> 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

- 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

: 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.

: 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