Angina - Diagnostica and Treatment?

  I am a white male, 53 years old with a family history of CHD.
  I have beeen under treatment for high blood pressure, taking 5mg Altace daily.
  I have been suffering angina in my right (sometimes both)arms, during mild execise.  It is much worse at higher altitudes such as in Santa Fe NM (1 mile), where just walking causes pain. Intermittently, I have pain after eating.  I have not had chest pain.
  I have had a nuclear stress test that has determined that an area of the ventrical is lacking oxygen at stress, but know causative effects were detected. Four years ago I had a cardiac cath that did not reveal any problems in the heart arteries.  
  With my current condition, I have been prescribed Topril, which I stopped taking due to lack of ability to sleep. It did not ease the angina at all.
  I have since been on Tiazac, which has had no effect in relieving the angina.
  I believe the angina stress threshold is decreasing over time.
  My physician suspects small artery closure is the cause and wants to perform an angiogram again.
  I am looking for a second opinion before I undergo another angiogram.
  Is there an alternative diagnostic method to a angiogram?  One that will give better results or more definative information?
  Is there a treatment for small vessel disease or a clinic that specializes in it?
  I am considering traveling to Cleveland for the second opinion, as your reputation is exemplary.
  Please advise as to alternatives or a referal for an invesigation in Cleveland.
  My physician has recommended immediate action.
  Thank you.
  Marc
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Dear Marc:
Symptoms of chest, arm, neck or jaw discomfort with exertion are all suggestive of angina.  Symptoms that occur after a heavy meal can also represent angina.  Angina often gets worse at higher altitudes.  Your symptoms are quite concerning, and you should be evaluated promptly.
Stress tests are the usual method used to detect whether pain that could be angina is due to coronary artery blockages.  There are several types of stress tests.  The most sensitive stress test is called a PET (positron emission tomography) scan.  It can quantify how much of the heart is in need of better blood flow and oxygen.  This is a very specialized test that only a few centers perform, since it requires specialized chemicals and equipment.
An abnormal stress test generally prompts a cardiac catheterization.  A catheterization is currently the best way to determine if there are significant blockages of the coronary arteries.  If there are blockages of the large arteries, these can be treated with bypass surgery or angioplasty.  If the small arteries are blocked up, surgery and angioplasty are rarely useful.  However, there are newer (experimental) therapies such as lasers and gene therapy that are potentially useful in people who have extensive small artery blockages.  The Cleveland Clinic is one of a few medical centers engaged in such research.
Information provided in this forum is of a general nature.  Specific diagnoses and treatments can only be made by your doctor.  If you would like to see a cardiologist who specializes in PET scans and heart catheterization, please call 1-800-CCF-CARE for an appointment at desk F25 with an interventional cardiologist.