Coronary Artery Disease (Drs Sabik&Raymond 1 25 12)
Russell Raymond, DO
Interventional Cardiologist in the Robert and Suzanne Tomsich Department of Cardiovascular Medicine
Joseph Sabik, MD
Chairman of Thoracic and Cardiovascular Surgery and Director of the Cardiothoracic Residency Training Program in the Sydell and Arnold Miller Heart & Vascular Institute
Wednesday, January 25, 2012 - Noon
Coronary artery disease (CAD) is the most common type of heart disease and is the leading cause of death in the United States for both men and women. Treating coronary artery disease is important to reduce your risk of heart attack or stroke. Cardiothoracic surgeon and Department Chairman of Thoracic and Cardiovascular Surgery, Dr. Joseph Sabik and interventional cardiologist Dr. Russell Raymond answer your questions about coronary artery disease.
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Coronary Artery Disease
Sophieann: I am a 65 year old woman with diabetes (30 years), high blood pressure, and now I am told that 2 arteries are 60% blocked. I am very depressed and feel that my situation is hopeless. Doctors have recommended a different regimen of blood pressure medication, 20 mg of Crestor, and exercise and weight loss. Still I feel that I am in a hopeless situation and nothing I do will really help. I am now afraid that if I exercise I will have a heart attack. Please advise.
Dr__Raymond: It sounds like you have several risk factors that would promote coronary artery disease, which underlies the importance of modifying your risk factors as often as possible.
This would include excellent blood pressure and blood sugar control, keeping your LDL below 70, exercise, diet, and weight loss.
There is good data to suggest that risk factor modification will slow up the natural history of your coronary artery disease. Don't be discouraged in the event that your blockages progress, there are many excellent options for therapy.
We have a Women's Cardiovascular Center that can provide you with help with your prevention efforts.
pfflyer: Doesn't it off times depend on where the blockages are....say left main or LAD? as to whether BP is suggested?
Dr__Raymond: Could you rephrase your question?
HeartHealth2_1: Does calcification in the arteries occur in artery walls themselves or is the calcium overlaying the plaques only? If both, are these two separate processes and can the type be determined from a CTA and calcium score?
Dr__Raymond: Calcium can occur anywhere in the arterial wall and cannot be determined by a CTA and/or calcium score.
Coronary Artery Disease Symptoms
judlarmcb: I've had CAD since 1995, & I've had 5-stents put into my lt main artery(03 & 04-2009). I'm on Plavix & other blood pressure lowering meds. Now I'm starting to have pressure pushing around my heart whenever I lay down, & the pain is now shutting down both arms. Although my Cardiologist can't seem to find any blockages. They redid a catheterization last yr. Any suggestions or thoughts on what happening to my body & specifically my chest & heart area?
Dr__Raymond: Chest pain can have many causes. This pain may or may not be caused by your heart. When chest discomfort occurs when lying down it is often from a GI etiology. perhaps a second opinion from a gastroenterologist may be of benefit
cabg09_1: I had a triple bypass in late 2009. I was 56. I returned to work quickly and for the most part am doing well, however maybe about once a week I get a brief feeling that the heart is going out of sync for a few seconds then back to normal. My cardiologist feels that I shouldn't worry about these...is this normal?
Dr__Sabik: That your doctor is probably correct, however you could wear a 24 - 48 hour holter monitor and this would determine if the rhythm is abnormal.
Cardiovascular Risk Factors
JohnF: Lipoprotein a and LDL have been named as indicators for CAD. I have low LDL and high Lipoprotein a , so what does a mixed signal like that indicate as to the possibility of developing CAD? Thanks
Dr__Raymond: A very good question. This is reflective of my own lipid profile. Lipoprotein a is a risk factor for thrombosis and coronary artery disease. If the Lpa is high we try to target an LDL <70. Other than statins and perhaps Niacin, there are no drugs targeted specifically for Lpa.
lmgaiso: Do you think that raising HDL with niacin is beneficial after LDL has been optimized?
Dr__Raymond: Absolutely. There are two schools of thought - the first being that a low LDL is more important than a High HDL. Most of us believe that both are important.
The only way to increase HDL is through exercise and niacin. Please try to optimize both.
hearthealth1: I am concerned with raising my HDL and want to know the best ways to do that? What statin would be best for this purpose? Does Lovaza raise HDL?
Dr__Raymond: The only way to increase HDL is niacin and exercise. Most statins have some effect but not near the potency as niacin.
tennbarb: With regard to LDL, how low is TOO low?
Dr__Raymond: We don’t' really know if there is an LDL level that is too low. We do believe that there is no clear benefit to driving it below 50. If someone has documented coronary disease we do recommend an LDL <80 and preferably <70. Otherwise, with risk factors present but no previous event, we suggest an LDL < 100
tennbarb: Omega threes- for primary prevention in high risk individuals- what dose and what source?
Dr__Raymond: Regarding Omega 3 fatty acids. The jury is still out on this but the general recommendation is 1,000 daily.
Sophieann: If a person has resistant hypertension, diabetes, CAD, and is overweight, which are the best medications for blood pressure control? I am currently taking 100mg Toprol, 40 mg Lisinopril, and 5 mg. amlodipine.
Dr__Raymond: Your best therapy is to control your risk factors along with medical management. Although this can be difficult it is important to lose weight, exercise and eat a healthy diet to help control your blood pressure.
jdjones: Are you persuaded that the diets promoted by Ornish or Esselstyn can reverse coronary artery disease? Overall, what steps would you recommend to a patient with very high calcium scoring in a CT Angiogram in order to halt or reverse the progression of CAD?
Dr__Raymond: Dr. Hazen, Section Head of Preventive Cardiology was recently asked a similar question. We agree with his statement: A plant based diet is low in cholesterol and saturated fats, and believed in general to be healthy. However, there are no rigorous studies demonstrating “reversal” of atherosclerotic plaque other than anecdotal cases. Your decision of whether to adhere to such a diet should be discussed with your physician.
In general, we recommend to our patients that a diet should be a life choice they can accommodate and still enjoy life with. We suggest that patients only adopt a strict plant based diet if they feel quite strongly about it, and do so in conjunction with a trained and certified registered dietician. We reiterate that it is very difficult to adhere to, and the benefits are unproven.
We believe a common sense approach to diet that is more balanced, and incorporates aspects of increased vegetarian component, is equally reasonable.
Diagnostic Testing and Follow Up
hearthealth1: I am a 44 year old male with a calcium score of 780. Is there any way to reduce your calcium score?
Dr__Raymond: Calcium score is a general measure of the presence of coronary artery disease. In general, a higher calcium score correlates with cardiac events but it is not the entire answer.
Our opinion is that the presence of calcium simply signifies the presence of some degree of CAD but is far from the entire answer.
In general, there is no way to lower a calcium score but we can retard its increase by modifying risk factors. Don't let your doctor talk you into another heart CT. You should have a stress test every so often to follow any progression.
mooreke126: Hi-I am a 54 yo female, exercise, 5'4", 135lbs., with extensive family history of heart disease. I have been proactive with prevention, statin, HBP meds, both have controlled these conditions. I had a 64 slice Ct 2 years ago and it showed <50 calcified in my LAD. I then switched to a plant based diet for even better results. When should I have the test again to see if there is improvement or no increase in the <50% number.
Dr__Raymond: Once you have one CT of the heart you don't need another. The calcium score won't go down and the only benefit of another is to see if the calcium content increases. The best way to follow any progression over the years is a stress test from time to time. It sounds as though you have been taking excellent care of yourself and the cholesterol. You probably don't have anything to worry about for a long time.
cabg09_1: What are recommended follow-up procedures and at what intervals to determine how a patient's CAD is doing after a bypass?
Dr__Raymond: It is reasonable to have a stress test every 2 to 3 years after bypass surgery.
mooreke126: I am a 54 yo female extensive heart disease in the family. I exercise 5-6 times a week have been eating a vegan diet for two years. have controlled BP 110/65 with meds take 20mg of simvistatin. numbers "perfect" per my cardiologist. I had the 64 slice 2 years ago and it showed <50% calcification in LAD. When should I be retested to see if it is better or worse.
Dr__Raymond: You should be congratulated in your efforts to modify your risk factors and prolong your life. You should not have another CT scan ever to evaluate your heart. With your strong family history of heart disease, you may consider a routine stress test at the age of 60 and perhaps every 5 years.
General Treatment Questions
lmgaiso: 10 Can you share the CCF mortality statistics associated with non-complicated stenting, bypassing, and aortic valve replacement?
Dr__Raymond: Morality at Cleveland Clinic for non-complicated stenting is 0.3%
Dr__Sabik: In 2011, at Cleveland Clinic, for isolated CABG, mortality was 0.6% and for isolated aortic valve replacement (AVR) is 0.6%. For CABG our morality is one third of that predicted by the Society of Thoracic Surgeons (STS) risk adjustment model and for AVR it is one sixth that predicted.
lmgaiso: A recent article in the CCF Newsletter noted that aspirin causes bleeds in 1.3 per 1,000 people per yr. This equates to a 10-yr bleeding risk of 1.3%. But, the article noted that aspirin’s potential harm outweighs its CVD benefit for people whose 10-yr heart attack risk is below 5%. Thus, if 10-yr MI risk is 3%, the article would indicate that you shouldn’t take Aspirin given the 5% cutoff. However, it seems to me that aspirin would benefit a person with a 10-yr MI risk of 3% because this is higher than the 10-yr bleeding risk (1.3%). Can you help me understand the disparity in my thinking vs the article.
Dr__Raymond: There is mixed data regarding this subject.
In general there does not seem to be any benefit for primary prevention of a cardiac event. However, it is very beneficial for secondary prevention if someone has had a heart attack, stent, bypass surgery, etc. given there are no contraindications to aspirin.
However, that being said, in my own practice I recommend a baby aspirin daily in men over 40 and women over 50.
lmgaiso: To clarify that is men over 40 even for primary prevention?
goldfinch11: Is aspirin good for angina relief? Do heart spasms and angina have similar symptoms? What tests other than a stress test can be used to diagnosis angina or heart disease?
Dr__Raymond: Aspirin is good for secondary prevention, meaning anyone who has had a coronary artery event whether that be a heart attack, stent procedure, or bypass surgery. There is no clear indication for aspirin in primary prevention but I still recommend it in men over 40 and women over 50. Angina is by definition any discomfort above the waist brought on by exertion and relieved by rest or nitroglycerin. Coronary spasm is a rare occurrence but symptoms can be very similar. Coronary artery disease can be picked up by any number of stress tests or a test called Cat scan of the heart. Of course, the most accurate diagnosis of CAD is a heart catheterization.
tirreno: I am 54 years old and had triple bypass 12 years ago. I have been taking a 325mg aspirin daily for 12 years. Is this dangerous? Should I be taking a lower dose? I concerned about internal bleeding!
Dr__Sabik: The current ACC/AHA guidelines are for 100 mg per day but this is not available in the U.S., therefore we give our patients 162 mg of aspirin after bypass surgery.
There is no clear benefit of 325 mg and the risk goes up for bleeding with the higher dose
sarczar: what is the best way to determine what dosage of aspirin should be taken after AVR surgery, and for how long?
Dr__Sabik: The baby aspirin dose of 81 mg, in some patients, demonstrates aspirin resistance. By increasing the dose to 162 mg, we overcome this resistance while keeping GI symptoms to a minimum.
Storyman: I had a quadruple bypass at the Clinic in 2000 w/o a heart attack before or after. I take a beta blocker and 162 mg of aspirin daily, plus supplements like fish oil. I have had no incidents since my bypass in 2000. I recently moved and have a new cardiologist who suggests that I take an ACE inhibitor (lisiniopril 5 mg) when I do not have hypertension, diabetes, or any other usual implications for taking an ACE inhibitor except for the fact that the HOPE Study indicates that there are fewer heart incidents when taking an ACE inhibitor. What is your practice in prescribing an ACE inhibitor to persons without diabetes or hypertension? Are there any side effects?
Dr__Raymond: You are asking a good question. From the information you have provided and not knowing your entire cardiac history I would suggest that an ACE inhibitor is not necessary.
CathyK: How many stents are too many? My husband has had three stents and now his doctor said he needs two more. How many is too many? Do they ever then decide bypass surgery would be better?
Dr__Raymond: Regarding the number of stents. Most people, if they are candidates for stenting and don't require bypass surgery, do well with anywhere from 2-4 stents depending on the location and length of the blockages. Unfortunately some pts have received a large number of stents and never offered the definitive treatment of bypass surgery. It is a complex question and not one correct answer. Again, it depends on how many blockages and arteries are involved. In general, the more arteries and blockages are present, the more one will benefit from bypass surgery and the opposite is true as well.
Dr__Sabik: Whenever you have anything done you do not want to limit your future therapeutic options, including surgery. One way to do this would be to have a heart team approach - an interventionalist and surgeon discuss your case to offer you the best options for care.
clairesse: tor message : We have read Dr Nissen's comments that stents do not prevent heart attacks. My husband's nuclear stress test showed restriction near the stent he had put in two years ago. The doctor wants to go in and do an angiography to look and see if there is scar tissue or additional blockage. My husband has no symptoms. What do we do? If the doctor goes in and sees narrowing, he will put in a stent. Is there never a valid reason for a stent if you aren't having symptoms?
Dr__Sabik: Percutaneous intervention can be very affective in preventing a heart attack in patients with acute coronary syndrome or an event. For example ACC guidelines suggest we get someone to the cath lab within 90 minutes of onset of symptoms.
For patients with chronic angina, stents have not been shown to be effective in preventing heart attacks but does prevent symptoms. If your husband is not having symptoms then medical management may be appropriate.
Dr__Raymond: For more information, feel free to Google the COURAGE trial and BARI2D trial.
HeartHealth2: When a patient has a moderate stenosis of 50-74% and is asymptomatic (no chest pain or shortness of breath, fatigue) with a normal stress test, would you recommend a stent as a preventative measure, or would you take a different approach with just monitoring lipid levels, diet an exercise and annual follow-up?
Dr__Sabik: When we intervene on someone with CAD it is either to decrease symptoms or improve survival.
There is no data to suggest you would have a survival benefit from an intervention, and because you do not have symptoms, a procedure will not make you better. Therefore we would suggest you continue with medical management and preventive measures.
Coronary Artery Bypass Graft Surgery (CABG)
craig_1952: What is the most minimally invasive option for bypass surgery? do they do robotic?
Dr__Sabik: Most surgeons who do robotic coronary surgery use the robot to dissect the mammary artery from the chest wall and then do the bypass graft through a small incision in the left anterior chest. This incision is usually about 3 - 4 inches.
At the Cleveland Clinic, we directly dissect the mammary through the small incision and then perform the anastamosis through the same small incision.
In heart surgery, the robot is mostly utilized during mitral valve repair surgery.
LauraK23: My husband has diabetes, history of PAD in his legs, and 50% kidney function. He needs to have bypass surgery and our local surgeon said it is OK and wants to schedule him. I am just wondering if this is OK and what the risks will be for him during surgery and recovery.
Dr__Sabik: Without knowing all his medical history, it appears he is at higher risk for renal dysfunction after heart surgery. Your physician would be best to determine your risks.
peripeteia: Should I even think about having another open heart surgery (#4) considering my age as well as the fact that I have epilepsy, or should I ride it out? The people making the calls at a heart clinic in Salt Lake wanted to do open heart surgery this month, I need to make a decision soon. I was Dr. Henry Swan's first cath recipient and it's been a good ride. I didn’t develop epilepsy until directly after surgery #2 and it was expressed (by the surgeon) that the epilepsy may indeed be directly related. Surgery or ride it out?
Dr__Sabik: Epilepsy is not a contraindication to surgery. It is important to discuss with your cardiologists and surgeons the benefits and risks of surgery vs. "riding it out."
We do have an online second opinion service if you would like a Cleveland Clinic physician to review your records.
CharleneP: Hi. I am a 52 year old woman who had triple bypass surgery a few weeks ago. I had to go in this week for treatment for pericarditis. I am wondering if that is common after bypass surgery. Is it dangerous? And - will it have any impact on my long term recovery and success of surgery.
Dr__Sabik: Pericarditis is inflammation of the lining around the heart. It is not uncommon after heart surgery. With appropriate care it will not compromise your long term results.
waimu: Any new procedures for high risk bypass patients with blockage of the grafts?
Dr__Sabik: When patients develop blockages in their bypass grafts they have two options - stenting or repeat bypass surgery.
sandraJ: My husband had bypass surgery a couple months ago. He does not seem to be back to normal yet. Not as with it as he was before surgery. He may be somewhat depressed? How long should this last before I worry?
Dr__Sabik: A couple of months after surgery, the patient should be getting back to normal. If it is a couple months after surgery, it may be time to get professional help.
MaralM: Do they do PICVA bypass at Cleveland Clinic?
Dr__Raymond: We are not doing this at Cleveland Clinic. It is a very investigational therapy. If it were recommended and highly successful it would be available in the U.S.
ritchreg: My bypass (done robotically 3/2011) collapsed and two surgeons have said that it cannot be redone because my vessels are too small. I'm stented and a walking pharmacy. Can't they take one out of my leg? How do other people get to have another surgery?
Dr__Sabik: Bypass surgery is a technical procedure. Some surgeons feel more comfortable operating on smaller arteries than others. We would be happy to review your records to see what your options are.
clara: I have had bypass surgery 2006 and 6 stents 2009 /20010/ 2011. I recently had a cath (not by the doctor that did the stents ) and was told they were going to do another stent. He changed his mind because of risks. He said one of the stents was narrowing. I have stents in all the major arteries and 2 bypasses. My stents are 2.5mm. Am I looking at bypass again?
Dr__Raymond: I need to see the last cath film and I could give you my opinion. I would be happy to see you if you like as well.
Cleveland_Clinic_Host: I'm sorry to say that our time is now over. Thank you again Drs. Raymond and Sabik for taking the time to answer our questions coronary artery disease.
Dr__Raymond: Thank you for having me today.
Dr__Sabik: Thank you for chatting with us today.
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