Seeking advice again from everyone. My husband has a 95 % blockage in his Lad artery . He had a stent 17 years ago which is moderately to severely blocked .
He is not symptomatic fortunately.
We had an appointment with the cardiologist where we discussed a triple bypass and possible re stenting. However we’ve just been told that after a multidisciplinary meeting they have decided the best option is for him to continue on medication. I am really worried. This doesn’t seem right when an artery is blocked to such an extent .
Everyone’s thoughts most welcome .
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Kewen
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No we haven’t had the letter from the cardiologist yet . This was relayed to us by his secretary. A letter is on its way apparently . Once we’ve received this I think we will ask for an appointment or call to discuss .
I read a few years ago and saw a You Tube video by two Cardiologists that some Cardiologists state that Stents don’t help blockages and so shouldn’t be done . However , thankfully some aren’t of that opinion . I’d tell your GP about what happened and ask to arrange an urgent second opinion . It’s no secret that the NHS try to save money . The hospital trusts have a budget . They consider whether it’s worth the expense of operating ( especially on an older person- but it can be at any age ) . A hospital consultant actually told me this
You could also get your hubby’s tests results and all his medical records and see a Cardiologist privately to get his/her opinion . ( Then revert back to the NHS )
Time and money is limited and whilst an actually bad option is unlikely to be offered it is possible that the very best option will not be the first one offered.
Best to chase the relevant notes so it can be interpreted and I agree with Dessert that a second private opinion might be useful. That will definitively inform you whether you are being offered the best option or not by the NHS and you can then push them for appropriate treatment, whatever that might be.
Presumably the thing you're worried about is your husband having a heart attack or a stroke, but there's very little correlation between the degree of arterial blockage and the risk of a heart attack. Some people have heart attacks despite stenosis (blockage) that is so small it can barely be detected. Other people, like both your husband and I, have stenosis at 90% or more, and yet have never had a heart attack. It's just that some people have plaque that's more prone to rupture (which is what causes almost all heart attacks) and other people have plaque that's calcified and stable, so at far less risk of rupturing. Incidentally, there's good evidence that statins help in this stabilisation process. So make sure your husband takes his daily statin!
Furthermore, the risk of a stroke has nothing to do with the arteries in the heart (ie the arteries that might be helped via stents or bypass surgery). Strokes occur when a plaque ruptures in an artery leading to the brain. So stents or bypass surgery will do virtually nothing to reduce stroke risk.
Any surgical intervention, either with stents or with bypass surgery, has some degree of risk. Bypass surgery risk is normally quoted as 2%, but in fact can range from below 0.2% up to nearly 20% depending mainly on age and co-morbidities. But the only concrete benefit of stents and bypass surgery is to alleviate angina. So unless and until your husband reports angina symptoms what's the point of an intervention?
Like his medical team have recommended, he's best off with medication and life style changes.
thankyou again Chappychap. I suppose what I find so hard to get my head round is the idea of a major artery such as the LAD only allowing 5% blood through to the heart. In my mind , and I know I sound basic , surely a replumbed artery is going to work so much better . By waiting is it putting off the inevitable , waiting for this blockage to start causing issues . The consultant explained the medication relaxes the artery’s doesn’t open them up . It’s all quite a lot to get your head round. But thankyou so much for your reply. Made me feel a bit better 😊
"what I find so hard to get my head round is the idea of a major artery such as the LAD only allowing 5% blood through to the heart"
I get what you're saying. However, a 95% blockage doesn't mean only 5% of the necessary blood is getting through.
Firstly, our arteries are oversized, it's like a prudent car designer fitting larger than necessary brakes, or a central heating engineer installing larger radiators than are strictly required. So the remaining 5% capacity might still represent 30% or 40% of what's actually required.
Secondly, we rarely need our full arterial capacity. I understand that your husband is a runner, but he'd have to be going full pelt up a steep hill for an extended period of time whilst carrying a sack of potatoes before he's taxing the limits of his heart capacity! For the 99.99% of our time that we spend ambling around, asleep, or sat at a computer, our hearts only need the merest dribble of oxygenated blood.
Thirdly, we mustn't confuse the diameter of a pipe with it's maximum capacity, if the blood runs faster then more can be supplied through a smaller pipe, although I grant you this is at the risk of increased blood pressure.
Fourthly, every area of the heart can be served by more than one supply of oxygenated blood. The heart has a unique ability found no where else in the body, if an artery starts to become blocked the heart can grow small capillaries that actually bypass the blockage. How amazing is that! It may not be enough for an Olympic marathon runner, but it's an extra bit of supply that can make all the difference.
"By waiting is it putting off the inevitable?"
Again, I see where you're coming from. However, take a step back and look at the whole life prognosis. Your husband's in his sixties. The grafts used in bypass surgery don't have an indefinite life, for a start they're veins (which aren't that strong) that are substituted for arteries (which are really tough). Twenty years is often quoted as a typical life expectancy for grafts. Some people may get longer, others may get less. And it's important to recognise we only ever get one bypass operation. After this there's no second chance. So it makes sense to put it off until really required.
In addition your husband currently has a good quality of life. Why put that at risk? I don't want to be a doom monger, but there are people on this forum who bitterly regret their bypass operations. Yes, they're far outnumbered by people life myself who reckon our bypass surgery was the best thing since sliced bread, but why take that chance? It would be like putting up an umbrella before the rain has arrived, lots of downsides without any benefit!
My goodness I am so grateful for your reply. You have managed to explain things so well and given me some peace of mind. Thanks again for taking the time to reply and helping me to understand why the medication route is probably preferred by the docs .
I suppose it depends on whether there is any other options. I asked my cardiologist this exact question when seeing him every day as I waited for a bypass and he said there were other options but they were really stupid ones.
Had I been offered viable medium term options at 70 i might have taken them but after ten years on medication I had run out of road. The veins used are not as robust as arteries and are smaller but as chappy chap says we dont generally need all the blood being pumped to the heart and they still provide more than enough. It takes a little time to warm them up so I have five minutes of gentle walking before doing anything more strenuous.
I was concerned at the number pf people in my ward who were in their late 40's or 50's and had been provided with heart surgery 10 years earlier, most were obese and hadn't learnt their lessons.
As I mention elsewhere I would want a second opinion to see if you have been provided with the best option, one based on the resources available or whether the alternatives come into the realm of 'stupid options.'
Chappychap has given you a very good and comprehensive reply.
There have been several large long term studies comparing bypass surgery, with stents and optimal medication as a treatment for stable asymptomatic angina.
The multidisciplinary team will have considered this research evidence and other information when making their decision.
As Chappychap has already indicated stents and surgery have been shown to alleviate angina rather than reduce mortality.
I suggest you ask for a written summary of the multidisciplinary team's meeting and discuss this with your husband's Cardiologist.
Here's a link to a discussion about the ISCHEMIA Trial results from the American College of Cardiology.
"The ISCHEMIA trial failed to show that routine invasive therapy was associated with a reduction in major adverse ischemic events compared with optimal medical therapy among stable patients with moderate ischemia."
thankyou Milkfairy. I find it all a bit of a minefield . My husband had two stents 17 years ago and I believe they served him well. He has a familial history of HA , mum 70 , Dad , 50 , two uncles at 55. His brother had a By pass two years ago . He had his stents at 50 when a severe angina attack took him to A & E . I suppose I’m just so fearful of that again. I’ve read so much contradictory stuff regarding stents and By passes, I think for peace of mind I’ll need a second opinion .
I had two stents about two years ago. My cardiologist only did them because I was suffering from angina. He believes that medication is better than invasive treatment and I don’t have follow ups but can always make an appointment. Good luck.
I have cardiac issues of my own, but I also work in cardiac theatres and I see bypass surgery every working day. The procedures are so dangerous, and I think medication first is the best way, especially as he's not currently symptomatic. I've seen otherwise healthy young people die from cardiac surgery and if I needed it myself, I'm not sure I would do it. Having the heart stopped while a bypass machine keeps you alive. The rewarming process and re starting the heart are always tense moments.
Interesting comments. My surgeon advised the risk of death due to bypass surgery was 1% for all cases. In my particular case (age 66, fit, active and healthy) the risk was estimated as being considerably less. I certainly don't regret having the op.
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I was 66 when I had my triple bypass, though my physiological age at the time was assessed as 58. Age is certainly a factor, but it is modified by other aspects of a person's attributes. I was fit and had good lungs on account of my hillwalking activities.
I don’t think it’s age related. Although he’s 68, he’s extremely fit , goes to the gym 4 times a week , walks and runs. But thankyou so much for your thoughts .
Hello Kewen,A good friend of mine has a blocked artery ,after consultations and indeed was on operating table ready for stent to be put in ,the team decided to leave it and treat with medication.
By the way he's triathlete,a triathlon coach (iron man) and they told him to carry on .
yes I did ask the consultant at the last and only meeting if it was ok if he continued weight training and going to the gym and he agreed he should carry on .
I think it’s reassuring that the decision has been taken by the MDT rather than one individual. This means others have been involved in a clinical discussion, the pros and cons, etc and come to a decision together.
jenny, very sensible answer. However they will be aware of the resources they have available and will have been told to operate within them. Their suggestions might be perfectly good but there MIGHT be a better option. An independent second opinion would be useful
Medical and surgical practice is evidence based. This means that the results of your partners tests and their history are looked at in the context of the body of published data. This data is assessed by a multidisciplinary team including surgeons, radiologists and medical doctors and is used to determine the best course of treatment. There will be numerous studies published in the medical and surgical literature assessing the outcomes of both interventions- surgical and medical on patients similar to your partner. These studies will take patients with the same diagnosis and randomly assign them to surgery or medical treatment then follow them for years to assess their progress. Often hundreds or thousands of patients are involved. It will be purely on the basis of this evidence that they will have concluded the best course of action. A second opinion would go through the same process and likely draw the same conclusion. What you don’t state, is how they intend to follow up and monitor their condition - I would hope that there’d be regular assessments of their condition to reassess the treatment plan. Bypass surgery would likely remain an option if there’s any changes. Perhaps these are questions to ask your GP.
Yes I think talking to the consultants secretary yesterday we will receive a letter and then we can schedule a meeting . That will be something we will ask , as in future monitoring of the condition. Although I suspect it will be a case of if he has any issues , eg , shortage of breath , or pain to contact the GP .thankyou
If you can afford it get a private opinion, cost about £200, probably you will get an entirely different opinion very best if luck, scandal but NHS is being broken up and those who run the world don't care because it dies have no impact on them 🤔😭
When budgets are tight compromises are made. The NHS are not miracle workers and it's difficult for us as patients to appreciate the difference between best practice and best options. No one would consider private medical care if this were not the case! Keep asking questions if you feel they haven't all been answered. Wishing you and your husband a successful outcome.
It is so difficult when the so called experts decide on something thst do not necessarily agree with isn't it!? Have you been part of these discussions? or just told of their decision. Not being a le to offer advice, I would perhaps try to ask them.wgat has led to their decision? Good luck.
We had one meeting with the consultant mid December , when he spent a lot of time with us. The multidisciplinary meeting took place in on the 7th Jan where the decision to keep with a medication only route was decided .
Kewen I'm the same as you my LAD artery is completely blocked and the territory around it is also non viable after my heart attack wasn't stented or offered bypass surgery as the doctors held a MDT meeting and they felt that surgery would be of no benefit ti me so I'm on what they call optimal medical management and lifestyle changes.
No they didn't say why but suspect it maybe because I have an indwelling shunt due to neurological problems and shunt that was inserted not long after birth.
Feel like I'm on my own as consultant has signed me off as well I would of thought they would of kept a closer eye on me for the first year which is up in April just under GP care I have diffuse CAD that I can find very little information about it.
Good morning Kewen, I was diagnosed with a severe stenosis of the LAD in February 2022. Like your husband, I did not suffer from spontaneous Angina. Had I not played tennis three times a week and been in the habit of walking briskly and began to feel breathlessness/strange feelings in my left hand I wouldn't have been aware of my condition.
Looking back the cardiologist who carried out my Angiogram perhaps in an effort to mitigate the diagnoses suggested a Bypass would be a great solution for me and it would give me another 20 years of tennis 🎾!
I was not given the option of medication.
However, having read some of the erudite responses to your query and having now experienced Bypass surgery first-hand I may well have pursued or looked into medication as opposed to Bypass surgery.
On another note I truly feel for you and your husband as I imagine it is similar to the one I and my wife experienced Following on from my Angiogram. Life is pretty much on hold. In my case it was until September 26th 2022 when I was called in for my op at zero notice due to a cancellation.
My personal view is having experienced Bypass surgery had alternative drug therapy been offered I would definitely have chosen to opt for it. However, 4 months on I'm playing as well as I did ten years ago and other than the side effects of the medications I'm feeling great so if your Husband does end up with a Bypass it's not the end of the world.
Whatever you decide all the best for the future, regards Denis.
Thanks Denis , grateful for your reply. I feel much more informed asking questions here than I did yesterday morning. I also feel we have some good guidance on questions to ask the consultant when we hopefully have the next appt
I think life was on hold waiting for news of a by pass op. Now I know medication is going to be the preferred option I think it’s time to get on with living whilst being conscious of any changes in hubbys condition .
Curiously we have just found out that his Aunt was told she needed a bypass approx 25 years ago , she refused , was a heavy smoker and she’s now 97 !
Glad to hear you are fit and well and the by pass worked out to be a good thing for you.
Thanks for your response, Kewen. I personally have derived great comfort from this forum as it makes you realise you're not alone and it brings home to you just how good the vast majority of people are.
Hiya...im not sure why they decide that meds are the better choice tbh...ive had my lad artery,which had a100% blockage, stented with stents and restented twice since, as they dont work properly..i was hoping that i could at least have an elected bypass,but they have put me on the said maximum amount of meds to help...which they really dont help much...i get wheezing as part of my angina as i also dont get pains etc...i have spoke to a few people that i know and they say that their symptoms are much worse since they had a bypass and on much more medication than im on..and i take a few lol ..so they make me stand back and re look at what i think would be better...although im with you on thinking that a bypass would be more beneficial in the long term.
I have not been told off by admin. And my experience jn theatre accounts for something indeed! I was merely trying answer the OP about why her husband was given medication instead of surgery. I outlined why I think this may be the case.
As for posting on messages from years ago, first of all, I don't really appreciate you looking at my posting history just to make a ridiculous point, but other people, such as yourself can see my posts and it may help others who can see them , or others who see them can help me.
This is the big debate right now. I had +90% LAD blockage with zero symptoms, in fact had never felt better. Yet given my family history, cardio opted for two stents.
Would I have had a HA due to that blockage? Who knows. I think my cardiologist played the odds and went for the safer option. Then again, 8 months later I had cardiac arrest due to a piece of plaque detaching in my circumflex artery...lesson: cardiologists aren't miracle workers but they will do what they think has the best chance of favorable outcomes. They don't want to lose a patient because of a decision they made.
I would be VERY interested to see the reasoning behind medications, as my cardiologist said that the LAD is the one artery you need to keep clear if possible...but then again, they have all read the recent study that posits medication doesn't lead to worse outcomes than procedures...
thanks Parsigal. I found Chappy Chaps explanation really helpful in understanding the medication route. But I will want to know how husband will be monitored going forward .
Slightly different, but after my HA 5 years ago I had moderate to severe mitral valve regurgitation, and the cardiologist referred me for mv replacement surgery. Two months later I met the surgeon who said “let’s wait and see if medication pulls the valve back into shape.” I’d been sick with worry about open heart surgery, so this plan was a huge relief to me. Six months later the regurgitation was mild to moderate and the threat of OHS has stayed away 😀
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