Brief Answer:
continue medication, NO revasularisation for OM1 / OM2

Detailed Answer:
Hello ,welcome to HCM, I am Dr Mody and I would be addressing your concern.
I went through the history and all the reports you have attached , Thank you for the same as it has given me complete insight into his condition .
I would like yo suggest.
1) NO form of revasularisation would be ever needed for OM1/ OM2 as circumflex is a non dominant artery and it will never ever cause any problem
2) Dobutamine stress for OM is not needed as I said , they are small artery and even if anything treatment remains ONLY medicine, the same regime he is on . Even attempting stent in such artery the chances of stent which will be less than 2 mm closing would be more the natural closing of those lesions . However a stress test either treadmill or dobutamine would be justified to know how LAD stent is faring.
3) The treatment offered too is optimum and no further change is required .
4) all other reports seems good ,however considering S.creatinine being on the higher side it's best to monitor the same and also potassium considering he is on ramipril.
5) medicine should be continued for a long period of time , and some life long.

Let me know if any furthur clarification needed and i would be happy to help.

Regards
Dr Priyank Mody , Cardiologist, XXXXXXX

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Brief Answer:
Do read the detailed answer . Regards

Detailed Answer:
Hello ,
1) The artery which are very small ( in his case OM1/OM2 ) , if you put a stent , the chances of it closing down is very high . Rather the three biggest stent manufacturers in the world don't produce stents of 2 mm diameter . Here there are more chances that in a natural course with medication it will never progress
2) The chances of heart attack because of Non dominant Lcx ( OM1/OM2) is rare , as the territory supplied by it will be very small and there are fair chance that there will be collateral .
All my observations are based on the angiography report sent .The best is to see the CD where we can get an exact idea of the size and importance of each vessel , so if a doctor after seeing the same suggests otherwise we would follow the same .
Lastly if you need any objective evidence than dobutamine thallium scan may be done .
We have to understand angioplasty is not angio cosmetic procedure , it should have some utility.
Most of the medication mentioned should be continued for lifetime . One anti platelet deplatt can be stopped after 1 year , rest combination can be given to reduce pill burden , I think here you should take things as they come and not plan for lifetime . Medication should be based on his symptoms and progress and may require titration every 3 months, so do follow up with your doctor .
Let me know if any clarification needed.
Keep me updated about his progress 6 monthly at least if possible.

Regards Dr Priyank Mody

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Brief Answer:
Do go through the detailed answer for all information needed .

Detailed Answer:
Hello ,

1) by cosmetic, I meant that angioplasty should not be done with the sole purpose of improving the look of artery . There should be some clinical benefit By opening it up
2) Yes by medical management we can delay progression of of OM1 and OM2 .
3) What are the chances of it progressing to 100 ? . 3 to 4 % per year .
And if we put a stent there the chances of it closing down is 8-9 %
4) titration of medicine means , all medication started for him are good one just needs to keep on changing the dosage according to the clinical profile and a regular follow up will help us prevent any future event by early detection of symptoms.
5) bypass for OM1 /OM2 of a non dominant LCX is nit justified .

Most importantly if there are symptoms like breathlessness on exertion or chest pain in spite of medical management and positive thallium , then consider putting a stent , not otherwise .
You may send the CD to
Dr. Priyank Mody ,
Lilavati Hospital and Research Centre,
Bandra reclamation , Bandra West , XXXXXXX

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Brief Answer:
Risk benefit ratio would weigh towards Conservative approach .

Detailed Answer:
Hello , Welcome back to HCM.

With proper medicines and life style change , the chances of the OM1 /OM2 closing is 3-4 % per year , it means in just 4 people out of 100 in one year will it close .

Also if it closes because the area of supply is not huge while the damage to the heart is minimal .
If you put a stent the chances of it closing because the vessel would be small , so the stent used would be of smaller calibre .

Smaller the calibre higher chances of it closing, so no symptoms it's not worth to go for revasularisation.

The diet and lifestyle you have mentioned is adequate and I am a firm beliver of quality of life , so at 73 further restrictions are regressive steps , just take care of timely dosage of medicines , unless oily food , can consider adding Omega 3 fatty acid ( cod fish ) capsules 1 gm a day as supplement. Flax seeds is a good vegetarian source for the same .

You can always mail the CD to the hospital and I will get back to you as soon as I go through them .
I am not very good technology wise and Dropbox would be difficult , I answer here while I am travelling to keep the mind working .

Trust me I am a young cardiologist and would love to do angioplasty in such lesions , however in my short experience I have learned it's better to leave things alone after some age if quality of life is maintained and nothing usually occurs . The risk benefit ratio weighs towards conservative management.

Statistics are usually for only our satisfaction and in real life world don't hold true and we have to understand all data is derives from XXXXXXX population and we have no data out for our country .
Hoping I could help you out .

Do rate for others reference.
Regards Dr Priyank Mody

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