Coronary Artery Disease and Treatments (Drs. Nissen & Sabik 8/16/11)
Tuesday, August 16, 2011 - Noon
Joseph Sabik, MD
Chairman, Department of Thoracic and Cardiothoracic Surgery, Miller Family Heart & Vascular Institute
Steven Nissen, MD
Chairman, Department of Cardiology Cleveland Clinic Miller Family Heart and Vascular Institute
Coronary artery disease (CAD) is the most common type of heart disease and is the leading cause of death in the United States for both men and women. Treating coronary artery disease is important to reduce your risk of heart attack or stroke. Take advantage of this rare opportunity to chat live with a heart doctor and heart surgeon in a secure online setting.
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Cleveland_Clinic_Host: Welcome to our "Coronary Artery Disease Treatments" online health chat with Steven Nissen, MD and Joseph Sabik, MD. They will be answering a variety of questions on the topic. We are very excited to have them here today!
Thank you for joining us, let's begin with the questions.
Dr__Steven_Nissen: Let's get started.
Coronary Artery Disease (CAD)
jack92: How does plaque form and how long does it take to build up in a persons arteries?
Dr__Steven_Nissen: This question is beyond the scope of a simple answer in this forum. Plaques form for many reasons including cholesterol disorders, hypertension, smoking, diabetes and other factors. The rate of formation is highly variable, but most evidence suggests that the disease starts early in life and progresses for decades.
natdenjay: How many stents can someone have? I have had 2 quad bypasses and 15 stents in the last 23 months. I was told I could not have another bypass and they keep failing. I am 51 years old and am trying to figure out how long I have left.
Dr__Steven_Nissen: You should get a second opinion at a place such as Cleveland Clinic who is experienced in treating patients such as you are describing. You can come here - or you can learn about MyConsult online second opinion at:
ritchreg: Why does a person continue to have angina even if their stents appear to be working well?
Dr__Steven_Nissen: There are several possibilities:
- The pain is not actually coming from the heart - there are many structures in the heart that can cause pain - such as reflux in the esophagus can cause pain that is similar to angina.
- There are also some individuals that have disease involving the small blood vessels of the hear that are not visualized in angiography. Specialized tests can sometimes detect this syndrome.
Faith57: How common are atypical cardiac symptoms and which ones should not be ignored especially in women?
Dr__Steven_Nissen: Unfortunately atypical symptoms are extremely common and it can be very difficult to distinguish between atypical symptoms that indicate the presence of card an atypical symptoms that may be due to a non coronary cause.
marilynmann_1: The September 2011 issue of Consumer Reports recommends that a sedentary middle-aged person with cardiac risk factors, who is asymptomatic, get a stress test before starting an exercise program. Do you concur?
Dr__Steven_Nissen: No. Its sensitivity is about 60% and its specificity is about 60% in patients without symptoms - therefore it is slightly better then a flip of a coin. If the test is positive it may lead to unnecessary further studies that may lead to procedures that are not indicated.
esrebro: If there is a history of cardiac problems in a family, for example, stroke, blockages, bypass surgery, at what point should an adult child from that family background start looking into the possibility of his/her own cardiac health and risks considering that no unusual symptoms are currently present. What tests would be in order, if any, along with the usual lab work, lipid profile, blood pressure, etc., that is routine in most physical exams?
Dr__Steven_Nissen: You listed the right tests (lipid profile, BP). These tests should be started in your 20s. No other tests are indicated. Avoid the temptation to get any of the following tests unless you have symptoms: CT angiography, calcium scanning, stress testing, and echocardiography. Inappropriate testing can lead to more problems than it solves. You should eat a heart healthy diet and exercise regularly because both these interventions can help prevent heart disease.
Dan: What does some scaring on a nuclear stress test mean? Is it something to be alarmed about and does it need immediate attention?
Dr__Steven_Nissen: Scarring suggests that you may have had a heart attack in the past. The size and location of the defect are important factors in deciding whether you have a problem that needs attention. If you have areas with poor blood flow during the exercise portion of the nuclear stress test, a cardiac catheterization may be indicated. Some people may have evidence of "scar" that is a normal variant and this should be considered carefully by your physician.
Pam: If a 12 lead EKG shows a septal infarction on a 57 year old woman with no symptoms does this mean she definitely has had an MI?
Dr__Steven_Nissen: Not always. There is wide variation in the normal patterns observed in an EKG. Please discuss with your doctor.
DANOCON: I recently had a nuclear stress test. I was told that the results indicated no blockages but there was some scaring. What could this mean? My follow up appointment with my cardiologist is not for several weeks and I am concerned.
Dr__Steven_Nissen: See my answer to Dan above.
carduini: Could you kindly comment on how improved diagnostic cardiac functional data, obtainable now with MCG, that avoids radiation, could modify or even improve CAD treatment?
Dr__Steven_Nissen: The magnetocardiography test is FDA approved, but there is little scientific evidence supporting its use. I can find no serious scientific studies documenting any patient benefit. Avoid this test until there is better evidence of a benefit. We think the FDA made a mistake in approving this test with so little evidence of benefit.
jack92: How do you determine what is restricted blood flow?
Dr__Steven_Nissen: It is often difficult to tell by only looking at an angiogram whether a blockage is restricting blood flow - particularly if the blockage is between 50 - 80%. Therefore, we rely upon symptoms, imaging stress tests, and sometimes, direct measurement of flow in the coronary to determine whether a particular blockage needs to be treated.
Faith57: What is the best, least invasive method for assessing an artery that has had triple stenting 11 years ago?
Dr__Steven_Nissen: The best gauge of the adequacy of blood flow is the presence or absence of symptoms. If you don't have chest pain with exertion, your stent is probably ok. Looking for trouble will frequently find it and can lead to unintended consequences.
lmgaiso: Under what circumstance should an asymptomatic person have a stress test?
Dr__Steven_Nissen: There is only one circumstance of when it is recommended - if you are an airline pilot for commercial airlines or a school bus driver.
jabber20: I had an ST depression show up on a stress test last month what does this mean? is that bad?
Dr__Steven_Nissen: It all depends on the reason for the stress test. If the stress test was performed due to chest pain with exertion then ST depression may be indicative of a coronary blockage. f the stress test was performed in the absence of symptoms; it is much more likely to be false positive.
jack92: Which test is better a Stress Test or a CTA in following up people with a history of CAD?
Dr__Steven_Nissen: There is no indication for performing either test in individuals without symptoms. I would particularly discourage getting a CTA because it involves a large amount of radiation and has not been proven to improve outcomes. In general, if patients with CAD have no symptoms - they need neither test.
JoyceR: Is there any way to assess the stenosis in a stent other than by angiogram to avoid total blockage and an MI if a patient is asymptomatic?
Dr__Steven_Nissen: If the patient is asymptomatic they should not worry about whether there is stenosis in a stent - in general , the lack of symptoms suggest that the blood flow through the stent is adequate. Further testing may lead to unnecessary procedures.
ritchreg: What are the names of the tests used to visualize the smaller vessels of the heart that cannot be viewed with angiography?
Dr__Steven_Nissen: Some experts use a Doppler probe in the coronary artery to measure a parameter known as coronary flow reserve. This is a highly specialized test performed in only a few large medical centers like the Cleveland Clinic.
lmgaiso: What is the chance that a stress echo test performed on a 45 year old male would have a positive affect on his long term outcome? What is the potential to negatively affect his long term outcome?
Dr__Steven_Nissen: The value of this test is highly dependent on the circumstances for which it was ordered. If the patient has no symptoms, the test has limited value. If a patient has symptoms of chest pain the test may help to determine whether CAD is present or absent.
Happ6: Re diagnostic tests: Is a PETscan of use in determining viability of areas of the heart??
Dr__Steven_Nissen: Yes. The PET test although expensive and complicated is an accurate way to determine whether heart muscle that is poorly supplied with blood remains viable. Viable muscle may begin to work better if better supplied with blood from a stent or bypass.
When to Treat Coronary Artery Disease
jack92: If a person has CAD and a known blockage of 50% in the LAD directly above where a stent was placed 6 years prior would it be best to be proactive now and open the blockage at this time? Or should the person wait? Thank You!
Dr__Steven_Nissen: It is never a good idea to intervene on an artery in a patient with stable CAD unless the blockage is severe enough to cause symptoms (angina) and/or restrict blood flow. “Opening” a 50% blockage can actually do more harm than good.
Coronary Artery Bypass Surgery
Happ6: Is a LIMA procedure (robotically) recommendable if there is also substantial occlusion of the RCA? I sent this question in earlier but maybe not to the right place:
Dr__Joseph_Sabik: When undergoing coronary revascularization all the areas of the heart that are viable and have compromised blood flow should be revascularized to have the best long-term outcome.
If the heart muscle in the area of the right coronary artery has died, then revascularization of only the LAD may be appropriate. However, if the heart muscle in the area of the RCA is still alive, the RCA should be revascularized as well.
zenrunner53: I have recovered from a successful coronary revascularization of 2 vessel disease and echo's showed no evidence of heart damage. Is there any advantage in graft survival (or my survival) in taking a beta blocker? As an endurance athlete, I'd like to avoid taking one if there's no significant benefit. Also, how do you feel about the study that suggested that low dose warfarin improved graft survival? Thanks
Dr__Steven_Nissen: Beta blockers are not routinely indicated in patients with normal heart function following bypass surgery. There is not strong evidence for a benefit of warfarin, but low-dose aspirin should be taken for life.
WILHELMED: HELLO DR SABIK. MY NAME IS ED W. YOU OPERATED ON ME 14 MONTHS AGO. I FEEL GOOD AND AM DOING GOOD. MY QUESTION HAS TO DO WITH MIN. INVASIVE BY PASS SURGERY. I WAS NOT A CANDIDATE FOR IT, I HAD A STERNECTOMY, TO WHICH I STILL FEEL SOME EFFECTS, WHICH I KNOW IS NORMAL. I HAVE READ MERCY HOSP.IN CANTON IS NOW DOING 4 AND OR 5 VESSEL SURGERY MIN. INVASIVELY. I KNOW YOU AND THE CLINIC HAVE DONE 1 VESSEL,WHEN CAN WE EXPECT THE CLINIC TO DO MULTI VESSEL SURGERY MIN. INVASIVELY. THANKS FOR ANSWERING MY QUESTION, NOT SURE IF YOU REMEMBER ME. ED W.
Dr__Joseph_Sabik: We don't only consider the number of vessels but the extensiveness of coronary disease and quality of distal vessels as well as body size. But we have done multi-vessel bypass surgery as well.
Hugh: Have "minimally invasive" techniques (off pump / robotic / endoscopic?) been developed and tested sufficiently to commend a LIMA bypass procedure when there is also substantial occlusion of the RCA? Apparently I have considerable "revascularization" by corollaries / collaterals serving the lower parts of my heart, as I am almost completely asymptomatic. Yet an angiogram has shown serious compromise of the RCA, LAD and circumflex arteries. I am presently using medication and exercise and doing quite well but do not want to be grabbed by a "widow maker" heart attack.
Dr__Steven_Nissen: In the absence of symptoms we would like to know whether or not you have had an imaging stress test (nuclear stress test or exercise echo) that shows inadequate blood flow to the heart muscle. If you have neither symptoms nor evidence of poor blood flow by one of these imaging tests, surgery is usually not indicated. If you have some symptoms and stress test is abnormal, some patients may benefit from surgery.
As to the surgical approach, there are many things to be considered:
- The extensiveness of CAD and whether it can be taken care of through a small incision approach.
- The experience of the surgeon with different procedures.
CharlesK: Dr. Sabik. I am interested in learning more about port access for bypass surgery. I understand the robot is not good for all surgeries but you have some type of minimally invasive option. Can you talk about what that involves - how big the incision is? Is the incision down the chest? How quick is recovery?
Dr__Joseph_Sabik: We do some bypass operations through a small incision in the side of the chest. The incision is usually 3 to 4 inches in length. The recovery is 4 - 6 weeks.
natdenjay: can a 3rd bypass be done on someone who has already had 2 quad bypasses and 15 stents in 22 months
Dr__Joseph_Sabik: It often can be - it depends on whether the patient has vessels to use as by pass grafts. Secondly whether the coronary arteries are still suitable for grafting.
Cholesterol and Lipid Management
Barbara: I would like some information on lowering LDL particle amount and size. There is a great deal of information on LDL C reduction but not much on LDL P reduction. What is the latest information available- is particle amount and size inherited? What is best treatment? I have normal cholesterol C panels but the LDL P panels are very high. ( 2123) and very small particles( 1117). Thank you
Dr__Steven_Nissen: LDL particle measurements have taken on a cult-like popularity. There are not strong data suggesting that these expensive “fancy” lipid tests provide any value to patients. Most patients with small dense LDL have high triglycerides. Therefore, we usually direct therapy at the triglyceride problem, not LDL-P. High doses of fish oil are usually effective. Save your money and avoid LDL particle measurements.
JoyceR: My husband who is 64 years old and is otherwise very healthy has experienced SIX MIs. At least 8 stents have been used, 3 of which have re-occluded plus a quadruple bypass 9 years ago. After Dennis' last episode 6 weeks ago a cardiologist told us that Dennis' blood tends to clot and thus the six MIs. This cardiologist changed Dennis' regime from Plavix to Effient, as well as the previous 81mg aspirin, metroprololol 25mg BID and . Incidentally 3 of the four grafts have also re-occluded. After a recent consultation with a lipidologist, Dennis was put on ezetrol since he cannot tolerate any of the statins. Side-effect extreme muscle/joint pain. My husband also takes the supplements co-enzymeQ10 and fish oil with high omega 3 content. The last MI was just 7 weeks ago.Can you suggest anything else Dennis can do to avoid this apparent high-clotting factor? Look forward to your suggestions
Dr__Steven_Nissen: It is essential for your husband to take a statin drug. Ezetrol (ezetimibe or Zetia) is not adequate. We often try creative regimens to get patients like Dennis to be able to take a statin. Some of the lesser used statins such as fluvastatin have a very low incidence of muscle problems. Some people with muscle pain on statins have an underactive thyroid. Your husband should be tested. He needs to see a lipid specialist with an interest in stain-intolerance. We almost always find a solution to this problem. If he has a clotting disorder, there are specialists that can evaluate the problem.
zenrunner53: Which Statin would have the least effect on muscle function in a professional athlete?
Dr__Steven_Nissen: There is reasonable quality data to suggest that one of the rarely used statin fluvastatin (lescol) has a very low incidence of muscle pain.
However, it is not a particularly effective statin so it is suitable for patients who do not need a large amt of cholesterol lowering
johnd: As a result of the AIM-HIGH study with Niaspan (3000mg of niacin), my cardiologists recommended coming off my normal regimen of low-dose (250mg daily) time-release niacin. Do you agree that regular niacin has no benefit?
Dr__Steven_Nissen: The AIM HIGH study has not been published. It is unwise to make medical decisions based on the release of studies in a press release rather than that in a scientific publication.
However, you should also know that 250 mg of niacin has no measurable health benefits.
JoyceR: Could you recommend how to start your creative regimen.....?
Dr__Steven_Nissen: There are a wide variety of strategies for initiating statin therapy in statin intolerant patients - some patients will administer fluvastatin (lescol) a drug that has a very low incidence of muscle side effects; often starting with a low dose and gradually increasing.
Other physicians will try a more potent statin such as Rosuvastatin (crestor) in a very low dose (5 mg) taken three days a week. Both of these strategies may allow patients who do not tolerate statins to get started on therapy.
nancyh: Are any of statins implicated in ITP?
Dr__Steven_Nissen: Not to my knowledge.
ritchreg: How long has EECP been available and does it work for everyone even when CABG has failed and stenting still leaves a person with angina?
Dr__Steven_Nissen: EECP has been around for several decades. Results are mixed, but in some cases, improvement in angina does occur. If all other options are exhausted, it may be worth a try.
Blood Disorders and Coronary Artery Disease
Kelly: have hlab27 which has caused two heart attacks caused by tears in arteries which stents were placed. is there a medication to take to stop it from happening again ? they told me the next one will be fatal. I am crestor, plavix and metroprolol.
Dr__Steven_Nissen: Your description of the problem is not entirely clear, but we do sometimes see patients who have spontaneous dissections (tears) in the coronary arteries. Your treatment regimen of Crestor, Plavix, and metoprolol is very reasonable. There is no other recommended therapy.
liesel: In 2004 I got a bare metal stent in the LAD. After 12 hrs. I had MI & I received another bare metal stent. Three mon. later I received radiation therapy due to in-stent restenosis12/2009 heart catheterization showed a 50% blockage in one of the bare metal stents. Cardiologist would insert medicated stent inside blocked stent. I am very nervous about that due to danger of blood clots. I have Factor V Leiden homozygous. Question: 1) Is there any other procedure to get rid of the blockage? 2) With medication and excellent life style, how high can the blockage be (%) before intervention?
Dr__Steven_Nissen: Management of Factor V Leiden is complicated. You need to see a specialist in treatment of this disorder. Dr. Bartholomew is an expert in this area. See my.clevelandclinic.org/staff_directory/staff_display.aspx?doctorid=998 for more information on Dr. Bartholomew.
High Blood Pressure
regorecniv: Does simply getting older (I'm 62) lead to a rise in blood pressure in an otherwise health male?
Dr__Steven_Nissen: A controversial question. In modern society, BP tends to rise with age, but this may be a reflection of our unhealthy lifestyles. At age 62, a normal BP is less than 120/80. A value between 120/80 and 140/90 is considered indicative of pre-hypertension and should result in lifestyle modification (read about the DASH diet). Above 140/90 we often give medications. For the very elderly, we set the threshold for treatment higher, but this is still controversial.
Abnormal Heart Rhythms
FibroJoe: I'm a 60 year old man with well-confirmed CAD (moderate OSA, diagnosed FMS, IBS, and Osteopenia). Complained of unusual exaggerated "pulsing", "fluttering", "throbbing" sensation in mid-chest, throat and hands while at rest or passive activities like TV, reading, etc. I've been taking Ambien (generic) for quite a while to overcome the "loud pulsing/pounding" in my ears when I lay on my pillow. I have dizziness from sitting to standing regularly, but not always. I just had a pacemaker implanted 10 weeks ago after my resting pulse became well below 40 (29-39). PM is set at 70. I complained of low pulse more than a year, but GP said it was metoprolol prescribed by cardiologist and still taking. Any suggestions for treating (curing) this very bothersome exaggerated pulsing/fluttering/throbbing sensations which have gotten worse since the implant?
Dr__Steven_Nissen: Your problem is too complex to make a diagnosis from a distance. You should see a cardiologist, perhaps a specialist in Electrophysiology for further testing.
FibroJoe: During the chat, you've recommended seeking out evaluations from specialists in "electrophysiology" and a "lipid specialist with interest in statin-intolerance". How would you suggest going about finding competent and appropriate practitioners as recommended in these specialties?
Dr__Steven_Nissen: That is a difficult question since there is relatively few sources for patients to find the best specialists. One approach is to seek care at a large medical center that is highly ranked by independent sources such as U.S. News & World Report. If you seek care at one of the top 10 or 20 centers listed you are likely to get good care.
jack92: How long can a person remain on Plavix after receiving a coated stent?
Dr__Steven_Nissen: We routinely treat with Plavix for 12 months, sometimes a little longer. Aspirin MUST be taken for life. If you stop BOTH aspirin and Plavix, the risk of stent thrombosis (clotting) is very high.
DANOCON: Is there any alternative to metoprolol for a patient with a history of coronary heart disease and heart bypass surgery in 2006 ?
Dr__Steven_Nissen: What problems are you having with metoprolol? It is a very widely used drug but there are alternatives such as carvedilol (coreg). One common alternative is not recommended (atenolol - tenormin) because this drug does not appear to improve clinical outcomes.
jack92: What are your thoughts on fish oil tablets as a supplement to a diet?
Dr__Steven_Nissen: Routine use of fish oil remains controversial however, fish oil is widely used to lower triglyceride levels in patients with elevated triglycerides. There is a prescription product that is very effective but expensive. Some physicians use certain brands of over the counter fish oil that are carefully tested for purity. One brand that is widely recommended by physicians is Carlson Super Omega 3 Fish oil which is relatively inexpensive and appears to be effective. The dosage to lower triglycerides is 4 - 6 capsules per day.
srbrsn11: There is a lot of confusion regarding fiber supplements to reduce cholesterol. I take psyllium fiber twice a day. There is also a "super fiber blend" that Waiora sales that is supposed to be good but is very expensive. Does it make sense to take either, or both?
Dr__Steven_Nissen: None of the dietary supplements for lowering cholesterol make any medical sense. Psyllium fiber does lower cholesterol a little bit, but not enough to make a difference. Most of the others are fraudulent. Don’t get scammed by promises made by dietary supplement claims. These products are not FDA tested and don’t work.
volleyballer: Is there anything to chelation therapy? It's been shown to work to remove lead from blood:
What about cleaning out the arteries in general? Anything in development in the next 5 years?
Dr__Steven_Nissen: Chelation therapy has no benefits and is extremely dangerous (can be fatal). The people offering this “treatment” are actually criminals who prey upon sick patients.
Peppy: Cleveland Clinic's newsletter had a fascinating article about gut flora and the formation of arterial plaque. How can I modify my diet to lessen the possibility of increasing my plaque burden? Should I take a probiotic? Please discuss the findings and your thoughts. Thank you.
Dr__Steven_Nissen: It is very preliminary scientific research - not ready for the application in the treatment of research.
fran: What is the new status for the Apo A-1 Milano?
Dr__Steven_Nissen: Research is continuing. However it is quite difficult to manufacture this therapy and new studies will not begin for several years.
natdenjay: Do you have any clinical trials available to help get rid of plaque. I am currently 51 and am the worst cad patient in Greenville SC. I am on lots of drugs but still go into have a stent about every 6 to 8 weeks. I would volunteer for any trials or studies that a available
Dr__Steven_Nissen: No - there are no studies but a second opinion by another hospital may be useful. We would happy to see you here.
JoyceR: Thank you both for your response to all these questions. This has been an extremely informative session. joycer - Toronto, Canada.
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