How to treat unstable angina?

Hello,

Welcome to icliniq.com.

I have gone through your query and understand your concern.

I have reviewed all the documents you have shared. According to the records, you had at least severe narrowing in two of your heart vessels, which was addressed with two stents. There is also disease in a small branch vessel and moderate disease in another artery, both of which are being managed medically.

Now that the stents have been deployed and blood flow has been restored, there are certain measures you need to adopt to prevent stent occlusion and to prevent the progression of disease in your other arteries.

1. Take all medications as prescribed. You need to take dual antiplatelet medications, which are Aspirin and Prasugrel, for at least one year. After that, your cardiologist may decide to switch you to only one antiplatelet medication.

2. Manage your blood lipids, such as LDL (low-density lipoprotein) and HDL (high-density lipoprotein). LDL, being the "bad" cholesterol, should be below 70 to achieve maximum benefits. You are already taking Atorvastatin and Ezetimibe for this, and these should be continued. They will also help to increase your HDL, also known as "good" cholesterol. These medications will also take care of your raised triglycerides.

3. Engage in a daily walk for at least 20 to 25 minutes, at least five days a week, to support your heart health.

4. Consume a heart-healthy diet. This includes more vegetables, fruits, fish, and chicken, and avoiding red meat. It also includes using vegetable oil and avoiding precooked and processed foods.

5. Always take your other medications on time and monitor your blood pressure and heart rate. Consult your physician if these are not within the normal range. High blood pressure and high cholesterol are among the main causes of coronary artery disease, along with cigarette smoking, a sedentary lifestyle, and diabetes.

6. As you are taking Thyroxine, this indicates you have hypothyroidism. If hypothyroidism is not properly managed, it can cause blood pressure and lipid imbalances, which can lead to progressive coronary artery stenosis and may promote occlusion of already deployed stents.

7. If you experience any health issues, such as chest pain, shortness of breath, dizziness, elevated blood pressure, or low blood pressure, consult your physician immediately for diagnosis and timely treatment.

Since you have coronary artery disease, raised triglycerides, and hypothyroidism, you are at risk for peripheral arterial disease (PAD). If you experience symptoms such as leg pain, numbness, or cold or pale limbs, consult your physician promptly to be evaluated and treated for PAD. Lifestyle management, as described above, and your medications will also help prevent PAD.

I hope I have answered your question.

Let me know if I can assist you further.

Kindly follow up if you have more concerns.

Thank you.

Hello,

Welcome back to icliniq.com.

I can understand your concern.

It is encouraging to see that you are proactive about your health and concerned about your well-being. To accurately assess your concerns regarding the ECG (electrocardiogram) findings, I would appreciate reviewing your ECG and echocardiography reports. This will allow me to determine if the findings you mentioned were genuinely present in your ECG.

The interpretation you shared is likely machine-generated. Automated ECG readings are often unreliable due to various interfering factors. An ECG should always be interpreted by a physician, taking into account the clinical examination, patient history, and laboratory findings.

Regarding the anteroseptal infarct, its presence should be confirmed with supporting laboratory and echocardiographic evidence. Typically, the ECG would show ST-T changes, T-wave inversions, and pathological Q waves that are over 40 milliseconds in duration and more than 25 percent of the depth of the R wave. To determine whether these findings are present in your ECG, I would need to review the actual report. The interpretation you provided mentions only T-wave inversion and a Q wave of 35 milliseconds. As noted, these findings require confirmation through laboratory and echocardiographic evaluation.

If such findings were genuinely present during an episode of chest pain, they would warrant concern and further investigation by a healthcare provider.

Considering you already have two stents, these ECG findings could be related to previous coronary artery stenosis that has been treated.

As for the ECG from three years ago indicating left atrial enlargement, if this is not supported by your echocardiogram, it is most likely a machine error or artifact.

Your other recent ECG interpretations are unremarkable.

I hope this explanation is helpful. Please feel free to contact us with any further questions. we are happy to assist you.

Thank you.

Hello,

Welcome back to icliniq.com.

Thank you for writing us back and sharing your ECG with us. Please note that the provided ECG is not a standard 12-lead ECG. However, it demonstrates a normal sinus rhythm. The available leads do not indicate any infarction, nor is there evidence of atrial enlargement.

This stress ECG reveals an adequate cardiac response to stress. No arrhythmias or aberrant heart rhythms were observed throughout the test.

If your blood pressure is low, it is better to hold Amlodipine. If it remains low, Lisinopril can also be held for a few days, followed by Toprol XL if needed. Once blood pressure is adequate, these medications can be restarted gradually. If your systolic blood pressure is below 90 mmHg, your mean arterial pressure is below 65 mmHg, or you have symptoms such as dizziness, blackouts, extreme fatigue, or cold and pale extremities, please consult your physician so that necessary treatment can be implemented.

I hope this helps.

Kindly follow up if you have more concerns.

Thank you.

Hello,

Welcome back to icliniq.com.

It is good to receive your message.

I am glad to hear that you have started physical activity and are enjoying playing softball. At this point, I would like to emphasize a few important considerations. It is crucial to build physical stamina before engaging in any activity of more than mild intensity.

Softball is generally considered a game involving moderate to severe intensity. You can gradually increase your level of exertion, starting with reduced intensity, until your muscles are adequately trained and your body adapts to this particular activity or game.

We sometimes advise an exercise tolerance test to assess physical fitness and guide exercise prescriptions. In your case, you can undergo an exercise stress test while your ECG and vital signs, such as blood pressure and heart rate, are monitored for any fluctuations.

One possible reason for the fatigue and muscle aches you've mentioned could be the use of statin medication, specifically Atorvastatin 40mg with 10mg of Ezetimibe.

I recommend repeating a fasting lipid profile, as approximately three months have passed since your last one. Please discuss these results with your doctor to explore any possibility of reducing these medications. Statins can sometimes cause myopathy, which may lead to symptoms such as fatigue, muscle aches, and weakness.

Since you are taking Thyroxine, checking your thyroid function is also recommended. Inadequate Thyroxine levels can also contribute to these symptoms. Repeating baseline labs such as a complete blood count (CBC), Serum electrolytes, and Serum Creatinine would also be good to ensure everything is fine.

Overall, the symptoms you have described are not alarming; however, they do warrant medical attention and proper management. Please continue to follow a healthy lifestyle and avoid foods that are not beneficial for you. It is also important to remember that being overweight can contribute to easy fatigue for various reasons.

I hope this helps.

Thank you.

Hello,

Welcome back to icliniq.com.

Listen to your body and exercise as much as you comfortably can. You can continue playing softball as long as you feel good. If you're wondering how much exercise is safe for you, an "exercise tolerance test" (ETT) can help determine that.

Please get the tests that I recommended done. Most importantly, I strongly advise you to join a cardiac rehabilitation program. These programs are designed to help you gradually start exercising and build your stamina without putting too much strain on your heart.

As you mentioned, what you're feeling during the activity right now doesn't seem like angina. Still, a follow-up appointment is recommended to ensure your well-being.

Take very good care of yourself.

I hope this helps.

Regards

Hello,

Welcome back to icliniq.com.

I hope you are taking your medications on time. I also wish that your vitals, especially blood pressure and heart rate, are within the ideal range on your current medication. As we have previously discussed, the potential role of statins causing myopathy and easy fatigue was also discussed and ruled out with your primary healthcare provider. Similarly, I also assume that you have enrolled yourself in a cardiac rehabilitation program.

Now, regarding your queries, specifically about easy fatigue-ability and shortness of breath on exertion, you have raised three concerns: Could it be the diagonal branch? Could it be stent re-stenosis? Could it be microvascular angina?

As I have checked your previous record again, you had a severe disease in your diagonal branch that was not stented, the reason being that it was a small-caliber artery. This branch can cause angina-like symptoms, but since your nuclear test and echocardiogram were normal, this makes diagonal branch ischemia less likely.

Similarly, negative results on both of the above tests would make stent re-stenosis and microvascular angina a very unlikely diagnosis. However, these tests would not pick up 100 percent of the cases, and there is a possibility of false-negative results.

It would have been useful if you could have shared your previous and fresh echocardiogram reports and the report of your nuclear test. If any type of ischemia is suspected, then further labs are warranted. A CT (computed tomography) would pick up any re-stenosis; however, it would not always be very reliable or accurate. A CT would also not determine if a stenosed or narrowed segment is causing significant ischemia.

Other modalities such as a Cardiac MRI may be done to diagnose ischemia more reliably. In your case, an invasive angiogram would be of high yield and would also give an opportunity to do further functional testing, such as fractional flow reserve and coronary flow reserve, within the same procedure, and provide an opportunity to attempt revascularization if needed.

If there is any evidence of ischemia on any modality, especially due to the diagonal branch or any re-stenosis, then stenting or only ballooning (if not stentable) can be attempted. Please remember that for any health issue regarding the cardiovascular system, medical management is the first-line treatment, followed by invasive treatment if needed.

I wish you good health and a swift recovery.

Regards.

Hello,

Welcome back to icliniq.com.

I have reviewed your echocardiogram and nuclear stress test. Both, as you said, are normal.

You were able to exercise for eight minutes and 45 seconds, achieving 10 METs (metabolic equivalents of task) and 89 percent of your age-predicted maximum heart rate. This is reassuring.

Still, if ischemia is a concern, then as we have previously discussed, you would need an invasive coronary angiogram, which is the gold standard.

Your cochlear implant needs to be checked for MRI (magnetic resonance imaging) compatibility. While most implants are compatible, if yours is not, then an MRI would be contraindicated.

An MRI, if possible, would be far more sensitive and specific than a nuclear stress test. Please continue with the healthy lifestyle you are already on. Let me know if you have any health concerns. I am always here to help.

Regards.