HEART CONDITION

[Sancha76]

I need some expert advise on my father's health. He was perfectly alright until October 2010 until he was hospitalized. I need your expert advise for that. He was hospitalized for a week and he was under cardiac surviellance for a week under which he went through ECG, Echocardiogram, Angiogram, and Stress Thallium Test (after 15 days of discharge from Hospital).  His stress thallium states as follows:

Patient is a case of CAD, hypertension, and type 2 diabetes mellitus with ischaemic cardiomyopathy. Recent CAG shows 70% mid and distal LAD stenosis, 50%om2, and 60-70% RCA lesion. Stress MPI scan is being done to evaluate for reversible ischaemia.

The LV cavity appears dilated at both stress and rest.

Stress SPECT images reofmrate din the short and long axes shows an area of moderate perfusion defect invoving the Apex, apicoseptal and apicoanterior segments and inferior wall of the LV myocardium which shows mild reperfusion in the resting images.

Tracer distribution in rest of the left ventricular myocardium is within normal physiological limits at both stress and rest.

Quantification using the emory cardiac toolbox shows evidence of reversible ischameia involving the LAD and RCA territories. Note: The extent of ischemia in severe triple vessle disease may be underestimated due to balanced hypoperfusion.

Functional information: Multi gated rest SPECT images show global hypokinesia of the LV myocardium with reduced systolic wall thickening with overall reduced resting left ventricular systolic function. LVEF 15+/-5%.

IMPRESSION:
Scan evidence of mild stress induced reversible ischaemia involving the apex, apicoseptal and apicoanterior segments and inferior wall of the LV myocardium.

Reduced resting systolic LV function with RWMA as described as estimated by quantitative GATED SPECT. Please correlate clinically.

Above the report of Stress Thallium test. Kindly suggest what to do. We took several opinions from several doctors, some says he should go for stenting, some says nothing can help him. We dont believe as heart can get deprived so fast without the patient knowing or feeling any indications before. Please suggest what to do. He is taking following medicines. I m giving you generic name:
1.  furosemide (trade name in India is Lasix)  20 mg b.i.d.
2.  spironolactone (trade name Aldactone)  25 mg o.d.
3.  remipril (Trade name Cardace) 10 mg o.d.
4.  Asprin, ASA ( Trade name Ecosporin AV 75 MG) h.s.
5.  Glimepiride (Trade name Amaryl 2 mg) O.D.
6.  Ivabradine (Trade name Ivabrad 5 mg) o.d.
7. GLIMEPIRIDE 2mg and Metformin Hydrochloride IP    850 mg ( GLIMADAY - HS 2 mg )
8. Paracetamol (Pacimol)
9. Glimepiride (Trade name Amaryl 1 mg)
10. Voglibose (Volix 0.3 mg )

Kindly suggest us what to do. IF you want to see Angiography report i can post that also.

[kenkeith]

This forum is an experienced oriented membership that have heart disease and the treatment received.  Your questions seem to pertain to reading treadmill, EKG stress testing and myocardial perfusion scintigrapy results.

For some insight , when both the exercise EKG stress test and the perfusion images are abnormal, the likelihood of coronary disease is greater than when only one of the tests is positive. However, the overall accuracy of perfusion scans is higher than that of the exercise EKG stress test. It happens in practice, many patients have a negative treadmill test and are then found to have an abnormal perfusion scan. In these patients, the likelihood of coronary disease being present remains quite high, despite the negative treadmill test. It is important, however, to pay appropriate attention to the results of both the exercise treadmill test and the perfusion scans that have been treated.  Has there been any treatment, and were the tests with our without medication?

The AAC/AHA have guidelines to treat coronary occlusions and as the COURAGE study indicates and other information agree that occlusions less than 70% should not be treated unless there are symptoms (ie, chest pain, etc) and if there are symptoms treat with medication.  If medication does not effectively treat symptoms, then a stent implant, and if a stent is not appropriate because of size, location, etc. then a bypass.  It should be noted that any of the three treatments for CAD do not extent life and are considered equal in that regard, the focus is on treating symptoms....the report indicates there may be an under estimation of occlusion that is sometimes seen with triple vessel disease!?.  This is because the technology measures blood relative to the other symmetric vessels and does not involve quatification of individual vessel blood flow...so there is a relatively balanced blood.

QUOTE: "Functional information: Multi gated rest SPECT images show global hypokinesia of the LV myocardium with reduced systolic wall thickening with overall reduced resting left ventricular systolic function. LVEF 15+/-5%."

>>>>My personal experience 7 years ago was to be hospitalized with heart failure and a LVEF below 29% (considered heart failure...normal is 50 to 70%...amt of blood pumped with each heartbeat).  There was lung congestion (edema), enlarged left ventricle that reduced the EF. The underlying cause was ischemia (lack of blood flow) as with your father.  My RCA 98% occlusion was stented, the 70% circumflex remained as before, and I had a 100% occluded LAD that had developed a natural bypass over time with collaterial vessels.  Medication reduced the heart's workload and the heart size has returned to normal and the EF is currently at 59%.  

Also, I had global hypokinesis of the left ventricle wall.  That condition is a result of a failure of heart cells to receive adequate blood supply and the heart cells exist on a low oxygen level.  However, there is an impairment of heart wall movement and that impairment reduces contractility and lower EF.  An increase in blood flow to the dormant cells can revitalize the cells and functionality will returned to normal.  I had had a silent heart attack, and I was shocked as I considered myself in fairly good health...in ICU several days to drain fluids and establish a normal oxygen level. etc.

My medication was lasix to reduce fluid levels, digitalis to increase contractions, and ACE inhibitor to dilate vessels, a beta blocker for vessels and heart rate stablization, aspirin and plavix for a year to help prevent blood clots, and I take a nitrate for for the 70% occluded circumflex prior to 3x weekly aeorbic workout.

It seems your father could benefit from just medication if the medication opens the coronary vessels to better blood flow and that would be evident with no angina (chest pain),  However, sometimes older indivitduals and/or diabetics don't have any angina so there can be a problem without distinquishing symptoms!  

I have provided a perspective that may help you and your father decide on the options available.  You may have misunderstood when a doctor said there wasn't anything that can be done...I hope this helps and if you have any further questions or comments you are welcome to respond.  Thanks for sharing, take care.