Wednesday, January 15, 2014 - 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. CAD is caused by the narrowing or blockage of the coronary arteries, usually caused by atherosclerosis or plaque build-up. Treating coronary artery disease is important to reduce your risk of heart attack or stroke. Dr. Ellis answers your questions about coronary artery disease.
- View more information on heart disease and treatments.
- Register for future chats and/or log in.
- If you need more information, contact us or call the Miller Family Heart & Vascular Institute Resource & Information Nurse at 216.445.9288 or toll-free at 866.289.6911. We would be happy to help you. Tell us if you would like to be notified about future webchat events!
- View previous chat transcripts.
Coronary Artery disease: Symptoms
victoria1102: Hello Dr. Stephen, my question is in regards to physical/medical profiling of a patient for CAD. I am a healthy 36 year old woman. I have experienced a fleeting mild ice pick like sensations in the left side of my chest that lasted briefly and subsided. I have experienced this on several occasions and also have had a slight dull pain go up to my shoulder and halfway to my arm, but was not accompanied by any chest tightness or pain. I have had EKG's done as well as a treadmill test in which both were normal. I feel that because of my age and good health history that both my GP and cardiologist rule out me being at risk for CAD. I also experience what seems to be heart palpitations/PVC's. I'm not sure if they are the same thing medically, but I was told they are normal and common. When I get them I feel like my heart is beating faster and fluttering but it is at 62-64 beats a min at rest. Can you let me know what you think? Thank you!
Stephen_Ellis,_MD: Chest pain lasting less than 30 seconds at a time is almost always not related to blood flow from the heart. Most people have occasional palpitations but if you are getting them more often you may need to be evaluated with an ambulatory monitor. Early palpitations are an early indicator of problems such as mitral valve prolapse.
steelguy: 60 year old with multiple stents. Recent stress test with 2 questionable areas (not getting enough flow?), chest pain with exercise during the test and otherwise. Had angiogram as a result with no additional stents needed. Question is in regards chest pain with moderate exercise. Cardiologist suggests daily nitrates but I do not want to give up Cialis, etc. Any alternative meds available? Tough choice otherwise!!! Thanks.
Stephen_Ellis,_MD: Calcium channel blockers and ranexa are alternatives to nitrates for patients with angina who do not want to or cannot take nitrates.
rheudean: I am a 36 year old female that recently went to my doctor for fatigue and SOB. My echo showed "mild myxomatous changes in the mitral valve, mild mitral and tricuspid valve regurgitation. My calculated EF was 51%. My last couple ECG's have been showing a shortened PR interval. My father died of a massive MI at age 26 from CAD, per his autopsy report. My doctor says it is nothing to do for it. I am not a MD although it sounds to me that I should be referred for surgery. I had an echo in 2000, no regurg present and a cath in 2001, my arteries were not blocked, although "a lot smaller than expected" per my MD. I don't want to wait until my heart is so weak that I can't have surgery. I want to know what the guidelines are for timely surgery. All local physicians brush young adults off, as if they don’t have MI's. My father was 26 and per his autopsy report "perfect candidate for heart bypass surgery". Will you please give me some advice?
Stephen_Ellis,_MD: It sounds like you have several potential issues going on here. Myxomatous changes often progress - you should have periodic echo evaluations to see if your leakage worsens. You may be at genetic risk of heart attack. Despite your young age, you should be evaluated for risk factors such as lipid profile and blood pressure. It might also be useful to get a calcium score to see if you are building up plaque as your father did. Lastly, a shortened PR interval is sometimes related to important arrhythmias. I would suggest a follow up with a cardiologist.
jan13283: I have CAD with 11 heart stents implanted three years ago within the space of six months. Never had any pain just shortness of breath. Felt really good for the first couple months then developed pain, shortness of breath, weak arms and then started developing weakness in walking. Now I recently am developing weakness in upper arms and sometimes pain in my lower abdomen during all of these symptoms. I call it ghost angina pain as nothing shows on the tests. I sometimes feel like a rhino is sitting and poking me in the chest. Is this common with so many stents? Why? I see my cardiologist every six months.
Stephen_Ellis,_MD: Symptoms like those you described are not common with heart stents unless they have re-block or unless there are other problems. If your symptoms generally come on with exercise and are relieved by nitroglycerin under the tongue then they are particularly concerning. If that is the case then it may be well worth pursuing a cardiac catheterization in spite of other test results. If your symptoms are not so typical, then a stress test would likely be the first major test that we would recommend.
Kali2014: If you do feel shortness of breath during walking or steps climbing, does it mean any issues with heart? How to do further testing to make sure it's nothing related to the heart? If a person who has stent(s) and is currently on a DAP regimen feels like they may be experiencing a heart attack, should they chew an aspirin before heading to the ER in addition to taking a nitro tablet?
Stephen_Ellis,_MD: The causes of shortness of breath with exertion are several – it could be problems with the heart or just as well problems with the lungs or perhaps anemia. The single test most likely to help sort this out, if there are concerns about the heart, it would be a stress echocardiogram. Regarding your second question, yes, you should chew an aspirin and take a nitro as you call 911 (don’t drive yourself to the hospital).
Anne.P: Who does CAD affect the most men or women? And are differences in signs and symptoms between men and women? Stephen_Ellis,_MD: CAD affects both men and women, although it occurs somewhat more often in men. It is, however, the leading cause of death in women. For some reason women’s symptoms tend to be a little less typical – remember scenes in a movie where someone clutches his chest and falls to the ground. Chest discomfort lasting a few minutes associated with exercise or stress is most worrisome. Short twinges are seldom from the heart.
Diagnostic Tests – General
kali2014: What is the good way to check for the heart disease or symptoms much earlier before it gets too late ?
Stephen_Ellis,_MD: The best initial test to see if someone is beginning to build up plaque is the calcium score of the heart. The best screening test to see if they actually have blockages due to plaque build up is a nuclear or echo stress test. We don’t like to over utilize these tests, however. Certainly if the person we are speaking of has a number of risk factors for coronary disease (genetic history, smoking, diabetes, hyperlipidemia, hypertension) than there may be a role for these tests.
laneavery: Hi Dr. Ellis - for someone like myself who has coronary artery disease and stents, is there a non-invasive test that can be done to determine if arteries are getting more plaque, staying stable, etc.? I've had an echocardiogram but was wondering if there is a newer, better or more precise test available. I've heard some talk of 'heart scans' for example. Thank you!
Stephen_Ellis,_MD: All current non-invasive tests to see whether or not stents are blocking up have some limitations. For years stress tests have been recommended (thallium stress or an echo stress). They are not always accurate, particularly if the stent was placed in a small blood vessel. There has been some increased use of CT angiography for this problem, but unless the stent itself is very big (3.5 mm or greater) it tends to cause an imaging artifact that makes the test difficult to interpret. Heart catheterization is, of course, the gold standard test.
rickjensen How can coronary artery blockage be detected?
Stephen_Ellis,_MD: The best non-invasive test to detect heart artery blockages is a CT angiogram. We don’t like to do these too often on a repeated basis because of the radiation dose. Stress testing would be an alternative. The gold standard is invasive coronary angiography.
Diagnostic Test – Stress Test
KEbling: I am a 49 y/o female with a clear stress test, minor abnormality of EKG, strong family history of heart disease, and NO CHOLESTEROL problems or Diabetes. I recently had bilateral neck pain, and dr's could not find problem. Angio was performed for diagnosis, expecting nothing. My left anterior artery had 99% blockage. How can I monitor? How do I know problems are occurring? Without immediate symptoms, and then a near heart attack? They want to put me on statins, with no way to monitor labs since all normal. What can I do? How do I monitor? Most doctors that I have met, say this is uncommon, and not really seen. HELP!?!!?!
Stephen_Ellis,_MD: You're having a severe blockage and normal stress test points out the limitations of stress testing. At a minimum you should be on aspirin and statins with a target LDL of less than 70. I would like to hear more about the details of your "clear stress test" before making recommendations regarding further monitoring - we would be happy to see you.
sinaihospital: I have high blood cholesterol, high blood pressure, type 2 diabetes, plus my dad died at age of 48 an heart attack, plus I am overweight. This puts me at risk for coronary artery disease. I am only 48 years old, I see a cardiologist. How often should I get a stress test, a stress echo, an ekg, and cardiac blood tests by my cardiologist to detect coronary disease.
Stephen_Ellis,_MD: Stress testing has only a limited role to evaluate how coronary artery disease is progressing. It is more important to focus on risk factor management - see answers to previous questions.
q01011960: I am 52, don't have any symptoms, am reasonably fit and eat mostly healthy food now. But that was not true for the first 40 years of my life. How can I tell if my heart or arteries are clogged?
Stephen_Ellis,_MD: For you, the best test to see if plaque has built up in your arteries is a calcium scan.
Diagnostic Test – Cardiac Angiography (Catheterization)
clara: I have had the aortic valve replaced, two grafts and eight stents after the open heart surgery. All grafts are in major arteries. None have closed up. My question is the last cath, I had a spasms in the LAD. He said it was a severe spasms. He put a stent in the left anterior descending artery. How would I be able to tell the difference of a spasm or artery needing a stent? I am having some symptoms again that are a concern. I get periods of SOB and chest pressure. I do have a severe tricuspid valve. I do not know if that makes a difference. Thank you.
Stephen_Ellis,_MD: It is sometimes difficult to tell the difference between symptoms from spasms and those from build up of plaque. Those related to spasms tend to be a little less consistently related to exercise. Both will likely respond to nitroglycerin. If the problem is in the large artery, such as the LAD, stress testing could be performed to see if there is a high likelihood of build up of plaque. If the problem is spasm, it is unlikely that the stress test would show an abnormality, although occasionally exercise precipitates spasm. The tricuspid valve, at least if I understand correctly, is not in play with this particular issue.
aorticvalve51: What is the difference between a heart cath and an angiogram? What is the best test to have to find out if you have any blockages?
Stephen_Ellis,_MD: The words heart cath and angiogram are often used interchangeably. More technically, heart cath means placement of catheters in the heart or in the artery supplying the heart and angiogram means that through these catheters x-ray dye has been injected. These are both invasive tests. Depending a little bit on your circumstances, a CT angiogram or stress test may be the best non-invasive way of seeing whether or not you have blockages.
Diagnostic Test - Calcium Scan
shones: Recently, as part of a Global study, I had a heart CT Scan. The scan showed that in the proximal portion of the lateral segment of my right coronary artery, there is a densely calcified plaque with an estimated stenosis between 50-75%. What should I do? What does this mean? I showed the CT report to my PCP and he said change my diet, but since I show no symptoms he was not going to refer me to a Cardiologist. Also, my Calcium Score was 961.3. Should the blockage described above be operated on soon?
Stephen_Ellis,_MD: Coronary calcium accumulates in areas of chronic plaque. So you indeed must have plaque in your heart arteries. Coronary CT scans tend to overestimate the severity of blockage - in this instance we would recommend treatment with aspirin and aggressive risk factor modification such as cholesterol management, diabetes control, stop smoking, etc. If you are inactive, then we would recommend a stress test but if you are active and have no symptoms, then risk factor management should suffice.
Shones: This information should be added to the question I previously submitted. I am a 67 year old male. My Cholesterol levels are well within the normal range and an August Echo was normal.
Stephen_Ellis,_MD: It is good that your echo was normal. That suggests no heart muscle damage and normal heart valves. The fact that your cholesterol levels are within the “normal range” isn’t necessarily reassuring given your CT scan results. For persons like you we generally ask that the LDL or bad cholesterol target be less than 70.
Jack_in_Florida: I've heard mixed reviews on the importance (or even accuracy) of a "calcium heart score". Can you comment?
Stephen_Ellis,_MD: Calcium accumulates in areas of chronic plaque. It is a good inexpensive marker for that problem. Information from this test adds considerably to the risk factor profile that we typically review – genetic history, smoking, diabetes, high cholesterol, hyperlipidemia, obesity, exercise, etc. A positive calcium score does not mean you have a blockage; however, just that plaque has accumulated. The finding of a considerably abnormal calcium score should trigger an aggressive review and treatment of risk factors, and under some circumstances, stress testing.
Coronary Artery Disease: Prevent Progression
Asaf: I had open heart surgery, five bypasses, that failed as a result of HIT in 2009. I had three stents placed in the main artery. In December 2013, I experienced uncomfortable feeling in my chest and my cardiologist decided to perform a Cath and discovered that one of the stents was 99% blocked and another artery was 80% blocked. My cardiologist put in two stents. I have been taking some statins but due to knee & back pain have not been able to exercise much. Besides diet, exercise, statins, proper sleep and reduce stress what are my options?
Stephen_Ellis,_MD: As you may know, the processes leading to blockages inside and outside of stents are somewhat different. When a patient has a recurrence inside a stent it is usually due to scar tissue. We have little control over the likelihood of this although, for instance, smoking and diabetes are known to increase the risk. On the other hand, we have somewhat better understanding and more control over blockages that arise spontaneously. This, of course, is related to cholesterol and inflammation, with the principal risk factors being genetic heritage, smoking, diabetes, hypertension and high cholesterol. In your case, all of those risk factors need to be addressed but it still may not have very much impact on the risk of redeveloping blockages inside your stents. If that occurs and the blockage is short, then another stent is often useful, sometimes to be supplemented by other medications. There is data to suggest that medications such as sirolimus and cilostazol may have a beneficial affect in this situation and occasionally we resort to brachytherapy.
In your circumstance it is particularly important to stay on blood thinners such as aspirin and plavix. Beyond cholesterol, important risk factors to consider are diabetes, high blood pressure, obesity and smoking. You should exercise as much as you can. Often water exercises are good for people with orthopedic problems.
JMA: Is there a way to slow and/or reverse the progression of CAD when it is in its early stages? If so, how?
Stephen_Ellis,_MD: Conceptually speaking, coronary disease has two stages. Chronic build up of cholesterol leads to scarring and calcification - these lesions tend to be stable. Alternatively, relatively fresh buildup of cholesterol can lead to plaque rupture or heart attack or can be removed from the artery wall with medications, diet and exercise. At a minimum, aspirin to prevent the thrombotic complications of plaque rupture and statins to "suck the cholesterol out of the artery wall" are generally indicated. Although the data are not 100% clear, research shows you need to get the LDL at less than 50 to successfully achieve plaque regression.
FionaFrazier2327: I'm from State College, PA and my local dr. is from Penn State, Hershey. After my CT scan of the arteries to the heart I found out I have CAD. He told me to go home, eat steel cut oats, drink Metamucil daily, eat healthy and exercise. I have since been to Cleveland Clinic for extensive testing for a 2nd diagnosis, which I'm much happier with. I do walk two miles in 35 min. 5X a week (joining a gym in February), eat VERY well, read labels to eliminate sat. fats and trans fats, and am already sick of oatmeal! My question is... is steel cuts oats and Metamucil "crucial" or even important, as my doctor here suggested, to prevent my CAD from getting worse?
Stephen_Ellis,_MD: For you, diet and exercise are very important. The best exercise is walking, swimming, cycling - and getting your HR in a moderately high level (65 - 75% max HR) at least 30 min per day, five times per week. It sounds like you have a good diet - oats and Metamucil reduce cholesterol a little bit but not as much as a statin such as rosuvastatin or atorvastatin.
kali2014: Many Questions: 1) What are the few heart friendly foods you can suggest? 2) If the LDL level is much lower, does it mean a serious problem? What is the quick way to correct it and make the level normal? 3) How about taking the 0mega- 3 tablets? Will it help the heart problems?
Stephen_Ellis,_MD: Omega 3 fatty acids are one option to treat high triglycerides. They can, however, cause the LDL or bad cholesterol to go up. They are, therefore, helpful in some circumstances but not others. There is also some suggestion that in a patient with a prior a heart attack that they reduce the chances of sudden cardiac death. I am not certain that I understand your question about lower LDL levels exactly, but if they are very, very low (eg <40 or so) and you are not taking cholesterol lowering medication this sometimes indicates occult cancer. Levels in the 40 to 60 range on statin treatment, however, seem to be safe in general.
Saints: Since my CAD diagnosis, in addition to having a stent and being prescribed a blood thinner and aspirin daily, I am also on a statin and metoprolol. I was not on any medication prior. Are all of these medications absolutely necessary?
Stephen_Ellis,_MD: For persons having a coronary stent it is very important to take the aspirin (usually for a life time) and Plavix or similar medicine for one year or so. These are very important because until the artery has fully healed around the stent there is some risk for having a blood clot form in the stent, which often causes a heart attack. Other treatment medications should be directed against the causes of your blockage in the first place. Statin therapy is often very, very useful. Metoprolol is more usually given for prevention of angina, rapid heart action or elevated blood pressure; it also reduces the risk of a second heart attack if you had a heart attack to begin with. It is a little hard to know what you should be taking without having a complete clinical history.
tommy44: I have been diagnosed with cad about 10 years ago ,the first two years I had numerous stents placed about every three to four months. Then triple bypass eight years ago, left main coronary artery could not be stented. No stents needed for about two years. Since then I've had stents placed about two to three times a year (for about six years). Last Dec., I was having exercise chest pain and was scheduled for cardiac catheterization. During the procedure it was determined to another by pass. I'm now at home recovering from the bypass. I'm a type two diabetic ,slightly anemic, 20 lbs. overweight and have not been exercising much because of the chest pain. My total cholesterol is in the 90's hdl 50's and ldl 30's a1c 6.2. I'm told this is hereditary. What are my options?
Stephen_Ellis,_MD: Your situation sounds complicated and it is a bit difficult to offer advice under these circumstances. It would be important to know whether all or most of your blockages have developed within stents, which would suggest a restenosis problem, or whether you keep having new blockages outside of the stents. You do not mention anything about smoking or blood pressure control. Perhaps you should seek a second opinion from an experienced cardiology team.
Q0112: What can I do to prevent progression of a 50% LAD stenosis and a CAC of 450? Cholesterol 140, LDL good, HDL needs improving. Thanks tricuspid.
Stephen_Ellis,_MD: The best approach to prevent progression in your circumstance would likely involve a good diet, exercise as we have discussed before, being put on aspirin to minimize the risk of a blood clot forming on your blockage (most common cause for a heart attack), paying close attention to the major risk factors which caused blockage in the first place. That would mean not smoking, getting your blood pressure under control, getting your LDL less than 70 and being evaluated for diabetes.
Coronary Artery Disease – Risk Reduction
sandor: Dear Cleveland Clinic, I am writing from Italy. I had MI last September, my question is: can I go to the gym and exercise a little with weight? I know the Sinatra Method and I would like to start it, what do you think about it? Yesterday I have had the first cardiology examination. The Doctor said I am recovering very well, I can provide you all the details of my heart condition. Awaiting for your kindly reply. Have a great 2014. Sandro
Stephen_Ellis,_MD: For someone who has had a heart attack, diet, exercise and the correct medications are extremely important. You should be on aspirin and an additional medication such as Plavix. You should be on a statin, ace inhibitor and a beta blocker. Assuming you did not have a very large heart attack, exercise is certainly appropriate. Ideally it would be monitored exercise at least in the beginning. The Sinatra method is one of many forms of exercise that could be helpful.
Purry: I have been diagnosed with Coronary Artery Disease. I have five stents. What type of exercise should I do? Should I be on a restricted diet? I have cut out salt. My medications are Plavix 75 MG, Metoprolol Tartrate 25 MR, 1/2 tablet twice a day, Aspirin 81 MG, once a day. What are my most important risk factors and what can I do about them?
Stephen_Ellis,_MD: Diet and exercise are very important for someone who has had stents. It is difficult to provide detailed dietary information - a visit to the dietitian would be helpful. The best exercise is walking, swimming, cycling - and get your HR in a moderately high level (65 - 75% max HR) at least 30 min. per day five times per week. The single most important risk factor is your genetics, then - diabetes, lipids, blood pressure, and smoking are also important. At minimum you should be on statins in addition to the medications you listed.
Irish: Can I help prevent unstable plaque or is it strictly genetic? What tests and/or lifestyle changes can I do if applicable? Can high stress situations cause plaque to become unstable? I have heard/read that this is the main reason for a sudden cardiac event, not necessarily advanced CAD.
Stephen_Ellis,_MD: While buildup of plaque has a genetic component there are a number of lifestyle changes that can minimize the risk of heart attack. This includes diet, exercise, use of aspirin and statins. High stress situations can cause plaque rupture (there are an increase in heart attacks after an earth quake). Overall stress reduction in patients with high stress can be useful.
hunter16: How often should cholesterol level be checked while on statins?
Stephen_Ellis,_MD: The answer to your question depends on how well controlled your cholesterol levels are. If they are well controlled, and have been stable for sometime and you have had no major change in diet, exercise or weight, then once a year would be fine, perhaps even once every two years. On the other hand if there are instabilities in any of the items I just mentioned then the cholesterol level should be checked more frequently. It is important to bear in mind that any change in diet, medications or exercise usually takes two to three months to be fully reflected in the cholesterol values. Additionally, you’ll recall that sometimes cholesterol medicines can adversely affect the liver and periodic blood testing for this problem needs to be done.
Jack_in_Florida: Is there a correlation between CAD and diabetes?
Stephen_Ellis,_MD: Yes, there is a strong relationship between diabetes and the development of CAD. This appears to be due to diabetes per se and also some of things that often go along with diabetes – obesity, hypertension and hyperlipidemia, in particular.
Coronary Artery Disease Treatment Follow Up
sax64: I am a 66 yr. old Indian woman who suffered a heart attack two and a half years ago and have got three DES and one BMS, all in my right coronary artery. I am on Thrombyl 75 mg, Metoprolol 25mg (since Aug 13, earlier 50mg), Felodipin 2.5mg and vytorin 10x10. As tested on 17.01.14, my total chol. 106mg, HDL 40mg, LDL 52mg, TriGly 102mg, sugar fasting 83mg. ECG on yesterday showed heart rate 76/min, Impression Sinus Rythm, low voltage complex. ECHO cardiograph Conclusion Good left ventricular systolic function, LV diastolic dysfunction. LV Diastolic Internal diameter 3.29. I walk for about 45 minutes every day and practice yoga for about 50 minutes. I also do Cooking and other household work. After reducing the dosage of metoprolol I feel better. My BP is about 128/78 in the morning. I am very panicked because I have inherited this disease from my maternal grandmother's family. Please tell me what other tests should I take and how often. Don’t I need an annual checkup? My doctors say that if I can walk for half an hour without feeling breathless, then I am OK. Is it true? Jan. 2013, I had Cardiac CT. They found a 30% blockage in the left coronary artery. I eat vegetarian diet except Fish. What more should I do?
Stephen_Ellis,_MD: While it seems in many ways your evaluation has been good and you have been doing well - you don't mention a couple key issues such as diabetes and smoking. Many persons are diabetic and not aware of this (particularly in Southeast Asians). If you have typical symptoms with your heart attack and you are exercising then no stress testing is needed. If your symptoms were not usual, then stress testing may be indicated. Are you on aspirin - you should be.
Coronary Artery Disease Treatment – Stents
bobrenzi: Almost six years ago, at age 61, I was experiencing some mild chest pains, probably now due to strained chest muscles. After undergoing an EKG, echo, and stress chest and everything found normal, I was recommended to have a catheterization. At that time, my Dr. said I had about a 70% blockage and inserted one stent. After later conferring with a cardiologist who reviewed the disk with the procedure, it was found I had only a 50% blockage in one artery. My question is two-fold, should I have been given a stent and now that I have it, could there or be any long term consequences of having it. I am 6'2", 180 pounds, and have exercised regularly throughout my life and maintain a healthy diet without any smoking and only social drinking once a week. This whole thing has had me both concerned and irritated since then. I feel the Dr. was negligent and greedy by giving me a stent when I didn't need it. After the stent, I still had the same chest pain as before.
Stephen_Ellis,_MD: With the results of recent clinical trials they have found that stents are particularly helpful for patients having symptoms or those having a heart attack but in general, stents did not prevent a heart attack for persons who are otherwise stable. It is difficult to pass judgment without looking at your records. It is unusual to recommend stenting unless you are having symptoms or a grossly abnormal stress test. You should be on aspirin and statins. Have a prudent diet and exercise regularly.
mfgold: I have two questions: 1) Should all coronary occlusions be stented that show at least a 50% reduction in flow, regardless of symptoms; and, 2) What is your current opinion of the bio-degradable stents that are currently in development? Thank you for your reply.
Stephen_Ellis,_MD: Stents have been found to be very useful to prevent angina but not to prevent a heart attack. Therefore, we do not recommend stenting for all blockages over 50%. Additionally, we have found that coronary angiography finds it difficult to discern 50% stenosis does not always reduce flow. Stress testing or the invasive test FFR are better ways to evaluate if a blockage reduces flow. Biodegradable stents may reduce the long term risk associated with permanent stents but this is yet to be proven.
patb1: I wonder why they don't make stents nickel free. I had to have open heart surgery because I am allergic to nickel. I had two blockages. And I`m 72 years old now. It was so hard on me.
Stephen_Ellis,_MD: Nickel is a common component of alloys used in stents. The choice of metals to make stents is dependent on a number of factors, particularly how they stand up to the constant pressure and beating of the heart. New stents made of plastic and non-nickel alloys are currently under investigation.
aorticvalve51: I have an allergy to nickel, too, but I have a stent. When I questioned the doctors about this they told me the stent was stainless steel and not to worry about an allergic reaction. Should I be concerned about this now?
Stephen_Ellis,_MD: As you likely know, there is nickel in stainless steel. That said, the relationship between skin testing for nickel and allergic responses to stents is rather weak. If you have had the stent for more than a couple of years and it has not caused a problem it is unlikely to do so. I might be inclined to have you continue on Plavix for more than the usual 12 months, however. As you probably know, in general stents are permanent implants, and it is difficult even at the time of surgery to remove them.
xdwl: Hello, Doctor, I had coronary angiography and cardiac CT scan three years ago for pre-cardiac surgery screening (myectomy). The angiography was normal, and CT scan showed coronary calcification. I may need to have another surgery for my aortic dilation in a couple of months. I would like to ask whether I need another screening of coronary angiography before the surgery. How long a normal coronary angiography can be "valid" for? I am 55 year old female, menopause. I have no chest pain, no hypertension, no diabetes and no family history, and blood tests all are normal. Thank you!
Stephen_Ellis,_MD: You are asking about a question that is somewhat debated. If your angiography was truly 100% normal, it would be unusual to form significant blockages in that number of years. However, most surgeons prefer to be certain whether or not there are blockages prior to surgery - in your case CT angiography may be an alternative to the traditional coronary angiography.
Aorticvalve51: How long should a stent be expected to last?
Stephen_Ellis,_MD: Stents undergo an initial healing phase that lasts about one year and sometimes results in new blockage. That risk is dependent on the type of stent, the nature of the blockage and the person into which it was implanted. The risk of reblockage in the first year averages around 15% for current second generation drug eluting stents. Thereafter, the risk of problems is less on a annual basis, average about 1-2% a year failure rate due to blood clots or the development of new plaque.
hunter16: What are the risk of cardiac stents?
Stephen_Ellis,_MD: The risk of cardiac stents are generally thought of in two phases – during the implant itself there is around a 1% risk of serious applications such as a heart attack, stroke or dying. This risk varies dependent on the clinical situation. After the stent has been in place there is a risk of blood clots forming on the stent which diminishes over time, but also a long term risk of developing plaque within the stent. With that said, the average durability of a stent is probably on the order of 10-15 years.
SarcoidLady: Can stents be placed into collateral arteries if they should fail?
Stephen_Ellis,_MD: Unfortunately collateral arteries are very small and stents can not be placed into them.
Coronary Artery Disease – Re-Blockage
aorticvalve51: I had a stent put in my LAD artery, which was blocked 95%, in August and they said I had a 30% blockage in another artery but that was too small to stent at the time. I continued to have symptoms but passed a stress test so they thought everything was fine. By December that artery was blocked 95% and they couldn't put in a stent because it was the diagonal artery off the LAD and they were afraid if they put a stent in it would damage the stent already in place. They went through the stent and cleared it with angioplasty. My question is how are my arteries blocking so quickly? What can I do to keep this from happening again?
Stephen_Ellis,_MD: The process of reblockage inside stents is somewhat different than how blockages originally arise. It is due principally to scar tissues and perhaps stents that are not expanded enough. Other than not smoking and managing your diabetes well if you have diabetes, you have much less control over this process. If you have repeated reblockage doctors may prescribe medications such as sirolimus, cilostazole, or even brachytherapy at the time of therapy.
edstevens: Four years after a cardio by-pass operation (two arteries, two veins) one of the two veins closed up. The interventional cardiologist (New York Presbyterian) opened up the by-passed vein with four DES (Resolute Integrity). Five months after this intervention I am experiencing angina. My cardiologist has suggested that I might need a stent(s) to be placed within one or more of the existing four stents in the native by-passed artery. Of course he does not know in the absence of a radiological study. This is suggested as the only option. I have been reading the technical on-line literature that mentions that there is a technique involving a balloon angioplasty technique where the plaque is cut away, a procedure which is not used much anymore. The four stents are, in total, approximately four inches in length. QUESTION: If it turns out that there are multiple blockages what options are there to remove the scar tissue blockages? Is the placement of a ‘metal sandwich’ the only option?
Stephen_Ellis,_MD: In most instances, we no longer use cutting or ablating treatment to remove scar tissue inside stents because placement of another drug eluting stent generally provides better results. Recurrence rates after treatment of long blockages are not ideal, however, there may be merit to using sirolimus, cilostazole, or brachytherapy in this instance.
edstevens: If a stent is placed within a pre-existing stent because of restenosis, what is the chance that this procedure will work? It seems that if the first stent resulted in restenosis, then the same would happen to the second stent, and this would result in the need for a surgical revascularization operation. Am I reasoning correctly?
Stephen_Ellis,_MD: Reblockage inside a stent may be due to scarring, inadequate expansion of the stent or a combination of the two. Therefore, although it is a little counter-intuitive sometimes replacement of a second stent with a different medication eluted from it is often successful. That said, long blockages often do not respond well - we are evaluating the usefulness of sirolimus and cilostazole in these circumstances.
edstevens: Four Resolve Integrity DES were placed next to each other to open up a coronary artery that was bypassed by a vein which failed. I am now experiencing angina. If there is a blockage- uni/multi-focal- within the artery, what is/are the possible solutions?
Stephen_Ellis,_MD: The optimal treatment of reblockages within stents depends a lot on the nature of the blockage. We advocate intravascular ultrasound or OCT to see whether the blockage is due to primarily to accumulation of scar tissue or whether the stents themselves were under expanded or have cracked over time. In general, if blockage is short then re-stenting is a very reasonable alternative. If the blockage is longer, then simple re-stenting is less likely to have a good long term outcome. Under these circumstances we sometimes utilize medication such as sirolimus or cilostazol to diminish the risk of reblockage. Sometimes, however, it is necessary to have another bypass surgery.
Plavix and Aspirin
Thomas Phipps: December 2012, 13 months ago I had a DES in my LAD and then in March of 2013 my Subclavian to my Left side was 100% blocked so they did four hours of plumbing and got a large stent in it. I do have hardening of the arteries and it runs heavy in my family. Dad died suddenly at 55 (healthy otherwise and I am now 57 (5'9'' 195# and fairly active). Question: I cannot get anyone, General doc or my cardiologist, to tell me how long to take plavix. I don’t like thin blood and all the side effects but they just shrug and say some take it a year some take it all their life. And that's about it. It's been 13 months and I have asked this is several visits but never get an answer. What is the general rule or let’s say 80% of people like me do with Plavix? Tom from Michigan.
Stephen_Ellis,_MD: General recommendation for plavix after stenting in a person like you is 12 months - sometimes recommended longer if the stent procedure was complicated in the heart arteries. Even though your subclavian was complex, it would not require taking plavix longer.
aorticvalve51: Is there enough vitamin K in a multivitamin to interfere with Plavix working properly? My multivitamin has only 80mcg and I take 75mg of Plavix.
Kali2014: How does the Aspirin therapy or taking regular aspirin helps with the heart in the long run? Does it avoid getting heart attacks?
Stephen_Ellis,_MD: For patients with arthrosclerosis long term aspirin therapy is useful to reduce the risk of heart attack and stroke, albeit with some increase in risk of internal bleeding. The principal mechanism by which it acts is as mild blood thinner. It also has some beneficial anti-inflammatory effects.
Thomas Phipps: On average, how long or is there a way to get off plavix? Step down? lower dose?
Stephen_Ellis,_MD: Plavix is given under different circumstances, so it is a little difficult to answer some of your questions. After a stent it usually is given for 12 months, although with newer stents it sometimes is safe to discontinue it after six months. If someone has a heart attack, particularly if the atherosclerosis is advanced, sometimes it is useful to be on Plavix much longer than that. There is no need to step it down or gradually get off Plavix, as is sometimes useful with other medications.
loveitaly: I am a 58 year old female. Since my early 30's I have had high cholesterol. I've tried all the statins ending in "or"-Mevacor,Lipitor,Crestor,Zocor, etc., and I've always reported pain muscle, even back to the time it was not advertised. Xetia gave me severe gastric problems, Lopid didn't help that much. I have severe Meniere's disease, and fish oil makes me dizzy, probably due to salty ingredients. Lovaza also gave me dizziness. I have family heart history of my brother and my dad. The dr. says my heart is fine, my BP is perfect but he is worried about cholesterol. Another dr. told me about lecithin 500mg,with Pantothenic, Garlic and CoQ10. Another suggestion for people as sensitive as I am? I am allergic to aspirin , so I take Plavix every other day for prevention. I have several other conditions for which I take meds, such as low potassium, low magnesium, non FDA meds. I take for the Meniere's, also a water pill for the ear condition. Thank you for your input.
Stephen_Ellis,_MD: Lecithin, garlic co q10, Metamucil and oats all have a mild anti-cholesterol effect. However not everyone with high cholesterol develops plaque focusing on all of these supplements if you are not. Getting a calcium score may be useful to address whether or not you are susceptible to plaque before going overboard on supplements.
hunter16: What is your opinion regarding Calcium supplement for a person who has a stent placed in LAD for 80% blockage & Ct revealed Calcified Aorta and FMD of b/l ICA and Vertebral arteries?
Stephen_Ellis,_MD: In the situation described it sounds like calcium has built up sort as a bystander effect. With that said, the calcium supplementation is somewhat controversial. Other than using it in conjunction with Vitamin D for osteopenia, it hasn’t been found to be very terribly useful except under limited circumstances.
FORQUER: How important is COQ10, what should it be for someone on STATINS?
Stephen_Ellis,_MD: COQ10 has been advocated by some to be used alone as a preventive for atherosclerosis, but the data on this are relative sparse. It also has been utilized for patients who have muscle pains with statins and it works about half the time (although if you and your doctors try it, you need to make certain that there is not muscle necrosis going on by utilizing blood test to check for it).
wswanlund: Hi Dr. Ellis, I'm being treated now for Coronary MVD, (small vessel disease or microangiopathy). My Dr.'s notes from a 2011 exam: "He had a new left bundle branch block on the resting EKG. The EKG looked normal but for some minor septal dyssynchrony as expected in a LBBB. Conclusion: increased symptoms would relate to MVD. An adenosine nuclear was remarkably normal concluding that it is a small region ischemia not detected with the study. Known sub branch lesion OM. He presented a new LBBB. Cause not clear. Not in the area of his most intense ischemia. Echo looked good other than some slight septal dyssynchronous contraction as one would expect with the LBBB. Follow LV function by echo somewhat more closely 2-D w/CFD Echo to be done in seven months". I understand research is being conducted to study MVD to find effective ways to treat. Is medical management the best way to treat MVD because surgery and angioplasty are not possible or effective? Are there any alternatives?
Stephen_Ellis,_MD: There is some controversy about the best way to start treatment of micro-vessel disease - there are drugs available but different patients respond differently and there is a certain amount of trial and error. On a background of aspirin and statins I would try beta blockers or ranexa - nitrates and calcium blockers are also effective at times. You and your doctor need to know that ranexa interacts with a number of medications. Also - remember a heart healthy lifestyle.
Atypical Coronary Artery Disease
my_joy: My question is regarding atypical CAD. I had a MI when I was 32. The only risk factors were a family history of heart disease and that I smoked. Otherwise, I was extremely healthy. It was assumed the MI was caused by a blockage which was never found. Fifteen years later I suffered a cardiac arrest. There were two partial blockages but the doctor said they were not responsible for the arrest. it has since been determined I have a highly reactive vagal response. I use 1500 mg slo niacin for cholesterol control. I have adverse reactions to Statins and other cholesterol meds. My diagnosis remains CAD and not atypical CAD but there is a big difference in treatment. Is it more common for women to suffer from atypical CAD and why is it not discussed more? Though it is not positive, it is believed now, that I suffered from syndrome X.
Stephen_Ellis,_MD: Over the last several years it has been well recognized that women develop heart problems that are somewhat different than men – more notably diffuse, small vessel disease, with somewhat atypical symptoms. Your situation sounds somewhat complex and I am a little reluctant to offer much advice in this forum. I do think, however, the history of cardiac arrest that you likely should have been evaluated by a electrophysiologist.
Aashri22@gmail.com: My father got heart stroke in 2012 and put it into stent he still having aspirin tablets. May know which foods are avoided? Which foods are healthy for him. He got coronary artery disease.
Stephen_Ellis,_MD: Patients with strokes should be on aspirin and if possible be on a good diet and exercise - if you are specifically asking if aspirin reacts with foods as do other meds - there are no major interactions that most people need to be aware of.
kahuna8: I have recently been diagnosed with Polymorphic Ventricular Tachycardia (From a stress EKG). I am 77, male, excellent overall health with the exception of severe aortic valve stenosis (0.9 area, 52 gradient, Eject F. 72%.). No symptoms. What further tests would you suggest (if any) to further evaluate the PMVT? I anticipate that in the intermediate future I will need to have the aortic valve replaced. Thank you. HWH
Stephen_Ellis,_MD: Polymorphic VT in the setting of aortic stenosis is a potentially worrisome finding. We generally recommend aortic valve replacement for exercise induced angina, short windedness or dizziness. Are you symptomatic with the VT? Based upon the echo results alone you will probably need AVR in a year or two. In the meantime I would stay away from exercise and pay close attention to your symptoms.
adourian: I have excellent blood results for HDL (100), total cholesterol (190) and low triglycerides (25). Blood pressure good and nuclear stress test normal. I thought I was bullet proof until I started having paroxysmal Afib episodes two years ago and recently found out I had low moderate AS. A lot of excitement has happened recently on TMAO as a better indicator of future cardiovascular disease. Am I a candidate for such a test?
Stephen_Ellis,_MD: Although we do not understand all causes of aortic stenosis or AS, there is clearly a genetic component and cholesterol is important. We don't know if TMAO is related to AS. Your paroxysmal AF may be related to your AS. You should have periodic echoes to assess the progression and severity of your AS.
rosed: In November I had my Aortic Valve replace. A catheterization was done that showed all arteries to be clear. Do I still have to consider myself as having CAD?
Stephen_Ellis,_MD: If all your arteries were truly clear at cardiac catheterization then you do not have to consider yourself has having CAD. The term “clear” is sometimes used rather freely, however. CAD means evident of buildup of plaque in the heart arteries.
rheudean: Can CAD lead to a myxomatous mitral valve and cause mitral and tricuspid regurgitation? I am a 36 year old female and have been having extreme fatigue and SOB. Echo results showed myxomatous changes to the mitral valve and mitral and tricuspid valve regurg. My EF is 51%. Another thing worrisome on my ECHO was my LV diastolic volume was only 51ml. My father died at age 26 with massive MI from severe CAD. Strong paternal family history for CAD. My doctor told me there was nothing to worry about, that I was fine and I didn't need any further treatment. I seem to disagree. I should not feel this way at 36 years old. I personally think I need to be referred for valve repair. An echo and cath was done 13 years ago and no abnormalities found other than SMALL Coronary arteries. No regurg at that time.
Stephen_Ellis,_MD: CAD does not lead to myxomatous mitral valve degeneration. The usual indications for mitral valve repair for mitral valve prolapse are weakening of the heart muscle as manifest by decrease in ejection fraction or enlarging systolic volume, or a very large amount of regurgitation flow across the valve. Given your family history of coronary disease, a normal cath 13 years ago is not 100% reassuring. The best non-invasive test to see if you have a build up of plaque is usually a calcium score. This is, however, sometimes misleading in persons as young as you are. Obviously you should refrain from smoking and make sure your other CAD risk factors are under control.
Psych: Hello. I have fluctuating BP (started May, 2013), tachycardia (started about June, 2013), and at least one arrhythmia, not A-Fib (started about November, 2013). I am a 65 year old woman who takes the lowest doses of Lipitor and Cozaar/hydrochlorothiazide. No other heart medication has ever been needed. Do you have any idea what underlying issue/disease, etc. could cause this combination of symptoms? At what point does this combination produce damage to the heart? What would either or both of you suggest as a next step for me? I have learned I have bilateral renal stenosis 0 to 59%. Such numbers are entirely useless. At what “percent” does bilateral renal stenosis have cardiac significance? I have stenosis in the chest vessels, also. What can be done to rectify the stenosis and/or reduce the progression of the problem? I have been to Cleveland Clinic and had numerous tests, resulting in no answers nor any direction to go in order to find answers.
Stephen_Ellis,_MD: Although there are numerous causes of high blood pressure, more often than not we are unable to pinpoint the exact cause in an individual like yourself. Blocked renal arteries are one of the causes of high blood pressure, but generally this is not a problem until the blockage exceeds 70% narrowing in both kidney arteries. It is a little hard to discuss the nature and possible treatment of your tachycardia without hearing more about the details.
xdwl: Hi, I am 55 year old female with HCM (post-surgery, NYHA II), menopause in age 51. I was found aortic arch calcification five years ago by CXR. Chest CT in 2012 showed calcification in aorta and coronary artery. Fortunately, my later coronary angiography was normal. Recent echo found ascending aorta 45mm. I would like to get your advice: 1) I used to take calcium 500mg/day from age 45-53. Is it the reason for these calcification? 2) I stopped calcium one year ago, and continue skim milk 250ml/day. But I got back pain. I do not do much outdoor activities. So my doctor put me on Vit D 300ug/day, my back pain improved. Now, I want to continue taking Vit D 300ug/day for long term -- would Vit D make artery calcification worse? 3) I do not smoke, no family risk, no hypertension, etc. But I got high hsCRP 6.36mg/L (double of normal), high HDL 82mg/dL, and high normal LDL 120mg/dL. Would these factors, plus artery calcifications, be risks for heart disease? What is the ideal aim for my LDL? What about HDL?
Stephen_Ellis,_MD: I think that low level vitamin D supplementation as long as your vitamin D and calcium levels are normal should be safe. The process of calcification in the aorta is more related to potential genetic changes and blood pressure and lipid control. With a 45 mm ascending aorta, you should be on beta blockers to decrease the rate of pressure change in your aorta. Get a CT scan to better delineate the extent of enlargement and periodic testing based on the results of the above. You should also have further investigation about why your CRP is so high.
Q0093: Hello Dr. Ellis. I'm working with a patient who was recently diagnosed with Afib after cardiac arrest four-five months ago. Several other complicating health conditions, diabetes (five years), morbidly obese (460 lbs.), family history of heart disease and fatality, no real social supports. I'm an LPC, current role with this patient is a health coach (BCM). What medical advice could you give me, based on this brief synopsis, to better help me understand his condition? Understandably he is despondent and apathetic, refusing further outreach to gain support for increasing depressive symptoms. Thank you in advance.
Stephen_Ellis,_MD: This is a difficult situation. It would seem important to see if you can figure out what can motivate this patient, in particular, to begin to work on problems such as diet and exercise. It is clearly important for them to see a physician regularly and take medications as prescribed. Does he have children or grandchildren who he wants to see grow up? It sounds as if dealing with his depression and motivation are the underlining problems that need to be dealt with.
Hypertrophic Cardiomyopathy – HCM
cmack216: Dr.Ellis, I was diagnosed with non-obstructive HCM. What can i do to keep it from becoming obstructive? Are there any dieting or exercising I can do to that may help.
Stephen_Ellis,_MD: Unfortunately there is no form of diet or exercise that can halt the progression of this problem. Beta blockers can minimize the dynamic nature of the obstruction to some extent. HCM also has been associated with sudden cardiac death in some patients. This is often familial - if this runs in your family you should see your cardiologist to be evaluated.
Stem Cell Therapy
earlused: Has any progress been made in Stem Cell Therapy to isolate the cells to repair damage done to the heart muscle? If not is that form of treatment not feasible in the near future? Thank You for taking the time to answer my questions.
Stephen_Ellis,_MD: Progress in stem cell therapy has been somewhat disappointing - we have learned that taking stem cells from the bone marrow where it is easiest to get and injecting it into the heart is not particularly effective. Different types of stem cells (such as from the heart itself) are presently under evaluation at many advanced centers.
Thomas Phipps: You don't have to respond, I just want to say thanks a bunch. As you can tell I am severely scared and depressed over not able to find a good Cardiologist. Your answer was more than I could get at hospital or doctors. Email me if you would like. God Bless. Thomas Phipps.
Lexi77: Thank you Dr. Ellis - you are the BEST.
Q0029, chrisriley7: CAD - When it comes to age, gender, and heredity - Why is there a standard chosen age groups over heredity when it comes to this #1 Heart Condition-Killer in this country? Can minimal CAD untreated over several years, cause Arrhythmias such as Bradycardia and Paroxysmal Atrial Fib with Cardiac type symptoms-such as Unstable Angina, Cardio-Syncope, etc.? What preventive testing is needed to detect and what treatments are available if needed?
Stephen_Ellis,_MD: I am not certain that I fully understand your question. Our overall approach involves taking inventory on factors that make someone predisposed to the development of atherosclerosis; if that inventory suggests high risk then we would generally recommend treatment of those risk factors, although there is another school of thought that says not all people with risk factors develop plaque and test such as calcium score should be done in advance of treatment. Untreated minimal CAD can occasionally cause arrhythmias but more likely these are due to other problems such as high blood pressure or valvular heart disease. Minimal CAD can lead to unstable angina, although this usually takes many years to develop.
asadchowdhury: My blood serum creatinine level 1.04. Ultrasound of picture of kidney is okay. I am male. In that time, I had urine infection and rbc in urine, but after antibiotic treatment Rbc and albumin found nil. Am I safe or my kidney is ok. In that time I have done my teeth treatment and eat some pain relief medicine. How can I reduce creatinine level.
Stephen_Ellis,_MD: As you may know, creatinine is a waste product which is eliminated by the kidneys from the blood. Your overall level would generally be considered normal, but a more precise measure of kidney function called is the creatinine clearance, which takes into consideration age, body size and other things. The single most important thing to do to try and keep your creatinine in range is to make sure your blood pressure is well controlled. Some medicines do tend to damage the kidneys, particularly with chronic ingestion. These would include pain medications such as Motrin and Naprosyn.