Brief Answer:
I would explain as follows:

Detailed Answer:
Dear,

I am glad to discuss with you again!

I remember our last talk and would like to emphasize my opinion regarding the best strategy to follow in an acute coronary syndrome patient (which is similar to your case).

Let’s start with the definition of a critical or life-threatening condition.

We have seen in our daily clinical practice (working many years at an intensive cardiac care unit) that there are no clear cutoffs of the atherosclerotic plaque burden and the risk of an acute coronary syndrome (myocardial infarction).

In other words, a myocardial infarction may occur in the presence of a 100% occluded coronary artery, as well as a dangerous and life-threatening heart attack may happen because of a 30% or 50% coronary stenoses.

We have assisted many patients complicated with life-threatening cardiac arrhythmias (ventricular tachycardia and fibrillation) and apparently with clinically non-significant coronary stenoses (less than 70% - 75% coronary stenoses).

If left untreated they would have otherwise died. This in not because only of the reduction in blood flow within a fixed stenosis coronary artery but because of other superimposed disorders such as coronary spasm (more likely in a moderately narrowed artery), or clot over a destabilized coronary plaque.

That’s why it is difficult to predict with certainty whether it is completely safe deferring a second revascularization procedure to a distant time outside the first hospitalization.

My personal professional opinion would go in favor of performing the second revascularization intervention (LAD angioplasty and stenting) within the first hospitalization a few days after RCA treatment.

This would sound medically safe and may be more cost effective (probably you would not need to pay a separated expensive treatment).

This latter strategy would help to better monitoring of any hemodynamic changes (due to abrupt blood pressure and heart rhythm fluctuations) and promptly treating any possible complications from the first coronary angioplasty (such as stent thrombosis which fortunately was not the case).

So, to conclude there are several reasons why the completion of all the coronary arteries revascularization should be done during the first hospitalization.

From the other part, there are hospital policies trying to minimize the time of hospitalization and reduce costs, even in a public hospital (this is universal rule). And I believe in your treating hospital they have followed similar rules, of course tailored in accordance with the local legal background.

I am afraid that it is difficult to raise sufficient doubts on their decision t o follow a two stage coronary revascularization, as this is supported also by the medical and scientific evidence.

What could be discussed and probably reasonably claimed is the fact they have discharged you from the hospital a bit earlier than what should in fact be your hospital stay.

They confirmed on their response to your concern that you have not been introduced on your discharge to any vasodilator therapy (such as Lisinopril), because your systolic blood pressure was borderline (99 – 100); which in fact is a clear tendency of hypotension.

This shows not a yet stabilized hemodynamic profile, nevertheless you were discharged from the hospital, which could have posed you to several risks starting from severe hypotension with detrimental effects on the coronary stent to the other side of the coin (bouts of hypertension that could aggravate cardiac ischemia in the presence of an untreated second coronary stenosis), without mentioning the risk of a life-threatening cardiac arrhythmia, a potential complication around the early period of an acute coronary syndrome (heart attack).

You should discuss with an expert who owns high proficiency in medical legal issues to support you in affording with a rational request for reducing treatment cost from the hospital.

Hope to have been of some help to you!

In case of any further questions, do not hesitate to ask me again!

Kind regards,

Dr. Iliri

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Brief Answer:
You are welcome!

Detailed Answer:
Dear,

I am glad to have been helpful to you!

I would just encourage you to follow a healthy lifestyle (like you are doing now) and periodically check your blood lipid profile every 6 months.

A close monitoring of your blood pressure is necessary too.

It is also important avoiding straining physical activity (weight lifting, etc.).

Hope you will find this answer helpful!

If you have any other questions, please let me know!

I would be glad to answer to all of your questions at any time!

Wishing good health,
Thanks
Dr. Iliri

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Brief Answer:
Opinion as follows:

Detailed Answer:
Dear,

You are right when you think of stress as a cause of those blood pressure and heart rate bouts. It seems to be an anxiety disorder behind such fluctuations.

It doesn’t matter which one is the triggering factor: thoughts about work, health issues, family, bad relationships, etc.

The outcomes are the same: palpitations, tachycardia, and elevated blood pressure values, sometimes skin flushing, nausea, near fainting, abdominal cramps, etc.

The most important issue in this regard would be to control the stressful factors (thoughts, situations, activities, etc.); and this would by properly facing with them and not avoiding them.

In other words, I don’t think that you should restrict your daily activities including work, but instead engaging in more leisure activities such as outdoor walking, cycling, yoga, aerobics would be very helpful in this regard.

In addition, just the presence of a few high blood pressure bouts would not be a rational reason for increasing the daily anti-hypertensive dose.

Instead it would be better to closely control your blood pressure values for a couple of day up to a week (several times daily) before thinking of a therapy modification.

Meanwhile, the best strategy would be continuing to follow a healthy life-style, physically active daily profile and a lot of fun.

Hope to have been helpful to you!

In case of any further questions, feel free to ask me at any time.

Kind regards,
Dr. Iliri

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Brief Answer:
You are welcome!

Detailed Answer:
Dear XXXXXXX

I am glad to have been helpful to you!

These blood pressure values are within the normal ranges and there is nothing to worry about!

Hope to have clarified some of your uncertainties!

If you have any other questions, please feel free to ask me again!

I would be glad to answer to all of your questions!

Wishing good health,

Dr. Iliri

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