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60 year old stemi patients. Angioplasty done. Taking medicine. Getting mild angina. Proper treatment?

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Practicing since : 1981
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I am 60 year old STEMI patient - right artery blockage removed within 90 minutes with angioplasty July 19th 2012. No stent fitted. I have been on standard meds - aspirin 75, clopidogrel 75, ramapril 2.5, rosuvastatin 10mg, Isosorbide mononitrate 25mg. Minimal heart damage. Steady bpm and pulse.
125/75 and 65bpm when resting. I get mild angina during exercise and mild angina in bed sometimes. No sweats or nausea. I use GTN spray to help. I have signs of dyspepsia (upper stomach cramp) . I have been thinking of discontinuing the aspirin and clopidogrel to see if my dyspepsia signs will dissappear. then re-introducing 1 by one or using supplements (nattokinase).
3 questions.
1. Should I try a PPI for the dyspepsia - if so which is the best in combination with my meds.
2. whats prognosis for restenosis with angioplasty only. (I have read 6months ish)
3. whats the recommended way of stopping clopidogrel / aspirin.
Posted Fri, 22 Feb 2013 in Hypertension and Heart Disease
Answered by Dr. Anil Grover 4 hours later
Thanks for writing in.
I am a qualified and certified cardiologist. I read your mail with diligence,
Let me state at the beginning for one year after successful angioplasty and stent implantation and stent implantation you should ideally be followed by the same group of cardiologists. So that a constant protocol is kept. So answering your question number 3, what I do to my patients give clopivas and aspirin combination for 8 months and in a patient with dyspespsia, I omit aspirin and whereas Clopidogrel is continued for indefinite period. As you are having suspicion of angina, I would want you to be seen on routine basis by a cardiologist for follow up. It may not be angina at all.
Yes, some of cardiologist do not give PPI for dyspepsia, however in my opinion these do not interfere with cardiac drugs to the extent it has been publicised and all drugs of the group of similar effect. So ask your doctor to prescribe you any of the perazole preparations(If they are available OTC as in some countries, you can choose yourself). You are right for first 6 months we cardiologist are prepared for restenosis occuring but this complication diminishes with time. Only fear of stent thrombosis remains so Clopidogrel 75 mg is continued indefinitely. I must point out that the risk factors like hypertension, smoking, diabetes, stress, obesity with lack of exercise and abnormal cholesterol should be sought for and treated that helps in the long run. If you have any further query, I will be happy to answer. Good Luck.

With Best Wishes

Dr Anil Grover
Above answer was peer-reviewed by
Follow-up: 60 year old stemi patients. Angioplasty done. Taking medicine. Getting mild angina. Proper treatment? 1 hour later
Thank you for your reply.

I am lucky that I am being followed by the same group of cardiologists that carried out my angioplasty so I do have continuity but this is in 3 month gaps. My concern is that my medication is not being adjusted to my current symtoms.

My angina symptoms are similar to the ones I had before the heart attack but with the exception that I am not getting the sweats and slight nausea that preceded the attack. When I got the attack it was the same but the sweating lasted for 20 minutes plus I had the chest pressure. (MY RA blockage was on a smaller artery off the main RA.)
Thats why I attribute these central chest restrictions to the symptoms I had before the HA.
They might not be angina because I had good aerobic capacity before the HA and once the blockage was removed I do not see why I should have a damaged aerobic capacity.

So to clarify:
remember I do not have a stent. From what I have learnt Clopidogrel is normally continued if you have a stent.

So before I try the PPI are you suggesting I could stop the aspirin and see if the dyspepsia disappears.

But you are suggesting I stay on the clopidogrel.

I agree with stopping/starting one medicine at a time.

The reason why I am questioning my platelet medication is that I had full aerobic capacity before HA. My HA was minor. but something is stopping me exercising fully without getting a setback . (the setbacks I get after exercise are lower left chest pains and weakness - that I slowly recover from - for all I know this might be dyspepsia and not my heart). It is sometimes difficult to distinguish between the HA pressure and the stich kind of pressure that I am now associating with dispepsia. This is because I think I can now distinguish between my heart Pains and my upper stomach area pains. For instance I know my heart is stable at the moment.

At the moment I am able to swim 20 lengths and do other gentle exercise but not to the extent I was able to before the HA.

I have no problems with my hypertension treatment - I continue to take the ramapril.

So in Summary.
Do you think its worth stopping the aspirin for a week to see if the upper stomach stich pains disappear? before trying the PPI - And staying with the clopidogrel.

Thankyou for your advice
Answered by Dr. Anil Grover 3 hours later
Thanks for writing back. I am sorry if I conveyed the impression that a stent was implanted. What you had undergone is Plain Old Balloon Angioplasty (POBA). However, after causing controlled injury to a vessel in a patient prone to coronary artery disease precautions of maintaining him/her on blood thinners and thus the protocol is not much different. So long as you maintain yourself well hydrated and other diseases under control you can do the experiment of remaining free of aspirin for one week that is before 8 months of procedure is a deviation from well accepted protocol. On the other hand with procedure on 19th July, you are in 7th month. So, my opinion is please go ahead discontinue aspirin and if pain disappears continue with Clopidogrel 75 mg once a day. If you are taking enteric coated aspirin and that also after meals that should not contribute to pain. However, without confusing the issue a "Yes, why not' to your question as you have worded in summary. If there is further query, I will be only too happy to answer. I am glad that you are doing exercises like swimming that also 20 lengths. It is a pleasure interacting with knowledgeable patients like you.
With Best Wishes

Dr Anil Grover
Above answer was peer-reviewed by
Follow-up: 60 year old stemi patients. Angioplasty done. Taking medicine. Getting mild angina. Proper treatment? 20 hours later
Thankyou for the confirmation.

I have 3 reasons for trying to stop the anti platelets.
1. To see if the stich I seem to have in my upper stomach disappears.
2. To try and get my blood back to normal consistency to see if it will reduce my angina symptoms.
3 Both aspirin and clopidogrel have potential for stomach ulcers.

I swam this morning without taking any GTN and I got mild angina on the end of the first 6 lengths. I continued to complete 20 lengths and felt better for it. And I experience the "angina" more often now than 3 months ago. As you say this may not be angina. But it is the same central chest restriction I experienced before the HA - without the nausea or sweats. As long as I continue with my hypertension tablets - that is keep my blood pressure within range then I think returning my blood back to normal consistency might be a good thing to try and see if my full strength returns to my exercise regime.

I have an appointment with my cardiologist in 6 days so I will stop the aspirin until then and see if it helps the problems above. I will continue with the clopidogrel as you advise. I am due to stop the clopidogrel in July. I keep my GTN spray and an aspirin with me all the time these days.

I have looked at supplements and I would like to try nattokinase (for blood thinning) and hawthorn extract (for blood pressure and cholesterol). I already take serrapeptase. I keep my doctors informed about these as well.
Do you have any opinion on these supplements?
I am a bit more paranoid because I do not have a stent holding my blockage open. But I also realise not having the stent may be a good thing as well.

Would you like me to report back to you in 7 days time?
Thankyou for your advice.
My cardiologists are busy people but Its a shame they do not keep this door open to their patients over the 6-12months after the initial intervention. Or even via their junior doctors. I do email my diary to them before each meeting. So I appreciate this advice I am getting via yourself and this website. I also appreciate how fantastic and accessible the internet is for educating yourself.
You may appreciate these 2 links I found in my own research.
WWW.WWWW.WW Prevention and Treatment of Venous and Arterial Thromboembolic Disease: The 9th ACCP Guidelines on Antithrombotic Therapy and Prevention of Thrombosis
Answered by Dr. Anil Grover 3 hours later
Thanks for writing back. I had written full answer which could not get across for internet connection problems. Please write to me on YYYY@YYYY for I would like to know how your are doing without aspirin. I am impressed by your ability to do aerobic exercises and your searches for information. I will go through the links provided by you and yes I want to know what your cardiologist has to say 6 days later. Good Luck.
Best Wishes

Dr Anil Grover
Above answer was peer-reviewed by
Follow-up: 60 year old stemi patients. Angioplasty done. Taking medicine. Getting mild angina. Proper treatment? 34 hours later
I have stopped the aspirin for 2 days now after 6 months use. I feel a slight reduction in the stitch in my upper stomach area but its still there. It will be interesting to see if my angina chest pains are reduced or worsened when I go swimming on Tuesday and Wednesday. I see my cardiac doctors on Wednesday as well.
I am sure they will not be happy that I have stopped the aspirin but may make them realise that Although my heart seems stable I have this stitch that may or may not be due to my current medication.

I will let you know the outcome by this thread or via your email.
Thankyou for your kind approach and considered advice.
Answered by Dr. Anil Grover 7 hours later
Hey, Doctors are unhappy because of their genuine concerns for an individual patient. And 6 days of discontinuing Aspirin was a legit decision. Proof of pudding is in eating as they say; protocols were devised for patients not doctors. You felt better, I am happy about that now let us see what your real cardiologist has to say about it. (Believe me the advice of virtual cardiologist that is me was also in as much of good faith as that of the real one: some times for logistics reasons there can be difference of opinion) Well, in nutshell, you know the advice of doctor who sees the patient ought to pervail. Good Luck.
Best Wishes. I appreciate your keeping me informed.

Dr Anil Grover
Above answer was peer-reviewed by
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