Heart Issues: When to Consider Angiography vs. Medication

Cardiac issues

Hello Doctor: I would like to ask some questions.
I had an exercise stress test that showed signs of ischemia, and my doctor recommended a cardiac catheterization.
Later, I took the report to another hospital for a consultation, where the doctor ordered a myocardial perfusion scan.
After reviewing the report yesterday, the doctor mentioned that the extent of vascular blockage is not significant and that I can manage it with medication for now, so a cardiac catheterization is not currently necessary.
The medications prescribed are Concor 1.25 mg twice a day and Aspirin 100 mg once a day.
I would like to ask if it is possible to manage myocardial ischemia without undergoing cardiac catheterization? Does the recommendation to start medication indicate that my ischemic condition is not severe? Can a myocardial perfusion scan determine the severity and extent of vascular blockage? These two medications were prescribed before I underwent the exercise stress test and myocardial perfusion scan, and the doctor advised that I continue with the current medications.
Is cardiac catheterization always required for myocardial ischemia, or is it not necessarily the case? I appreciate your clarification on these concerns.
Thank you.

Mr. Wang, 40~49 year old female. Ask Date: 2017/03/02

Dr. Li Han reply Cardiology

Hello, sir.
Coronary artery disease is indeed a common cardiac condition among middle-aged and older adults.
Clinically, it may present without obvious symptoms, or it may manifest as angina pectoris or myocardial infarction, and in more dramatic cases, sudden cardiac death.
When you are diagnosed with angina, it is often based on clinical judgment rather than a definitive diagnosis.
There are many causes of chest pain; broadly speaking, clinical manifestations caused by myocardial ischemia can be termed "angina." This is usually due to luminal narrowing caused by coronary atherosclerosis.

For example, it's like trying to catch a thief with both the person and the stolen goods.
If a patient experiences angina and the electrocardiogram (ECG) simultaneously captures consistent changes indicative of myocardial ischemia, then the diagnosis is established.
Unfortunately, patients often seek medical attention when symptoms are not occurring, and at that time, the ECG may appear normal.
If the physician suspects your symptoms resemble angina but cannot identify other non-cardiac causes, they may initiate treatment and arrange for further diagnostic tests to determine the underlying cause.
Exercise stress testing and nuclear myocardial perfusion imaging are commonly used non-invasive diagnostic tools in clinical practice.
Although they cannot provide anatomical assessments like coronary angiography or multi-slice computed tomography, they can offer functional evaluations as a reference for risk stratification.
For patients with moderate to high-risk coronary artery disease, it may be justified and necessary to undergo invasive coronary catheterization or interventional treatment.
Additionally, there may be differing treatment opinions among physicians, and various options exist...
but I believe they are all based on sound reasoning and are intended for your well-being.
The Changhua Hospital of the Ministry of Health and Welfare cares about you.

Reply Date: 2017/03/02

More Info

When considering the management of heart issues, particularly regarding myocardial ischemia and the decision between angiography and medication, it's essential to understand the underlying conditions and the implications of diagnostic tests such as myocardial perfusion imaging (MPI) and stress tests.

In your case, the presence of ischemia indicated by your exercise electrocardiogram (ECG) suggests that your heart may not be receiving enough blood flow during periods of increased demand, such as exercise. This can be due to various factors, including coronary artery disease (CAD), which is characterized by the narrowing or blockage of coronary arteries. The recommendation for a coronary angiogram (heart catheterization) is typically made when there is a significant concern about the severity of blockages that could lead to serious cardiac events.

However, your subsequent MPI results indicated only mild to moderate ischemia with no significant blockages, which led your physician to suggest a conservative approach with medication rather than immediate angiography. This decision reflects a few key points:
1. Severity of Ischemia: The MPI results showing mild to moderate ischemia suggest that while there is some impairment in blood flow, it may not be severe enough to warrant invasive procedures at this time. The fact that your physician noted the extent of blockage is not significant implies that your heart's blood supply is still relatively adequate under normal circumstances.

2. Medication Management: The medications prescribed, such as Concor (a beta-blocker) and aspirin, are aimed at managing your symptoms and reducing the risk of further ischemic events. Beta-blockers help to lower heart rate and blood pressure, reducing the heart's workload, while aspirin acts as an antiplatelet agent to prevent blood clots. This combination can effectively manage mild ischemia and improve your overall heart health without the need for immediate intervention.

3. Monitoring and Follow-Up: Your physician's recommendation to start with medication suggests that they believe your ischemia is manageable at this stage. Regular follow-up appointments and possibly repeat stress testing or imaging may be necessary to monitor your condition and determine if further intervention becomes necessary in the future.

4. When to Consider Angiography: Angiography is typically reserved for cases where there is a high suspicion of significant coronary artery blockage that could lead to severe ischemia or myocardial infarction (heart attack). If your symptoms worsen, if you experience more frequent angina, or if follow-up tests indicate a progression of your condition, your physician may reconsider the need for angiography.

In summary, the decision to manage your condition with medication rather than immediate angiography is based on the current assessment of your ischemia as mild to moderate, along with the absence of significant blockages. It is crucial to maintain open communication with your healthcare provider, adhere to the prescribed medication regimen, and report any new or worsening symptoms promptly. Regular monitoring will help ensure that any changes in your condition are addressed in a timely manner.

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