Collaterals

[Kiwi01]

Dear Dr.

I am a 55 yo male that had 2 failed stents and bypass surgery 4 years ago. My original presenting problem was r.arm pain that has never really gone away. One year ago after having had counterpulsation treatments the pain seemed to not only be in the r. arm but in the chest as well with exertion. They did a cath which showed improvements in some of the diffuse narrowings that I had so that was good. Six months later they did a stress echo which was abnormal (the dr felt it showed a possible problem on the right side of the ht which had always been the better side)and wanted to do another cath but I asked to put it off 6 months and repeat the echo(I have a LBBB). The repeat echo in April showed no change. I've resisted a cath because I figured it would lead to stents which I've had bad luck with. The doctor feels we can continue with drug treatment since it is stable. My symptoms have improved during this time in that I can walk more vigorously and farther before the pain comes on. I also will walk up 6 flights of stairs most days (with some pain) whereas before the pain would come on much sooner. So I have been trying to push it by exercising through the pain because it seems like this approach has led to greater tolerance. I am considering starting some mild jogging. I follow the Ornish program, take zocor, a beta blocker, norvasc, ace inhibitor, plavix, and niaspan. My questions are:
1. What is the best way to build collaterals?
2. Is pushing it as I am inclined to do via exercise a safe and effective way?
3. Any other treatment suggestions?
Thank you

[CCF-M.D.-RCJ]

kiwi01,

Thanks for the post.

Q:"What is the best way to build collaterals?"

Great question.  We have circumstanital evidence of possible mechanisms, but no one has done a trial to show collateral development.

Persons that have angina prior to an MI have better survival.  If a person develops angina at 100 yd, stops and then starts again, they can more frequently than not walk further than 100 yd without developing angina.  Rats who are subjected to ischemic insult show more efficient use of energy substances than those who are not.

All of these pieces of evidence fit into the "Ischemic Preconditioning Model".  Molecular changes are responsible for some of the changes in this model, but do not wholely explain the findings.  Perhaps collateral development also helps explain the phenomenon.

Q2:"Is pushing it as I am inclined to do via exercise a safe and effective way?"

If done in a supervised setting.

Q3:"Any other treatment suggestions?"

Look's like you are on the right track.  Be sure to be monitored if pushing to angina.

Best of luck.

[Dr. Erik]

How do you tolerate the Niaspan? Do you get flushing? What if any any side effects did you have? I am conteplating starting Niaspan but I get PVC's and PAC's and have had A-Fib before and I am afraid Niaspan will aggravate my heart. Did you get any palpitations with the niaspan? Just curious. It sounds like you are doing the right things to keep your CAD stable and maybe even reverse it. It has been proven that Zocor and Niaspan can reverse CAD. Best of luck!


Erik

[Kiwi01]

Thanks for your post.  I had some flushing that felt like hot flashes and could be uncomfortable from the niaspan.  I have been able to minimize the problem by having some food before taking the medicine (which I take at night).  Some foods seem to work better than others for me.  A bowl of cereal like cheerios works well for me.  I think a low fat dish is important.  I haven't noticed any other side effects of the type you mentioned.  I should also mention that I haven't seen an increase in my HDL which is why I was taking it (it's been about 6 months)but did have a sizeable drop in my triglycerides.  Good luck to you.

[Healthyself2]

I would say that trying to exercise through angina is dangerous and can cause further damage.  In your condition jogging is out of the question.  With that much ischemia, you would be at high risk for a fatal arrythmia.  Pushing through ischemia will put you into heart failure a few years down the road.

In your situation you want to do slow steady exercise with a very long and slow warmup.  If you can stay below the angina threshold you will be able to exercise much longer.  If you push through angina, you just end up paying later and can't exercise as long.  Angiogenesis is a natural response to mild ischemia, so you do have to learn to push right up against your limit, but not through it.  Walking would probably be best.  If you have a place where you can walk up and down gentle hills that would be good.

A long duration mildy aerobic exercise is the best way of building collaterals and increasing HDL.

I would say that the only case for using Niaspan would be if you need to raise HDL significantly.  I raised my HDL from 29 to 55 with Niaspan and exercise.

I had a heart attack 5 years ago and have a totally occluded RCA, a 70-90% ostial occlusion of the circumflex, and a "cratered" plaque in my left main.  I gave the docs 2 failed attempts at angioplasty and now consider it fortunate that they never left any steel in me.  I refused bypass surgery on 2 occasions even though I was given a dire prognosis.  Again, I am glad that I didn't go that route.

My RCA is now well collateralized and I don't even consider it a problem anymore.  If someone told me they could fix it tomorrow, I wouldn't even bother.

My EF is now in the normal range and my cardiolgist said that, if he didn't know my history, he would think that I was in good health.

I keep my total cholesterol betwen 140 - 150 and HDL > 50 with a multiple drug cocktail of Lipitor + Niaspan + Welchol. I had pushed it down to 110, but thought that was a bit too severe and backed off the meds a bit.

I'm not a fan of beta blockers, diuretics, or blood thinners such as Plavix, although in your case you might need it.

During the work week I walk twice a day in a wooded setting, up and down hills for a total of 3 miles.  I try to do something a little more strenous on the weekends like skiing or hiking.  I take the summers off and try to hike 10,000' of elevation gain every week.  It took a few years to get to that point.  Fortunately I live in a part of the country with a lot of mountains and public land.  If you live back east, consider moving and cutting your work back to 9 months a year - living is worth it.

Good Luck to You.

[Clogged]

Anyone ever hear that collaterals disappear after CABG or PTCA? Sure would be nice if they would stick around for "back-up"

[Healthyself2]

Collateral vascularization is mainly expansion of the capillary network already in place.  They say that these disappear when blood flow is restored via interventional revascularization.  I suspect that the network is still in place, but the blood now takes the path of least resistance, so they just don't see the collaterals on the angiogram.  They probably also contract in response to local lower blood pressure.

I would suspect that if the blood flow through the primary circuit diminishes again, as local blood pressure increases and VGF is released in response to ischemia, any prior collaterals would report for duty again.

[Dr. Erik]

I would think that after a Bypass, the collaterals of the arteries that were bypassed would be useless since they are no longer in use.