Recovering from a stroke and next steps for my father who is 80 year old

[Sharlin]

My dad who is about 80 years of age suffered a heart attack on the 5th of Aug'09. An Angiograph was done and it identified that the right coronary artery had 99% mid segment blockage. We did not do the angioplasty as we thought we would do it at another bigger hospital after clarifying the same with some other doctors or after a week or so as the doctor also said there was no urgency and it can be done in a week’s time.   He reacted very adversely to the die and had problems with the kidney and lungs. The creatinine level increased to about 1.7. It took him about 2 weeks to get out of the situation and now has been advised another 2 weeks rest.
The doctor has suggested going for a Thallium test to check the heart muscles now and if the muscles are ok in the region where the blocked artery is supplying blood then it will make sense to do an angio plast and fix a stent.
My questions are:
1) Do we need a thallium test to tell us this? What are the risks of this test for an 80 year old? Radiation risks also are there.
2) Can this same thing (condition of the heart muscles) not be seen from an echo cardiogram?
3) If we have to go a stent, what are the precautions to be taken during the angiography? for e.g. use of a non ionic dye
4) What needs to be done to prevent the creatinine issue from happening again?
5) What are the other precautions to be taken, what can go wrong and what are the preventions?

Thanks and warm regards,

[Dr Rajgopal]

Hi Sharlin,
Thallium test is a nuclear imaging test that shows the efficiency of  blood flow into the heart muscle, both at rest and during activity. Complications during the test are rare  but may include Arrhythmias, Increased angina pain during the test, Difficulty breathing or asthma-like reactions, Extreme swings in blood pressure or  Skin rashes besides the radiation risks.
The condition of heart muscles may be detected by an EKG but Thallium tests are more specific and accurate.
Non ionic dyes are used instead of ionic dyes for placement of stent during angiography. The side effects associated with ionic contrast media are prevented by using nonionic contrast agents. However, some incidences of thrombotic events occurring during routine angiography with nonionic media suggest that nonionic media may be a procoagulant.
Increased blood creatinine is usually a sign of  kidney function disorder. The creatinine level is also raised with injury to muscle, during increased breakdown of muscle tissue or increases in muscle mass.Diseases that affects the filtration process of the kidneys tend to raise serum creatinine. Diseases known to increase creatinine levels include glomerulonephritis, pyelonephritis, diabetic nephropathy, shock and congestive heart failure. The methods to  reduce the creatinine levels are- Drinking 6 glasses of water every morning, avoiding morning coffee,  
avoiding dairy products, meat, fish, and foods rich in protein, going for a steady walk every day if possible, keeping a protein tracker to have an eye on your daily protein intake and monitoring the level of creatinine periodically.
Please discuss the suitability of the diagnostic procedures with your cardiolgist.
Hope this answer helps you. I wish your father a good health. Take care and regards!

[nazliatefi]

A related discussion, recovery from hemorrhagic cva was started.

[Sharlin]

Dear Dr. Rajgopal,

Thank you very much and deeply appreciate your quick response , the detailed guidance provided and your kind words .

I look forward to advice  on the 4 Q's points  listed below :

1) Appropriateness of a Thallium test for a 80 year old. Secondly , if it shows heart muscles are in good condition and an angioplast is needed on the artery ( right coronary artery had 99% mid segment blockage)  , we any way need to go ahead with the agiography and angioplast . So why expose him to both , the radiation from the thallium nuclear imaging test  and the effects of the  angiography dye ? Could we instead do a echo first and then decide to either do a thallium ( if there are no risks ) test if there is any doubt and go ahead with the stent process if that is identified as needed?

2) What are the radiation risks of the Thallium test ? I read that the radiation level of this is 590 times that of the exposure during an  X ray ? Is this true ? How do we have to tackle this in case we have to go for a Thallium test ?

3) What is the care to be taken before an angiograph this time ? I read from your mail that the non ionic dyes may be a procoagualant which may not be good . The dye may have caused the kidney dysfunction last time leading to the creatinine levels increasing? Is this conclusion right? What otherwise could be the reason for the increase in creatinine because he did not have any problem relating to kidney dysfunction before and has been having water therapy for many years. What is the suggested way forward this time? His creatinine levels have settled to normal now.

4) He did get a severe lung infection while in the hospital. It was severe as while coughing blood was seen in the sputum, initially discussed as due to the blood thinning drug that was given. The scan done showed a patch in the lung identified as a pneumonitic patch due to bacterial and fungal infection which is being treated. Is there something we need to watch out for?

Thanks and warm regards,