Severe Coronary Artery Blockage in Elderly Patients

Severe coronary artery obstruction?

My father is 78 years old and underwent a coronary angiogram in May.
The doctor informed us that: 1.
All three major coronary arteries are severely blocked.
2.
One artery requires two stents, and 3.
Another artery requires over ten stents, which is quite complicated (the doctor did not mention how many stents are needed for the third artery).
At that time, I was quite flustered and inadvertently kept the doctor waiting, so I casually responded that we should first place stents in the artery that was easier to manage (the two stents).
Therefore, my father had two stents placed.
However, during each follow-up visit, I always ask the doctor when we will address the more complicated artery that requires over ten stents, but the doctor never responds.
This lack of response makes me doubt whether the doctor is confident in proceeding.
I have been considering switching hospitals.

I would like to ask the doctor: 1.
What is the appropriate blood pressure range for elderly patients? 2.
If I switch hospitals for my father, can he avoid in-person visits and I can simply bring the original hospital's examination CD for the new doctor to review? (I feel reluctant to put my father through the hassle of traveling.) 3.
If we eventually return to the original hospital for treatment, will it offend the original hospital's doctors? 4.
For asymptomatic coronary artery disease, is it possible to avoid stenting? (Although the angiogram results show that my father's three arteries are severely blocked, he reports not experiencing any discomfort.)
Dear Dr.
Huang, I am very grateful for your previous response.
May I ask you again: 1.
My father is 78 years old and has had diabetes for nearly 30 years; is he a suitable candidate for coronary artery bypass grafting? 2.
If we decide to place stents in the severely blocked artery, A.
Can all the stents be placed in one session? B.
If the stents are self-paid, the costs would be substantial; we plan to use health insurance—will it cover the expenses? (The last two stents placed were self-paid and cost NT$170,000.) 3.
If we transfer to a larger hospital, should we first see a cardiologist and then a cardiac surgeon? (Currently, the cardiologist has not informed us whether stenting or bypass surgery is better; after the angiogram, they only asked if we wanted to place stents.) 4.
Is a blood pressure of around 101/61 better for elderly patients, or is around 132/73 preferable? My father originally took one 1.25 mg (Concor) and half of a 5 mg/160 mg (Epanutin) tablet, resulting in a systolic pressure of around 110 and diastolic pressure in the 60s.
Recently, the doctor recommended stopping Epanutin.
After stopping, his systolic pressure sometimes reaches around 130, with diastolic pressure around 70, and occasionally 119/70.

Bu zhi suo cuo, 30~39 year old female. Ask Date: 2019/08/06

Dr. Huang Yinghe reply Cardiology

1.
As previously mentioned, bypass surgery is one option, and its suitability should be discussed with a cardiac surgeon, taking into account factors such as anesthesia risks and the overall nutritional status of the patient.

2.
Health insurance coverage for coronary artery stenting is limited, with a maximum of four stents per year.
Full coverage is only provided for standard metal stents (approximately $15,000), while for complex lesions, it is generally recommended to use drug-eluting stents, which require an additional payment of about $50,000 to $60,000 per stent.
Additionally, special equipment, such as a coronary atherectomy system, may also require out-of-pocket expenses.
Therefore, if multiple stents are needed, the financial burden can be significant, and typically, placing five or six stents at once is already a considerable amount.
One must consider the potential for prolonged surgery time, the inability to complete all necessary vessel interventions in one session, and the risk of surgical failure.
3.
If bypass surgery is decided upon, you can directly consult a cardiac surgeon; otherwise, it is advisable to first seek an evaluation from a cardiologist.
4.
A systolic blood pressure of 100-130 is acceptable, provided the patient does not experience any discomfort.
If the systolic blood pressure drops to the 90s or lower, it is considered too low and medication adjustments may be necessary.

Reply Date: 2019/08/06

More Info

Understanding severe coronary artery blockage in elderly patients, particularly those with multiple comorbidities such as diabetes, requires a comprehensive approach that considers both the medical and psychological aspects of care. Your father's case, with significant blockages in three coronary arteries and the need for multiple stents, raises several important questions regarding management and treatment options.

1. Blood Pressure Management in the Elderly: For elderly patients, maintaining a blood pressure that is neither too high nor too low is crucial. Generally, a target blood pressure of around 130/70 mmHg is considered appropriate for older adults, but this can vary based on individual health conditions. Your father's blood pressure readings of 101/61 mmHg may be too low, especially if he experiences symptoms like dizziness or fatigue. Conversely, readings around 130/70 mmHg are more favorable and may indicate better perfusion to vital organs.

2. Transitioning to a New Hospital: If you decide to seek a second opinion or transfer your father to a different hospital, it is indeed possible to bring the imaging studies (such as the catheterization films) without requiring him to travel. Most hospitals will accept these records for review, and many have protocols in place for remote consultations. However, it is advisable to call ahead to ensure that the new facility can accommodate this process.

3. Returning to the Original Hospital: Generally, patients can return to their original healthcare providers without causing offense. Physicians understand that patients may seek second opinions or additional care, especially in complex cases. Open communication with the original physician about your concerns can help maintain a good relationship.

4. Management of Asymptomatic Coronary Artery Disease: In cases where significant coronary artery blockage is present but the patient is asymptomatic, the decision to place stents can be complex. While stenting can improve blood flow, it is not always necessary if the patient is stable and symptom-free. The risks of the procedure, including complications and the need for long-term antiplatelet therapy, must be weighed against the potential benefits.

5. Surgical Options for Elderly Patients: Given your father's age and diabetes history, the suitability for bypass surgery (CABG) should be evaluated by a multidisciplinary team, including cardiologists and cardiac surgeons. Bypass surgery may be more beneficial in cases of severe blockage in multiple arteries, especially if stenting is not feasible or if the arteries are too diseased. The decision will depend on his overall health, the extent of the blockages, and the potential for recovery.

6. Stenting Multiple Arteries: If the decision is made to proceed with stenting, it is typically done in stages rather than placing multiple stents in one session, especially if it involves a significant number. The financial aspect, particularly regarding insurance coverage, can vary. In many cases, health insurance will cover medically necessary procedures, but it is essential to confirm this with the insurance provider beforehand.

7. Consulting Specialists: If you are considering transferring to a larger hospital, it is advisable to first consult with a cardiologist who specializes in interventional cardiology. They can provide insights into whether stenting or bypass surgery is more appropriate based on your father's specific condition.

In summary, managing severe coronary artery disease in elderly patients requires careful consideration of their overall health, the severity of their condition, and their individual preferences. Open communication with healthcare providers, seeking second opinions when necessary, and understanding the implications of treatment options are all critical components of effective care.

Similar Q&A

Understanding Cardiac Catheterization: Risks, Types, and Considerations for Seniors

My father is 70 years old and has hypertension, coronary artery disease, and diabetes. Recently, after an examination by a hospital physician, he was advised to undergo cardiac catheterization. The doctor mentioned that in the past, cardiac catheterization required incisions of s...

Dr. Li Fangzhong reply Surgery
Dear Ms. Miho, Thank you for your letter. Cardiac catheterization is essentially a coronary angiography procedure, primarily performed by a cardiologist. A catheter is inserted into the blood vessel and a contrast agent is administered near the coronary artery openings for imagi...

Understanding Cardiovascular Blockage: Treatment Options and Risks

Dr. Lin: Hello, I have concerns regarding cardiovascular blockage and would like to seek your advice. My mother is nearly sixty years old and has diabetes. In recent years, she has frequently experienced unexplained chest tightness and pain, with several instances severe enough t...

Dr. Lin Xinjing reply Cardiology
Hello: Generally speaking, the heart has three coronary arteries. After a detailed examination, if there is a blockage, balloon angioplasty with stent placement or coronary artery bypass grafting (CABG) may be performed. In general, the prognosis is good. However, for diabetic pa...

Can Traditional Chinese Medicine Help Severe Coronary Artery Blockage?

Hello Dr. Yan, my father is 78 years old and has been suffering from diabetes for several decades. In recent years, his heart condition has worsened, and after a doctor's diagnosis, it was found that all three of his arteries are severely blocked. I would like to ask Dr. Yan...

Dr. Yan Sumei reply Traditional Chinese Medicine
Dear online friend, Thank you for your message! It may be difficult to achieve your goals solely through traditional Chinese medicine for severely blocked arteries and gum recession. While traditional Chinese medicine has blood-activating and stasis-resolving herbs that can enha...

Understanding Right Coronary Artery Blockage and Mitral Valve Regurgitation

Dear Dr. Wu, My mother is 68 years old. At the end of last year, she experienced pleural effusion for the first time in her life. An echocardiogram revealed moderate to severe mitral valve regurgitation, which caused fluid buildup and shortness of breath. After a thoracentesis p...

Dr. Wu Xueming reply Cardiology
If the heart's contractile function is poor and symptoms of heart failure and pulmonary congestion remain uncontrolled despite medication, it is advisable to address the issue of vascular obstruction. Surgical bypass surgery will only be considered when catheter-based interv...