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Coronary Artery Disease Treatments (Drs. Ellis and Sabik 1/10/11)

Monday, January 10, 2011 - Noon

Joseph Sabik, MD
Chairman,
Department of Thoracic
and Cardiothoracic Surgery,
Miller Family Heart
& Vascular Institute

Stephen Ellis, MD
Section Head,
Invasive/Interventional Cardiology
Department of
Cardiovascular Medicine
Miller Family Heart
& Vascular Institute

Description

Coronary artery disease (CAD) is the most common type of heart disease and is the leading cause of death in the United States for both men and women. Treating coronary artery disease is important to reduce your risk of heart attack or stroke. Take advantage of this rare opportunity to chat live with a heart doctor and heart surgeon in a secure online setting.

More Information

Cleveland_Clinic_Host: Welcome to our "Coronary Artery Disease Treatments" online health chat with Stephen Ellis, MD, and Joseph Sabik, MD. They will be answering a variety of questions on the topic. We are very excited to have them here today! Thank you for joining us Dr. Ellis and Dr. Sabik, let's begin with the questions.

Dr__Stephen_Ellis: Thank you for having me.

Dr__Joseph_Sabik: Let's begin.


Candidate for Treatment of Coronary Artery Disease

metman: I have had 3 small stents put in over the last 11 years in the lower part of Lad, all other arteries are clear. I am 57 yrs old and have never had any typical symptoms, no chest pain, no out of breath, and play a fair amount of sports. Each time I go in for these stents they say I have 80 to 90% blockage. Does this seem like the right path I am going on, my Dr says this is not a serious enough problem for any surgery. Would the minimally invasive approach to bypass this area be advisable? I do not like to keep going in for the caths.

Dr__Stephen_Ellis: This is a difficult question to answer without seeing your cath film, however revascularization with stents or bypass surgery is usually reserved for patients with symptoms or severe proximal disease—it seems like you have neither. Therefore, preventive measures would be in order. We would be happy to review your cath films.

maggiemay: Hi I am 53 years old and a diabetic for 37 years. I had triple bypass Nov 2009 at first they said I needed quadruple but decided to just do the three big ones will three months later they tell me two of the three were already closed up my doctor said another bypass or stenting was not an option so he gave me 2.5 mg nitro patches and sent me home with an appointment to follow up in 6 months, I seem to be doing ok unless I try to do lifting walk to far but lately I get a tightening in my chest at night when I'm lying down and sometimes when I am sleeping wake up with this tightening when I sit up it goes away maybe it is heartburn or something else I don’t know why is another bypass or stenting not an option and is there something else that can be done with all the new treatment I am wondering about laparoscopy bypass or other possible solutions to fix rather than treat.

Dr__Joseph_Sabik: It is hard to say without seeing your cath films.

Dr__Stephen_Ellis
: Large tertiary referral centers often have treatments available that other centers do not have - we would need to look at your cath films to see what options are available to you.


Symptoms of Coronary Artery Disease and Diagnostic Testing

judlarmcb: I currently have 5-stents implants (2-Mar 09, 3-Apr 09. I also have an AngelMed Implant device. I still have pressure or sharp pain while in resting mode that will last 5 to 20 minutes. I had a heart cauterization in Aug 010, but everything looks good. The Heart Dr's believe that possible stress buildup made be causing blockage. They put my on Imdur, 30mg, & plavix, 75mg. Any suggestions I can give my Cardiologists that we might look at, or any other suggestions?

Dr__Stephen_Ellis
: We would be happy to provide you with a second opinion consultation with you to review your cath films to provide suggestions. It sounds like you are bothered by your symptoms. Questions like yours are difficult to answer with out looking at your cath film.

Dr__Joseph_Sabik
: Symptoms such as yours may or may not be due to heart disease. Therefore, it may be worthwhile to look for other etiologies of your discomfort if heart disease is ruled out.

Wendy: I am a 41y/o female with a family history of Cardiac disease. At 39 I had a cardiac cath secondary to calcifications of LMCA showing up on spiral CT of chest. The cath showed that the artery is clear and the calcification is of the artery itself. With no dilation I have been restricted to HR no higher than 140. I have in the last 3 mos especially been experiencing constant fatigue, shortness of breath with exertion and intermittent chest and upper middle back pain. What would be next course of action if cath still show no blockage?

Dr__Stephen_Ellis
: The cause of your pain could be due to progression of blockages, microvascular disease or non-cardiac etiology.

Dr__Joseph_Sabik
: A stress test with imaging may be the next important step in determining the etiology of your pain. If microvascular disease is suspected, an MRI perfusion study is best.

leslie: my mother is a 75 year old with a history of heart disease. she suffered a heart attack at the age of 57 and underwent angioplasty. in 2003 she had a triple by-pass surgery. She also has stents in both carotid arteries. She is significantly overweight, is mobile but suffers from stable angina. I would like to arrange for her to have an assessment in Cleveland to determine if there is anything that can improve her quality of life and her mental outlook (her last cardiologist indicated that 'she was lucky to be alive and shouldn't really be' so there wasn't much he could do for her). Her family physician can provide a referral. Who should I make an appointment with? Thanks for your assistance.

Dr__Stephen_Ellis
: You should make an appointment with one of our clinical cardiologists—they would be happy to see her - they could manage her heart and vascular disease. We also have a specialized center for women with heart disease—that is also an option.

metman: What is the best stress test, a thallium stress or a stress echo?

Dr__Stephen_Ellis: It depends on your body shape and local expertise. Across general populations they perform comparably but for individual patients one may be recommended over the other.

connies: My entire family has died from heart attacks, 3 of my cousins and I were talking and found that all of us have had the same symptoms- chest heaviness, pain, dizziness. One has actually passed out. We have all had stress test with no problems indicated. Should we have had a different test or are we OK?

Dr__Stephen_Ellis
: You are having symptoms—that is not normal. A thorough a cardiac exam and echocardiogram would be recommended.

elliott: When I had chest pain neither the stress test or EKG showed a problem. They had to do an angiogram to determine that I had multiple blockages. I had a double bypass. How, going forward, can we monitor for progression of disease without having to do an angiogram. Again, the stress test and EKG come out normal? Yet, I had major progression of disease within 6 months and had to have the bypass. Besides reporting symptoms, would a heart CT (non invasive like an angiogram) be a tool to use to see if my disease is progressing? or do you just have to wait to have symptoms and then do an angiogram? what other procedures can be done to watch for progression of disease? thank you.

Dr__Stephen_Ellis
: The appropriate role of CT angiography continues to evolve. Most cardiologists do not recommend it for routine follow up due to its poor spatial resolution and high x-ray dose. However, as the technology improves it may be utilized for this reason.


Coronary Artery Bypass Surgery

dboyer: My cardiologist believes that the risks are too great for the expected outcome for additional coronary intervention. I have 5 stents and had 3 bypass grafts One graft is 100% blocked 1 1/2 yrs. post surgery and causing angina.

Dr__Joseph_Sabik: Risk is related to many factors such as the extensiveness of your heart disease and other co-morbidities. If you have good heart function and few or no co-existing conditions that would impact surgery, the risk may not be high. Large experienced centers such as ours may be able to provide you with therapies at a lower risk than other centers.

chris66: In 2005 I had a double bypass for a blockage in my left main. The lima graft failed to mature so the put a stent in there. That sent is now 100 percent blocked and I was told my LAD is very small and diffused. Could I ever get the lad better enough to do be able to stent it or have surgery on it?

Dr__Joseph_Sabik
: Without knowing the quality of the coronaries it is hard to say. We would need to review the cath films to determine your options.

Peachy: How can I request non-invasive mitral valve and coronary artery surgery?

Dr__Joseph_Sabik
: You can contact the Heart and Vascular Institute Resource Nurses—they would start you on your way and provide you with what you need to send in for a surgical review. The surgeon would review your information and determine if this is an option for you. 866.289.6911, e-mail heartcenter@ccf.org, or chat online from our website.

joelh: I wrote to you before, but forgot to ask one question, so please be as honest as you can. 57 year old male. I had an emergency stent placement due to chest pain and after 6 months of aggressive therapy, etc., had progressive disease. I never had a heart attack or heart muscle damage. I had to have a triple bypass: left mammary artery to the LAD, 2 leg vein grafts to the ramus and marginal obtuse. I have lost 30 pounds ( am 5' 8" and 180), cholesterol in excellent range, aggressive drug therapy, exercise 40 min. per day). WHAT IS REALLY MY PROGNOSIS? HOW LONG DO BYPASSES REALLY LAST? will I get more blockages beyond the bypasses? what else can I do? I am trying to plan my life. THANK YOU FOR YOUR HONESTY.

Dr__Joseph_Sabik
: Atherosclerosis is a progressive disease. You have made great strides to decrease your risk of progression—continue on this path.

Studies have shown that that patients who have had bypass surgery at 10 years, 10-20 percent will need either an additional surgery or PCI.

jillrn: Can you please identify inclusion criteria for mini-invasive bypass surgery?

Dr__Joseph_Sabik
: The extensiveness of the disease is important and the body shape. If you have greater than three blockages standard surgery is probably best. Minimally invasive bypass surgery can be done in any area of the heart, but the front of the heart is more commonly performed. We would be happy to evaluate you to determine if this is an option for you.

elliott: Hi, I read that for a bypass, because the veins are taken from the leg, they don't do well because they are being used for a different purpose than intended. is this why the vein grafts don't do well? can you please explain this? also, is there a reason why synthetic grafts haven't been invented and used with success? thank you.

Dr__Joseph_Sabik
: Vein grafts develop atherosclerosis and that is why they fail over time. The internal mammary arteries very rarely develop atherosclerosis and that is why they stay open for very long periods of time.

Synthetic grafts have tended to close very early after surgery and that is why they are not used.

Peppy: Can pig tissue be used in these heart grafts?

Dr__Joseph_Sabik
: It is used in tissue valves but not in bypass grafts.

Jad_Ali: I need a bypass surgery but due to my age and health is not that good they said they cannot do it here in Saudi Arabia .is it possible it can be done in your clinic in usa ?

Dr__Joseph_Sabik
: We would be happy to evaluate your heart films and see if you would be an appropriate candidate for surgery.


Stents- Interventional Procedures

JohnS: In 1999, I had a quad bypass. I now need a stent in one of the grafts done during that surgery. The doctor is talking about placing three stents in the original artery that was blocked in 1999. Is this common, and what are the consequences?

Dr__Stephen_Ellis: Atherosclerosis is a progressive disease and it is not surprising that the blockages have progressed.

Once a vein graft has developed blockages severe enough to require stenting (excepting at the anastamoses) it is rather common that they need intervention in the next few years—hence it is recommended to treat the native vessel when possible.

kent1954: How many stents can you have?

Dr__Stephen_Ellis
: There is really no limit to the number of stents you can have, but if you are requiring multiple stenting procedures one has to ask if your risk factors have been adequately treated and/or if you should be evaluated for surgery.

Dr__Joseph_Sabik
: You need to be careful that you don't have such extensive stenting that your options down the road for surgery are eliminated.

mike714: mike714-i had a massive heart attack 4/2007,an angioplasty and two stents, my ef is 37-42%,my pb is 110/70 I am taking coreg 12 mg in the am and 9mg in the pm is that enough?

Dr__Stephen_Ellis
: Although treatment has to be individualized, most patients with your situation should be on aspirin, high dose statins, ace inhibitors in addition to coreg (a beta blocker).

Peppy: My cardiologist told me to quit Plavix after three years post DES/Taxus in the diagonal. I'm on 81mgs. aspiring of course. Isn't there a rebound effect? I've read about it.

Dr__Stephen_Ellis
: Your risk of a heart attack discontinuing plavix this late after a stent is very small. It sounds like you should stay on aspirin indefinitely however.


Restenosis (Reblockage) of Coronary Artery Disease

hardymichalski: It seems that there are many things being worked on for Coronary Artery Disease but it’s always years away in the future. Is there any new procedure available in good hospitals or at your clinic that ca be of help now. I had a 4 bypass 3 yrs ago and 3 bypasses are already closed again. I'm being treated with drugs. Another bypass or stents are not an option. I'm a 5' 5" male and my arteries are too small. Thanks for any info.

Dr__Stephen_Ellis: If you are really having symptoms, it is unusual for the arteries to be too small to not do something.

We would be happy to evaluate you to see if there are interventions that could be available to you.

jpersico: What is the recommended testing for evaluating re-stenosis of stents?

Dr__Stephen_Ellis
: After stent procedures, the recommended follow up has evolved over time. If you had routine angina prior to the procedure, then routine stress testing is not recommended unless the stent was placed in the proximal LAD or left main coronary artery.

If you did not have typical symptoms then talk to your doctor about stress testing every one to two years.


Ongoing Follow-up and Disease and Risk Factor Management

joelh: Hi, I’m a 57 year old male had multiple blockages and had a stent in LAD. Took plavix, aspirin hypertension meds, lipitor. 6 month later NEW blockages including 2 95% blockages just beyond a patent stent. new disease in circumflex marginal obtuse. had triple bypass. should I stay on plavix to try to keep bypasses open? since stress testing and ekg revealed nothing during my chest pain, how can we monitor to see if I have progression? is a CT of the heart indicated down the line? I am scared. my disease progressed so fast. my cholesterol is under control in the most desirable levels. I lost 30 lbs., exercise everyday, bmi is 28. thank you.

Dr__Joseph_Sabik: Although it has not been rigorously studied, plavix has not been shown to keep bypass grafts open. Aspirin has been demonstrated to keep bypass grafts open and therefore should be taken. We will need further studies on the affects of Plavix and bypass graft patency to know whether it will be beneficial.

Dr__Stephen_Ellis
: Your target LDL should be less than 50 - 70 mg/dl. Regarding your monitoring - perhaps you need a sophisticated form of stress testing such as PET or MRI. Continue with your lifestyle changes that you have made - that is important.

Cleveland_Clinic_Host: For those just joining, we are chatting with Dr. Ellis and Dr. Sabik, who are taking your questions about coronary artery disease. If you would like to review what already has been discussed, please click on the 'Transcript' button above. If you would like to submit a question, please type in the text box below and click 'Ask.'

mikec: I am 51 years old and my coronary artery disease is being managed medically. Four years ago I had a heart attack and was diagnosed with coronary artery disease. The blockages were diffuse and distal I was not a good candidate for either stents or bypass. Is there anything that I can or should do to see whether the disease has either improved or progressed? I am on high dose statins, exercise regularly and watch my diet closely.

Dr__Stephen_Ellis
: Great job with the lifestyle changes you have made. Although imperfect, a stress test is the best way to monitor disease progression periodically.

jillrn: Are there new treatments to allow going off of mega-dose of niacin (due to intolerable side effects)?

Dr__Stephen_Ellis
: The answer depends on the reason for taking niacin (low hdl, high triglycerides, high Lp(a)). High dose omega 3 supplementation for the former two - there is no other good treatment for the latter.

Peppy: I had a single artery (diagonal) DES procedure three years ago. How long are beta blockers used after this procedure? My nuclear was normal and my EF was 60. This metropolol seems to affect my tri's and HDL lipids.

Dr__Stephen_Ellis: Beta blockers are used to treat angina and hypertension—it depends on why you were placed on the drug. If you have neither—you may be able to stop this medication. Talk to your doctor - don't just stop on your own.

susie: should you only take enough statins to achieve a certain result or should you take all the statins you can tolerate?

Dr__Stephen_Ellis
: There are different target LDL levels depending on the nature of one's disease. Current guidelines are under revision and may lower the targets. If you atherosclerotic disease, current LDL target is less than 70 mg/dl.

susie: is there any truth to the possibility of caffeine poisoning and heart disease? Have either of you heard of this - where it may be an inflammatory thing? rather than anti-inflammatory?

Dr__Stephen_Ellis: Literature on caffeine is somewhat contradictory - different caffeine preparations seem to have different CAD risks. You probably do not have much to worry about if your coffee consumption is less than 3 cups per day or equivalent.

UneElle: How common is it to experience pain and tightness at the surgical site after undergoing quadruple bypass surgery? My husband (69 yrs. old) had CABG 2-1/2 yrs. ago at the Clinic and he still has pain/discomfort and tightness surrounding his surgical scar. It's definitely NOT internal chest pain (i.e. associated with heart attack, etc.) rather its pain and discomfort associated with the surgical area.

Dr__Joseph_Sabik: It is not uncommon for patients to have pain up to a year after surgery - 2 years is long and you should be evaluated for other causes of the pain. If the sternum did not heal well, there can be persistent discomfort. He should contact the surgeon who performed his surgery to be evaluated.

Cleveland_Clinic_Host
: We received a large amount of questions and Dr. Ellis and Dr. Sabik will try to get to as many as they can. If you have already submitted a question, it has been added to the queue.

elliott: I had a double bypass and have managed to get my cholesterol in the best range, my weight down with a BMI of 28, rigorous exercise, take all my heart medications and seem to be doing well after 1 year. I have a VERY demanding job which creates A LOT of stress. There are also some personal stressors (illness of family member, other typical worries about family). Please tell me HOW BIG OF A ROLE DOES STRESS PLAY IN HEART DISEASE? I know that as doctors you know what I mean by a stressful job. It's hard to control certain things about earning a living. I have made modifications, but things are always stressful. Can stress REALLY contribute to heart disease - and please explain how it does. Thank you.

Dr__Stephen_Ellis: Stress results in blood pressure and release of hormones that have an inflammatory response that leads to coronary disease. It is difficult to quantify that. Stress by itself does not cause coronary disease but it contributes to it. I would suggest you see someone to help you with this risk factor. At Cleveland Clinic, Dr. Pozuelo sees patients for stress management for patients with coronary disease.

rbaldassari: I am 62 year old male; heart attack about 2 years ago; went into cardiac arrest in hospital; have 2 stents in LAD artery; my Lp(a) is 60 and I take 1,500 mg of niasan. Is there a way to tell my chances of having a SCA again?

Dr__Stephen_Ellis: That is a hard question to answer without having more detail. You can optimize your chances by aggressively treating risk factors and if your ejection fraction is less than 35 percent, then consider an ICD.

If your LP(a) have not fully responded to your dose of niacin, it will be difficult to lower but it is only a "minor" risk factor relative to things such as diabetes, LDL cholesterol and smoking.

martinl: How long should a coronary artery disease patient remain on simvastatin?

Dr__Stephen_Ellis: based upon present data, if you have coronary artery disease, you should be on simvastatin forever to get your LDL cholesterol less than 70 mg/dl.

Additional risk factor management questions are answered below.


Microvascular Disease

jpersico: Please explain microvascular disease.

Dr__Joseph_Sabik: This is blockages in the non-major arteries. It is in the arteries below the resolution of catheterization but can be detected by coronary flow reserve determination (a catheterization based procedure) or often by a MRI stress test.

Cleveland_Clinic_Host
: We have approximately 15 minutes left in the chat. If you would like to submit a question, do so now. If you have additional questions after the chat, please use our contact link clevelandclinic.org/webcontact to submit your questions or go chat online with a heart and vascular nurse.


Percutaneous Valve Treatments

mike714: mikek714-my 90 year old mother has severe stenosis in her aorta valve and is not a candidate for surgery, how safe is the procedure with the catheter

Dr__Joseph_Sabik: If you are talking about percutaneous valve replacement, this can often be done with a hospital mortality of less than 10%—this is still an experimental treatment. We have a lot of information on our website about this if you want to learn more.


Coronary Artery Disease- Secondary Prevention of Risk Factors

Stanley Hazen, MD, PhD
Section Head,
Preventive Cardiology and
Rehabilitation, Department
of Cardiovascular Medicine
Miller Family Heart
& Vascular Institute

The following questions were asked during the chat but best answered by our preventive cardiology expert, Stanley Hazen MD, PhD, Section Head of Preventive Cardiology.

Susie: Are the doctors familier with myloperoxidase and how it contributes to CAD and if so, what therapies do you recommend to get the myloperoxidase levels in line.

Dr__Stephen_Ellis: This is a great question. Can you email heartcenter@ccf.org? Our expert Dr. Stan Hazen can answer this best—we will get back to you.

Dr. Stanley Hazen
: Myeloperoxidase (MPO) is a marker that is associated with atherosclerotic plaque burden and vulnerability. When elevated, it indicates an increased long term risk for major adverse complications of cardiovascular disease including heart attack, stroke, need for revascularization, development of heart failure and death. Because MPO testing is relatively new, there are no national guidelines on how to treat an elevated MPO level yet. We frankly don’t chase after the MPO level, but just move the patient to a higher risk category and treat more globally aggressively on all preventive fronts when we see an elevated MPO. A similar strategy is done with elevated CRP.

Thus, when an elevated MPO level is seen we recommend more globally aggressive overall preventive efforts, including closer attention to reaching LDL (bad) cholesterol goals (including sometimes lowering goals to more strict levels like < 70-80 range if feasible), closer attention to blood pressure control, glucose / diabetes control, and weight reduction and exercise program. Because MPO is associated with increased risk of thrombotic event like MI, low dose aspirin (81mg) if there is no contraindication, is also suggested. As for lowering the MPO level itself – there are only a few studies that have looked at that. In general, statin therapy has been shown to lower MPO levels. In addition, there are a few studies that have shown a reduction in MPO level with niacin (intermediate acting form Niaspan was use). There are also some reports of reduction in MPO levels in diabetics treated with piaglitozone (Actos), a diabetes drug.

Peppy: I was just told I have 50% blockage in both my carotids. Devastating news. They're going to monitor. How can I keep this plaque "calm" and even reduce it? I follow the Ornish diet-three years now.

Dr. Stanley Hazen: Blockage in the carotid arteries increases the risk for stroke and should be followed over time (annually), since if it progresses to >80% intervention may be warranted. Carotid stenosis is also considered a “coronary artery risk equivalent”—that means—it is equivalent to having a history of known coronary artery disease or prior heart attack history, in terms of future cardiovascular risks.

Statin therapy and aiming for aggressive LDL goals (< 70) is recommended. This can be a very effective anti-stroke intervention, and can help to retard progression, and even promote slow regression of atherosclerotic plaque buildup. Adherence to blood pressure goals, and platelet prophylaxis with low dose aspirin therapy (if not contraindicated) are also warranted in someone with carotid plaque. For selection of anti-hypertensive therapy type (if one is needed), we often try and use an ACE inhibitor or ARB (angiotensin receptor blocking agent) as these have data to support an anti-atherosclerosis and anti-inflammatory/anti-oxidant effect on the artery wall.

As for diet type—just focusing on eating a healthy diet low in fat and carbohydrate (simple sugars) is reasonable.

Peppy: So much confusion on a good heart diet. Ornish, Esselstyn, Med, low carb, etc! Vegan or high protein? Where is the research for best outcome for heart patients?

Dr. Stanley Hazen: There is no comparative outcome trial data with respect to cardiovascular risk reduction and the diets you are asking. I personally think the “best” diet is one that isn’t a “diet” but a something that the individual sees as something they can adopt as a life long change and maintain, and are comfortable with. It is tailored to the individual. A “prudent heart healthy” diet. Something low in fat and limits the proportions of carbohydrates/sugars (the white stuff—pasta, potatoes, bread).

Peppy: I have a Taxus DES in the diagonal. Three years old. What can I do to keep this artery/stent functioning forever? Statins give me migraines except for Crestor 5mgs.

Dr. Stanley Hazen: Bringing LDLc down to a goal of <70 helps to retard progression of atherosclerosis. If you can not tolerate higher doses of statins, and Crestor 5mg (which still should be pretty effective at LDL lowering) doesn’t get you to goal, then you might want to consider addition of alternative lipid lowering approaches (like niacin, and/or plant starols,etc) to help to reach goal.

Plant sterols called stanols are cholesterol analogs that help lower cholesterol by blocking its absorption from the diet.These are found in margarine spreads like Benecol, Smart Balance, and Take Control.For ease of use you may consider using a sterol supplement like Benecol Smart Chews, 1-2 chews twice daily (www.benecol.com), Cholest-off capsules, 4 grams per day, or Imu-Stat, mix 1/4 teaspoon with 8 ounces water or juice daily.Imu-stat may be purchased on the internet at the website: www.saponins.com.It costs approximately $30 for a 3 month supply.You may also consider trying Minute Maid Premium Heart Wise orange juice that contains plant sterols.You may also take Centrum Cardio Multivitamin.

Peppy: Crestor 5 mgs. has raised my blood glucose readings 20 points! I was fasting in the 70's and 80's and started Crestor 5mgs and went to 100! Only statin I can tolerate. What to do?

Dr. Stanley Hazen: Continue with the Crestor. Fasting glucose bounces around. I do not believe the change is attributable to the Crestor, but rather, part of biological variability (and what you ate the day before). Hemoglobin A1C level is a more stable and integrated index of overall glycemic control over the preceeding 3 month period (the life of the red blood cell). That is the best index of overall glucose/diabetes control.

Merrie: Some low carb diets say high glycemic carbs cause heart disease and that fat itself does not. What is your diet relative to carbs and fat and heart disease?

Dr. Stanley Hazen: High glycemic carbs like sugar are increase risk for subjects with diabetes and prediabetes for progression of the diabetes. It is not clear if they by themselves cause heart disease, though the presence of diabetes clearly leads to increased heart disease.

We recommend a low fat diet. Limit your intake of foods high in saturated fat and transfat. Omega 3 fatty acids, monounsaturated fats, and polyunsaturated fats are healthy and should be incorporated into your diet. These include oils like olive oil, canola oil, as well as foods like avocados, walnuts, almonds, and ocean fish.

Try and limit simple sugars and refined foods from your diet. Cut out soda, juice and juice drinks, alcohol, candy, table sugar and any other source of refined sugar. In addition, you may reduce your intake of refined starches like white rice, processed cereals, white bread, crackers, pretzels, white potatoes, regular pasta, and snacks. Consider switching to unrefined foods such as whole grain pasta, brown rice, whole grain cereals and breads, dried beans, lentils, and split peas. These foods are good sources of dietary fiber, which help to reduce how quickly sugar from foods is sent to the bloodstream. This may also help with weight loss, and lowering triglycerides to a goal of below 150.

As a rule, we also recommend subjects consider trying to increase your intake of dietary fiber to 20-25 grams per day using soluble fiber sources such as whole grains, legumes, whole fruits and vegetables. You may also wish to try adding 20-25 grams of soy protein per day to your diet as an alternative protein source that is low in fat. This could include tofu, soy milk, soy burgers, soy nut butter, etc.

Peppy: This is a wonderful feature and service. Thank you. Because of this I am considering making an appointment in the summer for preventative heart care at Cleveland, Ohio clinic.

Dr. Stanley Hazen: Happy to see you.

jpersico: How does one ameliorate a high "lipoprotein a " number (170).

Dr. Stanley Hazen: LP(a) does not change easily with interventions – it is highly genetically linked. It is a known risk marker for heart disease.

We have shown in large studies (n>4000 subjects) of the subjects seen in preventive cardiology clinic at CCF, that those who achieve LDL <70 have no increase in attributable mortality risk from the elevated LPa. For this reason, when a high LPa is seen, we push for aggressive lipid lowering therapy with a goal LDL (bad) cholesterol of < 70. Also, if not contraindicated, we also recommend low dose aspirin (81 mg) in subjects with high LPa since this marker is associated with increased thrombotic risk. We also push for more globally aggressive overall preventive risk reduction efforts.

Peppy: Because I'm on the Ornish diet they keep telling me HDL's will be low and that is ok. Is it?

Dr. Stanley Hazen: If you enjoy and tolerate the Ornish diet, it is a perfectly fine diet to use. Some folks find it somewhat stringent/harsh.

As outline in responses above, there is no real data (looking at MI, stroke and death outcomes) of nutrition trials in subjects with heart disease. The “best” diet is one you can follow and still enjoy life, and that improves your overall health. Aim for a low fat, low cholesterol diet that limits the simple carbs. A balanced diet that is full of fruits and vegetables as recommended by the AHA is what we recommend.

Puzzled: when on amiodarone I seem to be ok but when they took me off it the afib returned what are long term problems and/or alternatives. I have an implanted defib.

Dr. Stanley Hazen: AFib can sometimes recur. You should meet with your physician to discuss treatment options.

Merrie:in your practice, does high ldl and low hdl really correlate highly with heart attack episodes

Dr. Stanley Hazen:Yes.In every ethnicity and race it does.

jpersico:With high numbers for genetic markers for atherosclerosis, is there anything that can be done to stop the progression or do I just wait for the next heart attack? I currently take plavix, aspirin, crestor, metoprolol and fish oil.

Dr. Stanley Hazen: We all can’t change our genes. But we can minimize environmental exposures, and aggressively treat risk factors, to mitigate risk.

A globally aggressive preventive risk reduction program that focuses on lipids, blood pressure, smoking, diet, weight, exercise, diabetes, chronic inflammation, platelet/thrombosis, can help bring about substantial collective additive risk reduction—often halting progression, and even promoting regression of disease. It sounds like you are already on many appropriate medications. We recommend you speak to your Dr or see a Preventive Cardiology specialist to see if your risks are optimally being reduced and things like lipids, BP, etc are optimally treated to goal.

Grandmaster: Does Vitamin K and Pomegrante slow plaque buildup in coronary arteries

Dr. Stanley Hazen:Unknown. There are no randomized trials. I do not recommend taking Vit K for this reason, or taking Pomegranate extract. If you like the fruit—by all means eat a pomegranate a day. I do when they are in season and available! But that is because I like them, and they take 30+ minutes to get all the seeds out first, before eating with a spoon—so it slows me down!

Seriously—getting our nutrients from the original fruits and vegetables, not supplements, is strongly recommended. The supplements have little oversight in terms of monitoring, and even less studies to support claims often that are made with them.

Grandmaster: Can coronary artery disease be reversed?

Dr. Stanley Hazen: Yes.Studies have shown that lowering LDL to low levels (< 70) can help not only retard progression, but in some folks, promote regression. The lower the LDL (most important), and the higher the HDL, the more regression seen. You may ask how low is too low for LDL?<25mg/dL is what was used as the safety cutoff for the many recent trials looking at low LDL levels. We have many patients with LDLs in the 30s and 40s doing very well without side effects. We encourage getting the LDL down to this level, if possible, especially in subjects who keep having progressive disease despite having LDL < 100 on statin therapy. This is especially true when LPa is very high—a phenotype often seen (recurrent progressive disease with LDL < 100 on therapy and concomitant LPa elevation). In that patient we drive the LDL down as much as possible without causing side effects.

rbaldassari:how does Lp(a) affect CAD

Dr. Stanley Hazen: LPa is a protein that both enhances atherosclerosis (buildup of plaque in artery walls) and is prothormbotic (increases risk of intracoronary clot—what causes a heart attack).

Reviewed: 01/11


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