CABG

[nagrajjain]

"After six years I have second heart attack.IWMI.Angiography shows all three major vessle blocks to the extent of 90% at near end and 70% block at far end.Physical capacity of body is normal. No pain even during exercise. May be due to colateral circulation. Advised CABG. Fearing problems after surgery not feeling to do that.Please advise."

[ed34]

didn't you already ask this question here?
http://www.medhelp.org/posts/Heart-Disease/coronary-arteries-blockage-Angiography/show/1329279

If test show you are not suffering Ischaemia, then you likely have sufficient flow. It has to be remembered that NOT all people get symptoms and some people don't even realise they have had a heart attack.  Have you had a Stess echocardiogram and/or a Nuclear scan? What problems are you anticipating after surgery?
If tests reveal no Ischaemia, then it should be fine to avoid surgery, but you have to understand that the disease is likely to worsen.

[nagrajjain]

Yes. I had already askd the question.

As now I understand I have vulnarable plaque. The solution for that lies in stabilising plaque and not by-pass surgery.

Recently my two friends have experienced broken wires of cut chaste bone and they were operated again.Doctor is not giving any guarantee about operation without any problems. Then fearing some thing worst will happen why to go under knife.

[ed34]

There are risks associated with any surgery and I can understand your fears because I had a triple bypass three years ago. I, and millions of others, had no complications from the surgery at all. You are correct to say that bypass will not stabilise the plaque, BUT it WILL get a good blood flow to the areas of the heart which have an insufficient supply. The only way to somewhat stabilise the plaque would be to find a cardiologist who can perform angioplasty on your vessels.
I can understand your way of thinking, I was very much the same and still am. I was not happy with a bypass, leaving the plaque in place, where it could continue to grow and probably cause more problems in the future. I wanted my vessels cleaned.
My bypass failed after just three months, because my Left artery was coated all the way down with quite a thick layer of plaque, and had a huge total blockage at the top. My case was given to a teaching/research hospital which has the best cardiologists, the professors and one cardiologist took on my case. He managed to use angioplasty and remove all the total blockage, then he used rotablation and laser to remove the plaque down three quarters of the left vessel. This leaves the lining quite rough and it took 5 of the longests stents to cover it. Now nearly all the vessel is plaque free. However, I am still getting angina because there are two tiny  blockages right at the bottom so I need to ask his opinion on those. A year later though, the 5 stents are still fully open and working great.
It has to be realised also that not everybody seems to accept stents as well as others. Some people seem to form new disease very quickly around stents and form new blockages, much more quickly than would normally happen. Although research is continuing, it isn't really understood why this happens with some people. Stents also give some people discomfort and the reason for this again is not really conclusive. I had a stent in my circumflex artery nearly 4 years ago, which is still open and disease free. This told my cardiologist I am one of the lucky ones who seems to accept stents with no problems and gave him the boost needed to clean my left artery. If it had diseased again, he said he probably wouldn't have attempted it.

[ed34]

Just to add. Search until you find the option you are happy with. It took me two years but knowing the disease and blockage is now gone from my left artery, I feel much happier. Ask your cardiologist to refer your case to a research hospital.

[kenkeith]

QUOTE: "As I now I understand I have vulnarable plaque. The solution for that lies in stabilising plaque and not by-pass surgery".

>>>>As you know vulnerable plaque is the soft plaque the resides within the vessel linings. It is this condition that has the highest probability of rupturing and causing a heart attack. I had a test that scored my calcium and soft plaque several months ago.  You are correct, treatment is to prevent any further progression and some people believe the condition can be reversed.  You don't need a bypass.  

Thanks for sharing.  Take care.

[nagrajjain]

I am sweemer. In case of me I feel there are chances that my vulnerable plaque may get dislodged due to going under water and suddenly coming up. The sudden blood pressure variations may be the cause. I got my chaste pain during sweeming only.

My normal blood pressure is 140/90. I would like to know how far my blood pressure will increase when I am under 6 feet of water. My doctor was not in a position to tell me. Should I continue sweeming ? I have now all normal activities except sweeming. Or it will again dislodge vulnerable plaque. It may be very interesting to all. Thank you for sharing your information. That will enable me to take my decesions.

[cath911]

Swimming causing pressue? How deep are you going? Are you talking about scuba diving here and using gas mixes?

[nagrajjain]

I am not talking about scuba-diving as is evident "under 6feet of water'. Will blood pressure rise or fall and to what extent? If you know please tell me.

[kenkeith]

Good question.  There isn't decisive reports regarding arterial blood pressure and values during breath-hold diving is scanty. I found some information with the Journal of Applied Physiology. There has been some reports that have taken blood pressure at the water's surface showing slight or no increase in arterial BP, and from a single study of two simulated deep breath-hold dives in a hyperbaric chamber. Simulated dives showed an increase in ABP to values considered life threatening by standard clinical criteria. For the first time, using a novel noninvasive subaquatic sphygmomanometer, we successfully measured ABP in 10 healthy elite breath-hold divers at a depth of 10 m of freshwater (mfw). ABP was measured in dry conditions, at the surface (head-out immersion), and twice at a depth of 10 mfw. Underwater measurements of ABP were obtained in all subjects. Each measurement lasted 50–60 s and was accomplished without any complications or diver discomfort. In the 10 subjects as a whole, mean ABP values were 124/93 mmHg at the surface and 123/94 mmHg at a depth of 10 mfw. No significant statistical differences were found when blood pressure measurements at the water surface were compared with breath-hold diving conditions at a depth of 10 mfw.

Hope this provides the information you ask.

[nagrajjain]

Thank you for interest shown. Now I will tell you my exact observation before I got my second heart attack.
I used to submerge in water till the neck and used to walk in water with reduced weight in water. The floor of water tank being slanting the depth of submersion was getting reduced as I walked slowly. It is unique observation that when water came to the level of my heart and when my heart level came out of water I had a strange feeling of sudden change in pressure. This unique observation I was experiencing dailly for about five days. Then on sixth day while doing the same thing I started feeling mild chaste pain and thinking some thing wrong I came out of water immediately. After five minutes I had severe chaste pain which did not stop after Sorbitate and two ecosprine tabs too.This lead me to ask this question of blood pressure changes in water. Thank you once again. But definitely it needs a lot of thinking and research on the subject.

[nspower]

I am trying to draw some message from your observation. If I understand you correctly, you had no other symptom prior to your second heart attack except your observation in the swiming pool.

I am had MI in 2007, a stented LAD and 100% blocked LCx. My EF is around 30-35%. I do not feel discomfort during my normal walks and I believe that I am fine. But relating to your experience, the symptoms may emerge only under some specific conditions; like in swiming pool in your case.

How to make sure I do not get second MI. Sorry for interrupting in your question but I am now concerned.

[nagrajjain]

Thank you for communication. Regular medicine and life style i.e. food and exercise are very important. In my case additional stress was very important .I am personality type 'A'. Perfection being my motto I get a lot of stress every where in dealing with people. And I am sure my both attacks were as a cosequence of my stress . But stress was not immediate cause. After some years we become lax in every thing. That should not happen. I still feel that this time too I will manage with medicine alone. Wishing you will not have second attack. Take care.

[ed34]

A few years of stress and high blood pressure as a result would be enough to start the process of atherosclerosis. Your heart attacks would have been caused by a clot or rupture of existing disease. As disease progresses, most people experience symptoms which enable the blockage to be diagnosed before 100%. Now that Doctors are making a more accurate diagnosis regarding cardiac problems, deaths from heart attacks are reducing in the UK.

[nagrajjain]

What you said is right. If bypass is the solution for valnerable plaque? I do not think so.Please tell me the proper test to confirm the extent of ischemia to heart. According to me my physical capacity is the best indicator which takes into account colateral blood circulation too. However LVEF is the second best indicator. Please tell me in detail because that is going to enable me to go for bypass or not. I wonder extent of blockage shown by angiography and my LVEF which is 50% do not agree.Why doctor do not think about that. Thank you once again. Please tell me for sure. Or should I think of CPK or CPK-MB?

[kenkeith]

I believe your questions were answered in another post? May be it was another member's question. Anyway to determine the degree of soft calcium plaque (calcium between layer of the vessel) can be determined with ct scan 64 or greater slices.  Soft plaque accounts for the highest percentage of heart attacks when the plaque ruptures through a crack in the lining.  Hard plaque can dislodge and cause a heart attack as well.

A bypass is appropriate when there vessel stenosis (partial blockage usually hard plaque seen with cath angio).

I had a heart attack about 6 years ago, and my EF was below 29% and an enlarged heart.  With medication a stent, my heart is currently a normal size and the EF is 59%.  

Ejection fraction is the amount in a percentage of the blood pumped with each heartbeat.  Normal is 50 to 70%.  When there is a decrease in the EF it is usually due to heart muscle damage that impairs contractility due to having had a heart attack.

I haven't been following all of your posts, and ed is certainly capable of giving you helpful information.  Take care.

[ed34]

Why do you feel there's a link between your LVEF and your blockages?

[nagrajjain]

Thank you both of you. Blockages result in reduced blood supply to heart muscles. This may result in ischemia of heart muscles. Due to this heart can not pump as efficiently as before. LVEF get reduced. This is the link.
My question about test to find out extent of ischemia remains unanswered.Thank you once again.

[ed34]

Interesting, but LVEF doesn't necessarily reflect Ischaemia occurring. It would really depend on the amount of heart tissue being affected. In my case, just the bottom of the LV is low on blood and my EF is 70% which it always has been.
The best test to show blood supply to the heart tissue is a nuclear perfusion test. This comprises of 2 scans, one with the heart stressed and one with it at rest. It gives a good idea to the cardiologist if collaterals have formed and which vessels are likely to be giving problems. In some cases a stress echocardiogram can reveal a weaker function in certain areas of the heart due to Ischaemia, but most are inconclusive and the patient ends up having a nuclear scan.

[nagrajjain]

Thank MedHelp and all who answered the questions. My own decesion is not to go for bypass and manage with medicine.On 21st I will be seeking second openion with cardiologist. I have faith in him that he is not interested only in money. In my first heart attack also I had consulted him. I will let you know about that.
Answers both by ed34 and kenkeith were in agreement with my openion. When we three agree there is little left to be decided. Till then thank all of you.

[kenkeith]

QUOTE: "Why do you feel there's a link between your LVEF and your blockages?"

In my situation, the blockage and lack of oxygen caused hypokinesis (heart wall movement disorder) that weakened heart wall contractions and lowered the EF to below 29% (heart failure range). The good news is/was the heart cells were hibernating (google for more info) and the heart cells were revitalized with an increase of blood flow with a stent and medication.  After several months an echo indicated hypokinesis was minimal and my heart size and EF were now normal. Take care.

[nagrajjain]

First and formost requirement is my body should get adequate quantity of blood. This means heart should pump out that much blood to body. If heart muscles are damaged herat's capacity to pump blood will be reduced. Heart muscles will be damaged if coronary arteries supplying blood to heart are narrowed or blocked. In this process LV plays important part. And if blood supply through coronary artery to LV is affected quantity of blood pumped will be affected. Therefore coronary blockages and LVEF are linked. Provided other factors are normal.
Thank you for giving me opportunity to explain.

[ed34]

"If heart muscles are damaged herat's capacity to pump blood will be reduced"

It depends on how much heart tissue is affected. Like I said, just the bottom of my LV is restricted and I have 70% LVEF.

[kenkeith]

I agree with ed that the location of the damaged heart cells will have an effect on the cardiac output (stroke times heart rate)..

QUOTE: "And if blood supply through coronary artery to LV is affected quantity of blood pumped will be affected. Therefore coronary blockages and LVEF are linked. Provided other factors are normal".

>>>>>Cardiac output involves compensating system components that include heart rate, ejection fraction (not static....will normally dilate to increase contractility), vascular constriction and dilation, etc.to maintain a balance of blood flow between right and left side of the heart.  If the normal condition is compromised and not properly treated, the LV will continue to dilate (over compensate) to the degree that is abnormal and that will cause a drop in LVEF (Frank-Starling mechanism).  

You are correct, if coronary vessel blockage is severe, the normal compensating components will be ineffective and the result will be an enlarged left ventricle and a drop in the LVEF. If  there is blockage that is not significant the LVEF will likely be in the low normal range or possibly lower!  Referring of course to an ischemic heart condition.  

[nagrajjain]

My LV dimentions are normal after 2D-echo. No hyper trophy. IWMA-inferior wall motion abnormality is observed. Inspite LVEF is 50% then why go for bypass? MY heart beets 60 bm. My blood pressure 175/105.According to me you have fully understood me.Thank you for your contribution. Your answer is the best answer. I will verify with second openion to to find out the best solution.