Stents/Restenosis/CAD reversal

[Taurus]

Hi,

I had a couple of stents placed in my circumflex artery and left anterior descending artery in third week of September, 2000. The stents were placed using a transradial procedure. My recovery has been good thus far. Currently I am on a cardiac rehab program.

I will try to present the context and the situation as best as I can. Would appreciate your views.

1. I had a heart attack when I was on a business trip to San Francisco. My stent procedure was performed in the Bay Area, CA in September, 2000. Since then I am back in Hartford, CT where I live and with the help of my primary physician I have selected a cardiologist. My current cardiologist did a 2 Day Sestamibi Stress/Rest test last week. He shared the results of the test on 12/13/2000. He said the tests indicate anterior, lateral and apical hypokinesis. He said he had some concerns (not articulated clearly) and would like to do an angiogram to know more. I mentioned that I felt fine with no pain. In fact during the stress test as well I did not feel pain. He remarked he could not understand why I did not show any symptoms and suggested I come for an angiogram next week. I asked him whether I must have the angiogram and he said he was not twisting my arms but as my cardiologist he would like to know.

2. I said I would like to assimilate the results of the test and then decide whether I would go in for an invasive test. I did inform him my reluctance in going for invasive tests. After I left the cardiologists office I had a chance to reflect about everything and do some research as well.

3. My cardiologist in the Bay Area had suggested that I have a checkup (implying angiogram as well if needed) after 6 months.

4. On 12/15/2000 I called my cardiologist and mentioned my reluctance as tactfully as I could. He said he would not push it and agreed (barring any untoward happenings) we would try to do angiogram in March, 2001.

Medications:

I am currently on the following medications and supplements:

Metoprolol 50 Mg 1/2 tablet twice a day Diovan 80 Mg 1 tablet every day Pravachol 40 Mg 1 tablet every day E.C. Aspirin 325 Mg 1 tablet every day

Supplements:

Vit E 400 IU 1 capsule every day Vit C 500 Mg 1 tablet every day Folic Acid 400 mcg 1 tablet every day Cod liver oil 1 capsule every day

I feel fine and do my cardiac rehab exercises without pain.

My questions:

1. Is it too soon to do the Sestamibi test and come to conclusion on need for further angiograms?

2. Should one allow time for medicines and diet changes to take effect in reversal of disease? (I have slowly started transitioning into an Ornish reversal diet.)

3. Are there any specific nutritional supplements that could help minimize the formation of scar tissue/restenosis? Could this be obtained naturally from any food?

4. Would appreciate any other information you may have come across regarding stents and prevention of scar tissue formation/restenosis.

5. I read somewhere (from heart surgeon's perspective) that angioplasty-stent ( and other interventional cardiology approaches) is a prelude to a bypass heart surgery eventually.  Is this just a inter specialty rivalry speaking or is there some empirical evidence?  What are your thoughts on this?

6. Most data on guidelines for selecting the cardiologist for performing angioplasties (if needed during angiograms) suggest a good experience of over 200 angioplasties a year to minimize chances of complications during procedure. How does one go about obtaining this data about a cardiologist while selecting one? (In San Francisco I ended up at the San Francisco Heart Insitiute by accident and with God's grace.)

7. How does one go about selecting a cardiologist who tries not to focus just on tests but also looks at other complementary care that address other risk factors such as stress, etc.? Any tips on questions to ask.

8. Would appreciate any recommendations for cardiologists in Hartford, CT (preferably those who are open to complementary care approaches).  I must confess I have become partial to the trans radial approach to angiography.

Thank you very much.

[Lorraine Perkinson]

My husband had a heart attack while we were on vacation in April of 1999.  We were air-vaced to Puerto Rico where they put in 3 stents.  When we got back to our home in St. Louis my husband visited a cardiologist who reviewed his charts and saw no problem.  In turn he began to have some symptoms of angina in August and the cardiologist put him through all the non-evasive test pronouncing him in great shape.  My husband continued to be concerned with the angina and the doctor said the last test to give my husband piece of mind was an angiogram but it would be up to my husband.  We elected to have the invasive procedure done at once.  The angiogram was done at 7:00AM and within two hours the cardiologist came out and said my husband was a walking time bomb.  That the stents have grown scar tissue and the best solution was a by-pass.  He had the bypass at 12:00 that day.  This was in September 1999.  While he always said he didn't want bypass surgery it was the best solution for him.  He was not a good candidate for stents.  We are members of a support group called Mended Hearts and we were surprised to learn how many stents don't succeed.  Many people, unfortunately are not candidates for by-pass surgery so stents and angioplasty are wonderful alternates.  But if you are other wise in good health and follow doctors advice a bypass could be the best thing that could happen for clogged arteries.  I hope this has help.  Usually a good cardiologist is more interested in quality of life for his patients rather than covering his overhead.

[WJS]

I would suggest getting another opinion.

Angiogram $ drive their businesses and doctors appointments provide very little $.  Some are highly incentivised to get you in that cath lab or through their bypass factory and their best medical opinion is sometimes clouded by that.  

You had a heart attack and it is going to take some time to heal.

[Taurus]

Thank you very much Bill.  I do appreciate your suggestion.  

Wish you a Merry Christmas and a Happy New Year.

PS: I called again today for my 2 day Sestabibi (test done on Dec. 7 and Dec. 8) report and as yet I have not got them!!  I wonder why the delay...

[CCF CARDIO MD - DLB]

1. No.
2. It sounds like a very abnormal stress test. If accurate, it means that you probably should not wait for the catheterization.
3.Nothing that is proven.
4.Radiation treatments are the only approved treatment that appear to effect restenosis, but long term risks are unknown.
5.Currently, there is a role for both angioplasty and bypass surgery. At least 50% of angioplasty patients never need bypass surgery and thus angioplasty saves these patients the risk, inconvenience, pain and expense of surgery. Patients with extensive blockages and/or multiple restenosis are very likely to need surgery, but at least angioplasty postpones surgery in these patients also, such that hopefully they will need only one surgery to get them through their lifetime.
6.You could ask your caridologist, though he may be unwilling to share the specifics with you. This minimum volume data is controversial. I think it is more important to pick a good hospital than to focus on the individual cardiologist.
7. Most cardiologists focus on the technology driven aspects of care. This is probably one reason why cardiac care has improved so dramatically in the USA. Truthfully, the role of stress has been overrated in importance, at least as far as chronic coronary artery disease is concerned.
8. No specific recommendations. The transradial approach is good when it works, not well-suited for complex cases though.