What Do The Following Test Reports Indicate?

Brief Answer:
I would recommend as follows

Detailed Answer:
Hello!

Thank you for asking on HCM!

I passed carefully through your medical history and I would like to explain that yours is a complex clinical situation: ischemic cardiomyopathy with decreased overall cardiac performance, a multi vessel coronary artery disease, diabetes.

I would advise some key points as follows :

1.The most important issues to consider are the clinical presentation of new onset chest pain (or its equivalents like dyspnea, etc.), as you have experienced recurrent episodes of ischemic angina in the past, coupled with several revascularisation conditions (PCIs & CABG), it is of utmost importance to seriously take into consideration any new chest pain symptomatology as a sufficient trigger for further coronary status reevaluation. This will prevent further deterioration of your cardiac function.

So I would like to know which is your actual clinical scenario?

2 .Regarding your therapy it seems to be okay.

Just keep in mind that a double antithrombotic therapy (aspirin+clopidogrel) is very important and should not be missed, even a single daily dose.
Concomitant clopidogrel and citalopram may increase the risk of bleeding, so a close monitoring is necessary.

Renal function tests, fasting glucose and HbA1C are necessary to determine a possible switch to insulin.

If clinical signs and symptoms of congestive heart failure are present, possible addition of diuretics should be evaluated.
You have to discuss with your attending doctors about these issues.

3. Meanwhile keep on preventing /treating your coronary risk factors: hypertension, diabetes, dyslipidemi, avoid close smoking contacts, follow a healthy diet and lifestyle.

Periodic medical follow ups are necessary.

Hope to have been helpful to you!

Feel free to ask me any other questions , whenever you need.

Greetings! Dr. Iliri

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Brief Answer:
You need to discuss with your attending doctor.

Detailed Answer:

Hi again, dear Mr. XXXX!

Facing you medical history seems that you have at least 5 intra-coronary stents implanted. A precise view of that would be yielded by your respective hospital medical reports (if you could upload them all).

Nevertheless, I could confirm you that a discussion with your attending doctor should be performed regarding a possible therapy modulation (adding diuretics), as your NT-proBNP results are higher than 125 pg/ml (which is the upper cut off value for heart failure presenting in a non-acute way).

Other lab parameters seem almost OK. Congratulations!

Your blood glucose and lipid profile seems acceptable, but as you have low ejection fraction cardiomyopathy (overt heart failure), a discussion with your doctor for possibly switching to insulin would be encouraged.

Hope to have been helpful!

I remain at your disposal if you have further uncertainties!

Best regards,

Dr. Iliri

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Brief Answer:
Coronary multivessel disease represents a really serious clinical condition

Detailed Answer:
Hello!

Seems really a troublesome clinical progression of your coronary artery disease.

I would like to say that your clinical scenario is typical for a complicated diabetic patient: a diffuse multi-vessel coronary artery disease, treated firstly with PCI and stent implantation of the culprit LAD (responsible for the previous anterior myocardial infarction), and after complications (stent restenosis), a switch to a more stable solution (CABG) has been decided.

I have reviewed your numerous revascularization procedures.

(1) 2 Dec 2000. PCI and stent implantation on LAD.

(2) 29 DEC, 2000. Angiography revealed diffuse clinically non-significant stenoses.

(3) 22 MAY 2001. Revealed 2 vessel coronary disease (intra-stent restenosis on LAD, and clinically important coronary lesions on LCX). Recommendation for CABG.

(4) 20 February. Coronary grafts resulted patent with a good runoff. A progression of coronary lesions on LCX.

(5) 29 XXXXXXX 2009. Coronary angiography, PCI and stent implantation on RCA.

(6) 26 May 2010. 75% rstenosis at the site of prior LAD stent. Proximal LCX total occlusion (distal supply from collaterals).

(7) 9 October 2010. PCI with stent implantation to left main coronary artery and LCX.

(8) 14 April 2014. Stent implantation on LCX (intra-stent stenosis).

(9) 23 XXXXXXX 2015. Coronary angiography. Recommendation for continuing conservative treatment.

So, all these interventional procedures seem to have been necessary facing a very aggressive progressive coronary artery disease, and the underlying stents complications (restenoses).

The only debatable issue is the exact quantification of those coronary lesions in certain periods of time (during those consequent angiographies).

It is necessary to review all the performed coronary angiography and PCI films to give a professional opinion on indication's reliability of coronary revascularization, and the chosen time-schedule on each procedure.

I could hardly believe that all the above interventions could be a mixture of disease complications and medical malpractice.

As an intensive care cardiologist, I have seen a lot of similar patients experiencing numerous procedures and subsequent complications. But, when judging for a multivessel coronary artery disease and low EF cardiomyopathy, each therapeutic strategy (though expensive) would have its well known drawbacks, and at the end no clear differences on life expectancy benefits would been obviously seen.

I wish you good health!

Regards,

Dr. Iliri

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Brief Answer:
Your actual treatment is completely justified.

Detailed Answer:
Hello Mr. Rozwani!

You have multi-vessel coronary disease, going through numerous coronary revascularization procedures. You have suffered an important myocardial infarction and consequently a low EF cardiomyopathy.

From the other part, you are suffering from diabetes, articular disorders, and have chronic constipation.

So, it doesn't seem that your actual therapy is exaggerated. Let me explain:

(1) After performing several percutaneous coronary angioplasties and stent implantations it is necessary to continue on dual antiplatelets therapy (Aspirin & Clopidogrel), They help to prevent thrombosis and protect coronary stent
patency.

(2 )Clonidine, Losartan and Metoprolol are necessary to treat hypertension and maintain a favorable hemodynamics in the presence of ischemic cardiomyopathy.

A beta-blocker is important (Metoprolol, Carvedilol, Bisoprolol, etc), and should be always present, while the others may be changed for alternative drugs (always if your attending doctor judges that way [to avoid any present side effects, or to switch to more effective alternatives]).

(3) Isosorbide and Nitrostat are potent vasodilators, helping to improve coronary blood flow, relieve anginal pain as well as affecting positively cardiac pre- and afterload. Their use may be modulated, depending on BP values trend and the presence of anginal symptomatology.

(4) Regarding Metformin, probably a discussion with your attending doctor about a possible switch to insulin would be advisable, as a more robust control of your blood glucose level would be especially beneficial hereafter.

(5) A statin (pravastatin, atorvastatin, etc) is very important and should be always a member of your maintenance therapy (you suffer from coronary disease and are diabetic). You should never avoid that drug, unless an evident contraindication would be present.

(6) Glucosamine, constipation pills (stool softener), Multivitamin are mainly symptomatic treatment, not permanent and their future use may be variable.

(7) Ranolazine is an important anti-anginal drug, especially in your conditions (multi-vessel coronary disease).

So all your current treatment is medically justified.

Nevertheless, the most indispensable drugs not to avoid are: Aspirin, Clopidogrel, a statin (Lipitor, etc), a beta-blocker (Metoprolol, etc), diabetes treatment, and an acceptable antihypertensive scheme.

You need to discuss with your attending physician about the concrete modalities.

Hope to have been helpful!

Best regards,

Dr. Iliri

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