Thank you for your recent request for a second opinion consultation from Cleveland Clinic. Please find below the second opinion consultation written by Department of Cardiovascular Medicine.

Diagnosis / Reason for Consultation:

In your preliminary materials provided, you asked three specific questions. These include:
  • What treatment options can Cleveland Clinic offer us given that our current cardiologist has advised us that he considers the Ramus to be too small for angioplasty/stenting at our current medical facility (CABG was also ruled out as an option leaving only medical treatment)?
  • What is the long-term prognosis if we continue on the current treatment plan versus what might be available at a more advanced level of care facility?
  • Given that the patient has suffered 3 or 4 "coronary events" without any demonstrable damage to his cardiac muscle tissue, what kind of limitations or decrease in his quality of life might we anticipate in the future?

    • Diagnostic Summary / Treatment Summary:

    Upon review of your records, you are a 59-year-old gentleman and with the exception of your coronary artery obstructive disease, remain quite healthy. Your cardiac history dates back to 2001 at which time you demonstrated multiple episodes of severe chest pain. This culminated in a three-vessel coronary artery bypass grafting procedure performed at Providence Alaska Medical Center in September 2001. This involved a left internal mammary artery bypass graft to the first diagonal branch of your left anterior descending coronary artery and a free right radial artery graft sequentially grafted to the right ventricular marginal branch and distal right coronary artery.

    In the year 2002, your severe chest pain recurred and in March you underwent a balloon angioplasty to the left internal mammary artery graft. Unfortunately, your severe chest pain recurred in April 2002 and an intracoronary stent was placed to the insertion site of the left internal mammary artery graft into the first diagonal branch.

    You presented once again in August 2002 with recurrent severe chest pain post angioplasty and stent placement. At the time of this catheterization, similar to prior catheterizations, your heart function remained normal without evidence of prior heart damage or myocardial infarction. Your native coronary circulation again remained relatively unchanged, fortunately only demonstrating mild obstruction in your left anterior descending coronary artery. The circumflex coronary also, had at most, mild to moderate obstruction but nothing flow limiting. The right coronary artery had severe native disease but continued to be served well by a patent right radial artery graft sequentially placed. The left internal mammary artery graft was also widely patent and demonstrated prompt flow to the diagonal branch. There was at most modest in stent re-stenosis. The native diagonal branch, which was located close to the distal or terminal aspect of the left main coronary artery demonstrated a subtotal blockage near 100% with very slow antegrade or forward filling of this vessel.

    In addition, no retrograde flow from the left internal mammary artery graft was seen into this vessel. Therefore, while the predominant portion of the first diagonal branching system was adequately perfused and subserved by the patent left internal mammary artery graft, a portion of the native vessel remained compromised at the time of the August 14, 2002 catheterization due to the antegrade stenosis and lack of retrograde filling via the left internal mammary artery graft.

    It should be mentioned that serial nuclear perfusion tests have demonstrated an excellent workload without evidence of inducible myocardial ischemia. Additionally, lipid values have remained satisfactory with the most recent total cholesterol being 158.

    Your current medications include Diltiazem in an extended release form at 120mg daily, Protonix 40mg twice daily, Imdur 60mg daily, Folic Acid 800mcg daily, Ecotrin 325mg daily, Atenolol 25mg daily, Plavix 75mg and Lipitor 20mg daily.

    Second Opinion Recommendations:

    It is apparent to me that you have received both excellent and thoughtful care locally. Cardiac catheterizations and percutaneous interventions in the form of angioplasty and subsequently an intracoronary stent have been appropriately applied in your situation. The chest discomfort that you continue to experience on an intermittent basis is most likely secondary to the high branching first diagonal coronary artery, which is in close proximity to the left main coronary artery. This is an extremely small vessel but can provide symptoms of myocardial ischemia in circumstances where oxygen supply does not meet oxygen demand.

    At the present juncture, I see the risk to benefit ratio favoring medical therapy. Angioplasty and stenting of this native high branching diagonal coronary artery I believe, would be rather high risk as it is a small vessel and also, it's proximity to the left main coronary artery is of significant concern. A retrograde complication into the left main coronary artery could be very serious and life threatening.

    I should also add and emphasize that this diagonal branch subserves a small proportion of your heart muscle or myocardium. While responsible for intermittent symptoms of angina pectoris (cardiac chest discomfort), I do not believe that this small artery is prognostically significant and will not adversely affect your future health. I agree with your local physicians that bypass surgery would not be worth the risk and also, the likelihood of maintaining a patent graft to such a small native coronary artery branch, would be on the lower side. Thus, continued medical treatment seems best.

    To mitigate your symptoms, reducing oxygen demand in the setting of reduced oxygen supply is best. While the Diltiazem medicine was appropriately prescribed initially in the postoperative period to prevent spasm of your radial artery graft, I believe this is a medication that should be limited. Reduction of your Diltiazem dose and potentially discontinuing it will allow your local doctors to increase the beta-blocker dose in the form of Atenolol. Beta-blockers such as Atenolol have been proven to extend life and prevent re-infarction in patients with coronary artery disease. The same cannot be said for a calcium channel blocker such as Diltiazem. I would actually favor that your local doctors switch your Atenolol to a longer acting form of Metoprolol such as Toprol XL. The target dose would be at least 100mg daily. I believe this would be attainable in the setting of a reduced and possibly discontinuing Diltiazem.

    In addition, a program of regular exercise and dietary discretion is highly recommended. I have noted your height and weight and I presume you are of appropriate weight. I suspect you could lose approximately 5-10 pounds through an even more active exercise program and a program of dietary discretion. However, based on the numbers, your weight seems quite appropriate.

    Goal lipid values should include a total cholesterol of less than 150, an HDL cholesterol greater than 45, an LDL cholesterol less than 100 and a triglyceride value less than 150. If you are not at these goals, further dietary modification is in order. The Folic Acid and Imdur medications seem most appropriate. I also agree with the long term Plavix. I believe your aspirin could be reduced to 162mg maximally as the Plavix and higher dose aspirin are felt to expose you to a higher bleeding risk but without significant therapeutic gain from the higher dose aspirin.

    Thus, in summary, I concur with your local physicians that medical therapy is best. I suggest you approach your local doctors about adjusting your medications as I have outlined. Achieving your cholesterol and triglyceride goals may involve further dietary discretion and increased exercise. I should also add that your local doctors should check a rather new blood test termed an ultrasensitive CRP. CRP stands for C-reactive protein. If this is elevated, increasing your Lipitor (Atorvastatin) dose is appropriate.

    In addition, you are not on a medication of the ACE inhibitor class. In patients with coronary artery obstructive disease, this is felt to be a helpful medication to reduce the likelihood of repeat heart attacks and sudden death in patients with coronary disease. I would encourage you to do some research on the Internet if you are so inclined. This would involve searching the HOPE Study findings, which involved a medication called Altace, also known as Ramipril. Approaching your doctors about this type of medication is appropriate. If you take the above lifestyle modification measures and continue with your medications, I suspect your future prognosis is excellent. I also think your quality of life will be very acceptable and above average. Particularly, given the lack of heart muscle damage, your ability to exercise and remain active should remain optimal.

    We appreciate the opportunity to provide you with a second opinion consultation through the Cleveland Clinic MyConsult program. We hope that you find it informative and helpful.