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Have sleep apnea. Use CPAP. BP 123/65. LAD blockage addressed by a stent. Had chest pain. Using verapamil and metoprolol. Suggest?

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Thanks for working the holiday weekend.

I have sleep apnea and use CPAP every night for about two years.

I am 5'7" and 181 pounds. BP right arm 123/65 pulse 57 left 122/70

In November or 2010 I had an MI due to a 99% LAD blockage that was addressed by a stent.

On and off since early 2011 I had some chest pain. The chest pain became acute with the cold weather during the 2012 winter. My cardiologist took me off 25mg metoprolol and put me on 180 mg verapamil that was increased to 360mg till the chest pain went away. The verapamil made me so constipated I could not stand it. I was the put on 1.5 of the 25mg metoprolol that made the chest pain tolerable. He also gave me a stress ECG and echo and told me both showed no problems what so ever about two months ago. This week I saw the pulmonologist about my CPAP. He asked about changes to my medical history. I told him the above. He took out prescription pad and told me he was prescribing a new cardiologist as it was his view I must see an interventional cardiologist because any chest pain is not normal, typical nor are stress echo or stress ecg's good enough to detect all problems. To make his point he told me chest pain is sometimes the first clue there is a problem however too often the second clue is sudden death. I wish to determine your opinion as to the necessity of seeing an interventional cardiologist.
Posted Sun, 22 Sep 2013 in Hypertension and Heart Disease
 
 
Answered by Dr. Sukhvinder Singh 37 minutes later
Brief Answer:
please see details. stress test details?

Detailed Answer:
Respected Sir
1. Most important issue is to historically (by interview) recognize the type of chest pain you have. The anginal pain is more a type of heaviness/ discomfort which is placed behind your breastbone or over whole chest and comes with running/ exertion/ using stairs/ carrying weights. It comes more easily on walking uphill or in cold weather. This may be associated with feeling of shortness of breath. The pain which lasts for less than a minute, can be localized to a finger, does not come up / increases with running is less likely to be anginal.
2. If a patient has normal Stress test (Stress ECG and Stress ECHO) he is usually not a candidate for angiogram. However there are riders with this statement. A. The patient should not have any chest discomfort/ pain or undue shortness of breath during the stress test. B. He/She should have achieved optimal exercise capacity without symptoms C. It should have been done by stopping the drugs like Metoprolol and verapamil for about 4-5 half lives or say ~48 hours. If all these conditions are satisfied and the stress test is negative, the likelihood of finding significant lesion effecting large area of heart is low and in such circumstances if patient is asymptomatic on drug therapy, Angiogram is usually not done.
3. In this paragraph I will explain what are the effects of above riders. If we do not stop metoprolol/ verapmil the pick up rate or sensitivity of stress test decreases. If the patient do not achieve optimal exercise capacity for whatsoever reason, the likelihood of a future cardiac event increases. If patient gets symptomatic during the stress test but otherwise has a negative test, the likelihood of having underlying disease increases because no stress test has a pickup rate of 100%.
4. The incidence of sudden death on the background of a structurally normal heart with good exercise capacity is very low. For your age excellent exercise capacity would be 9.0 METs. Even a capacity of 7.6 METs without symptoms is fair.
5. A physician may choose to get an angiogram done in patient with typical history but normal stress test, depending upon his assessment, just to look at the anatomy of coronary lesions. It is mostly done to rule out Left main artery lesions and equivalent.
I hope this provides you insight into the problem and the way we think. If you can provide me the details of your stress test as well as how symptomatic you are currently (in the form of walking distance before you get short of breath or angina, or how many flight of stairs you can use before getting chest pain), I will be able to discuss it further.
Sincerely
Sukhvinder Singh
Above answer was peer-reviewed by
 
Follow-up: Have sleep apnea. Use CPAP. BP 123/65. LAD blockage addressed by a stent. Had chest pain. Using verapamil and metoprolol. Suggest? 11 minutes later
Doctor,

I'll do my best to answer the questions you have asked

1. Most important issue is to historically (by interview) recognize the type of chest pain you have. The anginal pain is more a type of heaviness/ discomfort which is placed behind your breastbone or over whole chest and comes with running/ exertion/ using stairs/ carrying weights. It comes more easily on walking uphill or in cold weather. This may be associated with feeling of shortness of breath. The pain which lasts for less than a minute, can be localized to a finger, does not come up / increases with running is less likely to be anginal.

The pain is general chest pain that I can not "point to" it does not at all get worse when exercising or running up steps. Although I feel short of breath from time to time I have not been able to link the times I am short of breath and have chest pain. However if I did feel short of breath with chest pain that got worse when I ran up the steps I would consider that a potential emergency.

2. If a patient has normal Stress test (Stress ECG and Stress ECHO) he is usually not a candidate for angiogram. However there are riders with this statement. A. The patient should not have any chest discomfort/ pain or undue shortness of breath during the stress test.
I had no pain or or undue shortness of breath during the stress test.

B. He/She should have achieved optimal exercise capacity without symptoms C. It should have been done by stopping the drugs like Metoprolol and verapamil for about 4-5 half lives or say ~48 hours. If all these conditions are satisfied and the stress test is negative, the likelihood of finding significant lesion effecting large area of heart is low and in such circumstances if patient is asymptomatic on drug therapy, Angiogram is usually not done.

I had no advance notice of the stress test and was taking my meds normaly during the stress test.

3. In this paragraph I will explain what are the effects of above riders. If we do not stop metoprolol/ verapmil the pick up rate or sensitivity of stress test decreases. If the patient do not achieve optimal exercise capacity for whatsoever reason, the likelihood of a future cardiac event increases. If patient gets symptomatic during the stress test but otherwise has a negative test, the likelihood of having underlying disease increases because no stress test has a pickup rate of 100%.

4. The incidence of sudden death on the background of a structurally normal heart with good exercise capacity is very low. For your age excellent exercise capacity would be 9.0 METs. Even a capacity of 7.6 METs without symptoms is fair.
5. A physician may choose to get an angiogram done in patient with typical history but normal stress test, depending upon his assessment, just to look at the anatomy of coronary lesions. It is mostly done to rule out Left main artery lesions and equivalent.
I hope this provides you insight into the problem and the way we think. If you can provide me the details of your stress test as well as how symptomatic you are currently (in the form of walking distance before you get short of breath or angina, or how many flight of stairs you can use before getting chest pain), I will be able to discuss it further.

I feel short of breath from time to time and have chest pain from time to time I have not been able to link the times I am short of breath and have chest pain. exercise does NOT make the pain worse.

I by no means want to have any angiograms or catherizations I do not need because I very much realize these procedures carry real risks of cancer, infections and long list of things that can just go wrong.

Are you an interventional cardiologist?

Where are you located?
 
 
Answered by Dr. Sukhvinder Singh 45 minutes later
Brief Answer:
Hold! discuss with your primary cardiologist.

Detailed Answer:
1. I am a certified cardiologist in India (New Delhi) authorized to practice interventional cardiology But I do not practice in Catheterization lab. I do see cases undergoing intervention/ report angiograms/ angioplasties on daily basis.
2. Your pain does not worsen with exercise and the stress test (although it was done with drugs) is negative and you did not have any problem during the stress. I hope you achieved good exercise capacity also (as I detailed above). If you do not have any pain or discomfort on routine work/ using 1-2 flight of stairs on usual pace. In such circumstances I would concur with advise of your cardiologist. I would like you to discuss out everything with your primary cardiologist including the advise of your pulmonologist before taking a final decision about undergoing angiogram. He will be able to give you more insights as he has much more information available to him than us.
Hope this helps. Feel free to discuss further.
Sincerely
Sukhvinder
Above answer was peer-reviewed by
 
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