appropriate treatment and prognosis

[indtube]

I am a 45 yr old male, 5ft 6 inches tall, 148 pounds, smoker for 25 years now quit after MI on 8/5/2010 most likely due to going off plavix .Family history of cardiac disease, father died at age 36 from stroke related to high blood pressure. My  history before MI I received 6 stents due to blockage of 80% in 2 arteries, LAD i believe, in 2006.These were what is called kissing stents since they were placed back to back on both sides of the "widow maker".I was on asprin 325 mg, toporol xl 25mg 1 tab daily, lipitor 40mg 1 tab daily, lisinopril 10mg daily, plavix 75mg 1 tab daily.VAP scores were 110 total 60 LDL and 40HDL.
MI occurred while surfing, 1 hour till intervention in ER, Cardiologist did not put any new stents in but did ballon on 2 areas that had formed the thrombosis, he also removed another thrombosis. Ejection fraction was estimated in hospital at 50. was placed on lisinopril 10mg, effient 10 mg, lipitor 40 mg, toporol 25mg, niaspan 1000, asprin 325mg.  Starting 9/7/2010 went through 2 months of cardiac rehab cardiologist took me off lisinopril and did not replace it, at rehab I  buildt up to 7.7 METS for 62 minutes a day, with avg heart rate at 130. 10/15/2010 Taken off effient and back on plavix due to severe bruising over 80% of my body, I looked like a blue berry. After completing rehab I had a nuclear stress test that showed a 30 ejection fraction. Cardiologist discontinued toporol and placed me on coreg 3.125 mg twice daily. Since I felt great I thought reading on ejection fraction had to be wrong, went for second opinion at Mayo Clinic, did cardiac mri, showed major damage to heart muscle on left and bottom of heart that was through entire depth of muscle, right and top of heart seemed to be unaffected.Estimated ejection fraction was 25. Now am scheduled for ICD implant, and aggressive coreg/lisinopril combo with previous meds. scared to death any opinion on prognosis & treatment?

[CCF HeartMD-1]

Well, sounds like you have had a rough 6 months! Sorry to hear that.  I would tell you that a cardiac MRI is very precise in terms of EF so I would believe the 25%.  I would also agree with Mayo Clinic's opinion of an ICD and definitely getting back on lisinopril in combination with coreg.  Toprol would also be fine but if you are doing alright on Coreg I would just stick with this combination.  Just so you know, on the maximal amount of Coreg and Lisinopril that your heart rate and blood pressure can handle, the heart muscle can get stronger and we can see the EF improve!!!  I think you may have 15 years left to your heart but you need to be very careful and take all of your medications (never stop plavix again with all of the stents you have) as prescribed and continue exercising at least 30 min 3-4x per week.  You also should now be followed closely by a Cardiologist every 6 months or so.  

Hope this helps.  Good Luck!!

[CCF HeartMD-1]

We usually use EECP for uncontrolled angina which is not controlled with medications well.  It will do nothing for your heart failure but definitely can help angina.  It is safe and does not come with any risks, so if you are on good anti-anginal medications such as beta-blockers (I know you are on Coreg) and nitrates and/or ranexa and you are still having angina then I would recommend EECP if we could not fix anything with another stent.  

[CCF HeartMD-1]

I doubt your heart has gotten worse recently.  It may be over the years when you have had all the stents placed that you have had small, silent MI's and maybe recently although you got in within an hour you had a larger MI.  Some people who have a lowish EF like yours actually are asymptomatic.  I have one patient who has an EF of 15% and feels great walking 3-4 miles multiple times a week.  The fact that you feel great and are able to surf for hours at a time is a very good sign.  We start talking about heart transplant when patients are very symptomatic from heart failure requiring multiple hospital admissions and medicines cannot control their heart failure anymore.  You sound to be nowhere near that point!!!  

[CCF HeartMD-1]

Unfortunately, besides niaspan, statins and fish oil, we do not have any other agents to raise HDL.  You are on the maximum dose of niaspan also which is great! There are a few new agents which are being studied but likely won't be on the market for awhile.  Make sure you are exercising 30-45 minutes 3-4x per week if possible because exercise helps raise HDL also.  You will have to see if any of the stem cell trials whether you would qualify but it is worth looking into.  We have one here at the Cleveland Clinic too!! I think it would be worth seeing if you would qualify!!

[CCF HeartMD-1]

As your blood pressure goes down, your heart is actually most likely pumping better (seems counterintuitive) therefore the heart rate comes up slightly which is why we again would want to go up on the Coreg.  I think your Cardiologist is doing a good job.  Maximal doses of Coreg and Lisinopril are 25mg bid and 40mg qd respectively and if your blood pressure tolerates it I would keep going up on both (20mg of Lisinopril would be ok too). I think you are on good medications for now.  However if you are still having some angina you are on no anti-anginal meds such as Imdur, Isordil or Ranexa (we usually start with Imdur or Isordil which are long-acting nitroglycerin pills), therefore you should use meds prior to EECP therapy.  

[CCF HeartMD-1]

Hey there,

I actually agree with your thoughts.  In November it appears that you definitely had viable myocardioum with the stress test showing normal perfusion at rest (which means the myocardium was most likely alive then) and then with stress the perfusion to the inferior and lateral walls decreases suggesting blockages causing ischemia.  

However, what makes it difficult now is that your most recent MRI in January (2 months after the stress test) is now showing that the inferior and lateral walls have scar and are most likely not viable.  We can tell with MRI if the walls are viable are not.  Here at the Cleveland Clinic we also use PET scans to look for viability but an MRI usually tells us the same thing.  If we cath you again and you have blockages in the area of the lateral and inferior walls of the heart and we put stents in both places, but the tissue is dead or non-viable, these stents will not help you at all.  Does that make sense?  The question is whether we believe the MRI or not?  If you are concerned, you could get a Cardiac PET using FDG (sugar) which if the ares are viable the myocardium will be using FDG and we can see those areas light up on PET.  That would then reassure you and everyone else that the myocardium is definitely dead.  If it is viable, the EF will improve with stenting most likely because of the restoration of blood flow.  

Hope this helps.

[indtube]

I was researching my information since my heart attack on 8/7/2010. Upon release from the hospital an echo stated my ejection fraction was 50%.Meds 325 asprin, lisinopril 10mg daily, lipitor 40 mg, metorolol 25mg daily, Plavix 75 mg daily zetia 5mg daily.
Then  I began cardiac rehab for 6 weeks and was working out at 60 minutes a day at achieving a MET level of 7.5
On 11/3/2010 had a nuclear stress test that stated my ejection fraction was 36%. It also stated "there were no abnormal ST segment changes in response to exercise. The EKG was abnormal at baseline , therefor, no interpretation can be made." INTERPRETATION: Stress tmographic images of the left ventricle revealed inferior and lateral wall defects seen of moderate size. The resting tomographic images revealed normal perfusion. Gated images revealed abnormal systolic thickening in the inferior and lateral walls. The ejection fraction is calculated to be 36%.
CONCLUSIONS: A) No anginal symptoms in response to exercise and with evidence of ischemia.
B) The isotope study revealed evidence of ischemia in the inferior and lateral wall of large size.
C) Left ventricular ejection fraction is 36%.
Clinical correlation is required. Recommend medical therepy with continued observation. This is likely representing stunned myocardium. Cardiologist had me stop all excersize at that time. same meds as above but took me off lisinopril.
Went to Mayo Clinic for second opinion and they did cardiac MRI.
Cardiac MRI on 1/31/2011. this indicated ejection fraction of 25%, large area of damage, ie scar tissue on left side and bottom of heart. now on the 25mg coreg, 30mg lisinopril, 325 asprin, 75 plavix, 40 lipitor and 5 zetia. Supplements are 100 mg co-q10 bid, 2500 fish oil bid, HDL RX 2 tabs BID, vitamin E 400mg daily,
My question is why does it seem my ejection fraction is getting worse since heart attack on 8/7/2010?  This progression is getting me worried that there is a blockage in artery to heart thus damage to the heart muscle  is continuing. Would these tests and numbers indicate a cardiac cath is in order now to dtermine if there is blockage affecting the heart muscle? As a layman I am looking at this saying how will the muscle improve or ejection fraction improve if a blockage is still present. Cardiologist doesnt feel cardiac cath is needed right away, he said we could do it, find blockage and stent it just to provide the blood flow to dead tissue which will not help it. I worry that some of the muscle is still viable and that the possible lack of blood flow will ensure it does not comeback. Any ideas on this would be greatly appreciated. Thank you.

[indtube]

Thanks,Your responses have been very valuable to me !
I think I have finally found a good cardiologist.
Got through the ICD implant, one lead. Blood work and BP fine on coreg 12.5 Bid and Lisinopril 10mg QD. Today upped Lisinopril to 20mg QD. Kept Coreg same for this week. Will do labs again next week and if ok up Coreg again. BP 118/75. Heart rate 78.
Cardiologist believes my root problem is low HDL, any insight into raising it beyond niaspan(i take 2000mg) also looking at stem cell therapys like vescell and regenocyte. Any opinions on this type of treatment for the heart?
Thanks again for all your help!

[indtube]

Having a guidant icd implanted tomorrow. I think over time I will come to view it as the medical community does, my personal safetynet. Now on 7.25mg coreg BID, 10 mg lisinopril QD, lipitor 40mg QD, zetia 5mg QD, Plavix 75mg QD, asprin 325mg QD, Pristique 50mg QD, 100mg co-q10 BID, fish oil 2500mg BID, Niaspan 2000 mg QD bedtime after asprin. HDL RX 2 tabs Bid.  Cardilogist wants to gradually bring up coreg to 25mg BID and lisinopril 20mg QD. Cholesterol numbers are 110 total, 44 HDL and 58 LDL, Triglycerides are 86. As we increase will have weekly blood test for creatinine and potassium levels, also doing BP daily and recording. I have noticed as BP gets lower the heart rate increases. Is this normal with this med therapy and is this part of the remodeling? Does this look in line with current accepted treatment of major MI 6 months ago and current Ejection fraction of 25 ?

[indtube]

Have you heard of eecp therapy? my local cardiologist is recommending it to me to help possibly increase ejection fraction and keep symptoms such as angina  at bay. Not sure if this is safe.
thanks

[indtube]

Thank you for the response. Yes I will never go off the plavix again and am slowly moving up on the coreg and lisinopril. doing blood work each week to monitor and blood pressure once daily. I understand the ICD to be a safety device due to the higher occurrence of rapid heartbeat and sudden death when ejection fraction goes below 35. will have it implanted next week.  What confuses me is that I was able to kick butt in the cardiac rehab and felt great. On appearence one would never believe I have heart disease. just a month ago I was out surfing 8-10 waves getting the heart rate up to 155 for short periods over 3 hours. Could the heart have gotten worse since then?
At what point does one become a candidate for heart transplant? MRI shows 50% of heart seems to be dead muscle.

[indtube]

further I am one who shows no symptoms, I feel fine, no angina, blood pressure 120/80, has always been this number except when on lisinopril brings it down to 110/70. need 15 more years out of this ticker.