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Your Good Health: Patient wants to go against advice

Dear Dr. Roach: I am 71. I’m overweight at 300 pounds and have had Type 2 diabetes for 15 years.

Dear Dr. Roach: I am 71. I’m overweight at 300 pounds and have had Type 2 diabetes for 15 years. I haven’t had any chest pain or heart problems, but a recent nuclear stress test lead my doctor to suspect a buildup in one of my arteries and he wants to do a cardiac catheterization.

I do not want to do this, partly because I feel that once you let doctors start messing with your body, you will only experience more problems (such as a stent or something) and your life will never be the same. Is there anything else to clean the arteries? I don’t want to offend the cardiologist, but I really do not want to do this. Am I completely wrong?

P.R.

Making a decision after knowing all the pertinent information isn’t wrong, even if it isn’t the decision the doctor recommends. I’d like to be sure you have all the right information.

A nuclear stress test uses a radioactive dye to look at blood flow to the heart. Although they are very accurate, like almost every test, they can be mistaken. This is why your cardiologist ordered the cardiac catheterization — the best test we have to look for blockages in the arteries. The risk in a cardiac catheterization, also called an angiogram, is low. If there are no blockages, that information is helpful and might allow your cardiologist to have you stop some medications.

If you do have blockages, you have a choice of medical treatment (such as a statin, beta blocker and Aspirin), catheter treatment (such as angioplasty with or without a stent) and surgical treatment. Knowing more about the location and severity of any blockage you might have can allow you to make a more informed decision about which treatment is better. Stents and surgery would be less commonly used in someone without symptoms, unless the blockage was very severe or in a critical artery.

It’s not unreasonable, given your medical history, to assume that there is a blockage that might need medical treatment. In addition to the medications I mentioned, taking excellent care of your diabetes, losing some weight, making sure your diet is proper for someone with suspected heart disease and participating in a monitored exercise program all can reduce your risk of a heart attack. In fact, these are important even if you do get a stent or surgery.

I don’t think your cardiologist will be offended if you can give him your reasons for declining an angiogram, even though he and I are recommending it in order to provide the best information to decide whether further intervention is necessary.

 

Dear Dr. Roach: Should your blood pressure go higher as you age? Is the top number or the bottom more important? I don’t like medicine and my blood pressure was 145/82, but the top number sometimes goes to 150-158.

J.S.

Both the systolic (top number) and diastolic blood pressures are important, and the difference between them is occasionally important (for example, a blood pressure of 160/60 is more worrisome than 160/85). Blood pressure does go up with age, but even in people over 60, the recommendation is still to get it down below 150. I try to aim for 140 if there aren’t too many side- effects. It often takes several tries to find a regimen that gets the blood pressure where it should be without affecting quality of life.

Email questions to ToYourGoodHealth@med.cornell.edu.