Ask the Heart Doctor: Coronary Artery Disease Symptoms, Diagnosis and Treatment Options

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. This podcast will explore disease prevention, testing, medical and surgical treatments, new innovations and more. Enjoy.

Faisal Bakaeen, MD:

My name is Faisal Bakaeen and I'm the Surgical Director of the Coronary Center at the Cleveland Clinic. I'm pleased to be here today with Dr. Donna Kimmaliardjuk and Dr. Tarek Malas. We're going to be talking about coronary artery bypass grafting, better known as CABG. We're going to start today by asking a simple question. Can you talk about the symptoms of coronary artery disease?

Tarek Malas, MD:

First of all, patients can present generally with chest tightness or chest discomfort, and that can be a sign of coronary disease. Some patients also feel short of breath, whether that's when they exert themselves or at rest, and some patients don't necessarily have symptoms.

I wanted to pass this to Donna, what are your thoughts about patients who have disease without having any symptoms?

Donna Kimmaliardjuk, MD:

Absolutely. It's a really great question, and the answer is yes. There's so many patients, I'm sure you both see them too in clinic and they say, "I feel great." Or, "I have no pain." But they're found to have triple vessel disease. Unfortunately, it does happen. We see folks without the classical chest pain symptoms. Especially in folks who have diabetes, I find that they might not experience pain the same way. But there's other patients I see that tell me, "Well, I didn't have pain go down the arm, so I didn't think it was my heart." But they've been having very classical angina or chest pain caused by ischemia from blockages in their arteries to their heart.

So, I always like to advocate that it might not look like the pain you typically see on TV or in movies where it has to be on the left side of your chest, it has to be going down the arm or it has to be going up the jaw. You can have pain there that just feels like a discomfort or pressure. Some patients describe indigestion or they notice pain after eating a big meal. I think all these are symptoms that folks can experience when they have coronary artery disease.

Faisal Bakaeen, MD:

It's interesting that women tend to have atypical symptoms.

Donna Kimmaliardjuk, MD:

Absolutely. I've seen a lot of women too. They have maybe pain in the back or a big symptom that I notice is fatigue. They just don't feel themselves. They feel really, really tired.

Faisal Bakaeen, MD:

Well, these are all good tips because there's a whole spectrum of presentation, as you heard. What kind of testing do we typically do at the Cleveland Clinic for patients with coronary artery disease?

Tarek Malas, MD:

So, some of the testing that we do for coronary disease is, first of all, we want to take a look at a snapshot of your heart. First with ECG, an electrocardiogram to look at your rhythm. Then for patients with coronary disease, we also want to see first of all, if we're trying to screen for coronary disease, we do something called a stress test. We try to stress the heart and take a look at the function of the heart and see if there's any signs of what we call ischemia or lack of blood flow to certain parts of the muscle of the heart. That can be either in the form of a treadmill stress test, or it can be in the form of a nuclear study as well.

Before bypass surgery, other tests that we perform are also CT scans to look at the anatomy of the heart. Of course, we want to look at the anatomy using something called the coronary angiogram, which is basically where we inject dye into the vessels of the heart, and that gives us a snapshot, super clear picture of the coronary anatomy and where the blockages are. This allows us to prepare for surgery.

Faisal Bakaeen, MD:

Donna, you do minimally invasive cardiac surgery. Do you want to comment about any additional testing to assess the suitability of a patient for a minimally invasive approach?

Donna Kimmaliardjuk, MD:

Absolutely.

Faisal Bakaeen, MD:

And what do these approaches look like, maybe?

Donna Kimmaliardjuk, MD:

I'd like to also put the shout-out that you do it too, minimally invasive. I think the nice thing is we've talked about what tests we feel are important or necessary to see if someone's a candidate for minimally invasive. In addition to the tests that Dr. Malas has already mentioned, too, patients will need an echocardiogram because we want to look at how the heart is pumping. Also, we want to make sure there are no major issues with any of the valves inside of the heart. There are some patients we see that are referred for bypass surgery, then we do an echo and they have severe tightness or severe leakiness of a valve that needs to be repaired or replaced. We'll need an echo, but specifically for minimally invasive, what I've started doing in the last couple of years, after talking with [Dr. Bakaeen], is a CT scan of the chest. That is so valuable to really show us the anatomy of not just the heart and the blood vessels on the heart, but the blood vessel coming out of the heart, the lungs, the whole space within the chest. It's really, really important for planning, but also to see if we think someone will be a candidate for bypass surgery, minimally invasively.

Another test I think is really important is a breathing test, or what we call a pulmonary function test. That's going to test to see how strong someone's lungs are because when we do minimally invasive bypass surgery, we have to completely deflate the left lung. You will be breathing just on the right lung for the duration of the surgery, which is a few hours. I want to make sure that the one lung is going to be strong enough to breathe on its own. Unfortunately too, I've seen patients where I think I might do minimally invasively, and then I see they have severe COPD or their lungs are very, very weak and well, we can't do it this way. So, that breathing test is very important.

Then I also like to do carotid ultrasounds. I want to make sure that there are no blockages in the arteries that go up the neck, but also that we look at the arteries that come out to the arms. That's important because the artery that we use for minimally invasive bypass surgery, the left internal thoracic artery, comes off an artery that goes towards our left arm. I want to make sure there's no blockage there because if there's a blockage in that artery, it's called the subclavian artery, and we take that mammary artery and it might look great, might look beautiful and perfect bypass, but if there's a blockage in the actual artery that supplies blood to the mammary artery, the bypass is not going to be sufficient. It's not going to work.

So, that carotid artery ultrasound, I find very helpful. You also get that same sort of information or good information from the CT scan to make sure there's no blockages there. But those would be the other tests that I think are really important for planning for minimally invasive bypass.

Faisal Bakaeen, MD:

Yeah, you obviously do more testing for minimally invasive because the stakes are higher. You want to make sure that when you go in, there's less chance of a problem and less chance of a conversion to a traditional procedure. This carotid scanning, et cetera, is probably more relevant in patients with left main disease because they tend to have the predisposition to have blockages in other major vessels. But you're right, coronary artery disease is not a separate island. It's usually part of a spectrum of disease affecting the arteries in the body.

One additional test that we do is called conduit mapping. We're going to use bypass grafts, and we want to make sure that we use the best conduits for the bypass. Those conduits or bypasses can come from the chest, from the internal mammary or thoracic arteries that run on both sides of the sternum, and also the radial arteries typically from the non-dominant hand, which is the left hand, and the veins from the leg. We don't like any surprises. We want to know the size and the quality of those vessels. So, we do ultrasounds to assess the quality and size of those conduits so that when we go in, we have a perfect plan and we have the perfect combination of conduits for the bypass.

Now, we talked about the diagnostic testing, the symptoms. Now, once we're done with the diagnostic testing, who are the ideal patients that meet the indications and should undergo CABG, versus who are the patients that are high risk or perhaps surgery is ill-advised in those patients? Tarek, maybe you could start with the optimal patient for CABG in terms of the anatomy of the disease and the overall status of the patient.

Tarek Malas, MD:

That's a fantastic question and there are a lot of questions from the audience about who is a surgical candidate. Those are all fantastic questions. It's a difficult decision to make. First of all, the most important thing is that patients who have blockages in multiple vessels are generally excellent candidates for coronary artery bypass grafting. We have the left coronary artery as well as the right coronary artery. The left coronary artery divides into the two major branches called the left anterior descending and the circumflex artery. Generally speaking, when you have multiple blockages, those patients fare well with coronary artery bypass grafting. In addition to that, patients who have diabetes also benefit significantly from coronary artery bypass grafting. Patients who also have some cardiac dysfunction, meaning their heart is not ejecting normally, benefit significantly in coronary artery disease.

Donna Kimmaliardjuk, MD:

Absolutely. Those are kinds of the things that we look at when I'm going through a chart initially. Then we all then assess in clinic, but also through other past medical history, I want to make sure that a patient is strong enough to undergo sternotomy. That’s the incision through the breastbone. If we need to do multiple bypasses, that's the approach that we take is through the breastbone, if we have to do two, three, four or five, however many bypasses. I think that's a really important thing, looking at a patient's overall health, overall functionality, mobility and so that you can't always gather from a chart. I think it's really important to assess in person.

And two, I always advocate, and I know we all do as a group, about shared decision-making. Really, what are the patient's goals in terms of quality of life, quantity of life? How bad are they affected by chest pains? How bad are they affected by other medical conditions they might be suffering from or being treated for? And how can bypass surgery fit in with that? So, I think those would be kind of the big things. I always talk about the anatomical factors that we look at. The blockages, the conduits, can I technically, physically do the bypasses? And then the patient factors.

Faisal Bakaeen, MD:

In general, when patients have multi-vessel disease, CABG is recommended. When they have the left main disease, that's also another strong indication. But also when they have complex anatomies, even for a single vessel, we would do a bypass surgery with an option of a minimally invasive robotic-assisted approach.

Surgery is very safe, CABG is very safe. We hardly ever turn down a patient for surgery unless, for example, they have extreme forms of disease, such as a bad liver, like advanced liver cirrhosis or really bad lungs. Those are the patients where we need to think twice about offering surgery. Age, there's no absolute cutoff. We've done octogenarians, we've even done patients well into their nineties with good outcomes. However, there are other options for patients who are too frail or too sick for surgery. Donna, perhaps you could shed some light on those other options that may be available.

Donna Kimmaliardjuk, MD:

Whenever I see patients and we're talking about surgery or we're talking about blockages, I always say there are three main pillars of treatment or three options. Surgery being one of them, so bypass surgery, stents as another option, and then medication. I break it down into those three categories. If we feel that surgery is not an option for a patient, then it kind of leaves us with looking at stenting and I say “and/or” medication and I always say too, "Whether someone is still going to have stents or surgery, you're still going to be on medication." So, I say surgery or stents are not a way to get of medication.

Faisal Bakaeen, MD:

That's an important point.

Donna Kimmaliardjuk, MD:

Absolutely. You're not going to get off the medication. I say, "Those really help the bypasses and help the stents." So, medication is kind of always there in the background, but then it really I think comes between stents or surgery.

Faisal Bakaeen, MD:

Tarek, what's the difference between a stent and a bypass?

Tarek Malas, MD:

So, that's a great question. Two different approaches. One is a transcatheter approach and one is an open heart or generally a surgical approach. A stent, we usually go through the native coronary arteries themselves, and we blow up a balloon and place this metal frame inside of a blockage and that reopens an artery. That's done in the cath lab by interventional cardiology.

Donna Kimmaliardjuk, MD:

Usually through the wrist or through the groin with those little needles.

Tarek Malas, MD:

Exactly. Those are done through wires and catheters, and it's generally a less invasive approach compared to open heart surgery. With open heart surgery, what a bypass is, it's like a detour in the road. That's the way I think about it. We don't usually touch the blockage. We usually add a secondary circulation after the blockage, and that helps optimize blood flow to certain parts of the heart that are not receiving blood. That's basically what a bypass is. Whether we use arteries from the chest wall, the arm or veins from the leg, that supplements the circulation.

Faisal Bakaeen, MD:

That's an excellent explanation because many patients tell me, "What are you going to do with the blockage?" I say, "Well, we're going to bypass it. You don't have to worry about the blockage." So, the stent is a local treatment. The bypass is just adding an additional route beyond the blockage. That's why we pay attention to the technical aspects of surgery and the durability of the bypass conduit, because if you put a durable conduit there, that should stay open in perpetuity and protect the heart from future blockages, whereas a stent treats that blockage and that's it.

Another difference between the modalities of treatment, the PCI (percutaneous intervention) and the CABG is that the PCI tends to be a really good choice in patients who have an acute infarction, especially what's called ST elevation infarction, where they come in with a blocked vessel and they're in the cath lab and they're doing a diagnostic procedure and they find a blockage that's causing the heart attack. If it's technically feasible, then they could put a stent in that acute setting. That works pretty well. In the chronic setting or the stable setting, and in multi-vessel disease setting, CABG tends to be the modality of choice.

Announcer:

Thank you for listening to Love Your Heart. We hope you enjoyed the podcast. For more information or to schedule an appointment at Cleveland Clinic, please call 844.868.4339. That's 844.868.4339. We welcome your comments and feedback. Please contact us at heart@ccf.org. Like what you heard? Subscribe wherever you get your podcasts or listen at clevelandclinic.org/loveyourheartpodcast.