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Heart Calcification - Non Operative
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Heart Calcification - Non Operative

Hi,
I just had triple bypass surgery. I was to have another 1-3 possibly done at the time but was told there was too much calcification and this was not possible.

My question is ... now what ??? What (if any) treatment options are available. If one of these other three become blocked is that 'it' ? I am on a variety of medication and am diabetic which wasn't properly controlled but is now a lot better controlled. Is a transplant an option down the track ???? Is there anything surgically that could be done further down the track ? I'm fairly young 47 for this apparently. But am unsure as to what now happens if one of these other three become blocked further down the track. My lifestyle and diet has changed ENORMOUSLY which i am fine with but what if this isnt enough ?


This discussion is related to Calcification.
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Avatar_f_tn
With my husband they had to actually cut the artery to remove the palque and then stent them.  He has another area which they say is too dangerous to risk doing.  You really need to discuss your options with your cardio doc.
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367994_tn?1304957193
If your medfication is controlling your symptoms, there may be no need for further intervention.  Three therapies, medication, stent and by-pass only treat the symptoms and does not cure nor lengthen life expectations.  Going on 6 years now,  I had a 98% RCA  stented, 73% circumflex not stented and 100% blocked LAD that had developed collateral vessels (natural by-pass).

Good healthy diet, exercise and diabetes under control may not advance any occlusions.  Some doctors in the medical community belief coronary artery disease can be reversed, and it appears based on exercise tolerance that may have happened to me.
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976897_tn?1379171202
"Three therapies, medication, stent and by-pass only treat the symptoms and does not cure nor lengthen life expectations"

I think you have made a mistake here, but probably an oversight. I believe in many cases stents and bypasses certainly do lengthen life expectancy. Surely everytime an emergency operation is performed on someone having heart attacks, their life is extended?

As Mammo stated, there is a procedure where arteries can be opened to remove the plaque but these are risky. The first is a basic 'scraping' but scraping the plaque off the lumen tends to turn it into a horrible sticky sludge. The danger is that the surgeon can plug up other arteries with this procedure. The second is an end type arterectomy. A small incision is made in the end of an artery and the lumen is actually pulled out, along with the disease. This leaves a fairly rough surface and heavy anti clotting agents are required for a long period of time. This procedure can only be performed once on an artery. I was in your shoes a couple of years ago. I had a blocked LAD, a blocked RCA and was told a triple bypass was my only option. This was performed and it was just my luck that it all failed after just three months. After being told by three hospitals that my only hope was a transplant, I searched for two years for an alternative. A research college in London agreed to attempt angioplasty on my LAD, which all other cardiologists had refused to do. They successfully opened up the vessel using 5 stents and now I only have the RCA to think of. My advice to you is, don't let it worry you. Stress is the biggest killer and creator of disease in your arteries. You are a long way from needing a transplant and every year angioplasty has new techniques introduced. So much research is ongoing with heart disease and you are not a lost cause with the technology available today, let alone tomorrow. So just relax, try medication and working with your GP, keep in touch with your cardiologist with regards to what they can do to improve matters. If they feel they cannot do anything, and your symptoms feel bad, ask your GP to refer you to a research hospital. This is where the 'real' experts are. These are the guys who teach the cardiologists that the rest of the public get to use.
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367994_tn?1304957193
"I think you have made a mistake here, but probably an oversight. I believe in many cases stents and bypasses certainly do lengthen life expectancy. Surely everytime an emergency operation is performed on someone having heart attacks, their life is extended?"  

That may or may not be true!  I'm referring to I believe is the COURAGE study for life expectation regarding cad therapy, emergency notwithstanding. In an emergency there are few options if any as time is of the essence.  
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Avatar_m_tn
Thanks for all the replies. I am seeing my cardio surgeon on the 23rd Dec so will ask then.... when I last saw him I just didnt think to ask as I was taking everything else in... its only know that I realise I should have asked then... so was just wondering what the options/outcomes are... when I see him again on the 23rd I'll ask and then post his replies here....

thanks everyone....
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976897_tn?1379171202
"That may or may not be true!  I'm referring to I believe is the COURAGE study for life expectation regarding cad therapy, emergency notwithstanding. In an emergency there are few options if any as time is of the essence. "

Such studies seem quite localised. I believe the one mentioned was a tiny proportion of the US and Canada. The other problem is that techniques and advancements in technology improve all the time. So if you take patients from 1999 and follow them for 7 years deciding PCI is a waste of time, you could be totally inaccurate because new methods could have been introduced in 2000. These researches are out of date the moment they start.
  
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367994_tn?1304957193
ed, where is your documentation and why go back to another century?  You have a very limited knowledge of statistical probability as I have discovered.  As noted from another post recently you can't even identify a population for sampling yet you erroneously comment digging yourself in deeper :).  Your lack of knowledge again misleads you and good research seems to evade you on many topics.  I know what you have read,  and it is obvious you don't know the significance of randomizide sampling that was done as part of the test.  I apologize to the readers if I sound harsh, but sophism should not prevail to misinform this forum.

Harry
I'm referring to recent 2007 documentation by AAC. The take away is "there was no difference in the endpoints of death or non-fatal myocardial infarction at a median follow-up of 4.6 years. The findings of COURAGE are in fact generalizable and the study should have a major impact on the practice of medicine in the United States" (ed states from his source the test was too specific and under represented).

The major news from the meeting that captured the attention of the media and meeting participants alike were the findings of the COURAGE study.  COURAGE made the front page of the New York Times and was featured as the lead article published on line by the New England Journal of Medicine. This study conducted at 50 US and Canadian centers randomized 2287>> (ed, this doesn't mean the population)>> patients with chronic stable angina to optimal medical therapy alone or optimal medical therapy combined with percutaneous coronary intervention (PCI). There was no difference in the endpoints of death or non-fatal myocardial infarction at a median follow-up of 4.6 years. There was better control of angina with PCI, but at 5 years 74% of the PCI patients and 72% of the medical patients were free of angina. These findings threaten the economic interests of the device manufacturers and the narrowly defined interests of some interventional cardiologists. Not surprisingly, efforts at spin control began even before the findings were presented at the late breaking trials session on Tuesday morning. For example, there were comments made by some prominent figures in the interventional cardiology community that COURAGE patients were not representative and that the findings could not be generalized. Well, we enrolled 64 patients in the COURAGE study at the Manhattan VA and our COURAGE patients were extraordinarily representative of the types of patients with chronic stable angina who come to our cath lab and that you see in your clinics. The findings of COURAGE are in fact generalizable and the study should have a major impact on the practice of medicine in the United States.

To better appreciate what the findings of COURAGE really mean and to separate the hype from the reality it is important to understand that COURAGE was not intended to be an attack on interventional cardiology. The study was in fact in large part designed and carried out by interventional cardiologists (including me) who were interested in better defining patient populations who would benefit from intervention. It is well established that PCI is of enormous benefit to patients with acute coronary syndrome. Furthermore, PCI provides effective and clinically important symptom relief to patients with very severe angina and coronary anatomy suitable for PCI.  So the first major lesson to take away from the COURAGE study and that is emphasized by the COURAGE investigators is that PCI continues to be a valuable therapeutic option for large numbers of patients with coronary artery disease. This is supported by the data from the study since over 30% of the medical arm patients in COURAGE had to crossover to revascularization to obtain symptom relief.  We just did not know how much benefit (if any) was derived by patients with mild to moderate angina and stable symptoms. Your clinics are full of these types of patients and they are referred for catheterization all the time. We now know that intensive medical therapy is just as good as PCI for these patients.
The second major lesson to take away from the COURAGE study is that medical therapy needs to be intensive! I have always found that the cath lab is a great place to educate patients and practice preventive cardiology. Patients are extraordinarily receptive to messages concerning diet, exercise, smoking cessation and adherence to statin therapy when an 8F sheath is pulled from their femoral artery at the conclusion of an interventional procedure. You are now challenged to deliver the same kind of message to your patients. Mean blood pressure at 5 years in COURAGE patients was 122/70; mean LDL cholesterol was 72.1 mg/dl; statin use was 93% and aspirin use was 94%. Achieve that in your patients and they will do very well.
f
Finally, it is noteworthy that the steering committee of the interventional cardiology group at the ACC selected the OAT study publication in the New England Journal of Medicine as the most important manuscript of the year and invited Judy Hochman to accept an award for this work.  All of us at NYU should be very proud of the important contributions Dr. Hochman has made.


Clinical Correlations @ April 5, 2007

1 Comment
a.Joseph Descina
July 29, 2007 @ 9:50 pm
The author writes above: “Patients are extraordinarily receptive to messages concerning diet, exercise, smoking cessation and adherence to statin therapy when an 8F sheath is pulled from their femoral artery at the conclusion of an interventional procedure.”

I’m not sure why the author is using 8French sheaths to perform PCIs in 2007!!! Almost all interventions in the US (and abroad, for that matter) are performed with 6 Fr sheaths (or even smaller). This fact (i.e., that most PCIs today are performed with 6 Fr sheaths) can easily be confirmed with a query to any and all current guide makers (Cordis, Boston Scientific, Medtrronic, etc).

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976897_tn?1379171202
You are steering away from the original comment you made which was....

"Three therapies, medication, stent and by-pass only treat the symptoms and does not cure nor lengthen life expectations"

I stated that I do not agree, and gave reasons. You then took my reasons out of your equation. However, I still fail to see how this statement can possibly be accurate in any way. Let's just take a very simple scenario. A lady aged 50 develops angina. An angiogram reveals blockages in each of the three major vessels of 90%. Now, we give no medication, no PCI and no bypass to this lady, we let her live her life as is. She dies at the age of 60. According to your statement, if we gave her medication/ stents or a bypass, she would never have lived beyond 60.
Not knowing when someone is going to die without treatment, how can anyone know if intervention has extended a life? so to me that makes the statement invalid. If we all had an expiry date printed on us from birth then maybe we could create statistics from this data, but unfortunately nobody knows when their time will be up.
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976897_tn?1379171202
Oh, and I think it's important to add. In some individuals, it has been noticed through a history of angiograms that atherosclerosis has been stopped in its tracks through medication and in some cases improved. Can we really honestly say that this has not extended their life expectancy? knowing the arteries would have clogged up?
Trying to work with such data is too difficult in my opinion because everyone is treated as a stereotype and yet every person seems to react differently. Some handle medication, some cannot tolerate it. Some have no problem with stents, some experience restenosis. Some people survive with bypasses, others experience them fail.
Too many variables.
It is my personal opinion that there is something regarding the heart which has not yet been discovered. As with the term 'refractory angina' many people have clear arteries yet still experience painful angina. It seems as though these patients are being accused of having mental problems causing this illness, like its all in the head and doesnt exist. There has to be a discovery yet to be made to account for these problems because my LAD is clear now, but I still get angina. I can tell you it is not all in my head. I want nothing more than for this to go away and believe me I know the real thing when i feel it.
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367994_tn?1304957193
My statement: "If your medfication is controlling your symptoms, there may be no need for further intervention.  

______________________________________________

Three therapies, medication, stent and by-pass only treat the symptoms and does not cure nor lengthen life expectations".She dies at the age of 60. According to your statement, if we gave her medication/ stents or a bypass, she would never have lived beyond 60.
Not knowing when someone is going to die without treatment, how can anyone know if intervention has extended a life? so to me that makes the statement invalid. If we all had an expiry date printed on us from birth then maybe we could create statistics from this data, but unfortunately nobody knows when their time will be up.

>>>>Three therapies, medication, stent and by-pass "only treat the symptoms and does not cure nor lengthen life" expectations.  That is a quote by a doctor that  I have adopted recently from the expert forum..

I don't know if I understand your question.  What I mean is that one should not expect to live longer if one or the other therapies are administered.  What I have read from some posters is that they believe a by-pass will extend their life and that according to the
COURAGE study is not true.  My brother-in-law had two emergency heart by-passes many 12 or more years ago.  Obviously, it was believed to have saved his life, and from that view point it probably did.  Until I read the COURAGE study years ago, I believed that was the best treatment in the long run and that a by-pass was a cure and life expectancy would
continue on to a ending other than a heart attack (that was my expectation). However, an accident ended his life.  You are rightly parsing my sentence, but it seems to me one with common sense would rule out the misunderstanding you may or may have concluded.

QUOTE: Oh, and I think it's important to add. In some individuals, it has been noticed through a history of angiograms that atherosclerosis has been stopped in its tracks through medication and in some cases improved. Can we really honestly say that this has not extended their life expectancy? knowing the arteries would have clogged up?

>>>There hasn't been anything said that would reject that proposition, but the minor proposition is would a by-pass or stent result in the same outcome?

QUOTE:"Trying to work with such data is too difficult in my opinion because everyone is treated as a stereotype and yet every person seems to react differently. Some handle medication, some cannot tolerate it. Some have no problem with stents, some experience restenosis. Some people survive with bypasses, others experience them fail".

>>>>That is true, but random sampling is believed and does overcome at least in theory the differences. Fairly, it is a cross section of the population and it should include all contingent medical liabilities. The larger the sampling the greater the confidence of a fair result.  The study relates to end-of-life and excludes all deaths due to anything other than CAD.  The degree of confidence of the study result does relate to the size of the sampling, number of variables, accurate records, etc.  The pros can argue and come to agreement or rejection, and it appears there is agreement with the study.
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976897_tn?1379171202
">>>>That is true, but random sampling is believed and does overcome at least in theory the differences. Fairly, it is a cross section of the population and it should include all contingent medical liabilities. The larger the sampling the greater the confidence of a fair result.  The study relates to end-of-life and excludes all deaths due to anything other than CAD.  The degree of confidence of the study result does relate to the size of the sampling, number of variables, accurate records, etc.  The pros can argue and come to agreement or rejection, and it appears there is agreement with the study. "

So with virtually 7 billion people on the planet, what would be classed as a satisfactory sample, and from how many areas within how many countries?
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367994_tn?1304957193
QUOTE: "So with virtually 7 billion people on the planet, what would be classed as a satisfactory sample, and from how many areas within how many countries?"

I can appreciate your use of the Socratic method to gain some knowledge, but questions should be plausible not ridiculous, don't be silly, or I'll put a dunce cap on your head.

There is no satisfactory sample to test a population of global dimensions because statistical inference requires the collection, analysis and interpretation as well as the the planning of the collection of data, in terms of the design of surveys and experiments.  It's an organized scientific procedure, and there is an assumption of independant and identically distrubuted random variables having finite values of expectation. Graphically it can be represented as a bell curve.

In statistics, a statistical population is a set of entities concerning which statistical inferences are to be drawn, often based on a random sample taken from the population. If it were possible to answer your question for world-wide analysis requires a subset(s) of a population (subpopulation).  

If different subpopulations have different properties (which they would have), they can often be better understood if they are first separated into distinct subpopulations.
For instance, a particular medicine may have different effects on different subpopulations, and its effects may be obscured or dismissed if the subpopulation is not identified and examined in isolation (this would be the situation with world-wide analysis).

Similarly, one can often estimate parameters more accurately if one separates out subpopulations: for instance distribution of heights among people is better modeled by considering men and women as separate subpopulations.  Populations consisting of subpopulations can be modeled by mixture models, which combine the distributions within subpopulations into an overall population distribution (subsets would be the procedure for global).

I can't answer the sample size of a hypothetical population(s). There is no data available, and even if there were I'm not statistician...an individual with a ph.d  I'm not.
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