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Old 06-14-2007, 12:50 PM   #1
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Post-stent heart stress test questions

My husband suffered a major mi in 2001 while playing icehockey, 39 years old, no heart history. Lost back of heart muscle and had one stent. 2004 had a dream he had a heart attack, had the stress test, and found another blockage. Stent. November 2006 (story is posted on this site) paul had stress test and felt chest pain at peak heart rate, never felt chest pain during heart attack. Paul is "poster adult for heart disease). angio showed a blockage that didn't exist in 2004 stress though he has others. Stent. June 2007 post stent stress test...good news is Paul felt no pain. Just got the report from the cardio.
In Nov 2006 his left ventricular ejection fraction was 51 (in 2001 it was 55), in June 2007 it is 45. Why? Also report states left ventricular cavity size is dilated but in 2006 report it was normal. what does that mean? Gated imaging reveals inferior akinesis. It reads that the patient had an abnormal maximal Bruce exercise tolerance test. The patient developed no anginal symptoms but positive ischemic EKG changes. SPECT sestamibi revealed inferior and inferolateral M.I. can someone explain in laymans terms why his ejection fraction has gone down? I'm worried and his cardio is away till next week to answer our questions. i thank youso much

 
Old 06-15-2007, 08:44 AM   #2
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Re: Post-stent heart stress test questions

Hi Rose,

EF and left ventricle dilation have an association to normally compensate to help regulate blood output into circulation as needed. Normally each variable will be in the higher range when compensating. EF normal is around 55 to 75%. And there is a normal dimension range for the left ventricle.

It becomes pathological when there is over compensation. An abnormal enlargement will decrease EF as the heart muscle will lack its normal contractual strength. Lower EF, less blood into circulation with each heart beat. This condition will add to the heart's burden and continue to increase left ventricle size in a futile attempt to meet blood/oxygen demand

To help explain your husband's circumstance based on what has been written, it indicates there is some heart muscle damage (akinesis) in the area described from an ischemic MI (muscle damage due to lack of blood).

Heart muscle cell damage appears to be mild for contractual functionality (dependant on location and degree of damage). When there is some muscle damage and ischemia the heart needs to work harder and the left ventricle will enlarge and EF will drop after the enlarged heart exceeds the normal compensating size.

 
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Old 06-15-2007, 03:00 PM   #3
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Re: Post-stent heart stress test questions

Ken,
Thank you for explaining all this in terminology I understand. I truly appreciate that you took the time to respond to my questions. Ken,
my husband is very worried as we have yet to speak to our cardio but did do some research and we don't know what can be done to improve his efficiency. We've always dealt with the continous blockages, even seeing the director at Framingham Heart Study, Dr. Castelli, who really does not know what to do with Paul given his great numbers. He pretty much told us most people have heart disease reversal given the numbers Paul has, his diet and exercise regime. Dr. Castelli does not have any answers for Paul..no special medicine...and now to get the 6 month post-stent stress test results with less heart efficiency and left ventricular cavity dilated...what can we expect??? What should we ask the doctor??? Thank you so much. Rose

 
Old 06-15-2007, 05:49 PM   #4
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Re: Post-stent heart stress test questions

Three years ago my EF was below 29% and an enlarged left ventricle, heart muscle damage and valve problems . The enlarged heart caused severe mitral valve regurgitation. A recent echo indicates an EF of 60%, normal size left ventricle with a consequence of a reduction of MV regurgitation. I had had a silent heart attack, some minor heart muscle damage, and coronary blockages as well.

Protocol was stent implant (RCA 98% blocked). LAD artery completely blocked (collateral vessels developed provides a natural bypass)...no stent. Medication is an ACE inhibitor to reduce blood pressure, beta blocker to reduce heart rate, diuretic to reduce fluids. This medication provided relief to an over burdened heart. Additionally aspirin to prevent clots and medication to increase heart contractions.

The medication, proper diet, exercise can reverse remodeling (remodeling is the term for an increase in size), if the heart is dilated due to overwork. The stent may provide sufficient blood to the damaged muscle area. Sometimes heart cells can be revitalized with an opening of a vessel that provides sufficient blood to heart cells that aren't dead, the cells are known medically to be hibernating.

 
Old 06-16-2007, 04:40 AM   #5
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Re: Post-stent heart stress test questions

Quote:
Lost back of heart muscle and had one stent
That's the inferior MI and gives the result , "inferior akinesis," meaning the back of the heart doesn't move (doesn't contribute to pumping.)

Now the OTHER two heart attacks/blockages...depends on where they are:
Quote:
SPECT sestamibi revealed inferior and inferolateral M.I.
Inferolaterolateral also means the back bottom of heart and Q-wave discrepancies. It MAY be just from the ONE heart attack becasue inferior and inferolateral aren't really very different terminologies.

Quote:
Ejection fraction going 55>>51>>45
means the heart attack and noncontributing right heart is having an effect on pumping ability. This is taking it's toll on the heart by making the left ventricle work harder

Quote:
left ventricular cavity size is dilated but in 2006 report it was normal
and thus grow larger.

rose,
I hope he is keeping his LDL as low as humanly possible and that not a day goes by without aspirin...325 mg. ("Poster adults" can't afford to play around with the kiddie doses. )
He should continue to exercise on a daily basis to the limit of his cardiac ability to get as much collateral circulation as he can to help his heart get good blood flow around present and future blockages.

 
Old 06-20-2007, 07:41 AM   #6
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Re: Post-stent heart stress see dr. today

Lenin and KK,
Is my husband heading toward heart failure disease given the enlarged left ventricular? These are his numbers as of May 07
TC-102
HDL-29
LDL-36
Tri-186 (high as in Feb 07 it was 80)
****-5
lp(a) 58
Dr. Castelli from Framingham heart study who is a lipid specialist said his numbers are so good that he should be having reversal...today we meet with his cardiologist to discuss the dilated left ventricular cavity and the ejection fraction output change from 51 in November to 45. I don't want to be passive with our doctor, nor do I want him to be passive with us. what direction is his heart heading?

 
Old 06-20-2007, 07:04 PM   #7
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Re: Post-stent heart stress see dr. today

Quote:
Originally Posted by rose827 View Post
Lenin and KK,
Is my husband heading toward heart failure disease given the enlarged left ventricular? These are his numbers as of May 07
TC-102
HDL-29
LDL-36
Tri-186 (high as in Feb 07 it was 80)
****-5
lp(a) 58
Dr. Castelli from Framingham heart study who is a lipid specialist said his numbers are so good that he should be having reversal...today we meet with his cardiologist to discuss the dilated left ventricular cavity and the ejection fraction output change from 51 in November to 45. I don't want to be passive with our doctor, nor do I want him to be passive with us. what direction is his heart heading?
Do you know the underlying cause for an enlarged LV. Is the dx'd cause ischemia (lack of blood supply do to blockage)? Valves? Viral? ideopathic (cause unknown). Based on your post it appears to be ischemic?

Also it would be helpful if the dx identifies the hypertrophy such as concentric, eccentric, compensatory, adaptive, etc. To know the classification helps to understand the underlying cause, prognosis and treatment.

What is the LV size. The M-mode values on a report would list. The size of LV and EF are estimates at the time of the test, and there could be a margin of error of 10% and may not be representative of the average measurements.

With the information you have provided, it is probable there has been some heart muscle damage that compromises the heart's pumping functionality. It is difficult to speculate what the long-term circumstances will be as related to the heart condition.

You may want to get a copy of all medical reports.

The total chol is very good. HDL is a little low (normal 30-7-)...too low can indicate a liver problem. LDL (normal 50-160), Trig (normal 35-160). For additonal info, LDL/HDL (normal 2.5-4.0) and chol/HDL (3.5-5.5) that appears to be within the normal range.

I don't know about lp(a) and ****-5. Does not show on my record.

 
Old 06-21-2007, 05:07 AM   #8
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Re: Post-stent heart stress test questions

rose,

What drugs is your husband on?

It sounds like he IS headed towards eventual heart failure, but that is by no means to say that it is the only possible outcome...and "eventual" can be a LONG time.

The difference between 51 and 45 is not huge and may fall within or close to the realm of expected error. Same with the degree of ventricular dilation. Probably a confirmatory estimat of bothe should be made by ann independent physician at a different hospital/practice.
I think his HDL is drastically low but probably not in reference to his superlative LDL's...sounds like high dose statins at work???

What were the units given for Lp(a)...there are two competing standards: nmol/L and mg./dL, and within each of these categories, the differences from lab to lab can be extraordinarily wide. It is an extremely atherogenic particle and his is probably too high but there is little one can do about it except choose new parents.

Homocysteine of 5 is fine.

What kind of exercise, especially sustained cardio, has your husband been getting since his ice hockey days of 2001?

Last edited by Lenin; 06-21-2007 at 05:11 AM.

 
Old 06-21-2007, 05:57 AM   #9
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Re: Post-stent heart stress test questions

KK and Lenin,
Thank you...Cardiologist wants to do an echo on Paul's heart next week as he's never had one. Given the change in EF he feels it should be done thought the nuclear he had is just as effective but you are right about the margin errors.
Paul is on the following: aspirin-81mg, plavix-75mg, metoprolol tartrate 25mg 2x per day, folic acid-1mg, crestor-10mg, zetia-10mg, lisinopril-5mg, vitamin B, and 1500 mg of trader joe's fish oil. He jogs three miles a day and uses weights in our home gym. Very diligent about exercise.
So, he'll have his echo, but I'm sure the fraction will be the same. Dr. showed us his heart pics from stress test and wasn't sure why the dr's who performed the test stated left ventricular cavity was dilated, though it was somewhat dilated, cardiologist didn't think it was enough to be concerned. hmmm.

 
Old 06-21-2007, 09:29 AM   #10
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Re: Post-stent heart stress test questions

Aspirin 81 is the amount prescribed for my eschemic chf and is adequate to thin the blood and Plavix (75 mg) was prescribed (for a year) to help prevent clot formation at the cite of drug eluding stent implant. Up to a year subsequent to implant there appears the DES site is generally vulnerable to clots. Lisinopril (ACE inhibitor), and the beta blocker helps reduce the heart's workload. My beta blocker is Coreg to slow the heart rate and HELPS dilate vessels together with Lisinopril.

The usual protocol for an MI recipient is an EKG (low tech for heart muscle damage) and X-ray (visually view heart's configuration). Then the echo to measure the heart's wall and chamber size. I watched the tech, and he explained as the test was performed. Because the test is taken in real time the borders of the chambers are fuzzy making it difficult to distinquish the exact border of the chambers. The tech estimates and outlines the chamber and wall with the transducer at maximum size (systole, varies from beat to beat!) and minimum size during diastole and the equipment's technology calculates dimensions.

EF is determined by volume, larger than normal maximum LV size and a larger than normal wall size (reduces flexibility) together with impaired contractions (usually due to heart muscle damage), will as a consequence, increase the volume of blood that remains in the chamber and that increase will cause a back up of blood into the lungs and system. The condition is referred to as left-side heart failure, and I believe (based on what you have stated) may be the condition in question if the heart is enlarged and EF is reduced.

The LV size would be of little concern if the EF is sufficiently meeting the system demand for blood/oxygen and has the ability to be flexible. Normally, the increase in LV size increases stronger contractions until it overcompensates and an excessive enlargement reduces contractional strength.

Last edited by started04; 06-21-2007 at 09:46 AM.

 
Old 06-21-2007, 11:51 AM   #11
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Re: Post-stent heart stress test questions

I hope to be with Paul during the echo so I can watch given the information you gave me. Tell me, how did you become so very educated in the heart field? You have helped me tremendously and I truly appreciate it.

 
Old 06-21-2007, 04:48 PM   #12
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Re: Post-stent heart stress test questions

rose,

Quote:
He jogs three miles a day and uses weights in our home gym.
Let me atttenuate my first statements because if he can jog 3 miles a day, his heart is in far better shape than I first thought.
I think it is the BEST think he could be doing for himself.

I caution the two of you to be alert to any signs of significant bleeding, gastritis, ulcers, nosebleeds, dizziness or visual problems with the Plavix-aspirin combo if being taken on a permanent basis. I am VERY leery of the "Plavix forever" Rx.
Otherwise his drug regimen seems fine and he deserves congratulations for being able to cover three miles with daily metoprolol...it can readily cause significant fatigue.

Last edited by Lenin; 06-21-2007 at 04:49 PM.

 
Old 06-22-2007, 05:17 AM   #13
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Re: Post-stent heart stress test questions

Lenin,
After his 2001 heart attack Paul was home recovering for two weeks and was quite fatigued, tired, napping alot. It was hard to see him like that but he was recovering. After each angio w/stent procedure Paul would take a while to bounce back, then, he's back to himself. He jogs outdoors now that it is nice weather which I worry about because he normally jogs on treadmill at home before I leave for work. Paul never felt pain in 2001 attack, and stress tests revealed that he needed angio as there were always changes from previous stress tests. The first question cardio always aks Paul when he calls with the results is "how have you been feeling?" and Paul always says "great...!" Then the news that he should have an angio based on test results...Only during peak of treadmill stress in 2006 did Paul feel something "odd" thus the angio, and the stent. I say all this because I'm so very happy that he CAN jog without tiring. He is non-symptomatic which is my biggest fear.

The echo on the 27th will give us more information on his ef number since the June 5th number from nuclear came back at 45 down from 51 from 55...and I agree that jogging is the BEST for Paul. After reading his results he won't slow down, blaming himself that he has not been working out enough when he has. Sometimes he wishes he had symptoms as the blockage in 2004 was 90% and all due to a dream that he was having a heart attack and looked gray, tired, ect...The plavix for life certainly concerns me, but, what other choices do we have? I will post later what the echo came back at...I wish you could see the "map" of his heart which I have from his angio's...he is one lucky man. Thank you for all your help, it does mean so much.

 
Old 07-03-2007, 08:55 AM   #14
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Re: Post-stent heart stress test questions/june echo

My husband called for his echo results. The nurse practioner read them to him over the phone. She told him that his EF was 50, and that there was a slight regurgitation in the ? valve. Cardio on vacation.
Did my search on the web with limited info as usually I ask that the stress results be faxed to me so I can read and ask you! Our cardio did the echo after we told him our concern with the EF drop and the "dilated left ventricle" stated on the stress test results. So, I don't know what valve is showing a slight valve reguritation and from what I've read about echo results, the 50 ef could be "less than 50 or greater than 50"

Any thoughts given Paul's history, dead muscle, scar tissue? I will call to have report faxed to me.

 
Old 07-03-2007, 03:41 PM   #15
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Re: Post-stent heart stress test questions

Rose, as you know, the EF measures the % of blood pumped OUT of the LV with each heartbeat and into circulation. The regurgitation, mitral valve non-compliance, indicates some of the blood back flows into the left atrium rather than into circulation so technically the true measurement of the EF is less than what is reported.

Impaired heart muscle, scar tissue requires medication to reduce the heart's afterload (easier to meet oxygen demand) and increase contractions for a higher EF.

Additional information: There is a measurement called fractional shortening. If your report shows M-Mode calculations, LV end diastolic dimension minus LV end systolic/LV end diastolic dimension can be calculated. Above 30% is considered normal, 26to 30% mild decrease in LV function. A decrease in the shortening fraction usually precedes a detectable decrease in the EF.

Last edited by started04; 07-03-2007 at 03:54 PM.

 
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