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Ischemic Heart Disease

Short summary

A very physically active 49-year-old male with a history of labile hypertension and hypercholesterolemia with an LDL cholesterol of 126 mg%. He underwent an exercise stress test which revealed reversible inferoseptal ischemia at a peak heart rate of 171 bpm and peak blood pressure of 195/85. In the expert's opinion, the results suggest that the patient has silent myocardial ischemia and may be at risk for sudden cardiac death, especially in light of the marked exertional level of activity. The expert suggests additional testing in order to confirm or exclude a coronary artery obstruction, and to determine the right medical therapy and/or intervention. In the meantime he suggests a reduction in physical activity.

Patient's questions

Questions raised by patient:
1. My question is regarding the diagnosis itself in light of the scan files and the results of the strain tests. If it is Ischemia, at what level of severity it is and is it supposed to affect my physical activity?

2. My second question is regarding any limitation to my physical activity. Up to date, I am running 10Km a day at a heart rate of 145. Should I lower my efforts or can I increase strain?

3. Regarding medications and blood pressure. I would like to get more information please (especially in light of my blood tests that don’t show a high level of Cholesterol and a good LDL/HDL ratio)

Following the advice of my family physician, I stopped taking BISOPROLOL FUMARATE after it gave me a drop in pulse under 40 and a feeling of heaviness.

In addition, when I tested my blood pressure at home, it showed much lower levels than the findings (around 120/80 ±5). My pulse at rest is much lower than the test shows (50-55 and not 75 as the test shows). I believe that the reason for this difference is my excitement from the test which raises my pulse and blood pressure. According to my Cardiologist, it does not matter and blood pressure should be lowered during these events of excitement and strain.

Medical Background

Male , 49 years old
Diagnosis: Ischemic Heart Disease
Referral for cardiologic consultation was done due to the following:

03/2009 No heart problems or complaints, very active aerobically, runs 30-40 Km a week

Ergometric tests results - up to 12:08 at 85% of maximal pulse, no pressure with a drop of rising ST in the marginal joints, passing after 4 minutes of recovery.

04/09 scan shows a light reversible cardiac ischemia on the Infero-septal wall (fitting PDA) with EF values of 67% at rest and 57% at strain. The subject of discussion is silent Ischemia under high aerobic load.

Risk factors for CAD: labile hypertension, LDL 126 ; risk for CAD according to Farningham scans – 5% - low.

Functional evaluation: 1, Angina pectoris evaluation: none, Weight: 84, Height: 178Kg, BMI: 26.5, Blood pressure: 164/104, Heart Rate: 75 regular

Testing at the Institute: Summery of Ergometry from 3/2009
Pulse achieved: 146, Percent of Maximum Pulse: 85.3, Duration of exam: 12.08 minutes

Significant ST depression W/O symptoms - suggestive of Silent Ischemia
Without effort induced arrhythmia/conduction defects
Normotensive response to exercise
Good aerobic capacity

Recommending a follow up imaging investigation of heart to rule out IHD
: Ischemic Heart disease chronic
Infero-septal silent ischemia per thallium
Hypertension labile

Medications: ASPIRIN 100Mg , 2.5 mg,

Summery and Recommendations:
03/2009 - 49 yrs. Old. No complaints with a borderline exercise test.

Since actively engaged in sports - heart scan will be done under maximal effort before commencement of physical activity.

04/09 scan shows a light reversible cardiac ischemia on the inferior wall in the PDA region.

Since there is no active angina, functional capacity is high and ischemia is not frontal, the risk-benefit ratio to the patient is high and does not justify coronary catheterization at this stage.

1. Will begin taking Aspirin -
2. Will begin taking Statins to lower LDL levels under 100 –
3. To restrain blood pressure elevation under stress and exertion - β blocker will be administrated
4. Follow-up with a yearly Ergometry

Invitation for follow up: under clinical need

04/2009 - Heart Scan with TC-MIBI with strain G-SPECT
Cause of referral
: suspicion of active Ischemia in the Heart muscle
Graded strain was done on a treadmill according to Bruce protocol
Strain was stopped after 12:34 minutes at stage 5 METS 14.4 due to target pulse
Chests pains under strain: NO
Heart Beat at rest: 74, at peak strain: 171, per minute: 100% of maximal pulse
Blood pressure at rest: 167/90, at peak strain: 195/85
ECG at rest: SR, Lateral ST drop
ECG under strain: not diagnostic for Ischemia
60 sec. before the end of the strain 10 milicurie of TC-MIBI were injected
Scan was done at rest after the injection of 25 milicurie of TC-MIBI
Temporary widening of left ventricle: none
EF at rest: 67% EF at strain: 57% (according to G-SPECT)

Region                                          Segment

N- Normal R- Light reversible
Defects in filling were demonstrated in the following regions:
Reversible: Inferior Wall
Partly reversible: none
Permanent: none
Conclusion: Scan shows evidence of light ischemia in the inferior wall

Medical opinion

Of note, the LVEF at rest was measured at 67%, falling to 57% with exercise. Of further note, two blood pressure values at rest are noted to be 164/104 and 167/90 mm Hg.

Additional information which would be of interest:
Additional medical history for this patient would be valuable. For example, is there any history of glucose intolerance? Is there a family history of hypertension, coronary artery disease, cerebrovascular disease, diabetes mellitus, gout, or hyperlipidemia? Does the patient have any drug allergies? Does the patient smoke (or is there a history of tobacco use)? Does the patient take any medications?

With respect to the findings of ischemia, does the patient ever experience shortness of breath? Chest pain? Difficulty lying flat in bed due to shortness of breath? Palpitations or an irregular heart beat?

Has an echocardiogram ever been performed? Is there evidence of left atrial enlargement or of left ventricular hypertrophy?

What are the findings on his electrocardiogram? Is there evidence of left atrial enlargement or left ventricular hypertrophy?

The answers to these questions and the additional information would affect my suggestions for the approach to further testing and treatment.
In the absence of this additional information, I would suggest the following:

1. The results of the stress test suggests strongly that the patient has silent myocardial ischemia and may be at risk for sudden cardiac death especially in light of the marked exertional level of activity. A further effort to define the presence or absence of a significant coronary stenosis should be undertaken. Although coronary angiography is not necessarily needed immediately, I would suggest that a CT coronary angiogram be obtained and that the results of that procedure guide the decision as to proceed with cardiac catheterization. The fall in LV ejection fraction with exercise suggests that there is indeed a significant coronary obstruction which results in LV dysfunction at peak exertion.

2. A complete fasting lipid profile including HDL and LDL cholesterol, and triglycerides and high sensitivity C-reactive protein (hs-CRP) and fasting blood sugar should be obtained. Depending on the results of this testing, the patient's family history of hyperlipidemia, the family history of vascular disease, and the results of the testing suggested above, the patient may need/should be placed on high dose statin therapy (Lipitor 80 mg QD or Crestor 20 mg QD).

3. A more accurate assessment of the patient's blood pressure should be obtained. The two readings reported are clearly abnormal but the patient reports much lower values at home. The results of the EKG and echocardiogram will help to determine whether his blood pressure is higher than expected. A 24-hour blood pressure recording and multiple additional measurements at rest would be helpful. If blood pressure values in excess of 140/90 mm Hg are found frequently, aggressive blood pressure control should be initiated with anti-hypertensive agents, which may or may not include a beta-adrenergic blocking drug if ischemia is confirmed.

With regard to the specific questions raised by the patient:

1. Based on the data presented, I believe there is indeed evidence of myocardial ischemia and that medical therapy and/or intervention (angioplasty/stent insertion) will be required. Additional testing as suggested above will be needed to confirm or exclude a coronary artery obstruction.

2. Until the presence or absence of significant coronary artery disease is determined, I would suggest a reduction in physical activity.

3. I can't comment on the treatment of lipids as the materials submitted only include an LDL value. A complete lipid profile, along with CRP determination, and fasting blood sugar are needed to make further suggestions.