The Specialists will know best as they have all the scans and tests in hand and the knowledge needed to make a decision as drastic as Bypass Surgery. I am sure they are monitoring his condition and it depends on his overall heart function. Bypass surgery, or any open heart surgery, is very risky and drastic intervention, so they only do that when it is absolutely life-threatening.
The heart is wonderful by creating Collaterals, but that will help with some blockages, for a number of years and then, no more and that is normally why sudden cardiac attacks begin. There is medication to prevent further damage to the existing blocked arteries and to dialate the arteries and Lipitor and a heart-healthy diet and moderate excersice will keep the rest of his arteries clean.
All the best,
Unfortunately there is no way to reverse the disease, yet. Yes it is obvious that collateral development has occurred because, and I'm being honest here, he wouldn't still be here. If there are no symptoms until heavy stress, then the collaterals are doing a pretty good job. Now, what can be done. Well, that all depends on the skill level of the cardiologists you are seeing. Personally, if this was my heart then I would do this in 2 stages. First of all, I would make an appointment with the cardiologist and sit with him, looking at the angiogram images of the arteries. It is important to establish which vessel is supplying these vessels and get it as clean as possible. There are 3 main vessels, the right/ left coronary arteries and the circumflex. If 2 are blocked and the one supplying the collaterals is starting to block, then big trouble lies ahead. Once you establish the vessel feeding the collaterals, I would have any disease treated with stents to make sure it's fully open. This will then give plenty of time to look at options with the remaining blockages. There are a handful of hospitals which take on very difficult cases with stenting, but finding them is a task. Nearly all cardiologists quiver in their boots when it comes to stenting high levels of disease. It took me 2 years to find someone to re-open my LAD and it took 5 long stents. I found the best solution was to approach a training/research hospital because this is where all the experts and best equipment are. The man who did my LAD was the person who installed the very first stent in the UK and was the first to use a balloon here. Around 30 cardiologists from different hospitals came to watch the procedure, all the ones who said the task was impossible. My arteries are finally fully open and it has been a long journey.
Thanks for such good news. My husband's LAD and the Posterior Right Descending artery are both 100 per cent blocked. We were told there are two doctors in the US who have the equipment to unblock or attempt to unblock this kind of blockage. I am encouraged by your report/reply. Last summer we hiked and he also did trail maintenance like bending/lifting/cutting down heavy branches but has never had a twinge of discomfort or any other symptom. Fortunately he has been an athlete all of his life and his heart rate is excellent (resting is 51). He notices a lack of stamina. He takes 2000 mg of Niaspan, 20 mg of Lipitor, and Plavix plus a whole host of vitamins - no more then ten fat grams a day, no beef just fish or chix or turkey. The most important thing I am hearing from you is that you have survived living with the blockage to the point that the doctors felt compelled to do bypass surgery and you survived that! The most challenging thing I face is that my husband has steadfastly refused to do anything invasive because his brother died at age 48, his dad at age 62 and his mom mid-seventies from unsuccessful by-pass surgeries. Two years ago after the first PET scan the dr called us en route to the office for labs to let us know he was lining up surgery(angiogram) but my spouse refused anything invasive despite the doctors persuasiveness. At least now, two years later, with nothing changed in the blockages, he is pondering the IDEA of an angiogram at some point. Soooo with two such blockages (100%) of major arteries... he must have a lot of corollary blood flow?
what is the medication to dilate and prevent further damage? Thank you for being so kind to reply! I do so appreciate your message.
I erred. The distal branch of the right coronary artery also called the posterior descending artery is the name of the other 100 per cent blocked site.
Hi, you are always welcome. In fact, I think your Husband has been wise to avoid intervention so far, because in many cases it can make you feel worse. Perhaps if I explain my history briefly, you can learn many things from it. What I experienced is far from uncommon.
In Jan 2007 I was training 5 days a week in martial arts and working 7 days a week in the construction industry, very labour intensive. In Feb 2007 I got what I thought were severe stomach cramps after eating an evening meal. I sweated heavily for about 15-20 mins and it went away. The following day, the same thing happened. On the third day I went as white as a sheet so went to the hospital where it was discovered I was having MI. I was rushed for angioplasty in London where my left circumflex was discovered to be clotted. It was also noted how my LAD was blocked at the top with solid calcified plaque and my RCA was totally blocked half way down. These blockages had existed for years without me knowing. Now, you would assume (logically) that now my circumflex was open again, that I should be as fit as I was before. After all, my arteries were now the same as they were a week before. WRONG, I felt like I was 90 years old at the age of 46. I now know what happened. I had very good collateral feeds from my left circumflex feeding the LAD. My RCA had its own collaterals, going straight around the blockage. When I ate something, the extra demand on the heart was too much for digestion, the blocking left circumflex didn't have enough flow to supply all the collaterals, giving me Ischemia. When the stent was inserted into the Left circumflex, the much larger flow seemed to alter the way my collaterals were configured. It appears that the same collaterals don't always open, you can have many configurations each time they open. The rear/left of my left ventricle was getting a great supply now, but the front, left was poor. I was then told I would benefit greatly from a triple bypass, and this would last me the rest of my life. I of course agreed (stupid me). They grafted an artery from my chest to the LAD (Lima) and took 2 veins from my leg, one for the bottom of the LAD and one for a diagonal vessel. After 3 months, I was suddenly on my knees for 5 mins gasping for air. Then I seemed to recover. The two veins collapsed, and some collaterals opened up. Angina was now back again with any exertion. I went to three top heart hospitals to speak to the experts, gathering possible options. Most said I should go on a transplant list. A top surgeon in the UK said he would be willing to remove the inner layer of the LAD, but I decided against it. Then a Cardiologist in Imperial College London heard of my case and said he would re-open my LAD and stent it. He was so confident too giving a 1% chance of problems during the procedure. He managed to get through the blockage with the catheter but pierced the artery wall, which he stented quickly because it was leaking. He stented the whole vessel, which took 5 of the longest stents. In recovery I did have a strange episode where my heart suddenly went to over 200 bpm, and they knocked me out. I woke up 6 hours later feeling like new. I then had a lot of stress at home and developed a new blockage in the left circumflex, requiring 2 more stents. At the end of last year, I received a letter saying I need more intervention because the left circumflex looked like it had a low flow rate. During the procedure nothing could be seen but they used a flow sensor on the catheter which gives a constant read out of blood flow and pressure at the tip of the catheter. Microscopic irregularities in the artery wall were causing blood flow to slow down, not visible to the eye. 2 stents fixed this and I have felt great again since. So, what have I learned in all my journey? Have the right tests. A nuclear perfusion scan is important because it shows where good levels of oxygen are being received around the heart, something you cannot see in an angiogram. This gives a good clue which vessels require attention and where good collateral feels are present. Most collateral vessels do not show up in an angiogram because they are much too small, like hairs. During any angiogram, insist they use FFR, to know what blood flow is really like in any vessel. This is the sensor on the tip of the catheter, but very rarely used. A vessel may look narrow but could have good flow. It isn''t always the big blockages which cause issues, small ones can be worse.
The most common medication to dilate arteries is GTN spray. However, I avoided this because it gives a sudden drop off in blood pressure, giving nasty headaches. If there are no symptoms when sitting down, or standing still, this is the best way to recover.I used to do my chores then if angina appeared, I would stand still for 2 mins, then carry on.
I have to ask this.....what are his cholesterol numbers? My brothers and I inherited our father's "Familial hypercholestrolemia" (I think that's it) My trigs were over 2100 2 years ago. I take a fenofibrate and a statin that have helped lower my numbers dramatically. I am still unsure about the use of statins and fenofibrate, but I have stented arteries (iliac) in my stomach to my legs, 3 in my heart and now have lost vision in one eye because of plaque in a small vessel to my retina. I have to consider these consequences when making a decision about taking the drugs or not. Which one out weighs the other. Take care, Ally
OHHH. Thank you for sharing this harrowing story, I just received his PET written report and feel a lot more confident that he knows his own body and family's history with invasive procedures: a younger brother died at age 48 and dad at age 62 after bypass. Mom died a few years ago three mos after bypass. They don't have good veins. I am going to post his lab report here:
Good Morning! I had failed to include the second page of the test results. Ron is optimistic that he can keep the heart stabilized. I would be grateful if Bill could tell me he agrees. love and hugs, Cynthia
1.) The Relative PET images a large, severe, septal apical and mid inferior, stress induced defect involving 25 per cent to 35 per cent of the left ventricle in the distribution of the mid LAD and mid Posterior Descending (right) coronary arteries.
2.) Absolute Myocardial perfusion combining CFR and max cc/min/gm show severely reducted flow capacity throughout the hear in addition to the localized stress induced abnormality reported above.
3.) The CT scan done for the attenuation of PET data shows moderate coronary calcification throughout the coronary arteries. These results indicate sever diffuse calcific coronary atherosclerosis in addition to severe stenosis indicated above.
4.) Gated PET perfusion images showed normal left ventricular contraction. The ejection fraction was 61% at stress.
5.) The current study, 5455 on 1/4/2012 compared to the previous study 3111 on 1/14/2010 shows no change, indicating stability of diffuse calcific cornonary atherosclerosis.
6.) Based on the PET scan, coronary arteriography with potentioal revascularization procedures is appropriate due to the size and severity of the rest-stress PET scan abnormalities. Whike I recommended a coronary arteriogram just as after the PET two years ago, in view of the stable images, absence of symptoms and good exercise capacity you elected to continue the medical management with my concurrence
INDICATION: Chronic ischemic heart disease; unspecified (414 90)
Brief History: Patient i a 64 year old asymptomatic male who is seen for routine follow-up PET scan to assess status of CAD. He came for initial screening PET two years ago due to strong family history of CAD and was found to have a large, severe, septal and apical, stress induced defect involving 25 per cent of the apex. He refused cardiac catherization and began strict lifestyle changes and medication. He has been exercising up to 4-5 hours a day until the last six months when he developed knee problems. His diet is excellent and lipids have been well controlled, intitial Lp (a) of 120 reduced to normal.
Description: Myocardial persfusion imaging was carried out by positron emission tomography (PET) with computed tomography (CT) attentuation correction. Imaging was done at rest and during dipryidmole stress (142 mcg/kg/min administered intravenously over four minutes) using N-13 Ammonia (18.4mCi at rest. 1.3 at stress).
Procedure: There were no complications with the procedure. The patient had no angina but had less than 1 mm ST changes on EKG after dipyridamole, had a headache and a sensation of fullness resolving after intraveous Aminophylline.
Baseline blood pressure was 90/53, heart rate was 43. At maxiumum stress, blood pressure was 93/46, heart rate 59, a normal response after dipyridmoklle stress.
Results: Relative Myocardial Perfusion Images: The relative PET images a large, severe, septal, apical and mid inferior stress induced defect involving 25 % to 30 % of the left ventricle in the distribution of the mid Left Anterior Descending and mid Posterior (Right) Coronary artery.
Absolute Coronary Flow Reserve and Mycardial Perfusion (cc/min/gm): Fort he whole heart, absolute mycardial perfusion (cc/min/gm) averaged 0.46 at resting conditioins, 0.96 after dipyridamole stress and coronary flow reserve averaged 2.05 for the whole heart, indicating that cornonary blood flow during stres increases to 205% of the baseline level. Rest flow is low due to low blood pressure and heart rate.
Average maximum absolute perfusion is severely reduced and absolute cornonary flow reserve is moderately reduced diffusely in addition to the localized stress defect above,. In the septal-apical-inferior region of the stress induced defect, the coronary flow reserve is 1.25 indicating severely reduced capacity for increased coronary blood flow to only 125% of baseline levels.
Coronary Flow Map with Plot of CFR and MAX cc/min/gm
Low flow thresholds of 0.9 cc/min/gm and CFR of 1.7 identify patients with myocardial ischemia. Reduced but adequate flow capacity with no ischemia may be due to adequate CFR associated with low rest flow despite limited max stress flow in cc/min/gm, as commonly seen with beta blockers.
Therefore, quantifying severity of coronary artery disease requires integrated analysis of both CFR and maximal stress cc/min/gm show the floolowing as percent of the left ventricle:
9% No ischemia, minimally reduced flow capacity
44% No ischemia. Mildly reduced flow capacity
15% Moderately reduced flow capacity
32% Severely reduced flow capacity
1.) The CT scan done for attentuation of PET data shows moderate coronary calcificatioin throughout the coronary arteries.
2.) These results indicate severe diffuse calcific coronary atherosclerosis in addition to severe stenosis indicated abov.
3.) Gated PET perfusion images showed normal left ventricula contraction. The ejection fraction was 61% at stress.
Comparison to Prior Study: The current study, 5455 on 1/4/2-12 compared to the previous study 3111 on 1/14/2010 shows no change when considering using N-13 ammonia now compared to RB-82 two years ago. This result indicates stability of severe calcific coronary atherosclerosis.
Diagnoses: Chronic ischemic heart disease: unspecified (414.9)
Chronic ischemic heart disease: unspecified (414.90)
Special Comments: Based on the PET scan, coronary arteriography with potential revascularization procedures is appropriate due to the size and/or severity of the rest-stress PET scan abnormalities. While I recommended a coronary arteriogram as after the PET two years ago, in view of stable images, absence of symptoms and good exercise capapcity, you elected to continue medical management, with my concurrence.
Recommendations: Risk factors for progressive coronary atherosclerosis are well controlled with lipid profile on July 1, 2-11 showing total cholesterol at 121 mg/dl, triglycerides 40, LDL 50 and HD 63 while on Lipitor 20 mg once a day and Niaspan 2000 mg before bed.
Continue the current low fat diet (10-20 mg fat day), low carbohydrate, high protein food with at least 80 gm protein from non-fat dairy products, veggie burgers, egg white omelets, protein supplements, fish, beans, chicken, or urkey breast meat, extra lean pork and soy protein products.
Exercise 4 to 5 days per week by fast walking 30 to 45 minutes per day and or other activity including repititive weight lifting, stationary bicycling as knee injury permit.
oops i failed to edit comments from an email I sent to a cousin who is a cardiologist!
His cholesterol panel was good; he was lean (an athlete all of his life) but the PET scan in 2010 was a shocker so the dr ordered a test from Berkley Labs, cardiologists do not often request, called LP(a) . The high on this test should be 30. My spouse's score was 120. It is a genetic component that affects 3 percent of the male population causing the LDL to potentiate and it does not show up in regular cholesterol tests. The remedy is megadoses of Niaspan. He takes 2000 mg Niaspan per day. Regular Niacin over the counter is not the answer. I posted his entire PET lab report including the July cholesterol test regular panel. The LP(a) score was still high in July at 35. We are waiting for the test results from Berkley taken ten days ago.
I think I answered this question above! If not, look at other comments. I had intended to reply to you with the lab results. 2100 is shockingly high.
Read Caldwell Esselstyn's book "Heart Attack Proof" and go 100% vegan. No animal or dairy products and not oil.
dr caldwell esselstyn says this:
Total cholesterol <150
If you can do that, your triglycerides will be OK. Same for HDL.
All the other vegan diet proponents say <150 too for total cholesterol.
so that's what i am hoping alan and i can achieve. less than 150 for total cholesterol
you are in the same zone and won't die from cardia problems. More than 150 you could be
at risk for vulnerable plaque. That is the deadly plaque that ruptures without
warning - causing sudden heart attack.