Palm trees. Warm breezes. Christmas decorations. The city of San Juan Puerto Rico was getting ready for the holidays. The streets were crowded with people buying gifts and fancy pastries. In tobacconist shops, men were grabbing up handfuls of cigars, and gift cartons of cigarettes. Cheerful crowds filled the bars and taverns, where people gobbled empanadas, greasy wings, and burgers, washing them down with rum and beer.
Omar Pietro Vincente (a pseudonym), however, stayed away from the pastry shops, tobacconists', and bars. He neither drank nor smoked, and when it came to eating. . . well, he was a trim man. No one in his family had died prematurely of coronary artery disease. He never experienced chest pains or shortness of breath. So he might have been more than a little surprised when - out of a clear, blue December sky - he had a heart attack.
Pietro Vincente spent the weeks leading up to Christmas in a Puerto Rican hospital bed, recovering from a myocardial infarction. At the hospital, he got excellent care. To find out what had caused Pietro Vincente's heart attack, his cardiologist did an echocardiogram, performed nuclear stress testing, and took him to the catheterization lab for an angiogram (x-rays during injection that show narrowings of the arteries around the heart).
Even after the heart attack, Pietro Vincente didn't have any major symptoms of heart disease, outside of a sore back. But the tests showed problems. Some were mild. Some were serious. The cardiologist laid out some treatment options. One of those options was something the patient did not want to hear: coronary artery bypass. Major surgery.
Pietro Vincente was filled with anxiety at the prospect of surgery. There had to be some other treatment that would help him. But where would he find out about it? His own doctors were very good. But there had to be other experts out there with other opinions.
Once out of the hospital, he went straight to the internet. There, he found his way to Cleveland Clinic. There, he found just what he was looking for - Cleveland Clinic's MyConsult® Online Medical Second Opinion program.
The MyConsult Online Medical Second Opinion program is a sophisticated, Web-based extension of Cleveland Clinics 90-plus-year role as one of Americas most respected referral institutions. The secure, online program provides second opinions from Cleveland Clinic specialists for more than 1,200 life-threatening and life-changing diagnoses.
Being from Puerto Rico, Pietro Vincente couldn't imagine what winter was like in Cleveland. But he did know that Cleveland Clinic was America's number one center for heart care. So he initiated his interactive relationship with MyConsult. Following directions, he answered the online questionnaires and forwarded his medical history, a CD of his echocardiogram and angiogram, and nuclear stress test films to MyConsult for evaluation - and a second opinion.
He wanted to know: Am I a proper candidate for bypass? If so, when should I have the surgery? Since I am currently stable, are there any alternatives? If I don't have a bypass, will I have another heart attack? What are the risks of treatment vs. the likelihood of my having a normal life?
At Cleveland Clinic, Pietro Vincente's records were carefully studied by one of the nation's top cardiologists. The doctor wrote up his findings in detail - a kind of "state of the heart" summary of Pietro Vincente condition. Among his findings were that Pietro Vincente's coronary arteries were dangerously narrowed in several places. Not only that, but they bulged, too - in some places right next to the spots where they narrowed. The heart attack had killed tissue toward the front of his heart, leaving it more-or-less non-functioning "scar."
The Cleveland Clinic doctor laid out three alternatives for Pietro Vincente which he read online through the secure website. The first was fundamental to whatever other course the patient decided to follow: pharmaceutical therapy plus diet and exercise management. From there, the options were interventional: angioplasty and stenting or coronary artery bypass.
Angioplasty and stenting might have been useful. New medicated stents were available that could hold the arteries open longer than bare metal stents. But Pietro Vincente wasn't a candidate for these. His narrowings were adjacent to bulges - also known as aneurysms - which stretched the artery wall thin.
A stent could pop through that thin wall. Also, the new medicated stents were sometimes known to reduce the thickness of adjacent artery walls, something Pietro Vincente's already ballooning blood vessels could ill afford.
Bypass surgery would have the advantage of dealing with both the narrowings and the bulges by simply going around them. But there was nothing simple about Pietro Vincente's condition. One of his diseased arteries fed the portion of his heart affected by the myocardial infarction.
This was essentially scar tissue, and would not benefit from increased blood flow. Another of his diseased arteries had no critical narrowing. A third artery was significantly narrowed, and a bypass would significantly improve blood flow here. But tests showed that this part of the heart was not suffering any blood-flow deficit when it mattered: under stress.
Medical therapy alone might have been called for. After all, Pietro Vincente was not suffering from angina or other symptoms of coronary artery disease. Unfortunately, medical therapy alone would not lower his overall risk of death. That risk came not from the likelihood of another heart attack, but from another dangerous heart condition known as arrhythmia - a sudden and deadly disruption of the heart beat. From looking at Pietro Vincente's test results (especially at one result called the ejection fraction), the cardiologist could see Pietro Vincente was at risk for an arrhythmia.
Taking all this into account, the Cleveland Clinic cardiologist made a detailed recommendation. It called for Pietro Vincente to receive medical and lifestyle modification therapy, in addition to a single bare metal stent in the one of his narrowed arteries most likely to benefit from such a placement. Most importantly, the cardiologist recommended that Pietro Vincente receive a portable implantable defibrillator. This surgically implanted device, the cardiologist wrote, "would sit and watch the heart's rhythm and as long as the rhythm is normal do nothing. But if it detects a life-threatening rhythm disturbance, the device would use electricity to shock the heart back into a regular or normal rhythm." The cardiologist report was made available to Pietro Vincente in Puerto Rico through the Cleveland Clinic's secure web portal.
In Puerto Rico, Pietro Vincente was overjoyed to see that his Cleveland Clinic MyConsult cardiologist did not recommend bypass. No open heart surgery! He was pleased that he had a good chance of leading a normal life after the procedures that were recommended.
After the holidays, Pietro Vincente returned to his local cardiologist with the second opinion in hand. Thanks to Cleveland Clinic MyConsult, Pietro Vincente greeted the New Year with new confidence, knowing that it was very likely his condition could be treated without open heart surgery. New Year's Day came and went, and Pietro Vincente had reason to hope that it might be a very good year indeed.