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Anthony Bray, MD
Anthony Bray, MD, Doctor
Category: Health
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Experience:  14 years as clinician in the field of Family Practice
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sob without any angiogram results coming out positive

Resolved Question:

sob without any angiogram results coming out positive
Submitted: 5 years ago.
Category: Health
Expert:  Anthony Bray, MD replied 5 years ago.
Hello! Your shortness of breath is explained by your COPD. Do you have any idea of how awful 300 peak flow is? Mine is 900. That hopefully will give you a better idea of the severity of your lung disease.Your shortness of breath is not so mysterious. I hope that you are no longer smoking!!! (Most COPD ; the vast majority is caused by smoking. There are a few other causes such as alpha 1 antitrypsin deficiency)Let me know if by chance you are one of the few that do not have a history of smoking as the cause of your COPD. Unless this should be the case then your shortness of breath is no mystery. I hope this information helps. further questions are welcome if you have any. If my answer has been helpful and to your satisfaction then please remember to press the "ACCEPT" button. Thank you and Best Regards,

Anthony Bray MD
Customer: replied 5 years ago.
have been a non smoker for 25 years. my COPD was diagnosed several years so why the increasing severity now. i don't think that is the cause of the severe sob
Expert:  Anthony Bray, MD replied 5 years ago.
Hello again! One possibilty of worsening could be pulmonary hypertension. This may been ruled out as well if you have been followed by both a pulmonologist and a cardiologist.The diagnosis is tricky but can be established during a cardiac catherterization if they check the pulmonary artery pressure. If elevated then the current recommended treatment (believe it or not) is Viagra. This medicine it turns out helps to reduce the resistance of blood flow through the lungs. As you have been diagnosed also with cardiac disease then I suspect that your problems are likely to be multifactorial. (No one single thing causing the shortness of breath but the combination of factors coming together.) How long ago has it been that your stent was placed? The stents have a tendancy to close up faster than the normal vessel. In the short run it may have a clot formation. In the long run it may have accelerated atherosclerosis.You should be on a regimine of Plavix plus aspirin following a stent placement. Some advocate this regimine for six months following. I recommend continuing the Plavix plus aspirin for an indefinite period of time unless there is a contra-indication such as a bleeding ulcer. Your complete blood count should also be checked if this has not been done recently. If your hemoglobin is low (ie you are anemic then this reduces the oxygen carrying capacity of your blood. Usually a person with COPD has a high or high/normal hemoglobin to help compensate for the lung disease.If your hemoglobin were 9.0 instead of 12.0 for example this would represent a 25% reduction of your oxygen carrying capacity.This would make a huge difference in how you feel and your tolerance of exercise. Looking back at the heart issue if you had a blockage of the LAD then it is a certainty that the same process that affected this main artery to the heart also affects smaller blood vessels. The buildup of atheroscerotic material in the smaller vessels can cause a diffuse worsening of perfusion that might be experienced as shortness of breath or poor exercise tolerance. It is important that you risk factors for heart disease are aggressively managed. Your blood pressure should be well controlled. Your cholesterol should be well controlled and your goal for the bad cholesterol fraction (LDL) is 70 or lower.(This is often a difficult goal to achieve.The statin group is the most effective at lowering LDL cholesterol and the most proven as effective at reducing the risk of heart attacks, and the need for further interventions such as your stent.Crestor, Zocor, Lipitor are among the best choices.Zocor is now available as a generic; simvastatin)Your exercise pule oximetry would be useful test. If you have a resting pulse oximetry of 94 to 98 % then this is normal. (90 to 93% resting is low but still acceptable. If with exertion your pulse oximetry drops much below 90% then you may need to use oxygen with exertion.) If you are over weight then this would increase your body's requirement for oxygen and this would be a confounding factor making things worse.Take note if you have wheezing or a sense of tightness in the chest. If tightness of the chest then this is sometimes a symptom of angina and sometimes a symptom or spasm of the large airways. Wheezing is a symptom of constriction of smaller airways. Spiriva is the mainline maedicine recommended for COPD.You might benefit from a short acting albuterol if you have wheezing or episodic shortness of breath. Often an addition of a combination inhaler of a steroid plus long acting bronchodilater may be helpful. Examples of these include Advair/Symbicort and several others. If you feel short of breath when lying flat then this is often a symptom of congestive heart failure but other disease processes can cause this symptom. The need to prop up at night in order to breath comfortably is suscpicious for us to look at the prospect of congestive heart failure. The combination of overlapping problems of pulmonary nature is another possibility. People can develop asthma superimposed on COPD.Interstial lung disease such as pulmonary fibrosis can overlap COPD. Pulmonary function testing and a chest CT may help to rule these disorders out. Certain meds can contribute to problems. it is common with heart disease to prescribe a beta blocker. Beta-blockers can cause bronchospasm in COPD patients however. A couple of the beta blockers are more specific to the beta receptors of the heart and blood vessels and have minimal effect on the beta receptors of the lungs. Bystolic/Zebeta/Ziac/bisoprolol would be among the safer beta-blockers for you if you are on one. Your vital signs of respiratory rate, blood pressure, pulse may provide important clues as to the likely underlying cause of your problem. I hope this information helps. Further questions are welcome if you have any. If you wish to have me review your meds , I'll be happy to do this as well. Best Regards,

Anthony Bray MD
Customer: replied 5 years ago.
As of 10/05/09, when angiogram was done, these are my official diagnoses: VHD ? pulHTN s/p RHC; CAD 1(this has a 0 on top of the 1,on right side)stent LAD;what looks like unduel(that's what the spelling looks like) LI of RCA 20-30% distal LAD; E(?)F60%; trace-HMR mild TR; HTN; Dyslipidemie; obesity (UGH weigh is 210 at 5ft-8in.); mild CAS 1-39%BLCA(or BKA); OSASSSSS/asthma; GERD----meds arePlavix 75mg 1x d; Aspirin 325mg 1x day; Ranexa 500mg 2x day; Benicar HCT 20/12.5 1xd; Advair 2puffs bid; Lexapro 20mg 1xd; Spiriva bid---otc drugs-0-magnesium(with chelated zinc) 1xd; omega 3 fish oil 1000mg tid; vitamin b-6 50mg 1xd; folic acid 400mcg 1xd; b12 1000mcg 1xd;----
was taken the following off the list til after allergy testing--Nasonex; singulair; loratadine; benadryl and chlorotab---thanks for previous answer; please reply to what I have sent you regarding diagnosis and meds.
Expert:  Anthony Bray, MD replied 5 years ago.
Hello again! Sorry i haven't got back to you soone. (My daughter has been on the CPU this afternoon/evening)I can help with most of the information that you have relayed but a few of the abbreviations are not ones that I'm familiar with. You have a noncritical degree of blockage of the distal left anterior descending artery of 30%. This is beyond the area of the stent placement.(Critical is > 50% blockage. Less than 50% blockage does not require intervention such as a bypass or stent) You also have 20% (or 20-30%) stenosis of the right coronary artery which is noncritical. The right coronary artery supllies the right side of the heart and part of the septum and lower portion. The LAD supplies the anterior wall of the heart which includes a major portion of the left ventricle which is the highest pressure and hardest working chamber of the heart. The VHD, I'm not sure if this was meant to be VSD (ventricular septal defect) or possibly a reference to ventricular hypertrophy if you've had a long history of hypertension then this may be possible. The placement of the ? between this and a shorthand for pulmonary hypertension makes me question if the diagosis of pulmonary hypertension is made or is this the diagnosis in question? Further clarification from your cardiologist is needed on this point. The official dictated repot will probably be sent to your PCP or pulmonologist as well. The s/p RHC stands for "status post>> right heart catheterization.I think that you are indicated to have an EF(ejection fraction) of the left ventricle of 60%. This is a perfectly normal result for left ventricle function. It represents the amount of blood ejected in a typical beat from the left ventricle. EF 55-60% is normal. EF< 45% would indicate systolic heart failure.I think that the 1-39% is probably indicating between 1 to 39% bilateral carotid artery stenosis ( noncritical but not any detailed attempt at any exact measurement----a quick look is what this sounds like to me indicating that your carotid arteries are OK but just not a detailed measure) but some of these notes may be individualized shorthand.The unduel---I don't know what they mean...OSAS could stand for obstructive subaortic stenosis but with the 4S's following this I'm again unsure of interpreting this shorthand.(If you had thickening of the septum of the heart then this can partially obstruct the outflow from the left ventricle. This condition if present would be worse with exertion , higher heart rate. I see that you carry the diagnosis of esophageal reflux but you are not on any meds for this. Gerd can worsen breathing problems. This especially at night may cause aspiration of fluid that comes from the stomach up to the upper esophagus and the back of the throat. If you have had symptoms of cough, hoarseness, heartburn then this would be a distinct possibility. For this problem I would strongly recommend two steps that may help you considerably. For one elevate the head of the bed on blocks 4 to 6 inches. This incline helps gravity to help keep the contents of the stomach stay in the stomach. Also it is helpful for you to wait 90 minutes after you eat before you lie down. An aspiration syndrome associated with GERD could very well be a logical possible explanation of your worsened shortness of breath. Of note if this is the case then Prilsec and other acid reducing meds will help with heartburn but would not help with reducing the aspiration of fluid.(This is a fact often overlooked) Also many people if directed to elevate the head of the bed with blocks they often substitute extra pillows but this is not as effective. This tends to bend your neck and the slight elevation of the upper trunk is what is needed. I can't be sure that this is a significant contributor to your problem but ask your PCP or pulmonologist if this may be the case.With your meds it appears that you are not believed to have asthma or that allergies are a significant contributor to your problem. I'm surprised that you are not on a statin. The omega three fish oil helps mainly with triglycerides. Lowering the LDL is the key to reduce the risk of atherosclerosis more so than triglycerides. The Renexa brand name is XXXXX XXXXX that I'm familiar with but the dosing makes me think it is probably a generic brand of metformin for diabetes.Diabetics tend to have more problems with high triglycerides and so this would make sense. It appears that you are on good standard of care meds for your COPD. If you should be diagnosed with pulmonary hypertension then this can produce severe drops in an individuals blood oxygen content. This could be a very possible cause of your acute worsening.(Again if you should be confirmed to have this diagnosis then don't think your pulmonologist is crazy when he/she prescribes Viagra daily)The magnesium is a good idea in that it can be helpful to reduce irritability and palpitations of the heart and it relaxes smooth muscle which includes the muscles around your airways.The Benicar/HCT is good for your hypertension and is the recommended class of med for protection of the kidneys in diabetics. You would benefit to lose some weight. Depending on the outcome of these tests and your diagnoses then you will likely benefit from a pulmonary exercise program. The exact diagnoses will make a big difference in this. Oh and the mild MR is mild mitral valve regurgitation backflow of blood through the mitral valve. The mild TR is mild tricuspid valve regurgitation. The mild backflow of blood through these valves is not anything for you to worry about. This is just an incidental finding. The status of the valves is a standard part of the report of a cardiac cath. The mild regurgitation is a very common finding and is not significant.With your meds the only thing that I see to question is whether you should have a statin added to your omega three fish oil.I hope this information helps. If you have further questions then I will be happy to get back with you.Best Regards,

Anthony Bray MD
Anthony Bray, MD, Doctor
Category: Health
Satisfied Customers: 7055
Experience: 14 years as clinician in the field of Family Practice
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Anthony Bray, MD
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