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Coronary Artery Disease (Drs. Ellis and Mick 7/31/13)

Wednesday, July 31, 2013 - Noon


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. Cardiologist Dr. Stephen Ellis and heart surgeon Dr. Stephanie Mick answer your questions.

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Coronary Artery Disease - General

skajj01: My husband, who just turned 70, saw his cardiologist and he said he has coronary atherosclerosis of native coronary artery. He put him on Atorvastatin Calcium 10 mg tab & Aspirin 81 mg. What does atherosclerosis of native coronary artery mean?

Stephen_Ellis,_MD: Atherosclerosis refers to plaque formation that can cause narrowing of a blood vessel. The term native coronary artery refers to the fact it is a vessel of his heart. (not a surgical bypass graft)

SarcoidLady: I have been diagnosed with a 100% blockage in the right coronary artery with no stents placed - have collateral arteries there. Also have the same situation in the left circumflex. Can you tell me if collateral arteries become permanent or will they also need future attention? This naturally gives me great concern. Am under the care of a good cardiologist and just had another nuclear stress test that showed very slight decline in function. Am 72 year old female.

Stephen_Ellis,_MD: Your situation is very complex - we know that collateral arteries can be present long term but are subject to the same disease processes that affect native coronary arteries. You and your cardiologist should pay very close attention to your symptoms and test results. You may want to seek a second opinion from an interventional cardiologist and/or a cardiac surgeon.

sofatax: Would hard heart muscle and diastolic (?) dysfunction fall under CAD?

Stephen_Ellis,_MD: They can be caused by CAD although there are many other causes such as high blood pressure.

Praego: I'm 70 and have had 2 major heart attacks and an EF of about 30 (up from 25). Should I expect to build muscle and strength?

Stephen_Ellis,_MD: Generally heart muscle function after a heart attack won’t increase much without treatment. If you haven’t had these yet, your doctors should consider a defibrillator, biV pacer and stress test.


nutzy: I did an angiography almost ten years ago before my mitral valve replacement and maze procedure. Because my Atrial fib. problems I take for rate control high doses of beta-blocker and calcium channel blockers. A dual chamber pacemaker was implanted. I hardly can manage with this medicines I have breathing problems and pain in my upper chest. I discussed with my doctor but he is not worrying about this. I can't say about me the same thing because I remember that my father died at age 58 (in 1971) after MI. I HAVE ALSO GERD problem. PLEASE, comment about chest pain, how to recognize its cardiac origin.

Stephen_Ellis,_MD: You should see a cardiologist for evaluation. It is always important to rule out heart causes first.

Stephanie Mick MD: Yes I agree with this – it is very important to have this formally evaluated by a cardiologist.

RickyM: I have had chest pain ever since heart surgery in 2006. I have pass every test that my heart doctor Has giving me. I have osteoarthritis could this cause the pain in my chest what kind of treatment or medicine can I do?

Stephen_Ellis,_MD: Chest pain should always be taken seriously especially with a history of coronary artery disease. If you have areas of tenderness, especially where the ribs connect to the breastbone, when you press on them your problem may well be due to arthritis. However, while there can be other causes of chest pain other than the heart, heart must be ruled out first. A second opinion is warranted to explore cardiac and non-cardiac causes of chest pain.

Stephanie Mick MD: Agreed.

kmo123: I am a 58 year old man, and have always been very athletic. 12 months ago, I had a heart attack and subsequently had CABGx3 and also had my ascending aorta replaced. 9 months ago, one of the bypass grafts closed off, and my doctor inserted a stent. I’ve been working very hard to stay healthy, including regular exercise and healthy (low fat, low sodium) eating. In the past couple of months, I’ve had periods of extreme exhaustion, accompanied by some chest pain and shortness of breath. This happens about 1-2 days a week, and on these days I can barely get out of bed, and I end up sleeping most of the day. I’ve had both stress echo and nuclear stress tests, but my doctor says that they haven’t shown anything that would cause this exhaustion, nor has a spirometer test. He's also ruled out sleep apnea. Is there anything you can suggest that might be causing my exhaustion, or any other tests that might help my doctors to figure out what’s causing this exhaustion?

Stephen_Ellis,_MD: The symptoms you are expressing (chest pain, shortness of breath, fatigue) are very concerning for worsening coronary disease. We recommend a second opinion with a doctor accustomed to treating complex cases like yours. We would be happy to see you here.

steelguy: I have heard the term "exercise angina" where angina occurs early in exercise but fades or disappears as the workout progresses. For me I get some arm pain but it will fade or stop about the time I work up a sweat. Please explain. (13 stents, med, diet, etc.) Thanks.

Stephen_Ellis,_MD: It sounds like you are referring to what we call “walk-through angina”. This often is caused by a total blockage to which there are collaterals. The collaterals “warm up or dilate” as you exercise. However, any angina that occurs with exercise is concerning and should be discussed with your doctor.

Microvascular Disease I'd like to know what can be done for "micro vascular coronary artery disease" patients besides taking pills like Ranexa. Are there any "future fixes" on the way like using a laser to clean out these tiny arteries?

Stephen_Ellis,_MD: Microvascular coronary disease is a special challenge. At present the mainstay of treatment is medications. EECP is often helpful. Laser treatment generally doesn’t work well. Consider seeing someone who specializes in microvascular coronary disease and chronic chest pain.


eatveggies: When clopidogrel is prescribed long-term, what are the benefits, and how long should a patient continue it? I'm a 67 yr. female. Acute MI 3 yrs.& 4 months ago resulted in emergency PCI with placement of two bare metal stents in my LAD. I was put on 75 mg. Plavix and 81 mg. aspirin daily to prevent another heart attack and revascularization of the stents. My side effects were easy bruising and development of GERD, so after the first year passed, the dosages were halved, and I now alternate the drugs daily - one day aspirin, the next day clopidogrel. (I don't bruise as easily and my stomach is a lot better.) My last ECG, nuclear stress test (treadmill), and lab results were all normal (I take 10mg Crestor daily): total cholesterol 129, HDL 50, LDL 70, triglycerides 46, glucose 84 (no diabetes). I have made major life style changes: lost 30 lbs. (5'4", 128 lbs), strict low-fat diet (vegetarian & fish) exercise daily, BP normal. How to best assess and monitor risk now?

Stephen_Ellis,_MD: The ACC/AHA guidelines state that patients in your situation should take clopidogrel (plavix) for one year after heart attack, although some studies show a benefit if a patient takes it longer.. However, duration of therapy depends on individual circumstances and should be discussed with your cardiologist. Aspirin 81 mg daily should be taken for life in most patients in your situation. You have made favorable changes to your lifestyle. Your numbers look good and we encourage these changes - continue to do close follow up with your doctor.

Muckle: I have artery disease that is being treated with medication as follows: Blood Pressure Diovan HCT 160Mg/12.5Mg; Effient 10Mg (Treatment for recovery from 2 stents inserted in my Circumflex artery in Oct. 2012); Lovaza 4Grams per day; Synthroid 25Mcg (Treatment for hypothyroidism diagnosed in early July 2013); Omeprazole 40Mg; Metoprolol 25Mg; Simcor 1000-40Mg;Asprin 325Mg. I have a history of low HDL, high LDL and Triglycerides for last 15 or 20 years. Latest blood work as follows: Chol 188Mg; Trig 138;HDL 37 mg/dl; LDL Calculated 123.4Mg/dl:VLDL 27.6mg/dl; Trig/HDL 3.7;Chol/HDL 5.1%. My question: Should I be concerned with the interaction of all these medications. I have noticed sever bloating and some weakness in my legs. Since I am a 75 year old male my age may be a factor. Please review and advise if you think medication is excessive. I work out about 1 1/2 hours at the gym 3 or 4 times per week. I do 45 minutes of cardio and the balance of time is spent on strength.

Stephen_Ellis,_MD: Bloating and leg weakness can be side effects of medications, but they could also be from artery blockages.. Your aspirin dose should be reduced to 81 mg a day. Are you intolerant to crestor or Lipitor (your LDL is too high)? You should discuss each of them in detail with your physician.

Peppy: I have read more negative comments about Metropolol Tartrate than good lately. It increases diabetes in females, it is not that affective in controlling bp, weight gain, fatigue, and there are better agents today. I had a non-stemi and a stent in the diagonal seven years ago. I'm still on 25mgs. 2X's a day. Would another drug be better and not have the risk for diabetes, etc? How do you get off this stuff w/o migraines and other problems? I tried once with the cardiologist's instructions for weaning and had terrible headache that went on and on. Scary stuff. I want the best treatment though without the diabetes risk. Thank you.

Stephen_Ellis,_MD: Metoprolol may not be the best medication for you now. We would have to know more about your blood pressure, heart rate, whether you have diabetes or not to comment further. You should talk to your doctor.

Bbergen: What is the current thoughts on using Vytorin?

Stephen_Ellis,_MD: As you probably know, Vytorin has 2 components. One of these, ezetimide, is controversial. Generally we recommend using the highest tolerated dose of statins before considering Vytorin.

Gwilson1951: For a patient taking Furosemide 40 mg and Potassium CL 20MEQ, would either Inspa/Eplercnone or Aloactone/Spironolactone be an advisable/more effective replacement to accomplish the same goals?

Stephen_Ellis,_MD: Possibly, but either can be a bad combination under several conditions such as weakened kidney function.

Eatveggies: Can beta-blockers be discontinued 3 yrs. post-MI if no angina, normal ECGs, echocardiogram and nuclear stress tests, and normal lipid profile with cholesterol ratio of 2.6?. I think the beta-blocker (generic Coreg, 3.125 mg. once a day) causes insomnia, and bradycardia - heart rate is often high 40's or low 50's. I had permanent heart damage from the MI, so what purpose is long-term beta-blockers?

Stephen_Ellis,_MD: Beta blockers have been shown to reduce the risk of a second heart attack, but the main effect is in the first few years after the MI. To fully comment we would need to know your blood pressure and other things. You should ask your doctor about this.

Carotid Artery Disease

Bigtex: I just had Carotid Artery disease screening and the results are: Mild; Fairly low to moderate amount of plaque buildup not affecting blood flow velocities. The velocity levels fell below 110 centimeters per second. How do I clear my arteries 100%?

Stephen_Ellis,_MD: At present we do not have a treatment that clears arteries 100% however you should speak to your doctor about risk factor modification (smoking cessation, blood pressure, and cholesterol management) to reduce your risk of future disease progression. Generally to have any hope of reversing artery blockages you need to get your LDL cholesterol to <50-60 mg %.

!mlg944x: I have blocked Carotid Artery's about 30% on Right, 40% on left. What is the best practice to make sure they do not get worse. I have an Ultrasound once a year to measure the blockage. Also is there any other risk factors associated with having blocked Carotid Artery's with my percentages of 30% & 40%? If they become blocked to a point when a procedure must be performed, what is the best procedure to reduce the blockage? Thank You.

Stephen_Ellis,_MD: Generally to have any hope of reversing artery blockages you need to get your LDL cholesterol to <50-60 mg%, so that should be a goal. You need to attend to your other risk factors also. Generally a 70-80% blockage should be considered for revascularization. You’ll need to see a specialist to help decide between surgery and stenting.

Diagnostic Tests

circusman: I had a nuclear profusion scan in February. My ejection fraction is 68% and my left ventricular end diastolic volume is 78 ml and the end systolic volume is 25 ml. Is this a cause for concern?

Stephen_Ellis,_MD: The numbers you have listed are in fact normal. The normal ejection fraction for a healthy person is typically 55 - 70%. This refers to the percentage of blood "ejected" from the pumping chamber (left ventricle) with each heart beat.

GNT: What are the minimum parameters of cardiac calcium blockage for an Atherectomy to prevent a first heart attack? Are there any clinical trials? Am I a candidate?

I have just completed a CT scan showing total a total calcium score of 145.7 (2007 was 93.5) of which 28.7 (2007 was 8.6) is in the left main, 103.5 (2007 was 85) is in the left descending, Circumflex 2.4, (2007 was 0) Right coronary 11.2 (2007 was 0). I have a total cholesterol of 124 with no statins, exercise daily, 6'2" 180 pounds. eat a heart healthy diet, not smoked in 35 years, 67 years old, but family history, dad, died at 59 of 3rd heart attack. Mom was 88 died of COPD. Taking daily baby aspirin and 50mg of cozaar since 2011. (BP normal).

Stephen_Ellis,_MD: Atherectomy generally doesn’t reduce the risk of a heart attack (nor does stenting unless you’re in the throes of an MI). Aspirin and statins are the cornerstones of prevention. Your LDL should be < 100 (preferably under 70). You should have your HbA1C checked. Diet and exercise (minimal walking 30 min 5 times a week, or equivalent) are also important.

Treatments – General

Shawna: What is your opinion about long term EECP and medication vs surgical treatment for coronary artery disease and angina?

Stephen_Ellis,_MD: EECP is a good treatment for angina but does not prevent heart attacks. The choice between therapies depends on symptoms and the extent of your disease.

Bob2233: My dad is 80 years old with triple vessel disease, something like 80%, 70% and 55% blockages. His doctor wants to treat him medically - but he is limited by chest pain. Is that too old for surgery or stent - or why would they not offer that? He also has diabetes and arthritis.

Stephen_Ellis,_MD: Age and medical co-morbidities increase risk of surgery or stenting but they may not be prohibitive. A second opinion is very important for someone like your father.

Interventional Procedures – Angioplasty, Stents, Atherectomy

RichS1942: I am a 70 year old male and I have pulmonary fibrosis and am currently using oxygen. Two weeks ago I under went a heart catheterization where one stint was put in place but the other two coronary arteries were too blocked for stints. Afterward my cardiologist said there were few options. Once was open heart by-pass surgery. The second option is for atherosclerosis, which he described as similar to using a "roto-rooter" to clear pipes. The third option was really to do nothing except for taking medicine. The next day a heart surgeon came by my hospital bed to discuss the open heart surgery. Basically he said I am not a candidate for the bypass because of my breathing issues, and the high possibility of not being able to be removed from the ventilator after the operation. I know that the atherosclerosis procedure has risks of perforation and also the chance of clots being sent into my arteries. I want to know what the perforation chances are. 10%, 50%?

Stephen_Ellis,_MD: It sounds like you would be a poor candidate for surgery due top your lungs. In general, discussion with your cardiologist about benefits and risks of certain procedures is always warranted. There may be several options for treatment of your coronary artery disease. We recommend a second opinion with an interventional cardiologist who could review your symptoms and angiography films and give you an individualized assessment of your risk of the procedure. In general, the chance of perforation with rotational atherectomy is estimated to be less than 5%.

RichS1942: If an artery is ruptured during rotational atherectomy is there much of a chance that you will not bleed out right there on the table?

Stephen_Ellis,_MD: It depends very much on the state of your arteries and the size of the hole in your artery. Death due to perforation is fairly rare, but it happens.

BenM3: How many stents (de-luting) operations should be considered reasonable for a person with coronary disease.

Stephen_Ellis,_MD: There are no hard and fast limit on number of stents - this is an individualized assessment/decision based on evaluation by your cardiologist. Alternatives to stent include heart surgery or medications.

eatveggies: What is the best way to monitor coronary bare metal stents for revascularization 3 yrs. post heart attack in a symptom-free patient with normal exercise nuclear stress test?

Stephen_Ellis,_MD: Symptoms and stress tests, as you have had. Depending on your original symptoms and level of activity, stress testing may not even provide much information. Make sure your heart risk factors are well treated.

Heart Surgery

Prune: I'm a 65 year old male in good health. I had a heart attack and a quintuple bypass 18 years ago. Last October I had a significant heart attack with 2 stents in the same graft. I also learned that I lost 2 other grafts. My cardiologists says I 'm at too high of a risk for another bypass because of the scar tissue from the first one and the only way I'll have another bypass is if I lose another graft. Is there more risk the second time around and would It be in my best interest to seek a second opinion? Thank you.

Stephen_Ellis,_MD: Need for stenting in a blocked bypass graft this long after surgery generally means more blockages to come in the next few years. Both surgeons and interventionalists different in their level of skill and willingness to take on risk. The risk is higher the second bypass surgery due to scar formation under the breast bone. It would certainly help you understand all your options to seek a second opinion.

Stephanie Mick MD: There are indeed more risks the second time around, as Dr. Ellis mentioned, due to scar formation from your initial surgery, however, not necessarily so high that surgery is not an option. I agree that a second opinion is warranted.

Karikristen: I received a bovine valve recently and was told it could last from 10-20 years. Is there anything I can do to help prolong its life (and therefore mine?). Also, should I get regular tests to find out if my current valve is failing? How much warning will I get? Is it safe for me to travel to remote places, far from medical care?

Stephen_Ellis,_MD: Not much has been shown to increase valve longevity, but there is some weak data for statins and ACE inhibitors. We generally get echos every 3 yrs or so until year 8, then every 1-2 yrs thereafter, depending on how things look. In 10-20% of cases, symptoms come up pretty quickly. At this point in time I wouldn’t cut back on travel for this reason alone.

browna20: What percentage of CAD has to be present in order for a surgeon to classify it as "significant"?

Stephen_Ellis,_MD: Traditionally a narrowing > 50% diameter by angiography is considered significant, but we now know that 50-70% narrowings sometimes don’t reduce blood flow. Today we rely more on perfusion or echo stress testing and FFR determination to determine “significance”.

Stephanie Mick MD: Generally we consider a blockage of over 70% significant, however in certain arteries (for instance the left main coronary artery) we consider a 50% blockage significant.

hawk83: My Mom aged 55 is diabetic since 30 yrs and Hepatitis B affected. She had myocardial infraction on 12/7/13 was asked to go for CABG, as angioplasty is not possible. During angiography she is diagnosed with acute inferoposterior MI lysed at local hospital on 12/7/13, CAG showed 3 vessels disease.

Kindly let me know the risks whether to go for CABG or any other alternate or just continue medication to save her life to live longer. If needed any reports I can provide upon request. Please let me know asap, thanks a lot in advance.

Stephen_Ellis,_MD: We would need to see a clinical summary and heart cath pictures to be able to comment.

Stephanie Mick MD: Generally, diabetic patients with three vessel coronary disease are best served by coronary artery bypass grafting – this is the approach that has been proven to prolong people’s lives who have these conditions. There are certainly risks to cardiac surgery, however there are also risks to leaving her coronary artery disease untreated. I would strongly recommend she continue in her evaluations for potential coronary bypass grafting.

DorothyP52: Can you talk about the new procedures for bypass surgery that are available and for what types of patients - for example can they do a robot surgery for all arteries and if not can you do stents and robot at the same time if you don't want a big incision; can this be done with all blocked vessels. My husband had radiation to his chest some time ago and we understand that full heart incision would be risky but he has blockages and wonder the best approach for him.

Stephanie Mick MD: Robotic coronary artery bypass grafting can be used to bypass any artery on the heart. Single or multiple bypasses can be performed using this technology. It is also possible to use the robotic approach for one or two arteries with stenting performed as well. If performed, stenting is usually performed in a separate procedure following the robotic procedure. Generally, robotic bypass surgery is best for patients who have not had previous heart surgery or scars inside of the chest and who are in good health otherwise. Radiation to the chest can cause scarring in the chest as well as heart tissue damage. Unfortunately, if your husband has been told he is at high risk for full incision heart surgery, it is very likely he would be too high risk for robotic surgery.

NevadaChuck: My dad was told he needs bypass surgery but he only has one kidney. This has been a problem with the dye with his cath and other times he has had procedures. What are the issues with bypass surgery? What should we ask the doctors and monitor after surgery? He also has diabetes and I am nervous that he will have troubles after surgery.

Stephen_Ellis,_MD: The risk of xray dye induced kidney failure goes up as kidney function declines, but usually a heart cath can be done safety unless the kidney function is really bad. The kidney can also be damaged during heart surgery as the blood pressure is low for a period of time, and also from being on the heart pump. Sometimes dialysis is required. That said, unless the creatinine clearance is < 30-45, with an experienced team the risk is low. He should be seen at a high volume center with a good track record.

Stephanie Mick MD: During cardiac surgery, there is a period of time when the heart and lungs are stopped and a heart-lung machine pumps blood to the body. Your heart surgery team would need to take special care that the kidney received very good blood supply during and after the operation to ensure that its function is not impaired. Depending on its level of function, there is a risk he could need dialysis after the operation. I would recommend that he be evaluated by a kidney doctor before the operation to give you a better idea of the risks in his particular case and that they watch over him after the operation while he is in the hospital.

Many patients who undergo heart surgery have diabetes and in general heart surgery teams are very practiced at managing this. I recommend you discuss with your heart surgery team the ways they manage this to alleviate your concerns.

Risk Factor Modification

bkrt1950: I recently had angioplasty with one stent to remove a 98 percent blockage in the right coronary artery. I have an additional 60 percent blockage that remains. I have completely overhauled my diet (in addition to a statin) in an effort to reduce my cholesterol, with emphasis on reducing my LDL to under 70 mg. No smoking, drinking, and walking upwards of 5 miles per day. Is it possible to actually reduce (significantly or marginally) the blockage through diet? Thank you.

Stephen_Ellis,_MD: Current thinking is that old plaque that is mostly fibrotic is unlikely to change, but more recently acquired plaque is more fatty and can be reduced if you can get your LDL cholesterol < 50-60mg%. It sounds like you are on the right track. We know that statins can reduce or stabilize plaque progression - continue your excellent statin and lifestyle therapy.

shadow@102: What is the best way to lower LDL level . Currently, taking Fenofibrate and Atorvastatin, exercising 5x week and eating 1200 calories per day, BMI normal. Have had two stents in LAD, CABG double-bypass surgery (LCA) and carotid subclavian bypass within 21 months. CAD is due to genetic factors. What else can I do to lower my LDL level of 112 (woman). What is the recommended triglyceride level for someone with CAD?

Stephen_Ellis,_MD: You would benefit from a preventive cardiology clinic - someone who specializes in lipid management to reach your goal. The guidelines suggest your LDL should be less than 70 mg/dl. Your triglycerides can be addressed by a lipid (cholesterol) specialist who can take into account their role in your coronary risk. Issues such as thyroid status, alcohol intake and type of exercise that affect LDL cholesterol should be addressed.

Jim01: How do you reduce a small amount of plaque in your arteries?

Stephen_Ellis,_MD: Risk factor management including diet, smoking cessation, exercise, cholesterol management (target LDL < 50-60 to reduce plaque that is already present), and medications such as a statin can be helpful in optimizing your plaque burden and cardiovascular health.

bobbonner: My wife's Lp(a) is off the chart. What can she do to bring her Lp(a) number down. I have read that statin drugs can increase Lp(a). Should she concentrate on increasing the particle size of her LDL?

Stephen_Ellis,_MD: Please refer to Dr. Hazen's article at Lipoprotein(a) -Treating the Untreatable.

cardio_al: Good day, Doctors. I would like to have your opinion on findings by some medical scientists, that increased incidence of heart disease over the past 20 years hasn't been so much from dietary fat & cholesterol, but that our increased consumption of refined sugars & fructose has been the real culprit. This being metabolized so as to cause damaged & clumping blood cells (inhibiting blood flow), inflammation of blood vessel walls, along with obesity, diabetes, artery disease. Thank you for your input on this.

Stephen_Ellis,_MD: The incidence of coronary disease in the US has actually decreased, but obesity and sugar consumption are threatening to reverse the decrease.

Stem Cell Therapy

sgwilson1951: For a pt who suffered a serious LAD MI, still with a low ejection fraction three years later and damage that does not seem likely to repair, are there any current stem cell trials which the pt could join that might help restore the damage?

Stephen_Ellis,_MD: You don’t fit for any of our trials here, but I’d check to see about those at other hospitals.

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Reviewed: 08/13

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