Tuesday, January 12, 2010 - 12 Noon
Coronary Artery Disease: Diagnosis and Treatment with Ravi Nair, MD
Your heart is a strong muscular pump that is responsible for moving about 3,000 gallons of blood through your body every day. Like other muscles, your heart requires a continuous supply of blood to function properly. Your heart muscle gets the blood it needs to do its job from the coronary arteries. When these arteries become narrowed or blocked it is referred to as Coronary artery disease (CAD). CAD affects 16.8 million Americans. The American Heart Association (AHA) estimates that about every 34 seconds, an American will have a heart attack. Cleveland Clinic Interventional Cardiologist Ravi Nair, MD answers questions related to how to diagnose and treat this harmful disease.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Ravi Nair. Dr. Nair is Interventional Cardiologist in the Heart & Vascular Institute at Cleveland Clinic. We are excited to have him here today for this chat so thank you Dr. Nair for joining us!
Speaker_-_Dr__Ravi_Nair: Thank you for having me.
Diagnostic Testing for Coronary Artery Disease
JJAltoona: Dear Dr. Nair I recently suffered my second MI in just over three years. I had restenosis of a stent in the LAD which was one of three stents in that artery. I also have two other stents in other arteries. I passed my yearly nuclear stress test last Summer with no problems detected. Since I have advanced CAD, is there a test or procedure that could be used either with the stress test or as a substitute that would be more effective in locating blockages or potential trouble spots?
Speaker_-_Dr__Ravi_Nair: No other imaging studies to do. What you need to do is aggressively modify your risk factors and check your CRP or c reactive protein. The CRP test if abnormal predicts greater risk of future events.
marce: What is the difference to proceed with an angiogram via the groin and the hand? Is one better than the other? Also there are two types of stents - coated and uncoated? Can you explain the difference and advise which is better?
Speaker_-_Dr__Ravi_Nair: There are pros and cons to both approaches and the decision is made by the cardiologist performing the procedure what approach is used.
"Coated" stents are also known as drug eluting stents and made up of a steel mesh covered with a thin layer of plastic mixed with a medication. In most situations, the coated stent is better than the bare metal stent. The decision which is to be used depends on certain clinical situations and the decision of the interventional cardiologist. The coated stents are associated with good long term results but require long term treatment with "blood thinners."
jmk: I had a cardiac cath and it said I have moderate disease in the LAD and mid subtotal occlusion. Also the marginal branch has moderately severe disease proximally. Do you think that angioplasty and stent could be used – I am trying to avoid surgery. My doctor seems to think bypass surgery is the answer?
Speaker_-_Dr__Ravi_Nair: I cannot really advise without looking at your cardiac catheterization films. This is an important decision and should be discussed with your doctor - or you can have a second opinion from an interventional cardiologist.
JJAltoona: I mentioned previously that I recently had my second MI. Once I begin Cardio Rehab, is there a measure other than Ejection Fraction that would give an accurate idea of just how much strength I have regained in the heart muscle itself, or is this still the number that I need to concern myself with?
Speaker_-_Dr__Ravi_Nair: Ejection fraction is the metric we use to quantify left ventricular ejection fraction.
sharon_g: Are there any instructions about how long you have to wait to have an MRI after stent placement?
Speaker_-_Dr__Ravi_Nair: You can have it done at any time.
Peppy: Do you test long-term Troponins after angioplasty/stenting?
Speaker_-_Dr__Ravi_Nair: Not usually.
suzie980: I have a family history of coronary artery disease. I exercise. I am on zocor and my cholesterol numbers are good. I exercise and don’t smoke. I had an hs-crp test done and the number was high. Waiting to go back to my doctor – but what is really the significance of a high crp if they are already treating high cholesterol?
Speaker_-_Dr__Ravi_Nair: high crp is a risk indicator for cardiac events such as heart attacks in the future. Further efforts to lower it may change your risk profile.
Risk Factor Modification/Lifestyle Change for Coronary Artery Disease
JamesS: I have seen articles that suggest drug and lifestyle programs are as good as angioplasty for persons with symptoms associated with artery blockages.
Speaker_-_Dr__Ravi_Nair: Each patient is unique. In stable patients with certain locations of blockages that can be true. Angioplasty is usually indicated for patients that are refractory to medical treatment and behavioral modification. Even after angioplasty one has to modify their lifestyle to minimize risk factors.
Decision on angioplasty and conservative therapy can only be made after the angioplasty has defined the extent - severity and location - of the blockages.
tirreno: I'm a 51 year old healthy mail with no heart disease in my family. 10 years ago I had triple by pass and 5 months ago I had 2 stents put into my Ramus, because the bypass collapsed. I feel much better now and I'm assuming that this collapsed years ago since this the best I felt even after the bypass. I exercise three times a week, what else can I do to assure I continue along a healthy with a long future.
Speaker_-_Dr__Ravi_Nair: Maintain ideal weight. Achieve ideal numbers for cholesterol with diet, exercise and medications if necessary. Continue your exercise program with moderate levels of exercise 5-7 days per week.
tirreno: I have read about heavily concentrated Vitamin C that possibly can help with artery health - is this true?
Speaker_-_Dr__Ravi_Nair: The current literature on Vitamin C is controversial. But apparently not harmful.
tirreno: What do you mean controversial??
Speaker_-_Dr__Ravi_Nair: There have been a few studies but there has not been enough data to prove that vitamin C specifically has positive benefits.
Peppy: Describe the "strict diet" you referred to earlier. What would it consist of? Vegan?
Speaker_-_Dr__Ravi_Nair: It is not so much the content of the diet as it is to achieve and maintain ideal weight and cholesterol values. If you are a diabetic, you need to control your hgb A1c and glucose should be at goal with the appropriate diet and medications.
tirreno: What do you mean by aggressive lifestyle modification?
Speaker_-_Dr__Ravi_Nair: Diet - exercise moderately 5-7 days per week - achieve ideal body weight - achieve goal cholesterol levels. Achieve goal hbg a1c if you are diabetic. Prevent smoking primary and second hand. Practice relaxation techniques and reduce stress.
Symptoms of Coronary Artery Disease
cadinterest: In 1991 & 1992 I had 5 angioplasties (no stent). Recently in cold weather I have a sensation of fullness or bloated feeling near the diaphragm area of my stomach when I walk (not angina) only. Could this be cardiac related?
Speaker_-_Dr__Ravi_Nair: Very well could be. Please see a cardiologist soon to evaluate.
Coronary Angioplasty and Stents
Peppy: I have a Taxus stent now for two years and still on Plavix. I have seen too many friends now have a "bleed" and three have died. My cardiologist tells me "if" something happens we will deal with it then. That is not good enough. Is there no answer to this problem? The new antiplatelet drugs seem to have the same bleeding risks and in one case increased bleeding risk. My stent is in the diagonal artery. I understand the older Taxus stents are more likely to have thrombosis and more so as time elapses.
Speaker_-_Dr__Ravi_Nair: It appears that there is a small incidence of very late stent thrombosis with any stents. There is some information to suggest that the incidence may be higher with Taxus stents. Continue therapy with aspirin and plavix generally reduces the risk of late stent thrombosis. Check with your doctor about your concerns - perhaps after some time your plavix could be discontinued.
Peppy: Could you discuss drug eluting balloons. Can they be used successfully to open a restenosed stent?
Speaker_-_Dr__Ravi_Nair: There is some data from Europe that it is associated with some positive results. Not yet available in the United States.
tirreno: Since the ramus in not anatomically in a groove - is there a chance that a stent will migrate out.
Speaker_-_Dr__Ravi_Nair: Stents do not migrate once deployed.
pixtaker007: My dad has blockage in the mid LAD and the doctors suggested angioplasty – can medications be used instead. What are the risks of this procedure. My dad is 70 years old.
Speaker_-_Dr__Ravi_Nair: There are major risks with these procedures but the occurrence of these risks are very small. Discuss your concerns with your father's doctor. Medical therapy and stent placements are equally good options. The decision is individualized to the patient.
James_H: How long does an angioplasty with stent usually last?
Speaker_-_Dr__Ravi_Nair: It can last for a long time. It depends on the risk factors and the type of stent that is used.
tirreno: How long do drug coated stents last? Is there a time frame to see if a stent is working or failing?
Speaker_-_Dr__Ravi_Nair: More than 95% of the drug eluting stents are patent for more than 5 years. (we do not have enough long term data as they have not been around for more than 10 years). There really is not a time frame to see if a stent is working or failing - if stents are patent after a year - they generally stay open long term.
Peppy: Could you elaborate on your answer to James_H? I was told my Taxus DES would last me the rest of my life. From research that I have read I am not so sure?????
Speaker_-_Dr__Ravi_Nair: Refer to the previous question. Any drug eluting stent is associated with long term patency.
wings: My dad was told he has inoperable coronary artery disease – what are the possibilities for him? Is it possible they could still stent him?
Speaker_-_Dr__Ravi_Nair: A specific opinion cannot be given without reviewing the angiograms. We would be happy to take a look at your father's catheterization films by econsult or an appointment.
mvp00: Is it possible to do an angioplasty through an artery that is 100% blocked?
Speaker_-_Dr__Ravi_Nair: Sometimes yes. Success rates are from 50-70 % blockage. Special wires and other devices are used in such situations.
marcier: My mom had coronary artery disease and needs to have an angioplasty on her LAD. When they did the tests, they found she also has an 80% blockage on her carotid artery. Can they open up both arteries with angioplasty at the same time?
Speaker_-_Dr__Ravi_Nair: it is not advisable to do two major procedures at the same time.
snowflakes: If one has a blockage in the LAD and RCA – how does one decide upon surgery vs. angioplasty and stent. What are the pros and cons of each?
Speaker_-_Dr__Ravi_Nair: Pros and cons are best discussed with a one on one with the procedural cardiologist. There are pros and cons to both approaches. You need to look what is best specifically for you.
lopwise2: I am a diabetic controlled with anti-diabetic pills, and was diagnosed with dilated cardiomyopathy in 2000 with an original ejection fraction of 30%, now it is per ultra sound about 50% but was 40% in 2007 when angiogram was done which showed blockage with two coronary arties 40% in both. The cardiologist elected to treat the blockage with medication instead of putting a stent in. In addition to the anti-diabetic medications, I am on an ace inhibitor, beta blocker, aspirin and statin. So my question is when is it generally suggested that a stent be used versus treating the blockage with medications?
Speaker_-_Dr__Ravi_Nair: Generally obstructions of more than 70 percent are treated with stents - especially if patients are symptomatic.
carrie05: My mother had bypass surgery 2 years ago – now they say her grafts are blocked – is it possible to do an angioplasty in a graft to open the graft?
Speaker_-_Dr__Ravi_Nair: Yes. It is possible to do an angioplasty in a graft. It depends on the extent of disease in the graft.
ggint: Is there a limit to how many stents that would be placed in an artery?
Speaker_-_Dr__Ravi_Nair: No - but more than 10 would be very unusual.
jillians: I had an angioplasty and stent placed a year ago – since then my stress tests with thallium have been normal. What medications do you usually suggest and what tests to prevent and diagnose re-blockage in the future?
Speaker_-_Dr__Ravi_Nair: I always recommend lifestyle modification to my patients post angioplasty and stent to achieve lipid goals, blood pressure goals, and weight goals. Continue use of aspirin and cholesterol lowering medications have shown to be of considerable benefit. Plavix if it is indicated. Regular cardiologist follow up and stress tests at the discretion of your cardiologist is advised.
christopher: I am on beta blockers for hypertension over ten years. Is it true that beta blockers also have a benefit to reducing progression of coronary artery disease?
Speaker_-_Dr__Ravi_Nair: No benefit on reducing benefit of coronary artery disease. But - it is an important drug in patients who have had previous heart attacks.
tirreno: Can a combination of beta blockers, plavix, and statins cause erectile dysfunction?
Speaker_-_Dr__Ravi_Nair: Of the drugs you mentioned, beta blockers are mostly associated with erectile dysfunction. Aspirin and Plavix are not. Underlying disease can also be responsible if it is associated with vascular disease
Peppy: How long are patients kept on beta blockers after angioplasty/stent? The metropolol tartrate (50 mgs.) cause weight gain for me. My blood pressure seems too low also. This morning it was 78/47. They had stopped the Lisinopril a year ago. Is this a common problem with this particular beta blocker?
Speaker_-_Dr__Ravi_Nair: Weight gain is not a usual side effect with beta blocker. Metropolol is not necessarily used long term after angioplasty, although you may have another reason to be on this drug.
tirreno: Is metaprolol a beta blocker?
Speaker_-_Dr__Ravi_Nair: Yes it is a beta blocker.
tirreno: I have been on metaprolol 50 mg a day for 10 years after my bypass surgery - is this normal?
Speaker_-_Dr__Ravi_Nair: Metropolol is indicated in patients with hypertension, cardiac arrhythmias, previous heart attacks, there are many indications - it is not unusual to be on metroplol chronically. Check with your physician if you have questions about your medications.
Coronary Artery Disease
flower12: Is coronary artery disease progressive or can you slow, stop or reverse the process?
Speaker_-_Dr__Ravi_Nair: In the majority of situations it is progressive. The other two can be true with aggressive lifestyle modification and treatment.
tirreno: After triple bypass and 10 years later my cardiologist told me that after reviewing the catheterization films that my heart disease shows no sign of progression - is this possible?
Speaker_-_Dr__Ravi_Nair: Yes it is possible.
smith_m: I'm 50 years old ; have small vessel disease and coronary artery disease. I have had 10 stents placed. I have chest pain and use nitro patches and tablets all day. My doctors say they have done all they can. Do you have any information that can help me?
Speaker_-_Dr__Ravi_Nair: You can certainly come here with all of your data - including films - and we can give you a second opinion.
nngoal: I just moved to a new town and going to see a new cardiologist. How do you know if one is good or not. I am 68 years old – had bypass surgery in 2005 and type 2 diabetic. What questions should I ask him?
Speaker_-_Dr__Ravi_Nair: Check your cardiologist's profile. Check with colleagues and friends and your primary care physician.
Stem Cell Therapy for Coronary Artery Disease
sweetjill56: My husband has had a couple bypass surgeries and multiple stents – we are at the end of the road I think for treatment and the doctor is talking about heart transplant. What doe stem cell therapy do? Can you explain this type of research and what it hopes to do?
Speaker_-_Dr__Ravi_Nair: Stem cells can grow new vessels or new heart muscle. Research to prove this is underway. You can look at current studies underway to see if your husband is a candidate for stem cell research at www.clinicaltrials.gov.
There is more room for aggressive risk factor modification - following a strict diet - reaching cholesterol goals, as mentioned before.
Radiation Heart Disease
benlomondeast: I'm a 28 year survivor of Hodgkin's Disease treated with t. nodal R.T. that included a 4600 cGy delivery to the mediastinum, the first 1000 cGy in 200 cGy daily fractions without blocking to relieve distressed breathing. Aortic and mitral valves now show premature calcification on echo, the carotids are narrowed, and I am symptomatic. What are the treatment options in cases such as my own where damage to the great vessels, and subsequent occlusions, are R.T. related?
Speaker_-_Dr__Ravi_Nair: If you have symptomatic occlusions and the severity is confirmed by imaging studies, then the valvular disease may require surgery and the great vessel disease can be treated with surgery or in some circumstances percutaneous techniques. You need to have an initial evaluation and then follow closely with a cardiologist.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Ravi Nair is now over. Thank you again Dr. Nair for taking the time to answer our questions.
Speaker_-_Dr__Ravi_Nair: I just want to re-emphasize the importance of lifestyle modification and reducing risk factors for patients with coronary artery disease. The importance of achieving and maintaining your ideal body weight can not be over emphasized.
Goodbye and thank you for having me today.
Technology for web chats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC).