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Forum Name: Ischemic Heart Disease

Question: T-Wave Abnormality; Anterior Ischemia


 clbouchie - Wed Jul 28, 2010 5:40 pm

My husband had a quadruple bypass 8 weeks ago and has healed very nicely, yesterday he went to his pre-op appt to get things done for his gall bladder removal this morning and his EKG came back abnormal with T-wave abnormality; anterior ischemia.

He hasn't had any tightness in his chest since they did the bypasses, has genetically high cholesterol and very small veins and arteries. one of the grafts that they did from the harvested vein in his leg was showing signs of disease already. THis is the first ekg since his release from the hospital and I was shocked to see this considering he's been exercising daily, low fat, low cholesterol, low sodium diet, been on his plavix, lisinopril, baby asprin, metoprolol, co-q-10, Vita E8, vita D3 and the Vytorin until last friday when they removed two of those and he wasn't able to take his meds this morning but took his metoprolol and vytorin as directed last night. I am concerned as he is only 37 years old and active duty military with one year left in the service. What does this mean and will these results from yesterday's EKG be forwarded to his Cardio-thoracic surgeon and Cardiologist...... should I be concerned at all and what should we do?
 Faye Lang, RN, MSW - Sun Aug 01, 2010 9:40 pm

Hello, clbouchie,

What a trying time for you and your husband. It would be usual practice to forward the results of your husband's recent electrocardiogram to his cardiologist; however, it would be a good idea to double check to see that it was done.

An electrocardiogram traces the electrical activity (depolarization) of the heart beat, and the most basic description is designated as the P, QRS and T waves. Very briefly, the P wave is a normal beat in which the electrical depolarization spreads from the right atrium to the left atrium, resulting in the beat of the upper chambers of the heart. The QRS portion is the rapid depolarization of the right and left ventricles, resulting in the beat of the lower chambers of the heart; since the ventricles are larger than the atria, that portion appears larger on the electrocardiogram. The T wave represents the repolarization (or recovery) of the ventricles. Ischemia occurs when blood flow is decreased through one or more of the arteries in the heart muscle; in this case, to the anterior portion of the heart. The main risk factors that can lead to ischemia are elevated cholesterol levels, elevated blood pressure, and diabetes. Ischemia can be the result of coronary artery disease (atherosclerosis), in which plaques formed of cholesterol and possibly other cellular waste products build up on an artery wall and restrict the blood flow. This is the most common cause of myocardial (heart muscle) ischemia. Some other conditions include blood clots, causing a sudden ischemic event which may lead to heart attack; coronary artery spasm, which is brief and temporary; and severe illnesses, such as those leading to blood loss.

Medications used in the treatment of ischemia include aspirin, which reduces the tendency of blood to clot, and nitroglycerin, which temporarily relaxes/opens arteries; and beta blockers, which relax the heart muscle, slow the heart beat and decrease blood flow, with the result that blood flows more easily. Cholesterol medications include statins, which interfere wwith the synthesis of cholesterol in the body; niacin, which boosts "good" cholesterol; fibrates, which are usually used as an adjunct to other cholesterol medications; and bile acid sequestrants, which help block fats. Calcium channel blockers, which relax and widen blood vessels by acting on the muscle cells in the arterial walls, which slows the pulse and reduces the heart's workload. ACE (angiotensin-converting enzyme) inhibitors, which inhibit arterial constriction and helps relax the blood vessels and lower blood pressure, and Ranlozine, which helps relax the coronary arteries and is used when other medications aren't effective. The cholersterol lowering medications target lowering LDL (low density lipoprotein) or "bad" cholesterol and boosting HDL (high density lipoprotein) or "good" cholesterol. Of the medications that you listed, Plavix is used to prevent blood clots, lisinopril is an ACE inhibitor, metoprolol is a beta-blocker, and Vytorin is a statin. Bypass surgery is an option, as your husband has had. "Stenting" may be used, which consists of inserting a specially prepared thin tube into a narrowed artery, where a balloon is inflated that widens the artery, and then a small mess coil (stent) is inserted to keep the artery open.

Familial hypercholesterolemia is a genetic disorder, with high cholesterol levels, particularly LDLs, which results in early cardiovascular disease, often by the age of 30 or 40. Treatment is with statins, bile acid sequestrants or other cholesterol lowering drugs. There is some early indication that a weight-reduction drug called Relacore reduces LDLs and boosts HDLs, but that is preliminary. In severe instances, LDL apheresis may be used, which is removing LDLs in a treatment similar to renal dyalisis. In severely resistant instances, liver transplant may be considered, though this is uncommon.

Recommended lifestyle changes are to stop smoking if one is a smoker, exercise, a healthy diet, and having regular monitoring by a physician, which your husband is already doing. With the combination of contributing factors that your husband is facing, there is real concern about managing the long term effects of his condition. A conference with his cardiologist is the best place to start, asking what would be the best long term plan to optimize his overall health.

I wish you the best of luck.
 John Kenyon, CNA - Sun Aug 01, 2010 11:37 pm

User avatar Hi clbouchie,

I was asked to review your post and see if I could add anything. Faye certainly covered the matter thoroughly and it might be helpful to print that out and keep as a general reference. However, I still have a question or two that might help clear this up. First, when the EKG came back abnormal ("anterior ischemia"), was this the machine's computer analysis or had the EKG actually been read and signed off on by a cardiologist? The EKG computer repertoire is not only somewhat limited, but, like all computers, has no sense of context at all. For instance, many people who've had recent heart surgery will show abnormalities that have been present since early stages of the original disease. Also, due to that limited computer "brain" there are some abnormal findings that are rather common, and this is one of them. The only way it can be clarified is to have it read by a live doctor (who won't even give that computer analysis a second glance). Also, T-wave abnormalities are common and often innocent or non-specific. Again, in someone with a recent heart surgery, they are more likely to show up. This may now be a "normal" for your husband. Even if a cardiologist from the center where the pre-op workup was done read and signed off on this, your husband's cardiologist is the one who should have the final say in giving or witholding cardiac clearance for what should be a fairly simple (probably laparoscopic) surgery. While this may, in fact, signal some new problem (your husband's relative youth suggests he will likely have some additional future problems, since this is almost certainly a genetically-caused disease pattern), 8 weeks post-op is really awfully soon to see such a significant change, so odds are that's not what it is.

Given the meds, regimen and recent surgery, your husband shouldn't register ischemia on an EKG even if the process actually has begun again. To find such a clear sign, while not impossible, would be a very rare thing indeed. Far more common is the simple, out-of-context computer analysis. I hope your husband's cardiologist will look at this and find it to be withing normal limits (WNL) and give him the green light for the gallbladder surgery. Please let us know how this all turns out. I'm betting on it being a very common computer error.

Good luck to you both!
 Dr.M.Aroon kamath - Mon Aug 02, 2010 2:57 pm

User avatar Hi clbouchie,
I am really fascinated by the very thorough, informative and thought provoking replies to your post. As it has been pointed out very clearly, only your husband’s cardiologist will be best placed to infer from his latest EKG and decide whether the T wave abnormality does represent an ischemic change or otherwise.

Although slightly out of context (as the following excerpts pertain only to EKG changes in the first 3 days following routine CABGs), i felt that I should share with you, and the readers at large, this very relevant information.

These excerpts are from a very interesting study published in 2006.
"Electrocardiographic Changes after Coronary Artery Surgery".
Kerim Cagli, MD, Cemal Ozbakir, MD1, Kumral Ergun, MD1, Vedat Bakuy, MD, Renda Circi, MD, Pinar Circi, MD

Asian Cardiovasc Thorac Ann 2006;14:294-299

The authors had tried to establish the “normal” EKG changes that may inevitably occur following routine, successfully performed CABGs.

The background scenario is as follows.

Take a typical prospective candidate for a CABG. He/she will have an underlying coronary artery disease, and the EKG findings that go with it. Certain non-physiological procedures performed during the surgical procedure, including cardiopulmonary bypass (CPB), cross-clamping, hypothermia, hemodilution, cardioplegia, as well as postoperative complications (hemorrhage, graft occlusion, arrhythmias) have detrimental(NEGATIVE) effects on the electrical and mechanical activity of the heart. However, restoration of blood flow to the myocardium has a POSITIVE beneficial effect.
Interpretation of a postoperative EKG and trying to differentiate normal from abnormal findings is not obviously easy.

In addition, several postoperative factors including degree of ischemia, tissue oxygenation, blood pressure alterations, electrolyte disturbances, use of antiarrhythmic and postanesthetic drugs, pain control, and duration of surgery make the analysis of postoperative EKG changes all the more difficult.

Despite improved techniques in intraoperative myocardial protection as well as surgical techniques, some degree of myocardial ischemia inevitably occurs during CABG, but only a minority of patients develop an actual myocardial infarction (MI). The diagnosis of MI after cardiac surgery is more difficult than at other times because of the nonspecific ST-T wave abnormalities and occurrence of nearly universal elevation of cardiac enzymes.

Open heart surgery affects the amplitudes of R, S, and T waves in the EKGs in many different ways. Decreases in QRS voltage because of large effusions and formation of a QS complex (pseudoinfarction pattern) are just a few well-known examples.

The authors surmise that while operative procedures may be predominantly responsible for the changes (NEGATIVE) occurring on the 1st postoperative day, changes observed on day 3 might be the due to the POSITIVE effects from relief of ischemia.

Thus, this study highlights the difficulties in interpreting post-CABG EKGs.

Although it has nothing to do directly with your husband’s condition or management, I hope this information is useful in some way.
Best wishes!

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