Avatar universal

to stent or not to stent?

Thank you for taking my post. I hope your holidays were good.I won't repeat all of my history from last posts. I had an angiogram a month ago. 60% blockage LAD just above original stent(mid-LAD). It was undecided as to whether or not blockage was causing my symptoms because they are not always exercise related(often more anger/stress related).

Doc called a few days ago(after I called to cancel follow up appt.). He has changed his mind about fixing blockage. Given that my PET scan in Dec. showed ischemia to the septal? part of my heart and my MI last June, he reviewed my films with 2 interventionalists(?) who said blockage was 75-80%  and they suggested another stent (a medicated one?).
I can live with the symptoms and would really rather not have another stent unless necessary, but do not want to risk damage to my heart or another heart attack. Choking feeling/pressure etc are no better, but no worse. They are concerned about my history and being an "unusual" case.

what are the risks of leaving blockage?(no risk factors 39 yr female). If most MIs occur in smaller blockages, why are they so concerned? I was told my MI (90% block) was unusual, would it not be unlikely to happen again?
what are pros and cons of fixing as opposed to leaving it?
what is the septal(?) part?
a 6mm lesion sounds small to me?
How can opinions change after reviewing the films(he had already reviewed them briefly with a doc while I was still on the table)and decided then not to fix blockage?
I'm confused now.
what would you recommend if I were your patient?
Thanks very much.
7 Responses
239757 tn?1213809582

There is not a right answer if your symptoms are not coming from your blockage on whether you should have an angioplasy/stent.  That said, if you are having symptoms and you have ischemia on your stress then an intervention may help.

There is also not a right answer as to whether a stent will make a significant difference in the long term from a mortality standpoint. That said, I think revascularization is better if you truly have ischemia, that way there is not a chance when pushing your exercise to your upper limits.

Im not sure of the terminology you are using for your lesion, the significance really is in the stenosis percent, as it is generally believe that lesions over 70% can predispose you to ischemia. If you have a lesion in the territory suggested by the stress, then it would be reasonable to fix it.

It is common for people to differ in their interpretation of lesions. Some people are more conservative some more aggressive. What may be reasonable is for you to decide. You could try to maximize medical therapy and see if that makes a difference. But if you still are having persistant symptoms, I would recommend revascularization.

I cant make specific recommendations without revieing your films. One option would be to try to get another opinion, or use the Cleveland Clinic E Second opinion service to review your data.

good luck
Avatar universal
Go to a center where they do many of these and see a specialist.
Avatar universal
Hi Dotty
Thanks for the advice. However, this is one of the largest Heart Institutes in Canada and they are specialists.  I guess because some of my symptoms are atypical, and my age and lack of risk factors are uncommon, they are as confused as I am.

I have been seen by one cardilogist after another (7 in total) because each one wants to get another opinion. Before they found the 2nd blockage, some docs hinted that it may be anxiety causing my symptoms (GI problems have been ruled out). I was open to their suggestion, however, in my gut I felt that something was wrong. While a couple of them felt that even though some of the symptoms were not typical for angina, I should have an angiogram to find out (I was the one holding off on the angiogram).  

I finally agreed to the angiogram in Dec and they found a 60% blockage. The doc said he reviewed the films with someone else briefly, but at this point he did not feel the blockage was significant enough to warrant fixing.  He also said the films would be reviewed in the near future by other specialists. From what I understand, 2 other doctors reviewed the information and films this week and suggested to the doc that did my angiogram that the blockage looked bigger (75-80%)than what he thought it was and that it should be fixed.

What seems to be throwing them the most is the fact that my symptoms can and do occur at rest and exercise, but they are not consistant. 15 minutes on the treadmill may cause chest discomfort one day, but the next day 30 minutes may not cause any.  The strange thing is that that's the way it was the day before my heart attack.  My chest felt full and I had a lot of pressure and a choking feeling. I went to a wedding reception that night and danced. The dancing did not seem to have an effect on my discomfort one way or another.
I guess I'm getting frustrated, discouraged and feeling a bit like a hypochondriac.  I just want my life back and to put this behind me. Hopefully they figure out what is going on and I can get back to my normal routine.
Thanks again for your advice.
Avatar universal
the problem with seeing N doctors is that you'll get N+1 opinions...and then You have to Choose...it's nce if the data/opinions converge but that is not always the case; remember that the studies that underly the treatment regimes are statisitical studies of large poplulations but docs have to diagnose and treat Individuals with all their uniqueness;

so one hopes to get very skilled and experienced diagnosticians, clinicians and surgeons who can put their experience and judgements into the mix;

your MI at age 39 and female gender is 'premature' and therefor unusual absent any other risk factors, illicit drug use, etc ;

any family history of premature CAD ? CCF recently issued a report of a family of 13 with a very high rate of CAD and the results of their genetic scan is that they found a (first ever) 100 % incidence of a gene and IIRC heart attack;  

w.r.t. a 'change of opinion' after furthur review of films, well the measurment of % of blockage is often pretty much an 'eyeball' thing certainly while on the table in the cath lab...the CCF doc can be more explicit about how they 'measure' these things and you could ask your docs...IIRC they measure the reduction in size of flow in the image of the tracer dye and don't see the plaque per se,  or artery wall thickness etc...and of course they don't know what you looked like before the MI..;

the location and nature (focal: very localized to a pont , or 'diffuse': more spread out) of a 'blockage' can be an (very) important factor as well;

'septal' means the area between the two ventricles at the bottom half of the heart;

some people develope 'collateral' arteries that function like 'natural bypasses' so to speak and can mitigate some of the risk of a blockage...these collaterals are often seen during the angiogram process;

how soon after your MI was the initial stent placed in the LAD and did you get 'clot buster' therapy within hours of your MI ?

have you had a stress ECHOcardiogram since the stent to check heart pumping function, look for MI damaged muscle, etc ;

inconsistent anginal symptoms can be classified as 'unstable angina' and merit a higher level of scrutiny; are these symptoms relievd with usage of nitroglycerine pills ? "chest pains" can be notoriously difficult to trace to underlying disease and there are gender differences that are becoming more apparent...;

a family friend (7x y.o woman) had an excellent result with an aneurysm repair at the Ottawa Heart Centre...;

what 'medical' treatment have you been advised to do ? exercise, STRESS/ANGER REDUCTION- meditation, diet (lots of whole fruits and veggies), cholesterol lowering meds, BP meds, Beta blocker med , 81 mg aspirin, Plavix....? and have you complied ?

be well my friend;

Avatar universal
Janne, while it is true that you did not have the usual risk factors for CAD, the fact that you DID indeed have a heart attack, makes it irrelevant.  Now you DO have a serious risk factor, namely a previous heart attack!  You have documented coronary artery disease!  Also, many times patients do not present with typical pictures and that is why medicine is not an exact science.  Isn't consulting with 7 doctors a bit of overkill?  I think you are just going to have to make your own decision and that will be that.  No one person has a crystal ball.  There is not always a clear answer.
Avatar universal
You may want to ask your Cardiologist to test you for coronary spasms. I have a lot of the same symptoms that you describe and get chest pain at all hours of the day and night and for varying reasons. I can sometimes exercise and other times I can't. I sometimes get chest pain while resting, and other times I don't. I had an angiogram where they shoot some sort of medication into you to induce spasms, and was found to have diffuse spasms through my coronary artery system, which is causing my problems. I am still not fixed, but at least we know the cause of the anguish! Good Luck.
Avatar universal
Thanks for you comments everyone.  I guess mmfd was correct with his comment that no one has a crystal ball.  Somehow I was hoping someone could provide me with a definitive answer, knowing full well it is not possible. I was hoping someone would say, "Yes, if you don't have the stent, there is a risk of MI, but the risk is very small and it will probably never happen".  But, I realize that is not fair of me to expect a doctor to say that. He can't possibly predict what will happen.  I was kind of hoping for a pros and cons "probability" list though haha.  The docs on this forum have helped me (as well as the people on the forum) in that they have provided me with information about CAD, stents, tests, etc. and sometimes just supplied a place to share/vent with people in the same boat who have the same frustrations.

Just for the record, I agree that 7 docs is overkill.  But, I did not run around requesting these appointments.  Each doctor that has seen me seems confused/unsure of what to recommend. So, they end up saying to me that they would like to refer me to someone else for yet another opinion.  
Having said that, it is my fault that I have allowed myself to be bounced around from doctor to doctor and still not been able to make a decision. I am still left with the decision as to whether or not I should have the stent put in. These doctors all seem very good, yet they have completely different opinions. It's difficult to make a decision about something when the experts cannot agree on what the best route is. But, as someone said, it's  not an exact science and no one has a crystal ball.

I guess I have just wanted to arm myself with all the information on the pros and cons of putting the stent in before I go ahead with it.  It was only after my MI and the first stent I had put in that I discovered through this forum that a stent is for life and that it can never be removed. It bothers me that I was not really given a choice and that the stent is stuck in there for good. That's not to say that it wasn't the best route to take at the time, but I decided after that that I had been really stupid and not asked any questions.  In this case, I will just have to decide based on the knowledge I have.

Bryan56, thanks for the suggestion of the coronary spasm test.  That has been suggested and I spoke with the cardiologist about it, however, apparently he said they did not do that test here anymore as it was found to have too many risks(not sure what he meant by that).

Raildown, thanks to you too for all of your help and advice. You were very helpful. In answer to your question; no, I do not, and have not done illegal drugs. I did however used to smoke cigarettes.  There is no known CAD in any of my family members. In fact, my Mom passed away last year and was the youngest woman to die in our family at age 64 (cancer). Her Mom is still alive, just had a hip operation and will be 99 in a few months(her 3 sisters, all mid-nineties are all still alive and well too).  My dad died at age 46, but it was all alcohol related and his autopsy report did not show any signs of CAD or heart problems with the exception of alcohol-related damage to his heart.  But, just because we are not aware of any CAD in our family, does not mean it doesn't exist. Up until last June, I would not have thought I had it either.
The only thing I can tell you about my blockage is that it is anywhere from 60-80% blocked in the LAD and approximately 6mm in length.  I was told that it is just above my original blockage/stent which is mid-LAD. I was told that the ischemia on the imaging portion of the test was in the septal part of the heart , which he said is fed by LAD. I'm not sure what all that means, it sounds like you would understand it better than I.

No, I have not had a stress echo.  Yes, nitro(spray) helps.  I have also been given the patch to use as needed, but it makes me feel crappy and I'd rather live with chest discomfort, so I don't use it.  The meds I am on are lipitor 10mg/day, metoprolol 50mg twice per day, ramipril 2.5mg/day, plavix 75mg/day, novasen 325mg/day.  I went throught the cardiac rehab program at the heart institute (it was excellent) for 3 months. I took everything from nutrition courses, to a stress management course, and an exercise program.  I have complied with everything I can, with the exception that I don't get enough fish in my diet.  I think that just about answers all of your questions. Thanks again for your help, I really appreciated it.

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