Heart Disease

Wow, what a difference a year makes. As many of my readers will notice, I have been given a top blog award from disease.com. I am pleased this blog is recognized as helpful for those suffering from heart disease. That is my goal and continues to be my goal.

Updating has been sparse of late, partially due to other demands on my time. However, I actually do plan to begin paying this blog more attention and although I believe the current information to be quite comprehensive, there is always the latest news and breakthroughs that I would like to begin covering once again.

My last appointment with my cardiologist was last week. It has now been 18 months since my last stent, and 6 months since my last stress test. I am overdue some blood work and I intend on addressing that issue after the holidays when I get a chance to lose some of the weight I know will gather about my waste. Until then, have yourself a wonderful Thanksgiving, merry Christmas, and a happy New Year.

As I stated in My Story I am a proud member of Shepherd of the Hills Presbyterian Church.

I consider the pastor, Larry Coulter, an influential, inspiring and entertaining speaker. His presence can lift even the lowest of spirits and his sense of humor hints at the possibility that had he not chosen being a pastor, he could have ranked among the best of comedians.

From PTCA.org comes an excellent article converning the use of IVUS (emphasis mine):

A study, published in the current issue of JACC Interventions, details 120 drug-eluting stent cases as viewed by intravascular ultrasound (IVUS) in order to examine characteristics that may lead to in-stent restenosis (ISR) or stent thrombosis.

Underexpansion of stents, both drug-eluting and bare metal, has been long identified as a significant predictor of adverse clinical events. Prominently discussed by Dr. Antonio Colombo in the early days of stenting, inadequate expansion of the stent struts is known to increase these problems.

This latest examination studied whether there was a difference in the type of underexpansion that caused thrombosis (blood clotting) versus in-stent restenosis (the growth of excess tissue inside the stent) in drug-eluting stents (DES). Dr. Akiko Maehara and a team from the Cardiovascular Research Foundation and Columbia University Medical Center in New York looked at 20 definite DES thrombosis patients, which represented all definite thromboses from 1,407 consecutive DES patients who underwent intravascular ultrasound imaging. These were compared to 50 risk-factor-balanced ISR patients with no evidence of stent thrombosis and 50 risk-factor-balanced “no-event” patients with neither thrombosis nor ISR.

Using IVUS allows the cardiologist to see not only the amount of blockage, as in a 2D angiogram, but the spatial and volumetric relationship of the blockage to the actual arterial wall in three dimensions. An issue with inadequate stent expansion is that, using angiography alone, the operator may not be sure that the stent struts are pressed up against the interior surface of the coronary artery. Additionally, by using a 3D real-time reconstruction of an IVUS “pull-back” (the right image above), the interventionalist can see immediately after stent implantation any eccentricities of the arterial segment and can ensure that full expansion has occurred. If the stent is not adequately expanded, the placement can be “touched-up” with a high-pressure balloon expansion in all or part of the stent. Incomplete expansion allows a space to exist between the stent struts and arterial wall, a space where thrombus can form and can also promote unwanted tissue growth which then blocks the stent.

85% of the thrombosis studied in this report occurred within 30 days of the stent procedure, pointing up the fact that inadequate placement, not the drug or polymer or other characteristics of the drug-eluting coating, was the prime predictor. The study concluded, however, that there is a difference between underexpanded stents that thrombose versus underexpanded stents that restenose: the underexpansion in DES that thrombose is more severe, more diffuse, and more often proximal in location. The researchers found that in cases of thrombosis, the proximal parts of many of the stents were inadequately expanded, possibly because stents are usually sized more for the center and distal ends of blockages where there is more disease.

The 85% statistic is all the ammunication necessary to demand the use of IVUS in your own procedure. If you cardiologist is not able to perform IVUS due to lack of exposure to the technique or lack of the proper equipment, I would strongly recommend finding another cardiologist. Ask your doctor if he/she uses IVUS and what level of expertise they possess. Although we all hope a visit to the emergency room is not in our future, if you are a heart patient, talking to your cardiologist now and possibly switching doctors before your next procedure makes sense.

Fractional Flow Reserve, or FFR, is a guide wire-based procedure. Its utilility is that it can accurately measure blood pressure and flow rate through a specific part of the coronary artery. Is is performed through a standard diagnostic catheter during the actual coronary cathaterization. Using Fractional Flow Reserve, the interventinalist can assess whether or not to perform angioplasty or stenting on “intermediate” blockages – blocakges that may or may not cause angina symptoms or lead to serious ischemic events.

The entire point of using a stent in the coronary arteries is to increase blood flow to the heart. However, a number of studies have shown that if a “functional measurement”, such as Fractional Flow Reserve, indicates the flow is not significantly obstructed, the blockage or lesion does not need to be revascularized (angioplasty) and the patient can be treated safely with medical therapy.

The Interventinalist’s tendency to stent is well documented. Some more aggressive than others. In the case of my cardiologist, if he notices a blockage of 75% or greater, he will stent it. Some cardiologists will stent a 50% blockage. But what if FFR indicated that an intervention won’t have a significant impact on a particular blockage? Being able to better select cases not only saves health care costs, but contributes to more appropriate patient care.

The recent COURAGE trial has only re-emphasized what all current medical guidelines recommend: that for low risk patients, even those experiencing angina, optimal medical therapy should be the initial treatment. For those patients whose disease progresses, or for whom chest pain is not alleviated, revascularization, either through angioplasty and stenting or surgery, should be performed. Fractional Flow Reserve can be a significant tool to help physicians in deciding whether to intervene or not. Here are some results of some additional studies:

• DEFER study: Patients who have been screened out of angioplasty by using FFR have not experienced an increase in adverse outcomes. And in these studies, two-thirds of the patients were judged not to need an intervention with balloons or stents.
• FAME study: FFR allowed elimination of a third of the lesions that might have been stented using angiography alone, with better outcomes for patients.

In the next post we will be talking about Intravascular Ultrasound (IVUS) and why you should insist your cardiologist use this technology if you are going to get a stent.

I can only say, “Thank you God”. It seems like being put on the prayer list at my church really worked a miracle. Only two minor blockages were noted on my heart nuclear stress test, something of little significance, especially given my diet for the last four months. Steaks, hamburgers, nachos, cheese, Scotch – you get the picture.

My total cholesterol did increase from 99 mg/dL to 141 mg/dL, with my Triglycerides topping out at 197 mg/dL (140 is the maximum). HDLs were 44 (they were 41 last time). LDLs were 58 (they were 33 last time). CRP was still very low at .3 mg/L (anything less than 1 is great).

My kidney function was off (creatinine of 1.54 mg/dL and eGFR of 50L). Creatinine should top out no higher than 1.34 mg/dL, but I have often seen numbers higher than this. This is the first time for an eGFR measurement and it registered low (it should be greater than 60L). My physician did not seem too concerned, given that I lifted weights the day before and was taking my wife’s Naproxen for a pulled muscle for the week previous to the test. I concluded after studying eGFR lab online in medical journals that it is on shaky ground as far as viability is concerned. My physician’s greater concern was my A1C – a measurement of the average blood sugar for the past 6 months.

My fasting glucose is usually around 95-99 mg/dL – right near the high end. This time it was 85, but my A1Cs were 5.9. They have always been a little high, 5.7-5.9. A value of 6.0 is indicative of diabetes. In my past are multiple glucose tolerance tests, and I usually fail only one of the four blood draws over the two hour period; or pass all four. One could say I suffer from pre-diabetes, also known as glucose intolerance, also known as metabolic syndrome X. Scary name, that last one. I recall the first time I was told I may have metabolic syndrome X. I remember thinking, “My God, they don’t even have a name for it yet! This does not bode well”. Well, suffice to say this is just a fancy name for glucose intolerance. No laughing matter, mind you, but not as sinister sounding as “metabolic syndrome X”.

My physician wanted me to clear with my cardiologist the use of Byetta – a twice a day injection just prior to breakfast and dinner. The needle is very small and given subcutaneously. There is little chance of hypogonadism unless the user is simultaneously on other medications that contain a sulfonylurea – a pill that increases insulin release from the beta cells in the pancreas

The purpose of this medication for me is to lower my A1C (the value of 6.0 basically translates to the loss of 50% of my pancreatic beta cells responsible for metabolizing sugar). The medication also has a bonus side effect – weight loss.

Which brings me back to my testosterone. Last time, my last measurement was 550 ng/dL for total-T. This time it was a meager 317ng/dL. As abdominal fat aramotases testosterone to estrogen, I believe I know the cause of most of the reduction – my 12 lb. weight gain.

So here is the plan of action. Take the Byetta for blood sugar control to stop the onset of full-blown diabetes. Start Niacin to boost my HDLs. Then there is diet and exercise, which along with the Byetta should substantially reduce my weight and bring my testosterone back up into a better age-matched range. All of this will be accompanied by blood work to monitor the status of my liver, A1C, lipids, and testosterone.

The conclusion? I am responsible for my low testosterone, weight gain, and accompanying increase in lipids. Still, it is also within my power to bring all of these back under control. With Niacin, if I can lower my lipids to their previous levels the chances of reversing my heart disease are good.

My stress test is final proof that it was tolerance to 75mg of Plavix (I now take 150mg daily) that lead to the multiple stent procedures. Since I have started 150mg of Plavix, I have passed three stress tests. This does not mean that re-stenosis is not in my future, but that my current heart health is directly within my control.

However, that is not the miracle I referred to in my opening. My previous stress test indicated a left ventricular ejection fraction of 40. This was so stunning my previous cardiologist ordered an ECG (sonogram of the heart) to discern my real LVEF (it was 52). Anything below 50 is considered the beginning of heart failure. This time my LVEF was 65 (the range is 50-70) – the highest it has ever been. Also, my left ventricle – which experienced minor thickening over the past four years is now within the normal range.

So the prayers were answered; along with a friendly warning from above. The things that were within my control were I consciously ignored (with the exception of exercise). I indulged in food and a little too many drinks – hence the higher lipids. However, a silver lining to my self-induced cloud appeared. My physician, not knowing of my fall from discipline, thought I was going diabetic. He had just come back from a symposium on Byetta and immediately recognized the benefit it would have for me, even though I was not diabetic. How lucky for me that my physician saw the potential in this new drug and offered me something that will change the course not only of my glucose intolerance, but also my heart disease.

The Lord helps those who help themselves. I have been given a reprieve and seen a miracle occur in my own body. The rest is up to me. I put myself in this predicament with poor self control in the face of genetic factors that had heart disease warning signs flashing in my face since my early twenties. It will take discipline and a love of the temple that God has given me to keep going strong. Depending on your perspective, I have been either very lucky or very blessed. Did I die when my LAD was 100% occluded? No – my life was spared by a collateral artery that kept me barely alive. Did I die when I had an aneurysm in my LAD due to lifting too much weight to feed my vanity – no. It was caught just in time by the same cardiologist who saved my life the first time. Was I lucky to be sent to a cardiologist who is the only one is Austin possessing the knowledge and skills to keep me alive during my first procedure?

Thank you one and all for your prayers and thanks to Shepard of the Hills members for their prayers. My aunt in Toronto lit a candle for me at a Catholic church, so I like to think that Protestants and Catholics coming together are a force to be reckoned with!

If you are a reader of this blog, you will recall my last stress test was, in my opinion, poor. It was taken six weeks into my cessation of testosterone therapy with no attempt to renormalize my testosterone levels. I only made it ten minutes, which is 5.5 minutes less than my best. However, I passed the test. When my performance was the best, I failed. Go figure.

This time I made it 13.5 minutes, two minutes shy of my personal best and post testosterone renormalization. I won’t know the results for a week, but fingers are crossed that I won’t be in for another angiogram and possible stent.

Also, this week I should receive the results of my latest set of blood work. As soon as I know, I will post them here.

Hoping, hoping, hoping.

From CBS News:

How do you treat something that has no symptoms and goes undetected on standard screenings?

DE-CMR (delayed enhancement cardio magnetic resonance) is a new cardiac imaging technique that can detect if you’ve suffered a silent heat attack, which an earlier EKG might have missed.

Early Show medical correspondent Dr. Jennifer Ashton shared this new method of detection with Early Show co-anchor Julie Chen.

According to Ashton, a silent heart attack is “both silent and potentially deadly,” which is “very scary” because there are no typical signs like chest pain or shortness of breath.

“You as a patient might be unaware that you’re having one and it doesn’t leave its signature on the EKG after the fact so your doctor might not be able to tell that you’ve had one,” she explained.

That is all changing now, she says, due to a recent study from Duke University. The study is using an MRI technology, “which has been around for a while, to actually get a picture of the damaged heart muscle, so we might be able to pick this up earlier.”

The MRI technology, although not inexpensive, will be used in a new way.

“Well, for something to be considered a good screening test it really needs to be cheap, it needs to be fast, and it needs to be easily accessible,” Ashton said. “MRI is really none of those things. But it is accurate. So I think that cardiologists are going to be looking more in the future as to how they’re going to incorporate this and amongst what subset of patients.”

This is something that always concerns me. There have been times I have lasted over 16 minutes on a stress test with no angina and failed the test. Subsequent angiograms indicated up to a 98% blockage in one case. However, I also have to be skeptical. As one of the cardiologists I visited recently informed me, if I had pain in the past during any blockages, chances are my neurological system as far as my heart is concerned is intact and functioning. He called into question the need for even an angiogram in this case, thereby implicitly questioning whether there existed a 98% blockage to begin with.

Of course, this conclusion implies my original cardiologist is doing something unethical, which I personally do not believe. He comes recommended by many doctors from various specialties, some of them sending family members to him who are having heart issues. As one of the later cardiologists commented, “Yep, that many stents is typical of patients who see your cardiologist”. He elaborated that, in Austin at least, about 1% of cardiologists will stent you all day long, 1% will never stent you and send you for bypass surgery, and the other 98% will try drug therapy and lifestyle changes before making the decision. At this time, the debate still rages on about how much stenting is too much. I am beginning to lean towards the drug, exercise, and diet approach just because of the wisdom of the body.

While I am alive today because of my original cardiologist, I am also alive because my heart collateralized to the apex from the PDA to the LAD artery. My LAD artery was 100% blocked along most of its length. I should have died, but my body intervened.

Still, one has to worry about these silent heart attacks. I don’t believe the pathology and mechanisms are truly understood and it is prudent that all sufferers of heart disease are aware of this possibility. It is also why it it so important to comply with medical dosing and frequency, and make improvements in your lifestyle.

Update: In the comment section of this blog, reader Angus asks what supplements I do use. I mention N-acetyl-cysteine (NAC) due to its proven liver protection. I would also like to add to that Resveratrol – basically the stuff you find in red wine but in a pill so you don’t need the alcohol. It does have a great deal of supportive evidence for cardiovascular health, but I would talk to your doctor before trying it just to ensure it will not interfere with current medications. I have noted a slight increase in blood pressure (about 3%-5%). I have tried various brands and have found them to be similar in terms of an increase in exercise tolerance. The only real difference seems to be the price. Some of it costs $80 a bottle, some are less than $50 a bottle. It has been featured on 60 minutes, Oprah, CNN, and a host of other channels. A Harvard study heralded Resveratrol as the best thing in medicine since antibiotics.

Almost everyone believes the main purpose of statins is to lower cholesterol and this lowering reduces the risk of a cardiovascular event. However, how do we explain heart attack victims with normal cholesterol levels? While there are many culprits, one of the main areas of interest is C-Reactive Protein, or CRP for short. Measuring your CRP level can be a good indicator of inflammation, and inflammation leads to unstable plaque. So what if you could lower your CRP levels and stabilize your plaque? Your chances of a cardiovascular event decreases significantly. Read Decreasing Markers Of Inflammation Is As Important For Statin Action As Decreasing Ldl Cholesterol (Jupiter Study). From Medical News Today:

A follow-up study on the JUPITER* trial has revealed that a key component of the action of statins is reduction of high sensitivity c-reactive protein (hsCRP), a marker of inflammation, as well as reducing levels of bad cholesterol. The findings are published in an Article published Online First and in an upcoming edition of The Lancet. Publication of the Article coincides with the announcement of the findings at the American College of Cardiology (ACC) meeting in Florida, USA.

Present guidelines for statin therapy emphasise the goal of reducing LDL or ‘bad’ cholesterol. However, statin therapy works best in the presence of inflammation, which is characterised by increased concentrations of the biomarker hsCRP. It is thought that reducing levels of hsCRP helps prevent inflammatory cell adhesion – the process by which inflammation promotes cells sticking together and forming plaques in arteries. Reducing hsCRP could also help by preventing these cells sticking to the endothelium (or inner lining) of the artery, and favourably affect metal-containing enzymes key to plaque stability.

I still recall the days when the reputation of statins was stained by alternative medicine and even some doctors. I also recall listening to those “reports” which showed that taking more of this or that vitamin or herb would have the same effect. Listening to junk science is why I am in the situation I am today. While I do agree there is some evidence for alternative therapies to treat various illnesses, the lack of FDA control on the quality of these supplements amounts to a patient playing Russian Roulette with their health. That is why I do quite a bit of research and self-testing prior to settling on a brand. For NAC I use the GNC brand and Resveratrol Select is my choice or Resveratrol as it provides excellent benefits for less cost than Resveratrol that has some doctor’s endorsement – which basically means they are getting paid to promote one product over another and that cost is being passed on to you.

I am also aware that statins are not for everyone. However, if one heeds the warnings and regularly checks their liver function, statins are safe. I am far more concerned about the Plavix I am on and any future non-elective surgeries I may require than I am about Crestor. Also, if you read My Story, you will note that my CRP levels are extremely low – .5mg/L, with anything less than 1mg/L considered low.

So don’t listen to the negative talk from so-called experts who are out to sell you their latest non-prescription cure for your ailment without doing a lot of research first. In my opinion, there is nothing wrong with adding an alternative approach as a complement to medical therapy as long as your doctor is aware of any other supplements you are taking. Don’t play around with your health, or you may not have it for long.

It certainly has been awhile. It is good to be back.

A lot has been happening and I know some of you are interested in my current status. As far as my latest testosterone measurements, taken 1 month after stopping the oral medications Clomid and Nolvadex, was 550 ng/dL. Not trusting this number and knowing that increases in my testosterone levels have been accompanied by increased liver enzymes in the past, I asked to be re-tested. However, a severe cold held off the latest blood test until yesterday. This time I am checking my testosterone, liver enzymes, kidney function, C-Reactive Protein, lipid profile, thyroid, vitamin-D, and a few other tests. I should have the results back in two weeks.

Meanwhile, next week on Friday I have a cardiac nuclear stress test. If I pass it, it will be 8 months since the placement of my last set of stents. My cardiologist is taking an 18 month sabattical and assisting a poor area in El Paso, TX to build a cardiology community.

For me, that meant going on a search for a new cardiologist. My previous cardiologist suggested one of his partners. This is my first option. My own research lead me to two well respected cardiologists in the Austin area. No surprisingly, they were unhappy with my number of stents, saying that most of them were probably not medically necessary. However, they both agreed that some cardiologists are more agressive than others with the use of stents.

continue

The results are in – my total testosterone is 265ng/dl. This is lower than I would have liked. I get tested again in 1 month. Two weeks of the orals clomiphene citrate and tamoxifen are left and then I take a two week break.

Depending on my next test results, I have a few options according to the Houston doctor who specializes in treating hypogonadism. I could just accept the new number, take another month of clomiphene and tamoxifen once per day as opposed to two and then re-measure after being off the orals for two weeks, or go back on Testim gel for 12-18 months and then repeat the protocol of HCG, clomiphene, and tamoxifen.

What my Houston doctor found amazing is that, when he did this, many of his patients with numbers similar to mine bounced back to 500ng/dl, which is exactly where I would like to be. I think I will be taking this approach if my results are not satisfactory in one month.

The protocol has certainly not been a failure. My original total testosterone was 185ng/dl and now I am sitting at 265ng/dl. I now understand the possible cause of my maximum heart rate drop. My maximum heart rate while on Testim gel (total testosterone around 700ng/dl) was around 182. When my testosterone bottomed out after the Testim cessation it was around 162. Now it is around 166. I believe testosterone to be the main cause of this result. The most testosterone receptor cells can be found in the brain and the heart, so it just makes sense to me. The real test will be if I go back on the Testim and my maximum heart rate increases to 182 bpm.