human
This is an incredibly thorough reply, thank you for taking the time to explain all of that. My clinical brain cant function because all I can think about is getting another phone call and it being about him.So if Im understanding correctly, it sounds like the collateral vessels are more effective than I assumed. Hes a pretty active guy, is there danger if the left side cant meet the metabolic demands of the heart during exertion? Any risk of right sided ischemia?Ill be joining him at his appointment to take notes and make sure hes compliant with those lifestyle changes. He still thinks this is all routine and not a big deal. Your reply is helping me catch my breath a bit, so thank you again.
gpt
Yes the collaterals are presumably well-developed. The danger from over exerting himself through exercise isnt of much concern, he would be symptom limited well before there was irreversible damage. Other issues like sepsis could put some strain on the heart but unlikely to cause any sizable infarct.He needs to really maximize the medical management - strict risk factor control with high-intensity lipid lowering therapy (doesnt matter if cholesterol is high) and tight monitoring of blood pressure. If there is a hint of diabetes one of the newer agents also would be good.The medicines actually work quite well combined with lifestyle changes. CABG and stent are more bailout procedures if a lot of heart muscle is threatened by very narrow arteries, which is not the case here.
Worried about my dads cardiac cath resultsMy father is a stubborn mule of a man, and I need to know if Im right in pushing this issue until he gets the care he needs. I am a pediatric ICU nurse, so adults are not my thing.My dads history: 63yo male, normal BMI, moderate physical activity 5 days a week, former smoker x 30+ years (quit in 2017 when my son was born). He takes Repatha, losartan, baby aspirin, and ambien (he works nightshift & sleeps during the day). Generally healthy and active, only pmhx is high cholesterol (we are Cuban and he eats a very high fat diet and a lot of red meat), and two stents placed in 2017. Extremely extensive family cardiac history as follows (this is tough to keep track of so bear with me):His father: quadruple bypass, 5 TIAs then full carotid blockage, heart attack = died in 10/2014His mother: quadruple bypass, years later had MI & stroke = died 4/28/2008Brother #1: quintuple bypass in his 40s... died of heart attack in his sleep 5/2019 @ age 58Brother #2: stent in his 40sSister: MI (widow maker) & triple bypass 4/2019Brother #3: 3/2023 bilateral carotid 90% blockages, persistent A-fib.And those are just his immediate family. That history extends to every branch of uncles & cousins as well. They should give us a discount for buy two get two bypass at this point.My dad recently went for his annual cardiac appt and failed his stress test (he was unable to complete it) so they had him go for a cath. That revealed 100% blockages in several areas (diagram drawn by his doc here: https://imgur.com/a/0adwYqA ) but they didnt perform any interventions. The doc said theyd have to compare this cath to the one he had in 2017 to see the changes and decide how to proceed, but that he felt ok just watching things for now. His next appt is in June, and my dad seems to think all is well. He said oh it went fine, they told me my body made other pathways for the blood to flow. Ugh.I am alarmed. Cardiac isnt my specialty, but wouldnt this warrant a double bypass? Isnt his personal and family history enough to be more proactive with intervention? I was very close with my uncle and he passed away in his sleep just months after a normal cardiac exam. I dont want the same to happen to my dad, and Im concerned that hes heading towards a major event. Any insight? Am I right to want to push him to follow up on this immediately? Thank you.
So obviously your dad has significant coronary artery disease. The family history at this point (which is ridiculously extensive) doesn't really matter since we know his anatomy.It looks like his left main coronary artery and left anterior descending artery (LAD) are open. His right coronary artery is blocked but past this it presumably backfills from the LAD through enlarged (collateral) vessels that wrap around the apex of the heart. This is why he had a positive stress test - with enough exertion the oxygen demand is too high for the left side to keep up.Almost all of the benefit for a coronary bypass procedure is with patients who have significant narrowing of the left main coronary artery or both of the immediate downstream arteries. These feed a large portion of the heart muscle, and not just your dad but anyone does poorly if they are blocked.However when these are open, which is the case here, the benefit is less clear and this is doubly true in the absence of significant symptoms. A left sided graft may not even stay patent in this setting, since there is competitive flow down the LAD. We would not usually do a bypass just for right coronary disease, the benefits do not appear to outweigh the risks in this scenario.The other blockages are being backfilled by the open arteries, and unless he develops new symptoms then medical management is at least as effective and safer. It isn't that the blockages aren't a concern, it is whether bypassing them is beneficial. In this case if it were my dad I would prefer aggressive medical management and lifestyle changes as much as possible.