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.

This brings me to an interesting story. During my testosterone replacement cessation I reported a drop in my maximum heart rate (it has since returned to normal). So I thought I would ask a question on the Cleveland Clinic “ask the expert” forum. As the Cleveland Clinic is considered the best Cardiology clinic in the country, I thought asking them the question would fall under the category of a good idea. I told them of my heart rate issue and mentioned my 25 stents. Now imagine this – I go back and check for an answer a few days later and find that someone has addressed my concern. So I decide to read the response and ended up with a lump in my throat. The heart rate issue – no problem said the expert – before adding that he hoped all 25 stents were not in my coronary artery. Gulp! If an expert from the best clinic in the country is concerned, how should I feel about my predictament? In the end, my own research has lead to others who have even more stents. One of the new cardiologists I met with recently stated that one of his patients from my previous cardiologists had so many stents that had failed that additional stenting was deemed inappropriate therapy. A bypass could not be performed due to the presence of the stents, so the patient underwent a heart transplant. This caught my attention.

My attitude towards using stents as a first line of defence is changing. Aggressive drug therapy should always be tried first, especially if your angina is stable. It is now well known that statins like Crestor can stabilize plaque, and that agressive drug therapy, combined with diet and exercise can reverse or halt the progression of plaque buildup. Should I fail my stress test next week, I will probably undergo an angiogram. But this does not necessarily mean I have to get a stent. As a patient, always remember that. A good cardiologist should use the angiogram as a tool to determine the course of therapy. Having an angiogram does not equate to getting a stent. Make sure your cardiologist is aware you understand this. Depending on the blockage (is it re-stenosis or new plaque, or a cominatin of both) and its severity I will be instructing my cardiologist prior to the procedure exactly under what conditions a stent should be used. I have learned a great deal in the past three years and I am taking control of my care. More stents is not the answer anymore – at least not for me – unless absolutely necessary.

I did have angina during exercise up until about two weeks ago. The angina has since passed and my exercise tolerance has vastly improved – both cardio and weight lifting. It could be collaterals. I may know soon enough.

Best case scenario? My testosterone is still in the mid-normal range and I pass the stress test. I think I will allow myself some champagne should these two results come to pass.

I am very excited about my first Mended Hearts meeting next Tuesday. We will be discussing the left ventricular assist device – a device designed with heart failure patients in mind. I will be reporting on the meeting soon after.

Best Regards,

Gerald Merits

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.

Most of you have never heard of Mended Hearts. Hope is their charter. From their website:

Hope for recovery. Hope for a rich, full life. For more than 50 years, Mended Hearts has been offering the gift of hope and encouragement to heart patients, their families and caregivers.

Patients, spouses, family members, friends, medical professionals, Mended Hearts brings together all of us who are faced with the realities of heart disease to form a network of caring individuals.

Take some time to browse through our Web site and learn who we are and what we do. If you or someone you know is a heart patient who would like to visit with one of our accredited visitors online, by telephone or in your community, e-mail us now or call 1-888-HEART99 (1-888-432-7899).

Membership is not free, but the amount is very reasonable. My intention is to join the community of Mended Hearts and become a patient visitor. If someone about to undergo any operation, intervention, or other treatment for heart disease wishes to find someone who will listen to their fears and provide comfort, then I would be called to visit that person and provide support to them.

I was very excited to attend my first monthly meeting, but alas the weather caused a cancellation. Still, there is next month. Look for a local chapter in your area and get involved.

My first paycheck with the 10% cut will start next month. After updating my budget to include this new reality, my wife and I are in the red. Still, we don’t pass the means test for Chapter 7 and the Chapter 13 monthly draw to pay back my credit cards would be almost where it is now. The reason for this is the passage of the Bankruptcy Reform Act of 2005. The allowances for clothing, food, and medications are sparse compared to average expenditures. Even with excellent health care I pay over $270/month in co-pays for my medications.

We have six months left on our current home lease. After much discussion, my wife and I decided moving to a two bedroom apartment mitigates some of the pain. We will be saving almost $600.00/month. I won’t say how much I make, but the pay cut amounts to $500.00 less per month, so this looks like a good plan.

Even with all of this happening, I am still optimistic about the future. I know there a large number of families and individuals out there who are suffering greatly and I pray for them as often as possible. Getting a 10% pay-cut, while painful, is better than losing my job. Many folks have lost their jobs, homes, and retirement accounts. Some are forced to start from scratch. Some have committed suicide, some have killed their families, and some have done both. I can’t imagine the amount of stress it would take to cause some to crack in this manner. I consider myself lucky that my faith, my wife, and my friends are all there for me.

I am still working on getting my first post in my philosophy section completed. I want it to be perfect and communicate my ideas succinctly, so keep checking back on this site and follow the link on the main page to the philosophy section.

Good luck to all of you out there.

Best Regards,

Gerald Merits