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Forum Name: Ischemic Heart Disease
|Dr. A. Rajput - Wed Apr 16, 2003 11:36 am||
My friend's grandma had chest pain one month back..she was taken to a cardiologist who has suggested angiography/plasty..right now she is quite comfortable with medicines..her age is 85.
now,the dilemma is...whether to expose her to the procedure or not.i m a medical student too but i m in Russia and she is in India so i cannot comment on the ecg details or the on medication she is taking....also i got many differences of opnion..say says go or it while some say don't....
the factors what i think are:
1) her age..85 yrs... is it ok to expose her to the procedure at this age?
2) one more concern is her post op psychology...she is quite panicky...even if procedure is perfect and she has cough..she will relate it to the procedure and trouble other...
so considering these factors..is it ok to go for procedure or management just on medicines alone is ok for her age??
sir,till now i had heard many opnions.but i will take your opnion as the final one and will proceed accordingly because its high time we take some decision.
|Dr. Yasser Mokhtar - Wed Apr 16, 2003 5:48 pm||
Dear Dr. Amit,
Thank you very much for using our website and for the vote of confidence.
First of all i would like to to say that the person who should take the decision is the patient herself and not anybody else and if the decision that she takes is not in agreement to what we think should or should not be done, we should not try to force or pressure her to changing her decision. Putting in mind, of course, that she has the right to change her decision at any time.
i guess the first :?: question :?: that comes to mind is whether the angiogram is really indicated or not in this case? In my opinion, if the patient had a big myocardial infarction and developed or expected to develop heart failure, then i think (unless the patient is against surgery in the form of bypass) angiogram is the best way to go. If she is also having recurrent chest pains with maximum medical management then of course angiography is the way to go.
The second :?: question :?: is does she have any contraindications to do the angiogram like chronic renal insufficiency and giving dye could throw her into renal failure with subsequent need for dialysis and she does not want to have dialysis. Or, severe peripheral vascular disease with the risk of developing gangrene of the limb and subsequent amputation for example.
At such an age, i wonder if the cause of her symptoms could be due to aortic stenosis. This possibility should always be considered, do you know if she had an echocardiogram or not.
Regarding doing the angiography/plasty, as you might know it is not without risks including death, heart attacks, need for emergency bypasses, allergy to the dye, amputation of the limb secnodary to gangrene (although very rare) and renal failure secondary to the dye if patient is diabetic or with border line renal functions or has chronic renal insufficiency.
On the other hand, the benefits of doing an angiography is to know the anatomy of the coronary arteries, the function of the left ventricle, the valves' condition, if there is one lesion that could be plastied, it will be done.
Age should not be the only factor that directs the decision making process because there are healthy, active 85 years old and older out there and enjoying their life. What is her state of health in general? Does she have chronic diseases? Do you think that if a bypass is warranted, could she go through it?
i think the best way to go is to talk to the patient herself, explain in details:
1. Why the angiogram is needed.
2. What are the benefits.
3. What are the risks.
4. Her inclinations towars management options (i think before going for the angiogram you have to know, if she does go with the angiogram and then the angiogram shows that she needs surgery, is she willing to have surgery if she needs it. If she can consider surgery if needed, then i guess an angiogram is not an unreasonable choice but if not, then the angiogram although it will provide lots of useful information then doing it will not change the management then there is no need to do it).
5. Let her decide herself whether she wants to have the angiogram or not.
By doing this, i think that you will be fulfilling your duty as a doctor and a friend of the family.
Once more, thank you very much for using our website http://doctorslounge.com and i hope that this information will help you and the friend of your family to take the right decision. Please, keep me posted.
Yasser Mokhtar, M.D.
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