I am 65 male. Had first heart attach at 47, used a block buster to get rid of a blockage. Eight years later, in 2203 had a double bypass to fix a 100% and a 70% blockage. Have had a stent since. My most recent heart attack was 11 months ago. The cath revealed several small vessels nearly closed by my body had built bypasses. The only thing done was to double my metoprolol to 100 mg and to put me on isosorbide 30 mg.
Since then I have occasional angina relieved by aspirin and nitrolinqual spray. My doctor was less than forthcoming about what to expect. Although I was not told so directly if feels like nothing can be done to help other than getting though small episodes until I have a large enough one to kill me.
Thank you for your questions. The medical information you have provided indicates a significant history of coronary artery disease starting at a relatively young age. Coronary artery disease refers to narrowing or blockages in the blood vessels supplying the heart with blood and oxygen, usually due to build up of cholesterol. A complete assessment of your risk for future complications (like heart attack, need for additional stents, surgeries) does require more information than provided here.
For instance, what are your risk factors for coronary artery disease? Those at highest risk of coronary artery disease and its complications are (1) smokers (2) diabetics (3) those with poorly controlled high blood pressure (4) patients with high cholesterol (5) those with significantly reduced kidney function. Associated medical conditions can also increase your risk of heart complications, and include obesity, obstructive sleep apnea, anemia, and disease in other blood vessels (so called ‘peripheral vascular disease’), among other things. Your family history can also provide important clues about your risk of future heart events, but it is important to also consider differences between yourself and family members that may also impact risk (i.e. smokers vs. non-smokers).
In considering your risk of future problems, your doctors will also be interested to know whether the coronary artery disease has lead to other complications such as reduced heart function (described as a low “ejection fraction’) and changes in heart rhythm. However, I will do my best to answer your questions and concerns based upon the information that you have provided.
Firstly, I would like to reassure you that the treatment you have received to date sounds appropriate. Increasing the metoprolol and commencing isosorbide is appropriate for someone with angina. In addition to reducing the frequency of angina, metoprolol has the added benefit of re-strengthening the heart and regulating the heart rhythm. Following a change in treatment it is normal for heart specialists to wait a period of weeks to see whether the new treatments have improved symptoms (assuming patients are stable and tolerating their new medications).
What to expect in the future? I suspect your doctor is waiting to see how you respond to treatment rather than outlining the full range of future possibilities. Your recent cath revealed small vessel disease and this is likely the cause of your angina and best managed with medications rather than repeat surgery or stents. Not having disease in your bypass grafts or large vessels is a good thing.
In addition to metoprolol and isosorbide you will probably be taking aspirin, a ‘statin’ or cholesterol lowering medication, and possibly an ‘ACE-inhibitor’, recommended for high risk patients (assuming there are no contraindications or reasons not to take each of these drugs). Managing your risk factors is extremely important and should include stopping smoking, blood pressure and blood sugar control, weight loss (if you are overweight), exercise, and a diet low in saturated fats (as found in red meat, fried foods, and most take-out). Treatment of associated medical conditions such as anemia and obstructive sleep apnea is also important. Cardiac rehabilitation can play an important role in returning physical strength to patients with heart disease. Finally, we’re always on the look-out for symptoms of anxiety and depression, both of which are more common in patients after a heart attack. Symptoms such as low mood, decreased enjoyment of life, insomnia, irritability, and feeling stressed or anxious, should be discussed with your family physician if they are present.
Patients with coronary artery disease and low ejection fraction due to prior heart attacks (ejection fraction less than 35%) may be considered for protection with a ‘defibrillator’ – which is a kind of pacemaker device that shocks the heart back to normal rhythm. This is only recommended if the ejection fraction remains low despite what we call ‘optimal medical treatment’, which is the medications I described previously taken as recommended for 3-6 months.
None of your doctors will simply be waiting for you to die. The challenge we doctors face is providing the right amount of information for each patient. Some patients want to know everything and some patients prefer just to know what the next step is. I would suggest that you write down a list of questions and forward them to your doctor so that he/she can discuss them with you at your next visit.
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