Building Collaterals after 100% RCA.

[Mitch031965]

Hi

I'm 44 and had a mild MI 5 weeks ago, they discovered I had a CTO of the RCA, which they tried to stent but couldn't get the wire through. Subsequent perfusion test and Ct- Angiogram reviled it was a long standing blockage that had been building for 10-15 years. My perfusion test indicated that the area below the blockage is getting 90% flow at 85% of my max on the treadmill, this combined with the Ct-Angiogram has resulted in no further action due to collateral growth. (Luckily my LCA was completely clear)

As its only 5 weeks after the MI and failed Angio, is it wise to start pushing my heart to try and expand the collateral growth. My history is I’ve never smoked always eaten healthily... and done competition cycling/running up until the day before my MI. (In fact I thought it was indigestion and did a 12km run during it which made the indigestion/angina go away).

I've been doing 30 mins swimming in my pool every day and a 4km walk on the beach, but have noticed a mild feeling of heat across my upper back, I wouldn’t call it pain, so I was wondering what should I be feeling is this normal, or am I doing too much too soon.

Thanks in advance for any info.

Mitch

[ed34]

Am I getting this straight? You had a mild MI, angioplasty failed because they couldn't penetrate the blockage, and now they say you don't need intervention because you have good collateral flow?  So what in their opinion caused the mild MI is flow is good?
Maybe I'm reading it wrong.

[kenkeith]

I have a totally blocked LAD with collaterals (known for 6 years), and I exercise at my capacity which is 220 minus  age.  You have very good collateral flow if 85% on the distal side of the occlusion.  
Are you sure you had an MI?  With an Mi there is heart muscle damage, and usually an impaired heart wall contraction.  Did you have angina (chest pain due to blocked vessels)?

Quote: "As its only 5 weeks after the MI and failed Angio...",  Did you have a stent at that time on another occluded vessel?  If you did, a stent may have provided enough blood to the damaged heart cells (an MI) and revitalized stunned heart cells.

Depending on your condition you should be able to continue your exercising protocol if your heart rate is within normal limits and no angina.  The only way to be absolutely sure is to have a stress test that monitors your vital signs with exertion.  If you have had an MI, you should get the doctor's approval.

I'm with Ed regarding some confusion regarding an MI.

[Mitch031965]

Hiya

Yeah apparantly I had an MI, the troponin level was at 12... after the thrid bought of indegestion , they did a ultrasound and said the damage was zero to minimal, so I was lucky. They didnlt put any stents in as my Left side was totally clear and the right side totally blocked, and the further CTA and Thalium stress test  showed a long blockage in the RCA (roughly a thrid of the way down), thats why they believe it was slow growing, over many, many years.  Also the lack of any other build ups in any of the arteries made them indicate there was a genetic problem with that section of the artery.

The prefusion scan indicated at 150bpm (85% of my max) the area below the blockage was getting 90% flow from collaterals. The CT angiogram showed them quite clearly.

When I do excersie I'm using my pulse monitor and staying at or below 140bpm, and thats when I get the warm tingly feeling accross my back, I'm not sure if its related to the Statins (Lipator) as I'm 80mg for the first 6 months...

They said the MI was when the blockage finally closed off and basically the difference between the trickle through the restriction and the collateral back flow.

I hope that makes it a bit clearrer ?

Regards

Mitch

[Mitch031965]

Hi Again

Also thought I'd add, I had zero symptoms before my MI, and in fact had done a 12km run in 55mins a few days before, along with a 10km+8km run and a cycle ride to work in the same week... so when I was dragged to ER by my wife with indigestion it was a mega shock to be told I'd had an MI. I've never smoked, always eaten healthy, and done competition cycling and running and leisure surfing, swimming since I was 11yo, right up until the day before...my colestral was 5.3 so not mega high but my BP was 180/110 which my doctor said was slightly high, but now I’ve been told that it should have been medicated.

Personally, I tend to believe that the heart is an evolving organ and the continual exercise I've been doing over the years has force the collaterals to develop, the doc who did the angiogram took great pleasure in showing me my collaterals, all in the same breath as telling me I had a totally occluded RCA !..

Hope that fills in the picture..

Cheers

Mitch

[ed34]

I didn't realise that collaterals developed that quickly. Usually they start to form as the blockage develops and are ready in situ for when the artery completely blocks. In your case, to suffer MI, I have to assume the collaterals were not ready, or the MI would not have occurred. Now they are telling you that as the MI was occuring, the collaterals opened?

[Mitch031965]

Hi Ed

No they said the blockage was slow forming (10+ years), therefore the collaterals had time to develop. I am still totally shocked I had zero symptoms... like I said just after the first indegestion (heartburn) I did a 12km run well under an hour with my heart cruising at around 172bpm... I felt totally normal...

Mitch

[ed34]

I was the same. I filled up three 6yard skips with mud (wheelbarrow job) the day before my MI and I felt really healthy. I felt fine after my first stent for about 6 months, then angina returned. I then had a triple bypass but that lasted just 3 months. I now have received 5 stents to open my LAD but I still get angina. I can't help but think that the bypass surgery did something to my heart because I never suffered shortness of breath until then.

[Mitch031965]

Ok thought I'd post a 3 month update after my MI....

Things are going good, back into doing excerise regularly now, pulse bottomed out at 38bpm resting and struggled to get over 120 doing mild excercise. so they have taken me off the beta-blockers which has made a big difference, my resting pulse is now as it was before around 55, and training over the weekend I was holding 145-155 easy for an hour, power walking no pain or discomfort (I wanted to go harder but had to reign myself back). I even took my sons football trianing yesterday, so feeling pretty good My weight has now dropped 20kgs, and my Cholestral levels are at 2.9 total which is well under what they want, so I've requested a reduced Statin dosage (currently on 80mg Lipator).  The plavix will be stopped in a few months (no stent) and the Ramapril is wroking great with my BP now stabilized at around 125/75

Iv'e been following a strick no fat, high fibre, omega, fruit, veg, nuts, pulses, leumes etc etc diet a few light beers + red wine to keep me saine with the odd chunk of dark chocolate., but all in all been very dedicated and focused. Eating lots of recipes of the heartfoundation website...it's strange but the craving for bad food has completely gone now....my mind is so aware of the consiquence that ive coined a new phrase in my head.."A minute on your lips, causes heart blips"  stupid but its what I now say to myself... !..

The drugs are giving me some expected side affects, back pains from the statins, and some crazy dreams, some intermittent depression, but all in all not to bad.  Only one real issue with the drugs, which is erectile dysfunction, really weird, but apprantly normal... mind you it's been getting better this last few days off the metoprolol... so I suppose time will tell. Onwards and upwards I say...!!!

I'm looking forward to holding my wieght, eating healthy... and thanking my lucky stars !

Mitch

[kenkeith]

Thanks for the update.  You are doing well, but it may take some time to adjust to the medication, if not, consult with your doctor.

[Mitch031965]

ok, went to my first cardio rehab session with the trainer today and was really please with my recovery, we did some bike work first holding 160bpm for 10 mins, then some weights, arms, legs etc, then back on the bike to finish, where we did a bit of a stress test to see if there was a threshold I need to be aware of. After a coupe minutes holding 160 we increased the resistance and cadance and increased my heart rate upto 180, which I held for 3 mins... no pain or symptoms, then backed off and held 175 for another 3 mins....(the highest reading was 182)

As you can imagine I'm pretty pleased with the results and all feels like normal, which is great.... !....

[Mitch031965]

Ok, after over a week off the metoprolol the ED is still not any better... so its back to the doctor this week... Lipitor is going to be cut in half (down to 40mg)... my lipid levels are way low and its freaking me out now, I think something is affecting my memory.... keep forgeting stuff and cant concentrate... been on statins 3 months now and the fear factor is kicking in... what else is it doing to me !.....

[ed34]

It is a known fact that the brain uses a lot of your cholesterol to protect the connections between neuron cells. It basically coats them in fat to make a permanent connection. It has been reported on several occassions by different Doctors that some of their patients have suffered memory loss. Is this rare? who knows, it seems everytime a Doctor tries to raise a problem it gets swept into the background and under the carpet, by who I have no idea. I do know that Lipitor has the least number of side effects reported and your cholesterol would have to be off the scale for over 40mg to be prescribed. I have familial hypercholesterolemia and 40mg does more than enough. If you have no severe muscle pains, then I doubt if the Lipitor is doing anything else to you.

[Mitch031965]

Ok, another week of cronic ED, the doc has halved my Lipator to 40mg...I'm begining to think something has stripped me of all my testosterone.... low libido...pathetic erections and loss of feeling in the penis....what the F has this stuff done to me.....3 months ago when I came out of hospital everything was fine... now 3 months later its mentally ruining my life....its either the plavix, ramipril or Lipator.... they stopped the metoprolol 3 weeks ago, so I'm assuming thats all gone now.... my BP is down the 125/75 in the morning before the BP tablets.... resting HR at 53....so its back to the docs this week...
My excerice levels have still been good did 2 bike rides over the weekend....  1 x 20km ride and 1 x 40km ride....both holding an average of 160bpm... no issues...feeling good... apart from the ED issue...  any ideas, thoughts anyone...

[Mitch031965]

I'm tempted to stop the Lipitor myslef and see if it makes any difference... the ED is reduced the further from taking the Lipitor, what little there is last thing at night before I take the tablet....
... I'm sure my mega low cholesteral and strict diet is wrecking the balance....  it seemed to rapidly get worse with doing excercise....hmmmm  

[ed34]

The problem often overlooked is that Cholesterol is used in all areas of the body. It is seen as a 'killer' but without it we would die, which is why the body makes it. The UK actually raised the recommended cholesterol level of heart disease patients last year in belief that if the level is too low it will cause too much harm.
After three weeks the beta blocker will definitely be out of your system.
Ramipril is very unlikely to give you any problems, this is one reason Doctors love the drug. My Cardiologist said it actually does something to help the kidneys too, but she got a bit over technical explaining that one. Your personal problems, in my opinion anyway, are psychological rather than physical. I have heard after having heart issues, this is not an uncommon thing.

[kenkeith]

QUOTE:" I didn't realise that collaterals developed that quickly. Usually they start to form as the blockage develops and are ready in situ for when the artery completely blocks. In your case, to suffer MI, I have to assume the collaterals were not ready, or the MI would not have occurred. Now they are telling you that as the MI was occuring, the collaterals opened?"

An acute blockage can develop collateral vessel perfusion.

[ed34]

"An acute blockage can develop collateral vessel perfusion."

Thanks I didn't know that. I assumed they always developed to counteract a lack of blood supply once the blockage was over a given percentage. I wonder if collaterals close back down if a stent is used to open a fully blocked vessel. I assume the greater pressure flowing through the opened native vessel would be too much for tiny collaterals to push against?

[kenkeith]

Yes, if I understand what your saying, if a blocked vessel is opened there will be less gradient pressure and blood flow will again flow through the previous, now opened blocked vessel and less blood through the collaterals.  That may be a good reason not to open an occluded vessel that has good collateral blood flow.  Blood will flow through the least resistant channels and that would be the wider diameter of the opened vessel. Collaterals usually have a smaller diameter and more resistance.

You are correct as the occlusion grows the gradient pressure increases, and new channels with less resistant collaterals begin to develop.

[Mitch031965]

Ok, docs agreed today to do a trial 3 week stopping of my Lipator....  My lipids are mega low.... I'm eating a mega healthy diet, doing lots of excercise and my BP is way down...110/68 today aftter doing 60 mins in the gym....resting pulse 50....Doc agrees that maybe the ultra low Cholesteral maybe affecting pathways and nerves, memory issues... so lets see what happens.... if there is no change... I'm gonna go through the other ones... although the plavix will be stopped in jsut over two months anyway as I didn;t have a stent.

[Julie62785]

Hi All!
Sitting here reading these posts regarding Mitch's reaction to lipitor and his problems with memory.  I had exactly the same thing happen to me following placement of two stents in my distal RCA. I had 99% blockage at that time.  The blockage caused heart stunning, which means it took a bit for the heart to function normally again, but my cardiologist put me on mega dose - 80 mg of lipitor even though my cholesterol levels were where they were supposed to be at 10 mg.  (In hospital test showed my LDL at 57 and after MI they want to see LDL level below 70, I didn't say that I previously had two heart attacks about a year prior to that from artery spasms...not blockage).  He told me he prescribed higher dosage because the higher level of lipitor also reduced the inflammation which should prevent a recurrence of blockage...however, I had body pains and HUGE memory issues shortly after starting the high dosage.  Hated it...Also, my LDL level was down to 17 which concerned me because the brain needs some cholesterol to function properly.  When I questioned the low LDL, I was told there is no such thing as LDL too low???  WTH???  Really???  How do they know that?  How many people walk around with LDL of 17?  NONE that I know of...I will be interested to see how you do with reduced dosage.  I am now down to 40 mg because I complained so loudly and so long!  Good luck!  

[oldie]

please clear a point. Your doctor   pointed out your collaterals during the angiogram. Was this a catheter angiogramm or a CT-high tech procedur?. I have long wanted to know how collaterals are SEEN.

[ed34]

I dont think all collaterals are the same thickness, not from what my cardiologist was saying. I had an angiogram last year to see if any were large enough to be forced open using a stent to give a bigger flow, something he has done several times before. Alas, none were good enough, they were so small that only a nuclear scan revealed their obvious existance.

[Mitch031965]

Hi

Yeah the collaterals can be clearly seen on the Angiogram, and in the CT-Angiogram, Iv'e had both done. They are well foremed and one very large feed from the Left side, with multiple feeds of various sizes feeding the distal side of the blockage. The doctor only commented alst week how impressive they were, and Im assuming thy are all ehalty as I'm doing virtually as much excercise as before with no issues... did a 45km bike ride yesterday holding 160bpm...crusining really....(BP now 120/68 at rest...24 hours after tablets, so hopefully they will lower that med too)   Pulse is around 50-52 at rest...

Update on the Lipator... I've been off it now for juat over 4 days... and already I'm feeling better..... the vaugness in my brain and gonads is disspearing slowly... hopefully I'll recover fully.... but i was on 80mg for nearly 3 months... I'm just hoping the stuff hasn;t perminanlty damaged me.... My cardiologist wan;t happy, but with my diet and excerise I took the decesion that 1 x 100% blockage can;t get any worse..!... and no build up anywhere else the risk is lower of plaque peeling off etc....

Well give another update in a week...

Cheers

Mitch

[kenkeith]

QUOTE: "Yeah the collaterals can be clearly seen on the Angiogram, and in the CT-Angiogram, Iv'e had both done. They are well foremed and one very large feed from the Left side, with multiple feeds of various sizes feeding the distal side of the blockage."

It seems collateral vessels (arteriogenesis ) develops with larger vessels due to intravascular gradient pressure, and can be visualized conventionally.

However, angiogenises is the formation of smaller vessels that develop and provide a link between larger vessels.  It is a network of vessels <30 um (limit of resolution for conventional imaging) that requires SR microangioplasty to visualize.  It appears the stimulation of endothelium cells (lining of vessels) and the production of VEGF grows the network of smaller vessels.


Since improvement in collateral-dependent flow typically results from the proliferation of vessels less than 180 μm in diameter [8–10], it is possible that conventional systems of angiography, which cannot visualize arteries <200 μm [11, 12], fail to display the full extent of collateral formation, leading to an underestimation of the angiogenic potential of VEGF. vessels. This improvement in blood flow was documented by intravascular Doppler analysis and magnetic resonance imaging. In some cases,

Arteriogenesis refers to formation of mature collaterals. Its three-layer structure is indistinguishable from a normal coronary artery of the same size. Migration of monocytes, smooth muscle cells and endothelial cells as a result of the increased shear stress induces this transformation. Angiogenesis refers to sprouting of new vessels from preexisting blood vessels and results in the formation of smaller, capillary-like structures. Migration and proliferation of endothelial cells occurs with formation of capillary sprouts.
Recent investigations in animal models indicate the feasibility of using angiogenic growth factors to augment the development of collateral arteries. We [2, 3]and others [4]have shown that the endothelial cell (EC) specific mitogen, vascular endothelial growth factor (VEGF) [5, 6], is a potent agent for augmenting the development of collateral vessels in the lower extremity and in the coronary circulation. This new approach to the treatment of vascular insufficiency has been termed therapeutic angiogenesis