New incidence of Angina

[sillysally]

I had a stent placed 30 months ago, due to 90% blocked LAD.  Since then I've passed a stress echo and one with thallium injection, 7-8 minutes running each time.  Thallium test was a routine one yr followup, the other 6 months out from the stent placement due to some recurrent angina.  

I'm a 42 yr old female, 6 yrs type II diabetes, normal blood pressure, total chol 100-125, HDL 30-40, high triglycerides, blood sugar control ok not great, A1C about 7.1.  Meds are lisinopril 10 mg., glucophage and insulin as needed, multivitamin, CoQ10,aspirin.

I've been symptom free 2 years until 2 weeks ago.  Then I began having angina appear, in the morning, usually after I get the kids off to school, so after light activity, nothing heavy.  It is relieved by nitroglycerin.  Happens once or twice a day, almost always in the morning.  Not every day, but almost all. Also have noticed feet and ankles swelling in the morning and late at night, with none midday.

In addition, I've had trouble sleeping flat in bed.  If I lay flat, my chest feels uncomfortable, pressure and fast hearbeat feeling.  I have to sleep propped up somewhat on pillows to get comfortable.

Passed another stress echo with flying colors.  The cardiologist wants a heart cath within a week, plus is adding metropolol and Zocor.

2 questions - Is angiogram really necessary?  Could angina be simply due to stress (busy family life, happy marriage, 3 kids but money stresses)? Part of me wants it to answer ??s, part says be conservative and wait.

And why a statin when total cholesterol is not too far above 100?

[CCF-M.D.-RCJ]

Sally,

Thanks for the post.

(1) From what you have described, you have new onset angina and mild heart failure symptoms.  A cath (angiogram) at this point is appropriate and indicated.

(2) Statins have been proven to reduce mortality in patients with CAD or CAD risk factors, like diabetes, even when total cholesterol is not elevated.  The HPS study came out approximately one year agon in the Lancet, and clearly showed benefit even in those patients whose total cholesterol was not elevated.  If I was seeing you, with the information provided, I too would place you on a statin.

Good luck.

[sillysally]

Forgot to mention, my stent was placed at a point where two smaller arteries branch out that also had some minor blockage.  Cardiologists have pointed to spasm of these smaller arteries as the reason for angina in the past.  They say that spasm of these branch arteries is not life threatening, so if the angiogram shows spasm is likely to be the cause of my angina, they would monitor it with nitro.

[3rdMajor]

Sally,
    You ask some good questions.  You sound very informed and intellilgent on these issues.  Why dont you pose these questions to your cardiologist?  Thats why your paying him the big bucks!
In regards to a statin, I think they would want your hdl to be 35 or more, and your ldl to be below 80.  The metoprolol would keep your heart rate down until they figure out what is causing the angina.  New angina has to be taken seriously.  Not to alarm, but it might be related to the previous stent.  Only way to know for sure, would be to do the cath.  Best of luck with this.

[sillysally]

Thanks for your comments 3rdmajor.  I did ask the cardiologist these questions but he was not my regular dr - he was just the first available appointment and my regular cardio guy didn't have anything for a month.  And when I went into the ER a few weeks ago with the first episode one cardiologist recommended angiogram, and the 2nd said wait and see.  So there doesn't seem to be a consensus, which is kind of nagging at me.  I keep coming back to stress and my busy life and wondering if I can stop the symptoms if I take better care of those factors.

Then again, there could be a blockage which should be dealt with.  So I guess I am resigning myself to another cath (I had two in 2001).  I just wish it didn't cost $20K to take that peek inside, even though insurance covers most of it.  The stay in the ER and CCU a few weeks ago was $8K - that was for a whole 9 hours that I was there!  

The thing I find hardest about having CAD is that there's no definitive way to sort this stuff out without going to the ER.  And with my history, they slap that IV in, start giving me all kinds of injections and stuff and so I really avoid it unless my body tells me 'time to go!'  

I'm hopeful that the angiogram will provide some answers.

[3rdMajor]

sillysally wrote: <snip>
"The thing I find hardest about having CAD is that there's no definitive way to sort this stuff out..."

Dont remind me.  I was a fit 47yr old, playing basketball at the YNCA four times a week.  Prior to developing angina, I had resting EKGs and Sonigram, and was pronounced "fit as a horse", despite my complaints of "blacking out" during heavy exertion.
So, I researched the angina, and went back to my GP with a self diagnosis of ischemic heart disease.  Another EKG, and he had to agree.  I was scheduled for a heart cath, with everyone thinking best case scenario. After the cath, they didnt want me to leave.  I underwent 5x bypass, and they didnt bypass everything.
So, "fit as a horse" in June, and critical in November.  That sums up the current state of cardio diagnostics.

Hard to believe that today's technology cant provide a non invasive method for assessing CAD.