confusion regarding cath result

[Jay4471]

I had a cath done 5 months after getting stent for cto of lad and another One month ago w/ ultrasound that said there was a 20% restenosis in stent on report. I got the disc and took to top guy to review and he said stent was wide open ie, no stenosis. How can something that would appear to be cut and dry objective observation be so differently interpreted especially since cath report is rather specific about the appearance of the lesion eg, smooth, irregular. I get so flustered that I walk out w/ more ?s than answers and it is impossible to get these people on the phone to clarify. They get most annoyed when it is they who are the problem.

[Jay4471]

not talking about the fruit itself but a concentrated extract called amlamax that seems very promising as an additional tool. check out the data. Indians also probably have as many if not more bad habits so there are many factors at work.

[ed34]

I've seen this fruit promoted on numerous occasions as I fly through the entanglement of the world wide web. I can understand it being good for you because it's a fruit. I can understand it being even better for you if you are lacking something which the fruit offers. Broken down into its basics, the fruit is nothing magical, sadly. It's also worth noting that it's a very common ingredient in India, and of course they have their fair share of heart disease patients.

[Jay4471]

one of the annoying things about my country are the endless ads on tv for pharmaceuticals. statins are making me prediabetic and Im very pissed about it. might have found a wonder drug. indian gooseberry or alma.

[ed34]

No, the UK seems to have predefined lists of medications for different conditions. These were chosen for both effectiveness and least reported side effects. Obviously if a patient reports a side effect, a different brand will be tried but this isn't very often. For heart disease the following is the standard,
Bisoprolol for BB, Ramipril ace inhibitor (blood pressure), Atorvastatin (lipitor), Omeprazole (proton pump) to reduce stomach acid, Clopidogrel for life (anti coagulant), Aspirin for life (anti coagulant).

[Jay4471]

good to hear. guess i have to wait to talk to dr. about whether bb is indicated but i do get those feelings. just want to keep meds and side effects to a minimum especially since my body appears to be highly sensitive to all medications. before heart problem I thought cardiology was one specialty where they had pretty much gotten it straight. boy was i wrong. did u ever take metoprolol? if so any side effects?

[ed34]

Well I took BB to allow cells to recover but I also need them because I have major restriction in my blood vessels. Without them I would have a lot of Angina. It doesn't stop the angina with serious exertion, but enough for me to do the usual chores in life. I guess what I'm saying is I can't run to my shops, but I can walk. I take Bisoprolol which is a powerful BB and I only require 1.25mg twice a day to make a difference. It doesn't affect my blood pressure or give any side effects. The beta receptors on the heart react to Adrenaline and kicks the heart into overdrive ready for fight or flight. With these, I'm neither ready for fighting or flighting, more like chilling :) You know them butterfly feelings you get in your gut when somethin' worrying happens? I haven't felt those in a long time.

[Jay4471]

yeah I get it  for me its b/c there is a small part of the wall that is hypokinetic ie. dead and the ? is whether that was a result of a small mi or a residue of defect from cto lad. the only reason I care is b/c i was told bb treatment is indicated when there is a bonafide heart attack. whatever, i just want to give my body the best,most appropriate treatment w/ minimal side effects. being six months out from stent don't know if heart still needs bb crutch so guess ill just have to ask dr. but the contradictory opinions on basic issues makes things harder than they should be. last ? did u and do u continue to take bb for angina or as a temp thing to allow cells to recover?

[Jay4471]

was this recent heart attack your first? I was told by stent dr. that I didn't need betablockers b/c in his opinion didn't have a heart attack. two weeks after stent had a very scary rhythm episode and they gave a little lopressor but I soon stopped it. this last dr, I brought my discs to look at said he believes I did have a heart attack and prescribed bystolic. I told him I didn't have high blood pressure but he didn't care. were u given betablockers after stent to lad w/ no heart attack or only after attack?

[ed34]

I am the same. I was prescribed 5mg of Bisoprolol and the alarms were going off every time I went to sleep. My heart rate was dropping into the low 20's. They reduced my dosage to 2.5mg but still couldn't get my rate up when sleeping and was discharged. I decided to let my heart kind of reboot itself, so I stopped the Bisoprolol until my heart rate was normal. I then had 1.25mg prescribed as I requested from my Doctor and my heart felt great. I now take this dosage twice a day and can handle it nicely. We have become good friends and without it, angina it much much worse. I tried many other beta blockers but my heart was not reacting properly to them. One brand even sent my rhythm crazy. Bisoprolol doesn't seem to touch my blood pressure, which is why I need ace inhibitors in the form of Ramipril. When I last spoke with my Cardiologist about Aspirin, he said "You need to take Clopidogrel (Plavix) and Aspirin, but I'm happy enough if you take one or the other".

[Jay4471]

I dont take beta blockers. tiny dose dropped my pressure and hr too low. everyone is different and that is part of the problem. In the future, as medicine matures, everything will be personalized genetically and they will be aghast at how things done now. As for diet, 20% of cholesterol comes from diet and I have always eaten low fat, sugar, cholesterol diet and it meant nothing. as for trusting drs.  I trust technical capability on the table of my stent dr.  outside of that,   I would only say trust but verify.

[Jay4471]

I'm in usa, new york to be exact, so i go by mg/dc. I only know aspirin therapy can amplify preexisting stomach/esophageal issues. Statins for me are a difficult issue, would like to get a particle test so I know exactly what the deal is and how aggressive to be. wish I could ignore the side effects but its obvious there is a problem, tsh, blood sugar, a1c all going up. hope you can figure a way to handle the aspirin b/c u need it.

[Flycaster305]

I can't remember what type of stent needed housekeeping, I've got both types, but do know the reason for the restenosis was caused by what they called tortuous (twisted) arteries, which were straightened.

I would disagree vigorously that diet is a minor cause of cholesterol issues.  Like Ed, I also manufacture too much cholesterol but changing my diet to a heart healthy intake plus taking statins really saved my life. Statins take a bad rap, in my opinion.  The fact that you are tired and have gained weight seems more in line with what all of us experienced initially when taking beta blockers.  

Like Ed, every time I refused t take a drug I paid for it.  In my opinion, part of recovery from heart problems starts with acceptance, trust and commitment.  I'd choose a heart doctor, and establish a relationship.

[ed34]

I haven't been checked for a stomach ulcer, are the symptoms correct? I wondered about an Ulcer but I would expect pains to exist with certain foods. Only the Aspirin seems to cause pains. I was prescribed Omeprozole proton pumps to see if it would help, but it seemed to make it hurt even more. I have no idea what's going on and even my Doctor seems to be scratching her head over many of the problems. I see my Cardiologist in Feb, the Doctor had it brought forward from May, so I will type a list and slap it on his desk to read. I don't know what country you are in, so have no idea if you use mmol/L or mg/dl. Anyway my total cholesterol was 9.7mmol/L before statins which is way way too high. Average is 5 and heart disease patients should be 3.8-4. If you can get down to 4 or less, then there is apparently lots of evidence to suggest much lower risk of cardiac related death. My total cholesterol on 40mg of Lipitor was 5mmol/L. Now on 80mg of Lipitor it is 3.9 mmol/L. All I know is, when I stopped medication, my conditioned got a lot worse over 12 months and another artery totally blocked.

[Jay4471]

flycaster,  where was the stent that restenosed? was it bms or des? were any a calcified total occlusion mid-lad? your on the money about my frustration in that all I want to know is what the new lesion in the stent is. scar tissue, plaque (hard or soft) a bit of context and what it means for the future of the stented area. Thats why they did the ultrasound in the first place. I blame myself to an extent for not being more focused in this consult but I was absorbing the fact that he told me I had a heart attack when the other guy said no. one thing Ive noticed w/ these interventionals is they can be quite patronizing and insulting of ones intelligence. my diet and weight have always been good but ironically since starting the stain Ive gained 15 pounds of fat around the middle, my metabolism has basically stopped and the drs have no answers. oh, also what meds are u on if u dont mind?

[Jay4471]

I too have tiredness and weakness after eating that might be a form of hypotension. usually it happens to older people but im just 42. seems there are a host of weird changes since the stent. have you been checked for a stomach ulcer? this last consult I did had a whole page w/ questions about falling asleep easily that I hadn't seen before so it is relevant. I've already had experiences w/ these people where if I wasn't proactive and aggressive they would have missed important things. The indifference and even incompetence is disturbing. I think cholesterol in food issue is minor to begin w/, as u say its the liver but beware of cognitive and emotional changes w/ 80 lipitor, I became very irritable and foggy over time. hopefully over time you can go back to 40 and ur heart will start to function a little better and reduce the tiredness.

[Flycaster305]

Jay, I understand your frustration.  I'd consider a cath the gold standard, and also understand there is soft plaque and hard plaque.  There are many other factors involved, including where the blockages are occurring in the artery walls.  Like Ed, I have had multiple stents, either 9 or 10.  I've had some of them for almost 15 years, must have had at least a dozen caths.  I've had only one incident of restenosis, which is blockage of a treated area.  Another big factor is how twisted and turned your arteries are.  

Ed gives great advice, center on reduction of stress, lose weight if you need to, control diabetes, and find a heart healthy diet that matches your lifestyle, and above all, exercise daily aerobically for at least 1/2 hour daily.

[ed34]

I stopped Aspirin because the stomach pains I got were as bad as a heart attack. I have no idea why they do this now, when I managed them for years prior. I am not too worried about the Aspirin though, I have a pack ready to take if I have another attack which the Doctor is ok with. Yes 80mg is high, but I had blood tests last week again and the results all look normal. Well I say normal, but as usual my white cell count is slightly elevated and always seems to be, has been for years. The trouble is I have hypercholesterolemia which means even if I didn't eat, my Liver works overtime shifts to over produce lipids. I seem to have one other new symptom since this latest attack. If I eat anything, no matter how much, I suddenly feel very tired. So tired that I can't fight it and fall asleep for at least an hour. I have mentioned this to the cardiologist and Doctor but neither seem concerned. I spent 48 hours in hospital with the last attack and I swear 40 of those must have been sleeping.

[Jay4471]

  my condolences on the terrible loss you have suffered. I hope you can find some peace no matter how u choose to proceed. Stress is certainly number one on the list. thats what did it to me im sure. only more of a physical stress stemming from a couple of  ent surgeries that caused chronic issues am still existing w/.  why did u have to stop the aspirin? also 80 lipitor will cause significant side effects.

[ed34]

My stents were all open and I was doing very well taking aspirin 75mg Clopidogrel 75mg and Lipitor 40mg. It took a few years to realise that stress was the key issue with me and I managed to get that under control too. Then my wife passed away in the last 2 years, aged just 44 and I was so angry. I stopped taking all my medication because I hated life to much. I even saw a cardiologist last year who said I was doing great, which reinforced for me that I didn't really need meds. Just a few weeks ago, I suffered a bad heart attack and an Angiogram revealed that my grafted Lima had now blocked (from triple bypass in 2007). All 5 stents in my LAD were now also blocked. Collaterals had once again opened from my left circumflex to feed into the LAD and saved me. Doctors said it was the lack of medication which caused the problem.I was put on Aspirin 75mg, Clopidogrel 75mg, Bisoprolol 1.25mg, Ramipril 1.25mg and had to see my Doctor several times to try and reduce my blood pressure which had risen to around 146/102. I could no longer tolerate Aspirin so had to stop that. My Lipitor was raised to the max (80mg) too. After a while we managed to get my BP to 120/75 and this is due to repeating the Bisoprolol morning and evening and taking 2.5 Ramipril morning and night. I get a lot of Angina, even at rest sometimes. Cardiologists/Surgeons had a meeting to discuss my case and concluded "We are confident that there is nothing more we can do to help vascularization. The LAD is full of stents and there is no clean area to perform a bypass graft".

[Jay4471]

to be clear, I dont find it unbelievable that the the stent can block after 5 months. Your articulation of the scar tissue makes sense in that I know the blockage was highly calcified and pushing it through the wall must have been traumatic to the artery, (no rotoblater was used). I was simply trying to get an answer as to whether this was likely to progress or not and was very surprised when the second opinion saw no 20% restenosis lesion when looking at the same images. that makes no sense, as to the other point, I brought the disc of the stent implantation cath so he could review both sets of images to address the very point u were making. I assume u were put on dual antiplatelet therapy, i take effient 10mg and a 325 aspirin. u have many stents don't know your timeframe but are you on indefinite dual therapy are have you stopped plavix/effient? also what statin do u take and how much? Im on 20 lipitor and not tolerating well. merry christmas

[ed34]

A DES can block as can a BMS. They block because of scar tissue. Many people are under the illusion that DES stop scar tissue 100% all of the time. This is not true, but there is a small margin of difference over the BMS. I'm sure you know that a stent is a mesh, when expanded the spaces become larger. Imagine you could shrink yourself down and walk through a stent, you would see a scaffold structure with many huge gaps. The medication to help inhibit scar tissue is on the scaffold, but not in all those huge gaps. When in position, a DES probably covers 1-3% of the artery wall with medication. We therefore have 97-99% of artery wall able to form scar tissue. I'm sure you know that the body doesn't take long to form scar tissue, it can take days to weeks. The more it grows inside that stent, the more it will block.So I can't understand why you find it so unbelievable that a stent can block after a whole 5 months?
Now let's move on to the other issue, the second opinion. 5 months ago they did an angioplasty to treat a blockage in your LAD. Let's assume the normal internal diameter of the Lumen is 3mm, and they inflate to Stent to 4mm giving a nice strong flow. A month ago you have another Angiogram, along with a Ultrasound, and it reveals that it is back to 2.8mm to 3mm. Even though this is the same diameter as the rest of the vessel, we know it has reduced in size because we have the original document and procedure images. You now request that the image be sent for a second opinion. A Cardiologist looks at the image and sees that the area of stent is the same width as the rest of the vessel. He assumes that nothing is abnormal because he doesn't have the 4mm image to compare it with. To him this vessel is fully open. Do you see what I'm trying to say?
Yes all my 10 stents are DES. 4 are open, 6 blocked. I don't have high blood pressure and my cholesterol is very low. I have lots of Angina because my left artery is blocked again.

[Jay4471]

did that blockage form in a des? u said u had a total occlusion in the lad like myself, was it there? what meds did they give u after clearing cto. also r u still having angina like symptoms that had no 'clinical' cause. that resonated with me. lastly do u have high blood pressure? I do not. also how often do u get angiograms?   ps. frustration stems from two top guys looking at same thing and one says 20% stenosis and the other doesn't see it. this makes no sense to me.

[ed34]

You would need clarification from a scan to know for sure if you've had a heart attack, unless it was severe enough to be picked up by an ECG. A nuclear scan would be the best scan for this. You can't tell unless it is backed up by a specific test. For a blockage to increase from 0 to 20% in a few months is certainly very possible. I had one form from 0 to 99% in just three months.