Dr. Sagar Ramesh Makode
Cardiology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello doctor,
About four or five years ago, a stent was placed in my 90 % occluded left circumflex cardiac artery. For four or six months before that, I had drenching night sweats and had to change clothes twice a night. After the procedure, the doctor prescribed Effient so blood would not clot. A few days ago, after I stopped Effient for a few days for a dental extraction, the sweats began. Last night I resumed Effient, and sweat was minor. I did not have the probably infected molar extracted yet. I have been taking Amoxi-Clav 875/125 mg for five days and will continue until the dentist extracts the tooth. I should add I have emphysema with oxygenation between 94 % and 95 %. I take Metoprolol for high blood pressure and a potential antiarrhythmic, Buspar, Lisinopril ACE inhibitor, Effient, a statin, and Amoxi-Clav. Do many people with stents need to have them replaced after five years? Why are the night sweats returning? What is the relationship between a clogged artery and profuse drenching sweats? I should mention that five years ago, when I went to the emergency room, I had atrial fibrillation stopped with chemo conversion, I believe. I had another bout of A-fib a few months after the procedure. The same chemo conversion, but it took longer. Please inform me of what might be happening and how to proceed medically. Thank you very much.
Hello
Welcome to icliniq.com.
I thoroughly read your query and understand your concern. Sweating may occur in clogged arteries but not in the pattern you are having. Twice at night, time is unlikely for clogged arteries to cause these. Sweating in heart patients may occur with a coronary syndrome, so having so many coronary syndromes is impossible. Also, it can occur if heart function is low, and you may get shortness of breath along with sweating due to heart failure. But relief with blood thinners also does not fit in a cardiac cause. Blood thinners will not immediately stop your sweating. However, if you are taking Aspirin and sweating has reduced, then it is likely due to its anti-inflammatory effect on sweating. Now, do you get symptoms like chest pain or heaviness on exertion or shortness of breath on exertion? If yes, it points towards clogged arteries, either the same or another. You should get the status of the arteries checked. For that, you will have to get an ECHO (echocardiography) done, and if ECHO shows no drop in cardiac function, then you should get a stress test like stress thallium done to look for status. It is not like you will routinely need to get the stent changed. However, blockages may form at the site of previous blockages, and one may need another stent to put in, for which duration varies from person to person. Hope this helps you. Get back if you have any doubts. Kind regards.
Patient's Query
Hello doctor,
Thanks for the reply. But the sweats were continuous last time. It occurred only once, and for all time, I slept. Now they are once. Note that I have emphysema for shortness of breath. Does that change the diagnosis?
Hi,
Welcome back to icliniq.com.
I understand your concern. Yes, this can be related to the emphysema part, but we cannot establish a definite relationship unless it is related to shortness of breath. I mean sweating associated with shortness of breath. Sweating that stops immediately after taking an Effient tablet cannot be explained by blockages and cardiac causes. This may have a psychological component as well. However, if you have a dental infection, it can cause sweating or fever. I suggest you get yourself evaluated by a local internist once for this problem as we should rule out other causes. I suggest you get some routine tests like a hemogram with ESR (erythrocyte sedimentation rate), CRP (C-reactive protein), LFT (liver function test), RFT (renal function test) done, and cardiac evaluation, as suggested. Also, let me know your heart ejection fraction. Have you changed any other medicines along with this? Please follow back with the answers. Regards.
Patient's Query
Hi doctor,
Thank you so much for recommending tests. The ejection fraction is 75%. The conclusion from the ultrasound was "stable." I apologize for not having told you one thing that troubles me. Sometimes when I am sweating, which is only when I am sleeping or just getting up from sleep, my heart feels like it is pounding and racing. This pounding and racing is something new that I feel. Regarding the psychological component, I do not think so because I did not experience the sweating stopping immediately, but only that it was reduced over the night. Perhaps we mean the same thing by immediately and overnight, though. I will bring up the tests you recommended to my internist this week when I have my appointment. Would you please comment on the rapid-pounding heartbeats? Please know that I am not moving or exercising when I am sweating, and my heart is pounding, so I wonder if emphysema can still play a part. I truly very much appreciate the time, effort, and great detail you went into to guide me in the determination of my difficulties.
Hi,
Welcome back to icliniq.com.
I understand your concern. Yes, that gives a different direction entirely. Rapid and pounding heart rate raises the first possibility of paroxysmal atrial fibrillation. It can explain all your symptoms. Also, another less likely possibility is panic attacks if you have psychological symptoms like fear, or bad thoughts, which I guess you do not have. Now the way to confirm is the ECG (electrocardiogram) during the episode, which is a difficult job, or else Holter monitoring for 24 hours or even portable mobile rhythm monitors. So I suggest you discuss this with your doctor and also hike the dose of Metoprolol for rate control. Emphysema is known to cause atrial fibrillation. Hope this has addressed your concern. Kind regards.
Patient's Query
Hello doctor,
Thank you very much for providing me with your knowledge and insight. That makes a lot of sense. It was a strong bout of atrial fibrillation that initially brought me to ER a number of years ago. Cardiologist wanted me to do a 30-day Holter, but how would I press the record button while asleep? I had no idea that emphysema could contribute to paroxysmal A-fib, nor that a pounding heart is associated. An interventional cardiologist who did the procedure said something about bradycardia having been my problem. Can that change to tachycardia, and do you suggest continuing remodeling? I take 100 mg Metoprolol succinate once per day plus 25 mg Tartrate BID. Is there room for more of this beta blocker? Would an ablation procedure help? From what you have read about my medical condition, is it more likely that my sweats this time and years ago are attributable to A-fib begetting more A-fib than to recurrent occlusion? Also, I have been under severe emotional stress for the past two years because my wife is in a nursing home, and although the staff is fine now, many nurses and aids were toxic until about six weeks ago. Will stress, as well as emphysema, exacerbate and cause the progression of paroxysmal A-fib? I will focus on recurrent A-fib with my internist and cardiologist when I see him. It is difficult to get an appointment with a cardiologist, so your responses are even more appreciated.
Hi,
Welcome back to icliniq.com.
I understand your concern. Yes, your sweats were likely related more to atrial fibrillation than blockages. As I mentioned, sweating in heart disease suggests acute coronary syndrome and will occur once in a while but not so frequently. So one cannot have ACS (acute coronary syndrome) so frequently and continuously. Sweating is a nonspecific symptom and is associated with any stressful condition, either physical or psychological. I guess you are not diabetic and on medicines, so hypoglycemia is ruled out. Try to correlate other things in the past as well, which have changed, and sweating has reduced. Emphysema and stress can certainly aggravate atrial fibrillation. Ablation may be tried but may not be very successful as this multifocal and diffuse atrial involvement is usually difficult to ablate, although parameters like atrial size etc., should have to be seen for suitability. Regarding the dose escalation of Metoprolol, it depends on heart rate and BP (blood pressure). Because both their parameters are reduced by Metoprolol, if one's resting heart rate is going down too much, then we cannot increase the dose. But, this low heart rate increases during atrial fibrillation episodes. So you discuss with the internist about starting some antiarrhythmic medicines like Amiodarone or adding another medicine like Diltiazem (slightly reducing Metoprolol) to prevent heart rate rise during episodes. You do not have to press any button to start monitors. It continuously records and sends data depending on the monitor. Hope this has answered your queries. Regards.
Patient's Query
Hi doctor,
Thank you once again. Yes, my BP is 100 systolic, 80 or lower diastolic, so your suggestion for lowering Metoprolol and adding the Ca channel blocker makes sense. Chemoconversion seemed to alleviate sweats, but the stent insertion was done at the same time, so I am unsure. I wonder if you have read about sleep and heart symptoms. I am confused as to why the sweats and pounding happen only as I sleep. I have read that there is a connection, but my internist tells me he knows no one who learned sleep medicine and cardiology. I now have much to discuss with my internist in the upcoming appointment.
Hi,
Welcome back to icliniq.com.
I understand your concern. With the current BP, there is little scope for a Metoprolol increment. So we have to reduce the dose and add others like Diltiazem or Amiodarone. Yes, there is a connection between sleep and atrial fibrillation, or any arrhythmias, for that matter, but this relationship is subtle, so it is not given much importance. Another possibility is your BMI (body-mass index) mentioned here 31, so I guess you are overweight, and there is a possibility of obstructive sleep apnea, especially if you are having symptoms like snoring, interrupted sleep, and an episode of breath-holding during spells. This may precipitate the fibrillation as well. So these are various possibilities, and we need to confirm these things with investigations. Hope this helps. Thanks and regards.
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