Options for treatment

[William B.]

Hello, Doctor!

I'm male, 61, in good general health, on dual Lipitor-Niaspan therapy, a
very low-fat diet, and a regular medically-supervised
exercise program. My lipids profile has become excellent since beginning the
dual medication about a year ago. I also practice meditation regularly. I'm
in a high-stress job, but I try to offset its effects by deep breathing,
mid-day walks, and cultivating a "let it go" attitude toward other people
(and myself). I'm not always as good at the last as I'd like, but have improved
a lot as I've gotten older.

I've had two CABG's over a 10-year period, with recent (February '99)
recurrence of exercise-induced angina after the second one 18 months ago.
Stress echocardiograms in December 99 and February 00 showed no obvious
problems, but the discomfort gradually  progressed from an occasional
"stitch" in the left shoulder to outright exercise-related angina, which was
relieved by sublingual nitro.

After another Stress Echo in May indicated some changes, an angiogram a week ago
showed all CABG grafts as being open, but a portion of one of the smaller,
grafted-onto arteries has closed and a small area of the left ventricle wall
is being supplied by a net of collaterals from a nearby patent artery.
Apparently the stenosis closed just recently, and the collaterals are not
yet well-developed enough to carry the load of strenuous exercise.

I'm not a candidate for another CABG, and the new stenosis is at the end of
an "s-curve", which apparently makes angioplasty impractical. My
cardiologist has prescribed Norvasc, Toprol XL, and sublingual nitro as
needed. This last week, I've been walking more - about 3 miles per day - and
have found that my exercise tolerance is good. I have not had any severe
angina - just a slight tightness in the left pectoral area that disappears
when I warm up. Among other things,  I hope to improve my collateral
development by following this exercise regimen.

My questions: Is this improvement likely to happen? Will increasing my
exercise tolerance actually offset the effects of the blocked artery?Also,
could you comment on the possibilities (and preferabilities) of VEGEF, TMR and EECP for a
person like me?

Thanks very much!!

William B.

[Cleveland Clinic, MD]

Dear William,

It sounds like you are really on the right track with your lifestyle modifications.  Don't get too discouraged by the recurrance of your symptoms.  Remember that just like a large boat takes time to stop heading one direction and start heading the opposite direction your lifestyle changes will take some time as well.  

If you are having adequate control of your symptoms with medication I would recommend continuing with that approach.  Exercise will also help but don't overdo it.  Other approaches could be considered if medications fail.  For example we will attempt angioplasties here that many other centers consider too difficult.  If you were interested in this your doctor could contact us and send copies of your angioplasty films for a second opinion.  I would recommend Dr. Pat Whitlow for this.  VEGEF and TMR are still experimental and would only be considered in someone with severe angina and no other options.  ERCP may have some benefit but it still new and somewhat uncomfortable to undergo as well as time consuming.

[just curious]

how long since your last surgery?....seems to me, that as the collateral arteries develop fully, the angina will diminsh.
your a success story in my book!
3 miles a day seems to be "pushing it a bit" to me, but im not a doctor....best of luck

[William B.]

To: "Just Curious". Thanks for the comment! My last CABG was about 20 months ago, and subsequent to it, I had very little indication of angina - just some tightness that my doctors and I assumed were artifacts of the LIMA graft that was done. However, I began to have "real" (i.e. intense enough to be unmistakeable - and require nitro) angina in February '99. It became progressively more frequent and intense, which led to the recent angiogram. My quest is for an approach that will limit the progress and reverse the tendency for the angina to become worse. Have been looking into the literature about various non-CABG, non-angioplasty options, since those appear to be unviable at this point.

[Bill Serrahn]

I have a totally occluded RCA, which couldn't be opened with Angioplasty.  It had already developed a collateral system that my cardiologist described as a 5 on a scale from 1 to 10 for the ones that he had seen.

I was referred for bypass surgery, but chickened out.

I have read several studies that speculate that the development of collaterals is a response to ischemia.  It happens in some people and not others and I don't think they are sure why.

In my case it had already happened, so I felt that it could be improved by producing a prolonged mild ischemic condition with moderate daily exercise.

Fortunately I live near the Cascade Mountains in Washington State and was able to hike every day.  I got an exercise heart rate monitor and found at first that I could hike uphill up to a H.R. of about 105-110 BPM before I started experiencing angina.  I just set the alarm at 110 and would stop for a few steps everytime that I exceeded it.

By the end of September, I was hiking 10-12 miles each day and able to go up and down 3,000-4,000 feet.  I continued back-country skiing all winter and am now back into hiking and plan to take the summer off to concentrate on my health.

Now, I feel no angina at all, but still limit my H.R. to 120 BPM when climbing uphill.  I don't think that there is any other exercise as good.  The other part of it is that it is extremely relaxing - you can't get the experience on a stair-stepper that you can being out in the forest.

I don't know what has happened with my collaterals, but I assume that they have improved because of the absence of angina and the ability to do much more.

I think that there is a real danger of heart damage leading to eventual heart failure, by taking the approach that I have, and I don't think that it's for everyone.  Although I believe that I am in good enough shape to run, I don't for that very reason.
  
I think that you walk a fine line, trying to improve your circulation without further damaging your heart.  In my case, I am willing to take this risk, because I have the irrational belief that once the heart surgeons open up my chest that they will own me.  I am sure that there are many success stories, but I also read all of the disappointing stories of reblocked arteries after bypass surgery and angioplasty.

A big test will be whether I make it up Mt. Adams (12,237') as I have planned to do in August.  People with poor cardiac circulation tend to **** out at high altitude.  This is how I got my last heart attack the morning after hiking at 10,000'.  Anyway this year I am doing a lot of conditioning working up to it.  I intend on spending about 3 weeks hiking and living from 7,000 feet on up in July.  I believe that high altitude is also a stimulant to develop collateral vascularization.

Good luck with your effort.  I believe that walking uphill every day is an answer.

Bill

[William B.]

Hi, Bill! I've seen your comments in other places in the Forum - In fact, your walking approach to collateral-growth stimulation inspired me to begin increasing my own walking activities lately.

I note with interest your intention to climb Mt. Adams - the altitude issue in particular - because my first inkling of serious trouble came during a recent trip to Salt Lake City (from my home in coastal Maine). I began having angina while walking in the downtown - which deterred me from going up into the canyons at all. I realize you've been walking at altitude for some time now, and are gradually acclimating yourself to going higher - will be looking forward to reading about your next adventure.

I've asked the questions of our doctors because I'm interested in possible alternative approaches to what I've either undergone (CABG's) or have had ruled-out (angioplasty). I'd like nothing better than to be told that walking is the best way to keep the collaterals growing. This part of Maine has some excellent walking trails, even within the city limits.

From what I've been reading, the process and effects of EECF might be similar to those of walking, so this might be another desireable approach to take. And, when you've lost saphonous veins in both legs, anything that would stimulate return circulation has GOT to be a good idea.

Anyway, good luck to you... Happy trails!

[Bill Serrahn]

Hi William,

The main thing is that you have some hills to walk up and down there in Maine.  I took a trip out there in the fall about 10 years ago and it was very beautiful.

I live in Seattle, which is also at sea level.   When I was working this winter, I would walk down to Puget Sound and back every noon hour.  The route was about 3 miles and about 200 feet up and down from the bluff to the water and it also had a couple of other hills in it.  In my opinion that is what really makes the difference - walking up hills.  It's great exercise even if you do it slowly.  It gives you great cardovascular conditioning without a high heart rate like running.

Most of my hikes here are from 1,500-3000' to 4-5,000 feet.  I drive 45-75 miles out to the Cascades and do a 10 mile round trip to some lake.

My cardiologist claims that the blockage was long standing and that with a 20% of normal supply provided by the collaterals.  They knew something was funny when they blew die into my left main and it perfused through to the bottom right portion of my heart.  Then they found out why when they went into the RCA and found it totally occluded about halfway down.  Even there, blood was taking a torturous detour route around the blockage - pretty amazing.  

The theory is that I outstripped the ability of the collaterals hiking at 10,000' in northwestern Wyoming last summer and had the M.I.  Of course I was overweight and had cholesterol of about 240 at the time.  I had been told a couple of times before that I had an old M.I. on my EKG, but was never hospitalized for it.  That must have been when the artery had finally totally occluded.

I'm now down to a T.C. of 147 on Lipitor and hope to go onto a dual therapy of Lipitor and Welchol when it shows up in the Pharmacy.  Hopefully that can raise my H.D.L. from 30 which is probably the causitive factor of my CAD.  I have been a little afraid of high doses of Niacin.

Last Weekend I hiked up, in the snow, from 5,400' at Washington Pass to a lake at 6,600 feet.  That's the highest that I have been so far this year and that's just about where I start feeling that the air is a little thinner.  The amazing thing is that I never have angina even on a fairly strenuous short hike at higher altitude, like that one, anymore.

Like the stock market, it's a long road with ups and downs, good weeks and bad weeks, with little gains and hopefully smaller setbacks, but overall I think that you can gain on angina and enhance collateral development if you work at it as much as you can every day.

Well, I'm out of here for the weekend.  

Have a good one,

Bill

[Bill Serrahn]

Also I just read the post that you did last week and realize that you asked a question that I didn't answer on the laser angioplasty.

The device probably doesn't have the capability of making sharp turns moreso than a normal guide wire used in angioplasty, but I only know a nominal amount about angioplasty devices.  It's called the Spectranetics Laser Wire and is basically a angioplasty guide wire that has a very fine laser in it.

From my limited understanding it can be torgued to make turns to follow a long occlusion, but I don't know if it is more manueverable than the standard wire.

I had previously been told that attempting to remove a long occlusion in a coronary artery was very dangerous because of the chance of burning out of the artery.

Supposedly this laser wire can be torgued to follow the blockage and get through it.  If it burns out, it is so small that, supposedly you won't bleed out and the wound will self seal.  Once they get through, everything is handled like standard angioplasty with the balloon and stenting as required.

One of the two experts in the world with this device is Dr. David Hilton who practices in Victoria, B.C.  The device is approved in Canada and the EU, but not yet in the U.S. and I don't think that it has any studies in progress for it, which are an expensive proposition for a device with limited revenue potential.

Dr. Hilton claims to have an 80% success rate, which is much better than the 25% success rate for passing total occlusions with a standard wire.

I bought stock in Spectranetics, but so far haven't made any money either.

Take care,

Bill

[WillB1]

Bill S. - one point worth mentioning about Niaspan: in conjunction with Lipitor, it has raised my HDL's substantially. It's potent stuff - needed to be titrated-up to a full dose over a period of several weeks. It's a time-release package, designed to work most actively in the early morning when the liver is most actively producing cholesterol. It has to be taken with food - and sometimes produces a characteristic skin flushing and prickling. It might be worth asking your doctor about - it certainly has helped my lipids profile.

The other thing that has helped my profile and general energy level has been to forego the use of refined sugar and white starches, and other foods with high glycemic indices. My triglycerides dropped about 50 points over six months when I did this - and my HDL's increased as well.

Now, all I gotta do is find a way to get around that blocked artery.

Best - William B.

[stirling]

Take it in the brown...

[roger]

I have enjoyed this conversation very much.  I have had the usual procedures, ending in 4 artery  CABG two years ago.   With  small dose of lipitor, walking, and following a diet plan similar to the Dean Ornish  diet plan, my blood lipids are pretty normal.  I am very much interested in doing whatever I can to help the bypasses last as long as possible.   Do  you have suggestions about other  things to do or know of a source of information on prolonging the life of bypasses.   Thanks, and good luck to both of you.

[WillB1]

Roger - about prolonging the life of grafts: I've heard that the best way to keep grafts open is to reduce things that will damage the vessel walls, like "bad" lipids - LDL's, VLDL's and triglycerides, also free radicals, poisonous substances like carbon monoxide and hydrogen cyanide gases (from smoking), and hostile hormones like high levels of corticols and other stress-induced substances.

Lipids are typically controlled by diet (a la Dean Ornish) and chemicals such as Lipitor and Niaspan, free radicals can be combatted by vitamins like natural E and C, and other antioxidants, and stress can be managed to a degree by meditation, relaxation exercises, etc. There's also research on the role of homocysteine (which can be countered by folic acid, I believe). High blood pressure can also cause vessel damage, so BP medication may help to keep things flowing smoothly

In general,  arterial grafts last longer than transplanted veins, because the latter are less able to stand the higher pressures of being used as arteries, and their walls lack the flexibility of arterial (muscle) tissue.

Arterials have been known to last 15+ years, while veins tend to last  5 to 7+ years (my 1st CABG grafts were all venous - they went 9-1/2 years. My 2nd was two veins and and my left internal mammary artery. After 1-1/2 years the grafts are all open, but I've developed a new blockage in a small branch of a natural artery below one of the grafts. C'est la vie...)  

As you can see, it's a complex disease, and there are no simple cures. Probably the best two-word answer to your question is "education", closely folowed by "commitment".

Good luck to you, Roger - it sounds like you've made a very productive start. Hang in there.

Best - William B.

[Bill Serrahn]

Hi Roger & William,

There is a new bile binder drug called Welchol which was just approved by the FDA a few days ago.  It shows good results when combined with Lipitor.  I am waiting for it to become commercially available.

My PCP is much more conservative on Cholesterol meds that I want to be.  I'm only on 10mg of Lipitor which has remarkably brought my T.C. down from 220 to 147, along with better habits and exercise.  I would like to double that and get on the Welchol also.

I think that the main thing is to suck as much of the bad lipids out of your arteries as possible.  The recent studies that show how important this is were done with Pravachol, but in my case Lipitor was a much more effective drug and I am betting that is will have the same effect on reducing the risk of subsequent heart attack.

I have went on a variety of vitamins and supplements over the last year.  Of those I think a Multivitamin, B Complex, E, and Folic Acid are the most important.  Other supplements that I think might be helping are CoQ10, DEA (Salmon Oil), Garlic, Lecithin, Hawthorn, Ginkgo Biloba.  But I have no idea if any one of them has a positive effect.  My philosophy is if they are not harmful and there have been claims that they help the heart, coronary artery disease, or lower cholesterol, I might take it.

Here is a full list:

Vitamins
===============
Multi-Vitamin
C
B Complex
E

Amino Acids
===============
L-Arginine
L-Taurine
L-Carnatine
L-Inosine
L-Lysine

Supplerments
===============
CoQ10
Folic Acid
Salmon Oil
Hawthorn
Grape Seed
Gingko Biloba
Beta-Carotene
Lecithin
Cayenne Pepper
Garlic
Rutin
Pectin

As I have said many times, I think that my salvation has been daily hiking and skiing.  There is just nothing like walking uphill.

Last Sunday I went out and walked up a mountainside near I-90 from 1,500' feet up to 4,000'.  I just took it one step at a time, keeping my heart rate below 120 bpm as much as possible.  It was nice when I got above treeline and saw a small piper type aircraft fly by a couple of thousand feet below me and Mt. Rainier 70 miles in the distance.

If anyone would like to correspond with me on the subject of pushing back coronary artery disease, my e-mail address is bill.***@****

[roger]

Thanks  William and Bill for the thoughtful replies.  I believe we are thinking along the same lines.  I feel that the whole subject area of protecting and preserving grafts after CABG surgery is not given as much attention by researchers and cardiologists as it should be.  Thanks for the email address, Bill, i will try to contact you so that we can share information.

About the lipitor.  It is my understanding that in addition to lowering cholesterol  counts, the lipitor changes the nature of the plaques so that they may be less subject to ruptures.  I too,  take only 10 mg. and while my cholesterol counts are  OK, I wonder if the 10 mg. is enough to receive the benefit of  changing the nature of the plaques.   Good luck.

[WillB1]

Roger - I've heard a bit about the plaque-changing action of Lipitor, but haven't been exposed to much follow-up on the subject. Do you have more information? Could the phenomenon be the same as the "regression" in stenosed vessels that's been suggested by Dean Ornish and other researchers?

I agree that more information about graft protection would be invaluable. I've had a couple of CABG's - both times were because they were the only reasonable way to deal with abruptly worsening severe angina.

After the first one, I did all the things that I was advised to, including secondary and tertiary-rehab exercise programs, stress management (tough, that last one...), low-fat diet, and various kinds of lipids-lowering chemicals. I had the best results on Lipitor, but even that wasn't enough to prevent the grafts from plugging-up in 9+ years and sending me back to the OR for an encore.

After the second procedure, I consulted a lipids specialist and was placed on Lipitor+Niaspan dual therapy. Then, I found the book "Sugar Busters" on my own, and cut-out the "no-fat" sugar-sweetened pastries and other such glycemic bombs I had been consuming to compensate for the lost fat.

Interestingly, I hadn't been told to do this by any of my cardiac support people - but when I mentioned it, I was told - "Oh yes - you can't substitute sugar for fats...!" Well, duh - I wish somebody had said so about five years ago!

Anyway, the medications and reduction in sugar consumption have combined to give me really good lipids readings for the first time in my adult life. It didn't happen in time to prevent me from having a "minor" occlusion of a small section of native artery, but the CABG grafts are still wide open and that artery is being supported by a bunch of new collaterals. I hope to keep them this way with my meds, increased levels of exercise (like Bill S., I walk up and down hills - at least little hills) and diet, and have reason to think that this program may actually reverse the course of my illness. It sure improves the way I feel, and my energy level!

Good luck - keep in touch. I'm at ***@****, if anyone would like to drop me a line.

Best - WB