You have some blockages that are mild, and some which are moderate, none which are severe. I would assume that you will be treated with medication and you should be advised of risk factors so you can reduce your risk considerably.
Q: I have taken last week CT Angiogram and its findings are worrisome. The main impressions are: Calcium score: 18, Soft plaques seen in proximal LAD and D1 segment.
....You had a CT angiogram and included is a separate procedure a calcium score. The CT angiogram views the channel (lumen) of the vessels for any hard plaque buildup that would cause a narrowing of the vessel for blood flow and if serious could cause symptoms of chest pain, etc. Soft plaque resides between the layers of the vessel
To add what others have said. The CT score is a procedure that views the anatomy of the vessel and looking for any soft plaque that would be observed between layers of the vessel. Your score represents "Soft plaques seen in proximal LAD and D1 segment. LAD - (Prox/Middle/Distal)- Type -III LAD with normal course. Focal Eccentric non-calcified plaque seen with moderate luminal narrowing".
D1 ----- Single large D1 branch seen with normal course. Mid vessel reveal plaquing with moderate luminal narowing".
.....The soft plaque can cause vessel remodeling...meaning the soft plaque buildup can reduce the lumen diameter without rupturing the inner layer but can bulge the inner layer into the lumen enough to reduce the diameter (positive remodeling of vessel)...if serious the stenosis (reduced diameter) can cause some obstruction of blood flow causing symptoms such as chest pain (angina pectoris).
To reduce soft plaque would be a heart healthy diet that maintains a good cholesterol levels and medication if necessary to keep cholesterol low . If and when stenosis is above 70%, that may require intervention as that may reduce blood flow enough to cause a problem.
You have a very good calcium score...my score was very high can have a stented RCA artery, totally blocked LAD and a 72% ICX with a total over 1000 score for all 4 major arteries....prognosis is a 20% probability of a heart event within a year. That prognosis was over 2 years ago and no problems...the CT scan was of no benefit or utility because I already knew and expected a high score...The risk with a high calcium score is that the soft plaque can rupture through the inner layer causing a heart attack. Your score is very good but there is a beginning of CAD.
Thanks. Your comments gave me lot of relief. I have been having high Cholesterol which was detected 16 years ago and my triglyceride has remained out of control despite medication and diet/exercise. The liplid profile became normal only at two occassions during the last 16 years.
My Dr suggested CT Angio after I had a couple of episodes during very brisk climbing walk and emotional stress. Now after seeing CT he ( as well as the radiologist) told me that CT angio is not very reliable and variation may be +-10-20%.I have been advised to go for catheter angiography. In India, if one goes for this procedure most hospitals/doctors whould ask for stent/s as they make more money.
I am wondering if medication may help for the time being and angiography/plasty could be postponed. I am not sure if by postponing the procedure, how much risk I would be carrying, though I know no one can easily predict.
You have to sign a consent form before the procedure, you can simply make in plain to the cardiologist, and write it on the consent form, that this is for investigation only, and in no way is intervention to be used at this time. Once this is written, they wouldn't dare insert stents because you have unquestionably stated you don't want them.
.Q:I am wondering if medication may help for the time being and angiography/plasty could be postponed. I am not sure if by postponing the procedure, how much risk I would be carrying, though I know no one can easily predict..
....If medication (nitrate) controls the episodes (assume angina pectoris) there is little to no risk to be on medication. I have been on mediction (medication) going on 8 years and no problems with any angina when exercising at medium level of activity. I agree, if there is a cath angiogram it is likely to be a stent implant included for the reasons you cited.
A CT angiogram has a high sensitivety and selectivity rating for a CT scan with a 64 slice or greater with a 90-95% respectfully for detection of lesions greater than 50% provided the heart rate is reduced very good images (about 65 HR or lower).
The COURAGE study (google for more info) indicates the 3 procedures (medication, stent implant and CABG) treat the symptom of angina and have no other advantage in terms of risk for a heart event.
Thanks. I found your answer/comments very useful and realistic and I have decided to take two more opinions from cardiologist next month. I have also decided, in consultation with my family, to avoid invasive angiography for the time being as it, I think, risk would outweigh any possible benefit.
Just be careful when you make your decisions. At the end of the day, you should listen to professionals and there are none in this forum. You say for example that the risk would outweigh any possible benefit, but arguably, how could you possibly know that for certain?
If I left any of my blockages, I can't even say with surety that I would still be here today, nobody can. Don't read too much into trials either, because many are just too selective and techniques/knowledge grows on a daily basis. You shouldn't base your opinions on outcomes/choices of selected individuals either, treatments work very well for the majority.
For example, I have 8 stents, and require only blood thinners and cholesterol lowering meds. I had two choices, pump myself full of nitrates and beta blockers for the rest of my life (if life is what you would have really called it), or get some stents. Risks in angioplasty are very low and problems during the procedures are very rare. All I ask is that you listen to the Cardiologists you see. They can obviously only advise you, but at the end of the day, the choice is yours. I wish you good luck in your journey.
That is a reasonable suggestion. I am going to see cardiologists early next month and then see what could be the best choice for the time being. My present cardiologist who practices non-invasive procedures has put me on aspirin 75 mg and atorvastatin (lipitor?) 10 mg. He advised me that there is no emergency but take cath angio. I have already adopted a diet and exercise regime as an attempt to retard progression of further narrowing of coronary arteries.
I will be seeing a couple of reputed cardiologists very soon though I remain skeptical about immediate stent planting in OM2 or D1.
When I took my CT Angio, the radiologist told me that CT scan is not absolutely correct and may have a variation of +-10 as regards coronary arteries and that cath angio is more accurate. My cardiologist also told me that there is narrowing which has to be assessed more accurately with cath angio. As I read recently, cath angio remains the gold standard. I also read a paper that says that CT angio is fairly sensitive and accurate and that a new machine launched by Toshiba and approved by US Govt. would give more accurate impressions.
CT angio is done in people with family heart history and those having other risk factors. This helps in making an early assessment of the condition of vessels.
Opinions are divided among specialists. Courage study done in the West shoes a considerable amount of debate and controversy. This means that doctors would be biased to their own specialization. Ultimately the patient and his/her family should choose an approach to be adopted which is low risk and high benefits. I too am confused and will be consulting a couple of cadio in Delhi next week and place the outcome summary on this site.
Thanks for your response. I have stent in my RCA and the CT angiogram can not view the lumen inside the stent as I understand. The diagnosis regarding the stent viability was to dteremine the flow of blood into the stented area and the output...newer technology with increased slices (256) is considered very good.
Let us know the information you receive. Take care,
Thank you all for valuable information. I hahve seen doctors manupulating results for commercial gains. That pains. Patient forum must force doctors to respond to their queries and counter check the claims by doctors.This sort of openness is necessary for the benefit of humanity.. Thank you all.
Studies can be misleading, remember they only cover a short period of time and are very specific to the types of patients who are in the trials. The courage trial basically stated the absolute obvious, and rules which most European countries have been following for years. Those are, with heart patients you have to go by two things. First is how the heart is actually functioning, and second, how the patients feels. You can guarantee that if you have 10 patients with a 70% blockage in the same part of the same artery, you will have 10 different sets of symptoms and 10 different levels of intensity. Some people feel nothing at all but their heart could be having all kinds of problems. So ALL decisions have to backed up with evidence, i.e. tests. I was intrigued for example when I read the following about the Courgage study....
Dr. Trippi, “A patient with a 70% lesion, few symptoms and good cardiac functional ability might do just as well with or without a bare metal stent provided the patient adheres to an intense regimen of medications. It should be noted that many of the medically treated patients in the study eventually ended up with stents or coronary artery bypass because of increasing symptoms. Patients who are getting bare metal stents when they have a moderately tight blockage with controlled symptoms don't have heart attacks or die any less because they get good medical treatment for all the other less severe lesions that are just as likely to thrombose causing a heart attack as the stented lesion. This study confirms that state of the art medical treatment is effective.”
So basically, do you ignore a lesion which has the consistency for a high risk rupture and stay on medication, or do you have it stented. Other trials have shown that lesions forming in the same place as stents or thrombus forming in stents is very rare, they are much more likely to appear elsewhere, and the key it seems, is the type of material in the blockage. You have to read very carefully between the lines with studies.
I ended up having 8 stents because medication proved to be very limited in my case. For some reason they all had very little effect on the symptoms of angina. So, I had no choice if I wanted a better quality of life, and a more comfortable one. However, if medication did work for me, I would follow this protocol....
a. What is the composition of the blockage ( is it the type more likely to erupt and possibly kill me).
b. Does the medication I am taking relieve symptoms and enable me to do all the tasks I want to achieve.
c. What risk factors am I ignoring and increasing my chances of developing more blockages.
If the type of blockage is one more likely to erupt, then yes I would stent. I would still have a stent if meds are working because of the risk of leaving that type of blockage. If the blockage was of the type less likely to erupt, and meds were working, then I would leave it alone for as long as possible, but in most cases, the symptoms eventually worsen.
In my case it is vulnerable plaque as told by doctor. Doctor told me I may die at any time if quadruple bypass surgery is not done. I asked doctor why I do not have pain even on exersion. Doctor told me I have colaterals. I asked doctor do you give guarantee that after bypass i will survive at least one year. Doctor did not agree. I went then for second openion and on medicine only I survived one complete year. What you will call all this.I do not have any pain now too. Even on exersion. Thank you ed4 for your valued information. That gives me courage to put my case in proper perspective.
There is a risk with angioplasty that some people ignore and believe a stent(s) is the answer to their cardivascular chronic angina and don't consider the risks of intervention.
The most common angioplasty risks include:
Re-narrowing of your artery (restenosis). With angioplasty alone — without stent placement — restenosis happens in as many as 30 to 40 percent of cases (requires another stent). The original bare-metal stents reduce the chance of restenosis to less than 20 percent, and the use of drug-eluting stents has reduced the risk to less than 10 percent. For awhile DES was out of favor and a return to bare metal due to some porblem.
Blood clots. Blood clots can form within stents even weeks or months after angioplasty.
These clots may cause a heart attack. It's important to take aspirin, Plavix and other medications exactly as prescribed to decrease the chance of clots forming in your stent. My last understanding was the risk up to a year.
Bleeding: Patient may have bleeding at the leg or arm site where a catheter was inserted. Usually this simply results in a bruise, but sometimes serious bleeding occurs and may require blood transfusion or surgical procedures.
Other rare risks of angioplasty include:
"Heart attack. Though rare, you may have a heart attack during the procedure.
Coronary artery damage. Your coronary artery may be torn or ruptured (dissected) during the procedure. These complications may require emergency bypass surgery.
Kidney problems. The dye used during angioplasty and stent placement can cause kidney damage, especially in people who already have kidney problems. If you're at increased risk, your doctor may give you a medication to try to protect your kidneys.
Stroke. During angioplasty, blood clots that may form on the catheters can break loose and travel to your brain. Blood thinners are given during the procedure to reduce this risk. A stroke can also occur if plaques in your heart break loose when the catheters are being threaded through the aorta.
Abnormal heart rhythms. You heart may get irritated during the procedure and beat too quickly or too slowly. These heart rhythm problems are usually short-lived, but sometimes medications or a temporary pacemaker is needed."
Risk for medication, very few if any. If in the future unstable angina develops and medication does not provide relief, the stent option remains to mechanically prop the vessel and there are no additional risks to forgo an immediate intervention with chronic stable angina....there are exceptions...if one is having a heart attack (acute) angina, emergency procedures are necessary. But having chronic angina is not usually an emergency condition and that is the issue to be weighed (risk v. benefit).
Going on 8 years, I had a silent heart attack and the 98% blocked RCA and stented, but the 72% blocked ICX not stented, and I have 100% blocked LAD. Medication has provided relief from angina with moderate exerecise and not needed for every day tasks, etc.
I haven't always taken the no intervention position regarding treatment. On another heart forum we have debated even with doctors participating that intervention was not always necessary and that was 7 years ago when it was almost unheard of to question a doctor's dx intervention for angina! My cardiologist of non-interventional persuation and continue to be persuaded for medication therapy and as more information develops it seems to support the position of no intervention for chronic angina if medication is sufficient.
So with a DES, the success rate is 90% or more. Those are very good odds for anyone. Of course, restenosis doesn't mean death. This produces symptoms like those originally felt and in most cases as stated, are treated with another stent, OR, laser. Heart attacks etc during a procedure are rare, and of course can be treated while on the table. The statement "There is a risk with angioplasty that some people ignore and believe a stent(s) is the answer to their cardivascular chronic angina and don't consider the risks of intervention" is not true, ALL people are aware because they are made aware of the risks before treatment, even emergency. Stenting has without a doubt saved millions of lives.
What we have to ask, to see the other side of the coin, is how many people survive if they refuse stents. If someone is having a heart attack or very bad angina, and they refuse stents, what are their chances?
I think you need to go back a step though. Why would you have an angiogram if A. there were no symptoms, or b. A stress test etc didn't reveal ischemia?
There would be a good valid reason for investigating with an angiogram. With regards to collaterals, you are correct, some are invisible because they are too fine. BUT, you can generally see in an angiogram if there is collateral feed from somewhere. I can give you such an example from my own history...
In 2007 I had an angiogram which revealed my LAD was totally blocked at the top. Now, I was not dead, so obviously there was blood coming from somewhere. When dye was injected down my Circumflex, it appeared in the LAD, showing it must be cross feeding. The blood was flowing UP my LAD instead of DOWN, another indication. You don't always have to see the collaterals themselves. But, yes, until something better comes along, angiography is the gold standard.
I think I explained this in another post.
Let's say you have a large blockage in your LAD near the top. You have a large blockage in your RCA halfway down. You have a small blockage in your Left Circumflex(anywhere in the vessel). Now, let's say that you have opened many collaterals, and have absolutely no symptoms. As you say, you could leave things alone, just use medication. Medication simply hides symptoms and doesn't make any physical changes to your problem. Now, it's important to picture the blood flowing around your coronary arteries. The blood has to come from somewhere to be fed to all areas of the heart muscle. If your LAD isn't receiving enough blood through its natural route (the left main stem), then it must be receiving blood from collaterals. Those collaterals will fed from another Artery on your heart, perhaps the Left circumflex. You now rely on the Left circumflex for TWO reasons. ONE, to feed all the heart tissue that the LCX would normally be feeding. TWO, to supply blood across to the LAD to help that vessel feed the heart muscle it's responsible for. So, IF the blockage in the LCX grows sufficiently, then you will suddenly have lots of problems because a) the tissue fed from the LCX will start to die, and b) the LAD will no longer be receiving an additional supply through collaterals and so more tissue will start to die. This will be a huge impact.
So to simply say "I have blockages but I feel fine because I have collaterals", is not reason enough to avoid intervention. You need to know WHERE the collaterals are being fed from, which vessel, AND what is the condition of that vessel. You also have to decide if you want your heart to rely on just ONE vessel to keep everything running, with no backup.
I was in this situation in 2007. My LCX was the only vessel keeping me alive. It was feeding the heart muscle it normally would, plus it was the FULL supply now for my LAD through collaterals. It was known by myself and Cardiologists that if I formed a clot in the LCX, then my life would be over because the left side of my heart would have no oxygen at all. This is why I pushed and pushed Cardiologists to open up and stent my LAD, even though it was a risky procedure. I now have 2 open feeds to the left side of my heart. The LAD and the LCX. If one blocks, I still have the other.
It's a bit like jumping out of a plane with a parachute and having no safety chute. If the first one fails, you die.
The conventional treatment with medication has been doing fine for the time being. But I think, as I feel inclined to agree with Ed, one has to weigh risks by going through invasive procedure or hoping that things would turn out fine. Perhaps at some stage it might appear that it is preferable to go through intervention procedure that may bring long-term benefits and address the inevitable problem of uncertainty and looming risk of a heart episode. \
In my case, after I get two or more opinions, if necesary I would have no alternative but to go through cath angio.
The scary part in health business here is that doctors do things for earning by their corporate hospitals (perhaps CEO sets revenue target). I have seen people going smiling to heart hospital and OTs and family getting body bags. Further, on angio many patients and families are scared to go through heart surgery or a heart attack is imminent...and so on.
Simply saying sense and non-sense is meaning-less. How ? You failed to explain.What I find here is that without taking risk doctor wants to grab my money. How far this is ethical.Why doctor can not guarantee the out come of his action when he is taking money.
Without the details you can't say it is nonsense. What arteries are blocked? by how much? which artery/s are feeding the collaterals?
NO medical procedure carries a guarantee. Ask any Doctor and they will NEVER say 100%.
Sometimes it can seem difficult to make a decision which is why you need to understand the details of your problems and see why the cardiologist feels the way he does about your case. The best thing to do is ASK. Everytime I see my cardiologist he has images of my angiogram ready on his PC, because he knows I will be asking lots of questions. I also ask lots of questions regarding whether certain areas of research are under human trials yet. Cardiologists love to be asked questions, they've told me this, many of them, but they aren't particularly fond of arguments :)
ed34 - What you say is perfectly true. Only difference is the doctor you came across and I came across are different. My doctor expects that I should blindly follow what ever he says.In India Doctors manupulate at your place I do not know. Not all doctors I am talking about. I have got all reports. I can discuuss those things. Doctor of his profession told me not to go for bypass. Two doctors differ. What is the alternative for patient. Please understand this. One must open to discuss.
What Kenkeith said is entirely true, but may be trivial: "If it doesn't make sense, it is non-sense." But does it abvance the discussion? I think it does. Why? You said, you don't have angina and in a different post you mentioned that your LVEF is 50%. That puts you in the same boat as I, although, I don't know what my actual blockage is. What I do know is that my Calcium Score is 1217 with the LAD at 782. My cardiologist said: "Don't worry, you are gonna live another 30 years". Which would be a neat trick, since I am already 75. They won't do any invasive procedure at this time since my heart seems to be ok.
Q: "Simply saying sense and non-sense is meaning-less. How ? You failed to explain.What I find here is that without taking risk doctor wants to grab my money. How far this is ethical.Why doctor can not guarantee the out come of his action when he is taking money".
...Statistical probability is not a guarantee. The doctor by his or her record of successful operational procedures can and should be considered competent to perform an operation but no guarantee of outcome. No doctor can guarantee you would not have complications and pain, etc. from a bypass...statistically that is a reality. So it doesn't make sense to risk the probability of complications, pain, etc. when the present quality of life is not impaired.
I know the extent of my CAD with a total calcium score over 1000 with totally blocked LAD and 72% blocked ICX. I have been doing well for the past 7 years...not one day of illness, not even a head cold and I am in my late 70's. It doesn't make sense to have an operation, and there would be no guarantee, nor would I expect a guarantee. I make the decision based on how I feel and the acknowledgement of the risks in consultation with the doctor if and when I would considering an operation...no guarantee expected just probability of risk v. benefit....presently all risk an no benefit...so it is nonsensical to even consider an operation and accoring to your posts your qualitiy of life can not be improved with an operation.
" I have been doing well for the past 7 years"
That's good, but we can't base every case on this, and I'm sure you're not.
I do have a question though to put to you and wonder what your decision would be if in this scenario...
After an angiogram you are discovered to have a totally blocked LAD in the proximal section. Your LAD shows retrograde filling which means you have collateral feeds into the vessel. Further investigation reveals collaterals are being sourced from your LCX, but this now has a 70% lesion in the mid section. You have no symptoms with normal daily tasks while on medication, but on high exertion you suffer stable angina. The cardiologist explains that if the LCX blocks, then there is an almost certain probability of death because the collaterals will also close, giving no blood to the left ventricle. So, you have a decision. Do you a) stay as you are because you feel good enough on meds with a normal quality of life, or b) have the 70% lesion treated ?
If they said they could also open the LAD, giving two main feeds back to the left ventricle would you have this done also? so you don't rely on just one vessel?
I'm just wondering what your decision would be if this was your case.
I am very happy with open discussions.What do you think probability is? It is guarantee only. No body expects 100 percent guarantee. Like probability guarantee too have percentages. Doctor should tell me that figure of probability. I will be happy with that too. I am engineer and not layman to be fooled by another expert.Thank you all for cooperation and openness. Nobody can be silenced by telling him he is fool.
Q:"So, you have a decision. Do you a) stay as you are because you feel good enough on meds with a normal quality of life, or b) have the 70% lesion treated ?
If they said they could also open the LAD, giving two main feeds back to the left ventricle would you have this done also? so you don't rely on just one vessel?
I'm just wondering what your decision would be if this was your case."
....Obviously, I have had over many years a reconfiguration and a normal adjustment of the blood supply to feed effectively heart cells over many years without any adverse medical circumstances. If the LAD is opened, that will displace the reconfigured geography of the present blood flow system and whether there would be a favorable readjustment would be a risk that is unnecessary. Additionally my coronary system is right dominant meaning the rightside feeds blood into the left side that a left dominant configuration would would feed.
Q: "The cardiologist explains that if the LCX blocks, then there is an almost certain probability of death because the collaterals will also close, giving no blood to the left ventricle. "
.....I don't understand the logic. If the LCX blocks, there can be cardiac failure and arrest whether there are collaterals or not!
If a Doctor guarantees 100% success, and something goes wrong, then he is liable. Not just by the patient if he/she survives, but to the family, relatives or friends also. We have to remember that medical professionals are only human and unforeseen circumstances can always present themselves. Obviously risk is seen differently by different experts, because at the end of the day it depends on their experience. A surgeon who has performed a particular type of operation 1000's of times would carry a much lower risk than one who has performed it just once. It was interesting when I had my LAD opened by the Cardiologist who was the first to use a balloon and Stent in the UK. The consent form stated 1% and he said "I'm not allowed to put zero, I have to put a higher number". All other Cardiologists I approached put the risk at 20% or more.
Here one famous doctor Mandake who performed more than thousand bypass surgeries succesfully died of heart attack at the age below 50 years. After my first heart attack I was adviced angiography but I did not go for and I had second heart attack only after six years. I am sure from the status of my health that I will not have third heart attack at least for three years. In the name of not to take risk all much more risky methods are adopted. i am talking about my personal individual case.Medical profession should be made more and more accountable for their uncalled action and surgeries from commercial point of view. That is the only way truth will come out. Being noble profession nobdy question them is not desirable. Medical science is technology and not miracle.
I saw a prominent invasive cardiologist today to discuss my case based on CT angio and seek his opinion. After reading the report he suggested cath angio. CT angio percentage narrowing does not give adequate indication. On asking he told that there was no emergency as there are no symptoms. According to him there are two approaches:
1. Go for cath angio for diagnostic purpose and if something is required in any artery could be done. If all is OK, a person feels reassuered.
2. Do not go for angio, but there may be anxiety if any chest discomfort or pain happens.
He has suggested Thallium test to find out flow of blood in coronary arteries. I have decided to go for it as it is a non-invasive procedure and would further give an idea of coronary artery narrowing.
He has prescribes-ecospirin 75 mg OD, Resuvastatin 20 mg OD, Concore 5mg. Resuv is more potent than lipitor (atorvastatin) keeping in view my long history of high cholesterol and triglyceride. Concore would take care of angina. This prescription is preventive according to him.
I am happy that there is no need for an immedeate cath angio. I will report to the group the results of Thallium test and another consultation with a non-invasive cardio.
Q: "I think it's important to also add. Never have new blockages formed around previous intervention. They have always occurred at a new site".
Doctors should be accountable and consider the effect of a stent implant on the coronary vessel system as it relates to the logical elements (blood flow, pressure, and resistence) of the other segments of the cardivascular system. For every action there has to be a reaction on the logistical characteristics of hemodynamics... there is no way other segments are not effected, and it can't be without some change to maintain a healthy or unhealthy equilibrium of blood flow .With that in mind someone who has had a multitude of stent implants increases the probability and appreciate(fully aware) the negative effect on the native vessels and a new site vulnerable for an occlusion.
Q:" I'm not quite sure what you are saying here? Are you saying that for every stent implant there is a 'new' risk that a lesion will form elsewhere, because of that stent?"
>>>>.Yes, based on fluid dynamics. For instance, when a there is a stent implant the coronary wall is propped open and the other sections of the vessel normally continues to dilate and constrict when stimulated,..This wil cause turbulence when a portion that has a stent implant has a wider fixed diameter than the lumen prior and subsequent to the stent portion and is directly proportional to the length of the implant and/or end to end implants.
Also as a result of blood flow that will change the blood flow and pressure to distal and prior portions of the stent implant and its contributory beds and vessels of the stented implant, etc. This will effect other segments in terms of blood flow velocity and pressure. Vulnerable segments can be adversely effected in an attempt to establish equilibrium of blood flow to all parts of heart tissues. etc. This can happen as a stent will shut down the collateral vessel's contribution to other segments that may not be directly related to the subject vessel's feed. A collateral vessel is not necessarily a direct bypass of a lesion but it can feed into another vessel that will feed the deficit portion of the heart to maintain the integrity of the system. Another stent will disrupt that blood flow!, etc.
To have many stents is to abnormally redistribute blood flow and may/will cause undue pressure to other vulnerable sections of the vessel configuration and in time another stent is required, etc.
"Yes, based on fluid dynamics. For instance, when a there is a stent implant the coronary wall is propped open and the other sections of the vessel normally continues to dilate and constrict when stimulated,..This wil cause turbulence when a portion that has a stent implant has a wider fixed diameter than the lumen prior and subsequent to the stent portion and is directly proportional to the length of the implant and/or end to end implants"
Oh wow. I really couldn't disagree more. This is why I asked you a question with a given scenario a while ago which you seemed reluctant to answer. Let me put it to you this way.
Coronary artery disease is not caused by stents, it is caused by a few possibilities, but certainly not stents. If a patient has high risk and progressive disease, eventually the coronary arteries will not be able to open and support collateral feeds in any form. The blood has to come from a coronary artery, but it flow/pressure is too low in all vessels over time because intervention is avoided, then nothing will develop. The patient is simply waiting to die. Collaterals have to get their feed from somewhere. Stenting doesn't cause lesions in other vessels or distal in the same vessel, turbulence in a stent can cause clots in that stent though which is why plavix is so important, especially combined with aspirin. If a patient ignores risk factors they can remove, such as prolonged stress or smoking, stents or not, they will continue to develop lesions. Collaterals closing down due to stenting is not bad thing either. The body opens collaterals in SOME patients when required, but if they are no longer required, they will close. If flow/pressure is adequate through the native vessels again, why would you need collateral vessels?
Stenting saves millions of lives every year but I still fail to see why you are so anti. When my LAD was opened, I felt fantastic and don't require nitrates, beta blockers or blood pressure meds. I have no restriction on exertion and have never felt better in 6 years.
In march this year I had to have 2 blockages stented. However, previous angiograms did reveal a small amount of disease in that area. I went through a period of high stress for 6 months due to family issues and this caused the progression. It wasn't because I had other stents, it was because of the stress. As I endured the stress I could feel problems developing and I warned Doctors. The new blockages were mid LCX and distal to this would have been the collaterals which were feeding my once blocked LAD. If my LAD hadn't been re-opened, I would have lost those collaterals, and had a blocked LCX. I would have very likely died. So it looks as though having my LAD opened was the best decision I've ever made in my life.
Each person can speak about his own case only and should not be generalised. With the help of doctor intelligent peoples can find out better ways for their own treatment. Probliem with some doctors is due to ignorance they do not want to share the procedure with patients particularly intelligent patient. Here doctor is missing opportunity of further research in the subject. Of course things depend upon the time available. How much desire I may have still I can not exchange all the information with me about my disease with you or even with doctor some time. Sufficient time is needed which does not come free. But due to that opportunity of knowing some thing new is lost. Still I am happy that discussions here are going on smoothly and with understanding.In my case I am disputing the results of catherter angiography because I discussed with doctor how percentages of blockages are caulated. I am sure doctor is wrong and i will be going for catherter angiography again some time next year or two. Thank you. I hope I will come back to you then to report.
I took Thallium (MIBI) test today which has the following report:
"Quantitative Gated Mycardial Perfusion Study performed using 99mTc Tetrofosmin in the one day Stress/Rest Protocol. The maximum Heart Rate achieved during stress on TMT was 147 BPM (91% THR). Max. Blood Pressure 134/82 mmHg, duration of exercise was 6.10 minutes (5 METS) on Bruce Protocol. Exercise terminated on as Target HR was attained.
LV cavity appears normal in size.
Tracer distribution in the entire left ventricular myocardium is within normal physiological limits at both stress and rest.
Quantification using the QGS/QPS Protocol shows no evidence of haemodynamically significant reversible Ischemia.
Functional Information: Multi Gated resting SPECT images show good wall motion and systolic thickening in all regions of the LV myocardium with good global LVEF.
• No scan evidence of stress induced reversible ischemia noted in the LV myocardium.
• Good resting LV systolic function as estimated by quantitative Gated SPECT."
I saw the Cardiologist and he ruled out necessity of cath angio as MIBI test showed good blood flow/circulation in my coronary arteries and there is no reversible ischemia. However, to deal with narrowing and preventing further narrowing I will be on statin and aspirin and no beta blocker.
My conclusion is first, CT angio is not very accurate. Second, one should not rush for cath angio if there are no symptoms of angina. Third, always take second and/third opinion if a Dr decares you having heart disease or on may have heart attack.
Thanks for all the members of this group for their useful opinions that helped me in avoiding cath angio intervention. It is goof forum and I will continue to participate and shere my experience and learn from yours.
agrajjain, Thanks for your response and sharing your experience. I agree with irshad for his assessment that stress test would be better for you and others with a similar condition. Why? If I remember correctly you do not have angina with exercise and you don't know your capacity for the most beneficial cardio workout (with angina one knows the limitation). A stress test lets your doctor know how well your heart muscle is being supplied with blood, its functionality, etc. and the test will provide your heart/respiratory capacity for a workout and what are your limitations based on the vital signs and it will also establish a basis for future tests.
A cath would observe if there are any blockages and whether or not a stent implant is necessary (my opinion at that time of intervention cardiologist is inclined to implant a stent rationalizing the patient would need a stent later and might as well do it now for occlusions that really do not require immediate treatment and possibly never.
About 8 years ago, I had stent implant in my RCA and a 72% ICX blockage and not stented at that time. About 2 months later the cardiologist wanted to stent the ICX, and could not answer my question why a stent now and not at the time of the angioplasty. The doctor left the employment a few weeks later...my current and subsequent cardiolost has never suggested an angioplasty!? In my opinion the first interventional cardiologist was attempting to double dip and somewhat evident he could not answer my question, why now?.
Q: Coronary artery disease is not caused by stents, it is caused by a few possibilities, but certainly not stents."
...Turbulance has a role to produce a site for a lesion. A good example is the branching of the LAD and ICX from the main. Increased blood velocity increases turbulance. Blood velocity is a function of pressure and resistence both which will enable an occlusion.
Q: "If a patient has high risk and progressive disease, eventually the coronary arteries will not be able to open and support collateral feeds in any form".
Collateral vessels develop from the gradient pressure of the occluding vessel. When collaterals are in place and functioning the end point of the occluded vessel can/will terminate and collateral vessels will hopefully supply the deficit area for sufficient blood flow. Your comment seems to suggest you believe there is a bridge from the proximal side of the blockage and a direct link to distal side of the occluded vessel....that is not necessarily so and frankly I don't believe that happens because the pressures down stream on the same occluded vessel won't happen for the reason you stated and that makes sense. If I understand the comment!
Q: "Collaterals have to get their feed from somewhere. Stenting doesn't cause lesions in other vessels or distal in the same vessel, turbulence in a stent can cause clots in that stent though which is why plavix is so important, especially combined with aspirin".
...It is my understanding plavix relates to blood clots not plaque, whatever. But that is another subject. It is my understandiong the distal end of the occluded vessels ends and contributory paths for blood flow dry up from the distal end of the occluded vessel. That is why to open an occluded vessel redistributes blood flow through the newly open occlusion and that puts pressure on other vulnerable segments of the cariovascular system and possilbly shut down the collateral flow and not that not effectively open the closed vessels. It changes the hemodynamics of the system associated directly and indirectly to other segments. If one envisions a closed circuit, it would be obvious for every element of the hemodynamics of blood flow and fluid physics there will be a reaction to the changing dynamics of the closed circuit that doesn't have infinite blood volume and must maintain the equilibrium of right and left side of the heart. Every hemodynamic action is compensated by a reaction and that may decrease blood flow to vulnerable heart locations, increase compensatory resistence, velocity and pressure.
Also, I don't know if I have said this on another occasion but a stent props open a segment of the occluded vessel and that does not constrict with the normal response of the proximal or distal portions of the vessel. This would increase the gradient pressure and turbulance, etc. etc. Just thinking about now, it could cause an aneursym.
"That is why to open an occluded vessel redistributes blood flow through the newly open occlusion and that puts pressure on other vulnerable segments of the cariovascular system and possilbly shut down the collateral flow and not that not effectively open the closed vessels"
Well, nothing is really 100% understood. For example, I have collaterals feeding the distal LAD, just a small section due to a blockage which is in a vessel too small to stent. The vessel is around 2mm. The collaterals are fed from the distal LCX. When I had my LAD opened, many collaterals closed, but not those feeding the distal section. However, in my recent MI, the lower section of the LCX was virtually shut off and those collaterals did then close up, making me feel even worse. When stented, after about 3 days, those collaterals re-opened again and everything returned to normal.
I am seeing my cardiologist next monday to discuss having a drug eluting balloon, to open the distal LAD. My very first attack in 2007 was particularly bad and life threatening because my LAD had apparently been totally blocked for years, but there was collateral feed from the LCX. Now this vessel was blocked 99% and blood flow was too low for collateral feeds to the LAD. It was basically a double whammy.
I agree it's common to have lesions form at bifurcations, especially LAD/LCX and Mid RCA.
I know Plavix is related to preventing clotting, which is why I said "turbulence in a stent can cause clots in that stent though, which is why plavix is so important"
None of the doctors suggested me to go for stress test till now. Why I do not understand. In my exercise plan I climb seven stories daily twice without any indication of chaste pain. I am normal in all my daily activities.Even sexual activity. When i asked to the doctor if I should go for any tests he said you are perfectly ok on examination and I do not need any test report for your treatment. I go daily for sweeming too. I feel your health indicates how the test reports will be. It will be better not depend on test reports only. Many times they may be misleading.This is my experience I wanted to share with every body.Thank you all.
"In my case it is vulnerable plaque as told by doctor"
I assume from your posts, that on arrival at the hospital, your symptoms diminished with anticoagulant medication? You was very fortunate that the erupted vulnerable plaque didn't cause a blockage that required emergency intervention. It sounds like a blood clot formed at the location of the eruption, but you passed the vulnerable plaque through.
I don't think angiograms are the best solution for detecting vulnerable plaques, unless the vessel wall is bulged into the lumen. Vulnerable plaque sits behind the artery lining, and an angiogram only basically sees where blood is flowing. A calcium scan would also not be very accurate because this will only detect calcified plaque, which vulnerable plaque is not. Your plaque is mainly the soft fatty type. I think perhaps a CT or MRI may detect it, but not sure because it would really have to be evident by bulging as a clue. You say they suggested a bypass, but bypass WHAT exactly? If you can't see the vulnerable plaque, how would you know where to graft? and this wouldn't make it less of a risk of eruption anyway. The only way to reduce the risk of eruption is to cover it with something like stent. I think your best option by far would perhaps to follow a very strict diet, raise your HDL and get LDL right down in the hope your body can remove a lot of the plaque on its own. If you continue to have high LDL levels, then it's likely the vulnerable plaque will just continue to get fed and grow. What do you think?
If you have not already taken, I suggest, you may consider to go for a Thallium test that would give images of blood flow in coronary arteries and even collaterals. Cath angio cannot provide any idea of these.
If you exercise and climb stairs w/o any pain/symptoms, I do not think you have ischemia (angina). So where is the need for a by-pass? One should go for a cath angio if there are symptoms and it would help in detecting blockage that could be dealt with stent/s or in worst case scenario by pass. Cath angio is a diagnostic tool and is more accurate than CT angio. In a CT angio dye is injected in a vein and after mixing it goes to arteries that affects clarity. secondly, as my Dr. told me, percentage narrwoing does not convey much sense in a CT angio.
It very often takes more than one test to back up a patients condition. In 2007 I had emergency stenting to my Left Circumflex and it was seen how my LAD was totally blocked, but fed by a few collaterals. My Cardiologist felt 100% sure that I would have suffered heart muscle necrosis. He ordered an echoscan which showed great results and a 70% LVEF. With the size of my LAD and knowing that the collaterals had been closed for a considerable period of time due to the blockage of their source in the LCX, he ordered a nuclear scan. Now keep in mind that I still had a lot of angina even with medication. You would expect the nuclear scan to show that insufficient blood was reaching the left ventricle. The results shocked everyone, they showed that there was no shortage of blood. So, the nuclear scan AND the echo scan showed perfect results and showed my heart was in great shape with no problems. My Cardiologist said "If you hadn't had a heart attack, emergency stenting and we hadn't seen your Arteries with an angiogram, you would have been classed as fit and healthy with no heart problems, due to those results."
So the gold standard Angiogram was the test that revealed my problems in 2007.
Now moving to 2010 after lots of stenting, it was a mystery why angina was still occurring. Angiograms revealed nothing, everything looked open and normal, so a stress echo was ordered. This revealed ischemia to the distal LAD, in the same area as a 2mm artery. After a few months collaterals fed into this area and killed all angina symptoms. So the gold standard this time was the stress echo scan.
This is why I get annoyed when Doctors simply order a EKG. When most people are laying still on a bed, they have no symptoms and the results are normal. Then walking back to the car park they feel the symptoms again, but feel confused because they've just been told it is nothing to do with their heart. Many heart attacks occur without ST changes and so I often wonder why an EKG is taken so seriously and prevents further investigation in many cases. Perhaps it's to save money? Perhaps the Cardiologist genuinely feels an EKG is sufficient?
Q:"So, you have a decision. Do you a) stay as you are because you feel good enough on meds with a normal quality of life, or b) have the 70% lesion treated ?
And if they said they could also open the LAD, giving two main feeds back to the left ventricle would you have this done also? so you don't rely on just one vessel? I'm just wondering what your decision would be if this was your case." _______ ...Reading your posts strongly indicates to me you do not have any understanding with merit of collateral vessel formation. Your responses appear preachy, some truths/half truths and platitudes of of common knowledge that cannot be disputed and offer no enlightenment on the subject. How can someone answer your report as evidence regarding (whether true) of how convoluted your vessel configuration you say and then ntermingle that with assumptions you make that doesn't in my opinion make sense...If you could stay focussed and limit your rhetoric to facts that would help communication.
It maybe my fault to understand but your posts seem preachy, making generalizations, half truths/ truths, etc. and rather than just telling, present some facts that supports your proclamations. You are permitted to quote some authority to avoid any plagiarism inferences and because this forum is a fair user of copyrighted material it is permissable to quote that source as authority and express your opinion and accept or reject my comments. So go for it!:)
For some clarification of your posted questions lets start with the above quote of your question because I don't understand what you are talking about? Doesn't make sense, but now that you have more information from a member you appear top modify. Please stay away from what happened to you and your condition, what doctors have told you unless you can support with some logic to support the hearsay! We can discuss logic, but hearsay can't be questioned as you may understand....lets maintan some intellectual integrity so we can all learn. Thanks and it may be awhile for an answer, but lets make this an informative exchange of ideas that have merit. Take care,
Sorry, I didn't answer your question to me shown on the other post and you do have the advantage of my prior answer... (: My answer is NO, why would you even ask, it doesn't make sense to me, so please restate and you may change your question now that you had read my prior post to your other questions or do you still not understand? I wish I could draw a picture for you or you could draw onbe for me?.You can build on the information from my prior post because it does, in effect, answer the question if you understand . I just don't know
your August 11 ,2011,10.16 AM post - You have perfectly understood my case. That is exactly I am doing now. No further test is of any purpose. I wonder how following blockages are shown on angiogram.
Left anterior descending artery -The proximal LAD has a 90% long segmentlesion followed by a 80% short segment lesion.The mid LAD has a 60% long segment lesion. D1 and D2 are diseased.
Left circumflex artery - The ostial LCx has a 80% excentric lesion.
Right coronary artery - The proximal RCA has a 90% short segment lesion followed by a 90% long segment lesion in its mid segment. the distal RCA is diseased.
Coclusion - Three vessle coronary artery disease.
In continuation - I doubted the results of the test and therefore decided to go for the same test again by some other doctor and after about two to three years. Other tests are of no much use to me. at present I am very much ok on medicines only for about an year. i would like to know your advice. thank you.
Wow, is the first word which I think of. It really is hard to imagine two things here. First that you have no symptoms, even with medication AND how are your collaterals getting enough flow? Your left circumflex is severely blocked at the beginning (80% min), your LAD is severely blocked at the beginning (90%), your RCA is severely blocked at the beginning (90%). So how are you getting enough flow from anywhere to keep the collaterals open?
I know we see things differently, with different opinions, but if this was my heart I would be having a bypass. The minimum bypass I would have is to get a feed into the left circumflex because this is likely to be the vessel doing all the work through collateral feeds. Personally, I believe that if this vessel becomes more blocked, collaterals will start to close down, removing feeds to the RCA and LAD.
Has your Cardiologist told you which vessel is feeding your collaterals?
Again I have to say WOW, I think you are doing amazingly well.
I saw my Cardiologist yesterday morning for a checkup and he showed me my angiogram from March, when I had MI. He showed me where they put the 2 stents (which I knew anyway) and then pointed out another blockage which they had missed.
I explained that I feel better now than I have for years, but his professional opinion is that this blockage will have already grown and will continue to grow. He wants to do an angiogram and if it's fairly large, he wants to stent it.
Do I believe him when he says the blockage will have grown and will continue to? yes. My history has proved this many times so I don't doubt it. Will I have the angiography? yes. I want to keep my Circumflex clear in case any of the many stents in my LAD block. That way I will have a good source to form collaterals if and when the time comes.
I know there is a tiny risk associated with angiography, but I will take a bet with anyone that I will be here typing soon after the procedure :)
My doctor did not tell me anything more about colaterals. If you remember I have raised one philosophical question that how heart muscles die for lack of blood when heart itself is full of blood. Are there any other ways? I may recommend you change of doctor or second openion.
Heart muscle dies due to ischemia - the lack of oxygen to the heart cells - not necessarily due to lack of blood, which of course, is the way it happens in most cases. If the demand by the heart cells for oxygen exceeds the capacity of the blood to supply it, then the heart undergoes ischemia and muscle cells can start to die.
The blood inside the heart is not what gives oxygen to heart muscle. Blood is pumped out of the left ventricle, through the Aortic valve and into the Aorta (largest artery). Hanging off of this huge artery are the small coronary arteries which run along the outside of the heart. This is what feeds the heart muscle.
" If the demand by the heart cells for oxygen exceeds the capacity of the blood to supply it, then the heart undergoes ischemia and muscle cells can start to die"
And the worrying thing is that this can happen in a very short space of time. For example, if a pocket of vulnerable plaque erupts, this can float down the blood vessel and block it in a narrower section. The area where the plaque erupted from will form a blood clot so repairs can take place. The trouble is, platelets are not intelligent and don't realise when an artery is damaged all the way through the wall, leaking. They are simply signalled that the artery is damaged and automatically they block it, not realising it will kill you if there is no leak.
Some people have ischemia and feel no discomfort or symptoms, and so will likely suffer tissue death because no intervention is received. On the other end of the scale, people are in agony with pain.
Of course, if a pocket of vulnerable plaque is stented, it cannot erupt. The compression of the stent prevents this.
When I find you have so many stents why my doctor did not put a single stent after my angiography and strait way told me about quadruple bypass surgery. My health is ok. Only my age of 71 years was of any problem I do not know. And you said for vulnerable plaque bypass is not the solution. Any way I will be going for third openion as and when time for will be suitable.Thank you all of you.
"And you said for vulnerable plaque bypass is not the solution"
Well, it would be difficult to decide where to bypass onto, if you can't see the vulnerable plaque beneath the artery lining. If you do opt for bypass, please make sure that the plan is good, because believe me, it is not nice going through all that discomfort for it just to last a very short period of time.
My father went for Coronary scan and these were the results. He is 68 years old.
- CT STUDY OF CORONARY ARTERIES WERE PERFORMED ON DUAL SOURCE 64 SLICE SCANNERS.
- CALCIUM SCORE PERFORMED
- 75CC OF NON-IONIC IODINE CONTRAST (350MG/ML) WAS GIVEN INTRAVENOUSLY.
Calcium score: 544.7
CORONARY ARTERIES: NORMAL ORIGINS RIGHT DOMINANT CIRCULATION
LMCA There is a calcified plaque with mild narrowing .
LAD : Ostium & proximal segments have calcified_plaques with severe
narrowing. Mid segment is normal. Distal segment has a calcified plaque with mild narrowing.
Dl : Moderate size vessel; Normal
D2 : Moderate size vessel; Normal
LCX : Ostium & proximal segments have calcified plaques with severe
narrowing; Mid and Distal segments are of small caliber diffusely diseased.
OM1 : Large vessel; Ostium & proximal segments have calcified plaque with moderate narrowing.
RCA prox calc mild.mid cad severe distal calc mild
AORTA: Root of aorta, ascending aorta and descending aorta are normal in size. No dissection. No aneurysm.
Doctor is suggesting to put stents in 3 places and get admitted immediately. Can anyone confirm if this is the only treatment for this?
The other option would be bypass, but of course, this is still an option further down the road if necessary. Bypass, like stents, carries no guarantee and recovery is long. My three bypass grafts lasted 3 months, they can last weeks or many years, nobody can say. I think the stents are the best initial choice. I also think, from looking at the report, the sooner the better. All three major coronary arteries have severe blockages and so the situation is urgent.
both have advantages/disadvantages but Drug eluting ones seem to suffer less scar tissue which can quickly cause a re-block. There are risks with stents, during the procedure, such as heart attack/stroke but believe me, the risks are tiny. I've had 10 now with no problems.
My LAD had a very long solid blockage, it was about a quarter the length of the vessel. The problem was finding a cardiologist with enough skills to do the job. A lot of the risk is to do with how confident the cardiologist is and his experience. I had already had a bypass, a triple, which failed after 3 months.
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