Post Bypass Symptoms

[Kiwi01]

Dear Doctor,

I am a 51 year old male who had 2 angioplasties/stents last November.  They closed and in February the doctors did a double bypass.  My presenting problem in both cases was pain in the right arm/shoulder on exertion and some at rest.  Very shortly after the bypass the same pain but at a lesser severity came back.  It has been 3 months post CABG and I still get the pain on exertion and some mild pain occasionally at rest despite on a nitro patch and 150mg of a beta blocker.  My cardiologist doesn't think it is angina but has offered an angiogram for peace of mind.  My primary doctor thinks it is classic stable angina and we are thus treating it medically that way (beta blocker/nitro). I have a left bundle branch block and mild cardiomyopathy.  I am a non-smoker, not overweight and watch my diet closely.  Maybe a little compulsive. My questions are:

1.  If not angina then what might it be and are there appropriate tests to persue?

2.  Is an angiogram the best test to get at this time?

3.  What is a good alternative to an invasive test?

4.  What is the best approach to try and eliminate the pain medically or otherwise?  

5. What is the best exercise approach to take for hopefully increasing exercise tolerance/ reducing pain.

I realize this is a bunch of questions; but your help is greatly appreciated.  Thank you.

[Brenda L]

my mother had triple bypass surgery four years ago. She has severe chronic pain in her chest since her surgery. She has been to several doctors who ran several tests. A Catscan of the sternum showed a mass "indeterminate etiology"and "vague lucency in left lobe of thyroid gland.

[Will B1]

Tim's situations sounds similar to mine. I'm 61, in good general health, using dual Lipitor-Niaspan therapy, a very low-fat diet, and a regular supervised exercise program. My lipids profile has become excellent since beginning the dual medication.

I've had two CABG's over a 10-year period, with emergence of similar symptoms to yours after the second one (18 months ago). Stress echocardiograms in December 99 and February 00 showed no ventricular hypokinesis or change in ejection fraction, but the discomfort has gradually progressed from an occasional "stitch" in the left shoulder to outright exercise-related angina.

A third stress echo a couple of weeks ago did show EKG changes and some slight hypokinesis and reduction in EF. I underwent an angiogram last Friday. It showed that all three of the CABG grafts were fully patent, but that a portion of one of the smaller, grafted-onto arteries had stenosed and a small area of the myocardium is being fed entirely by a net of collaterals from a nearby patent artery. Apparently the stenosis closed fully 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 a calcium-channel blocker (Norvasc), Toprol XL beta blocker, and sublingual nitro as needed. He also recommends the continuation of my moderate exercise program, but is skeptical about exercising to the point of angina without using the nitro. (He's also very cautious about suggesting VEGF therapy, since VEGF is a factor in the production and survival of carcinomas, but that's another matter......)

On the other hand, I've seen some recent published information (in Harvard Heart Letter) which tends to support Bill s.'s belief that mild ischemia stimulates natural VEGF production, which in terms promotes collateral growth. I'd be very interested in hearing more about this approach, and in comparing notes with you and others who are going through situations like ours. For obvious reasons, a graduated exercise program sounds a LOT more attractive than another invasive procedure. I'd also like to hear more from Bill S. about the doctor who has a laser-wire approach to angioplasty. Will it go around corners? Thanks!

[Bill B.]

Tim - your

[Bill Serrahn]

Hi Tim,

My exercise of choice is walking/hiking.  After having an M.I. last July followed by the discovery that my RCA was totally occluded and a failed angioplasty to open it, I was referred for bypass surgery.  Fortunately, I chickened out.

I did purchase one of these sports heart rate monitors and found that I could exercise up to a heart rate of 110 before I started getting angina symptoms.

I had taken the summer off which allowed me to exercise every day and just concentrate on my health.  Fortunately I live very close to the Cascade Mountains here in Washington.

I worked up from only being able to walk hundreds of feet without angina in July, to being to hike 10-12 miles and being able to go up and down 3-4000 feet in one day.

Now I live to go uphill.  I was up in the snow above 3,500' Friday night, Saturday, and Sunday on foot, on snowshoes and on skiis.  No angina whatsoever and in better shape than I have been in 15 years.

The reason is that I have built collateral vascularization around my blockage.  I believe that exercising up to a slightly ischemic condition everyday, but not overdoing it, is one of the keys to the development of collaterals.

I would suggest walking up to a level of mild angina.  As you get better, put some hills in your route.  Do at least 3 miles everyday, even if you have to go very slow to start.  If you can't motivate yourself, go to the animal shelter and get a dog.

Also get the meat and fat out of your diet.  And get on a good statin drug like Lipitor.  As long as your cholesterol and weight are going down, you will feel better and improve.  I grew up on meat and potatoes and never thought that I could change my eating habits.  But now most days I have no meat at all.  Instead of taking a sandwich on a hike for lunch, I take an apple, an orange, and a low fat energy bar.  I have a difficult time forcing myself to eat an orange, but there is nothing that I want more than a juicy orange after hiking or skiing uphill for 5 miles.

I recently had the opportunity to have my blockage removed by a doctor in Canada who uses a angioplasty with a laser wire designed to get through long total occlusions.  I procrastinated because, I no longer feel it's important to remove the blockage.

Sorry for the long response, and I know that everyone's situation is different, but having survived and thrived - at least for 10 months - I feel pretty strongly that bypass surgery and perhaps even angioplasty is overperscribed and has a high rate of failure.

[Cleveland Clinic, MD]

Dear Tim,

Occasionally patients will report similar symptoms after bypass to what they were experiencing before surgery.  This can present somewhat of a challenge for the doctors to sort out the cause.  Namely, is it from the heart or something else.  This explains the difference in opinions between your doctors.  I have tried to answer each of your questions, unfortunately there is not a black and white solution to your problem.

1. If not angina then what might it be and are there appropriate tests to persue?
A: Any of the other possible sources of chest pain such as gastric reflux, musculoskeletal, post-incisional pain, etc.
Depending on the other factors would determine the next best test.

2. Is an angiogram the best test to get at this time?
A: I would only recommend an angiogram if I had a high suspicion that the bypass grafts had closed down.  It is the gold standard for determining this and would not be an unreasonable test.

3. What is a good alternative to an invasive test?
A: The next best test would probably be a nuclear (thallium) stress test.

4. What is the best approach to try and eliminate the pain medically or otherwise?
A: The approach will vary depending on your doctor but a combination of medical therapy and additional testing if your symptoms fail to resolve would be a typical method.

5. What is the best exercise approach to take for hopefully increasing exercise tolerance/ reducing pain.
A: I would recommend enrolling in an exercise rehab program.  These are usually offered through your hospital.  They will take you from your current fitness level to a higher level in an ordered and safe manner.  Insurance will usually pay for this if your doctor orders it.