December 18, 2009
Dr. Michael Lincoff
Vice Chairman, Robert and Suzanne Tomsich, Department of Cardiovascular Medicine
Coronary artery disease (CAD) is the number one killer in America. Treatment of CAD is aimed at controlling symptoms and slowing or stopping the progression of disease. An interventional procedure is a non-surgical treatment used to open narrowed coronary arteries to improve blood flow to the heart, used when simpler methods of treatment are not effective. Dr. Lincoff, a Cleveland Clinic interventional cardiologist provides answers to your questions about the treatment of CAD and interventional procedures during a free online chat.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Michael Lincoff. We are thrilled to have Dr. Lincoff here today for this chat. He is the Vice Chairman of Cardiovascular Medicine at Cleveland Clinic. Thank you for joining us Dr. Lincoff. Let’s begin with the questions.
Speaker_-_Dr__Lincoff:: Thank you for having me today.
Angioplasty and Stents
maryz: What are the most common risks associated with stents?
Speaker_-_Dr__Lincoff:: All stents, the traditional bare metal or newer drug coated, carry a risk of re-narrowing or "restenosis" over the 6 to 9 months after they are placed. This is due to scarring, which forms around and within the stent and can gradually narrow the blood vessel.
Stents reduce that risk of re-narrowing from what had traditionally been as high as 40 percent when balloons were used alone. With bare metal stents that risk is in the range of 15 - 20 percent. And with the new drug coated stents, that risk is reduced further to as low as 7 to 10 percent. Generally patients have recurrent chest pain or abnormal stress test if their stents re-narrow.
The other risk associated with stents is blood clotting within the stent. This occurs infrequently in only about 1 percent of patients but can be associated with a major heart attack if it does occur. The highest risk period is the first weeks to months. The risk is reduced markedly when patients take their aspirin and plavix as prescribed. The risk of clotting may be a little more prolonged and a little higher with drug coated stents compared with bare metal stents and this is why plavix is prescribed for one or more years after a drug coated stent.
Peppy: I have read recently that interventionalists are not stenting the diagonal arteries so much anymore. Is this the case at Cleveland Clinic and why?
Speaker_-_Dr__Lincoff:: The decision of whether or not to stent a diagonal artery depends on the size of the vessel, the location of the blockage, and whether or not the patient is having chest pain.
smithw: I had 3 DES stents placed a month ago. How long do they usually last – does it matter what vessel they were placed in for the longevity? Mine were left side.
Speaker_-_Dr__Lincoff:: Drug eluting stents (DES) carry an approximately 7 - 10 risk of re-narrowing over the 6 to 9 months after they were placed. This typically means that a patient would have recurrent chest pain or their stress test would become abnormal again. After 6 to 9 months if this has not occurred the risk of re-narrowing is very low and the stents essentially last indefinitely. There is no major difference between re-narrowing rates in the different heart arteries.
maryz: What are the major considerations when you recommend stents versus bypass surgery? What type of situations would bypass be strongly preferred? And what would be the risk of using stents in those cases, if even possible?
Speaker_-_Dr__Lincoff:: This is a hugely complicated question and the source of much controversy in the medical community over the last 3 decades. The decision really needs to be made specific to each individual patient. In general, bypass surgery may be preferred in patients with extensive coronary artery disease, blockages in certain key locations, substantial heart muscle weakness, or blockages of several arteries in patients who are diabetic.
tim_54: My father is 80 years old. He had severe chest pain and sweating last week and went to the hospital. They said he has coronary artery disease in 4 places and needs bypass surgery. I wonder if there are other options for him. No heart damage luckily.
Speaker_-_Dr__Lincoff:: There certainly might be options of stents or medications. It would depend upon the results of his catheterization and other medical conditions. I suggest he seek a second opinion. If he does come here for second opinion, it would be very important that he bring the actual CD (film) of the catheterization, not simply the report.
clara: I submitted a question, but I probably did it incorrectly. I had bypass surgery 2 years ago and a stent in the posterior descending 5 months ago. I have 80% blockage in the distal circumflex that they could not stent. What can be done about that artery? I was told that I am a difficult case. Other blockages have gotten worse too including the grafts.
Speaker_-_Dr__Lincoff:: This is a complex problem which may be better addressed at a center with more experience with patients with complex disease. I suggest you seek a second opinion. And as mentioned in a prior answer, I emphasize that you should bring the film or CD of the catheterizations rather than simply the reports.
Coronary Artery Spasm
livestrong00: My sister had a heart attack 2 months ago and they said it was a coronary spasm. Is that something that is hereditary like blockage? Should I be worried too? I am 45 years old – My sister is 48.
Speaker_-_Dr__Lincoff:: Coronary spasm is generally not hereditary. Coronary spasm is a rare cause of chest pain but it is even rarer to have a heart attack from spasm.
jilln: My husband has Coronary Artery Spasms in the LAD where he has three stents in one place. Why are these stents causing spasms and is there a way to fix this problem? Would a By-pass take care of the spasms?
Speaker_-_Dr__Lincoff:: That is a very complicated question. It is often unclear if spasm is actually occurring or is the cause of chest pain. Spasm is actually fairly rare as a cause of chest pain. When it does occur, medications to relax the arteries are generally the therapy. Beyond this general information, your husband would need to be evaluated to provide you with specific advice.
Medications and Medical Management of Coronary Artery Disease
Peppy: Will eating lots of greens daily interfere with my dual antiplatelet meds?
Speaker_-_Dr__Lincoff:: vegetables do not interfere with platelet medications - you may be thinking of a stronger blood thinner called warfarin or coumadin, which is affected by dark green vegetables.
jason_mk: I need to have surgery on my knee and the doctor is taking me off my plavix. I had a couple drug eluting stents placed 6 months ago. I read online that they need to keep you on plavix for a year for a DES. Am I at risk – what do you normally do in this situation?
Speaker_-_Dr__Lincoff:: You absolutely should not stop the Plavix unless advised to do this by the cardiologist who placed the stent or by another interventional cardiologist who knows the details of your stent history. There is definitely a risk of clotting the stent and causing a heart attack if you stop Plavix or aspirin in the first one to two years after a drug eluting stent (DES) is placed.
When patients have had a drug eluting stent we delay any surgery that isn't an absolute emergency for at least one year. After one year, ideally, both aspirin and plavix would be continued before and after surgery. If this is not possible due to bleeding risk, the aspirin should be continued and the Plavix restarted as soon as possible after the surgery. I emphasize that each case is different and you should get specific guidance from your cardiologist before stopping either the Plavix or aspirin.
Peppy: Once you have a stent does that mean you cannot consider medical therapy should another event occur in the future and skip the stent?
Speaker_-_Dr__Lincoff:: The decision to use medical therapy vs. an invasive approach can be made independently for each episode of symptoms or each blockage. Having had one stent does not commit you to a specific course of treatment for the future.
Symptoms of Coronary Artery Disease
mizz_1: I have pain in my left arm pretty much all day – it sometimes goes into my chest – but I wouldn’t say it was over my heart. I had a risk screen at work and my cholesterol is ok and blood pressure – but do you think this could be heart related?
Speaker_-_Dr__Lincoff:: In general, pain that lasts continuously for hours or days at a time is not due to the heart. But - if you have concerns about chest pain symptoms you should see a physician.
waltz_b: I am a 50 yr old female, in the past year I have had 5 stents and some are medicated and - I still suffer chest pain. I wear a nitro patch daily and other blood pressure and cholesterol medications. I had a stress echo this week and the doctor said it was ok but I had chest pain during the test and couldn’t finish it. My mom and grandmother both died young from heart disease so I am very nervous. What are my options?
Speaker_-_Dr__Lincoff:: Seek a second evaluation - we have doctors here who specialize in the management of patients with continued symptoms - The Center for Advanced Ischemic Heart Disease may be an option for you - see http://my.clevelandclinic.org/heart/about/specialties/advanced_ischemic_heart_disease_center.aspx
cbn_12: I have chest pain every day. I have been told I have small vessel disease. My local hospital has tried to place 8 stents over the last year and no relief. I am having trouble doing day to day activities and had to take early retirement. Are there any things you can do for me for small vessels? I am on a nitro-patch and also take nitroglycerin tablets.
Speaker_-_Dr__Lincoff:: In this type of situation, we have a specialized clinic with physicians who treat patients such as you are describing. Please see my.clevelandclinic.org/heart/about/specialties/advanced_ischemic_heart_disease_center.aspx for more information.
Adee: In general, how does one distinguish between costochondritis issues and heart angina type pains?
Speaker_-_Dr__Lincoff:: Often by physical exam, pain due to costochondritis will be reproduced by pressing on the chest wall. But in any specific case, we use information derived from an entire evaluation including stress tests if indicated.
steelers08: I have a DES from last year and started having symptoms again. The doctor said I have a small artery blocked at 85% now but they can’t do anything with it. Please explain why.
Speaker_-_Dr__Lincoff:: The artery may be too small or the blockage too long for balloons or stents. Similarly in that situation, heart surgery would be too much risk for a small artery. In those situations, therapy with medications is appropriate.
Cardiac Catheterization: Arm vs. Leg
taylor: What do you think about cardiac cath through the arm? I have a cath scheduled next week and it is through the groin but then I read that they can go through the arm and the recovery is easier. Should I find another doc to do my cath who can do it through the arm? What are the benefits of going through the groin, if any?
Speaker_-_Dr__Lincoff:: The decision to use the arm or leg depends on a lot of factors including the likelihood that a patient will need a balloon or stent procedure. In general, unless a physician does a large number of cases from the arm routinely, the approach from the arm will take longer and be technically more difficult and perhaps more complicated.
The artery in the leg is larger than the one in the arm and generally accommodates the equipment needed to perform cath or angioplasty more safely. Thus, most physicians prefer to use the leg approach. Cath from the leg does require you to lay flat for a number of hours after the procedure and is associated with a slightly higher risk of later bleeding than from the arm. But - usually the advantages of a faster and less complicated procedure from the leg outweigh these disadvantages.
Follow up – Physician Visits
steven: I had an angioplasty 5 years ago. My doctor does a cath on me every year - is that the right type of follow up - is there any danger to having that many procedures?
Speaker_-_Dr__Lincoff:: Generally we do not perform catheterizations routinely after a stent procedure. Depending upon symptoms or where the stent was placed, it may be appropriate to perform stress tests every year or two but catheterizations should only be performed for either recurrent symptoms or an abnormal stress test. The one exception to this is when a stent is placed in a key artery called the "left main." In that case, it is sometimes appropriate to perform a single follow up catheterization 3 to 9 months after the stent was placed. Even in that situation, yearly caths are not warranted.
carrin: I am a 33 year old pregnant female (18 weeks) diagnosed with ST segment EKG depression and ischemia. I am looking for a second opinion on how to proceed in terms of medical care.
Speaker_-_Dr__Lincoff:: There are stress tests that do not require radiation or drugs that can be performed - these are known as stress echo. I suggest you see a cardiologist to have this evaluated.
floralsmile: I had an exercise stress test and the report stated old inferior MR, non specific ST during stress, abnormal resting ECG – achieved 85% of my predicted maximal heart rate. No exercise induced ischemia and arrhythmia. My doctor said the report was good and just watch my cholesterol and blood pressure. But what about the ST during stress and abnormal resting ECG. Is this the right treatment for this?
Speaker_-_Dr__Lincoff:: The stress test has to be interpreted in the context of your overall history and situation. In general, the EKG is not as accurate as imaging with a nuclear camera or echo. So - if the images look fine and normal, it may be appropriate to consider the stress test OK - but again that decision would need to be made knowing your overall situation.
Peppy: What is a non-stemi?
Speaker_-_Dr__Lincoff:: The term non-stemi refers to a heart attack that has certain findings on an EKG. It can be a large or small heart attack.
mandy: My dad has heart disease and my brother has coronary disease. I am on lipitor for high cholesterol and take an aspirin daily – but other than that I have no symptoms and no other risk factors. My doctor sees me every year but then has me do a stress test with nuclear every 2 years – is the stress test necessary? How much radiation is involved with a nuclear stress test?
Speaker_-_Dr__Lincoff:: I think it is certainly reasonable to follow you carefully given your family history - stress tests are also reasonable in this setting. You are correct that nuclear stress tests are associated with some radiation exposure - nearly the equivalent of that from a heart catheterization or CT scan. An alternative that may be suitable to you would be a stress echo, which uses ultrasound to image the heart rather than nuclear. Stress echo's require a fair amount of experience to read correctly, so I advise that you ask your physician to have it performed at a high volume center
Adee: My husband has been recently diagnosed with Hardening of the arteries; had a ct angiogram showing moderate blockages 60-68%. He sometimes has lightheadedness (like a drunken feeling) and rubbery limbs. Could this be related to the diagnosis and should we ask for some type of scan of the head?
Speaker_-_Dr__Lincoff:: The symptoms you described are likely to be unrelated to the blockages in the heart. There are a lot of possible explanations for such symptoms and you should seek medical evaluation by a neurologist or cardiologist. I would not recommend CT scans unless ordered by one of these specialists.
maryz: For someone with suspected coronary artery disease, what diagnostic tests (for example, you mentioned several types of stress tests) are typically done before the decision to undergo catheterization (for diagnosis or stent placement)?
Speaker_-_Dr__Lincoff:: Depending upon a patient's symptoms and risk factors, a stress test may or may not be necessary before catheterization. In some cases for example, a patient will have absolutely classic symptoms and many risk factors for heart disease (such as diabetes or high blood pressure). In such a case, the situation may be worrisome enough to proceed directly to catheterization.
In other cases, it is preferable to perform non-invasive testing with either stress echo or stress nuclear first. If these are abnormal, the decision may be made to proceed with catheterization. Where the use of cardiac CT scanning fits into this is unclear. There is growing recognition that these ct scans are probably being overused and that in many cases a careful medical evaluation and perhaps stress tests are preferable.
Peppy: I have read about late luminal loss in DES's. What is that and when would that occur?
Speaker_-_Dr__Lincoff:: The term, "luminal loss," refers to the extent of narrowing that occurs inside any stent. It can be measured by catheterization or by intravascular ultrasound (a special procedure performed during cath). Luminal loss occurs to some extent after any coronary intervention (balloon or stent). It is greatest after balloon alone, less after bare metal stenting, and lowest after drug eluting stenting. Luminal loss generally reaches its maximum within 9 months after an intervention.
Peppy: Are the new scans better than the stress tests to determine how the stent is working?
Speaker_-_Dr__Lincoff:: As noted in a previous answer, there is increasing recognition that the new CT scans are probably overused. They in general do not have the resolution sufficient to accurately determine how narrow a stent or artery is. That assessment is based upon evaluation by a physician as well as results of stress testing.
Spontaneous Coronary Dissection
garretc: Hi – my wife who is 35 years old was diagnosed with spontaneous coronary artery dissection and had stents placed. I cannot find information on this on the internet. Can you tell me more about this like what puts you at risk for this and could it happen again and is there anything to prevent this from happening? We also have 2 children but were thinking about another one – is that safe?
Speaker_-_Dr__Lincoff:: This is very rare. Aside from a few genetic abnormalities, we usually don't know what causes spontaneous coronary dissection in most patients. Seek a physician who has experience with this condition. You may want to go to the National Library of Medicine website and find a physician who has published on this topic.
sam: 4 years ago I had 2 stents placed in my LAD. I just had bypass surgery x 4 last month. I wonder why I keep getting blockage. I have no family history of heart disease. Have you seen this? What do you think is the problem?
Speaker_-_Dr__Lincoff:: We really don't know why some patients tend to re-narrow or restenose stents while others do not. We do know that diabetes and continued smoking increase the risk, but even patients without these factors will re-narrow stents 7 to 20 percent of the time depending on the type of stent you have. Now that you have had bypass surgery, the re-narrowed stents should not be an active problem for you. If you were to require stents in the future at some point, the risk of re-narrowing would not necessarily be any higher than that for the general population.
ttrm: I have had 5 stents in the last 5 years. I keep having re-blockage – do they ever switch to bypass surgery? Can you bypass an artery that has been stented?
Speaker_-_Dr__Lincoff:: In some cases, recurrent blockages, particularly in the same artery, are an indication to switch to bypass surgery. But - as noted in previous answers, the decision of whether to use stenting or surgery must be individualized.
carolb: Dr. Lincoff – do you know of any new research out there for people with coronary disease that keeps having restenosis even after multiple stents?
Speaker_-_Dr__Lincoff:: There continues to be intense interest in developing new stent designs and new drug coatings to prevent restenosis. Beyond that intensive control of cardiac risk factors may be the best option. I would suggest you consider evaluation by a preventive cardiologist if you have not done so already.
Peripheral Vascular Disease
geoff: My grandson had a stent put in his leg in March. He had a blocked artery. However, it was not l00% successful. They did angioplasty with the intent of opening up the leg artery again. When they went it, they found the stent was "crushed" and the whole operation was unsuccessful. He again now has a blocked artery in his leg. In March, they also did a partial by-pass around this. I have never heard of a crushed artery...What can they do next?
Speaker_-_Dr__Lincoff:: Your grandson should see a specialist in peripheral vascular disease interventions.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Michael Lincoff is now over. Thank you again Dr. Lincoff for taking the time to answer our questions about CAD.
Speaker_-_Dr__Lincoff:: Thank you for having me today.
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