DX a heart attack and Plavix Question

[MaryRoe]

Thank you for taking my questions.

3 years ago an EKG showed an MI. Cardiologists said leads were placed wrong.. All Subsequent EKG's showed the same MI except one.  Always told leads were placed wrong or it was my anatomy. Angina pains continued. Cardiac Cath did not show a heart attack..only an area of severe plaque in distal LAD that could not be stented or bypassed. Mid LAD stented.  Mid RCA stented.
Told again no MI and go about my business.  I asked for a Cardiac MRI. This did show the MI in the distal LAD.
Question:  Why doesn't a Heart Cath show a heart attack? Doesn't this give patients a sense of false information unless they resort to a Cardiac MRI?

Question:  How long must one be on Plavix to keep coated stents open?  I need knee surgery badly and need to be off Plavix for 5 days prior to surgery.  Cardiologist has vetoed all surgery.
I have 3 stents and with 2 of the stents, I have been on Plavix for 15 months and the last stent..on Plavix for 9 months. What is Cleveland Clinics thoughts on this?

Question #3.  Recent CT scan of chest shows calcification in the Lad and mid RCA. (had this scan looking for pneumonia) I thought once an area was stented..these arteries were cleared.  Does calcification remain after stents? How can one get rid of this calcification?

Question #4.  How does one tell if collaterals are growing?

Thanks doctors for your time in answering these.

[CCF-M.D.-MJM]

Hi Maryroe,

Good question.  

Why doesn't a Heart Cath show a heart attack? Doesn't this give patients a sense of false information unless they resort to a Cardiac MRI?

It is possible to have an acute clot form and disolve leaving no evidence of blockage yet still causing an MI.  We know that some people tend to have clot formation, some people get atherosclerosis (blockages) with no clots and other people get both.  100 years from now we will know a lot more.  When I see a heart cath that shows coronary artery disease, I treat them like they have had a heart attack with maximal risk reduction.  It most cases this catches everyone, including yourself.  There is a sub population usually in young people that can have a heart attack with an acute thrombus that completely resolves leaving no evidence of blockages.  These cases are difficult, but ultimately should be treated like coronary artery disease.  I seldom use MRI's to confirm previous heart attack.  I use them to show hibernating tissue to help decide if someone will benefit from a surgery.

Question: How long must one be on Plavix to keep coated stents open? I need knee surgery badly and need to be off Plavix for 5 days prior to surgery. Cardiologist has vetoed all surgery.
I have 3 stents and with 2 of the stents, I have been on Plavix for 15 months and the last stent..on Plavix for 9 months. What is Cleveland Clinics thoughts on this?

I think the overall recommenedation is a 3-6 months depending on if it is a taxus or cypher stent, but we usually try to keep people on it for atleast a year, sometimes indefinitely.  This is  an area that we need to learn more about.  I would also be hesitant to recommend coming off plavix for an elective surgery.  These are difficult situations with no one correct answer.

Question #3. Recent CT scan of chest shows calcification in the Lad and mid RCA. (had this scan looking for pneumonia) I thought once an area was stented..these arteries were cleared. Does calcification remain after stents? How can one get rid of this calcification?

There is no way to get rid of calcification.  Calcification remains after stents.  It is important to remember that stenting only relieves symptoms of angina or anginal equivalent, it does not effect mortality or the pathophysiology of coronary disease.  This is why it is important to stay on your statin, asa, plavix and other cardiac meds.

Question #4. How does one tell if collaterals are growing?

You can't.  Caths will show it, but there is no other way to know and I would never order or do a cath evaluate for collaterals.

I hope this helps.  Thanks for posting.

[MaryRoe]

Thank you Doctor for your speedy response.  I am not sure you are seeing this but my first 2 stents, 17 months ago was a Taxus and a Cypher. I remember the Taxus well, as they were having a problem in deployment and I was scard out of my wits.  They were so sure I did not have CAD going into the Cath room and we all did not expect this.  The last stent was a Cypher.(8 months ago)
I was not aware that there was a difference in Plavix Time between the Taxus and the Cypher. Yes, the cardio doctor said lifetime for the Plavix but I must be on Plavix for at least one year for all stenting.  I am avoiding complaining about anything (heart related) as I do not want another Cath or another stent. I need this surgery.(fell off a threadmill and tore a ligament and hair line fracture in the knee cap) I am having a hard time doing much.

As far as the Cardiac MRI goes, the heart cath doctor bet that an MI would not show up on the MRI as he said I did not suffer one. I suspected that I did have one, sometime. (woman's intuition) He lost the bet. It showed regional wall abnormality specifically in the distal half of the interventricular septum and the apex are severely hypokinetic/akinetic. Viability/scar imaging reveals transmural/near transmural scar in the distal half of the septum as well as in the apex.   Also, there is dynamic LVOT gradient due to SAM. I was told this area could not be stented or by-passed as the vessels are too small due to  being a female.  This is why I am very interested in growing collaterals.

Thank You again, doctor.  Yes, you have been a big help.

[MaryRoe]

Thanks Al.  What promted your need for a Cath last month?  

I am avoiding this like the plaque (-: as I fear I will have an agressive doc that will want to do another stent...LOL (feel the last stent was not necessary)

Another stent means another year on Plavix and another year of knee pain that needs surgery desperately.  I wonder how people on Plavix due to stents, have any type of surgery.  Last week, the Cardio doc vetoed getting a tooth pulled but my DDS and Oral surgeon said it was so decayed that this in itself can hurt the heart, so they pulled it.  They told me to continue the Plavix.  I did.  They did not stitch the area thus avoiding more bleeding.  I did great.  In fact this was the first time I hardly bled with getting this molar pulled.  The other 2 times, I was not on Plavix and I bled a lot more.  Maybe the "no stitches" this time was the factor. I was not given any Epherinphrine..only a shot of Carbocaine and I did well.

Have a nice day.

[MaryRoe]

Thanks again, Al.  It is always good to network with others similar.

Yes, getting a good Cath doctor is like winning the Mega Millions.  The first one I had....well......he was more interested in himself and another collegaue than me.  I nearly had by-pass surgery from his mess up and his arrogance. I am finding the older interventional doctors are better for me.  They do not have to prove anything. They have made their money and have made their name and have mellowed out.  (-:  I always check their birthdates now.  I am taking those born in the late 1940's -1950's now. LOL
No 1960's-1970's..no matter how much they tell me they are qualified.  

Al, where is your angina coming from?  I know with me, the first 2 caths and stents (with the babies) yielded NO relief whatsoever.  Those horrid, severe angina attacks kept coming...right out of the blue.  The babiee's excuses were terrible.  They blamed it on everything but themselves. Finally, asked for a senior doctor, and WRAP on wood, I have not had a bad one in 5 months.  Can you believe!  I am wrapping on wood as I am typing this..

I too am on Crestor and Zetia. Plavix for life, ZEBETA which so far is doing its job (this has taken the place of TOPOLXL) and Avapro 150.  I have 4mg. Nitro that I carry at all times. I have a diuetic to be taken only if I think I need it.  I see the docs every 3 months for EKG's and ECHO's.  Nuclear Cardiolites every 6 months so far. He does not want me in Rehab  as he fears my HR will go bonkers.  I do walk (no marathon) and do my own housework, etc. etc. so I do stay moving, despite a terribly painfully,swollen knee. I am on 800mg of Folic Acid and recently started B12 injections, once a month. In the past my C-RP was high (3-4) but the last 2 were below normal which is excellent.  Recently, there was an article talking about women and angina and how many docs miss it.  Thye talked about that Ultrasound you mentioned IVUS?  They also said not many places do this yet?  I am going to check the heart place here.

I am happy to be able to connect with our heart patients..who understand.  I did talk to a doctor who has had a by-pass and two stents.  He understands.  Wish he was in our plan...

The Best to you.

[chrisr]

I also had both a cypher stent(RCA bypass) and Taxus to distal LAD. While putting in the Taxus via a LIMA bypass (Baptist, Miami)this vessel thrombosed, went into spasm and finally dissected. I believe an IVUS was also done but did not help. Finally when no one wanted to attend my complication the doctors at CCF did a 2nd CABG in which they replaced the nonfunctional LIMA with the RIMA and probably save my life. Fortunately no longer on Plavix and Asp since I need to have a colonoscopy and GB removal soon. I also have a severe problem with calcification which caused Aortic valve replacement, aortic stenosis and may now be threatening my Mitral valve. I have also inquired extensively about calcification and no one sems to have an answer. There is however a Japanese product - Nattokinase which reportedly controls calcification in soft tissues. Since I am however also on COumadin I am presently seeking a doc who will supervise this combination. Would like to know of anyone who is or contemplating using Natto for this problem.

[chrisr]

You may be right since most problems developed after the taxus implant. The cardio stenter insisted that the LIMA spasm/dissection was due to the 'tortuousity' of this vessel and not the stent or implant procedure. However I had severe nausea, chest discomfort after taxus implant but not after the cypher. These problems (which needed continuous nitrate and cardizem treatment)ceased immediately after CABG 4 months ago and thankfully have not reoccurred.

[MaryRoe]

Yes, seems we both had problems with the Taxus stent....Boston Scientific. And, the Cath doctor never told me.  I just knew they were in trouble doing 'something' as I came to while they were talking loudly. Their loud voices woke me up on the table.

I read about the Taxus problem on the Cath report.  I feel every patient should be told when there is/was a problem. Strangly, they had to go back in 4 months later and put in another stent in the same location.  This time it was a Cypher.

Before I even knew I needed a stent, I had read a few weeks earlier that there was a problem with some Taxus stents not deploying.  When I signed papers for the heart cath, I said, "if I need a stent...I do not want a Taxus".  I was then told that these Taxus stents with certain seriel numbers were pulled.  Hmmmmmm.......

[MaryRoe]

Al, did you also have a Taxus?  When was your stent placed?  

My Taxus was also in the RCA.  

Chris, I too have problems with calcification.  I am very interested in what you are learning about this.  I cannot take "no there is no help for calcification".  The kidney doctor told me not to eat certain veggies and to stay away from Chocolate as these can contribue to my Calcium Oxylate stones. Hmmmmm.  I am wondering now if this will help the calcium build up in my arteries and in my teeth.

[MaryRoe]

I had no idea you were so young.  I have a son your age. I feel badly for you.

My Angina comes from inner stress of some sort that i am not aware of, i.e. waiting in line in the stores, reading a book, driving the car, thinking about a bad doctor, walking in a cold enviroment...I never knew what would set this off.  The Cath doctor who did the Taxus, just could not understand why I was doubling over with an Angina attack after his great handiwork, two weeks later. He yelled at me.  This brought on another angina attack. This is when I found out a lot more.  I even called Boston Scientific.

In my next life..........Whammo, I am coming back as a Stent Doc!~! lol

[chrisr]

MAry, If you go to afibbers.org site and search for cacification/and Natto you will find alot of info on this problem and product. If you are not on bloodthinners like I am then using it should be no problem. I am on coumadin so must seek medical supervision but this is much better than having to go in a third time to fix another calcified valve. I lost middle ear ossicles and hearing due to calcification. They were replaced 2x by prostheses and within weeks lost hearing again because of conduction loss due to calcification. I also have tremendous plaque buildup in my teeth requiring regular dental visits. When my stenosed aortic valve was replaced I was told it was bicuspid (a congenital problem)but now I stongly believe it was the normal tricuspid with two highly calcified leaflets giving it a bicuspid appearance. I do not wish to scare you but these are real calcification problems.

Al, I was not told about the IVUS until just minutes before stent procedure when i had to sign up. Post stent I was in ICU for almost 3 days before I learnt all about the compilcation with the thrombosed/spasmed LIMA. And then the story about the difficulty in the LAD Taxus stent implant all came out. Again no scare intended but the name Taxus is derived from the Taxus tree from which a chemotherapy derivative is used for cancer. Apparently this is the same derivative eluded by the Taxus stent and to which some folks like myself can be allergic hence my post stent nausea reaction. Cardizem helped with my chest pains. I am allergic to BBs now tolerate Coreg. Imdur worked but gave me headaches and unwell feelings. Nitro transdermal skin patches worked much better. Post CABG I am off these now. Take care, Chris

[MaryRoe]

I have often thought since the stents and the circus in the Cath Lab that I felt better physically before all of this.  Yes, I had the Angina attacks but once the Nitro kicked in and I layed down for an hour (side effects of the Nitro) I was good to go.  I am no where good to go anywhere, anymore.  AND, now with a problem with the Left Ventricle being osbtructed....All this since the stents.  I too fear if the Taxus is causing problems or will cause problems.  Too bad these things cannot be removed. And, with the second stent due to pressure readings low near the Taxus stent, this caused a rise in Heart enzymes. Not to worry, I was told.  Doc had to catch a plane for Europe so I was booted out of the hospital.

Al, if you were my son....my hair would be white as snow with worry. I worry about my son all the time. He is healthy except for Gerd and I am insisting he have an EGD this spring. He has to quit popping those Gerd relieving meds till someone looks and sees.

Chris, I got into afibber.com and could not register nor do I see where I look for calcium and the treatment.  I will get back in there later tonight. How are you doing since surgery at CCHeart?  You went to a top notch place. I got an e-mail from a person telling me to go to the Mayo clinic. I just wish there was an exceptional doctor here.  Heart disease is the pitts and you all are right.  It is hard to figure out complex cases and many do not want to do this.  

God just has to Bless all of those suffering. It is our hell on earth.