Question to general practitioner Maarten: Medication use after myocardial infarction and diving
Maarten Vasbinder lives in Isaan. His profession is general practitioner, a profession that he mainly practiced in Spain. On Thailandblog he answers questions from readers who live in Thailand and writes about medical facts.
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Dear Martin,
On 20/07/2017 I had a heart attack in the Netherlands. Been admitted on 25/7 and 28/7 and referred for examination of vessels and possibly placing stents. This also happened, 3 stents were placed. I was given medication and felt fine, but I also felt that way before the heart attack.
Do a lot of sport including diving, cycling and walking, age 65. And eat healthy. Weight 75 kg. Blood pressure 80/129 Cholesterol 4.2 gluc sober test myself around 7 on the advice of my doctor diabetes runs in my family. Also heart failure. Received medicines:
- Acetylsalicylic acid 80mg brand name Mylan
- Atorvastatin 40mg brand name Mylan
- Bisoprolol 2.5mg
- Perindopril 4mg
- Ticagrelor 90 mg brand name Brilique 2 x per day
- Pantoprazole 40 mg
After my first meeting with the cardiologist she told me: after six months diving again (she is also a diving doctor). After my last conversation before I left for wintering in Thailand, I don't think she was in a good mood. Had some questions about my medication and why I had to use it, including lowering blood pressure and cholesterol. Got a short and clear answer: BECAUSE I SAY SO. Wasn't really happy with that but too short a day before I left for Thailand. Her answer about diving had also changed: 'you will never dive again as long as you take these medicines' and I was very surprised.
The letter I received for my visit to a cardiologist in Thailand was also in Dutch. Ask why not in English. Everything in it are things that someone in Thailand also understands. I started looking myself and came to the conclusion that I don't have to use more than half of the medicines (perhaps stubborn but I feel fine with it).
Now I only use Ticagrelor 2 x per day and Acetylsalicylic acid 80 mg 1x per day. Would like to have me examined next month, including cholesterol, etc.
Please advice for an alternative to Ticagrelor and Acetylsalicylic acid but thought of Aspirin 81.
I would like to hear from you if I just have to take my meds or are these two enough?
Regards,
F.
*****
Dear F.
As complicated as the question may seem, it is not that complicated. You will receive medicines that fully meet the guidelines for treatment after a heart attack. The diving advice also fits in with this.
My opinion about the guidelines is not that important in this one, because they are among the "mandatory" actions of a doctor. A doctor who does not comply runs the risk of being punished.
After a myocardial infarction, where stents have been placed, you will in principle always be prescribed what you have been prescribed.
- An ACE inhibitor, such as perindopril, or ARB inhibitor. Not both.
- A beta-blocker, such as bisoprolol
- anticoagulants, with Ticagrelor 90mg being preferred along with
- 75-100mg aspirin. That is the same as Acetylsalicylic Acid
- A "High Intensity" Statin, such as Atorvastatin. Be careful with pomelo and grapefruit.
- A stomach protectant, such as Pantoprazole
Some caveats:
- In principle, Ticagrelor can be stopped after 1 year. There are indications that this is already possible after ½ year, but also that it is better to continue with a lower dose for longer. Follow the money?
- Anticoagulants are a relative contraindication in diving. www.divingmedicine.com
nl Relative in this case means that there is theoretically a danger, but that no major accidents have actually occurred yet. However, if you cut yourself on a sharp stone underwater, there is a problem, but the same applies above water. - Beta-blockers are also a contraindication because of the reduced effort the heart can make. They are a kind of speed limiters. This can become annoying in emergency situations where excessive effort has to be made.
- If you like to eat grapefruit or pomelo, you can replace the atorvastatin with rosuvastatin (Crestor)
- For more complete information, I recommend that you read this: www.
diving medicine.nl .
Of course you remain responsible for what you do with your body. We only give advice. As a doctor, I can't give you any other advice at the moment than not to dive for the time being. Instead, step up your fitness. Then after about half a year there will be no objection to it anymore. Then go to a real diving specialist to have yourself examined.
Sincerely,
Martin Vasbinder