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Coronary Artery Disease (Drs. Nissen and Sabik 8/22/12)

Wednesday, August 22, 2012 - Noon

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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. Dr. Sabik and Dr. Nissen answer your questions.

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Cleveland_Clinic_Host: Today's Online Health Chat "Coronary Artery Disease" with Steven Nissen, MD, and Joseph Sabik, MD, will begin at noon (ET). Please submit your questions by typing in the box below and then click "Ask a question".

Welcome to our "Coronary Artery Disease" online health chat with Steven Nissen, MD, and Joseph Sabik, MD, They will be answering a variety of questions on this topic. We are very excited to have them here today!

Let's begin with the questions.


SteveJ: What would the possible reasons be why a cardiologist doing a catheterized coronary angiogram might not be able to locate a particular saphenous CABG graft to see if it was patent or occluded, while certain other grafts were "locatable" during the same exam?

Dr__Nissen: This does happen although it is not common. The grafts can be attached to the aorta in a variety of locations and sometimes a graft can be occluded right at the attachment site. When that happens there is no way to see that the graft is there.

Cleveland_Clinic_Host: Dr. Ellis was called into a case this afternoon, and Dr. Nissen has graciously joined us to help answer your questions. We thank him for his time and expertise.

joanne: I have had 3 stents put in my heart over the last 3 years, I recently started neurontin and have been having a racing heart sensation and a feeling of heaviness in my chest it goes away but could it be the neurontin causing this?

Dr__Nissen: This is not a typical side effect of neurontin. You should probably talk to your cardiologist about these symptoms.

metropetro: Greetings all. Dr. Elis, you were referred to me many years ago on my first cardiac "incident" by my Brother-in-Law, Dr. Gary Woods (NE-AMA). Working now with Dr. Hammer. I have a couple of questions. 1) Is Cholesterol cumilative in the body? 2) Have there been any studies relating those individuals who donate blood REGULARLY vs occurrence of CAD? 3) If there is a relationship to low(er) occurrence of CAD, are there therapies that use blood donations (e.g. niacin) that can benefit both pt and society by the donation? As you are probably already aware, those individuals who are on Plavix and Statins can not donate blood.

Dr__Nissen: 1. The answer is yes. The accumulation of cholesterol and plaque is related to the level of cholesterol in the blood and duration of elevation.
2. There is no relationship to blood donation and CAD.
3. I am not aware of the ability to donate blood on statins and blood donation and will get back to you on that one.

RWhite: Dr. Sabik, 1. How do you determine which valve to use for an aortic valve replacement, and what are the benefits of one kind over another? 2. And, how and when do you determine where to obtain the veins used in bypass grafts? Thank you very much.

Dr__Nissen: The aortic valve - important determinant is patients age. we have two types of valves - one is biologic which comes from animals and mechanical valves. The mechanical valve is the most durable however it requires taking blood thinners - coumadin.

The tissue valves are not as durable but do not require the blood thinner coumadin. 

Therefore in deciding what valve to use it is a comparison of the risk of tissue valve failure with the risk of being on the blood thinner coumadin. An older patient may do better on a tissue valve - or a young patient who does not want to be on coumadin. A mechanical valve may be better for a younger patient who is willing to take coumadin. It takes a discussion with you and your surgeon to decide.

Dr__Sabik: The veins we take are from the leg and it is the greater saphenous vein. We also use the internal mammary artery as a bypass graft because it has the greatest longevity.

Another vessel that can be used for CABG is the radial artery in the arm. It is best used in bypassing very tight or severely obstructed arteries.

quest2: What is the main cause of stenosis, such as calcification of the aortic valve. Does alcohol consumption contribute toits development?

Dr__Nissen: There are several types - in one calcification occurs with age (over age of 70). iN others they are born with an abnormal valve - they are born with 2 rather than 3 leafelets (they tend to become stenostic in their 50s or 60s)

Dr__Sabik: Severely congenitally abnormal valves can become calcified or stenotic much earlier.

sharla77: Can you talk about coronary artery dissection? How is it treated? Is surgery the answer?

Dr__Nissen: There are two types. Spontaneous dissection which are rare, are sometimes treated with stent or surgery.

Dr__Sabik: Surprisingly these sometimes occur during pregnancy.

Dr__Nissen: The other cause of dissection is an interventional procedure such as stenting or cath, in which the artery tears. This is often treated by putting in an additional stent but in some patients require an emergency surgery.

kathyl: I have been told that I have coronary artery disease but my arteries are too small to treat with a stent. Does that mean they are too small to treat with bypass surgery? I have chest pain occasionally with walking up stairs and take a nitro and it goes away. Do I just live with it?

Dr__Sabik: Not necessarily. You should have am experienced coronary surgeon review your information to determine if bypass surgery is an option. We would be happy to review your case. In many cases I perform surgery on patients such as yourself who were deemed inoperable due to small arteries.

george: is calcium in the heart the same as coronary artery disease?

Dr__Nissen: No. There has been alot of discussion using calcium scans used to detect CAD but not all patients with calcium actually have blockages in the artery.

On the other hand you can have a blockage and not reveal calcium in the artery.

Cleveland_Clinic_Host: Take this opportunity to get your questions answered now! To ask a question, type in the box below and then click 'Ask'

MikeN: 61yr old male. AMI July 2000. Carotid endarterectomy Sept. 2010. Avg. cholesterol last 5 years-LDL 40-HDL 76-TRIGLYCERIDES 41-TOTAL 125. BMI 24.5. Glucose 85. Highly physically fit. Carotid artery went from 60% to 80% blocked in one year. Taking beta blocker, ace inhibitor and statin. Given this history, and no symptoms, would you recommend any regular or special follow up testing?

Dr__Nissen: You should have a lipoprotein (a) checked since this can be elevated and cause carotid and coronary artery disease. You should also maintain a normal BP and I assume you do.

Hearty1_1: I have just been diagnosed with cardiac bridging in my LAD. I also have kinking during systole as well as a 40per cent blockage in LAD. I am a 56 yo, currently taking bystolic and triamterine/hctz. My cardiologist is telling me I am as likely to have an MI as not, and I'm not clear on this prognosis, treatment and risks. I want to know if I'm on right medication and if there is something more I should be aware of. I've had a nuclear stres and cardiac cath this past week.

Dr__Nissen: Coronary bridging usually does not cause a heart attack or symptoms. Although occasionally we have seen patients where it has caused problems. In very rare patients a patient will have a stent placed because they will have bridging with very clear cut evidence for decreased blood flow in the coronary artery.

frankG: Can you talk about the new biodegradable stents and how they are different than current stents? Are they better for some people?

Dr__Nissen: The jury is still out. They are not available in the US but are used in Europe. Preliminary results are promising.

ShirleyJ52: I had a stent placed in June of this year and since that time I have constant hives. I think I am allergic to the actual stent. What can I do for this? Can they remove the stent itself? Will the symptoms go away with time?

Dr__Nissen: You are probably not allergic to the stent but you may be allergic to the blood thinner you are taking. We have seen this type of reaction to the most commonly used blood thinner clopedigrel (plavix). If you are allergic to the blood thinner there are alternatives that work very well. please discuss with your doctor.

Shaina44: Are there any new studies coming out soon for actually dissolving fat or plaque in the arteries?

Dr__Nissen: We and others are working on drugs to raise the good cholesterol HDL - but we have not yet developed a reliable way to remove plaque from coronary arteries. There is some evidence that very large dose of statins designed to achieve a very low level of bad cholesterol (LDL) can remove a small amount of plaque in the coronary arteries.

Current claims that very low fat diets reverse coronary disease have not been substantiated scientifically

charlesK: I need to get dental work and had bypass surgery 2 weeks ago. I was suprised to be told to wait to have the dental work for 6 weeks. What are the guidelines for procedures after having heart surgery? Is that what you tell patients? Is it just dental work?

Dr__Sabik: Usually after CABG you do not have to wait to have dental work, however if you have a valve replacement it is best to wait 8 - 12 weeks for the valve to be covered with cells.

LukeB: My dad needs a cath and he only has one kidney. They said the dye is harmful to the kidneys and I am nervous he will have complications. What do you do at Cleveland Clinic with patients?

Dr__Nissen: We do the cath using equipment that allows us to look at two views of the heart simultaneously and we use the minimal amount of dye. Whenn done carefully, catheterization in a patient with one kidney can be done safely.

Cleveland_Clinic_Host: Take this opportunity to get your questions answered now! To ask a question, type in the box below and then click 'Ask'

KenCA82: Deciding where to go for bypass surgery. I am wondering what types of minimally invasive options there are for bypass surgery. I have heard differing opinions and options depending on the place and wonder the differences and benefits - the side, between the ribs, robotic, etc.

Dr__Sabik: The type of incision you have for your cABG is dependent on what vessels are going to be used for the bypass grafts and where the arteries are that are blocked on your heart. Patients with limited coronary artery disease can be treated minimally invasively even through a small chest incision or with the robot. Your operation should be designed to best take care of your problem.

Dr__Nissen: The type of incision is less important than the ability to completely bypass all the arteries that need to be taken care of.

NEWYORKER: I have 2 RCA stents from 9/09 and 12/09 both in the same place, since then I have artery spasms and palpitations, I have side effects from all my redicines, now 3 years later I am having very bad anxiety. I am on plavix 3X a week, lovastatin, on hold due to muscle pain, isosdorbibide 30 mg AM/NOON/PM, spironolactone once a day 50 mg, verapamil 20 mg (giving me side effects) I just had to come off 5mg of Buspar because of the side effects. Vitamin/Vitamin D/CoQ10. I continue to have symptoms which 3 doctors say is anxiety related. Have contacted a psychiatrist for other anti-anxiety medicine. I do not know what to do any more, Thanks for your help.

Dr__Nissen: It is very difficult to give you advice without knowing more about your case. But, we can arrange for an electronic consult with one of our preventive cardiologists who specialize in this type of problem.

sunfish81: Is it possible to have a cath through the arm? Why would you want it in the leg if you can have it in the arm? My doctor is scheduling a cath for me and I am hoping they can do it in the arm.

Dr__Nissen: There are advantages and disadvantages to both approaches.
The leg is a standard approach and can be done at almost any center. A smaller number of physicians will do cath through the wrist which is quite feasible but in some patients who have cath through the wrist the artery can become occluded which is not a desirable outcome.

Irish: I recently read an article by Dr. Dwight Lundell , Chief of Surgery at Banner Heart Hospital in Mesa, AZ. In his article he tried to convey the message that cholesterol is not a strong an indication of heart disease. He claims inflammation is the number one cause stating that cholesterol travels freely through our blood and only attaches to the inflammation in our arteries. He states because of this a low saturated fat diet, statins, and other cholesterol lowering methods are inaccurate. What is your opinion on this theory?

Dr__Nissen: I disagree. There is overwhelming evidence of the importance of cholesterol in the genesis of CAD. There is some evidence for the role of inflammation but it is less certain and the primary target of therapy is still lowering cholesterol.

Hearty1: If you can speak about the risks assoicated with myocardial bridging with two kinks and a 40% blockage in LAD. Also what is prognosis and treatment

Dr__Nissen: Ordinarily a myocardial bridge is not a problem requiring treatment and usually a 40% blockage in the LAD does not warrant treatment. However there are exceptions and we would need to see your stress test and angiogram to make a complet assessment.

STL63011: What is the maximum number of stents that can be inserted in a patient?

Dr__Nissen: There is no limit although we usually recommend alternative revascularization strategies such as bypass surgery when extensive is necessary.

Hudson: What is the expected longevity of a triple bypass procedure?

Dr__Sabik: The longevity is dependant on multiple factors including the vessels used to perform the grafts as well as the patietns risk factors such as family history, smoking, cholesterol level.

A bypass operation is most effective when multiple arterial grafts are used to do the bypass grafting. And - agressive risk factor reduction occurs after surgery - such as cessation of smoking, cholesterol lowering and an active lifestyle.

Studies from our institution have shown that by 10 years after surgery one in 10 patients will need an additional intervention such as stenting or repeat bypass surgery and by 20 years 4 out of 10 will need an additional procedure.

cavaneng11: I have been diagnosed, by Mayo clinic, with endothial dysfunction causing LAD spasms and chest pain. I am taking several drugs in an attempt to lessen the pain. Ranexa, imdur are the major ones.; L Arginiine 12g per day, Norvasc, Tylenol for pain. No solutions to the problem seem to be available. Do you have any suggestions for treatment or medications?

Dr__Nissen: You are receiving the usual therapy for coronary spasm.

Irish: What is your opinion on prescribing a low statin (10 mg) as a preventive measure against CAD?

Dr__Nissen: A statin should be given to the right patients. We would need to know your risk factors and cholesterol level. We do not recommend statins for everyone.

Cleveland_Clinic_Host: We have approximately 15 minutes left in the chat. We will continue to answer as many questions as possible. If you have additional questions after the chat, please use our contact link clevelandclinic.org/webcontact to submit your questions.

JRae0802: What might be the cause of increasing fatigue while excercising? I have 2 stents and have been in Cardiac rehab, but I am not getting stronger, I am experiencing more fatigue...

Dr__Nissen: There are many potential causes for fatigue, anemia, valvular heart disease, depression and thyroid disease. You should see your doctor for evaluation for other causes of fatigue.

Irish: How common is no calcium in artery found and actual CAD exists?

Dr__Nissen: It is common in the early development of CAD and there are patients who can actually have a heart attack without calcium in the artery.

carduini: can patients with stents undergo MRI's?

Dr__Sabik: Yes.

steelguy: I have heard that statin use can lead to diabetes. Any truth to this?

Dr__Nissen: There is a very slight increase in the risk of diabetes with statins but all of the evidence demonstrates that the benefits of statins in patients who develop diabetes are just as great as in those who don't develop diabetes.

zettlr: What are the recommendations for exercise for an individual post MI/Stent and post cardiac rehab program?

Dr__Nissen: The more exercise - the lower the risk of recurrence of CAD, but the exact exercise prescription for an individual patient is best discussed with your doctor.

steelguy: I know there are precautions going onto Ranexa. Are there similar precautions on discontinuing it now that angina seems to be under control? Of course will see my cardiologist before stopping.

Dr__Nissen: There are no special concerns about stopping this drug.

Hearty1: is taking bystolic enough for treatment of myocardial bridging?

Dr__Nissen: There are no drugs available for treatment of myocardial bridging.

Dagmar: when do you recomend getting your cholesterol partical size checked

Dr__Nissen: Never. The test does not produce any incremental benefit over a lipid panel and it is costly.

Irish_1: Normal cholesterol, Dad died at 50 of 75% LAD. Had 3D artery scan that revealed small amounts of soft plaque. 10 mg Statin?

Dr__Nissen: WE do not recommend CT scanning for early detection of CAD. The decision on whether to treat with a statin requires full kniowledge of your risk factors and your exact cholesterol levels. It would not be based on the results of a CT scan.

carduini: What are effective methods/equipment to monitor efficacy of cardiac pharmaceutical treatment and/or monitoring of cardiac functional improvemrnt after interventional surgery ?

Dr__Nissen: It depends on what drugs you want to monitor. With regards to the assessing the function of the heart, echocardiography is the most commonly used method.

Hearty1: can you speak to risks associated with aneurysmal septal defect (as a result of mvp)-also have myocardial briding and hageman factor 12 deficiency.

Dr__Sabik: We do not think there is a risk associated with having an atrial septal aneurysm.

Irish_1: Better preventitive diet for CAD Mediterranean or Vegan

Dr__Nissen: Mediterranean has the best evidence. A vegan diet is fine but avoid the ultra lower fat diet advocated by Dr. Esselystyn.

Irish_1: How high of a risk factor is arthritis and psioriasis?

Dr__Nissen: These are definite risk factors for CAD however the exact mechanism is not understood. Active rheumatoid arthritis or lupus approx doubles the risk of having CAD.

Hearty1: are there risks associated with right bundle branch block - Dr says wait for symptoms

Cleveland_Clinic_Host: We are getting ready to close for today. We will try to answer as many questions as possible in these last few minutes. If you have additional questions, please go to http://my.clevelandclinic.org/heart/chat_with_a_heart_nurse.aspx  to chat online with a Heart and Vascular nurse.

Dr__Nissen: There are no risks associated with right bundle branch block.

Cleveland_Clinic_Host: I'm sorry to say that our time is now over. Thank you again Drs. Nissen and Sabik for taking the time to answer our questions about coronary artery disease.

If you have additional questions, please go to http://my.clevelandclinic.org/heart/chat_with_a_heart_nurse.aspx  to chat online with a heart and vascular nurse.

Get the latest news and views from the specialists at the Miller Family Heart & Vascular Institute at Cleveland Clinic on our regularly updated blog! We explore current topics related to research, Cleveland Clinic physician perspectives on breaking news stories and offer an outlet for Cleveland Clinic heart and vascular patients to share their story with readers.  Visit clevelandclinic.org/TheBeatingEdge

Reviewed: 08/12

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