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Diabetic. Getting mild chest pain. Stress test done. Should I take telma 40 or telma 80-H?

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I had recently gone for a stress test because I was getting mild chest pain some times on the left and some times on the right chest.Wanted to eliminate Cardiac Disorders as I was diabetic and also having BP recently and aged 64 Yrs. The test result was positive and the Cardiologist suggested to go for a Cardio Angiograph.Since I did not experience any pain in the chest nor I had any breathlessness the Chief Cardiologist suggested that I go for a CT angiograph but his assistant suggested that going for a conventional Angio will be better taking into my age and also that I am Diabetic.This was also okayed by the Chief Cardiologist as in this way both the Heart and the Kidney can be explored for any problems.He has prescribed telma 40 earlier and after the stress test he has asked me to take telma 80 H--- I-0-0 and Concor 2.5----0-0-I. By BP reading in the morning was 117/75 in my digital BP meter. My family Doctor suggested to take Telam 40 as the other is a bit too strong and to observe and take a decesion.Do I need to take Telma 80 H. Secondly the type of Angiograph I need to under go. please suggest.
For the last one year I am having some pin pricking sensation in the throat,sometime on the left and some times on the right.It was followed by Coughing and then I used to be okay.It was occasional may be twice or thrice a month. But the frequency has increase in the recent one months.Please inform the possible cause and if it is a cause for worry. I met my family doctor today and consulted him about the results of Stress test.He believes that the stress test may not be correct because it was done while was taking telma 40 for BP which should have been stopped for at least 24 hrs before the test. So he feels I need to cross check with another Cardiologist and according to him I am fine and may not require an Cardio Angiograph.More over my BP has normalised with above drugs. Please advise.Thanks XXXXXXX XXXXXXX
Posted Thu, 14 Mar 2013 in Hypertension and Heart Disease
Answered by Dr. Anantharamakrishnan 45 minutes later
Welcome to Health Care Magic

     Telma-H is combination of telmisartan and HydrocholoroThiazide. With 80-H dose, your BP is well controlled – Systolic of 110 to 130 and diastolic of 70 to 80 is very good control. This dose is proper. Keep it up.

     It is NOT necessary to stop Telma before the test. It does not influence the test or the result.
     On the other hand, Concor, being a beta-blocker, could influence the result. If anything, it can give a false negative result. Yours is strongly positive. (1 mm flat depression is the indicator / yours is 2.5 mm and down-sloping)

Absence of pain does not exclude heart problem.
This is especially true in diabetic.
     YOU MUST UNDERGO CORONARY ANGIOGRAPHY AS SOON AS POSSIBLE – with a view for possible intervention.
     If you are hesitant, the next step is to repeat stress test with thallium isotope – to assess the physiology (function). If there is a suggestion, the next step is to see the anatomy. CT angio is non-invasive study for the anatomy. If positive, you will need catheterisation, anyway. You will only be wasting precious time and money.
Coronary arteriography is invasive but it is the gold standard for this.

Your cardiologist is doing the right thing.
Keep following him up.

Take care
Wishing speedy recovery
God bless
Good luck
Above answer was peer-reviewed by
Follow-up: Diabetic. Getting mild chest pain. Stress test done. Should I take telma 40 or telma 80-H? 10 hours later
Thanks Doctor for your valuable advise.You have not answered this question.
"For the last one year I am having some pin pricking sensation in the throat,sometime on the left and some times on the right.It was followed by Coughing and then I used to be okay.It was occasional may be twice or thrice a month. But the frequency has increase in the recent one months.Please inform the possible cause and if it is a cause for worry. "The problem is I am getting constant dry cough following the irritation in the throat during the day and in the night in the last couple of days after taking the BP medication.Further I have still not started taking telma 80H yet as my BP was quite normal with telma 40 and concor 2.5.If you recommend I shall take telma 80 H in place of telama 40. I have also observed that my pulse is between 60 -70 sometimes and below 85 at all times.
Answered by Dr. Anantharamakrishnan 46 minutes later

It is rare for Angiotensin Receptor Blocker (ARB) like Telma (Telmisartan) to cause cough. Angiotensin Converting Enzyme Inhibitors (ACEI) are notorious in this respect.
If your cough is after the introduction of this drug, we have to give the benefit of doubt – stop it and see if it disappears. If not, it is not from the drug.
If it disappears, challenge again by taking it. It must come back.

If the cough was before the drugs, it is likely to be allergy. No fever, no sputum, no breathlessness, occasional and not persistent - are all highly suggestive of allergy. It could even be a post nasal discharge at times. Pulmonologist (lung specialist) has to see and do lung function test (Spirometry) for episodic obstructive lung disease. An ENT specialist will assess the sinuses and throat. Further assessment may need a battery of allergic tests.

I feel the cough disturbs you a lot / but it sounds more of nuisance than life threatening. Concentrate on the heart problem. Your coronaries need immediate attention. At this time, you must be more concerned about your heart...Discuss with your cardiologist for further assessment and assistance.

If the BP is controlled with Telma 40 – continue same. Don’t change.
Increasing the dose and adding a diuretic (Telma 80-H) may precipitate further fall.

The pulse is influenced by Concor. No cause for concern.

Above answer was peer-reviewed by
Follow-up: Diabetic. Getting mild chest pain. Stress test done. Should I take telma 40 or telma 80-H? 25 hours later
Thanks for your reply.I read about telma properties and I understand that it takes 4 weeks to get full benefit /stablise I have a new thinking and doubt. Since I have taken the stress test after only 3-4 days after starting the telama 40,it there a possibility that the stress test showed positive only because it was taken a bit to early even before my BP was under total control.Now that my BP has stablised to 130/80 and sometimes even 120/75 with the present medication,do you think another stress test after four weeks will show negative results. What I read about Telam is given below.

"It is important to continue taking this medication even if you feel well. Most people with high blood pressure do not feel sick. For the treatment of high blood pressure, it may take up to 4 weeks before you get the full benefit of this drug."

I am attaching the copy of the 2D echo,Sugar and Lipid profile taken a month Back.The 2 D Echo Heart taken about eight Months earlier showed the same results.
Answered by Dr. Anantharamakrishnan 3 hours later

The stress test is to evaluate the ability to increase the supply blood at the time of increased demand.
If the vessel is narrowed, the supply can not increase.
The resulting ischemia is seen as ST depression – positive test.

Most medicines take similar time (4/5 days) to reach steady state blood levels
And about 4/5 weeks to for maximum effects.

Telma has no effect on supply or demand.
It reduces the blood pressure and with that helps remodelling of the affected ventricle, in the long term.

An ECHO shows the valves, chamber dimensions, walls and gross function.
If the aim is to evaluate ischemia, a stress echo (like stress ECG) has to be done.

Ischemia can only worsen with time.
If we repeat after a time, it is unlikely to change – it may even be worse.
Waiting is likely to increase the chance of heart attack during that time.

The aim of an investigation (test) is to modify the treatment, based on the result.
This result is strongly positive and needs management – angiography is the best option.
If still not convinced, repeating the stress test with Thallium isotope is the next step.

Above answer was peer-reviewed by
Follow-up: Diabetic. Getting mild chest pain. Stress test done. Should I take telma 40 or telma 80-H? 5 days later
Dear Doctor
Thanks for your guidance and advice I have done the conventional Angiograph on 19th of Feb and found that I had two blocks 90% and 70 % .The doctor did the angioplasty with three drug eluting stents at the same after he consulted with us to go ahead with the same.The reports are attached for you to check up advice.I was asked to stop my diabetic drugs on the day of procedure though I read later that 48 hrs before and after the procedure.Can this have any adverse effect? I am fine now but I still have slight pain on the chest occasionally which last for a minute or two,which was my original complaint. I have been checked twice at the Hospital and each time an ECG was taken and I am told that this is nothing to worry and it was not pertaining to the Angioplasty.Kindly advise.
Answered by Dr. Anantharamakrishnan 25 minutes later

At last!
Delayed – but not denied!
It is good to hear that you have had the test and the treatment.
A block of 70% and more needs intervention, as soon as possible.
Great, you could have it.
No one should suffer from a preventable or manageable malady...
You are in good hands.
Keep it up.

There will be NO adverse effects from stopping the diabetic drugs before the procedure.
As a matter of fact, strict control may! - Low sugar has adverse effects immediately (seconds, minutes...) / high sugar over after long time (hours, days and so on...). The drugs are reduced or stopped to avoid the adverse effects during the time, when the patient may not be able to respond appropriately – eg. drowsy.

Some problems are uncommon but not unknown – after the procedure.
Normal ECGs are gratifying.
If you continue to have problems, you should see your doctor / do blood tests, ECHO... Usually, they are not necessary.

You need regular follow up
You need to take your drugs regularly

All the best
Above answer was peer-reviewed by
Follow-up: Diabetic. Getting mild chest pain. Stress test done. Should I take telma 40 or telma 80-H? 57 minutes later
Thanks for the prompt reply.Have you gone through the reports. Is the medication okay or needs modification in line with your thinking and treatment. I am told that Drug eluting Stents are good for Diabetic Patients. Is it true and why?
My sugar levels fasting 145-170 and PP 200-300 is being observed in spite of starting back the diabetic drugs.Can you please explain and do I need additional medication for controlling sugar levels.I have uploaded the PTCA procedure on BOX cloud.If you let me have your email ID I can share this with you in the cloud and you can have a look at the same. Bye
Answered by Dr. Anantharamakrishnan 8 hours later

I had seen them already except the ECHO, which could not be opened...
Even the other ones were warned by my computer - of possible harm to the system...
The medications are OK of course!
How could a team of specialists in a Tertiary care centre do otherwise?
Don’t you have confidence in them?

ECOSPRIN is Aspirin (It reduces platelet aggregation > reduces the chance of clot formation.
Effient is Prasugrel (has same function, by a different mechanism of action).
Both of them are a must for all treated with angioplasty.

Concor is Bisoprolol (It has several actions and helps in pressure, heart, anxiety and so on. Beta-blockers are a must after the procedure)

Diamicron is Gliclazide / it stimulates insulin release
Obimet is metformin / it promotes peripheral utilisation.

Atorva is Atorvastatin (It reduces bad Cholesterol)
Everybody with heart problem and diabetes should take, even with normal levels.

Hosit supplements Folic Acid, cobalamin and Pyridoxone
Pantop is Pantoprazole - given to prevent gastric problem from other drugs; can be stopped – because of some suspicion of interference with effects of anti-platelet drugs.
Alprax is Alprazolam, used in anxiety / can be stopped after a few days.
Cremaffin is liquid paraffin - It is a laxative. It is alright for occasional use, but Lactulose is preferable for long term, if in need.
It is right that drug eluting stents are better than bare metal stents for anybody, especially in diabetics.
That is because of efficacy and safety, as seen in large studies.
The sugar is not controlled very well probably from lack of activity, anxiety and stress.
If it is not well by another week, increasing the Metformin (Obimit) to twice daily is the first and safer step. There are specialists exclusively for diabetes.
I am sorry to say I don’t see ‘cloud’ due to security issues.
Even these attachments sent were deemed harmful by our computer....

You sound rather anxious!
You seem more suspicious (or plain inquisitive?!) of several things!!
I am wondering /surprised, why you have spared the treating doctors of these questions!
Believe your doctors! What they are doing is the best and state of the art .

All the best

Above answer was peer-reviewed by
Follow-up: Diabetic. Getting mild chest pain. Stress test done. Should I take telma 40 or telma 80-H? 2 days later
Dear Doctor
Thanks for your reply in detail.I am neither suspicious nor inquisitive.Also I have full confidence in the Cardiologist and his team and I have know him for many years.Only for reassurance do I contact specialists like you.I do ask the treating Doctors many of my doubts and get them clarified.The detailed explanation of the drugs I get it from the NET.As I have told you earlier I was still getting the mild chest pain even after the Angioplasty and on checking up I was assured by the doctors that it has nothing to do with my heart and that every thing was fine. What can be the cause for this?Some times the pressure was a bit high 160/80 during the day and pulse 60-70 but in the mornings it is normally 120/70 and pulse 60-70. I was asked to take Concor 5.0 mg in place of 2.5 in the night.I am yet to start on concor 5.0,which I will start to day. I have started taking short walks in the morning and I am fine and I do not get tired or breathlessness.Thanks once again for the guidance and it has been a tremendous help for me.
Answered by Dr. Anantharamakrishnan 47 minutes later

The web is an excellent source of information.
But the problem is sifting ‘sense’ from ‘mis-sense’ and nonsense.
For, there is no true censorship of the contents – especially technical information.
And hence the need to be aware of the reliability of the site.
Your confidence and thirst to know deserve appreciation.

Chest discomfort during or immediately after the procedure is from dissection, rupture, residual stenosis, recurrent block, perforation, pericarditis and so on – which are detected by ECG, enzymes and echo. Over the years, they be may be from block in the stent or native vessel.
     With normal ECG and blood tests, and no relation to effort, the present pain is most likely non-specific - from chest wall muscle spasm or gastritis

The standard dose of concor is 5 mg and it is likely to settle the issue. It has wide variety of actions – heart rate, blood pressure, angina, anxiety and so on. Beta blockers have been proved to protect the heart at least in the first year, after the procedure. If the heart rate is slow or the pressure not controlled, they may add another drug from a different class.

Good that you have started walking. If there is no pain or breathlessness, all is well and there is generally no cause for concern.

All the best
Above answer was peer-reviewed by
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