artski

[artski]

i am a 59 yr old male that works out 6 days a week and has no symptoms but had both parents die of heart disease (one heart attack one stroke by the age of 60).  my ecg is considered "different" and combined with family history went through a series of tests (nuclear stress test, regular stress test both normal) but angiogram showed 90% long blockage in the LAD which cannot be stented and 70% blockage in 2 other arteries.

i have differing opinions from cardiologists as to whether to have a triple bypass or medical therapy with reduced exercise intensity because i have no symptoms.

i really don't want to have to alter my lifestyle or live with the fear of an attack at any time but the thought of a bypass is scaring considering i have no symptoms now and son't want to feel worse later.

[artski]

thanks to both of you.  will let you know how it goes

[skydnsr]

Yay.

[ed34]

If you need to ask any question about bypass, please feel free, many of us here have been through it.

[ed34]

that's good news, it is very likely this bypass will last a very long time, likely the rest of your natural life.

[artski]

surgeon confirmed they will use the mammary artery for the LAD for exactly the reasons you noted

[ed34]

I had a triple bypass and the two veins closed after just 3 months, the lima is still fully open. I was told veins are not as robust as arteries and do not last as long. They can use radial arteries from arms, but apparently they are very prone to spasm.

[skydnsr]

I also have heard that the artery lasts longer as the bypass vessel than a vein does.  If you don't get a satisfactory answer to that question, I believe that is one situation in which, yes, I would seriously consider postponing the surgery for a second opinion on the whole thing.

[ed34]

Make sure they use your Left Internal Mammary Artery (Lima) from your chest as a graft to your LAD if this vessel is clean. Being an artery, as opposed to using veins, it will last a heck of a lot longer and give better results. You want this surgery to last and I'm sure you don't want to go for another bypass in 10 years.

[skydnsr]

But wait, you've already scheduled surgery, so I don't want to throw a monkey wrench into your plans by suggesting a second opinion.  If you're good to go, then great.  Good luck, and let us hear from you when you're able.

[skydnsr]

A bypass operation is scary, but what happened to your parents is scary, too.  Assuming your doctors are interpreting all the tests correctly, a bypass operation seems like it might be the only play you have with the cards you were dealt.  It never hurts to get a second opinion, just to make sure that another cardiologist (or team) sees your test results the same way.  You would not have to do all the tests over again, just provide the records for review.  If the second opinion is the same as the first one, you have more peace of mind about your choice.

[artski]

those (the odd EKG and the bad family history) were exactly what got the family physicians attention.  with the silent ischema factor i have decided to have the bypass, sceduled for the middle of March.  it was the "defective warning system" comment that finally made the difference.  until that information i could never rationalize in my mind how i could work out so oftern and to such an intensity, have no symptoms but be that seriously blocked.  now it starts to make sense and i really don't want to go the rest of my life wondering if every time i work out it was going to cause an attack without any warning.

[skydnsr]

There was an abnormal EKG, plus a very dramatic family history.  I think those two things are what initially got the doctors' attention.

[ed34]

I do agree, however, no with the stenting to the LAD if possible. I had my LAD completely stented, with 5 long stents and was very lucky it resolved the problem. When such extensive stenting is done, it is very unlikely that the vessel will remain open with no stenosis. I think it far better that the LIMA is used on the LAD. If I was a cardiologist with a patient like this, my decision would be clear cut. I can't understand why an angiogram was ever performed, or a nuclear scan, if there were no symptoms? I wouldn't even get a referral to a cardiologist unless a Doctor felt sure I had a heart problem.

[ed34]

oh ok, sorry, I didn't know you had a nuclear test. From the new information, you do have collaterals which I suspected, but these are not developed sufficiently to give enough oxygen when the heart is under load. There is a new problem now. Your collaterals are getting their feed of blood from either the Left Circumflex or the Right artery. You say that the Angiogram reveals 2 blockages of 70% in other arteries, but you don't say which ones. If one of those arteries is supplying the collaterals, you will need to keep an eye on that. If you get silent ischemia, then you have no early warning system, which is difficult. I think personally, if this were me, and taking into account the reliance on collaterals which could be coming from a vessel with a 70% blockage, I would opt for bypass to the LAD using the LIMA vessel in the chest if possible. This vessel, if not diseased, will last you many years, likely the rest of your natural life. The other 70% blockages could be left, but if I have silent ischemia, I would want them stented if possible. They could be left, but how would you know if those blockage are getting worse.
In a nutshell, you could leave everything alone and stay on meds. However, if the 90% blockage gets worse, even to 100%, you won't know and your cardiac muscle could become damaged.

[artski]

i had the nuclear stress test which only showed a concern when my heart rate got between 130 and 140.  i also had the angiogram which showed very small collaterals and that the blockage in the LAD was a long one and therefore unable to be stented.

[skydnsr]

There is something called silent ischemia, in which the blood flow is interrupted, but the patient does not experience pain.  I googled "defective warning system" and only saw references to that term from the 1980's, but there are recent references to silent ischemia, and the two terms seem to be referring to the same thing.  So I think the question is whether artski's doctors have truly established that he has silent ischemia.  The key test would seem to be, as ed34 notes, a nuclear stress test.  So, artski, if you have already had a nuclear stress test, then maybe you will want to get a second opinion on the interpretation.  If the interpretation that you have a defective warning system or, in other words, silent ischemia is correct, then you might want to get a second opinion as to whether the blockages can or can't be stented.  If you're having silent ischemia, and the blockages can't be stented, then it seems to me you're back to square one with the recommendations that you've already been given.  Ed34, do you agree?  

[ed34]

I am not a Cardiologist, but I can't understand what they are saying here at all? In your situation the next step is very obvious, even to me. Rather than open you up and perform what could be unnecessary open heart surgery, they should give you a nuclear stress test. This scan involves injecting you with a substance which goes around your blood, with the red cells carrying oxygen. As cells use Oxygen, they absorb the contrast, which is shown on the scan. The brighter the image, the more the Oxygen they are using. The first scan is done with your heart at rest. The second is done with your heart under stress and the 2 scans are matched. IF the first scan shows a bright area somewhere on your heart, whereas the second one is not any brighter, then this suggests there is a blockage because the second should be brighter. If your second scan shows as brighter everywhere, then you don't need surgery. This non invasive test is standard when a diagnosis is inconclusive such as a patient not having symptoms. Angina comes in many forms, and one is shortness of breath, probably the most common. I very much doubt if your LAD is that blocked that you wouldn't feel short of breath unless you have developed natural bypasses. I should also mention that natural bypasses vary in size. Some are quite large, while others are too small to see on an angiogram. I had many tiny ones which were detected using a nuclear scan. I congratulate you on digging deeper, and if in your shoes I would be very careful here. I'm not saying I am the average case, but I had a triple bypass at the age of 47, the worst decision I ever made. It only lasted me 3 months. The whole thing shut down before I had even recovered.

[artski]

thanks for the information.  i recently got further information with regards to the reason i have no symptoms and have been told that some individuals may have a "defective warning system" wherein  instead of developing angina as a warning the body never shows any symptoms.  i have received many professional opinions all of which agree the need for surgery vs medical therapy is not a black and white decision but that the surgery route is the more likely bet for a future lifestyle that is active with less concern of a heart attack.

[ed34]

thank you, it means a lot :)

[skydnsr]

Good post.  Wish we could "like" on here.

[skydnsr]

The only other thing I can think of is that, if heavy drinking or illegal drug use are at issue, those are like smoking.  There's really no way to argue that they aren't harmful for someone who's 59 and has coronary artery disease.  Again, I hope you find a way to resolve whatever decisons you have to make.  Best wishes for a healthy future.  Post again, if you feel so moved.

[skydnsr]

Because you do work out, you might have some good collateral circulation that is keeping you from having symptoms.  If so, maybe that will give you a cushion of time to figure out more about what you want to do.  If you smoke, there's really no way to argue that that's not harmful.  Regarding diet, some of the newer research that is coming out does not condemn fat but rather sugar.  

[skydnsr]

Forgive me, you did say that you already work out six days per week, so let me acknowledge that your risk factors don't seem to include a lack of exercise.  Congrats on staying fit.  Whatever else it is that you need to do, I hope you find a way.