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Jack54
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Jack54

I can make out from your posts that you have good knowledge of heart circulation system. May I request you to comments on my recent cath Report. I have not been recommended any surgery or stent implant by my cardiologist.

LM              Normal
LAD            Patent stent in proximal LAD
                  Mid ostial LAD has 30-40% plaquing
                  D1 medium sized and has 60% osteo proximal stenosis
                  D2 large and has 80% ostial stenosis.

LCX            Nondominant
                  Distal LCx100% occluded with three OMs filling retrogradely via LAD & RCA

OM1           Large and Normal

RCA           Dominant and Normal

PDA           Normal

PLV           Normal

Large RV branch has 90% ostial stenosis

LV             Marked apex & anterior wall hypokinesia.

These are results of repeat Angio 4.5 months(January 2008) after implant of stent in LAD following MI in August 2007. Is management of this condition is possible by diet, medicines and exercise? Which part of above report should worry me??

Thanks in advance.
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214864_tn?1229718839
Hi Tinu1959 :)

I appreciate your kind words but I am a layman only. I have had to study my own caths since I have had 10, lol. It is really scary to think of this but an angiogram, the "gold standard" of imaging coronary arteries and blockages are sometimes not entirely correct. A technology known as IVUS (Intravascular Ultrasound) is not found in every cath lab. This is why some angiograms are off a bit, I have read many times.

I had a very serious blockage in my LAD that would have been missed if not for IVUS, and this angiogram was done at the Cleveland Clinic. The cardio was so excited he had to explain it to me during the cath....

Here is an attempt to answer your questions, but there is a typo I think that I must assume the real meaning of. The typo I believe is when the blockage in "D1 medium sized and has 60% osteo proximal stenosis". Osteo means "bone", so I will assume it should be ostial.

1) Your LM or Left Main is normal and this is extremely important!

2) You have an "open or clear" (patent) stent in your proximal LAD. Really good news. No restenosis there.

3) It appears that the first branch coming off of your LAD has an ostial (opening) blockage of 30%-40% blockage. This opening is where the D1 arterial branch originates. The D1 branch has a 60% proximal stenosis, or blockage at the very beginning.

4) Your D2 is the second branch coming off of your LAD. It is a larger artery compared to D1, and has an 80% ostial stenosis or blockage at the very opening (ostial) leading to it. This type of blockage needs stenting because it is >70% blocked. The trouble is, these ostial blockages are hard to stent because the stent can cause the LAD to become smaller, and during the stenting process could cause plaque to travel up into your LAD and cause a heart attack, I believe. The medical term for these "Y" type branches is known as a bifurcation. They are trouble spots to stent.

One procedure that is commonly used on a blockage in a bifurcation, is Rotational Arthectomy, where a really fast, spinning cutting head shaped like an acorn is used to grind the plaque into very tiny particles and flushed on into the cardiac muscle via the artery being "drilled out", The particles are too fine to cause a heart attack.

After most of the plaque is removed, a stent is deployed where the blockage was. I have had this procedure performed on my "very proximal" (beginning) LAD in lieu of bypass surgery, two years ago. It restenosed after 17 months. I had another stent partially placed in it at the Cleveland Clinic. This stent protrudes about 1/4 of an inch into my Left Main (RYKES, lol).

5) Your Left Circumflex Coronary artery (LCX) originates usually at the Left Main close to where the LAD originates. It gives off (in your case) Obtuse Marginals (OM1, 2 ,3 &4). Your LCX is 100% blocked at the end of it (distal), and it appears the blockage is before the origin of the last 3 OMs. (OM1 is in great shape) The good news is the flow going to the LCX is blocked (which would normally cause a heart attack due to loss of flow to your OMs) but these OMs are being retrogradely (reverse flow) filled via, or by you LAD and RCA. This is a very serious blockage that needs stenting or bypassing. I believe it is hard to stent a 100% blockage but can be done.

6) OM1           Large and Normal

RCA           Dominant and Normal

PDA           Normal

PLV           Normal

All of these arteries are just fine. You are Right Dominant.

7) You have a large RV branch coming off of your RCA that has 90% ostial stenosis, or blockage at the opening. Again this may be hard to stent and may need Rotational Arthectomy before stenting.

8) LV   Marked apex & anterior wall hypokinesia. This means the bottom and front of your left Ventricle (LV) has a "lazy motion or movement" (hypokinesis) that can cause problems such as a low ejection fraction and in general poor performance of your heart as a pump. I am very sorry about this. More than likely all of these blockages have caused a lack of blood flow (nourishment and oxygen) to this portion of your LV and probably other areas of your heart.

You really need to have these blockages stented or bypassed very, very soon! The longer you wait the more your heart muscle will be damaged.

Remember that I am just a plowboy. Any or all of what I have told you could be wrong. This is a good question for the Doctor or Expert's Forum. I know that you need to find a great cardiologist that is affiliated with a great hospital.

The second or third page of this cath report should give all conclusions and recommendations. Did you get a copy of those or that page?

My prayers are with you and please try not to become disturbed and depressed. That will only hurt your heart more.

You need fast acting nitroglycerin with you at all times. The AMA also recommends chewing 2 aspirins and calling 911 if the nitro doesn't relieve your angina, which I know you must have.

My best to you,

Jack
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Avatar_m_tn
Thank you so much Jack. I t is going to be a great help when I talk to my cardiologist next time. Yes my Ejection Fraction is low. It is only 30%. I had MI in August 2007 and EF was 30% at that time. Than by december 2008 it improved to 40 %. Now recently it has again come down to 30%.

I did ask my doctor about the blockages several times. But he says that we will manage by medicines. He has so far not suggested stenting. Sometimes it is very difficult to understand why these doctors decide like this. I got my cath report reviewed several times and the answer was that there is no immediate and serious threat to heart. May be for the reasom that I had MI in august 2007 and than ICD in January 2008 the doctors think that bad news of doing a heart bypass should be given to me at a later date when I recover a bit.

I, now have a feeling that the reason for my EF going down from 40% in dec 2007 to 30% now could be poor supply of blood to my heart sections.

Jack, what do you think about development of collaterals which supplement blocked arteries to maintain blood supply to starved region. Is it true that these collaterals develop over a period of time and allow some of the blockages to be ignored. Like my LCX is blocked but the blood supply is restored through other atreries. In this case will it be necessary to open LCX(which may lead to other complications)?

What do you think about RV branch which is 90% blocked. Is it serious. Can it damage my heart.

One last question. Do you think with management of diet, medicines and exercise it is possible to reduce the blockages over a period of time. I know one gentleman who had 90% blockage in one of his arteries and in about 5-6 years it reduced to 70%. But he is very very strict about his diet.

Jack, I am sorry to hear about pains you have to take for your heart condition. I compliment you on  bearing with all these hardships. I wish and pray for speedy recovery from your heart problems. Thanks you once again for responding and sparing time to go through my Cath Report.
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214864_tn?1229718839
Hidy :)

The first thing that I would do is get a copy of your angiogram, on CD or DVD, that is made during every angiogram. Next I would get a copy of all of my cardiac medical records since your mi in August of 2007.

Now find a cardiologist not associated with the current group, that your cardiologist is in (if he is in a group and most are). Try to find a good one. Then send him all of the records and CD prior to the actual appointment. Boy do you need a second opinion!!! Check with your insurance on paying for second opinions.

How do you feel? Do you have unstable angina (angina at rest) or stable angina (angina during exertion) or both? Are you energetic at all? Some people, even though their EF is low, feel pretty good and exercise.

Collateral arteries are controversial a bit. Some believe that we are born with all that we will have, which is the old way of thinking, and some believe natural bypasses occur. These collaterals are usually tiny and do not support good health. They may keep a person from dying though.

In your case of 3 OMs being back fed from the RCA and LAD is due to the natural laws of hemodynamics or physics of fluid flow versus restrictions. This flow was not measured and could have been, using a method of what is known as Fraction Flow Reserve, or FFR. This is also not considered collateral flow.

Their are also collateral coronary arteries that do not show up on an angiogram, but help with maintaining the life of the heart.

What type of medicines are you on? You should be taking Coreg, which is the best beta blocker for heart failure. You need to be at your normal weight, your cholesterol should be normal, and your diet should be heart healthy.

I believe I know why you received the ICD. It was due to some loss of blood supply to the sino-atrial (S-A) node of your right atrium, which along with the atrioventricular node  
(AV), control the rhythm of your heart (electrically and physically). Your ICD is probably functioning as a pacer and a defibrillator. Trouble with blood supply to this area can also, considering the blockage in your large right ventricular (RV) artery, cause Vtach or ventricular tachycardia, which if not stopped by your ICD, can be lethal. It is the very worst of the arrhythmias. Your heart can go into ventricular fibrillation whereby the ICD "shocks" the heart node and restarts at a normal rhythm. If not cardiac arrest will occur.

The right ventricle has a very thin wall and operates at a much lower pressure than the left ventricle. It also can have many different arterial blood supplies. I have a congenital defect in my RCA. It is "insignificant due to size and is diffusely diseased", yet it is not large enough to stent. So my RV must be supplied from another source. The RV can also receive blood from it's chamber. My cardiologist have never been concerned with this.... I do not have any arrhythmias that I can feel, or that show up on an EKG ventricular node .

I assume that your heart attack was due to the proximal LAD, which was stented. Have you ever had an echocardiogram?  An echocardiogram is very important for you to have. The echo report will give very valuable information on what the blockages are causing within your heart, such as enlargement of certain chamber dimensions.

You have such a complicated cause of coronary artery disease (CAD), that it is very hard for me to get my head around. The more that I think about your condition, the more I think your doctors are proceeding with good care. I really don't know, but I would get a second opinion about revascularization of the affected areas of your heart.

I wish that I had more time, and will in the future but for now I must do some chores, lol. In the mean time, keep your chin up and ready yourself for any challenges that may lie ahead.

Thanks also for all of the kind thank yoos and you have many kind welcomes :) Remember to keep a great attitude. That is the best thing you can do for yourself. I can tell you from a lot of experience that worry damages the heart. Sometimes that is why cardiologist withhold some information.

Jack
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Avatar_m_tn
Thanks Jack.

My recent(10 days back) Echo reads:

Mitral Valve: Slope  110 cm/sec; DE amplitude 18.6 mm; EPSS  14.9 mm.
Arotic Valve: Arotic Root diameter 29.8 mm; Cusp Separation 18.1 mm.
LA Size: 45.2 mm; LA dilated
Tricuspid Valve: Normal
Plum Valve: Normal
Left Ventricular Parameters:
- LV Size(diastole) 61 mm
- LV Size(systole) 55.4 mm
- LV Volume(diastole) 118 mm
- Stroke Volume 39 ml.
- Cardic Output 3.33 L/min
- Ejection Fraction 30%
Mitral Valve Flow Velocity: e wave 108 cm/sec; a wave 34 cm/sec; e/a 3.5
IVS(diastole) 7.7 mm; IVS(systole) 9.0 mm
PW(diastole) 7.7 mm; PW(systole) 8.7 mm
LV Enlarged; Varying degree of hypokinesis of most of LV walls seen; The lateral wall is best preserved.
RV Normal

Tissue Doppler Analysis: LV systolic velocities are reduced.

I am 48 male. Had MI in august 2007 with LAD 100% blocked. LV has damaged muscles in parts of heart served by LAD. Stent was implanted. I also have ICD. My pulse rate remains 70-80 bpm most of the time. My BP is 108/70 most of the time. I am 6 ft and 78 Kg. I walk 1.25 mile daily in 30 minutes. After walk my pulse rate is 100. Last time (Nov 2007) my E/A was 1.3.
I take corag(betablocker) 18.75 mgx2; Ramipiril(ACE-I) 5mg(morning) 2.5 mg(evening); Aldectone 12.5 mg; Aspirin; Clopidogrel; Tonact Plus(for cholestrol). Are medicines OK for this heart condition?

As regard reason for ICD-I had syncope episode in January 2008 following a long sitting sequence(7 hrs). I had holter, MRI, Echo, blood tests and above referred Angiogram. Doctors could not establisg that it was due to heart problem. although in Holter I had 4 non sustained Vts(which doctors say cannot be considered in isolation as reason for ICD) and my Ef at that time was 35%.

I changed the team of doctors and went to different group of doctors in different hospital. They performed an Electrophysicological(EP) Study. The EP study was also negetive. The doctor still felt that considering my EF I may need an ICD. And with this background I was implanted single channel ICD.

One more aspect which may be of interest to you was that in January my Echo report showed 35% EF. The doctor performing Angio in January informed during the procedure that he can measure EF by angio also. When he did this the EF was only 20-25%. He scared me showing this EF. That is the reason why I left him. Later on I had come to know that EF measurement by Angio is always lower than by Echo. EF by Echo is the value which is to be used for all practical purposes.

Your opinion??

I did consult one more doctor. He scared me. He told me to stop going to work and relax at home. He suggested to bring down coreg from 18.75mgx2 to 6.25mgx2 daily. I have increased my coreg with great difficulty. With lower coreg my pulse rate goes high. I do not want to go back. I am regularly going to my office(five days a week). I travel  1.5x2 km daily to my work. I do not feel very tired. Is it too much for my condition??

I am very strict on low fat and low salt diet, weight management(my weight has not changed in last eight months), take antioxidents by way of vegetables, take fruits, 1.5 liter of water and all my medicines.
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214864_tn?1229718839
Tinu1959, your echo shows that you have dilated cardiomyopathy or DCM. Cardiomyopathy is a disease of or degeneration of the muscle of the myocardium. This condition can lead to progressive cardiac enlargement and remodeling.

The medicines that you are taking can sometimes prevent this remodeling, especially the ACE inhibitor. The rest of your medicines are standard therapy. Watch your potassium levels and STAY AWAY from salt You may also have to adjust your fluid intake later. 1.5 liters seems reasonable if you do not have edema or retain fluid buildup.

Your Left Atrium and Left Ventricle are enlarged, probably due to the very serious heart attack that you had. You are very fortunate to be alive, like so many of us. It seems like you survived a "widow maker" heart attack. This is when you have a blockage at the proximal (beginning) of your LAD. This portion of you LAD, with blockages is in a special class of it's own, because of the mortality rates associated with it.

I have been very busy, sick and pushed for time, so the other measurements will have to wait, or you can look them up. There is a very important measurement taken from your EKG, known as the QRS time.

You mention a "single channel ICD". I cannot find an ICD like this. They are either single chamber or dual chamber ICDs. The single chamber ICDs have one lead and usually go to the right ventricle. The dual chamber ICD goes to both chambers of the heart. Their is a new ICD, I think, that has only one lead and is a dual chamber ICD.

You need to know EXACTLY how and why your pacemaker is programmed. They can do so many things with regard to pacing and prevention of Vtach. It would seem that you would need a dual chamber ICD to better help your heart to achieve a higher ejection fraction (pacing) and a defibrillator since you may be at risk for SCD (Sudden Cardiac Death).

MaggieMag is a Registered Nurse or, RN and a member here. She is an expert on all Cardiomyopathies and ICDs (many other areas also). I would hope that she could step in and give you some advice and insight into your current situation.

You for sure need to go through cardiac rehabilitation, when your doctor says you are ready. You need to be monitored while rehabilitating.

Most importantly you need to limit your heart rate to ~65 while resting, your blood pressure less than 120/70 while resting. Coreg will control your BP and pulse rate if you find the right dose. You are taking immediate release Coreg. I take 20 mg of controlled released Coreg or Coreg CR. This type may work better for you. It has caused me to gain weight, which I am trying to fight.

It is important to remember that your combination of medicines, your ICD and restrained exercised can prevent remodeling of your heart and worsening of you condition, Another thing I failed to mention is your enlarged LA can cause atrial fibrillation which you may not necessarily be aware of. My LA is also slightly enlarged, and most other dimensions are at the high end of normal.

Keep a good attitude and use your natural power of meditation to envision your heart repairing itself. Demand answers from your doctor. Keep a copy of all of your medical records.

Keep us informed of your progress, Namaste :)

Jack
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Thanks Jack, for the advice. I am not sure how much meditation can help in my case?? I will have to be carefull not to get my LAD blocked again. I am looking for answers-how to avoid stenosis in the stent?? Today I met my cardiologist. He did not advice any interventional procedure. At the moment he wants to proceed based on medicines. I will keep you informed. Namaste.
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214864_tn?1229718839
With regard to stenosis in the stent, you need anti-platelet therapy, which the manufacturers of the stents recommend Plavix (Clopidogrel) and aspirin daily for a year after the stent was inserted.

This can be very hard on one's stomach though. Especially if you have ever had ulcers from the abuse of aspirin or any NSAID, like I have. I have taken Plavix since an mi and stroke in June of 2003. I had another stroke in 2006 though, but it only affected my ability to understand the spoken word (aphasia). I am much better especially around my family, but still sometimes have problems communicating with strangers.

I see that you are taking some type of cholesterol lowering drug, which I never found out what the ingredients was. It is used in India a lot....But you need to keep your LDL cholesterol and triglycerides lower than the standards for non-heart disease people. You also need to increase your good cholesterol, HDL, which is now considered most important by many cardiologist.

You need to take statins if your cholesterol is high. If your triglycerides are high, there is a class of drugs known as fenofibrates (Tricor) that are extremely effective in lowering triglycerides. It is dangerous to take Tricor with any statin.

Use olive oil to cook with. Stay away from saturated fats and lots of red meat. Take the omega 3 found in deep ocean cold water fish like Cod, and take the fish oil pills for increasing your HDL and adding an anti-inflammatory effect.

Niacin can also raise your HDL and lower your LDL. Niacin combined with statins can be dangerous. Some people cannot tolerate niacin (500 mg/day), because it makes them feel bad in general, and has nothing to do with the niacin "flush" that many people get with higher doses of statins.

Exercise as much as your doctor recommends, especially if you can get your heart rate as high as you can. The beta blocker you take will severely limit your highest heart rate. But try to "keep the tubes clean" without overdoing it.

Your body will tell you if the stent is stenosing by causing angina, like you surely had before the stent. Pay attention to this. The period of time after a stent is inserted and is  most likely to become blocked is within 3-9 months, I have read. I have one stent that has remained open (patent) for almost 2.8 years.

Remember that the combination of aspirin and Plavix can cause serious gastrointestinal bleeding.

Your religion probably omits the use of wine or alcohol, but 1-2 ounces of bourbon whiskey, or a glass or two of wine, might be good for you. I do not mean to insult you :) It is good for the blood. Talk with your doctor before use, because it might have an overall negative affect on your injured heart.

This is all I know.

Namaste,

Jack
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Avatar_m_tn
This mail of yours deserves a very big "thankyou". You have touched almost all issues I was looking answers for.

I take Clopidogrel(75mg).Asprin(150mg). Yes the problems with my stomach appear to have started. What is the way out??

On 11th of May I will be completing 9 months of my stent. Which means I am less likely to face the problem of restenosis(as per statistics).

For cholostral I take Tonact Plus(this is Indian name and may by sold in US by some other name). I am able to contain my total cholestrol at 129(limit is 200), LDL at 75(limit is 130), triglycride at 125(limit is 150). My HDL is low at 38(it should be between 40-50), VLDL is 16(limit is 40).

I do not take red meat at all(I have stopped it after MI). I take fish(thrice a week) and chicken(ocassionally). Although I am not aware what should be the quantities?

Exercise is one issue which still confuses and bothers me(rather "How much Exercise"). About one and a half month back I increased my beta blockers. Now I cannot reach my heart beat beyond 100 bpm. I am unable to walk even 20-30 minutes without getting tired and fatigued. I develop pain in my legs. I am now reducing betablockers to see if it helps me. But I am worried it should not have adverse effect on my heart. What should be the level of heart beats during walk/exercise to get optimum benefit??

I take wine and in fact I have a big stock of it. My doctor recommended red wine six months back. I am not taking because I fear that it may interfere with my medicines. I remember you mentioned to keep a gap of 2 hrs before and after medicines which means I have to take it during office hours. I am working on it and with your recommendation I will start it sooner.

I appreciate your valuable time.

Namaste
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