My dad has bad coronary artery disease and a poor heart

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My dad just had 5 stents put in his left main artery and left anterior descending coronary artery.  He is 58.  He had his first heart attack at 44 years of age.  He is now 58.  He has had several mild heart attacks over the years and stent procedures 2 other times so he has approximately 15 stents and the last time was 3 years ago.  He has A. Fib and Diabetes and High Blood Pressure.  He is on medication for all of these.  While in the hospital, the Cardiologist said that he would recommend having an ICD placed and this was scheduled for yesterday, but they changed their minds and said that he would have to wait 6 weeks after a procudere for this.  He has an ejection fraction of 20-25% and the doctor said it has been this low for a while.  It was this low the last time he had an echo done 6 months ago.  I know he is a big risk for Ventricular Fibrillation and sudden cardiac death.  Can you explain this further?  If he has the ICD in 6 weeks what can he expect health wise after this?  What is his life expectancy with an EF of 20-25%?  I know he should make healthy lifestyle changes and he has been prescribed medications to help reduce his risk, but what is his prognosis with the EF of 20-25%?  Thank you for answering.


Your dad has a number of complicated issues to deal with:

  • Advanced  Atherosclerosis
  • Advanced Coronary Artery Disease (CAD)
  • A damaged heart muscle with poor heart function
  • Risk of Ventricular Fibrillation (VF) & Sudden Cardiac Death (SCD)
  • Atrial fibrillation
  • Diabetes
  • Hypertension
  • Cholesterol problems (I am sure)

I. Let’s start with his CAD. Fifteen stents! When is enough, enough? Patients with Diabetes and diminished heart function and especially with Left Main disease do MUCH better with Coronary Artery Bypass Surgery than with stenting, as his constantly recurring disease has already shown. Was he ever sent to a Cardiac surgeon for consultation? If so, was he told he was not a candidate for surgery? I bet not! I once saw a patient who had undergone 31 angioplasties before he was finally sent for surgical consultation, had his bypass operation and finally stopped having to see his doctors every 3-6 months. Many physicians think cardiac surgery is a horrible thing to go through – it isn’t, certainly not when stents keep failing.

II. While true that bypass surgery becomes more risky in patients with poor heart function, if successful, the outcomes are often excellent. Among other things, there is something called “hibernating myocardium”, where some of the heart muscle is malfunctioning because of insufficient blood supply. After bypass surgery, it is not unusual to see those areas of the heart begin to function better. However, this is always a complicated situation that requires a team approach, including cardiologists & surgeons to come up with the best recommendation. Having said that, I have operated successfully on many a patient like your dad with just that (improved heart function) happening.

III. In some patients with poor heart function there is indeed a greater risk of VF and SCD. An Implantable Cardiac Defibrillator (ICD) can detect VF and shock the heart back to a normal rhythm before SCD occurs. In addition, the newer devices also have special pacing capabilities that may reorganize the heart rhythm (“resynchronize”) and thus improve heart function somewhat. Thus, an ICD may indeed help patients survive longer. However, since your dad also has atrial fibrillation, I would suggest he gets evaluated for an ablation procedure, to see if it is possible to get him back to a normal rhythm first. All these considerations require he gets an EP study.

IV. Patients with end stage heart disease become candidates for a heart transplant. I doubt your dad is there yet, but it points out that he needs treatment in a center with experience in all aspects. Major medical centers around the country specialize in the treatment of heart failure, and not every patient needs an operation. Certainly there must be ways to optimize his medical therapy with medications, diet & lifestyle modifications.

V. Finally, this brings me to the last part, diabetes, diet etc. Patients are usually quite willing to subject themselves to whatever pills & treatments their doctors come up with, but are often totally unwilling or incapable to improve their diet, exercise, lose weight and stop smoking. Nothing is going to change, unless your dad does takes charge in his own care. All the rest, the surgery, more stents, an ICD or even a heart transplant is just a stop-gap measure!

If you go to my website, browse around and you’ll find lots more information you will find useful. One thing you might want to do, is take this test to see from what treatment your dad might benefit the most:

I think I know the answer.

Hope this helps,

Dr T

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