Exercising After My Heart Attack and Natural "Collateral" Bypasses

After my heart attack in 2007 I had to make many lifestyle changes. They included:

• giving up smoking - was doing 40-50 a day at the time and had been smoking for 33 years.
• changing my diet
• learning how to cope with stress
• starting to exercise daily

Thank goodness I didn't (don't) drink much!

The smoking thing wasn't that difficult to deal with, oddly enough, in fact I gave up the night of my heart attack. 

Changing my diet took some work but I was able to make the required adjustments once I understood the impact on my health my bad eating habits were having.

Dealing with stress was and still is my biggest challenge but rediscovering photography and getting involved with helping my wife look after injured wildlife became natural ways for me to destress/avoid stress.  Can not emphasize enough the importance of finding a hobby, an interest when it comes to helping deal with recovering after a heart attack.

Probably the biggest change in my life was making the commitment to daily exercise and it is something I am still doing 9+ years after my heart attack - these days I still try to walk 20-30 mins a day.

photo courtesy of  Heart Foundation of Australia

I am lucky in that I can motivate myself to do something but for those unable to do so there are, in many communities, walking groups or similar activities that people can join in. Heart Foundation in Australia has many walking groups around the country and their locations can be checked out on their website: http://walking.heartfoundation.org.au/

I must admit though, I have had lapses in all of the above from time to time, except for smoking, have never touched one since. And from time to time will have some "fast food" and/or depending on the weather or on how I am feeling will skip my walking for a day or two.

These days, after my angiogram in May when a new 99% blockage was found in my RCA and could not be stented because it was too calcified and tortuous, I can appreciate the importance of my daily exercise since 2007. As my cardiologist explained after the angiogram. my body created a natural "collateral" bypass around this new blockage - new vessels generated themselves to take the blood around the stenosis.

The wealth of "collaterals" creating natural bypasses

around the blockage in a coronary artery (arrow).

What I later found out was the role of exercise in the creation of these "collateral" bypasses and you can bet, I will be continuing my daily exercise given my circumstances.

I also found out that an increase in angina episodes is not necessarily uncommon in people with collateral bypasses which has certainly been the case with me over the past 6+ months.

"In order to stimulate collateral artery flow, try walking for 10 to 15 minutes. This will form the basis of the start of your cardiovascular exercise, and that will help to get blood flowing through your blood vessels. In the event of any type of blockage, walking can help stimulate the growth of new blood vessels that will help collateral artery flow." - http://www.livestrong.com/article/281893-exercises-for-collateral-artery-flow/

In recent weeks, this topic of "natural collateral" bypasses has come up in discussion in some Facebook heart groups I am a member of and as I have found out, many people, like me a few months ago, are not aware of these so for those out there interested in this phenomenon it might be worth reading up on this topic and oh, getting back to daily exercise if you have let it go since your heart event!

Here are some links worth considering on this issue:
http://circ.ahajournals.org/content/133/15/1438.full
http://www.health.harvard.edu/press_releases/do-it-yourself-cardiac-bypass-surgery
http://heartattacknew.com/faq/how-dangerous-are-my-blocked-coronary-arteries/the-riddles-solution/
http://www.livestrong.com/article/281893-exercises-for-collateral-artery-flow/

You can google "collateral bypass" for more sites to visit.

Exercise became part of my daily routine after my heart attack in July, 2007. When my wife took this video in 2010 we had a wild corella we had named Honky visiting us daily. Enjoy.

Dani & Honky Exercising - Mar 10, 2010

Remember, if you don't look after your health, don't expect someone else to do it for you!

www.heartattackstore.com

Take control of your health or accept the consequences

I've written before about the need for us, especially those of us with a cardiac and diabetes history, to take control of our health and TO KNOW OUR NUMBERS! About being aware of our levels for:

- blood pressure

- blood sugar

- cholesterol

- weight/waistline/BMI

I've written before and always mention when I give a talk that it is up to us to be aware of what our bodies are doing and to seek out medical help if we feel something is not quite right. After all, who else knows your body better than yourself.

And when I give a talk I always suggest to people that they should request from their doctor a copy of blood test results, and any other relevant tests. Being a diabetic, knowing I have a cholesterol problem, a blood iron (ferritin) issue as well has having (had) Graves Disease (had my thyroid burnt out in 1998), I need to know what my levels are doing regarding HbA1c, LDL (bad cholesterol), ferritin and TSH (thyroid-stimulating hormone).

As I say, knowing our numbers and being aware of changes in our body and the way we are feeling can, for someone like me, often help me work out if I am having a diabetes related episode such as a HYPO due to low sugar or a dizziness and light headed issue due low blood pressure, to one of my heart medications.

And being aware of our bodies can help us make important decisions like when to call an ambulance.

Now I am pretty well attuned to my body and when I am having a HYPO or an angina episode and accordingly usually know what to do in each situation. However, we must always expect the unexpected and I wrote as much in a blog entry about this two years ago - http://my29lives.blogspot.com.au/2014/10/still-feeling-my-way-around-with-this.html:

In May (2014) I had what turned out to be a pretty bad angina attack which landed me in hospital for two days and I learnt a lot from this incident about the relationship between sleep, diabetes and angina. I wrote the following about what happened on my Facebook page:

"On Tuesday, May 13 shortly after lunch I sat down at my desk and began feeling clammy and sweating profusely. I also had a touch of nausea, a queasy feeling and felt light headed but these lasted only a minute or two. In addition I had very slight pressure/ache down both sides of my neck going up to the lower jaw on both sides. I took my GTN spray as I thought this was just another angina attack but the sweating and pressure in my neck did not go away - usually within a few minutes of taking the spray any symptoms I have go away. The week before I had two angina attacks two days in a row, both of which were the worst to date, and my GP said the next time I have an attack to call an ambulance to get it checked out.

Because the sweating and neck ache persisted and given that  I have blocked carotids - up to 69% on the right side and up to 54% on the left - I decided that this time I would get this episode checked out and my wife phoned 000 to get an ambulance. On arrival the paramedics checked my blood sugars which came up with 3.8 and they said I may be having a Hypo/low. Now this was strange as just before I had lunch I had checked my blood sugar at 12.30pm and the reading was 5.2 so to be told I was having a Hypo less than two hours after eating a toasted chese and tuna sandwich and not feeling the Hypo symptoms I usually get had me confused.

The paramedics confirmed that I should be taken to hospital to be checked out, especially given the neck issues. They gave a tube of glucose to suck on which I couldn't tolerate so I opted to eat a bunch of my glucose laden jelly beans. En route to the hospital my sugar levels climbed to 6.2 and from memory, by the time I arrived at the hospital it was around 10.

In addition, they gave me four additional shots of GTN en route and by the time we arrived at emergency the ache on the left side had all but gone - the right side ache disappeared earlier after a couple of GTN shots."

From this episode I was reminded about having "silent" hypos at night while sleeping, something I had not thought about a lot.

I wrote more about this in a NOTE on my Facebook page and also highlighted the need for me (others) to be more vigilant in taking control of our own health, specifically when it comes to CHECKING OUR NUMBERS including sugar levels/HbA1C, blood pressure, thyroid/TSH levels, iron levels, etc. especially if you are someone like me with a number of issues going on at the same time. From this incident I also learnt about the need for me to address my poor sleep patterns and breathing issues both of which I was told during my hospital visit would  be impacting on my heart and affecting my angina.

Which brings me to the point of this blog post. In 2011 I had a couple of visual problems, mainly through my right eye. I would get severe flashes, bright lights and it scared me. 

I went to see my optometrist and he did some tests. He could not see any issues but mentioned for someone with a history or high cholesterol and artery blockages I should get this checked out - he told me the issue could be neurological based but more than likely it was just a passing thing. He did say I should get my carotid arteries scanned just to see what was going on with these - a passing comment about a TIAs and strokes was made.

Well off I went to get the scans and I was shocked by the results - up to 69% stenosis (narrowing) in the right carotid and a narrowing ranging between 50%-55% on the left side. Here is the report:

 Report of first carotid artery scan - Oct. 2011

When I got these results I was in shock, paranoid even that I was on the way to having a stroke given my heart history, a heart attack in July, 2007 - 100% blockage in the RCA (right coronary artery) which was stented the night of the heart attack and an 80% blockage of the left main coronary artery plus 40% blockages of the LAD (left anterior descending artery) all of which required a triple bypass five days later.

And it needs to be understood that at the time of these issues with my eyes I had been dealing with ongoing SOB (shortness of breath) issues and in fact had been referred by my cardiologist a week before the carotid scan to go up to Brisbane hospital to have a Cardiopulmonary test.

And it should also be noted that earlier in 2011 I had a CT coronary angiogram which could not find any reasons for my breathing issues and that before being referred to Brisbane I had done yet another Bruce protocol exercise stress test and only managed to last three minutes. The CT angiogram did find that my stents and grafts were all working well.

Referral letter for Cardiopulmonary test

It would be fair to say I was confused, upset, worried, scared and a lot more when I got these results showing I had significant narrowing in both carotids.

Now I had a good relationship with my GP at the time but he often commented to me that he is not a heart specialist nor someone who could provide solutions for my SOB and lack of stamina issues. For those he would say I need to speak to my cardiologist. That did not make him a bad doctor, on the contrary, it showed that he was not prepared to guess and preferred I sought specialist advice where and when necessary.

With this in mind I took it upon myself to seek out a vascular specialist at our local public hospital. People need to understand that I did (do) not have private health cover so basically I was (am) a patient in the public system. And this being the case I was fully conversant with the process of your GP sending a request (referral) for an appointment as an outpatient with a specialist at the local hospital and waiting for such appointment to be arranged.

So me being me, I took it upon myself to seek out a specialist and I did exactly that. I TOOK CONTROL! 

I wanted to, needed to know what the heck was going on. Rightly or wrongly, I now knew I had what I believed to be significant blockages in both carotids. And I knew that just a few years earlier, in 2007, I had beaten the odds when I had a massive heart attack that involved 29 resuscitations/cardioversions, three stents for a totally blocked right coronary artery and a triple bypass for blockages on the left side. 

And by now I knew that blockages in the carotids can, could lead to TIAs and/or strokes. And having had eye/vision issues it would be fair to say I WAS SCARED SHITLESS!

I had the carotid scans on Wednesday, October 26 and on the following Monday, after a lot phoning around and almost begging for an appointment, I saw a vascular surgeon. He reassured me about the nature of the blockages in my carotid arteries and made it clear surgery was not indicated. It made me feel a whole lot better but not totally, knowing I had these blockages was still a worry. The specialist did suggest that I have a scan every two years to keep an eye on things.

Vascular surgeon's letter to my GP

Bottom line, I found a way to see a specialist without doing the usual roundabout of my GP sending a referral request and then being put on a waiting list - and the specialist's letter above says as much. And I would say that if I can do it, so can anyone else!

A year later I had another scan of the carotids which showed no changes and then in 2014 I had another scan, which noted there was a 60% stenosis on the right side and 40% on the left side plus there was a moderate calcification in each carotid bulb.

Carotid artery scan result from May, 2014

Last month I had another scan which summarized there was a 50-69% stenosis on the right side and less than 50% stenosis on the left side.

Carotid artery scan result from June, 2016

I should add, that in an angiogram I had in May a new 99% stenosis was found in the mid right coronary artery and an attempt to stent it failed due to the blockage being too calcified. Fortunately, so I was told, my body had created a sort of natural collateral bypass so blood flow exists around the stenosis - see my earlier blog post about this issue: http://my29lives.blogspot.com.au/2016/06/a-salutary-lesson.html

It would be fair to say, getting this result from the angiogram in May, pushed me to have the carotids scanned in June and when all is said and done, finding there has not been a worsening of the blockages in the both carotids was a relief, still a concern but a relief.

And getting back to the question of knowing your numbers, with which I started this post, I need to work on getting my bad cholesterol (LDL) down from 2.56 to 1.8 and obviously the benefit of this on the new blockage in my RCA will benefit the carotids and the rest of my body. So doing regular blood tests (every three months), monitoring ALL OF MY LEVELS is very important to me, I NEED TO KNOW what is going, what is improving and what still needs working on!

A Salutary Lesson

A week or so ago I mentioned in a post that last month I had an angiogram. I also mentioned that during the angiogram a new, 99% stenosis (narrowing) of the mid right coronary artery (RCA) had developed and an attempt to place a stent (angioplasty) had failed. 

I wrote then: "This new blockage was below where they put in three stents in 2007 for a 100% proximal RCA blockage. The good news was that my body had created a sort of natural "collateral" bypass around the new blockage. I was also told on the day that there was evidence of my body creating more "new" vessels around where I had previously had heart damage."

Because I had a history of a LIMA graft (bypass) it was decided the angiogram would be through the groin as this would present the best scenario should it be found a stent or two was needed. This is a whole other discussion for another time.

Left Internal Mammary Artery (LIMA) Graft

The positive side of the angiogram was finding out that both the stents and the triple bypass done at the time of my heart attack in 2007 were all "patent", working well with no issues and blood flow in and around these was good.

My cardiologist who did the angiogram explaining

what he found but I was bit out of it to totally understand

I saw my cardiologist recently to review the results of the angiogram and to try and understand a bit more what the implications of this new blockage meant for me - my cardiologist did the angiogram and is also the same doctor who was on duty the night of my heart attack and who stented me that night. So it would be fair to say he knows my body, particularly my heart, pretty intimately.

I wanted to know more, understand this thing about natural "collateral" bypasses so I asked questions. My doctor explained that in some situations new vessels can generate and create a pathway for blood to flow in and around the heart. He indicated that in my case such vessels did exactly this around the new blockage and he also mentioned there was evidence that similar activity had occurred where part of my heart had "died" the night of my heart attack.

Right Coronary Artery Collateral Circulation

Now I recall being told all this the day of my angiogram, however, still being under the influence of sedation I didn't really grasp what was being said. And I recall on the day being told that an attempt to stent the new blockage failed because the blockage was too calcified, too hard for the "balloon" (angioplasty) to penetrate and allow for the placement of a stent or two.

I don't mind saying that between being released from hospital after the angiogram with the above information and waiting three weeks to see the cardiologist I had more than a few sleepless nights. I mean, here I was having been told I have a new 99% blockage in the mid RCA just below where I had a 100% blockage which caused my heart attack in 2007 and then being told its all okay and you can go home.

So at my appointment I found out a lot more - not only was the blockage calcified and too hard for a stent to be inserted but the mid RCA where the stenosis was located was "tortuous" - a tortuous artery is one that twists and winds in a "tortuous" path - and that part of the artery was less elastic.

Tortuous Thoracic Aorta

I found out my natural "collateral" bypass comprises of microscopic vessels, that these in fact are very much finer than the RCA and that while they allowed for blood flow around the blockage, the amount of blood flow was less than what would normally flow through an unblocked or partially blocked RCA. 

However, some blood flow around that part of a blockage in the heart is one hell of a lot better than no blood flow at all!

And in so finding all this out came the understanding of why over the past couple of years I have been having increased episodes of angina related issues - including pressure on the chest, heart burn, left arm/hand tingling, tiredness, lethargy - both "out of the blue" when sitting at the computer and increasingly in recent months when walking, exercising or just exerting myself doing menial activities such as sweeping up around the house.

A few years ago, my cardiologist did suggest when I started using my GTN spray more and more that I have an angiogram just to see what is going on. I had a CT angiogram in early 2011 which showed nothing untoward, this was when I was also having similar issues with SOB (shortness of breath) and tiredness.

Being the "chicken" that I am, I rejected the idea of having a full-on angiogram when it was suggested. My memory from the night of my heart attack was and still is very vivid, of how I woke after having  stents inserted to find a "sand-brick" strapped over my groin. I was told I would have to lay flat on my back for 3-4 hours without moving and this turned out to be an 8+ hour ordeal due to a thrombosis (blood clot) issue. Remembering this and the deep purple my groin turned to after my heart attack was enough to keep me putting off the idea of having an angiogram.

My groin five days after my heart attack in 2007

However, in April at my annual checkup and after mentioning the increasing incidences of angina type issues - pressure on the chest, heartburn, SOB etc. - my cardiologist strongly suggested I not put off having an angiogram and three weeks later, in mid May, that is what happened.

And I should add that for 3+ hours after the procedure I did have to lie flat on my back before the sheath could be taken out of my groin. And then when they took out the sheath and after 15 mins of the area being massaged they found a small hematoma and a modern, mechanical version of the sand-brick was placed over this. And I had to remain quiet, on my back for another 2+ hours. And I did develop a purple patch but not as a bad as that after my heart attack.

Flat on my back after the angiogram

And here is where the salutary part of the whole discussion comes into play. An angiogram 2-3 years earlier possibly would have picked up the new blockage when it was less developed (less than 99%) and may have been more amenable to balloon angioplasty and/or a stent being placed. 

Whilst my doctor could not definitively say when the new blockage started it was clear it was not there nine years ago when I had my heart attack (it would have been picked up then) which means it would have developed over the past 8+ years and because it was so calcified (hard), he felt it would have been there for a while.

So, as I say, the salutary message out of all this for me is that in the future I will listen to my doctor(s) when they suggest something and put aside any petty concerns I might have. It might just be that an angiogram 2-3 years ago would have found the blockage, allowed for stenting and helped me avoid ongoing angina related issues I will now have to contend with.

The outcome of the angiogram given stenting was not possible was that I will be treated medically with an aim to get my bad cholesterol (LDL) down from 2.56 to 1.8 by changing me from Lipitor to Crestor and to do a blood test in three months and if my LDL is still high then Ezetrol will be added to help bring it down. In addition I will continue to use my GTN spray as required as well as continue to take Mononitrate Isosorbide (Duride) and if necessary an additional medication will be added if the angina gets worse.

I've been quiet for a couple of months.....

Well no, I haven't really been quiet over the past few months but I have had to deal with a number of health issues and to be honest, finding the motivation to post here in this blog just wasn't there.

I have written before about depression and dealing with health issues but, as they say, sometimes it is easier said than done!

And not wishing to look like I was complaining or wanting sympathy I simply felt it was best to just not write, leave it alone and wait until I was in a better frame of mind.

Since early February I had to deal with a bout of shingles for the first time which just lingered and wouldn't go away. Although I was able to get it treated quickly, the pain and discomfort went on for well over a month and it was pretty debilitating.

And then a week or so after being diagnosed with shingles, I broke a tooth (molar) which left half a tooth complete with root buried below the gumline, and it was impacting on the sinus cavity. I won't go into the issue of pain this was causing or the worry that an infection could have implications for my heart issues.

Had to deal with this and wait close to four weeks until I could get oral surgery to remove the offending broken tooth and root. And all this whilst I was still dealing with the shingles thing.

And whilst all this was going on I was finding myself reaching out for my GTN spray more than in the past with angina type issues - not surprising I guess, given what I was dealing with and the stress that came with it.

In early April, at my scheduled annual review, my cardiologist suggested I have an angiogram given what was going on with the increased episodes of chest discomfort and tightness and my increased use of GTN .

The angiogram took place mid May and this week I am due to see my cardiologist to get the full results. What I do know having been told this the day of the angiogram is that the stents and bypasses I had in 2007 when I had my heart attack are all working fine.

What got me somewhat concerned was hearing that a new 99% stenosis (narrowing) of the right coronary artery (RCA) had developed and an attempt to place a stent (angioplasty) had failed. 

This new blockage was below where they put in three stents in 2007 for a 100% blockage. The good news was that my body had created a sort of natural "collateral" bypass around the new blockage. I was also told on the day that there was evidence of my body creating more "new" vessels around where I had previously had heart damage. More details about this I hope to get this week when I see my cardiologist.

Right Coronary Artery Collateral Circulation

So I think you can see that I had plenty on my plate over the past 3-4 months. Just trying to keep a positive outlook over this period was and has been challenging at times but I kept up with giving my talks to our local cardiac rehab unit and last Wednesday did my first session for the year at an ultrasound college where I have been a volunteer patient for the past 5+ years.

A couple of other things that I tried to do whenever possible was my daily 20-30 minutes of walking and probably what was for me more significant was getting out there and taking photos, photos of our wildlife visitors, photos of live music events where we live and photos in and around where we live on the Gold Coast in Queensland, Australia.

For me, photography has become my "go to" activity when things are not going all that well and, as I have written before, I can not stress enough for people to find or develop a hobby/interest when they are dealing with recovering from a health scare or simply when they are finding life a bit challenging.

Some of my photos can be viewed at: https://www.flickr.com/photos/paradisephotos/albums/72157659917363575

And I haven't mentioned what is going on in our household with my wife following her being diagnosed with triple negative breast cancer in early 2013 and her having an oophorectomy and bilateral mastectomy in late 2014 and the after effects. Yep, lots of medical related issues over the past couple of months have kept me/us on our toes.

Good luck everyone, life can get tough but with a bit of planning, you and I can get past these obstacles.