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Suggest treatment for hypertension and GERD

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Posted on Mon, 9 Mar 2015
Question: I am a 77 YO male app 210 pounds 5ft 8 inches. and have been treated long term for hypertension, hypercholesterolemia and GERD. I have been taking 325mg daily aspirin for two years and prior to that I had been taking clopidogrel with aspirin (325 mg) for two years following insertion of two drug-eluting stents in minor coronary arteries.

I have had a long history of chest pain at rest with asthma.At present I have chest pain at rest and recently have developed chest pain on exertion and cold air exposure. I have had discomfort during dobutamine stress tests (relieved by nitroglycerine)

I am being seen by a cardiologist (long term) and have been consulting a pulmonologist (recently) who is treating me for COPD. I am taking Ranexa (BID) and Isosorbide dinitrate (BID) Over 20 yrs, I have had three angiograms with negative findings each time except when I was given the stents. My last diagnosis last October was Coronary Syndrome X after a negative angiogram which I was started on the two antianginal medicines this past October when I had chest pain (at rest).

I was originally prescribed clopidogrel five years ago with a baby aspirin after an ischemic CVA. (Good recovery)
My Cardiologist has taken me off clopidogrel for the past year maintaining that the 325mg aspirin daily is sufficient.
I have had negative endoscopic and pulmonary XXXXXXX evaluations last year.

a) is there evidence for clopidogrel efficacy/toxicity after five yrs?
b) In view of the fact that one of my siblings died from a pulmonary embolism at the age of 69 and I’ve a history of chest pain at rest, my CVA history, is the formation of an embolism a potential explanation for my chest pain at rest?
c) Should Prenzmetal’s Angina be ruled out?
d) Would reintroduction of clopidogrel pose an unnecessary bleeding risk?
e) Anything else you can suggest?
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Answered by Dr. Ilir Sharka (4 hours later)
Brief Answer:
I recommend you to relax first and talk for following

Detailed Answer:
Hello.

Thank you for your question on HCM!

I understand your concern and I would like to explain to you:
a. Clopidogrel is very important in preserving stent patency in the first year after implantation. After this period usually we switch to aspirin, it is judged by the attending cardiologist. No potential for drug toxicity exists after drug stopping. So relax and do not worry.

b. Chest pain in pulmonary embolism is an expression of pulmonary infarction presence or right ventricle ischemia and both these situations can be ruled out by chest X ray study and a cardiac ultrasound. But I don't think that the explanation is pulmonary embolism based on your history and pain nature. So relax regarding this suspicion.

c. Regarding Prinzmetal angina I would say that it may coexist with coronary atherosclerotic disease and be triggered by several stressing factors. ECG during pain episode, pain nature exclusion of other causes and some provocative tests may confer. At your situation I think that it would be enough to just add a calcium channel blocker to you current therapy for that; just talk to you cardiologist.

d. I don't believe that reintroduction of clopidogrel would be of much help for your situation, as you are on aspirin already, your stents are ok by coronary angiogram and you have not inserted new stents. So of course clopidogrel has the probability to impose a greater bleeding risk.

e. My suggestions: regarding your heart, after coronary angiogram report the important think is that stents are OK, sometimes stents implanted in small caliber arteries could exert ischemia on stress test, this can be confirmed by nuclear imagine tests or other options. Sometimes microvascular angina is the reason of ischemic pain when coronary angiography is without problems. Just talk to your cardiologist for these options. I personally would recommend you to rule out other chest pain options such as extra cardiac origin (based on your weight explore you back spine and talk to your pulmonologist for your complains).
Above answer was peer-reviewed by : Dr. Ashwin Bhandari
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Dr. Ilir Sharka

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Practicing since :2001

Answered : 7644 Questions

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Suggest treatment for hypertension and GERD

Brief Answer: I recommend you to relax first and talk for following Detailed Answer: Hello. Thank you for your question on HCM! I understand your concern and I would like to explain to you: a. Clopidogrel is very important in preserving stent patency in the first year after implantation. After this period usually we switch to aspirin, it is judged by the attending cardiologist. No potential for drug toxicity exists after drug stopping. So relax and do not worry. b. Chest pain in pulmonary embolism is an expression of pulmonary infarction presence or right ventricle ischemia and both these situations can be ruled out by chest X ray study and a cardiac ultrasound. But I don't think that the explanation is pulmonary embolism based on your history and pain nature. So relax regarding this suspicion. c. Regarding Prinzmetal angina I would say that it may coexist with coronary atherosclerotic disease and be triggered by several stressing factors. ECG during pain episode, pain nature exclusion of other causes and some provocative tests may confer. At your situation I think that it would be enough to just add a calcium channel blocker to you current therapy for that; just talk to you cardiologist. d. I don't believe that reintroduction of clopidogrel would be of much help for your situation, as you are on aspirin already, your stents are ok by coronary angiogram and you have not inserted new stents. So of course clopidogrel has the probability to impose a greater bleeding risk. e. My suggestions: regarding your heart, after coronary angiogram report the important think is that stents are OK, sometimes stents implanted in small caliber arteries could exert ischemia on stress test, this can be confirmed by nuclear imagine tests or other options. Sometimes microvascular angina is the reason of ischemic pain when coronary angiography is without problems. Just talk to your cardiologist for these options. I personally would recommend you to rule out other chest pain options such as extra cardiac origin (based on your weight explore you back spine and talk to your pulmonologist for your complains).