I am hoping I can get some advise. I am 50 years old. I have been two 4 cardiologists in the last 3 months. Yes, I know that sounds ridiculous, but below is the history, which I think sort of explains things. This all started with chest pain and shortness of breath in the middle of the night back in August.

1.) Cardiologist #1 - ran blood work (total cholesterol 202, LDL 126, no "little a" marker), nuclear stress test (passed), and echo (said "moderate aortic valve regurgitation"), calcium scan - 1005. He said he wanted to do a catheterization due to the calcium score, but said the nuclear stress test passing means I have no blockage over 70% and he would not stent anything under 70%. So, I questioned why do the cath and he said he was fine not doing it, so I didn't. This doc told me the aortic valve "is what it is". I was having several side effects after starting the statin. Tried to get someone from his office to call me back for 2 weeks and never got a call back (they finally called 3 weeks later after I made an appt with #2).

2.) Cardiologist #2 - went to get help with statin dosage since no follow up from #1. He said "with a calcium score of 1005, you must get a catheterization" and told me the aortic valve was not an issue. Said he would stent if he found something >70%. Woke up in recovery and told I had a 90% mid LAD blockage and 4 other 40-50% blockages. Asked if he put in a stent and he told me no and that I really needed to go see a surgeon about getting a "minimally invasive bypass" . He was almost insistent about this. I asked if a stent would be a viable solution and his response was "sure, it's an easy one to do and I do them all the time". I was still under meds, so that afternoon I messaged through mychart because I wanted to ask some questions - i.e, why was stent not a good option, pluses and minuses of stent vs. bypass, etc. The assistant was very nice and set up a video visit for the next morning. The doctor skipped it and the assistant called 15 min into the appt and told me "the doctor said he doesn't have time to talk to you today". I didn't feel like this was appropriate, so I didn't move forward with this doctor.

3.) Cardiologist #3 and #4. At this point, I was really confused about all of this, so I made appts with 2 other docs hoping to get an aligned path forward. I just wanted to hear a similar opinion from 2 doctors. Both reviewed my records. Both said exactly the same thing - cardiac MRI to assess aortic valve. If it needed surgical repair, then they would fix it and do a bypass while in there (open heart surgery). If the valve was OK, then they would stent the LAD blockage. Both said the stent was in a "simple" straight run and wouldn't be an issue. So, I got the cardiac MRI. It showed 10% regurgitation, which is very minimal. Went for my follow up appointment thinking I would be getting a stent, as discussed. The doctor said the aortic valve was fine but completely changed course and said he wanted to do another catheterization, but said he may end up sending me to a surgeon for open heart surgery (i.e do another catheterization with no intervention when he already had all the imaging from the 1st cath). I asked him why his direction changed and he said "well, your young, a bypass might be the right thing to do". I left completely confused. So, I made an appointment with #4 and took my cardiac MRI to him. He also said valve was fine. He went on to say, after also saying in appt #1 that he would place a stent if the aortic valve was OK, "I am going to put you on a treadmill and see what you can do. If you pass, I am going to manage this with meds since you don't have ongoing symptoms, angina, etc.".

I am sorry for the long post. But, I am hoping someone can help shed some light on why I have had some many varying opinions and changes of course. It's a little frustrating. I am almost at the point of just going on with my life and dropping this all together.

This is well above my pay grade but I wouldn't ignore the situation with a calcium score that high and 90% blockage in Mid LAD.

Cards loves doing procedures, you have discovered this


Your lipid panel is an incomplete picture, cannot judge your overall cholesterol health without particle numbers, lipoproteins, etc.

Calcium scoring is a poor screener, especially at your age

Cath-angio (which you did) is the gold standard for vessel assessment, however, it can also be technician dependent

IMO coronary CT-angio with AI will become gold standard and will bypass invasive diagnostic (which you had) cath-angios
Look into Clearly coronary CT-angio
https://cleerlyhealth.com/find-cleerly-near-you

Cardiac MRI is great for valves, yours sounds like it is not contributing


If it were me, I would try to get a Cleerly read coronary CTA, and if it was ~70(+/-)% would look into fixing (interventional cards)


** Disclaimer - I am not a heart doc **

You have multivessel coronary artery disease which is a very serious and potentially life threatening condition.

Regardless of the decision on revascularization, you need to aggressively treat all potential risk factors. That means aggressive lipid lowering, strict bp control, blood sugar control if diabetic, no smoking, weight in healthy range.

If you have normal cardiac function (sounds like you do) and no symptoms whatsoever (sounds like you had chest pain and shortness of breath at least once though) you could make a case to treat this medically. However most would opt to revascularize a 90% mid LAD lesion due to risk of heart attack leading to heart failure or even sudden cardiac death.

Stenting is less invasive but maybe not as likely to have a good long term result as bypass and will require blood thinners ( dual anti platelets drugs) for months afterwards. Bypass is more invasive but likely to yield an excellent long term result.

If I were in your shoes, I would find a good interventional cardiologist that you trust and stick with their advice. Also don't ignore any chest discomfort or breathing trouble. That needs to be evaluated immediately.

Where are you located?

My dad, who's 79, had a triple bypass and aortic valve repair back in December. His local cardiologist told him he'd likely need a stent and valve replacement, but the cardiologist referred him to Houston Methodist to see Dr. Gerald Lawrie for a surgeons opinion. Dr. Lawrie ordered a cardiac MRI and said something similar to you that the valve was fine.

Based on the heart cath, Dr. Lawrie decided to do a triple bypass due to blockage in multiple places in the arteries, and while they were in there, the valve was leaking more than the MRI revealed. So my dad ended up with a triple bypass and an aortic valve repair.

If you have the means, I highly recommend you see Dr. Lawrie at Houston Methodist. The care my dad received at Houston Methodist was top notch.

Thanks for all the responses. The doctors I saw are a combination of providers at Houston Memorial Hermann and Houston Methodist. The one I am currently seeing is a very well regarded Methodist interventional cardiologist (the one recommending medication only if I pass the stress test).

I would just summarize this all to say that medicine is not black and white and there are different styles and approaches. Doesn't make one right or wrong, just different options. Hence why you are likely getting different opinions from different cardiologists.

Like most things, the devil is in the details. I would say that there is no way to really weigh in on what you should do without seeing all of your actual studies. I would never decide to send someone to surgery or tell them they do or don't need a stent off someone else's report. Find someone you like and trust and follow their advice.

CCTA has come a long way and is a powerful tool. And computers likely will be reading all of them one day. But calcium creates an artifact on CT. With his calcium score being this high, a CCTA will most likely be inconclusive or be read as worse than it actually is.

He has already had a cath, which is the gold standard and offers the highest resolution images.

Does anyone have any idea why I have had 2 docs say bypass surgery is "better" than a stent for a 50 year old? My understanding is that drug eluting stents (which have been in use for 20 years) have a 3-5% chance of re-occlusion in the first year and then the risk goes way down if you behave and stay on the meds you are prescribed. I haven't been able to get a straight answer from anyone on what "better" means in terms of percentages of complications for one vs the other, etc. I would hate to think revenue for the hospital is in play here, but without getting solid answers from these guys, I am starting to wonder.

It could very well depend on your anatomy. I've seen some cardiologists decline to stent something that they didn't think they could adequately stent, and their partner took a look at it and said they could, and they did.

Some people need either a stent or surgery, but their anatomy is not amenable to either without significant risk.

Bypass also has longer usable life compared with stents. Although drug eluting stents do minimize restenosis, data shows better long term mortality and less need for additional intervention. However the data is, of course, looking at the aggregate. There are always outliers to the data, and it's hard to predict who will be an outlier.

Thanks for the reply. I am just really confused because I don't fall into any of the categories I have read, or that you mentioned, that suggest a bypass is the solution for me, but I have had 2 doctors try and push me that direction without an adequate explanation, just saying "it might be better for someone your age". The cardiac MRI I had (to assess an aortic valve leakage that turned out to be nothing) showed a 64% EF and no previous MI. I don't have diabetes or pre-diabetes and have a BMI of 24.7.

I have other blockages, but they are all 30-50% and they said they would not be addressed with either stent or bypass. The single 90% lesion is mid-LAD right after D1. There is a minor 10% blockage right past it that they said the stent would have to cover as well (apparently you have to stent from "healthy vessel to healthy vessel"), and they all said this would require a ~25mm stent, which is on the longer side, but still acceptable. It is not a bifurcation situation, either, as the lesion is far enough away from the D1 branch. All 3 cardiologists have told me a stent would be "easy" and would be an acceptable solution for me.

Anyway, I am planning to stick with this last doctor. He is basically putting me on a treadmill, and, if I pass, then he will treat with medications (rosuvastatin, baby aspirin, enalapril - for BP, and I think he said he would add Plavix). I guess I must have genetic plumbing or have developed additional vessels that are allowing for collateral blood flow. I jog 1.5mi a day with no issues. So, I wouldn't think I could do that if there wasn't something flowing around that lesion.

It sucks to have to take a hand full of pills like an 80 year old, but I guess it is what it is.