stress test/BP/aortic dissection

[raildown]

57 y.o. male with some family istory of CAD; maternal grandfather MI at age 55 and fatal MI at 75; paternal uncle with MI at age 55; father with AAA at age 56 ucessully repaired by Dr DeBakey; father died of stroke at 64; my BMI 19; lifelong runner/exerciser; Dec 2001 ER visit for 'tingling'& knot-type pain by left scapula and buzzing sensation in left hand/arm; ECG normal; blood enzymes showed no MI; subsequent ECG(s) normal; ECHO showed trivial tricuspid and mitral valvular deficits;treadmill stress test showed -1.5 mm upsloping ST depression in lead I,III and aVF which quickly (within 1 minute) resolved on recovery and were probably false positive,max HR 150 for 90% of predicted, peak BP 180/100 , Mets 14.6; PET scan indicated 'mild diffuse CAD with no evidence of hemodynamically significant coroary disease'; (2) chest xrays normal; CT scan w/contrast dye for thoracic and abdominal aneurysm show normal aorta throughout; recent Stress ECHO shows normal with peak BP at 166/78, METS 16 ;resting BPs normal; Tricor, diet have brought TG 275 well below 100 and HDL 30-35 to 47' TC and LDL previousy below normal are now well below normal; given the recent aortic dissection of John Ritter, I'm wondering (1) about the advisibility of another CT scan w/dye of aorta at some point;in view of dad's AAA (2) what is likelyhood of a spontaneous dissection _without_ prior (CT) visible evidence of (typically gradual ?) distension of an aortic segment ? (3) cardio had originally suggested an ACE Inhibitor for the elevated diastolic (100) on initial treadmill test, to protect the aorta, I (stubbornly ??) demurred and (re) focused on exercise and diet, both systolic and diastolic have resolved to normal range at rest and exercise peak BPs look better (166/78)...should I be on a BP med to prophylatically 'protect'  aorta at peak exercise ? NB: tingling/knot pain still persists near bottom of left scapula as well as in left hand/arm; "If I had more time, I would have written you a shorter letter"(Marcel Proust) ;-) thank you in advance;//

[Cleveland Clinic]

1) Anurysms really dont tend to form overnight.  Would it be unreasonable to screen you again in the future? No.  But that said, there really would be no need for frequent screening.  If you are worried about a AAA, an easy screening test would be an abdominal ultrasound looking at  In patients over the age of 65 only 1 percent who have a negative ultrasound will develop an abdominal aortic aneurysm in the next five years aorta.  Once detected, the standard of care is yearly ultrasound, if the size of the anueysm is under 5.5 cm, usually repair is not indicated, unless there is rapid enlargement. So I would basically get an ultrasound in about 5 years if you continured to be concerned and aggressively monitor your risk factors.

2) Very unlikely.

3) Ace inhibitors are good for hypertension. Listen to your doc.

good luck

[raildown]

thank yu for your speedy, thorough reply;

although I'm concerned about AAA in view of family history, I am put at ease by easy availabity of ultrasoud testing for it; the tech at recent ECHO stress test, at guidance, of cardilogist also checked for AAA (no signs found); however, the symptoms nearby the bottom of left shoulder blade keep me a bit anxious about aortic arch/thoracic site(s);

(1) I've also heard/read that these scapular pains can be an unusual/rare indication of angina and considering the PET scan dx of 'diffuse CAD' (mild regional heterogeneity of radiotracer uptake throughout the left ventricular myocardium with a moderate longitudinal base to apex gradient of flow mostly in the anterior segment), what would you think ?

(2) per cardio's advice, I'm on daily 81 mg aspirin (anti-thrombolytic), B-100 vitamin and 4 mg Folic acid (for high Hcy - possibly from Tricor; was 17, now 7), Tricor 57 mg (pre-treat TG was 275, HDL 30-35, TC 190, LDL 109), multivitamin, Vita E 400 mg, Vit C 1000mg, plus modified (fish, LF dairy) -vegetarian diet;

anything unusual, contra-indicated therein ?

(3) while my resting Bp was in the 13x/8x range in 2001, after a gradual 4 yr hiatus from regular exercise and increased life stress, it is now (with 1 hr walk/run per day, 6x per week plus upper body strength train w/ lot of reps with low weights -sometimes on machine, sometimes free weights, as well as some meditation/relaxation technques) back in the 12x/7x range at rest as it had been always before; sometimes at O.V. it is 11x/7x and sometimes 13x/8x; 24 hr ABPM showed it to be 'normal' although I have no more detailed data than that; resting pulse 6x BPM;

given all that, is ACE inhibitor still indicated with aneurysm family history ?

and what might the resting on-medication BP 'target' ?

[Cleveland Clinic]

1) I cant answer without more data. Probably not. A catheterization would answer exactly what you anatomy is. If you have ischemia on the PET and symptoms that would be the next step.

2) no. It is a good regimen.  Except I would not take vitamin E, it isn't helpful and may actually be harmful in coronary disease.

3) A low dose ACE would probably be beneficial. Target your BP as low as possible without symptoms. Usually aroun 100.

good luck