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Coronary Artery Disease (Dr Kapadia 1 23 13)

Wednesday, January 23, 2013 - 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.
Dr. Kapadia answers your questions.

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Coronary Artery Disease

Hudson: I've heard about small artery blockage causing angina and it only treatment is with medication. Can you comment on this subject?

Dr__Kapadia: "Small" is defined differently by different people. Many times patients who are referred with no options due to small arteries are actually treated with bypass surgery or stenting at Cleveland Clinic. More specific information of the anatomy and diabetic status is critical for further recommendations.

Symptoms of Coronary Artery Disease

rhodge9732: On 1/14/13 spread out through the day I had about 5 occurrences of numbness that ran down my left arm from shoulder to elbow only. I had concurrent nausea that felt like I was going to vomit. Never vomited but it was very intense. These symptoms that came and went at exactly the same time. I didn't have any other symptoms. I thought it could be from a nerve in my neck. I am 65 and never had it before or since. I'm thinking I should come to the Clinic for an evaluation of this. With so many departments in the vascular section, I not sure where to start or what department to contact. Do think I should start in the vascular section and where do I contact? Thank you.

Dr__Kapadia: The most concerning reason for your symptoms would be cardiac. Since cardiology is inclusive of other vascular expertise, I would start first with cardiologist with vascular expertise. We have a group of heart resource nurses that can help you find the right cardiologist.

carl68: I am a 68 year old male. Cholesterol and BP controlled on meds. Started to have chest pain about a month ago. I had a stress test that was normal. My doctor told me to continue what I am doing - nothing is wrong. I am thinking of a second opinion. My pain is a dull ache that comes on when I am walking for a bit. I am nervous he missed something. What would be the next step?

Dr__Kapadia: I agree that stress tests are not 100 percent. Different types of stress tests, coronary CT scan, angiography with or without stress testing are the second steps. I think it is a good idea to investigate further if you are having reproducible symptoms with exertion.

MarilynWI: Can coronary artery disease cause pain in your upper back?

Dr__Kapadia: Definitely. Since heart develops from the neck area in fetus, brain identifies pain from heart to any area that develops from the same area of the fetus. Therefore, any pain from jaw to belly button can be from the heart.

Diagnostic Testing

jackpat2: What % of patients will have a normal technisium scan and still have CAD? Which artery distribution cannot adequately be seen on the above scan?

Dr__Kapadia: The number varies depending on the population you study. However, it is in the range of 5 - 15%. The right coronary artery is sometimes difficult to be evaluated because bottom of the heart rests on the diaphragm which can cast a shadow on the stress test. This can be difficult to distinguish from a real problem.

bas46: With a lipid profile test what is the doctor looking for? What numbers are looked at to determine if the patient is at risk for CVD? I also know there is a ratio that is used to better determine the patient's risk for CVD. What numbers does this include and how is it calculated? Thank you so much for this great health chat!

Dr__Kapadia: Recommended lipid profile guidelines:

  • The LDL greater than 130 is clearly high for patients who do not have any coronary disease and requires treatment. For patients with coronary disease, we like to keep LDL below 100 and preferable below 70.
  • HDL cholesterol is the good cholesterol and should be greater than 45 for protective effects.
  • Triglycerides should be less than 150.
  • The ratio that you are referring to is of LDL and HDL and is better if it is low.

Treatment of Coronary Artery Disease

charlesK2: How does a doctor determine if a stent is better, robotic bypass is better or traditional bypass for a patient?

Dr__Kapadia: Depends on the anatomy of the blockage; as well as the risks for each of the procedures for an individual patient.


KristenS: What is a hybrid procedure?

Dr__Kapadia: Surgery and stenting are done in the same patient during the same procedure. This is typically termed "hybrid procedure."

Dan-Z: I had a triple by-pass in 2003 and within 6 months 2 of 3 arteries were closed. This was after 3 stents inserted over that time. Subsequently treatment includes continues use of statins to maintain acceptable cholesterol levels. Ranexa (ranalozine) is taken 2x a day at 1000MG level for angina relief. Should I consider additional surgical intervention? I will be 63 at the end of Jan. and wonder how long meds will work.

Dr__Kapadia: The risk of death and heart attack are reduced by proper medical management more effectively than surgery or stenting in your situation. Your outcome from the limited information you sent us appears excellent but more detailed information of anatomy and cardiac function can be helpful for specific recommendation. We are very happy to provide a second opinion if you think it is necessary.

Donald-H: In coronary arteries that are bypassed do the occluded vessels ever open again?

Dr__Kapadia: No. The native arteries remain blocked but the bypass provides an alternative channel for blood to flow beyond the blockages.

oldtimer: Recently had a stress test which resulted in a stent implant. Drs tell me I have aortic stenosis and will need surgery sometime in the future. What qualifications should I look for in selecting a surgeon?

Dr__Kapadia: The outcomes of surgery are published. Centers with larger numbers and more options including minimally invasive surgery or transcatheter valve replacement should be initial screening criteria.

trulavk1952: My mom has three arteries that are blocked more than 75%. The doctors said she needs bypass surgery. She has diabetes for 30 years. Can she have a minimally invasive surgery? What should we do to help her have good results after surgery?

Dr__Kapadia: It is possible to have minimally invasive surgery but it is highly dependent on the anatomy. The best way to recover fast from surgery is to remain active before and after surgery. You should have surgery at the best surgery center with all options.

jimman9: If you have a 50% blockage in only the LAD artery and you are going in for Mitral valve surgery would if make sense to have the artery repaired also?

Dr__Kapadia: If the blood flow to the heart is not restricted by the blockage even during exercise, there is no need for bypass surgery. Even if we do bypass on such an artery, it is possible that the bypass will not stay open. The best way to determine the functional significance of the blockage is to do stress test or functional flow reserve (FFR) assessment.

jblatch: I had open heart surgery 7 weeks ago to repair a regurgitant mitral valve. I also had 2 coronary bypass grafts performed, even though these two arteries were less than 50% blocked. I have never had angina, shortness of breath, or irregular results on any kind of stress test. I am 60 years old, have normal blood pressure without medication, do not smoke or have diabetes or have a family history of heart disease. I am 6 feet 1 inches tall, and weigh 194 pounds. What are some reasons that my surgeon believed that bypass surgery was necessary, when every other doctor that looked at my history and test results did not agree with this assessment? Two of the surgeons were from the Cleveland Clinic.

Dr__Kapadia: It is a surgical decision at the time of surgery. Many times arteries have to be bypassed when there is difficulty restarting the heart after surgery.

Angioplasty and Stent

joseph: My father has been diagnosed with LAD artery and RCA artery disease. His doctor scheduled angioplasty and stent. Does he have any other options like medications?

Dr__Kapadia: Absolutely. The stents are mainly to prevent symptoms in patients with stable coronary artery disease. They do not prolong survival or prevent heart attack. Medications do prevent heart attack and death. Depending on the anatomy and quality of symptoms, one can decide if stents are absolutely necessary or not.

sunnygal: My dad has 70% LAD, mid RCA total occlusion, Cx 80% prox. He has diabetes, cholesterol and high blood pressure but on medications to control all. His doctor said he needs bypass surgery to treat. Some people have said that you can’t treat the total artery and they wouldn't treat the LAD at 70% so no surgery. What do you think?

Dr__Kapadia: The percent stenosis is a very subjective measure. Patients with significant LAD disease benefit the most from bypass surgery. 70% is right on the border of significance. It is better to have some functional assessment (such as stress test or FFR) to determine if this blockage is causing less blood flow to the heart with exertion. If so, and if your dad is having symptoms, bypass surgery is a good idea.

Bypass surgery does treat total blockage to answer your second question.

DOCKY: As a triathlete diagnosed with "stable angina" one year ago and medically managed to date, I am curious as to my probable future need for stents/ angioplasty---I am 65 yrs old and have 30+ yrs of running, etc logged. Currently I walk vigorously, but am always curious about the future........... Is there a "standard" diameter of vessel which you consider for stents?

Dr__Kapadia: You probably will not need any procedure if you continue to remain active and manage your cholesterol and other risk factors for coronary artery disease appropriately. This day, stenting can be done in all different sizes from 2 mm to 5 mm, which are common sizes for coronary arteries.


adelle2356: I had a two stents 6 months ago. wondering 1) how long you keep your patients on plavix and 2) what other medications do you routinely put patients on after stent?

Dr__Kapadia: For medicated stents, you need to be on plavix for at least one year. There are reasons to stay for longer periods if you have overlapping stents; diffuse disease; history of stent thrombosis, etc.

Controlling cholesterol is of prime importance; blood pressure and diabetes if it exists should also be aggressively managed. This is not all. Most important is to have lifestyle changes with regular exercise and weight reduction.

wahamler: I had 2 stents put in 6 years ago and, in addition to other medications I take Plavix and a full aspirin a day. Does there come a time when I discontinue the Plavix?

Dr__Kapadia: I think you can cut your aspirin to a baby aspirin. Plavix is not absolutely necessary after so many years of stenting. But, the risk of bleeding also is low if you did not have bleeding for so many years. There is some data to suggest mild benefit of aspirin and plavix together for severe vascular disease.

Marta0923: Dr. Kapadia what do you think about generic heart medicine. I have heard that they can be not as potent as non-generic medications.

Dr__Kapadia: There is some concern about the quality control of generic medications. My personal experience, most generic medications work well. But, if you find a major difference in how you feel after you change your medications it should raise a red flag.

Primary and Secondary Prevention of Coronary Artery Disease


Dr__Kapadia: Most common risk factors are cholesterol; hypertension; smoking and diabetes. There are some patients who have bad family history. there are fancier ways to check bad cholesterol (LDL particle numbers) where were not widely available 5 years ago.

RayMC: Aside from diet and lifestyle changes, has recent research discovered anything to slow/reverse the buildup of plaque in the coronary and carotid arteries? Would arterial dilators, such as the herb hawthorne, be helpful?

Dr__Kapadia: As you point out, diet and lifestyle changes are the pillars for better health. Lipid lowering medications (statins) have shown to reduce the build-up of plaque and actually reverse the plaque. These studies were performed at Cleveland Clinic.

Hudson: There has been some talk of late about the value of taking fish oil. Is there a value in taking fish oil and if so what would be a recommended dose?

Dr__Kapadia: This is controversial and I do not personally recommend fish oil. It is better to have proper diet.

asgalian: My father required triple bypass surgery at 60 and then carotid surgery at 62. He just turned 80 and has been very well since then. Would it be expected that his children may also need treatment at some point in the 50s/60s?

Dr__Kapadia: Depends if father had environmental factors that contributed to his premature atherosclerosis like obesity, smoking, or lack of exercise.

Richard-H: A recent carotid ultrasound examination indicated a slight buildup of arterial plaque. My cardiologist said it was not anything to worry about because it was so slight. I do keep my cholesterol in the 130-140 range, take Niacin and Lovastatin daily, eat a low-fat diet, and exercise regularly. I am a 66-year-old white male. I had a mitral valve successfully repaired in 2004 and a successful pulmonary vein isolation catheter ablation for paroxsymal AF in 2011. I have take Coumadin/Warfarin for approximately 8 years for anti-coagulation therapy. My question - is there anything else I can do keep the plaque from building up more? Are other statins better for this than Lovastatin? Thanks.

Dr__Kapadia: It is important to check your LDL cholesterol including LDL particle numbers and size. It would be optimal to keep LDL below 70 and LDL particle numbers less than 900. You are doing other things correctly including proper diet and exercise. There are other medications in the same family as lovastatin which are more potent but without knowing your lipid profile in detail, I am not sure you have to change.

Rahim: I'm a 59 years old male running daily and watching very carefully my diet but my total cholesterol in 10-6-2012 was 212 and in 1-12-2013 was 218. My triglycerides =62, HDL = 106, LDL = 90, VLD IL =12.40 and ratio 2.1. What am I doing wrong? Has taking 1100 IU of vitamin D3 before Oct test and increasing it by 2000 IU more since October created this jump of total cholesterol? Please contact me by email or chat. Sincerely Rahim.

Dr__Kapadia: First of all 213 and 218 are very comparable values. I would not call it a jump. I think you are doing everything right. Your HDL cholesterol is enviable and LDL is also not particularly high for primary prevention.

Collateral Circulation

clsmith: If you have a 100% blocked artery, can you develop collaterals that would be enough? how do you do that - are there medications, what about eecp? how about exercise?

Dr__Kapadia: Most commonly totally occluded arteries have collaterals. Exercise, cessation of smoking and proper diet can help to improve collaterals. EECP is also a reasonable strategy for symptomatic patients. Nitroglycerin and medications that dilate coronary arteries improve flow through the collaterals.

Coronary Artery Bridging

sam23NY: Can you talk about coronary artery bridging? what is it and what exactly is the treatment. My dad was just diagnosed with this and I am trying to get information for him.

Dr__Kapadia: Coronary arteries typically lie on top of the heart. However, sometimes small segments of coronary arteries may travel through the muscle of the heart. This area of the coronary artery gets squeezed as muscle contracts. This is termed "coronary bridging."

Since most of the blood flow through the coronaries happen when the heart is relaxing, the bridging does not typically lead to any decreased blood flow to the heart. There is some evidence that bridging may increase the risk of developing future blockages but this is in my experience uncommon.

Coronary Spasm

NEWYORKER: Why do some people get artery spasms after stenting? I already take Isosorbide and a small amount of Verapamil, I also avoid caffeine and have lost 25 lbs. Can I do anything else? Might it go away on its own?

Dr__Kapadia: Diagnosis of spasm in your situation is unclear to me. It is not common to see spasm that lasts after coronary stenting. Actually the stented segment does not go into spasm because stents hold it open. If there is spasm in other locations, nitrates and other vasodilators are appropriate.

Aorta Disease

iltham: the CT scan results: 39 years Male with aortic root of 4.1 cm and ascending aorta of 4.9 cm. is it dangerous

Dr__Kapadia: It certainly requires further investigations by an expert to also evaluate the family and genetic history. The recommendations for surgery change depending on the exact cause, family history and genetics of the problem.

JCB: Dr. What would be your recommendation for a 54 year old male in otherwise excellent health but has a 5 cm aortic aneurysm at the level of the right PA? And a bicuspid aortic valve that has no stenosis and only trivial regurg? Do you replace the valve too?

Dr__Kapadia: There are valve sparing surgeries for aortic aneurysm which are done at specialized centers like Cleveland Clinic. Actually Cleveland Clinic is one of the best centers for this procedure which is called David Procedure - please see our website for more information, including a video of the procedure.

Right Ventricle Dysfunction

garchinh: In a recent exercise stress test, it was determined that I had a sluggish and enlarged right ventricle. What are the effects of this and what are the treatment options?

Dr__Kapadia: Right ventricle pumps blood to the lungs. most commonly, right ventricle has sluggish function due to high pressures in the lungs. The best treatment is to treat the cause of the right ventricular dysfunction. You need a more formal work-up and you are welcome to come to the Cleveland Clinic for evaluation.

Reviewed: 01/13

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.

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