Exercise and LAD blockage

[runnertom]

Doctor,
   Please forgive me for spouting heresy, but this has been a concern of mine for some time. Three years ago at age 54 I was found to have an LAD blockage that was successfully bypassed. This was almost unbelievable to anyone knowing me as I had been a competitive runner/cyclist/triathalete for 30 years. I had none of the normal cardiac risk factors such as smoking, weight, cholesterol (LDL 130, HDL 60, TG 60), BP, etc. Later testing showed I was high in homocysteine. I come from a family with longevity on both sides.
   Over the last three years, I have become aware of several other very heavy exercisers who found themselves in a situation similar to mine-blockage of the LAD at the first bifurcation. It has been speculated that the high amount of turbulence present at that point during heavy exertion could cause an inflamatory response that coupled with other borderline risk factors could cause a gradual lesion formation. Do you think this is completely ridiculous?
   The answer to this has great significance to me, as I am back working out as hard as ever, but have this little voice telling me I might be headed right back to the knife. Other than a daily Pravachol tablet that gets my LDL down to 75 and some B vitamins, nothing has really changed in my life that would prevent me from blocking up again. My cardiologist is similarly mystified how anyone doing the exercise I do with an HDL of 60 could have a heart problem.

[Prof. ATP]

Tom,

Between my first CABG and my recent stent there were 8 years of annual cardiologist visits much like yours.  These included treadmill tests and, occasionally, nuclear stress tests.  The cardiologist didn't feel that he needed to see me at all, but the tests were necessary to keep my medical certification for flying.  I took a daily aspirin all that time, cholesterol and BP were fine.  I did a Berkeley heart scan, which was unremarkable.  I was told that my blockage wasn't atherosclerotic.

So, I guess that "I blew it", as you put it, because I needed further intervention after 8 years.  The interventional cardiologist is much more aggressive about prevention and has me on Zocor (for secondary endothelial effects), Altace (for the same reason), and Plavix (standard post-stent).    I have changed to a cardiologist who actually believes that I have the disease, rather than the one who was in denial.

Medicine is scientific but it is not science.  All I can do is take my meds, eat a reasonable diet (hard to be disciplined with TC=133, though), have fun, and work out.  An unseasonably warm day yesterday meant that I got to do this week's long bike ride outdoors!  Now that's something to get excited about.

[MaryRoe]

I just read a very interesting story about one of the actors (Mary) in the old TV series, "The Waltons".  She had on going symptoms for years and went from doctor to doctor but to no avail  (I can relate)  After years of feeling bad and seeing so many doctors, a David Wallace, Rheumatologist in LA, diagnosed her with Lupus and Sjgroens Syndrome and now she also has Fibromyalgia.  

I have Been told I have Sjgroens.  I have had elevated SED rates and extreme fatigue. I have had many of the symptoms she has had.  Lupus and family can cause narrowing of the heart arteries, heart attack and a host of injury to many inner vessels and the skin.

Now, my eyes and Thyroid and Salvilary are involved.  I saw the MD Eye doctor the other day and he asked if I been worked up for Lupus and Sjgrons.  I said I had but now after reading Mary's story, I think more tests need to be done.  Food for thought here.  Wonders never cease.

[MaryRoe]

Curious...Are you male or female.  We have been yakking back and forth for over a month now and I am just curious if you do not mind telling.  Reason being, if you are female..I would definately consider getting a Cardiac MRI....men also but with women and small vessel disease...they mentioned this was better for us.  I had to fight for this as I was jeered but persistance paid off. Angiogram only showed some small blockages.  MRI showed the heart attack and a whole lot more. I was suppose to have another one in Decemebr but Cardio and his ditsy secretary messed up. His excuse was that the MRI is only good for showing scarring.  Well, we did have words. I am scheduled to have one in March.

Another thing I heard is be sure the radiologist reading this Cardiac MRI is expereinced in Cardiac MRI's or things can be missed or false positives.   Also, be sure your own Cardiolgist knows how to explain the report.  Mine did not.  He seemed to think it was an overkill. I think he was humoring me.  Does not surprise me.

If at all possible, Al, see if you can meet with the radiolgist a few minutes before your MRI to see exactly what he/she is going to do and what he/she is looking for and ask questions.  Patients have that right.  We pay good $$$ for these tests.

Good Luck to you.

[MaryRoe]

Yesterday I heard on NBC that women would benefit from getting a Cardiac MRI for chest pain instead of an angiogram for blockages as women tend to have smaller vessels that cannot be seen on angiograms but can be seen on a Cardiac MRI. (This is what happened to me)  Angiogram did not pick up the reason for my severe angina type pains...The MRI did.

Now, I do not know if you are female or male and whether you might consider a Cardiac MRI.  I have heard that these Cardiac MRI machines are not everyplace, YET.  Clevelnad Clinic has one as does my city and I am sure they have them in various European large cities also.  

They still consider Angiograms/Heart Cath the gold standard.  Perhaps in men but women....the verdict is still out.  

Good Luck to you.

[Mantels]

First the cardiologist lowered my Toprol from 50 mg to 25 mg because I was feeling chest tightness and lightheaded. He said I was fine. A few days later I went for a run and after 3 or 4 miles at 145-150 BPM I had some chest tightenss and nausua. Then I went to the GP or gave me Privacid, raised my Toprol from 25 mg to 50 mg and wants me to get an angiogram. Then my cardiologist says that my last stress test was great 20+ minutes 5 months ago and last angio was perfect except wher he put a stent 2 years ago.

Should I take another stress test or do the angiogram? I am doing everything right and it makes me angry.

[runnertom]

I don't want to drag this thread out forever, but nothing is really settled in my mind. Others have replied in similar circumstance to mine (Prof, RowerLarry), but it only makes the mystery deeper. My bi-annual 10 minute visits with the cardiologist are little more than a rubber stamp saying, "Yeah, you are doing great. Your cholesterol is where we want it, BP OK, yada, yada. Keep up the exercise". So what has changed from before my early CABG besides a Pravachol pill? (OK, maybe folic acid, B6, B12, fish oil, Paxil-all except Paxil self prescribed). I am really uncomfortable managing this thing essentially by myself only to find out in 10 years that I blew it. I think what I need is a real preventive cardiologsist and I can't seem to find one locally in southern Ohio. Does anyone have a positive experience with the Cleveland Clinic in that regard?

[MaryRoe]

I have a suspician that stents can cause chest discomfort. Doctors will say NO as they do not want to deal with this.  Too much digging, they say.  My Taxus was a bugger getting in and I feel this may be my culprit.  I do not want another Cath.  I do not want another stent. Stents bring in big $$$ to the hospitals. I am praying for collaterals.

Re: Exercise. I do not push myself to the limits.  When I start, I take my pulse. If it is 80, I know I can only go 30 over making it 110. This per some great cardio work out personnel at a health center. If my pulse is 100-110 prior to the work out, I wait until I can get it down into the 90's before exercise. I have a geat pulse alarm that I wear on my wrist.

Gerd can cause all sorts of discomfort.  I have GERD and I have a sliding hiatal hernia, also.

Enjoy the day...

[MaryRoe]

I also have my CD's of the Cath's but the Cath doctors do not want to be bothered to view them in my presence.  Typical, eh?

I would LOVE to see if I am growing collaterals.  

Al, 60% is a great EFraction.  72% is good but the normal range is between 55-65%, I was told.  AND, this fraction can flucuate up and down at times and not mean a darn thing....

Are you still going to Cleveland Clinic.  I wish you all the best.

[RowerLarry]

I just had a triple bypass for the three major arteries to the heart, January 13.  Two at 99% and the third with multiple 80+% blockages.  They scheduled me for surgery immediately the following morning following the angiogram.  I was getting by on excellent secondary circulation from a lifetime of exercise running, rowing, basketball, swimming, walking.

I went to the ER after getting back from vacation where I had about a dozen bouts of severe angina from 5-30 minutes duration with heavy sweating brought on mainly by altitude at only 2500 feet. No exercise was involved. I had two incidents, 5 minutes long each, just prior to vacation, that my internist dismissed as anxiety.

An article about a year ago on www.findarticles.com suggested a lot of people exercise way to hard, and when they think they get aerobic benefits, they are actually in CO2 debt and causing themselves severe anti-oxidant problems due to the overly high level of exercise.  Half the people in the study considered themselves very fit, but only two of 30 were actually getting aerobic benefits at 80% of max heart rate, the rest were in varying degrees of CO2 debt and hurting themselves at the pace they were at.

Just because we can push ourselves, does not mean we necessarily should.  From the "Dirty Harry" movies, "A man has got to know his limitations."  Maybe we all need to back off to just 70% of our max heart rate.  Boring, but could be no scars required.  Rowing, I know I and others 50+ push their heart rates to 70-100% of max for extended periods.  Great for bragging, but what is it really doing to us inside ?

[Mantels]

Had a 100% or so blockage of LAd 2 years ago and had 2 stents inserted. Went back to running a few months later.
, but kept HR below 160.

Got sick, virus like (fever, lightheaded, nausea for a few weeks) and went back to Cardiologist who lowered my Toprol to 25 mg 1 x per day.

Lightheadedness went away but nausea and heartburn remains. Now after 2 miles I get chest tightness and feel like throwing up and get really acidy. Walking home really bugs me but I don't want to deal with my heart again.

Going to see a GI doc now since my cardiolgist doesn't think it's heart realted since I did a stress test 6 months ago and lasted over 20 minutes.

I need my runs!

[runnertom]

Thanks all for your comments. Prof, I guess you make the fourth runner/cyclist besides myself with this affliction I have become aware of.
   I guess I keep beating this horse is that my disease seems so perverse in light of my activities and lifestyle. It truly worries me that my continued level of exercise might be killing me, and not by way of an infarct.
   I have found in some of my reading that stress or anxiety (more specifically "time anxiety, where you can't tolerate delays or heavy traffic, or need to alway hurry) is a very unappreciated risk factor. I could be a poster boy for this. The lipid specialist convinced me to take a low dose of Paxil for this reason. I do seem to sleep better. It could be that my need to get in my workout every day after work played into this. I am constantly defending my schedule to make sure I get off work in time to run or ride. I guess that can kind of run your life if you let it. I remember former President Clinton saying the first thing he would be thinking when he woke in the morning is when he would get to run. I can identify with the sentiment.
   Al, my blockage never resulted in any angina or pain. Transient shortness of breath in the first 1/4 mile of running was my only real symptom. I would never have had a clue from cycling, in spite of pushing myself deep into the "red zone" on virtually every ride. Riding with a group of 50 somethings who feel they could go back and bike race successfully leads to that type of behavior.
   My wish at this point is to get some feedback as to how I am doing. I refuse to have another cath to accomplish this, even if the insurance would pay. I'm thinking the new 64 slice gated CT scan would be just the thing. If I thought my disease was progressing to any degree, I guess I would give up meat completely, start taking the Prof's "Draino", and retire.

[runnertom]

Prof.
I re-read your reply and have to take issue with one statement:"there is no point in looking for the one bullet that is the cause of the disease". I guess that "looking for the bullet" or bullets has been the focus of my life for the last three years. I feel that if I don't find that or the collection of smaller bullets I am doomed to an early demise. My feeling that the "baseline" risk is nothing other than the average risk of CAD in those who don't have extraordinary risk factors such as smoking, high BP, etc. I don't think the human body has evolved such that CAD at age 50 is a reasonable expectation, even in some small percentage of people. I think the preponderance of evidence suggests that CAD is a result of an accumulation of "pro-CAD" environmental or lifestyle factors that must be minimized to stop the progression of the disease. I just hope I have not overlooked something.

[Prof. ATP]

It is nice to think that one's heart disease is due to a single anomaly, but my personal history refutes that idea.  After a lifetime of running, with no risk factors, I had 98% blockage of the LAD at the ramus branch, similar to yours, at age 43.  It was bypassed and I went back to exercise,  mildly impaired by the trauma the surgery caused to my chest wall.  My cardiologist speculated that the blockage was not atherosclerotic.  Last summer I won my age group (50 - 55) in a sprint triathlon (500yd swim, 20K bike, 5K run).  

A routine annual test (required because I am a professional pilot) showed a problem last fall.  So much for the cardiologist's speculation: my RCA was 80% blocked, requiring a stent.  Oddly enough, the LAD blockage was reduced to 30%, and my now-redundant bypass is no longer functional as the body has absorbed the mammary artery.   (I joked that the tri victory was a half-hearted effort.)

So: I now feel that CAD is CAD.  Once you have it, risk factors are irrelevant: they are predictive, not diagnostic  (neither one of us has risk factors, anyway), and there is no point looking for the one bullet that caused the disease.   The real issue is how to live with it.  We're good patients: we take our meds, eat right, exercise  (I was once called a "perfect patient.")  But physicians give conflicting advice about how much exercise is "safe": "Not more than an hour."  "Don't go anaerobic."  "You should be faster."  They mostly admit that they are blowing smoke.

It seems that medicine has not addressed the problem of athletes with CAD.  As the population ages there will be more and more of us.  I would be happy to participate in some kind of longitudinal study that would help uncover reasonable guidelines; I'll bet you would, too.  I'd also be interested to read other similar stories; it might help convince the cardiologists that there is a genuine problem to be addressed.

CAD is often a lifestyle disease, and that is the mindset from which our physicians approach our treatment.  It is not relevant to us.  But risk factors are factors: you multiply the baseline risk by the risk factor to determine individual risk.  There is still a baseline risk; that's the source of non-lifestyle CAD.  

My personal choice is to keep training but listen to my body.  So far, so good.

Good luck.

[Cleveland Clinic]

runner,

One of the most common sites of blockages in the coronary arteries is at sites of bifurcation. This is in all commers including exercisers and non exercisors. You are on the right track in thinking as a lot of people believe shear stress from these sites cause stress leading to accumulation of lipid.

Unfortunately, we only know of a relatively few powerful risk factors that lead to coronary blockages. I see patients often without many of the traditional risk factors and significant coronary atherosclerosis.

Physical actvity and healthy diets have been show to cause coronary plaque to stand still, and in some cases regress. While it would be nice to have something to pin your blockages on, I dont believe it was your physical activity.

Good luck