What options does my little sister have with 90% LAD?

[SisterKatrina]

My little sister is 25 years old. A little over a year ago she had identical twin girls. Shortly after that started having severe chest pains, but often ignored it. Finally when it became unbearable she was taken to the ER who referred her to a cardiologist who continues to run tests but is very vague with her, her husband and with our parents. Here's a snippet of her report which we are all trying to comprehend:  Occlusion of the mid-distal LAD beyond the dominant branch which itself has an ostial 90% stenosis. The RCA also showed low shaft high-grade disease with diffuse and focal stenosis up to 80%. Cause: giving birth to twins. Not felt to be good candidate for bypass or angioplasty with or without stent placement. Can someone PLEASE PLEASE explain this to me so that I can explain to my baby sister and our parents. Her doctor seems cold and heartless (no pun intended). All we want is a clear answer to what going on. Thank you!!!!

[achillea]

You are talking about a very young woman with dependant children and a serious heart condition.  Under HIPPA  (privacy) regulations, doctors cannot give information to anyone but her or perhaps her legal spouse, but the circumstances of this case seem to demand more information, at least regarding provision for the young twins.

If you cannot get at least a polite explanation from your sister's doctor, I suggest buying an hour with a good medical malpractice attorney.

[SisterKatrina]

Yes, I do understand the HIPPA regulations. Thank you so much for your response. I just didn't know what else to do or who to turn to so I started my own research. She and her husband are very young and I don't think they are asking the right questions and are not very assertive so I stepped in to try and help.  She seems so healthy and vibrant. Looking at her you'd never know she has a heart condition. In May she is registered to run a 5k in Santa Barbara. I REALLY think she should cancel it.

[Ger57]

Stenosis of the coronary arteries that shows up during or short after pregnancy is a very unusual event, but it sometimes happens.

It normally is treated with bypass or angioplasty or, in less severe cases, with medication only.
The 90% occlusions are normally too serious to be treated with medication alone and are best solved by bypass or stenting, whereas the 80% might be treated with medication only.

Did they give a reason why she is no candidate for angioplasty (or bypass)?.

[SisterKatrina]

Her condition was referred to as SCAD. When she was hospitalized the doctor said it happens 1/100,000 pregnancies. He also said "Given the anatomy the patient was not felt to be a good candidate for coronary interventional therapy." My thoughts were is he says this because her insurance isn't very good or what, because honestly we (the family have to take out a loan or put a second mortgage out on our homes to save her live we would.

[Ger57]

I am glad to read that they considered stenting and CABG and that at least the CABG option is still open.

What a lovely thought of you going to run in her place! You still have a couple of weeks in preparation to the run. You will do just fine, just as I expect and hope that your sister will through these rough times for your family.

God bless.

[achillea]

Good for you!  I hope your sister's health improves.

[SisterKatrina]

Hi Anchillea,

Thank you for the additional information and the link. You are appreciated!!!  

[SisterKatrina]

HI Ger57,
Thank you for your feedback and response. I really appreciate your thoughts on this subject. Yes, it could be fear because I agree, it seems many cardiologists are reluctant to try surgery because it could be complicated/challenging and they possibly don't have not much experience with this particular heart condition. You all have encouraged me to ask more questions and empower my little sister to ask more questions. Initially, it felt a little intimidating to question the doctor because "he the doctor" but still at this point WE'RE ASKING. :-)

[SisterKatrina]

Thank you for your response and feedback. It is appreciated. Yes, an angiogram was done. The good news is we are traveling to San Francisco tomorrow and we will have a list of questions with us :-)
Presently here is a list a medications she takes.
Adult Aspirin EC Low Strength 81 MG
Atorvastatin Calcium 10 MG
Clopidogrel Bisulfate 75 MG
Lisinopril 5 MG
Metoprolol Tartrate 25 MG
Nitroglycerin .4 MG

[tacolino]

Hi there. Im not a doctor but will try help. Its good that your sister has you to help. Direct questions need to be asked and direct answers got back from the doctor. Make a list of questions and go see the Cardiologist with your sister. Ask the right questions with her by your side. The doctor will deal with you once the patient consents that its ok and that they are present. Its a bit odd that a query regarding Health Insurance should be deciding the route of her treatment? Its a bit strange that the 90% is not having some form of intervention? If you have to , dont hesitate to get a second opinion from another Cardiologist. I am not at all familiar with SCAD. but I would be very cautious regarding the run your sister is considering.I would think its not appropriate in the circumstances you describe. As a matter of interest, what meds have been prescribed for the condition so far? Exactly what tests did they perform? I presume an Angio was done , given the results you report above? Does she suffer with high BP, if so what are her numbers like? Lets know

[achillea]

Here is more information about this condition:

http://www.heart.org/HEARTORG/Conditions/HeartAttack/AboutHeartAttacks/Spontaneous-Coronary-Artery-Dissection-Not-Just-a-Heart-Attack_UCM_454434_Article.jsp#.Vvrqb_BHarU

It does seem that when this happens to young women soon after giving birth, they do not do so well with surgical intervention.  Conservative management with medication appears safer.

About your sister's 5K run in May, since one of the aims of medical treatment of SCAD is to keep blood pressure down, this is *definitely* a subject she should discuss seriously with her cardiologist.  

I am not familiar with SCAD myself, but if I were interested in preventing further tears in the wall of a coronary artery--and continuing to live--I would take my cardiologist's advice very much to heart, so to speak.

[SisterKatrina]

Thank you for your feedback. Yes, the doctor also recommended that she not run. So I will be running in her place while she cheers me on.

[Ger57]

What does the cardiologist propose then? What does he suggest when both CABG and angioplasty are nogo areas for him?

I would seriusly consider to go for a second opinion from a cardiologist who is an expert in angioplasty.
Placing a stent in a ostial position is something that many cardiologists are reluctant to do because it is more complicated/challenging. Many have not much experience with it and fear complications.

[SisterKatrina]

I have mixed feelings about the appointment with the cardiologist in San Francisco. I think we are still processing all the information. Don’t get me wrong, the doctor was kind, informative, honest and frank and it was all very helpful and appreciated. Maybe I was looking to hear him say there was a cure or procedure that could be done that would put an end to my sister’s pain so she could live a normal life with her husband and little girls.  Basically, his second option confirmed her doctor’s initial findings, but he went into MUCH more detail and was much more pleasant with the family. He offered information about another medication that we have not tried or heard of so this was good news. It brought us comfort when he said he is presently treating a half dozen patients who have experienced SCAD but then that comfort was quickly taken away when he also said he’s never seen such a severe case in a 26 year only woman. Then we felt hopeful when he also said stenting is a viable option for most patients but in Diana’s case the arteries are too thin and another tear could form making her condition worse. Lastly, he mentioned a heart transplant which has a long list of people “on their deathbed” who will have priority.  It felt like an emotional roller-coaster.  Ultimately, we are glad we took the trip and have more information to explore.  We are going to consult with a surgeon regarding bi-pass surgery and see if she has “good landings” (according to the cardiologist in San Francisco).  Please keep us in your prayers and if you have any feedback please feel free to express them.
Blessings to you!!
She was planning to run 5k in Santa Barbara. She not going to run anymore but we are making this a sisters trip and I am going to run now while she cheers from the sideline. It will still be an amazing trip. …as long as I can make it across the finish line, because I am not in shape, lol.