CONTACTS 

SUBJECTS
Afib Diagnose Coronary Heart Disease Schedule 110310 24 Hour Heart M

6603 -
6603 -    ..
6604 - Summary/Objective
6605 -
660501 - Follow up ref SDS 78 0000. ref SDS 77 0000.
660502 -
660503 -
660504 -
660506 -  ..
6606 -
6607 -
6608 - Progress
6609 -
660901 - Stress Test Treadmill Reaches 100% Performance
660902 -
660903 - Follow up ref SDS 78 OF8F, ref SDS 77 OF8F.
660904 -
660905 - Gisela Brunskill, Cardiology Nurse Practitioner. supported treadmill
660906 - stress test, ordered by Doctor Egan during the meeting at the VA on
660907 - 110309 0900. ref SDS 76 OF8F  She is familiar with Lafayette
660908 - Reservoir, and asked if I hike the rim trail?  Explained only did the
660909 - rim once, and did not like the soft sand on the hills.  The paved
660910 - trail provides a distance for evaluating health improvement based
660911 - time.  The hills create short-term loads to strengthen cardio
660912 - endurance with periods of recovery.
660914 -  ..
660915 - Initial objective today is exceeding prior test that lasted only 7
660916 - minutes, reported on 091002 0900. ref SDS 10 1W5I
660918 -  ..
660919 - Today, after about 15 minutes, Gisela said the test had reached 100%
660920 - performance for age 66.  She asked if I wanted to continue?  We
660921 - continued for about 15 minutes at a faster pace and increased incline,
660922 - Started to run, but Gisela said that hiking actually puts a bigger
660923 - stress on the heart, which is the purpose of the test today.  So, had
660924 - to hike very fast.  Based on experience the past 8 years at Lafayette
660925 - Reservoir, there are not 10 people in 1000, who hike at the top speed
660926 - of the test today.
660928 -  ..
660929 - Gisela seemed to indcate the pace was faster than a 15 minute mile,
660930 - which is about my top speed hiking laps at Lafayette - 45 minutes for
660931 - 2.75 miles.  Recently on 110311, did 3 laps in 44 seconds each,
660932 - reported in case study on, ref SDS 48 964N; however, that is very
660933 - rare.  Since I did a lap this morning, and want to do 3 laps tomorrow,
660934 - decided not to risk injury to the knee, foot, hamstrings, back,
660935 - blisters, etc., reported recently on 110331, shown in case study
660936 - listed on 101010 0744. ref SDS 48 K29M
660938 -  ..
660939 - Gisela said that 1 of 10 nodes tested today shows very slight
660940 - irregularity.
660942 -  ..
660943 - This significantly improves prior test that showed all nodes
660944 - irregular, reported on 091002 0900. ref SDS 10 1W5I, and leading to
660945 - heart surgery on 091022. ref SDS 12 PQWU
660947 -  ..
660948 - Gisela explained that slight irregular blood flow at one node today
660949 - could be normal for the patient; or, reflect slight restriction at one
660950 - of the 4 by-pass grafts performed during heart surgery on 091022 0700.
660951 - ref SDS 12 PQWU  Gisela further advised something along the lines that
660952 - the surface of viens taken from the leg are not smooth like arteries
660953 - near the heart, where bypass grafts were constructed on 091022.  This
660954 - might cause slight restriction of flow near the heart, which registers
660955 - irregular in the test today.
660956 -
660957 -            [On 110415 0900 meeting with Doctor Egan concurred that
660958 -            Helter monitor test on 110406, and treatmill stress test
660959 -            results show very favorable results for cardiac health.
660960 -            ref SDS 80 SH5L
660962 -  ..
660963 - Discussed durability of coronary artery bypass grafts (CABG), citing
660964 - well publicized case of former president Bill Clinton, who needed a
660965 - 2-stent procedure 100212, about 6 years after quadruple bypass surgery
660966 - in 2004.
660968 -  ..
660969 - Gisela seemed to say that bypass grafts can last more than 20 years
660970 - for patients with healthy lifestyle.  This aligns with research in the
660971 - record on 091024. ref SDS 14 UJ5O
660973 -  ..
660974 - Gisela indicated that Metoprolol Tartrate and aspirin are protocol for
660975 - heart bypass patients.
660977 -  ..
660978 - We reviewed the record on 091104, showing these and other drugs were
660979 - prescribed on discharge from VA Medical Center in San Francisco.
660980 - ref SDS 20 414R and ref SDS 20 UN6L  In a meeting with the medical
660981 - team on 091119, post-surgery drugs were ended. 091119 1000,
660982 - ref SDS 22 LC5F
660984 -  ..
660985 - Aspirin was discussed for thinning blood.
660987 -  ..
660988 - Gisela explained that aspirin thins blood differently from warfarin,
660989 - and so the need for aspirin cannot be tested with an INR PTT blood
660990 - test, like Mil got the past 10 years.  There is a blood test for
660991 - effects of aspirin, but it is expensive.  The VA feels that giving
660992 - everyone aspirin is cheaper than determining, who needs aspirin.
660994 -  ..
660995 - Gisela seemed aware of published studies showing mixed results on
660996 - conflicts between aspirin and omeprazole.  She further seemed aware
660997 - that studies for conflicts with aspirin were performed for omeprazole
660998 - 20 mg per day.  There are no studies showing that taking asperin is
660999 - safe for patients taking Omeprazol 80 mg per day, 400% higher than
661000 - tested in studies, reported to the team in a letter on 110329.
661001 - ref SDS 79 0E4R
661002 -
661003 -            [On 110415 0900 Doctor Egan seemed aware of studies
661004 -            reporting conflicts between aspirin and low dose Omeprazole
661005 -            20 mg; he discussed consideration to reduce prescription
661006 -            for high dose Omeprazole 80 mg. ref SDS 80 UR7L
661008 -  ..
661009 - Gisela indicated that not all heart patients take aspirin, but the VA
661010 - is required to recommend this to align with protocol.
661012 -  ..
661013 - After the test and discussion with Gisela, met with reception at the
661014 - Cardiology Department.  Scheduled meeting with Doctor Egan for 110415
661015 - 0900.  The receptionist said the doctor is out of the office on
661016 - 110429, and so cannot coordinate with Doctor Lee's work, so that Kathy
661017 - can support meeting with Doctor Egan as planned in the letter last
661018 - week to the medical team on 110329.
661019 -
661020 -
661021 -
661022 -
661023 -
661024 -
661025 -
661026 -
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6611 -