Dynamic LVOT Obstruction, Plavix

[texas2step]

Good morning. 59/female. 8 yrs "severe non exercised,cyclic angina pains". No DX from cardio's. Research at CC & B/W Sites described PrinzmetalAngina/C.Spasms. This info was still ignored. Responded to Nitro(someone RX this)Finally Cath'd in 2004.Mid LAD,95%,RCA75% blockage.Taxus and CypherCoated stents. Distal LAD,Septal/Apex blockage could not be stented.NO MI seen and I was cured! Weeks later,severe angina.Same MO. New Cath,2 more stents in RCA and still severe Angina.Had MRI.Severe hypokinesia/akinesia in distal half of septum and apex.Viability/scar imaging revealed transmural/near transmural scar in that area also.I had a heart attack not seen on 2 Cath's.
Doctor, how can this be? Isn't a Cath the gold standard? 4 months later,had Acute Event. Different M.O. No Angina. Had irregular HR,SOB,Sweating,weakness. ER noted A-FIB at190HR.Normal Enzymes.Coverted to NSR.Admitted overnight.Enzymes repeated. Troponin 4.5,(peak)CK-MB 23.8. Fellow said NSTEMI. New Cath doc said NO MI,just an event. Stented 50% blockagein LAD,not stented by first doc and noted on report "Excellent Angiograph". BUT,now seen on 2D Echo's,"Dynamic LVOT Obstruction due to SAM" with 32mmHG gradient. No answers. Do not have CHF or HCOM. E fraction better than 60%.Cardio has never seen this. I found articles on Dynamic LVOT Obstruction in Acute Anterior MI settings as I feel I did have another MI.(Troponin level). 8 yrs of severe angina NOW gone.(-: Most likely no viable tissue left in distal half of septum. Doctor, Am I now at risk for a fatal complication? Your thoughts, please? Thanks for helping me.

[CCF-M.D.-MJM]

Hello,

Sorry to hear about your recent medical problems.

Isn't a Cath the gold standard?
Echo is a better test for picking up wall motion abnormalities, caths are good at characterizing the extent of coronary disease.  It is possible to have a heart attack and hours later have normal coronary arteries if your clot completely dissolved.  This isn't common, but we do see cases like this.

If you have a ck-mb of 23, that is a myocardial infarction. Many people think of an MI as an acute clot in the artery.  If you stress an area of the heart distal to a blockage and it doesn't receive enough blood flow and infarcts (dies), that is still a myocardial infarction -- it is certainly not a big MI though.

It is possible to have a dynamic LVOT obstruction for a septal infract.  Cases like this are usually treated with beta blockers to increase filling time resulting in decreased obstruction.

If you have an EF of 60%, your risk of fatal arrhythmia is VERY low -- probably equal to the population at large.  I would not worry about this.  Just make sure you are on the correct medications -- ASA, statin, beta blocker.  ACEI if your blood pressure is elevated.  Plavix if you have drug eluting stents.

Good luck and thanks for posting.

[texas2step]

I apologize as I had put Plavix in the title and ran out of room.  If you could be so kind as to comment what CC's heart center thoughts are on Plavix for those who have Taxus and Cypher drug eluding stents.  Must we be on Plavix for life?  My sister has bare metal stents and has been off plavix now for 3 years (took plavix for a year) and has not had any issues in 3 years time. They suspect hidden bleeding somewhere in me as Ferritin is very low. I swallowed an endo camera capsule and waiting for results. Thank you again,doctor.

[jmike1_]

I'm so sorry that you are going through so much.  I wish you the best.  Also, thank you very much for your post.  I will be watching to see what everyone has to say about Plavix.  My father has 9 stents, and his cardiologist is keeping him on plavix for life.  I am 39 and had 4 stents put in during various procedures done a few months ago - 2 of which are the drug-eluding kind.  I am on Plavix and have been told that I'll be on it for 1 year, but I also wonder if I should be on this medication indefinitely.  Was interested to see that you had an MRI done after your stents.  Like Al Dente, I have continuing angina (after exercise and at rest) and would like to have additional testing.  However, the docs tell me they are hesitant to do any more invasive procedures (had 4 caths in a 5 week time span) because they are worried they'll do more damage than good.  Plus, can't have another thalium stress test because I've had 4 of those as well, and they are concerned about the level of radiation I've been exposed to lately.  Maybe an MRI is the answer.  Although they keep telling me my pain is probably not cardiac related, I heard that before I had 4 stents put in and they don't have any good ideas of what else could cause the angina.  Anyway, sorry for rambling.  I just really liked your post, and am interested in seeing the responses.  God bless!

[texas2step]

Thank You for the reassurance.  My husband read your reply with a sigh of relief.  All research and answers we are looking for are coming from nice doctors like yourself and ONLINE!  I have the latest ER blood work here and the second set of heart enzynes, i.e CK-MB and Troponin and they do not escalate for no reason and I just knew I had suffered a heart attack but the cardiolgists said NO.  I think something was in their water that day.  Today, I called for all my records and gave them the name of the new Cardiolgists Group doctor that I want to see.  Hubby said we should of did this 2 years ago.  If he/she does not work out, I am on the plane to CC or Mayo in Rochester. I will answer the other two respondants also.  Thank You again, doctor for helping me and all the others who have HD on this forum. God Bless.

[texas2step]

I am sorry to hear of your heart problems and reading back Al, you are young also like Mike. Too young to be going through this.

PLAVIX:  I will post what I know and don't know. When I had the drug eluding stents, I was told I had to be on them for one year. It has been almost 2 years for 2 stents, 18 months for 2 other stents and now one year for the last stent.  I was nearing the end of this Plavix when I read in USA today and on the internet that doctors at a Heart Convention in March, 2006, feel that patients on the drug eluting stents may need to be on Plavix forever as they are seeing some patients with these drug eluting stents get off Plavix after one year and sufferingt a heart attack and or sudden death. Scary, to say the least. When I reads this News, I was furious.  Here I could of had the bare metal stents but felt the drug eluted stents would protect me forever.  My neighbor, my cousin, my uncle have bare metal stents and are doing great and off Plavix now for 3 years and no restenoses or MI. On another forum, a doctor was saying that cardiologists must discuss these findings with patients and give them the option of bare metal vs. drug coated as now it seems people may have to be on Plavix for a lifetime to keep the drug coated stents open and many people do not have the $$$$ to buy Plavix month after month and year after year. I wish I had the bare metal stents.  I would be off Plavix by now and not worry whether I will bleed soemtime in this course and not worry if I need a surgical procedure and have to be off Plavix for 5-7 days which could be disasterous. I also heard that there is suppose to be a new stent coming out in the future which is disposable? degradeable?  I hope I have those words correct.  But, we have coated stents now and I guess we are stuck with them and the Plavix.

MRI's...This test has no radiationn involved. It is a very good test and will show muscle damage and function and will view arteries for blcokages and all the heart valves.   It also shows the Ejection fraction.

MRI and stents.  The Cardiac MRI radiolgist said people can have an MRI right after stenting but I made sure I waited 2 weeks.  Some people wait 4 weeks. When I had my MRI, there were only about 12 in the country but now more centers are getting these highly specialized machines.  I hope to get another one soon to check the latest event. We have three Cardiac MRI places now in our city.  

Mike, Heart Cath is not without risk.  One doctor messed up one of my arteries.  He never told me but I found out later. I do not want anymore.  I will ask for another MRI.  They mentioned the CT 64 slice scan but this is a lot of radiation. I head a doc say they will be coming out with a 94? slice CT scan that shows a lot more but this also will be more radiation.  When you are young, they try to avoid a lot of radiation as this is all cumulative and both of you men, are soo young. You have a lot of living yet to do.  Now, if one is OLD and gray, LOL, I would risk the radiation and pray they do not nik another artery.  Make sure your cath doctor can SEE and does not drink  water first, LOL, and you go to a good heart center.

Keep on rambling.  This is what gets us through the days with HD.  Talking is good.

God Bless You all.

[jmike1_]

Thank you both for your posts - very informative.  I guess I have a lot of research to do on Plavix, and even more on CAD as a whole.  I usually just let the docs do what they must, but since my angina isn't going away, I should become more educated on the issues as both of you.  This site and posts like yours are a great first step in that direction.  Take care, and wish you both the best!

[texas2step]

Hi Al, Mike.

You mentioned a one sided approach (patient). I have seen this but seems the patient may know more than a particular physician on a particular problem.  No pun intended but some doctors are bombarded in hospital duties, teaching a class, charting,working in a lab and seeing patients one day a week.   I feel they do not have enough personal "patient" contact and if they have a case that is rare, they do not have the time to research a particular problem so it gets thrown into the "general pile". Then there is the doctor that has small children at home that keeps him up all night and he/she cannot function during the day.  I have seen it all.  The bottom line is that every patient has to do their homework and if a loved one needs help also, we need to step in. There is a saying, "an educated patient makes for a better patient".  

Three days ago, my daughter was diagnosed with a heart condition. She has not felt well for some time but faithfully went to her long time doctor who dismissed her complaints as "getting older" and her "thyroid".  I called her doctor and asked if he would order certain tests for her, mentioning my own health problems. This never happened.

Enter new female internal med doctor. She wasted no time.  Tests proved positive and daughter has an appointment with a leading cardiolgist soon. My daughter is frightened now and wished she had been more assertive with her former doctor or walked away sooner. She said she did not want to hurt his feelings!~!