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On March 6, 1997 I had a Bruce Protocol Stress Test, a copy of the
report on this test is attached. Based on the results of this test, the
cardiologist I was seeing recommended that I have an angiogram
performed, which I did on March 10. A copy of the Bruce stress test is
attached and the full text from the angiogram procedure report follows
my signature below.
Over the course of the next several weeks following the angiogram, I saw
the cardiologist twice. Based on his "experience" and interpretation of
the test results, he recommended a three way by-pass. Given that I had
not had any symptoms prior to, or since, either test, I felt that this
may not be the best solution.
I am now seeing a different cardiologist. He has reviewed the results
of both tests and is not recommending a "cardiolite" stress test to
determine if in fact a surgical solution is necessary.
Since March we have been treating my condition with drugs and diet. My
blood pressure is now in the 130-140/70-80 range, and my colesterol has
dropped from 245 to 123 LDL from 167 to 49. I have also quit smoking
and have gone on a no/low >10g/day fat diet. My weight has dropped from
260 in March to 235.
I guess what I would like to know if I am looking for a non-surgical
solution that does’t exist, and what if anything this addtional test
will tell me. What if it comes back positive? What is positive? Is
there an acceptable range or will it be up to subjective interpretation
by the cardiologist?
Any info anyone can offer will be of a big help.
By the way I was 53 in February, and was taking 50mg Atenolol/day at the
time the stress test was done in March. I have since added 10mg
Norvasc, 20Mg Zocor and 1 Asprin per day.
Thanks in advance for any info you can provide.
Walter
Text of procedure report on 3/10/angiogram follows:
PROCEDURE REPORT
REIM, WALTER
DATE OF PROCEDURE: 03/10/97
CARDIOLOGIST:
COMPLICATIONS: None.
PROCEDURE PERFORMED: Left heart catheterization, left ventricular
cineangiography, selective coronary arteriography.
INDICATIONS FOR PROCEDURE: The patient is a 53-year-old male with
exertional symptoms for up to six months who recently has had a strongly
positive treadmill test.
PROCEDURE: The patient was taken to the catheterization laboratory in
the poetabsorptive state. The log of the procedure as recorded is
essentially correct. The procedure was well tolerated.
LEFT VENTRICULAR CINEANGIOGRAPHY: This procedure was performed using a
power injection biplane. The left ventricle was of normal size and had
normal contractility throughout. There was no significant mitral
regurgitation. There was calcification of the proximal left coronary
artery system noted.
SELECTIVE CORONARY ARTERIOGRAPHY: This procedure was performed using
multiple hand injections of contrast media through the appropriate
catheters in multiple projections.
The left main coronary artery was fairly short. The left main coronary
artery was narrowed. I do not believe there is any normal segment of the
left main to estimate a true percent stenosis. The distal part of the
left main, in some of the shallow LAO views, is smaller than the
proximal part of the left anterior descending coronary artery. When one
adds in the intermedius and circumflex coronary artery into the total
vascular bed, one would have to say that there is a borderline
hemodynamically significant stenosis in the distal left main coronary
artery, based on these observations.
The left anterior descending coronary artery is a large vessel. Only in
the caudally angled LAO projection can one say there is probably a 50`
stenosis of the left anterior descending, just at its origin from the
left main. The rest of the left anterior descending coronary artery is
widely patent and a fairly large vessel. Just after the origin of the
left anterior descending there is a large diagonal branch; this large
diagonal branch gives off the first septal most likely and then becomes
totally obstructed, and two large subsequent sub-branches of this
diagonal can be seen to fill over the anterior surface of the heart by
collateral filling. There is a true intermedius branch, which has a
proximal 30-40% narrowing, without significant stenosis. The circumflex
coronary artery does not have any significant disease.
The right coronary artery is totally obstructed within 2 cm of its
origin, and distal branches fill by collateral filling on injection of
the left coronary artery.
HEMODYNAMICS: Left ventricular end diastolic pressure was about 13.
Ejection fraction is estimated to be 75`, with the exact number in the
printout.
DIAGNOSTIC IMPRESSION: 1. Two-vessel coronary artery disease in the left
anterior descending and right coronary artery systems, as described,
with a difficult to evaluate borderline situation in the left main, as
described. 2. Normal left ventricular size and function.
RECOMMENDATION: Given the strong positive nature of the patient’s
treadmill test, which would probably not have been that abnormal without
some significance either of the LAD lesion or left main lesion
hemodynamically, I am concerned that the patient is at some risk for a
significant event because of this poor exercise performance on beta
blockers. Consideration should be given to revascularization, which
would probably best be accomplished surgically in this situation. The
patient could have the right coronary artery opened up and have his
treadmill reassessed to see if it has improved enough to relieve
suspicion of the left coronary circulation as playing a major role. I do
not believe it would be possible or likely to open up the large diagonal
branch percutaneously because of the length of the total occlusion.
Medical therapy is also possible, with very close follow-up, but with
some exercise limitation having to be placed on the patient because of
the results of the treadmill test.
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Walter E.Reim (#wr21…@ix.netcom.com) wrote:
: I am now seeing a different cardiologist. He has reviewed the results
: of both tests and is not recommending a "cardiolite" stress test to
: determine if in fact a surgical solution is necessary.
I am assuming you mean "…is now recommending…"
: I guess what I would like to know if I am looking for a non-surgical
: solution that does’t exist, and what if anything this addtional test
: will tell me. What if it comes back positive? What is positive? Is
: there an acceptable range or will it be up to subjective interpretation
: by the cardiologist?
: DIAGNOSTIC IMPRESSION: 1. Two-vessel coronary artery disease in the left
: anterior descending and right coronary artery systems, as described,
: with a difficult to evaluate borderline situation in the left main, as
: described. 2. Normal left ventricular size and function.
:
: RECOMMENDATION: Given the strong positive nature of the patient’s
: treadmill test, which would probably not have been that abnormal without
: some significance either of the LAD lesion or left main lesion
: hemodynamically, I am concerned that the patient is at some risk for a
: significant event because of this poor exercise performance on beta
: blockers. Consideration should be given to revascularization…
The purpose of the Cardiolite stress test in this circumstance would
be to evaluate the hemodynamic significance of the lesions found in
your coronary arteries. In other words, do the lesions significantly
reduce the supply of blood to parts of your heart to the point where
they are at risk of being infarcted.
The location of the lesions in your coronary arteries are of great
concern. The left main and LAD vessels supply blood to a very large
portion of your heart. An infarction of those areas could be extremely
debilitating or fatal. So, they are trying to be very careful with you.
When lesions develop in coronary arteries, the heart can develop
collateral circulation to the affected areas. In other words, the
blood can arrive at the heart muscle by different routes, which might
be hard to demonstrate with coronary artery angiography.
Cardiolite stress imaging visualizes the heart in a different way.
The situation is seen a little further "down stream." The images show
the perfusion of blood in the muscle of the heart. The arterial lesions
themselves are not seen, only their effect on myocardial perfusion.
If the Cardiolite stress images do not show any significant defects,
your cardiologist can have more confidence that you are not at risk
for an infarction within the next few years. With that confidence,
he would be more likely to be comfortable recommending a non-surgical
approach. It sounds like you have done admirably with that approach
so far, but it doesn’t mean that you are not still in a high risk state.
The stress test you already had suggested that the lesions are
significant. But, stress ECG tests are subject to false results in some
circumstances. A stress test with Cardiolite imaging increases the
reliability of the test to something in the 90%+ range (it is generally
agreed).
The Cardiolite stress test is not particularly difficult to tolerate. It
will be a lot like the stress ECG you had with the addition of an IV line
for injecting the radioactive tracers (Cardiolite and/or Thallium), and
a little time lieing down and holding still while the scintillation camera
makes pictures of where the tracers went in your heart. It is certainly
not as difficult as a heart catheterization.
********************************************************************
Please remember that this is not medical advice and you should not
decide what to do based upon this alone. I am not a doctor. I am just
trying to help you understand what your cardiologist is telling you.
********************************************************************
Best regards, and good luck with your problem.
Bruce Finley, CNMT
In article <339F3F41.1…@ix.netcom.com>, "Walter E.Reim"
- Hide quoted text — Show quoted text -
<#wr21…@ix.netcom.com> wrote:
>Since March we have been treating my condition with drugs and diet. My
>blood pressure is now in the 130-140/70-80 range, and my colesterol has
>dropped from 245 to 123 LDL from 167 to 49. I have also quit smoking
>and have gone on a no/low >10g/day fat diet. My weight has dropped from
>260 in March to 235.
>I guess what I would like to know if I am looking for a non-surgical
>solution that does’t exist, and what if anything this addtional test
>will tell me.
>RECOMMENDATION: Given the strong positive nature of the patient’s
>treadmill test, which would probably not have been that abnormal without
>some significance either of the LAD lesion or left main lesion
>hemodynamically, I am concerned that the patient is at some risk for a
>significant event because of this poor exercise performance on beta
>blockers. Consideration should be given to revascularization, which
>would probably best be accomplished surgically in this situation.
You may indeed be "at some risk for a significant event" but bypass will not
prevent said event. "Events" are due to a sudden rupture of an
atherosclerotic plaque. Rupture is more likely to happen at locations in the
coronary artery with early unstable (but reversible) plaque which may look
perfectly normal on the angiogram. The obstructions causing the abnormal
stress test will not cause an event since they are already completely
occluded. A nuclear scan is expensive and will only confirm what you already
know. A bypass would only be indicated if you had intractable exertional
symptoms. No pain, no bypass. You are doing the right thing by changing you
lifestyle. This is much more likely to prevent an event than bypass. You
will not be running any more marathons but you can live quite comfortably
with your disease even if the arteries don’t open up with you noninvasive
treatment.
Colin Rose MD
Colin Rose (col…@odyssee.net) wrote:
: You may indeed be "at some risk for a significant event" but bypass will not
: prevent said event. "Events" are due to a sudden rupture of an
: atherosclerotic plaque. Rupture is more likely to happen at locations in the
: coronary artery with early unstable (but reversible) plaque which may look
: perfectly normal on the angiogram. The obstructions causing the abnormal
: stress test will not cause an event since they are already completely
: occluded. A nuclear scan is expensive and will only confirm what you already
: know. A bypass would only be indicated if you had intractable exertional
: symptoms. No pain, no bypass. You are doing the right thing by changing you
: lifestyle. This is much more likely to prevent an event than bypass. You
: will not be running any more marathons but you can live quite comfortably
: with your disease even if the arteries don’t open up with you noninvasive
: treatment.
Dr. Rose, aren’t you using a pretty narrow definition of "event", which
may not include all scenarios possible here? Are total obstructions the
only thing that cause abnormal stress tests? Are total obstructions the
only thing that cause abnormal myocardial perfusion studies? Your advice
may be good, but I don’t think you can be so sure about that. I suggest
you study up on those points.
Bruce Finley wrote:
> I am assuming you mean "…is now recommending…"
Yes, I did mean "now". Thanks.
> : I am concerned that the patient is at some risk for a
> : significant event because of this poor exercise performance on beta
> : blockers.
The one thing you picked up on (above) is something that has troubled me
from the start. As I understand it, Atenolol supresses the heart rate.
OK, so I’m on a treadmill, and my heart rate doesn’t want to go above
117. Is this because of the Atenolol, and if so I how can a conclusion
be drawn about a "poor exercise performance?".
I had the cardolite test done on Friday. It went well, got my heart
rate up over 142 and was in the 4th stage of the test and going great.
Since 1 min was needed to circulate the drugs, injection was given and I
kept right on going. Hope to get results today or tomorrow.
By the was what does the CNMT stand for? I’m new to all the Dr. stuff,
having grown up in a healthy family and having relatively good health
myself until this turned up.
Thanks for your response to my initial question, you’ve given me some
things to think about.
Walter