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My 74 Year Old Brother, Overall Very Healthy, Very Active

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Posted on Mon, 15 Feb 2021
Question: My 74 year old brother, overall very healthy, very active ...normal blood pressure, no diabetes, cancer, anything else...had a red flag on a stres test. The doctor performed an angiogram and found a blockage 100% in his LAD. I have the diagram from the doctor. He is recommending a bypass. Another doctor said that might not be necessary since my brother is asymptomatic, no chest pain or shortness of breath, excellent vitals, and has low blood pressure without the need for medicine. We would love to get a second opinion.
doctor
Answered by Dr. Ilir Sharka (58 minutes later)
Brief Answer:
I would recommend performing a stress cardiac MRI.

Detailed Answer:
Hello!

Welcome to Ask a Doctor service!

I understand your concern and would explain that in this case it is important performing a stress cardiac MRI, which would properly guide us on the necessity or not of a cardiac bypass.

You should know that this is an accurate test to help examine better the heart function and structure and also the myocardial viability ( tissue characterization). From the other hand this test can help investigate any potential cardiac ischaemia.

Only by performing this test, we would be able to come into a right conclusions and decide if bypass is necessary or not.

You should discuss with his doctor on the above test.

Hope you will find this answer helpful!

I remain at your disposal for any further questions whenever you need!

Kind regards,

Dr.Ilir Sharka, Cardiologist
Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Ilir Sharka (27 minutes later)
Thank you for the prompt answer. Is that different from a regular stress test?
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Follow up: Dr. Ilir Sharka (21 minutes later)
Thank you! I have never even heard of that test and glad to know it exists. We will definitely talk to the doctor about that. Our next appointment is Tuesday. I also have another question. Is the location of that 100% blockage a little less dangerous than if it was higher up? One doctor mentioned that the location of it was not as dangerous as in some cases.
doctor
Answered by Dr. Ilir Sharka (20 hours later)
Brief Answer:
My answer as follows:

Detailed Answer:
Hello again!

A cardiac stress MRI is different form a cardiac stress test, as it is a type of cardiac MRI and the patient does not do any physical effort during the test.

It can help examine the myocardial tissue viability and its collateral blood flow.

According to the angiogram report, there is a 50% proximal LAD stenosis and a distal 100% occlusion. In such case, the myocardium supplied by a distal 100% occluded branch could theoretically have two alternatives:

1- the underlying cardiac muscle might have not survived due to interruption of blood supply; the myocites may have died and been replaced with scar tissue. In such case performing a revascularization in such area (bypass) would be worthless as it would serve to nothing (there is no contracting muscle any more)

2- the second option is that some small collateral vessels may have developed with time giving a suboptimal but vital blood supply, such way saving the myocites from death. The cardiac muscle may decrease its oxygen request on its own and helping such way to reduce further damage expansion. In these conditions performing revascularization (bypass) would be really helpful as it would restore the blood supply and return the normal muscle metabolism.

Coming to this point, the cardiac MRI would help to differentiate between these two conditions, and conclude whether he should undergo bypass or not.

Hope you will find this information helpful!

I remain at your disposal at any disposal for any further questions whenever you need!

Kind regards,

Dr. Iliri

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (22 hours later)
Dr. Ilar

I cannot thank you enough for such an honest and comprehensive answer! Thank you so much. We are going to the cardiologist today and we are going to request an MRI. To be honest I’m surprised this is not a routine part of pre-surgery testing, but I suspect heart surgery rates would be greatly reduced if so....

So does the fact that the 100% blockage is in the distal not higher, make it any less of a ‘widow maker’? I guess just to be blunt, my question is : if XXXXXXX chooses not to do anything at his age, would he be in grave danger or is there also a likelihood of a good outcome given the fact he has low blood pressure, no diabetes no heart pain, 98-100% oxygen saturation all day, an excellent pulse, etc...

We feel like maybe he has had this blockage for a long time but I guess there is not a way to determine how long it has been blocked? Or maybe the MRI would give an indication?

Thank you so much I am really enjoying learning all these new things!! Truly, I believe I have gotten more solid information and reasonable advice from you, than from three doctors we have spoken to in person, here!!
doctor
Answered by Dr. Ilir Sharka (24 hours later)
Brief Answer:
I would explain as follows:

Detailed Answer:
Hello again!

I understand your concern and would explain that as long as he does not have chest pain or shortness of breath during straining physical activity, it may indicate that he may do well with medication, even without surgery.

Anyway, the cardiac MRI is necessary because it can give more information if the 50% stenosis is causing myocardial ischemia during physical effort or not.

Regarding the time of blockage, the cardiac MRI can give a lot information if this blockage is recent or it has happened a long time ago.

Hope to have been helpful!

I remain at your disposal in case of further questions whenever you need!

Kind regards,

Dr. Iliri

p.s.: Sorry for the delay in answering but I was too busy on a night shift.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (3 hours later)
Thank you again!! I was doing talk to text and I said we were going to the doctor today but it should have said Tuesday the 19th. I will follow up with you that evening or the next day. Again thank you so much, your help has been such great value!!
doctor
Answered by Dr. Ilir Sharka (12 hours later)
Brief Answer:
You are welcome!

Detailed Answer:
I'm glad to have been helpful!

Let me know how it's going on.

Kind regards,

Dr. Iliri

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (13 hours later)
Thank you Sir!
doctor
Answered by Dr. Ilir Sharka (11 hours later)
Brief Answer:
You are welcome!

Detailed Answer:
You are welcome!
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (3 days later)
Good afternoon! Well we went to the cardiac doctor on Tuesday but unfortunately the doctor wasn’t there and we saw the physician assistant. She seemed to indicate that before the insurance would pay for an MRI, that XXXXXXX would have to go through ECP therapy. Sadly I feel like this is a big waste of time and money because from what I have read it targets angina high blood pressure and fatigue. Steve’s blood pressure is 122/66 at the doctor and generally close to that at home, usually at 117-122/80 on daily home readings. This is without any medication. He mows an acre of land with a push mower every week and is extremely physically active he never sits down until the end of the day. It is not like he needs any type of ‘artificial’ heart exercise. So right now the physician assistant is looking into the insurance to see what can be done. We are really hoping they will approve an MRI without the ECP!

We are completely on board with the idea of an MRI, we feel like this will enable us to make a fully informed decision and we so greatly appreciate your advice! I’m not sure when I will know more because sometimes it takes several weeks to deal with insurance companies here in Texas! But as soon as I get another answer I will let you know.

Also the primary care physician suggested he double his statin dose from 20 mg to 40 mg daily. Oddly the cardiac doctor never did a lipid test, so the last one on file is from the primary care physician one year ago. It was normal at that point but the primary care doctor thinks it’s best to double the dose. He told him to start doubling the dose right away. Tomorrow my brother will be getting a lipid test and I assume we will have the results Monday or Tuesday. Historically his cholesterol has just been slightly higher than normal.

I will let you know as soon as I hear more and again thank you so much and I hope you and your family have a wonderful weekend!! you have been very much a blessing to us!
doctor
Answered by Dr. Ilir Sharka (15 hours later)
Brief Answer:
You are welcome!

Detailed Answer:
Hello again!

Of course the decision of increasing statins should be based also on the blood lipid profile results.

I would be glad to review his test reports as soon as you will be able to upload them for a second professional opinion!

Please let me know about everything!

Wishing all the best,

Dr.Iliri
Above answer was peer-reviewed by : Dr. Kampana
doctor
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Follow up: Dr. Ilir Sharka (8 hours later)
So appreciated! my brother went today January 22 to the lab so hopefully the results will be back Monday or Tuesday and I will give them to you!

Look forward to your opinion!
doctor
Answered by Dr. Ilir Sharka (24 hours later)
Brief Answer:
I remain at your disposal whenever you need!

Detailed Answer:
Please let me know about everything!

I would be glad to assist you at anytime!

Regards,
Dr.Ilir
Note: For further follow up on related General & Family Physician Click here.

Above answer was peer-reviewed by : Dr. Raju A.T
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Answered by
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Dr. Ilir Sharka

Cardiologist

Practicing since :2001

Answered : 9538 Questions

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My 74 Year Old Brother, Overall Very Healthy, Very Active

Brief Answer: I would recommend performing a stress cardiac MRI. Detailed Answer: Hello! Welcome to Ask a Doctor service! I understand your concern and would explain that in this case it is important performing a stress cardiac MRI, which would properly guide us on the necessity or not of a cardiac bypass. You should know that this is an accurate test to help examine better the heart function and structure and also the myocardial viability ( tissue characterization). From the other hand this test can help investigate any potential cardiac ischaemia. Only by performing this test, we would be able to come into a right conclusions and decide if bypass is necessary or not. You should discuss with his doctor on the above test. Hope you will find this answer helpful! I remain at your disposal for any further questions whenever you need! Kind regards, Dr.Ilir Sharka, Cardiologist