Jan 7, 2008

Open Letter Sent A Few Days Ago

January 3, 2008

Hello everyone. As you all know, when we were at Mom and Dad's in November, Mike had an "episode" wherein he ended up in the ER in Stayton. As he told people, he "had symptoms not inconsistent with a heart attack." After that happened, he started having "flutterings" in his heart. He's having fewer now but they're still there. As a result of it all, he's had a number of tests including wearing a 24 hour monitor, numerous EKGs, a nuclear stress test, and, most recently, an echocardiogram.

The monitor showed premature ventricular contractions (PVCs). That's when your heart sort of "skips" a beat. It's actually an extra beat that jumps in. He had about 300 or so in 24 hours but they don't get concerned unless it's in the thousands so that was ok. His stress test showed normal except that they thought he might have some heart wall thickening but couldn't really tell since the stress test isn't designed to diagnose that. The cardiologist also noticed an area at the bottom of his heart that didn't appear to be getting any blood but that was attributed to his diaphragm being in the way so that the heart wasn't being photographed well. EKGs always came out normal, too. The tech doing the echo had already told us that everything she measured fell within normal parameters. She was mainly looking at the heart wall to see if there was indeed any thickening. There wasn't. She also said that the valves looked good and were within normal range.

The doc's office (regular doc) called a couple of days ago because they wanted to talk about the echo because they said that there was some "mildly elevated pulmonary artery pressure." She stressed that it was mild and nothing to be concerned about. We had our appointment with his regular doctor today (an absolute genius and someone we trust absolutely) to talk about the echo results. He told us that the valves looked good and that's a really good thing. He also said that his heart is pumping at 60%, which is good. They want it to be anything over 50%. He said that there wasn't any thickening of the heart wall. But, he said, and "buts" aren't always good, there appeared to be some damage at the bottom of his heart. The area that didn't show up well on his stress test turned out to not be a case of not being photographed well. It was photographed just fine. The reason it didn't show any blood flow to the area was because there isn't any because it's been damaged. I believe he said that there was scarring, but I don't really remember. There was a lot of information passed around. He stressed that his heart is still pumping the way it's supposed to be and that's a good thing. He said that it appeared that Mike had a heart attack at some point. I asked if that's what the episode in November could have been and it now appears that it was. He said that what they try to do is to rule out all of the possible explanations for something to try to get to what the something might really be. At this point, they've ruled out just about everything else and all of this "circumstantial evidence" meshes perfectly with the explanation of a heart attack. The arrhythmia that he's having now would be a result of the episode. He said that a heart catheterization would conclusively show the damage as well as showing exactly what his pulmonary pressure is. The echo put it at 45. The doctor said he's not terribly concerned unless it hits 50. As we were talking, his doctor made some notes of 6 points to address. They are:

1. Did he have a heart attack?
2. Is the pulmonary hypertension for real?
3. Should he have cardiac catheter?
4. Restart aspirin, 162mg (2 baby)
5. Assuming heart attack, want LDL down from 110 to 70 - start Zocor
6. Should he be on beta blocker?

1 and 2 will be answered by 3, which he thinks he should have, but will leave it up to cardiologist. 6 he will also leave up to the cardiologist. Mike asked him if this was something he wanted to take care of himself or did he want the cardiologist to do it and the doc said that this would be the time his mentor would tell him was the time to "share the glory." He very much wants the cardiologist's opinions. We have an appointment on the 14th with the cardiologist and then back to his doctor on the 15th for more discussion.

He told Mike he knew he was concerned about his job and Mike reiterated that he wasn't ready to stop it. The doctor agreed and again stressed that his heart is working the way it's supposed to, that there's just a small area of damage. He said that the important thing was to start the zocor and aspirin today. Once the LDL is 70 and below, the zocor actually dissolves any plaque that may be there. If there is a blockage, the catheterization will show it. My guess is that if there is, a stent would be want they would do. This is what medline plus says about stents:

Angioplasty is performed in a special part of the hospital called a cardiac catheterization laboratory ("cath lab"). Angioplasty may involve the placement of a small wire device called a "stent," and the procedure is sometimes called "percutaneous coronary intervention," or PCI. A stent is shaped somewhat like the spring of a ballpoint pen and may be inserted into the artery to help it remain open after the clot is removed.

You can read about cardiac catheterization here: http://www.nlm.nih.gov/medlineplus/ency/article/003419.htm.

I asked the doctor why the enzyme test, which is supposed to be 100% accurate, didn't show a heart attack. He said that there were two schools of thought on the enzyme tests. One is to do one blood draw after a suspected heart attack and call it good. The other is to do a draw and then wait a little bit and do a second. He said that it can take a little while for the enzymes to show up. Mike told him his test was about 45 minutes after the episode and the doctor thinks if they'd done it a second time, it would have shown increased enzymes. I just found this on medline plus:

CPK-2 levels rise 3 - 6 hours after a heart attack. If there is no further damage to the heart muscle, the level peaks at 12 - 24 hours and returns to normal 12 - 48 hours after tissue death. CPK-2 levels do not usually rise with chest pain caused by angina, pulmonary embolism (blood clot in the lung), or congestive heart failure.
Apparently, they should have waited a while before they did the enzyme test. I don't think we were even in the ER for 3 hours. Sheesh. Seems like that's pretty basic information.

I know I've left some of the stuff we talked about out, but that's because my mind is too full right now. Oh. I did ask our doc about the advisability of Mike being awake for 24-36 hours at a stretch. He'd been up since yesterday morning. The doctor said that it was NOT advisable. I also asked about our new exercise bike that we got for his knees and if he could use it and he said that it was ok. He stressed that the pumping wasn't damaged and that his heart was working well. Mike asked if this (having one event) made him more likely to have a second attack and that was answered in the affirmative.

Mike's going to try the Zocor for a couple of months to see how it works. It works for 8 hours. You take it when you go to bed, which is when your body makes cholesterol. Since his schedule isn't exactly what you call normal, the doctor couldn't guarantee when his cholesterol is made. Also, since he switches schedules every three months, it may not work out. We'll have to see how he does with it. Lipitor would be the next one they'd try.

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