Brief Answer:
My opinions as follows:

Detailed Answer:
Hello!

Welcome back again on HCM!

I carefully reviewed again your clinical situation.

What I would emphasize in addition to the opinion I have explained In our previous discussion is as follows:

Regarding your actual treatment, the most important clue is to prevent further progression of those two other 50% blocked coronary arteries, or at least to delay this pathological process.

For this purpose, it is necessary to control your diet fat (to avoid certain foods reached in dairy products, meat, butter and other products rich in saturated fatty acids).

Also an aggressive anti-lipemiant therapy would be strongly advisable.

Coming to this point, Lipitor (atorvastatine) seems to be appropriate. Its dose is recommended to be at least 40mg daily. Metoprolol is a beta-blocker with well-known anti-ischemic properties. It exerts beneficial effects in lowering cardiac muscle requirements on oxygen and metabolic nutrients.

By the other side, Metoprolol also lowers heart rate and in this regard, improves coronary blood flow, which mainly takes place during diastole (cardiac relaxation). And by decreasing heart rate, the cardiac diastole is prolonged.

What I would like to advise is also starting an anti-platelet agent like aspirin 80-100mg daily , if you do not have any obvious contraindications (allergy, ulcers, gastritis, etc.).

Besides treating high blood lipids and decreasing potential cardiac ischemia it is necessary to control for other potential coronary risk factors such as hypertension, smoking contacts.

If you have high blood pressure values, it is necessary to start also an anti-hypertensive treatment such as an ACEI (ramipril, lisinopril, etc.) or an ARB (olmesartan, irbesartan, etc.).

Also, performing frequent physical activity will help to maintain a normal cardio-vascular endurance and improve blood circulation.

Now lets turn to your actual coronary lesions profile. Coming to this point, I would prefer dividing our discussion in two parts:

1- Regarding your chronic calcified and completely blocked coronary artery, it seems to be almost a closed history, because we actually have the consequence: an earlier myocardial infarction, which was unfortunately misdiagnosed. Here the point to discuss is whether the infarcted myocardial area is completely composed of dead tissue or there exists some alive and hibernated cardiac cell islands inside this area.

This can be clarified by performing an appropriate test which is called LGE cardiac MRI (late gadolinioum enhancement cardiac magnetic resonance imaging).
If alive cardiac cells are present inside the myocardial infarction area, then it would be worth to consider an alternative coronary revascularization (such as Bypass surgery), including these culprit chronically calcified totally occluded artery, along with the two other coronary arteries.

But this remains only an option to consider as a second hand, as you don’t suffer from any recent chest pain.

2- Returning to the point that I would consider more important, is the matter of those two 50% occluded coronary arteries. Apparently they don’t seem to be treated by stent implantation. But in a potentially near future, they should.

Now, as I emphasized you in our previous discussion, the best way to evaluate whether the time when revascularization therapy is necessary is to perform what is called FFR testing (fractional flow reserve evaluation), which is similar to coronary angiography. But with the addition of utilizing a special wire, for measuring trans-stenotic pressure gradient through the coronary atherosclerotic plaques.

This is necessary because, it may discriminate some apparently non-important coronary stenosis (less than 75%), but which may cause important obstruction to blood flow, leading to a potentially near cardiac ischemia and infarction.

You need to discuss on the above mentioned points with your doctor in the upcoming weeks.

Hope you will find this answer helpful!

Nevertheless, I remain at your disposal for any further explanations if necessary.

Kind regards,

Dr. Iliri

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