Brief Answer:
I would explain as follows:

Detailed Answer:
Hello!

Welcome on HCM!

I passed carefully through your medical history and would like to explain that as you have three vessels coronary artery disease (LAD stenosis/treated with stent implantation; RCA and LCX actually with non-critical stenoses) you need to be very attentive and seriously consider the following issues:

(a) actually the most important drugs that you should not miss even a day are:

- Ticagrelor (Ticarular) should be continued for at least one year after stent implantation 90 mg two times daily;

- Aspirin should be continuously used (if no any gastrointestinal disturbances or other contraindications appear).

Use of Aspirin and Ticarular is very crucial for the blood flow through your implanted stent and other coronary arteries non-critical stenoses.

Otherwise, thrombotic complications may appear and you may suffer a second heart attack, which might result in more aggravated clinical conditions.

- Lipitor is an important anti-lipidemic medication, which helps in preventing furtherprogression of your actual coronary stenoses or any potential new ones. That's why you should use it continuously (life-long). Doses at least 40 mg daily are highly encouraged.

Regarding Ramipril and Bisoprolol they are both important medication in a coronary diseased individual. Their doses will vary and depend on the values of blood pressure and heart rate under close supervision of your attending cardiologist.

What should be further investigated are your symptoms: itchy throat with dry cough, which could be an adverse affect of Ramipril as well as a clinical symptomatology of heat failure. In this regard, a comprehensive physical exam and an exact cardiac function estimation by a careful cardiac ultrasound (ECHO) are necessary.

Coming to this point, a first attempt to substitute Ramipril with an ARB (Valsartan, Olmesartan, etc.), which doesn't posses such an adverse effect is advisable at least temporarily.

Otherwise, if those complains are due to heart failure, probably mild to moderate doses of diuretics could be added to your therapy.

You should discuss with your doctor on this issue.

As you are experiencing recurrent episodes of angina, I would recommend to start a nitrate derivate (isosorbide dinitrate or mononitrate) in your therapy.

Remember that you have also left two coronary arteries (RCA and LCX) with non-critical stenoses which could yield ischemia and subsequent chest pain.

It is advisable to add a gastric protector, such as a PPI (Pantoprazole, etc.) to prevent any digestive impairment, because of Aspirin and Ticagrelor use.

(b) regarding prognosis, it will depend on a large proportion on the success of your therapy, life-style and daily diet regimen to prevent further progression of coronary atherosclerosis.

- For such purpose, besides a strict therapy strategy, it is recommended to follow a healthy diet (poor in fatty products and rich in vegetable fibers). Mediterranean diet is an optimal example to follow.

- Avoid future close smoking contact, as it is a well known coronary risk factor.

- Optimally monitor your blood pressure values periodically and discuss them with your attending physician.

- try to control your body weight (a serious interaction of a balanced diet with frequent daily physical activity) would yield the desired results. Fast walking at least 1 hour daily is recommended.

- Periodically check your fasting blood glucose; glycosylated hemoglobin (HbA1C) and fasting blood lipid profile.

(c) You should know that, as you have actually a confirmed coronary disease and a potential need for additional stents implantation ion your other coronary arteries (LCX and RCA), the only key to a timely successful intervention is a closely periodic medical check up for investigating appearance/exacerbation of cardiac ischemia with periodic coronary artery stenoses study for further potential progression.

You need to discuss with your attending physician on the above mentioned issues.

Hope to have been helpful to you!

In case of any further uncertainties, feel free to ask me again.

Kind regards,

Dr. Iliri

---

Brief Answer:
Opinion as follows:

Detailed Answer:
Hello again!

I) Let me explain that regarding SCD and the long term prognosis it is important to take into account both left ventricular EF and also myocardial remodeling (including scar formation as a favorable substrate for generation of life-threatening cardiac arrhythmia).

These can be both accurately investigated by means of cardiac imagine tests (EF by cardiac echo, MRI, cardiac CT, etc.; myocardial scar by cardiac MRI, etc.)

Nevertheless, what is of the same clinical importance is ischemic cardiac disease.

As I explained you before, you have still two other coronary arteries with non-critical stenoses, without mentioning your left main artery with moderate stenosis.

Coming to this point, you should be alert to detect in time any clinical symptomatology of cardiac ischemia (chest pain, etc.), because a deteriorating cardiac ischemia may pose you at a severe, immediate and progressive dysfunctional cardiac pumping function. In such case, a new heart attack would lead to extension of myocardial scar, decrease of LVEF, worsening heart failure.

You actually have a mild systolic and diastolic dysfunction, which are considered minimal changes in the broad spectrum of heart attack complication.

Also, your mild mitral and tricuspid regurgitations are clinically irrelevant without any prognostic importance (mild valve regurgitations are a frequent normal finding in healthy young adults).

Regarding heart failure, I would explain that , it is not so important to know the exact EF value for confirming heart failure.

Heart failure is considered a clinical syndrome (based mainly on clinical complains, such as dyspnea, fatigue, palpitations, etc.).

Heart failure may be present even in the presence of a normal systolic cardiac function (HF with preserved EF).

II) As you suffered a heart attack on mid July 2016, with minimal complication, that means you are quite able to perform every physical and psychological task suitable for your age.

Nevertheless, it would be more wise and prudent to follow a more gradual physical approach which would be necessary until myocardial remodeling and other implications of the previous heart attack are finished (myocardial stunning, hibernation).

III) Breathing problems represent a broad range; some of them are not explained by cardiac issues.

Vagal nerve modulation may have a direct impact in breathing, while anemia, overweight and systemic inflammation/infection may lead to increased frequency of breathing.

If breathing is deteriorated (difficulty and frequent breathing) compared with the period before heart attack, then a review of heart failure possibility should be done.

In this latter case, diuretics could be beneficial.

IV) Regarding your follow up plan, I strongly recommend to be in periodic contacts with a cardiologist, because a careful consideration of the best strategy of treatment and life-style modification are more important than every each coronary revascularization procedures.

Wishing you all the best,

Dr. Iliri

---

Brief Answer:
I would explain as follows:

Detailed Answer:
Hello again!

Let me explain as follows:

1) As I have explained you before, the first alternatives to exclude when facing a dry cough/itching is an adverse effect of Ramipril and a symptomatology suggestive of heart failure.

For clarifying Ramipril implication, it is necessary to stop that drug for a while and replace it with a safer one.

Regarding heart failure implication, some additional tests are advised (BNP, NT-proBNP, cardiac ultrasound).

2) Regarding your ankle swelling, I would suggest that besides the scenario of congestion due to heart failure, it is necessary to exclude/confirm the possibility of lower limbs vein insufficiency as a cause of underlying signs. In this regard, Doppler ultrasound of of the lower limbs vessels is required. You should know that in an overweight individual lower limbs vein disorders may be more frequent.

3) Regarding your breathing problems, a differential diagnosis should be done (to differentiate between a cardiac and non-cardiac issue, such as an allergy, etc.).

For this purpose pulmonary function tests (PFT) are necessary.

4) Regarding Bisoprolol, I would explain that it is an important drug in the therapeutic strategy of cardiac ischemia treatment.

It should be started and stopped gradually by escalating its daily dose, otherwise rebound phenomenon may occur.

Bisoprolol (as all the other beta-blockers) should not be stopped in a coronary diseased patient unless a strong reason exists. As you haven't any confirmed severely decompensated heart failure, no severe pulmonary disease, like bronchial asthma, no any known allergy from Bisoprolol, then its withdrawal in your clinical case is not justified.

I believe, most probably your prescribing doctor has missed it during prescription.

That's why you should discuss with him about Bisoprolol and all the above mentioned issues.

Wishing you good health,

Regards,

Dr. Iliri

---