Hello there,
Thanks for writing in.
I am a qualified and certified cardiologist and practicing cardiology for three decades. Many of my patients can not afford invasive treatment (like angiography and revascularization with stent implantation or coronary artery by pass surgery) for different reasons financial being most important. The reason for telling this that even without such treatment one live good quality life provided one takes medicines. I read your mail with diligence. After reaction with XXXXXXX any one would be scared and you can not be blamed for that. I had gone through the EKGs of April and July 2012 and they fit the description you gave. You have had four heart attacks therefore, every angina like pain is possibly angina only notwithstanding some ambiguous EKG. You wrote you are taking some Ayurvedic medications and nutritive supplements for you can tolerate these but you can not tolerate allopathic medicine, well in that case we have to do is as follows:
1. Let us be sure this not the end of the world. People do respond to these
medicines and nutritive supplements and lead a reasonably comfortable life. I
personally can vouch for scores of such patients.
2. On arrival to emergency with angina like pain- the abnormal q wave you are
describing is not of much significance nor are the poor progression of R wave
specially when there are no ST wave changes. Meaning, some episodes
may not have been angina at all.
3. Hypothetically, if a pain occurs with ST T changes, are you willing to try
relatively newer drug NICORANDIL intravenously? You may not be intolerant
to it or at least we do not know for it has not been given before. It is
different from GTN. Please allow ER physicians, to administer it with syringe
pump with very small dose say 2 mg per hour and can be stopped at the sign of
first intolerance/reaction on your part? Is it not fair deal. If we have an
allopathic drug in our hands which you can tolerate, we all be in much
happier situation. For this drug is available in oral form also to be tried later.
4. One thing I can assure you, over ten years after your heart attack, enough
natural collateral circulation would have developed in your coronary circuit
to make thinking of bypass redundant.
5. Yes, you have to keep close watch on risk factors which led to these episodes
eat proper low fat low salt nil cholesterol diet, surely, you do not want to
add to risk factors for angina and repeated visits to ERs.
6. Lastly, you will will keep watch on any associated illness of cardiovascular
system like high blood pressure or other systems like Diabetes, so that burden
on heart is reduced to maximum extent.

I hope the answer has been of some use.If you have some question, please ask, I will be most happy to answer that. Regards and Good Luck.

With Best Wishes


Dr Anil Grover,
Cardiologist
M.B.;B.S, M.D. (Internal Medicine) D.M.(Cardiology)
http://www/ WWW.WWWW.WW

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Hi there,
Good questions.
1. No two EKG do show that a heart attack could have occurred between the two.
2. Angina is a symptom, EKG if done during the pain show that pain could be
because of coronary artery disease. These EKGs do not show an ongoing insult
of ischemia that is ongoing mismatch between coronary blood supply and the
demand of heart. This is clinically termed as Unstable Angina.
3. Yes some evidence of previous heart attack is there like poor progression of R
wave and q wave in LIII. But this comes with correlation not in isolation.
I understand your problems and can feel the discomfort and pain you have gone through. Still I thought, perhaps wrong on my part, you will be able to try a totally different drug hence a suggestion was made. But as I said by now enough collaterals would have developed to obviate need of additional drug. Good Luck. I regret my impertinence. Take Care.

With Best Wishes


Dr Anil Grover,
Cardiologist
M.B.;B.S, M.D. (Internal Medicine) D.M.(Cardiology)
http://www/ WWW.WWWW.WW

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Hi,

I said angina is a symptom : it is what you feel, and it is not unusual to have no collaborative changes on EKG unless it is unstable. Specially, when due to heart attack (Myocardial Infarction MI) changes can be usually not present. You feel pain because there is enough live viable muscle which is deprived of blood supply it needs. It is just because of previous MI electrical changes are not so clear on ECG. Certainly, your angina is not unstable but it is definite pain due to mismatch of supply and demand. Undoubtedly, absence of EKG changes do not prevent it from being painful nuisance for you. Further clinical significance it is milder in outcome in angina with dynamic EKG changes. Nothing more nothing less.

Definitely, your EKGs show evidence of past attacks. These are not normal EKGs.

No one is saying they are not perceived as insignificant. One can argue yes, these are less significant than the EKG which shows dynamic changes of ischemia which are fortunately absent in your case. Poor R wave progression means the part which produces R wave has suffered heart attack and no longer able to generate that much electrical activity to cause good progression of R wave which is normal. I hope I made myself clear, if not please ask me again, I will be happy to try again. Regards.

Dr Anil Grover

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Hi there,
You have raised good and relevant points and I can answer only part of it scientifically , despite highest qualification and decades of experience I am the first one to admit that there are limitations of our knowledge cause far less than perfect advice. So I will tell you the truth I know no lies whatsoever. I had mostly been honest with my patients in my dealings. For if you tell a lie patient invariably finds out. So far also, I had been truthful to you.

Q wave is pathological based on its depth and duration. If it becomes significantly less on XXXXXXX inspiration, it looses its significance so one is always a little circumspect about q in Lead III and would rather call such changing wave as atypical wave.

You have blockade of coronary arteries which is causing less supply at the time when
a) there is spasm of coronary arteries and effective size becomes less b) whenever there is increased demand from heart say by exertion c) as you are not taking allopathic drugs one may suspect when some blood clot impinges on the block to further reduce the supply. It is not that always your blood supply to heart is less.

b) There is no reason to despair that much, for ten years the collateral supply to coronary artery, you can call them natural graft must have been growing and saving your heart from further ischemic insults. That is almost certain. It is none of your fault that you are allergic to medicines and simply can not take drugs. But inbuilt mechanisms in you are strong enough to protect you. Good Luck and Bye.

Sincerely,

Dr Anil Grover

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