Stent replacement and blood conversion reading query

[4MyEgo]

I was talking to a long time friend of mine back home today, and he asked me how I was and if I replaced the stent which was inserted in 2008 into my proximal left anterior descending artery after I had a mild heart attack at age 48.

 

Background:

 

I saw my Cardiologist in October last year and he didn't say anything except to lose some weight, (standard advice) as I was always around 90kg, my height is 183cm, my age is 59, and this time I took his advice and lost 14kg since October last year, so I am 76kg and am looking forward to my visit with him in October again to see the new me and to ask the question, i.e. do I need to replace the stent.

 

Whenever I see him, usually every 2 years at my request he never raises the issue of having to replace the stent, let alone discuss it, and when I saw him in October 2018 he prescribed me with an extra tablet e.g. Ezetrol 10mg to take with my Atorvastatin 40mg tablet for my cholesterol as my LDL reading was 2.0 mmol/L and has been the same since 2013 as far back as the blood test sheet goes, although varied slightly up to 2.1 twice, once in 2013 and once in 2017 which I thought was a normal reading, but he said he wanted it to be less than 2.0 mmol/L, so 1.7mmol/L or 1.8mmol/L is the preferred reading.

 

Long of the short, I had a blood test here in Thailand end January 2019 some 4 months after taking the additional tablet to see if it was successful in reducing my LDL level to what he wanted, i.e. 1.7 mmol/L or 1.8 mmol/L and the LDL-c (calculate) reading was 25.90 mg/dl so I had to convert it to mmol/L and after converting the reading myself from mg/dl to mmol/L it said my LDL was 0.6698 mmol/L so I stopped taking the additional tablet as it was well below what he wanted and I was a little worried that too low wouldn't be good ? suffice to say the additional tablet appeared to have worked in lowering my LDL level dramatically, if I did do the conversion correctly ?

 

The above said, I decided to come off the additional tablet, then had another blood test carried out at a different place 4 months later and the reading was 83-C (Direct) mg/dl which showed that my LDL level was raised to around 2.4 mmol/L so I went back onto the additional tablet as it seemed to be a higher reading to the original 2.0 mmol/L before I started taking the tablet, i.e. if I did the conversion correctly ? 

 

If anyone has any insight or knowledge/advice on the above would appreciate any feedback.

 

 

[Sheryl]

1. An LDL reading of 25.90 is highly improbable and the fact that it said "calculate" means it was not directly measured but rather estimated by a formula which can often give wrong results especially if the triglycerides are unusually high or low. Also, lab errors are far from unusual here. I would have had a repeat test and insisted on direct LDL measure.

 

2.  To convert cholesterol (total, LDL, HDL) values from mmol/L to mg/dL, you  multiply by 38.67, i.e. your desired range would be under around 70 mg/dl. 

To get from mg/dL to mmol/L you multiply by 0.02586. So yes, if that value was correct you were at about 0.7 mmol/l. But as mentioned I doubt this result and would have repeated the test using direct measure before doing anything else.

 

I suggest now that you have resumed your medication, after a month get a repeat DIRECT LDL measure at the same place you did the second test.

 

3. Stents are not replaced routinely, only if they become blocked. Are you having periodic stress tests done?

 

 

[4MyEgo]

1 hour ago, Sheryl said:

1. An LDL reading of 25.90 is highly improbable and the fact that it said "calculate" means it was not directly measured but rather estimated by a formula which can often give wrong results especially if the triglycerides are unusually high or low. Also, lab errors are far from unusual here. I would have had a repeat test and insisted on direct LDL measure.

 

2.  To convert cholesterol (total, LDL, HDL) values from mmol/L to mg/dL, you  multiply by 38.67, i.e. your desired range would be under around 70 mg/dl. 

To get from mg/dL to mmol/L you multiply by 0.02586. So yes, if that value was correct you were at about 0.7 mmol/l. But as mentioned I doubt this result and would have repeated the test using direct measure before doing anything else.

 

I suggest now that you have resumed your medication, after a month get a repeat DIRECT LDL measure at the same place you did the second test.

 

3. Stents are not replaced routinely, only if they become blocked. Are you having periodic stress tests done?

 

 

Hi Sheryl

 

As always your information is invaluable and I thank you very much for taking the time.

 

I suspected something was up with the 1st result not being in line with the 2nd result (different places) and as you say they were done/measured differently, suffice to say, as it's been 2 months now since I resumed my medication i.e. the additional Ezetrol 10mg tablet, I will book in the 2nd place again tomorrow and have another blood test LDL-(Direct) and see what the reading is, hopefully less than 2.1 mmol/L

 

I did a quick calculation using your formula and I got 2.14638 mmol/L when converting the 83 mg/dl which makes it sound about right as that is what the readings were in 2013 and 2017 without the recent additional tablet, and 2.0 mmol/L in 2014, 2015 & 2018, also without the additional tablet, so it makes absolute sense to get it checked again now that I am taking the additional tablet again.

 

Once I get the results I will update you.

 

As for the stent, that's great news as I don't intend on getting those arteries blocked, so no replacement, sounds good to me, best be eating right and exercising as I have been doing.

 

I don't do periodic stress tests, but I did another echocardiogram last October (usually done every 5 years) when I saw the Cardiologist and he seemed happy with the results, below if that assists:

 

RESTING ECG (non.orandard leads): Sinus rhythm

RESTING ECHO (limited study): Cardiac valves are normal.
Left ventricular size, wall thickness and systolic function are normal.
EXERCISE EEG:
Protocor: Bruce     prcd. max HR: 162 bpm  85% pred. max HR: 138 bpm Exercise time: 13 minutes  Workload: 14.7 METS     Test ceased due to Fatigue

Resting HR: 81 bpm       Resting BP: 125 / 80 mmHg
Peak HR; 182 bpm         Peak BP: 170 / 70 mmHg
Exercise ECG showed no significant    ST segment   depression
85% of age-predicted maximum heart rate was achieved

 

  

Edited July 25, 2019 by 4MyEgo

[4MyEgo]

19 hours ago, Sheryl said:

I suggest now that you have resumed your medication, after a month get a repeat DIRECT LDL measure at the same place you did the second test.

Update:

 

Previously at end May my LDL-C (Direct) without the additional tablet for my Cholesterol was 83 mg/dl or 2.14638 mmol/L after conversion from mg/dl to mmol/L

 

I did the blood test again today at the same place as I resumed medication 2 months ago and the results were even better than I expected.

 

No.  Test                  Specimen                 Results                     Unit               Reference Range

1 Cholesterol              Serum                       105                       mg/dl                 0-200
2 Triglyceride              Serum                       39                        mg/dl                 0-160 
3 HDL-C                     Serum                       59                        mg/dl              M > 35 - F > 44  
4 LDL-C (Direct)          Serum                       41                        mg/dl                 0-160

 

After converting the LDL-C (Direct) with the conversion numbers you provided me with, e.g. 0.02586 multiplied by 41 that gave me a reading of 1.06026 mmol/L which is well under the 1.7-1.8 mmol/L that the Cardiologist wants me to be around, so I will continue to take the additional tablet until I see him in October and do another blood test there and see what he says, i.e. to either stay on it, or get off of it, and perhaps take it every 3 months for a short period if the LDL-C goes up again after quarterly checks.

 

My previous blood test 2 months ago read as per below, so you can see a clear change in 1,2,3,4 above.

 

No.  Test                  Specimen                 Results                     Unit               Reference Range

1 Cholesterol              Serum                       144                       mg/dl                 0-200
2 Triglyceride              Serum                        65                        mg/dl                 0-160 
3 HDL-C                     Serum                        51                        mg/dl              M > 35 - F > 44  
4 LDL-C (Direct)          Serum                        83                        mg/dl                 0-160

 

I don't think that as my Cholesterol has dropped from 144 to 105 that its a bad thing as the reference range indicates 0-200 and I am well within that for all.

 

Triglyceride also dropped from 65 to 39 but the

HDL-C has gone up from 51 to 59, however everything appears good when I refer to the reference range.

 

Any further comments from Sheryl are always welcomed.

 

[Sheryl]

Higher HDL is better. Your values are very good.

 

Exercise EKG is same thing as a stress test.

 

As your triglycerides are low (which is good) it is essential that you always have LDL directly measured and not indirect/calculated measure as the latter will be inaccurate.

[4MyEgo]

11 hours ago, Sheryl said:

Higher HDL is better. Your values are very good.

 

Exercise EKG is same thing as a stress test.

 

As your triglycerides are low (which is good) it is essential that you always have LDL directly measured and not indirect/calculated measure as the latter will be inaccurate.

Thanks once again for commenting on the above Sheryl, I feel at ease now.

 

One last question, is the Cardioechogram that I do every 5 years the same as the stress test you are referring too, Exercise EKG ? 

[Sheryl]

No, echocardigram is a completely different test. It does nto show what the heart does under stress/exertion but it does give a very good picture of the state of the heart valves and chambers and their pumping action at rest.

[lopburi3]

As said above echocardiogram is an easy ultrasound type procedure which provides detailed report on heart condition, especially valves and overall efficiency of that 'pump'.  Very easy test for patient.

 

Stress test can be stressful but is designed to provide information on possible blockage.  And at least in my case provide somewhat erratic results.  The normal test is treadmill until heart reaches expected rate based on age or until unable to continue - in my case quickly could not breath although not tired.  Alternative method uses drugs to simulate - that would be my prefered method at older age (as hate the failing felling of not being able to walk enough on treadmill).

[4MyEgo]

45 minutes ago, lopburi3 said:

Very easy test for patient.

Have to agree, until they turn up the speed every 2-3 minutes

 

45 minutes ago, lopburi3 said:

The normal test is treadmill until heart reaches expected rate based on age or until unable to continue

As far as I recall, the Dr who was at my side said, all we want to do is get you to 185, we don't want to be on this for an hour, so as soon as we get you to 185 we will stop as we don't want to put you under any undue pressure, oh ok, I thought, but at 13 minutes she said do you want to stop, me having a bit of (BIG) ego, said no, I am fine, she then said, ok, let's get you on the bed for the ultrasound and we can go again.

 

Lucky for me, see saw something I didn't, I was struggling, however she did say to me at the end of the ultrasound, we have reached our goal, we should leave it at that, with me agreeing, because by the time I was resting when the ultrasound was being performed, I noticed just how pooped I was.

 

The above said, I have a treadmill here and I use it frequently and go for about 45 minutes, walking and then jogging getting my heartbeat up to 160 and then slow things down again, and then up again, I don't want to go to the 185 without a professional by my side just in case something happens, but I am comfortable at those levels that I go to.

 

I am still a bit lost with the stress test as you mention it's on a treadmill, is it done with like an incline and various speeds until you can't go anymore ?

Edited July 28, 2019 by 4MyEgo

[lopburi3]

4 minutes ago, 4MyEgo said:

I am still a bit lost with the stress test as you mention it's on a treadmill, is it done with like an incline and various speeds until you can't go anymore ?

Exactly but once you reach target heart rate you stop (if you can reach it).  The heart ultrasound test does not require any effort - just normal heartbeat and check so that was what I mean very easy.

[oceanbreeze851]

I do not know where you got your information but a stent is never replaced in the arteries of the heart. A stent can be place inside a previous stent or the previous stent can be ballooned open. If blood flow can not be reestablished bypass surgery is possible or if there is collateral flow it may not be necessary.

[faraday]

2 minutes ago, oceanbreeze851 said:

I do not know where you got your information but a stent is never replaced in the arteries of the heart. A stent can be place inside a previous stent or the previous stent can be ballooned open. If blood flow can not be reestablished bypass surgery is possible or if there is collateral flow it may not be necessary.

They are placed in Coronary Arteries, as well as other sites.

 

 

[4MyEgo]

30 minutes ago, lopburi3 said:

Exactly but once you reach target heart rate you stop (if you can reach it).  The heart ultrasound test does not require any effort - just normal heartbeat and check so that was what I mean very easy.

I think the confusion lay with my own wording as I should have put "exercise" before the word "echocardiogram" in my original post, as this now appears to be the same as the stress test, I say that because I was on the treadmill for 13 minutes with all the wires on me monitoring my heart and had to stop every now and again for them to do the ultrasound, which would represent the "echo" part of the "exercise echocardiogram" which is combined if you agree.

 

I say this because I just read the title on the paperwork, and note I previously did something different with the ultrasound 10 years ago, i.e. I had a Heart Echocardiography Ultrasound, bit of a mouth full which is different to the other paperwork and probably didn't have the cardio part in it, or it was on a separate paper as I don't have anything to refer to showing a cardio side of it. 

[lopburi3]

11 minutes ago, 4MyEgo said:

I had a Heart Echocardiography Ultrasound, bit of a mouth full which is different to the other paperwork and probably didn't have the cardio part in it,

Correct the normal Echocardiogram is just from heart without stress so just a couple sensors and ultrasound wand to take images.  Below outlines procedure.

https://my.clevelandclinic.org/health/diagnostics/16947-echocardiogram/test-details

[alfieconn]

1 hour ago, 4MyEgo said:

Have to agree, until they turn up the speed every 2-3 minutes

 

As far as I recall, the Dr who was at my side said, all we want to do is get you to 185, we don't want to be on this for an hour, so as soon as we get you to 185 we will stop as we don't want to put you under any undue pressure, oh ok, I thought, but at 13 minutes she said do you want to stop, me having a bit of (BIG) ego, said no, I am fine, she then said, ok, let's get you on the bed for the ultrasound and we can go again.

 

Lucky for me, see saw something I didn't, I was struggling, however she did say to me at the end of the ultrasound, we have reached our goal, we should leave it at that, with me agreeing, because by the time I was resting when the ultrasound was being performed, I noticed just how pooped I was.

 

The above said, I have a treadmill here and I use it frequently and go for about 45 minutes, walking and then jogging getting my heartbeat up to 160 and then slow things down again, and then up again, I don't want to go to the 185 without a professional by my side just in case something happens, but I am comfortable at those levels that I go to.

 

I am still a bit lost with the stress test as you mention it's on a treadmill, is it done with like an incline and various speeds until you can't go anymore ?

At 59 years of age your max Heart rate is no where near 185 BPM, more like 167-170, as a matter of interest what Max HR did you get up to on the treadmill ?

I'd be concerned if a doctor was trying to get my HR up to 185 BPM !

 

Edited July 28, 2019 by alfieconn

[lopburi3]

7 minutes ago, alfieconn said:

At 59 years of age your max Heart rate is no where near 185 BPM ! 

Indeed if 59 would likely have been 135 not 185 target.  161 is predicted max (220 minus age).

[4MyEgo]

15 minutes ago, alfieconn said:

At 59 years of age your max Heart rate is no where near 185 BPM, more like 167-170, as a matter of interest what Max HR did you get up to on the treadmill ?

I'd be concerned if a doctor was trying to get my HR up to 185 BPM !

 

Post #3 which I have copied and pasted below, may put some light on it, I am just going by memory, i.e. what was said, and may have made spagetti out it, but will agree, Google states that by subtracting your age from 220, that will give you your maximum, which is 161 bpm

 

RESTING ECG (non.orandard leads): Sinus rhythm

RESTING ECHO (limited study): Cardiac valves are normal.
Left ventricular size, wall thickness and systolic function are normal.
EXERCISE EEG:
Protocor: Bruce     prcd. max HR: 162 bpm  85% pred. max HR: 138 bpm Exercise time: 13 minutes  Workload: 14.7 METS     Test ceased due to Fatigue

Resting HR: 81 bpm       Resting BP: 125 / 80 mmHg
Peak HR; 182 bpm         Peak BP: 170 / 70 mmHg
Exercise ECG showed no significant    ST segment   depression
85% of age-predicted maximum heart rate was achieved

Edited July 28, 2019 by 4MyEgo