Diving while on medication after supercoronary graft transplant?

[Divealpha]

Hi!
My wife had went through surgery after a trombosis in early june, and we're heading for Malta the 24/9. She s now off her Marevan/warfarin) meds, but still on Selo-Zok 50mg & Adalat Oros, 30mg pr. day. Don't trust our regular doctor on this,cause he said she could just quit the Selo-zok(betablocker), before the dives....Read that it could be dangerous quitting Selozok on the fly....
I have read most of this forum, and as far as I can see she should be fine if she dives under conditions that does not put a strain on her...
I'll carry the gear, and make sure we don't do deep dives, max 20m.
She also takes Albyl-E and Lipitor(cholestrol). I will also bring with me an Epipen(adrenalin) injector,, just in case anything happens(the company who makes them asked for feedback if they hold up against the waterpressure, but I'm intending to use it above water should it be necessary.... We also just became DAN members..
Any views or advice on this?

 

[Agility]

Personal view:
Your wife's circulation should be stable before diving. If you consider taking an Epipen with you (other than as a prophylactic measure for allergies) you should rethink the issue. A person with a circulation stable enough to dive does not need adrenaline supplementation.
If she is taking betablockers for control of bloodpressure she should continue taking them and not risk hypertension during her dive.

 

[TSandM]

I agree about the beta blocker, especially if she is on a moderate or high dose. Withdrawal from them is real and can cause rebound hypertension or tachycardia (high blood pressure or rapid heart rate).

Three months post-op seems quite early to me for something as ambitious as diving, and I know Doug Ebersole, our resident cardiologist here on ScubaBoard, generally recommends a treadmill with a certain set of goals (13 Mets, IIRC) as a reasonable evaluation of the post-bypass patient for diving fitness.

If her original presentation was complicated by any major arrhythmias (which I might suspect, given your interest in having the epinephrine at hand) it might not be unreasonable to wait a bit longer before risking going underwater.

If Dr. Ebersole doesn't weigh in here soon, I'll PM him and ask him to have a look and add his thoughts.

 

[DocVikingo]

Hi Divealpha,

Selo-Zok is a brand name for the compound metoprolol, a beta-blocker. It is generally well-tolerated and side effects, e.g., nausea, tiredness, shortness of breath, slow heart rate, tend to be mild & transient. You can a find quality, recent discussion of diving on beta-blockers here --> http://www.scubaboard.com/forums/diving-medicine/433157-diving-beta-blockers.html. And you are correct about the precipitous discontinuation of a beta-blocker. Except in specific emergency situations, this class of drug is to be tapered off. Stopping it “on the fly” can result in worrisome and even fatal rebound effects (e.g., excessively high BP & heartbeat).

Adalat Oros is a brand name for the compound nifedipine, a calcium channel blocker. It is generally well-tolerated and side effects, e.g., constipation, cough, dizziness, headache, muscle cramps/ache, tend to be mild & transient.

Both of these meds are effective antihypertensives/antianginals that have long been in use.

Albyl-E is a brand name for the compound acetylsalicylic acid (aspirin). It is generally well-tolerated over extended duration in small amounts and taken with food. It may dispose the diver to greater than usual bleeding in response to routine barosqueeze to the ears, sinuses & lungs. The same holds true for such not uncommon events as falls on the boat, strikes to the body by tanks & dive ladders, and run ins with sharp objects that can be found on wrecks. However, in modest amounts this drug would appear to pose only minimal risk of excess bleeding.

Lipitor is a drug that inhibits the creation of cholesterol in the liver. It is generally well-tolerated and side effects, e.g., diarrhea, joint pain, nausea/stomach upset, runny/stuffy nose, mild & transient.

Given that this drug regimen is in fact being well-tolerated and exercise tolerance is suitable for the possible rigors of diving, it shouldn’t pose undue concern.

As for the EpiPen (epinephrine), I’m not clear why you want to take this along vis-à-vis the graft transplant. At nearly four months post a successful graft, an otherwise healthy & fit diver should have a degree of perfusion such that there is no need for any such emergency circulatory support.

Leaving the drugs aside, there also is the matter of the graft transplant itself. The existence of thrombosis that required surgery means that the heart may have sustained damage, and in any event it is post-operative cardiac function that primarily informs the wisdom of resuming diving. IMHO, your wife should undergo exercise stress testing and ideally be able to attain 13 mets or stage 4 of the Bruce protocol without chest discomfort or other worrisome symptoms. At the least, she should be able to maintain a steady state of 6-7 METs without issue. I would add that recovery periods typical for the safe return to scuba folowing this type of procedure are more on the order of 6-10 months, rather than just four.

You might be well served by seeking a consult with a cardiologist with some knowledge of diving medicine, but given a departure date of less than a week this would be a good trick.

BTW, Malta is very serious about certificates of medical clearance for divers with medical histories such as your wife’s. Be forewarned.

Best of luck.

Regards,

DocVikingo

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual, and should not be construed as such.

 

[Duke Dive Medicine]

Did I read this correctly in that you are bringing an epi-pen with you in case she experiences a cardiac arrest? If so, then a few things come immediately to mind: first, if cardiac dysrhythmia is that much of a concern, she should not be diving. Second, an adult epi-pen delivers 0.3 mg of epinephrine intramuscularly, which is less than 1/3 the initial recommended intravenous dose of epinephrine for cardiac arrest, which by itself has not been shown to improve outcomes.

That aside, I agree completely with TSandM in that three months is probably far too soon to think about returning to diving after bypass surgery. Has your wife completed cardiac rehabilitation and been cleared for full activity? If you're talking about carrying her gear for her, my guess is that she has not. Also, the advice to discontinue the beta blocker is ill-founded. Ditto TSandM on that as well. Forgive my bluntness, but at first read, this sounds like a statistic waiting to happen. <edit: credits to DocVikingo for the same advice; he posted while I was writing and editing>

 

[Divealpha]

Well. first thanks a lot for valuable information...seems our regular doc(which are the first to consult/rules here..) really is a bit out of line concerning just quiting the betablocker... As for the Epipen, it's related to the acute trombosis,5/6. The local hospital believed she had a anafylactic shock(instead, two doctors at the hospital contacted the Main university hospital in the capital ,where they did the diagnosis & surgery). The local hospital still considers this as anafylactic shock, and thought it could be something like "mastocytosis". However, 1 in 2 millions get this allergic disease, and the responsible doctor at the local hospital thought this was highly unlikely. That's for the Epipen/allergic part....
She's been fine since the second visit to the hospital, and it seems she had a silent stroke, due to a to low INR after the surgery, e.g. some bloodclotting due to the graft.

We are not planning for her to do "regular diving" as before(not yet), but just so she can have a few shallow dives. I'll gladly stay at 5 meters with her....
Bloodpressure is avg. 128/81 pulse 84 last months(daily measuring). We've been to Malta before, and will dive with the same center, which is one of the best we've been diving with around the world, (very responsible, does tech etc.)
We'll take the advices we get here, though, as it's actually seems easier(and safer) to get advice here
She will also have a scheduled CT at the Univerity hospital in December(just in time for the next (hopefully)divingtrip to Thailand....

---------- Post Merged at 09:22 PM ---------- Previous Post was at 08:51 PM ----------

The Epipen was recommended(as mentioned above) from the local hospital, because they did not believe she had trombosis... almost impossible to get the doc's there to believe she suffered anything other than an anafylactic shock...they think it was a coincidence she had the trombosis(just over her heart).
The University hospital are of the exact opposite conclusion. We choose to listen to the latter, as they are the expert surgeons/doctors in our country...and my wife has never been allergic, and have now also been checked for any allergic with negative results(except that one doctor believed it could be mastocytosis(checked out by phone from local doc to a german specialist). Still, they want us to have the epipen......

It's one of the reason I'm asking in this forum, we get to many divertet answers(hop my english is understandable...not so into medical terms in english..) from our local doc's.

Already, what I can conclude with of the answers here so far, is that:
1. Don't stop any medication
2. It's possible to dive with these meds, but not recommended
3. Make sure she's fit to dive (well, I always carry her gear on shore dives where the terrain is a bit like Malta, not on beaches, that's because of her shoulder/back/she's only 164cm, and, it gets me in better shape

A bit off-topic, but I guess she has been diving with this trombosis since we started diving almost 3 years ago...lucky...

 

[Duke Dive Medicine]

Divealpha,

Thanks for the clarification.

Regarding diving: I'd reiterate what I and others posted above about returning to diving after cardiac surgery. Depth is less an issue than the immersion itself. Immersion in water causes a fluid redistribution where between 500 cc and 1 liter of blood goes from the extremities to the torso. This sudden influx of fluid into the great vessels can cause undue strain on a heart that is still recovering from surgery. This happens whether you're at 1 meter or 100 meters. Not to be repetitive, but my question from before remains: has she completed cardiac rehabilitation and been cleared for full physical activity by her surgeon?

Best regards,
DDM

 

[Divealpha]

Divealpha,

Thanks for the clarification.

Regarding diving: I'd reiterate what I and others posted above about returning to diving after cardiac surgery. Depth is less an issue than the immersion itself. Immersion in water causes a fluid redistribution where between 500 cc and 1 liter of blood goes from the extremities to the torso. This sudden influx of fluid into the great vessels can cause undue strain on a heart that is still recovering from surgery. This happens whether you're at 1 meter or 100 meters. Not to be repetitive, but my question from before remains: has she completed cardiac rehabilitation and been cleared for full physical activity by her surgeon?

Best regards,
DDM

No, she has not been offered, adviced, or informed about any kind of rehabilitation, except for not beeing allowed to lift more than 500g the first 2 months, some more after 3. She will not see the surgeon or the hospital where she had the surgery until December. However, it's hard to keep her out of her kitchen(serving 200 each weekend,but we got employees for this)but she's not allowed to lift heavy stuff.. Guess she's doing that anyway when I'm not present...so, she's starting to get some exercise,and this week she started lifting some of my weights(I'm fixing my shoulder,age/wear.prescribed my my doc.).
We are trying to get a status on clearance, but since we get different answers, I posted this thread.(and that seems to be far better...)

Also, I'm not going to push this, because she's already accepted just helping out on the boat, or taking a dip in the ocean while I'm diving with instabuddies... Guess I'm not going to dive as we planned together, but that's not a problem. It's just goodto get some decent answers which clarifies things, escpecially as our local docs seems to be unable to answer. And, also because of this, and future diving, we signed up for DAN memberships already..

 

[Duke Dive Medicine]

Interesting. I'm not familiar with the Norwegian health care system, but in the US it's pretty much standard for a post-bypass patient to go through formal cardiac rehabilitation that is supervised by specially trained nurses. If your wife hasn't been seen by her surgeon and is not scheduled to until December, then I think it's a very good choice for her to stay out of the water for this trip.

Best regards,
DDM

 

[tracydr]

Interesting. I'm not familiar with the Norwegian health care system, but in the US it's pretty much standard for a post-bypass patient to go through formal cardiac rehabilitation that is supervised by specially trained nurses. If your wife hasn't been seen by her surgeon and is not scheduled to until December, then I think it's a very good choice for her to stay out of the water for this trip.

Best regards,
DDM

I haven't always seen cardiac rehab in the bypass patient. If the patient didn't have an actual MI they are sometimes not given cardiac rehab. I guess it depends on the patient and the doctor. Also, I think cardiac rehab is done less often nowadays, probably a cost savings issue.
However, it is certainly standard to require a treadmill prior to clearance for normal exercise activities and certainly diving.
Sometimes, the family practice doctors are trained in doing treadmills. I wonder if this might be the case in Norway?