Highly questionable use of the Persantine/Thallium stress test in this patient?

[CLYSTRON]

I need your expert and unbiased opinion on the following but in order for you to do so please bear with me as I give you detailed cardiac history information.

Spring '87: CABGX4 to avert an MI. No heart muscle damage. Winter '90: Unstable angina. 90% stenosis in SVG-LAD. PTCA performed. Winter '91: Unstable angina. 90-95 restenosis in the SVG-LAD & 90% new stenosis (lesion) in the SVG-RCA. PTCA performed. Winter '92: Unstable angina. 90-95% restenosis in the SVG-LAD. PTCA performed. Summer '93:
Severe dyspnea. Vasospasms in LAD. 50% restenosis (in actuality 75%-80%). No
PTCA. EF at 68%. Normal LV. Winter'94: unstable angina. Patient was completely intolerant to sedatives and calcium channel blockers which were administered causing vital signs to plummet necessitating the use of an IABP. 95% restenosis in the SVG-LAD & 90% restenosis in the SVG-RCA. PTCA performed on LAD and 3 days later on RCA. Angio showed 75% restenosis in LAD
with thrombus and a spiral dissection.
Patient not informed about intimal tear or thrombus. Poor mental status from drugs. EF at 31%. Poor LV function. Early Feb. '95: Patient still in extremely poor mental status from drugs.
Echocardiogram showed EF at 21% poor LV.
Late February '95: Unstable angina. Angio showed 95% restenosis in the SVG-LAD and total occlusion in the SVG-RCA. Begining of March, patient xferred to an affiliated hospital by family request for coronary stenting.
2 Palmaz-Schatz PS 1530 15MM stents were fully deployed in tandem with the use of IVUS to seal the dissection. Post angio: minus 5 percent residual stenosis. Prognosis excellent. EF at 18% poor LV. July '96 (16 months later) Unstable angina. Angio showed stents were widely patent (open) even though cardio misread them at first and proclaimed that the stents had closed up. There was a new (small) discrete stenosis just distal to the two stents. Patient was hit with drugs post-angio rendering him mentally incapaciated again. No drugs were administered during PTCA to open this new 95% stenosis. Residual stenosis 20%. For reasons unknown, no stent was deployed. EF 15-18% poor LV. Mid August '96 and against family wishes, cardio prescribed Persantine/Thallium stress test. Last day of August '99 on the morning of the test, patient developed severe angina at home. At heart station,
he was accompanied by his daughter. Cardio was informed about the severe pain by him and his daughter but cardio ignored and proceeded with an IV administration of Persantine (Dipyridamole). A few minutes later the pain instensified to the point where it was literally unbearable. The patient and the daughter asked the cardio to stop the test but he appeared to directing his attention to a woman on a treadmill. Finally when he returned, he gave the patient a nitro pill, which had no effect. Another nitro pill after that
had no effect either. Then the cardio administered Aminophylline (a bronchial dilator used to treat Asthma) which had little if any effect. Then he gave the patient Mylanta (an over-the-counter) ant-acid which obviously at this point had no effect and had no logic either.
The patient was in extreme anguish and the test was aborted and he was xferred to the ER where oxygen delivered via nasal cannula resolved the pain, albeit only temporarily. As expected by the family, the angio showed that the new stenosis that had just been opened less than 8 weeks ago had now restenosed to  99%. The drug Phenergan which was administed pre-ptca caused the patient's mental status to plummet but this time a another Palmaz-Schatz PS 1530 15MM stent was deployed with zero percent residual stenosis and a good prognosis. EF/LV remained unchanged from July '99.

This board certified cardiologist had known this patient for years and with the intimate knowledge of his medical history that he possessed, I can't think of any logical reason why this test was ever attempted in the first place. The patient was 86 years old at the time of the test. I believe that untold heart damage could have occurred from the drug induced prolonged episode of angina, an event that would have never occurred in the first place if a stent would have been implanted back in July of '96.

I know that this test is considered relatively safe, but in this particular instance, I believe the safety factor is
totally negated here.

You're comments would be greatly appreciated on this. Thank you so much.
Sorry for the long winded post.


CLYSTRON

    

[CCF CARDIO MD JMF]

Dear Clystron,

I am unable in this forum to make these kind of judgements on patient care.  I can say however, that persantine is safe and it does occassionally happen that people may develope symptoms.  This is one of the side effects or risks of this procedure as well as any other stress test with a pharmacologica agent.

[PazGlenda]

A related discussion, Fear was started.