Wednesday, December 15, 2010 - Noon
Steven Nissen, MD
Chairman, Department of Cardiology Cleveland Clinic Miller Family Heart and Vascular Institute
Back from the American Heart Association (AHA) Scientific Sessions 2010, Dr. Steven Nissen, Chairman of the Department of Cardiovascular Medicine, will be answering your questions about the latest treatments and diagnostic tests for cardiovascular disease and what is on the horizon.
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Cleveland_Clinic_Host: Welcome to our "After the 2010 AHA Scientific Sessions" online health chat with Steven Nissen, MD. He will be answering a variety of questions on the topic. We are very excited to have him here today! Thank you for joining us Dr. Nissen, let's begin with the questions
Dr__Steven_Nissen: Thank you for having me today.
Coronary Artery Disease
joel: I had a stent in LAD 6 months ago. had 3 blockages - 1 in LAD, 1 in ramus, 1 in diagonal. 6 months later, on aggressive drug therapy, disease progressed to 2 95% blockages and 1 80% blockage below stent. 2 new blockages in circumflex maginal obtuse. had triple bypass. still on aggressive drug therapy, exercise, diet. I am 57 yo male, 190 lbs., 5' 8". how do I keep the disease from progressing below the bypasses? I’m doing everything I can. why did the disease progress so aggressively despite 40 mg. Lipitor, hypertension meds, etc.? what can I do to stop it from plugging up the bypasses or developing beyond the bypasses? also, I never had a heart attack and LVEF is 65%
Dr__Steven_Nissen: First of all I am pleased you are doing everything possible. Sometimes coronary disease will advance in these types of rapid fashion. It is not unusual for the disease to "settle down" with good medical therapy. I am assuming that your good cholesterol levels (HDL), bad cholesterol (LDL) and blood pressure are very well controlled.
There are also some less commonly measured risk factors for CAD that should be measured for patients like you. These include other types of lipids such as Lp(a) which is an important risk factor not routinely measured. You may want to consult with an expert in prevention of disease so that these risk factors can be assessed. In the meantime, don't lose your focus on doing the right things and continue to exercise and take your medications as recommended. Hopefully your disease will quiet.
Coronary Artery Disease with no apparent Treatment Options: Advanced Ischemic Heart Disease
cyndichupp: My father had 4 bypasses 15 years ago and has recently gone through a variety of options to help his blood flow. He had stent put in a couple of years ago and has not been told there is nothing else they can do. His file was sent to Cleveland for the genetic research but he was not eligible. Is there anything now, or coming up, that may help? He has never had a heart attack and was very healthy. This seems to be a genetic thing.
Dr__Steven_Nissen: We frequently see patients who believe there are no remaining options. Recently we started a program for such patients who have chest pain that has been unsuccessfully treated using most conventional approaches.
If your father would like, we can do a consultation using online consultation process in which one of our cardiologists would review his history, laboratory studies, and heart catheterization studies to determine if there are new options available to relieve his symptoms. In many cases, we can help but the first step is to review all the information.
chris66: I have end stage CAD. My lad is diffused and small. I was told there is nothing that can be done. Is there new treatment on the horizon for people like me?
Dr__Steven_Nissen: We have a Center for treatment of patients with advanced coronary disease that has a variety of options available for patients like you. It is always important to aggressively treat the risk factors that drive the development of blockages no matter what the stage of the disease. I hope your cholesterol levels and BP are being well controlled. Our specialists for patients with advanced coronary disease would be happy to see you in person or via electronic consultation if we can be of assistance in helping you understand your options.
Coronary Artery Treatment: Stent, Bypass Surgery
BillH: after reading an article in the NY Times about unneeded stenting I would like to know his/their criteria for stenting. I should also add that I recently had two stents placed for blockage. I took the minimum amount of medicine so I could be coherent and see any issues and discuss them with the doctor "rationally." The pictures of blockage and a cessation of symptoms seemed to suggest they were required. Additional question about follow up medicine regimens; other than Plavix and aspirin, what do you consider normal and why. Thank you. Bill
Dr__Steven_Nissen: Stenting is most useful in 2 situations:
- Patients who have had a heart attack within the previous 2 hours should go directly for heart catheterization and if a blocked artery is found, a stent should be placed.
- The indications for patients with stable chest pain syndromes are less clear. Recent research has shown that for people who have occasional or even moderate chest pain with exertion that medical therapy (taking drugs) results in long term outcomes similar to those achieved with placement of a stent. Therefore many cardiologists try medical therapy (drugs) first and reserve stenting for those patients whose symptoms can not be relived with medications or who do not tolerate the meds.
Very specifically, research shows that for people with stable chronic chest pain syndromes stenting does not reduce the risk of heart attack or death. Therefore, stenting should be used primarily to relieve unacceptable symptoms that interfere with the patient’s lifestyle.
Peppy: Have the guidelines for Plavix duration after DES changed? Are the older stents requiring longer Plavix duration? Maybe even lifelong duration? Is aspirin being dropped by some cardiologists with the new antiplatelet agents?
Dr__Steven_Nissen: We currently recommend 12 months of aspirin and clopedigrel (plavix) for patients following a drug eluting stent (DES), however the result of the stent some cardiologists may treat patients for longer. It does appear that some of the newer DES are less likely to develop a clot and may need less duration of treatment, but the guidelines have not been changed and I would strongly recommend most patients receive 12 months of treatment with aspirin and plavix.
In some cases, if a patient has life threatening bleeding stopping the plavix may be necessary before 12 months. In virtually all cases, whether the stent is new or old, the recommendation for aspirin is to take this drug forever. It is important to know that the 81 mg dose of aspirin (baby aspirin) appears to be just as effective as larger doses and safer.
Annabelle: I have diabetes being treated with pills and diet - I recently had a stress test and going in for a cath next week. I read an article about stent vs. bypass surgery in people who are diabetic. I have a feeling that if I need a stent during the cath, my doctor will put one in, but should I talk to him about this before the cath. What do you think?
Dr__Steven_Nissen: It is always a good idea to talk to your doctor about possible procedures. I assume that you have chest pain with exertion. Neither stenting nor bypass surgery are usually recommended for patients unless they have symptoms.
cyndichupp: Doctors can use pig hearts to replace an ailing human heart, but is there something to use to replace arteries? An alternate to bypass if the person's own veins cannot be used or the arteries are too blocked or damaged?
Dr__Steven_Nissen: Yes - there are alternatives to using veins for bypass operations. Patients are commonly referred to Cleveland Clinic for bypass surgery in situations where their veins cannot be used for bypasses. Our surgeons sometimes use the internal mammary artery inside the chest, the radial artery in the arm, or even one of the stomach arteries as a substitute bypass. The results of this surgery are similar to conventional surgery.
clarence: I have chest pain resulting from endothelial dysfunction resulting in spasms to my LAD in which I have three stents. There is also a pinching of a small branch artery off the LAD, too small for a stent, which may be causing pain. My cardiologist has suggested surgically closing off the small artery to possibly stopping the pain. Is this a procedure which is commonly done and to whom would I go to have this procedure?
Dr__Steven_Nissen: We almost never perform this procedure. There is a syndrome that sometimes causes chest pain from endothelial dysfunction. Such patients appear to have abnormal blood flow in the very tiny arteries supplying the heart muscle that cannot be stented. Chest pain due to coronary spasm is readily treated with medications and should not be the cause of ongoing pain. We would be happy to have one of our interventional cardiologists review your catheterization images and your medical history to determine what the best strategy should be. Surgically closing off the small artery would be an absolutely last resort.
CharChar: Is there any new treatment ,drugs, findings etc. for low ejection fraction. Viral infection ?? left me with EF of 20 and absolutely no change after a yr. of meds from the start . Got ICD in April -didn’t do well and PVC's are couplets. 57 and in good health otherwise. Am I just to wait till I become a candidate for heart transplant, not that there are allot of those around??
Dr__Steven_Nissen: Your problem is a common one in which the heart muscle has been damaged by a viral infection or other causes. Fortunately with very good medical management many patients continue to do well for years without deterioration in the pumping function of the heart (ejection fraction - EF).
We have seen patients whose EF has remained stable for 20 years or more. there are not any breakthrough medications on the horizon but you should know that the standard medications are very effective. These include drugs such as ACE inhibitors (such as lisinopril) and beta blockers such as carvedilol (coreg). It is very important that you be on the maximum tolerated doses of these medications to achieve maximum benefit. Some patients will also benefit from addition of other drugs from this standard regimen. We generally recommend patients with advanced heart failure see a specialist in heart failure to make certain that the treatment is the best currently available.
CharChar: Sorry, can't figure out how medication that did nothing to repair damaged heart, maybe already scarred, is now the only cure. I would assume the little bit left is the same old healthy heart I always had. I know it can't cont. to pump oxygen & blood forever because I'm working with 20% EF however I don't want to ,nor know how to "be sick." I do everything I have always done the only thing is I can't climb "mountains" so I don't It's just when I show up at cardiac rehab "m put on a monitor and have to stop "running" 3.2 mphr because heart rate goes up?
Dr__Steven_Nissen: In most patients the medications are successful in preventing deterioration in heart function. Your EF may not increase but you can live a very long time with the current level of EF and the absence of severe symptoms. Your exercise program is very important in maintaining your high level of functioning.
HVNurse: Dr. Nissen, a patient called in about your webchat. Her question pertained to a Simpson reading regarding EF. She said her EF last year was 40-45%. This year she was told: EF 40 26 by Simpson. She is asking what the Simpson portion is.
Dr__Steven_Nissen: The Simpson rule is a method for calculating the ejection fraction that is often used with a variety of imaging methods. It is important to understand that EF is a relatively crude method of the function of the heart and can vary from day to day or year to year.
Dr__Steven_Nissen: It's important not to focus too much attention on small differences in EF from one study to another. If you are feeling well and you have a change in the EF, this may simply be the variability of the measurement method.
mike714: I have a EF of 37-42 and taking coreg 12 +mg in the am and 9+ in the pm is there a maximum amount that can be taken or how do I know how much to increase it to?
Dr__Steven_Nissen: We try to get patients on a maximum dose of carvedilol (coreg) because this drug when given in full doses has been shown to improve survival in patients with a reduced EF. A full dose is 25 mg twice a day although most patients are unable to take the highest doses.
The typical approach is to gradually raise the dose, stopping the increases if the heart rate gets to be too low, or the blood pressure is reduced to the point where the patient has symptoms. You should be communicating to your doctor about this.
JJAltoona: Hello Dr. Nissen. My wife had surgery performed by Dr. Cosgrove 13 years ago to repair an MVP (4+). She has been doing well so our last visit to CCF was in 2006. She has been receiving yearly Echocardiograms at her local Cardiologist. We just got the reports on this years Echo. and other tests and she has been diagnosed with Diastolic Dysfunction with Pulmonary Hypertension (Grade II). We are going to get a second opinion in Pittsburgh with the possibility of returning to CCF in the event that he agrees with the initial Dx. I know that DD with PH is not curable, but what is the latest protocol as far as treating the condition? At this point in time, she is mostly asymptomatic with her only complaint being occasional chest pain at night. Thank you.
Dr__Steven_Nissen: It sounds like she has done very well following her MV repair. The prognosis will depend on the severity of the pulmonary hypertension and diastolic dysfunction. Many women particularly as they age seem to develop diastolic dysfunction that may or may not be related to her previous MV disease. Interpretation of the echo in these settings is not a simple matter. We have several specialists here who treat patients with PH and DD who would be pleased to consult and may have recommendations for treatment that may be helpful.
Lipids – Cholesterol, LDL, HDL
FORQUER: IS RAISING HDL CONSIDER THE MAJOR MODIFIBALE RISK FACTOR
Dr__Steven_Nissen: No - the most modifiable risk factors are quitting smoking, treating LDL cholesterol and reducing BP. HDL is considered a secondary target.
Lipid Lowering Medications
virginiajim: I heard a netcast several months back in which Dr Nissen gave a talk where he noted that during trials involving statins one of the findings was that large doses of rosuvastatin reverses atherosclerotic plaques. This indicates to me that atherosclerosis itself might be reversed using this drug. I was surprised to hear nothing more about what appears to be a remarkable finding. What is the status of this work? Thanks JimVA
Dr__Steven_Nissen: We performed a study published in 2006 that showed reversal of the plaque buildup in the coronary arteries in patients treated with the top dose of rosuvastatin, which is also known by Crestor. The principle underlying this finding was that maximal lowering of the bad cholesterol (LDL) is associated with a dramatic slowing or reversal of the progression of coronary disease. As a result of this study and many others, new guidelines will be issued in 2011 from federal authorities who make recommendations for treatment of patients with CAD. We fully expect these guidelines to recommend more intensive lowering of LDL cholesterol for patients with existing CAD.
mike714: mikek does Lipitor 80mg do the same as Crestor?
Dr__Steven_Nissen: The two most potent statins are Lipitor and Crestor. There are differences however. The maximum dose of Lipitor is 80 mg and the maximum dose of Crestor is 40 mg. The 40 mg dose of Crestor will lower bad cholesterol (LDL) by slightly more than the top dose of Lipitor. Crestor also appears to raise HDL somewhat more than Lipitor. Both drugs are considered very safe and highly effective.
Peppy: How is the new statin-like drug that was in the news recently that will raise HDL significantly progressing in trials?
Dr__Steven_Nissen: This new drug is actually not a statin. It is a completely new class of medications that can substantially raise HDL cholesterol. In the recent study, the drug increased HDL by more than 100%, however we still don't know whether this form of HDL cholesterol is actually beneficial. Therefore, a 25000 patient study is now underway and should have results in about 5 years.
Kallar: Can you talk more about anacetrapib - the study showed promising results. How long from this study does a drug like this get used in the public? How does this drug compare with your studies of Apo A1 Milano trials
Dr__Steven_Nissen: Yes - this drug is the drug I was discussing in the previous comment. Anacetrapib is one of several drugs in this class that are currently under development. One of these drugs will complete its final stage of clinical trials in 2 - 3 years.
Carotid Artery Disease
Peppy: Were there any studies comparing endarterectomy, stenting, or medical therapy in the treatment of asymptomatic carotid stenosis? I was just diagnosed with 50% blockage in both carotids and I am devastated. So far it is asymptomatic. I had a friend have a bleeding stroke after a stent procedure for this and she is not the same person.
Dr__Steven_Nissen: This is a very controversial area of medicine. Virtually all authorities DO NOT recommend any of these procedures for individuals who have no symptoms and who have blockages in the range that you describe.
We do have very effective medical treatments for patients with carotid disease. I cannot give you specific recommendations without knowing more about your situation, but therapies include treatment of risk factors for developing plaque such as cholesterol and BP which can slow any development of plaque in the carotid arteries and we sometimes administer blood thinners such as aspirin or clopidogrel (brand - Plavix) in some patients who are at high risk for developing a stroke. You should know that a 50% blockage is not considered severe and generally does not require treatment with invasive procedures.
Medications: Plavix, Aspirin, and other Medications
Heath: What is the status of Exanta approval in the USA?
Dr__Steven_Nissen: Exanta is a new type of blood thinner that was rejected for approval by the FDA several years ago. It has been withdrawn from the market and is not available anywhere in the world. A related drug known as pradaxa was recently approved by the FDA for prevention of stroke in patients with atrial fibrillation and is available in the US and elsewhere. It is used as a blood thinner as an alternative to warfarin (coumadin) and has some advantages. The main disadvantage is a very high cost - about 8 dollars per day.
joel: One other VERY IMPORTANT Question for you - the expert - do you believe that people like me who had triple bypass should be taking plavix as well as aspirin? my doctor is keeping me on it but I don't know if he will discontinue it - what is the current thinking on this and what do any clinical trials show? THANK YOU!
Dr__Steven_Nissen: There are no clinical trials demonstrating and advantage of routine use of plavix after bypass surgery although your doctor may have other reasons for prescribing this therapy so it is best to discuss this with him or her.
Diagnostic Testing for Coronary Artery disease
Molly_K: Dr. Nissen, I understand that you helped invent the ivus procedure - do they use that in clinical situations to diagnose heart disease or to see if a treatment is working?
Dr__Steven_Nissen: Sometimes. It is a powerful research tool but it is also used every day in heart catheterization labs to make a diagnosis in situations in which the coronary angiogram is difficult to interpret.
Diet and Coronary Artery Disease
Peppy: Are there any studies showing dietary plans that will reverse or stop the progression of atherosclerosis? Can the Esselstyn diet reverse atherosclerosis? Are there studies to back this up? Is a plant based diet best?
Dr__Steven_Nissen: Most researchers do not consider ultra low fat diets to be healthy. We have learned that fat itself is not the problem - it is the type of fat that we eat. Saturated fat from butter and meat is harmful and certain fats known as mono-unsaturated fats present in canola and olive oil are healthy. Hydrogenated fats, commonly found in margarines and also known as trans fats are harmful. There are no well designed studies showing that any particular diet can reverse heart disease. Most of these claims are not based on high quality research.
Stem Cell Research
DanCL: Did they talk about stem cell trials that will help patients who had damage to their hearts from heart attacks. I understand there are trials going on - but what about results so far?
Dr__Steven_Nissen: The stem cell research is continuing but at a relatively slow pace. So far studies can be described as somewhat promising, but they do not clearly show that stem cells can reverse deterioration of heart muscle after a heart attack. Any clinical availability of stem cells is probably many years away.
Coronary Artery Disease and Alzheimers
Kevin_94547: Seems like many factors of heart disease is also linked to Alzheimers. My dad is 82 and has a history of coronary disease when he was 70. He had a couple angioplasties. Now he shows signs of dementia. I just figured it was a combination of aging and poor circulation 10 years ago. But maybe he should get checked for Alzheimers.
Dr__Steven_Nissen: There is a form of dementia that may be associated with Coronary heart disease. This is known as multi infarct dementia and appears to be caused by many small mini-strokes. It appears that the risk factors for having these small strokes are the same risk factors associated with blockages in the coronary arteries therefore it is not surprising that the same people can develop both disorders. It would be important for your father to consult with both a cardiologist and neurologist to see if there are mini strokes and to consider what preventive measures might be undertaken.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Nissen is now over. Thank you again Dr. Nissen for taking the time to answer our questions about the AHA Scientific Session.
Dr__Steven_Nissen: Thank you for having me today. Some terrific questions.
CharChar: Dr. Nissen, Thank you so much for your knowledge and words of encouragement.
joel: You just responded to my questions - thank you very much. This is Joel. Yes, my HDL and LDL are exactly where my doctor wants them. I don't remember the numbers right now but very very aggressive and they are perfect - everything on paper (labs) looks great, however, everything on paper looked great when the disease continued to progress! I’m really really scared. I did smoke for 27 years and quit 15 years ago. my diet is perfect and I exercise every day. I am doing everything. I need to take off at least 10 lbs. then, I’ve done everything. thank you very much.
mike714: mike714-thank you for your time
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