are doing well at max of 90. Something seems to have gone wrong in my case and I can't shake the notion that somehow my sometimes extreme exercise has precipitated it over the last 30 years. Obviously, I don't get much support for this theory among the medical community.
  I posted once on this forum asking whether there was any use in testing for infectious agents as a possible cause. The answer was that there was nothing to be gained. The theory has not been proven, and even if it is causative, there is no known solution. Antibiotic trials have been unsuccessful at altering the outcomes of those known to carry antibodies for the bugs. My personal opinion is that it would be good to know anyway for a number of reasons.

I am glad everything has worked out so well for you.  I had an 85% blockage in my lad which was stented.  I had two bouts with re-stenosis but since then have been pain free.  I know I had some additional re-stenosis(just can't quite do what I used to) but the Doc says leave well enough alone.  I also know that by-passes are especially tough on small women.

I do a lot of walking and hill climbing and I am never quite sure how good my lad is. I have some shortness of breath but no pain. I always pass all the tests (even with the blockage) so my doc doesn't do any stress tests anymore.

I was 48 also when I had a "plaque rupture" from some small plaque which was medically insignificant.  All my other stats (wt, BP, Chlolesteral) were great.

I am just confused as to my true condition.

Thanks for listening!

Terry

I guess I am in a bit of denial about the reported ischemia. I am not convinced about the accuracy of stress testing, as it missed my original problem, apparently due to the heavy collaterization. I had "symptoms" then of shortness of breath in the inital two minutes of runnning (none at all while cycling). Now, I have no symptoms at all and am feeling stronger than ever. Why would I want to have another invasive test?
   My real fear is that if I allow an angiogram, they may find something and I will find myself being a bypass patient for the second time in 6 months. I asked my GP, for whom I have a lot of respect, if he thought I was crazy. He thought a followup stess test in a few months would be a reasonable approach and I tend to agree.
   There is a local doc who does angiograms through the radial artery and I am considering interviewing him to see if I should jump ship to his practice. I lost confidence in my own cardio when I had to twist his arm to pursue some of the less common risk factors, one of which I appear to have. I must give credit to one of the commenters from my earlier posting who was from Sidney. He said that down there, it is more or less standard procedure to test for CRP, homocysteine, Lpa, and fibrinigen. Turns out my homocysteine is high and I never would have known it had it not been for this forum. All the statins and ACE inhibitors I have been taking would have had little or no effect on this possible root cause of my problems.
   Thanks for your interest.

Best Wishes to you runner Tom.... Hang in There.

I left a comment for you HealThyself around 7/8/03
with: Collapse of 48 year Old.
Thank You!
Gyzpe

I've read that 20% of grafts are failures from the start, so perhaps you are one of the unfortunate ones.  Or perhaps they did a Dana Carvey and bypassed the wrong artery.

I think that exercising through ischemia can be very dangerous for some people, so you might rethink your extreme aerobic activity until you get a better idea of what's going on.  The angio is the best way for that, but it does mess up the femoral artery for a while.  There are a few doctors that do it through the radial artery in the forearm.

I do more at 54, with advanced CAD, than I did when I was 35 -- I just do it slower and enjoy it more.

Good Luck to You.

Tom,

Sorry to read of your ordeal.

Anything is possible.  We simply don't know what is going on with the blood supply to the heart without an angiogram.  Your explanations about what you think your body is doing is possible, but in my experience most patients are not so in tune to their body that they are able to delineate anatomic problems by their symptoms.  Studies have demonstrated that cardiac proprioception (ability to sense the heart) is poor by the majority of patients.

Going to a major medical center would be a good idea at this point, if only for peace of mind.

Hope that helps.