Update on angiogram procedure yesterday

Positive outcome

by Xtrabeat - 2024-07-30 06:36:59

That sounds like a positive result Gemita - I imagine quite a relief to "know" what is happening. Did they actualy witness spasm at the time of the proceduerr - and did you have symptoms? Regarding stress management maybe some CBT would help? 

Yes they did

by Gemita - 2024-07-30 06:52:03

Xtrabeat, yes they witnessed the spasms yesterday and I was having symptoms at the time in the epigastric area.  

They gave me a cocktail of meds before the procedure.  I specifically asked them if they were sure the pain was coming from the heart and not gastric area since I have known oesophageal spasms too, diagnosed many years ago.  They can be a frequent cause of chest pain, but never as severe as I experienced yesterday.  They had to use IV pain meds to get it under control.  They confirmed it was vasospastic angina and not caused by my gastric problems.

As a full time carer, stress management is key I am sure.  I know CBT well.  An excellent therapy.

glad to hear you now know what is causing your problems

by new to pace.... - 2024-07-30 08:19:54

Good to hear you can  now start the healing process.  cannot beleive you wanted to stay awake during the procedure.  Not sure i would be brave enough.

new to pace

All done

by piglet22 - 2024-07-30 08:49:25

Not exactly a day out in the sunshine, but good to get it out of the way.

it does help to get some symptoms while under observation.

When I first saw a consultant in 2005, he didn't have to do a lot.

He wrote to my GP and copied to me, "this gentleman was in heart block during the consultation"

Quickest diagnosis ever "you have complete heart block, you need a pacemaker, urgently"

I take Coracten (calcium channel blocker) as well as the Bisoprolol and ACE inhibitor. Sometimes a struggle, but keeps the BP in control.

Stress is a big factor, but hard to control by thought alone.

Pleased to Hear

by Foxy49 - 2024-07-30 09:16:17

I'm sure was an ordeal but pleased to hear you have a diagnosis now. You handled it really well. It's a positive you have no blocked arteries at least. 

Can Vasospastic angina be a side effect of pacing?

by IrishToast - 2024-07-30 09:39:53

I know so little, but my thought was could a pacemaker cause heart or even gastric spasms?

How things have moved on

by crustyg - 2024-07-30 09:47:29

When I started training mid-70s, there was still a debate about whether Prinzmetal's angina could ever cause infarction, the logic being that the local auto-regulation would over-ride the vasoconstrictor drive (as the downstream heart muscle became increasingly oxygen-starved).  It can.

Not an easy diagnosis to make, and I'm impressed that they were able to do it all via the radial artery - that's a skill in itself.

Pacing wires and ablation catheters can certainly cause cardiac irritation (usually at the time of implantation or usage), triggering fibrillation, and putting a catheter into the coronary arteries can itself cause spasm (or intimal separation), but I don't *think* PMs or their leads can cause variant angina ab initio.

Results at last

by Aberdeen - 2024-07-30 09:58:00

I am glad they have discovered what was causing your symptoms and I hope the treatment will work well for you. Look after yourself!

Valerie

Hugs🌻

by Lavender - 2024-07-30 10:45:12

What a day you had! You are so brave! I would have asked to be unconscious and unaware. Lol

I am glad you finally had this done so you could verify what is going on and begin treatment to alleviate these symptoms. Good too that they were able to go through the wrist and avoid those awful after effects you had from the femoral entry last time. 
 

Perhaps Michael and you could look into home health care to relieve you a day a week? We just set this up for my bf's mom. Extra help. A day off. I know you will come up with ideas. 

New to Pace and Piglet

by Gemita - 2024-07-30 13:04:53

New to Pace, actually I remember asking my doctors to give me lots of pain relief and to put me to sleep but clearly they didn’t.   I was given IV Fentanyl.   I found myself unusually wide awake during the procedure but extremely relaxed, so I wasn’t really so brave.  I am glad I managed to stay awake.  I would have missed a lot of the discussion between my two doctors.   

Piglet, no it was certainly no day out, but the Day Ward was quiet and relaxed and shielded from the hot sun.   The nurses were really caring and the doctors looked as though they had all the time in the world for their patients, although they wanted us to take part in a research study to determine the accuracy of commonly used wires that measure the blood flow in the arteries that supply the heart when having an angioplasty and stents.  I did sign for it just in case I needed revascularization during the angiogram procedure.  The Research Study was called:  Systematic Evaluation by Randomisation of Intracoronary physiological techniques for Assessing tandem Lesions

crustyg

by Gemita - 2024-07-30 13:23:37

I attach some discharge notes in case of interest:

Positive Dobutamine Stress Echo (DSE) with symptoms of angina - worsening symptoms over last 3 months

This 75 year old lady with pAF gives a good history of angina, she underwent DSE which suggested ischemia in 2 segments.

RRA, 6Fr Sheath, 5Fr JR4, JL 3.5 guide

LMS: Unobstructed
LAD: Unobsructed
Lcx; Unobstructed
RCA: Dominant, Unobstructed

Proceeded to microvascular testing in LAD

5Fr EBU 3.5 Guide
PressurewireX to distal LAD
FFR 0.95

Rayflow microcatheter introduced: CFR 4.2
Some distal LAD spasm with low dose Ach infusion

Plan
1. Stop bisoprolol
2. Start Diltiazem 120mg MR in view of tendency to vasospasm

The doctor came to speak to me when I returned to the Day Ward and confirmed the diagnosis of vasospastic angina.  I attach a link which may be of interest:-

https://www.sciencedirect.com/science/article/pii/S0002914924001048

Foxy49 and Irish Toast

by Gemita - 2024-07-30 13:31:48

Foxy49, yes I was expecting a nasty blockage because of the level of my pain at times, but it is reassuring to know that medication may be able to stop many of my angina episodes.  So far, so good on Diltiazem.  Actually I had heard that it will also help with oesophageal spasms.  I certainly feel relaxed on it on Day 1.

Irish Toast, you are learning fast.  I suppose if pacing has not been optimised for us, it is possible that we could experience some unusual spasms.  I am perhaps thinking more in the diaphragm area, or in the stomach area because that is where I can feel some strange rhythm disturbances when my pacemaker is not managing to control my arrhythmias or when the settings are working against me.  And pacemakers certainly have no answer for stopping some of these irregular beats.  And with “irregular” rhythm disturbances, they can certainly lead in my case to chest pain whether I am resting or exercising.

I agree too with crustyg that pacing wires and ablation catheters can certainly cause cardiac irritation.  I was living proof of this for the first three months after pacemaker implant when my heart went wild and went in and out of atrial tachycardia/fibrillation/flutter.  My heart rate and rhythm were definitely difficult to control.  I don’t believe my angina has been caused by the pacemaker system. My autonomic nervous system is probably responsible for all of this, just as it is responsible for my oesophageal spasms.   Now that I have been diagnosed, I am hopefully on the right medication to treat both the oesophagus and the heart.  That would be such a relief.

Aberdeen and Lavender

by Gemita - 2024-07-30 13:47:43

Thank you both.  My new medication is certainly working well on Day1, no side effects whatsoever.  I did have some chest pain a short while ago, but it seemed to pass very quickly.  

Yes I think without the angiogram challenge, they would have kept me on the same beta blocker for the rest of my life.  The Diltiazem prolonged release capsule seems to be working brilliantly.  I had irregular heart beats before taking it and now my heart is feeling so regular.  Maybe this is the missing ingredient.

The bruise is spreading down my arm and into the hand now, but no pain or undue swelling, so I think it will heal nicely.

Lavender we are getting help now from family and friends and we have made a number of enquiries to see how we can better manage around the home in the future. The problem I have is getting the patient to acknowledge there is a need for help, a need for change.  

Finally!

by athena123 - 2024-07-30 16:31:41

Well done Gemita, the hard part is over and now look forward to some much needed rest. I see they put you on Diltiazem which will help constrict the blood vessels and help your heart function with some ease. Im so happy there no blockages and it looks like some of your irregular heartbeats have gone away. May you and Micheal have many more blessed years together to enjoy with your families. 

This is Great News

by Penguin - 2024-07-30 17:30:08

Prinzmetal's Angina happens mainly at rest apparently.   Stress management techniques such as finding a means of distracting from any stress trigger when you begin to feel the pain may be helpful if you can master it.  

Without wishing to be a harbinger of doom, 'unobstructed' may not mean 'no plaque'.  Unfortunately most of us have some. 

Spasm can dislodge plaque.  If the calcium channel blocker removes or reduces the risk of spasm, that sounds pretty helpful to me.  

Fingers crossed for you. 

Congrats on a job well done

by Andiek11 - 2024-07-30 18:31:21

Gemita - this most recent adventure sure wasn't easy, but at least you have some solid answers and actionable "next steps" you can take.  Sometimes just being able to give an accurate name to the "enemy" and create a game plan can help reduce some of the stress that goes with this new info.  I hope that this is the case for you.   

Vasospastic angina

by sgmfish - 2024-07-30 21:11:50

My wife has this problem. It caused some panicky episodes from time to time until it was finally diagnosed. She takes some med for it and the condition hasn't been a problem at all now for a couple of years. Gemita, just wanted to mention that the docs also gave her a bottle of nitroglycerin pills. If she feels an attack coming on, she pops one of those and viola, it's gone. (She hasn't needed the nitro in a while.)

Coronary Vasospasm

by Rch - 2024-07-31 02:15:45

Gemita

Glad to know your coronary arteries are clean. Hope you will feel better on the calcium channel blockers and NTG for symptomatic episodes. Generally there are some ST changes associated with coronary spasm. I'm not sure whether they were able to capture that during the episodes. In any case, a negative angiogram is very reassuring! 

Athena, Andie and sgmfish

by Gemita - 2024-07-31 02:26:48

Athena and Andie thank you both.  Yes I cannot tell you how relieved I am to have an answer.   It is the not knowing that can cause such worry with chest pain.  In the past few weeks this has added to my stress levels and worsened my symptoms.  Just knowing now what is going on and that I am on the right path with treatment will help.  I have to say so far I am not disappointed with the new medication, Diltiazem, a med I have always wanted to try as an alternative to a beta blocker.  My heart seems to be beating “steadily” and strongly with this med on board.  A good sign perhaps.  Yes getting a diagnosis has been truly exhausting but necessary to avoid the wrong treatment decisions.  

sgmfish, I was so happy to receive your contribution and to know that your wife was helped by medication alone.  That is so reassuring.  I know the nitroglycerine pills, sprays are often used during sudden attacks.  I have tried them too with enormous benefit and fast relief from symptoms, although they can lower my blood pressure very quickly, so I have to be careful.  Diltiazem so far has not done this and seems to be far superior in treating my rhythm disturbances and chest pain than was my beta blocker, Bisoprolol.   Out of interest, how was your wife diagnosed with Vasospastic Angina?  I hope she continues to be well

Penguin

by Gemita - 2024-07-31 02:31:10

Yes I am sure my blood vessels are not completely free from plaque. I believe the definition of non obstructed arteries is “no focal obstruction >50%” so they certainly don’t go in immediately with a stent, although I would hope ulcerated or diseased arteries would be treated regardless of the degree of obstruction?   My husband’s right coronary artery was treated shortly after they stented his left anterior descending artery because the right coronary artery wall was ulcerated and there was a high risk of blockage in the future.  

They used pressure flow wires during my angiogam study to test how strongly blood flowed through my arteries so I suppose they were satisfied that blood flow was adequate.  In any event, they only changed one medication (Bisoprolol to Diltiazem) and didn’t push for me to take any new meds like a Statin, so perhaps I can be reassured that there was no noticeable evidence of new disease?  

I found the attached link from the European Medical Journal a very useful read and I do seem to be on the right path with a calcium channel blocker,  although long acting nitrates may also help.  The article I see was written in 2016, but is still valuable/relevant today.

https://www.emjreviews.com/cardiology/article/current-concepts-in-coronary-artery-spasm/

Rch

by Gemita - 2024-07-31 03:23:04

it is always good to receive your thoughts.  It would be interesting to receive a detailed report of how they confirmed the diagnosis.  My discharge notes were all too brief. 

During the procedure they kept giving me different medication challenges and asking whether I had chest pain or relief from chest pain.  Yes they were looking for ECG changes but I am not sure what they found.  I heard them mention something about T-wave abnormalities when administering acetylcholine. 

I am definitely feeling better already on Diltiazem with a much steadier heart rhythm.  Yes I am relieved not to be facing coronary artery disease, although functional disease can still cause severe symptoms.  Aren't we complex creatures Rch

Sex & Ethnicity

by Penguin - 2024-08-01 03:12:19

Gemita, 

I thought you might find this much more recent paper interesting. It's on the subject of Coronary Artery Spasm and it looks into sex and ethnic differences.  I was interested in it because the Japanese researchers were 'all over' coronary artery spasm and it was suggested that the Japanese culture / genetic make up / environmental factors in Japan were responsible for higher levels of CAS.   I was interested in the 'stress' component and whether their culture causes this. This paper looks at how results are recorded for significance in Japanese papers vs European papers. 

More interestingly for you it looks at the angiogram test results and cohorts of CAS sufferers and how the condition affects women vs men.   https://www.ecrjournal.com/articles/coronary-spasm-ethnic-and-sex-differences

Great You Finally Have a Diagnosis

by SeenBetterDays - 2024-08-01 10:36:30

Gemita

Fantastic news that there are no obstructions to the coronary arteries and that you finally have an explanation for your chest pain.  I'm really pleased that you are already feeling the beneficial effects of your new medication - long may it continue.  It's strange how our autonomic nervous system which is meant to keep us alive can sometimes work against us.  As you so rightly said, I am sure that stress plays an important role in a lot of dysfunction in the body as it creates so many chemical and physical changes.  While I know that it is impossible to eradicate stress from our lives I hope you have a good support network around you and that you are able to find some time to relax and enjoy some quiet moments.  I feel as though you spend a big chunk of your time helping us with all our problems and concerns so hope that you are able to put yourself first occasionally.  You are incredibly strong and  resilient so I know that you will approach this new challenge with your usual determination and thoughtfulness.  Sending you love and really hoping that you continue to feel well x

Penguin and SeenBetterDays

by Gemita - 2024-08-01 19:30:00

Penguin, the link you provided was really helpful, thank you.  It filled in so many gaps.  During my coronary angiogram my doctors used the vasoactive substance acetylcholine as a provocation test. The spasms were detected in my LAD artery during the angiogram.  They initially found this artery to be positive for ischaemia in two segments during my earlier stress echo although my angiogram did not confirm any blockages.

I note from the link that ECG changes during testing like ST depression was seen more frequently in female patients and ST elevation more frequently in males.  

I was particularly interested to read that women have an increased sensitivity to acetylcholine, requiring a lower dose to elicit a pathologic test result.  I do recall my doctors mentioning that I was very sensitive to acetylcholine even at a very low dose which is why they didn’t seem to have any doubts about the final diagnosis of vasospastic angina.  Glad I didn't need more since it could have triggered a dangerous arrhythmia.

Surprisingly I see spasm provocation testing is not routinely carried out in Europe and the US as it is in Asia, although it has been proven to be useful and generally safe.  It is though an invasive test with some risks and is no doubt a lot more expensive than a CT angiogram.

I note that the vasoactive substance acetylcholine appears to provoke diffuse and distal spasms, whereas ?egonovine? testing is known to provoke focal and proximal spasms.  The link also revealed that diffuse vasoconstriction occurred more frequently in women, and focal spasm was observed more frequently in male patients.

What a learning process.  Thank you for this valuable find Penguin xx

SeenBetterDays, thank you so much for your lovely message.  Yes I am happy and relieved too!   Such a heavy burden has been lifted.  I was beginning to think I was imaging all of this or just attention seeking, but no it comes down to a functional problem again, but a problem that could cause real trouble if not controlled.  Just a simple switch to the new med has made such a difference already.  I almost want to hug my doctors for finding the problem and speedily offering a solution.   To think I nearly backed out of having the angiogram.   

I know I have some way to go before I can claim everything is under control.  It is clear I need time to myself to really unwind.  I have been on heightened alert for far too long without a break.  I am working on that part of my life too but it is not easy.  

I do appreciate everyone here and their wonderful words of support.  I think I receive far more than I could ever give back xx

.....how was your wife diagnosed with Vasospastic Angina?

by sgmfish - 2024-08-01 21:46:51

She had been having "attacks" a couple time a year for a few years where her heart would race, BP go way high, chest pain, and strong fatique. She became VERY anxious during these events. Not knowing the chicken vs egg of it, we decided these events were some sort of panic attack. Eventually one attack was so strong that we thought she was having a heart attack. We live on an island; so it ain't so easy to just get to the hospital, but we finally got to the Emergency Room. She was in a hospital bed for 2 or 3 days while they did tests. Everyone figured it was some sort of heart attack, but eventually the angiogram showed it to be angina resulting from carotid artery vasospasm syndrome.

sgmfish

by Gemita - 2024-08-02 03:08:50

Thank you so much for replying.  The more I look into this, the more I discover. 

Of course carotid spasms, like spasms in the coronary arteries, can lead to serious events too.   When a vasospasm happens in our heart or brain, the lack of blood flow to those organs can destroy tissue. This can have a severe impact on how well the heart and brain function. I am relieved your wife is doing so well on medication alone.  

I see that there have even been reports of stents being used for both carotid and coronary arteries in difficult to treat cases of vasospasm, even in the absence of arteriosclerosis.  It does seem that further research, as always, is needed to find better treatments to prevent serious problems arising from carotid/coronary vasospasms

OOPS.....

by sgmfish - 2024-08-02 16:10:28

Gemita, sorry to mislead you. I had been doing some internet research on carotid artries, that word must have stuck in my mind. My wife's condition is coronary artery vasospasm NOT carotid artery vasospasm as I mistakenly typed above.

P.S. BTW, I asked her and she said that the daily medicine she takes for this is: amlodipine (also a calcium channel blocker like diltiazem as I'm sure you know).

It happens

by Gemita - 2024-08-02 17:31:45

sgmfish, I did wonder whether you really meant “Carotid” artery vasospasm syndrome although my comments to you on Carotid and Coronary vasospasms are still valid.   I hope your Carotid arteries are clean and that you aren’t having any blockages or spasms.  Yes I know Amlodipine very well.  My husband tried it.  Diltiazem seems to suit me as a prolonged release med, once a day