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September 18, 2011

Great Docs and Technology Saved My Life Thursday

"You flunked the stress test," was the essence of the call Tuesday morning. I'd thought I aced it. "Don't do anything you don't have to. We'll get you in to see a cardiologist ASAP."

"But I got through the whole test," I told the cardiologist that afternoon. "The EKG was normal; they were surprised that it took so long to get my pulse up but that's because I climb mountains and play tennis all the time." I was in denial, just as I've been when I got the first mild chest pains during warm up for racquetball last spring and played through them; just as I was when my chest tightened at the beginning of most spring climbs and I kept walking (but a little slower). My denial had faded some in early summer when I woke up twice with chest pain, took two Excedrin, and went back to sleep. But it was only a little pain; really just pressure on my sternum. And it stopped happening.

Because I time everything and my Garmin watch tracks my pulse, I knew I was climbing mountains more slowly and reaching lower maximum pulse levels even though the pain went away. I hiked alone so people wouldn't have to wait for me (Bruiser, my labradoodle, can always find something to sniff while he's waiting). It bothered me that I was losing at tennis, usually in the second and third set when it was an effort to get my arm up to serve. I tried jogging to get in better shape and couldn't quite run a mile on the flat. But I am 68, getting older, but… So I asked my doctor to make an EKG part of my upcoming physical.

"There's a slight abnormality," she said. "And you have a lousy family history. I think you should take a stress test." I really did think I aced the test. I felt good. I could see the inside of my heart on the echocardiogram and it even had cool Doppler, which used color coding to show the velocity of blood and tissue in both directions. It looked like there was a cheerful little guy standing in the middle of my heart waving his arms up and down (the valves) and cheering me on "Yay, Tom. Yay, Tom." They took video of the heart at rest; then the treadmill up to 142 pulse; then more pictures so they could compare the stressed heart to the resting one.

"Much of the muscle wall of your left ventricle is not participating in the pumping after stress," the cardiologist said. "The test has only about 10% false positives. The most likely cause is a blockage in one or more arteries. You could die suddenly from that condition, most likely from a piece of plaque breaking off and corking something crucial. You should have an angioscopic examination to find where the blockages are." That means, in case you don't know, that a catheter is threaded through your groin or wrist artery into the arteries which supply the muscles of the heart. It injects die, which makes the blood flow show up clearly on a monitor.

"And then what," I asked?

"If the blockage is not too widespread, they'll put in a stent immediately as part of the same operation while the catheter is still in place."

"I've heard about stents," I said; "aren't they overused?"

"They're not overused here in New England," said the doctor. "The financial incentives are different and we tend to be very conservative in the use of stents." He explained that the most statistically significant trial of stents vs. medication alone vs. bypass surgery is somewhat inconclusive. The long term survival rate was about the same with either medicine alone or stents plus medicine. However, in the first three years, quality of life is better with stents because the blockage is immediately dealt with. Long term results are about the same for bypass surgery as stents for relatively simple cases and better with surgery for complex cases. Stents do sometimes have to be redone. There is, of course, more mortality associated with the bypass operation itself and recovery is lengthy and painful (as I know from friends and my father). One reason why results from all three approaches tend to converge over time is that people develop new blockages at new sites after the first blockages are cured – either because they haven't changed their lifestyle or because they can't change their genes.

Since the big trials were done, a second generation of drug-eluting stents has been developed which should be better than either uncoated stents or those coated with the first generation of medicine; so quite possible the next big trial will show significantly better outcomes for stents than either medicine alone or bypasses when there is an option to use stents instead of bypasses. The drugs discourage the body from growing new plaque inside the stent but do increase the risk of clotting. To counteract that risk, you take blood thinners for a year.

I checked all that on the web with the help of my brother Lee, who is a pediatrician with a strong interest in and knowledge of overall health. And I scheduled a second opinion just before the angiogram was scheduled to begin Thursday. I had no doubt I wanted the diagnostic information from the angiogram; I was skeptical I wanted to go right into having a stent inserted and knew, although I'd be awake through the operation and when we learned what the angiogram showed, I'd be much too dopey to give informed consent to anything at that stage.

"The EKG was normal," I said. I'm now back in denial. The report even says that my "functional capacity was above normal. I don't do anything with good form; maybe my heart doesn't either. You've already explained to me that it's normal to find some blockage in almost everyone, even children. How will we know I really need a stent? Maybe there isn't any serious blockage."

"There's a 99% chance, in my opinion, that you have a serious blockage – by which I mean a blockage of over 70% - in at least one artery," the cardiologist explained. "If there's no blockage above that level, we'll do nothing and have to reconsider what's causing the symptoms. If there are one or more blockages above 70%, if there aren't too many and they aren't too complex, we'd like to stent immediately. If it's worse than that, we'll stop and can consider options later with the new information we have. You wouldn't want the surgeon to put in stents if he doesn't think they'll work, would you?" He also told me, politely, that I'm not more qualified to determine whether I need stents than cardiologists are.

"OK," I said begrudgingly. "Numbers I can live with. Less than 70%, no stent. Too complicated, we put off the decision. Over 70% and relatively simple, stents away. But, if the decision is on the cusp, two things I know that the surgeon needs to know: I will stick with any post-op regime and I'd gladly take some risk to be able to stay active." We had a deal. Time to get prepped for the operation.

The surgeon was ready so two nurses prepped me fast and efficiently. IV already in, I said good-by to Mary (we were both scared) and was wheeled to the operating room on a gurney. The surgeon threaded the catheter in through my right wrist and guided it to the arteries serving my heart; I'm not quite sure how. I'd hoped to watch the catheter on the TV screen next to the operating table – maybe I did – but the sedative you get for this operation makes you forgetful even though you can respond to requests to move this way or that. I do remember him saying that they'd found 98% blockage in a major artery and showing me that on the screen. I could see that the thick flow of blood simply stopped at one point and became a tiny stream. "Can you stent it?" I remember asking.

A balloon is threaded over the catheter and the stent is paced over the balloon. The balloon is inflated in the blockage and compresses the plaque back to the artery walls (angioplasty); the same inflation expands the stent so it stops the walls from rebounding. Catheter removed from the tiny hole in my wrist. "It's done," he said some time later. "Do you want to go home tonight?"

The surgeon went off to talk to Mary and show her the video. Soon she rejoined me in recovery; I was out of the hospital at 6PM; amazingly just five hours after the operation began. In a week I can resume full activity and will, quite possibly, hike faster and win at tennis.

I was really stupid to ignore the first symptoms, especially to try to walk them off by hiking alone (please don't do the same). I am lucky to live in a time when techniques like echocardiography exist. The previous stress test I took relied on EKG only – and showed no problem. The EKG showed no problem this time; it only showed up on echocardiogram. I was also lucky to be treated by an amazingly skilled and compassionate team associated with Fletcher Allen Health Care. We're very well-served having them here in Vermont.

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