Brief Answer:
I would explain as follows:

Detailed Answer:

Hello,

After carefully reviewing your medical history I would explain that the decision to first treat the culprit coronary lesion (that's RCA) is an accurate treatment strategy.

It has been shown that treating multiple arteries in the setting of acute myocardial infarction in an escalated manner is a more safe strategy than doing multiple angioplasty at the same moment.

The decision of proceeding with LAD angioplasty in a second moment seems a rational approach.

Also the accompanying antiaggregants therapy (first Aspirin + Clopidogrel and thereafter Aspirin + Ticagrelor) appears to be the right strategy.

What is debatable seems to be the proper timing of the second angioplasty (on LAD).

In my professional opinion, the most appropriate time to proceed with LAD angioplasty and stenting would be the first hospitalization a few days after RCA treatment.

This approach would avoid subsequent anginal symptomatology due to LAD stenosis with the inherent risk of a second heart attack (myocardial infarction) and unequivocally the excessive burden increase of financial issues due to a second hospitalization.

Fortunately, there was no heart attack a second time and and you have been recommended to proceed on the right drugs therapy.

Coming to this point, the best strategy to follow is a healthy life-style with diet; avoiding potential coronary risk factors (properly treating hypertension, possible dyslipidemia, avoiding close smoking contact, controlling possible glucose metabolism disorders, following a physically active daily profile etc.)

A careful and periodic medical follow up and correct medication treatment remains an important key of success. That's my personal professional opinion.

Hope to have been helpful to you! In case of any further questions, feel free to ask me again.

Regards,
Dr. Iliri Sharka
Cardiologist

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Brief Answer:
My opinion as follows:

Detailed Answer:

Hello,

My answer is yes! Your detection is correct. ACE inhibitors and even beta-blockers are a must therapy in the majority of AMI patients and is highly recommended to start early after myocardial infarction diagnosis (if no contraindications exist).

Nitrates use is dependent on the underlying symptomatology (whether chest angina persists or not). They should have been started soon after the first PCI during the first hospitalization and your discharge prescription should have had those drugs included.

Anyway, we are not sure about the doctor’s doubts; probably they were afraid of potential risk of hypotension that may have been manifested during your first hospitalization.

It is well known the risk of hypotension is higher when associated with inferior myocardial infarction (+/- right ventricular infarction) compared with other AMI locations.

If right ventricular infarction were an associated condition (inferior AMI is associated in around 1/3 of cases with right ventricular infarction), then hypotension is a frequent finding and vasodilators (ACEI, nitrates, etc.) are contraindicated. But, we cannot be sure of that, as no medical statements on these issues is present on your discharge summary.

My personal opinion would be more in favor of an anticipated second PCI (on LAD) soon after the first PCI (on RCA) during the first hospitalization.

This strategy would lead to a more controlled hemodynamic status and probably lower treatment costs (nevertheless this depends on hospital policies and you should get more information why the costs were so high).

If you provide me with more medical data on your in-hospital clinical course during the first hospitalization, I could give a more detailed professional opinion.

Hope to have been helpful to you! Let me know if I can assist you further.

Regards,
Dr. Iliri Sharka
Cardiologist

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Brief Answer:
I would recommend as follows.

Detailed Answer:

Hello,

I reviewed your newly uploaded photo and would explain that it seems to be an infection/inflammation of the leg skin and subcutaneous tissues.

There are many possible causes that may lead to this type of injury:
- A local injury with acid or hot liquids
- A local bacterial infection
- A trauma
- Diabetes and immobilization, etc.

Coming to this point, I would recommend consulting a dermatologist or a plastic surgeon for a careful physical exam.

A local antibiotic ointment coupled with surgical resection of the necrotic tissues may be needed.

Some blood lab tests (complete blood count) for infection are needed too. If the patient has fever, antibiotic therapy may be necessary besides local ointment.

You should discuss with his doctor on the above issues.

Hope I have answered your query. Let me know if I can assist you further. Wishing you good health.

Regards,
Dr. Iliri Sharka
Cardiologist

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Brief Answer:
My opinion as follows.

Detailed Answer:

Hello,

I read carefully through your recent medical history and I exclude any hypothetical stent reaction in this regard. Any implication of the complex PCI procedure is excluded as well. No path physiological connection could be found between them.

It seems to be just a pure consequence of an uncontrolled hypertensive bout in line with a hyper dynamic state, leading to blurred vision, palpitations (tachycardia) and general discomfort.

Considering the fact that a bad experience happened while sleeping and no evidence of angina was obvious, a likely explanation of that BP bout could be an anxiety disorder (probably a panic attack?!!!)

Ticagrelor may be associated with dyspnea in up to 15% of patients, but before coming to a wrong conclusion, it is necessary to explore any potential alternative causes.

I believe that it’s time for some treatment modification, considering first the addition of a beta-blocker to therapy.

Carvedilol would be a rational option that would properly address any potential hypertension issue.

In addition to that, some medical tests would be helpful for the correct management of blood pressure and dyspnea:
- Resting ECG,
- Cardiac ultrasound,
- Chest X ray study,
- Complete blood count,
- Liver and renal function tests,
- Thyroid hormones level,
- Blood electrolytes level,
- Fasting blood glucose

You should discuss with your attending cardiologist regarding therapy optimization and additional tests.

Hope to have been helpful to you! In case of any further question, I would be glad to discuss with you again.

Regards,
Dr. Iliri Sharka
Cardiologist

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Brief Answer:
A careful BP monitoring is advisable.

Detailed Answer:

Hello,

I would like to explain that Terazosin besides form being used for BHP has also antihypertensive properties (it is an alpha blocker and generally leads to vasodilation).

This should be kept in mind when you stop this medication, as a trend to higher blood pressure values may occur.

That's why seems logical to closely monitor your BP values frequently and in case abnormally high BP numbers persist, a rational alternative would be increasing your daily Lisinopril dose to 5 mg in a week and to 10 mg/day after 10 to 14 days.

Nevertheless, it is necessary consulting your doctor in case a new dose adjustment is required.

Regarding the potential cause of that hypertensive episode, I agree that a panic attack may have triggered the unpleasant event.

Hope I have answered your query.

Regards,
Dr. Iliri Sharka
Cardiologist

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