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Heart Disease (Expert Forum)
4th cath in 4 month?
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4th cath in 4 month?
by boblkii, Oct 15, 2003 12:00AM
Dear Dr:
I am a male, 37 years old, with heavy family history of CAD. I am active in sports with my children. I weigh 186 pounds and my heightis 5"10". In April I had a Non Q Wave MI. A catherization was performed and found 95% blockage in my RCA in one spot and a 80% in the RCA at a bifurcation. My left conary artery was blocked 30-40% and LAD was blocked 40-50. The 95% blockage was angioplasted and stented. The other blockage was left due to me being unstable at the time. I was released only to come back the next month with chest pain. Another catheterization was performed and a stent was placed at the beginning of the bifurcation, however, this blocked off the other branch which was treated with angioplast. Chest pains continued and another angioplast was completed on the branch that was previously blocked when the second stent was placed. The chest pain continued, in July I was admitted again. A treadmill was performed and was ok. Chest pains have continued to date and in October a thallium treadmill test showed an area toward the bottom of the heart not receiving enough blood flow - LVEF - 65%. Dr. stated we could do another catheterization or treat medically. Currently, I am on Diatalzem, Lisinopril, Asprin, Plavix, Norvasc Zocor, and Niaspan. Blood work was good tot. cholesterol - 110, HDl - 40, LDL - 46, Trig 110-130. Was on atenolol but taken off due to spasms. Chest pain comes during activity and at rest. What do you suggest on a course of action? Medical therapy? catheterization? bypass? Your time is greatly appreciated.
I am a male, 37 years old, with heavy family history of CAD. I am active in sports with my children. I weigh 186 pounds and my heightis 5"10". In April I had a Non Q Wave MI. A catherization was performed and found 95% blockage in my RCA in one spot and a 80% in the RCA at a bifurcation. My left conary artery was blocked 30-40% and LAD was blocked 40-50. The 95% blockage was angioplasted and stented. The other blockage was left due to me being unstable at the time. I was released only to come back the next month with chest pain. Another catheterization was performed and a stent was placed at the beginning of the bifurcation, however, this blocked off the other branch which was treated with angioplast. Chest pains continued and another angioplast was completed on the branch that was previously blocked when the second stent was placed. The chest pain continued, in July I was admitted again. A treadmill was performed and was ok. Chest pains have continued to date and in October a thallium treadmill test showed an area toward the bottom of the heart not receiving enough blood flow - LVEF - 65%. Dr. stated we could do another catheterization or treat medically. Currently, I am on Diatalzem, Lisinopril, Asprin, Plavix, Norvasc Zocor, and Niaspan. Blood work was good tot. cholesterol - 110, HDl - 40, LDL - 46, Trig 110-130. Was on atenolol but taken off due to spasms. Chest pain comes during activity and at rest. What do you suggest on a course of action? Medical therapy? catheterization? bypass? Your time is greatly appreciated.
Doctor's Answer
by CCF-M.D.-RCJ, Oct 15, 2003 12:00AM
Boblkii,
Sorry to read of your story.
Firstly, thanks for the thoughtful history, it really helps me to help you.
I think you first need to ask yourself if the pain you have now is similiar to the pain that brought you in with the heart attack. It is not at all uncommon for patients to become hyper-sensitive to chest signs after a very traumatic event like a heart attack. If you are convinced that the pain is similiar, then proceeding with additional work-up and therapy makes sense.
Your medical regimen is good. I'm assuming that your blood pressure is controlled.
At this point, I think you need to seek expert counsel at a large center. If indeed your thallium test shows ischemia, and you are still having chest pain, then the culprit artery needs to be identified. Identification of this artery may require intravascular ultrasound (IVUS) or simply an expert angiographer. Both of these will be available at a large center. Medical therapy is reasonable if you can live with the discomfort. However, if your activity level is limited on maximum medical therapy (and your list is good), then medicines alone are probably insufficient. Bypass at this time is a poor option -- the LAD does not have severe disease. This vessel is the primary vessel that benefits from bypass.
Many good centers exist. I can give you some guidance if you are willing to post where you live (state or region of the country is sufficient).
Good luck.
Sorry to read of your story.
Firstly, thanks for the thoughtful history, it really helps me to help you.
I think you first need to ask yourself if the pain you have now is similiar to the pain that brought you in with the heart attack. It is not at all uncommon for patients to become hyper-sensitive to chest signs after a very traumatic event like a heart attack. If you are convinced that the pain is similiar, then proceeding with additional work-up and therapy makes sense.
Your medical regimen is good. I'm assuming that your blood pressure is controlled.
At this point, I think you need to seek expert counsel at a large center. If indeed your thallium test shows ischemia, and you are still having chest pain, then the culprit artery needs to be identified. Identification of this artery may require intravascular ultrasound (IVUS) or simply an expert angiographer. Both of these will be available at a large center. Medical therapy is reasonable if you can live with the discomfort. However, if your activity level is limited on maximum medical therapy (and your list is good), then medicines alone are probably insufficient. Bypass at this time is a poor option -- the LAD does not have severe disease. This vessel is the primary vessel that benefits from bypass.
Many good centers exist. I can give you some guidance if you are willing to post where you live (state or region of the country is sufficient).
Good luck.
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I live in Colorado. Also, I live at altitude (+8000'), could this be causing any problems? Any recommendation on a larger center would be appreciated. Again, thank you for you time.
I had a heart attack followed by angiography 4 years ago where it was discovered that I had a long standing 100% occlusion of the RCA, a 70% ostial occlusion of the circumflex, and some other diffuse narrowing in other arteries similar to yourself. An attempt at angioplasty failed to cross the occlusion. Two years later a second attempt with an experimental device was aborted because of the discovery of the remnants of a ruptured plaque in my left main.
Fortunately by then the RCA was showing a very good collateral system and seems to be getting a pretty good blood supply down stream.
I would say that if none of these conditions have killed you, they are not likely to if you live healthy and exercise.
After my second failed attempt at angioplasty, I decided that I would make no further attempts at revascularization. My main strategy is to control lipids to the extreme, control bp, and exercise daily.
I take the summers off and try to climb 10,000' per week. In the winters, I try to walk 10,000 steps per day (1.5 hrs) with 10% of it uphill. On the weekends I hike or back country ski at least 1 day.
After 4 years, I would say that I have gained on the disease a bit. I have quite remarkable physical endurance for someone my age although I don't do the highest aerobic demand activities like running or playing tennis. I think that it's really quite remarkable that a person with pretty much end stage 3 vessel CAD can carry a 55 lb pack up and down 7,500' and 30 miles over a 3 day period without any cardiac problems. It's the result of pushing up against the disease every day.
The main thing that I read from your post is that you are close to normal weight and have good lipid readings, except for a somewhat low HDL. I didn't read that you are dedicated to an exercise program.
Also, my experience was to ditch the beta blockers, blood thinners. I think and Ace inhibitor possibly combined with a CCB like Norvasc is good for BP. I would stay away from diuretics, although they are popular again. A statin is a must for cholesterol and inflammation reduction, if it can be tolerated. It might be good to supplement that with Niaspan in your case to raise your HDL. Take the whole works at bedtime - that's when it's most effective. You might have to also take BP meds in the morning. The aspirin is good, but ditch the Plavix. You can't have healthy blood with that **** ahd you need healty blood and exercise to have a healthy endothielial system.
If you can't get yourself out walking, get a younger dog that likes to walk. Make time to walk 30 minutes before work. Find some hills to go up and down whenever possible. Also work for your lunch. Instead of eating, walk for 45 minutes and grab a salad at McDonalds.
I don't advocate pushing through angina, but I do push up to it. Don't eat before exercise. Warm up slowly or you will pay for it later.
Good Luck and Live Long
University of Colorado is a large center in your area, but the closest major heart centers would be either in Salt Lake, Scripps in LA, or travel to the Midwest at Mayo or CCF.
Good luck.
Please can you tell me what's wrong with Plavix? My mum takes it everyday as she has had multiple strokes (she is 75). She cannot tolerate asprin due to stomach problems.
Thank you.
Linda
I would take aspirin, if I wasn't allergic to it.
It's just my philosophy, that if I want to have a healthy endothelial system, I need healthy blood.
As long as I keep my lipids very low, continue to exercise every day, and take some natural anti-coagulating substances such as Vitamin E and Omega-3, I don't think that I am at high risk for some type of trombotic event, so I don't take pharmaceutical anti-coagulants.
They sure have some marketing campaign. It seems to be aimed at older, relatively sedentary people, who have had heart attacks. That's probably the right population for it.
Regards.