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"Small" blood vessels contributing to angina?
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"Small" blood vessels contributing to angina?

I am 45 yo woman with moderate mitral regurg.  Have regular bouts of what cardiologist calls angina.  Underwent heart cath on Fri of last week and no significant blockage found.  I was still out of it when dr told me his findings but called his nurse yesterday due to bad side effects of Imdur (he changed me from beta blocker to this).  She reiterated that there was no significant blockage but cardiologist said I have "small" blood vessels which may be contributing to angina.  They gave me the Imdur to try and dialate the vessels.  Now his is switching me to a patch.  Not happy about any other nitro product.  Can you tell me more about "small" blood vessels?
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Avatar_n_tn
Yes, the left heart cathetrization excludes with great accuracy disease in the largest (epicardial) vessels, but is not as accurate about the small vessels into which these vessels empty. The way to treat these blockages is not with stents but with good medical therapy: lipid lowering agents, beta blockers and aspirin are the agents favored because they decrease mortality. Nitroglycerin and its derivatives may relieve symptoms of angina but are not known to decrease mortality associated with coronary artery disease.
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Avatar_f_tn
Thank you for your speedy reply!  It sounded more like they were saying I had smaller than expected size of the larger arteries but the nurse did not use the word stenosis.  She said "lumenal" so I thought she was saying the blood flow might be somewhat restricted due to the size of the vessels ... not a blockage of smaller vessels.
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Avatar_f_tn
Cath results below...any comments would be appreciated....

Left ventriculography in the RAO projection showed an LVEF of 45% to 50% with mild midanterior to apical hypokinesis.

Left main coronary artery originates from the left coronary cusp in the usual fashion.  The left main had diffuse plaquing in it to angiographically 30%.

It bifurcated into the LAD and circumflex coronary arteries.

The LAD had luminal plaquing probably to 20%. It was about a 3.25-mm vessel proximally and it became a 2.5-mm vessel very soon thereafter and wrapped the apex.  It was a 2-mm vessel and it had luminal plaquing in the distal 3 cm to probably 50%.

The LAD gave off one proximal diagonal vessel of 2.25-mm size in diameter to 2.5-mm size in diameter with minor luminal disease to 10% to 20%.

The circumflex coronary artery gave off a 2.25-mm anterior margin, a 3-mm midmarginal, and a trifurcating posterior marginal.  The anterior and midmarginals had luminal disease to 10% to 20% and the posterior marginal with luminal disease to 30%.

The right coronary artery originates from the right coronary cusp in the usual fashion.  It was a 3.25-mm diameter vessel.  It gave off a PDA and LV branch.  The PDA and the right coronary was esssentially normal, may be with minor luminal disease to 10%.  The LV branch actually retroflexed on itself and had luminal disease to 10%.  

Goes on to say he is going to treat medically with a change in meds from Coreg to Imdur with follow-up in two weeks.  I have also been diagnosed with MVP with moderate Mitral regurgitation.
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214864_tn?1229718839
Hello there :)

I am working diligently to "interpret" your cath results. I will make a general comment on them for now, which is you do have some problems or coronary artery disease (CAD).

I have been so busy, but I am making & keeping notes to interpret all of the report for you, as best I can :)  I wanted to write this note before your post goes off of the first page.

Best,

Jack
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Avatar_f_tn
Thank you.  I see the cardiologist on the 23rd (he is out of town) and want to have questions for him at that time so trying to collect my thoughts and gather as much info as I can.
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214864_tn?1229718839
Left ventriculography in the RAO projection showed an LVEF of 45% to 50% with mild mid anterior to apical hypokinesis.

Left main coronary artery originates from the left coronary cusp in the usual fashion. The left main had diffuse plaquing in it to geographically 30%.

It bifurcated into the LAD and circumflex coronary arteries.

The LAD had luminal plaquing probably to 20%. It was about a 3.25-mm vessel proximally and it became a 2.5-mm vessel very soon thereafter and wrapped the apex. It was a 2-mm vessel and it had luminal plaquing in the distal 3 cm to probably 50%.

The LAD gave off one proximal diagonal vessel of 2.25-mm size in diameter to 2.5-mm size in diameter with minor luminal disease to 10% to 20%.

The circumflex coronary artery gave off a 2.25-mm anterior margin, a 3-mm mid marginal, and a trifurcating posterior marginal. The anterior and mid marginals had luminal disease to 10% to 20% and the posterior marginal with luminal disease to 30%.

The right coronary artery originates from the right coronary cusp in the usual fashion. It was a 3.25-mm diameter vessel. It gave off a PDA and LV branch. The PDA and the right coronary was essentially normal, may be with minor luminal disease to 10%. The LV branch actually retroflexed on itself and had luminal disease to 10%.

Goes on to say he is going to treat medically with a change in meds from Coreg to Imdur with follow-up in two weeks. I have also been diagnosed with MVP with moderate Mitral regurgitation.
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Notes: (Wish I could use bold, italics and underlines in the info I quote. I had the links to all info, but removed them because I think it is against the rules. I can say that all of the sources were very good ones :) I will use an asterisk to highlight what applies to you in some info)

You seem to have a right coronary dominant supplied heart according to this information:
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"Objective: To investigate the relationship between length of LAD and coronary dominance.

Design: Retrospective comparison of 100 consecutive angiograms with left coronary dominance with 100 consecutive angiograms with right coronary dominance. The relationship between the length of the LAD and coronary dominance was analyzed.

Methods: We retrospectively compared 100 consecutive angiograms with left coronary dominance (the posterior descending artery being supplied by the circumflex artery) with 100 consecutive angiograms with right coronary dominance (the posterior descending artery being supplied by the right coronary artery). LADs were categorized into three types: type A, LAD terminating before the cardiac apex; type B, LAD reaching the apex but not supplying the inferoapical segment of the left ventricle; and ***type C, LAD wrapping around the apex and supplying the inferoapical segment.*** LAD typing was also analyzed in relation to gender.

Results: It was found that the LAD wrapped around the apex in 87% of cases of left coronary dominance but only in 47% of patients with right coronary dominance, and that the long LADs were more frequently seen in women than in men, irrespective of coronary dominance."

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Mid-LAD diameter was inversely related to in-hospital mortality. Percent in-hospital mortality was substantially higher in the smallest vessel-size category (1.0 mm: 15.8%) compared with those in the middle (1.5 to 2.0 mm: 4.6%) and largest (2.5 to 3.5 mm: 1.5%) categories (P[trend]<.001).

Overall, mean mid-LAD diameter was 2.04 mm for men (n=963) and 1.81 mm for women (n=362) (P<.001). Median vessel size was 2.0 mm for both groups. However, women were much more likely to have the smallest (1.0 to 1.5 mm) mid-LAD diameters, whereas there were significantly more men in the bigger (2.5 to 3.5 mm) vessel-size categories.


RAO projection (right anterior oblique) :

In this projection the broad surface of the interventricular septum is facing the viewer, and the apex is pointing to the viewer's right.

Hypokinesis = refers to decreased contractile function; diminished or abnormally slow movement

Diffuse = widely spread or scattered; not concentrated

bifurcation :To separate into two parts or branches; fork.

*LAD wrapped the apex = the ventricular septum receives its blood supply from the septal perforators of the left anterior descending (LAD) coronary artery and the right coronary artery. However, when the LAD artery extends to the inferior wall, beyond the apex (so-called wrapped LAD), the ventricular septum near the apex receives blood supply only from the LAD artery.

*Question:
Hospital angiogram records state that the "LAD is wrapped around apex". This is accompanied by a drawing. Is there something about this which is significant and/or would be something I might want to know about?

*Answer by Cardiologist:
It means that this LAD is an extra important blood vessel that supplies both the front and underside of the heart .  
http://www.heartmdphd.com/medfaqs.asp

3cm = 1.18 inches

Distal: The more (or most) distant of two (or more) things. The opposite of distal is proximal.

Retroflexed= Bent, curved, or turned backward. (I cannot find any references for this)

Trifurcation = Having three forks or branches trifuricate
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I looked up some of the above terms for you. The report starts off with the finding of "LVEF of 45% to 50% with mild midanterior to apical hypokinesis."

This means that your left ventricle (LV) midway and to the top, is mildly slow in movement (hypokinetic).

Your left ventricle ejection fraction is 45% to 50%. Normal is from 50% to 65%.

The left main had diffuse plaquing in it to angiographically 30%. IVUS (intravascular ultrasound) was not used I don't believe. This to me as best I can determine, is a non-concentrated amount of total plaque in the left main.

The 30% diffuse disease would not reduce flow as compared to a fixed stenotic lesion (a single plaque formation), but would have some lowering effect on flow through it and on to the LAD etc. Left main disease is serious. You do not have a big deal though, at this time.

A "luminal disease of x percent is speaking of a blockage. Your LAD wraps around your apex (bottom tip) and has a 2-mm vessel and it had luminal plaquing in the distal 3 cm (last 1.18 inches of the LAD) to probably 50%. *This 50% blockage classifies you as having CAD per many accepted standards.

It could be the reason for the mild midanterior to apical hypokinesis: (LAD wrapped the apex = the ventricular septum receives its blood supply from the septal perforators of the left anterior descending (LAD) coronary artery and the right coronary artery. However, when the LAD artery extends to the inferior wall, beyond the apex (so-called wrapped LAD), the ventricular septum near the apex receives blood supply only from the LAD artery).


AN EF or ejection fraction is a fraction with the numerator being "The amount of blood in your left ventricle after it contracts, over the denominator which is the total amount of blood in your left ventricle before it contracts". The fraction is always less than 1, because the LV never completely empties.

In your case, some of the blood pumped out of your LV could be going through your mitral valve and into your pulmonary vein, instead of going out the aorta to your arm and big toe. The MVR can cause pulmonary hypertension and other problems proportional to the degree of regurgitation. Other problems such as fainting, pulmonary embolisms, strokes, etc. Blood can pool in the pulmonary vein or pulmonary artery, due to the left ventricle pumping through the leaking mitral valve and against the lower discharge pressure of the right ventricle.

Blood should flow from the pulmonary artery, through the capillaries beds and tissue of the lungs, exchange CO2 for O2, then fresh blood onto the pulmonary vein and then through the mitral valve and into the LV.

I think you need to be taking beta blockers, but if your BP is too low....

I have to end this short. I have been studying this pump we have and the effects or affects of coronary disease for humpteen years, or since a heart attack. Still I barely know enough to argue with the docs, lol.

Maybe one will correct all of this bs........

Hope this helps instead of confusing :)
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Avatar_f_tn
Thanks Jack for all your investigation on this...it help validate some of the terms I was guessing at.

-bzmed
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