Dear Dr. Roach: I am an 82 year old male and started experiencing shortness of breath about 14 months ago. The condition continues to deteriorate. I had a stress echo test, nuclear stress test, lung test, chest X-ray and CT scans, all of which came back negative. Recently, a heart scan showed blockage in two arteries: 70% in one and 80% in the other. The cardiologist who performed the procedure found that the blockage was not enough to warrant stents. No suggestions?

– MRS

Dear Madam: A lot of people tell me they don’t know what shortness of breath is. It’s very similar to the feeling you get after an intense effort, like a sprint, when you just can’t get enough air in your lungs. Shortness of breath is a concerning symptom that requires thoughtful assessment. Almost any heart or lung condition can have shortness of breath as a symptom. Other conditions include severe anemia and many psychological disorders, especially anxiety. However, we are often unable to diagnose the cause, even after a thorough workup.

It might surprise you that the cardiologist doesn’t want to open the blockages in your coronary arteries with balloon angioplasty (the stent then holds them open). However, a CT scan shows the anatomy and a stress test reveals the physiology – how blood flows to different areas of the heart during exercise and at rest. If there is no lack of blood flow to the affected area, opening the artery is unlikely to relieve symptoms. And there’s plenty of evidence that in people with stable coronary artery disease, a stent doesn’t reduce the risk of heart attack or death.

The situation is totally different in someone who has had a heart attack, where opening a clogged blood vessel can have many benefits, including preventing heart cell death.

It can sometimes be very difficult to tell if the shortness of breath is coming from the heart or the lungs in someone who has conditions that affect both organs. In this case, pulmonary function tests or specialized cardiopulmonary stress tests can sometimes answer the question. It appears that your cardiological evaluation was very thorough. It may be time to review if there is something else going on in your lungs or blood.

Dear Dr. Roach: I am an 83 year old male and my urologist told me that I needed surgery to remove bladder stones. I understand it’s painful. Are there alternatives, like sound waves used to break up kidney stones?

—ML

Dear ML: Bladder stones are most often found in an older man with an enlarged prostate. The urine is never completely emptied due to the partial blockage of the prostate resulting in the crystallization of minerals in the urine. There are other causes, such as a kidney stone that is too big to pass. Over time, bladder stones usually grow larger, which is why surgical removal is usually recommended.

The surgery is normally minimally invasive. An instrument is inserted into the bladder through the urethra. The stones are broken up with a laser or sound waves (through the instrument) and removed from the bladder. The procedure is usually done under local anesthesia and sedation. Most of my patients tolerated the procedure well without too much pain.

There are promising reports of the use of sound waves (called extracorporeal shock wave lithotripsy) for small bladder stones; it is generally used for kidney stones.

Bladder stones often come back if the underlying condition is left untreated, so be sure to talk to the urologist about preventing future stones.

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