Ask The Heart Doctor: Women's Heart Disease and Surgery Part 1 - Coronary Heart Disease

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy, and information about diseases and treatment options.

Enjoy.

Leslie Cho, MD:

Welcome, everyone, to a session on Ask Your Heart Doctor. Today, our focus is on women and heart disease and we're joined by our surgeon as well as our cardiologist colleagues. We're going to go around and introduce ourselves first. My name is Leslie Cho. I'm the Director of Women's Cardiovascular Center at the Cleveland Clinic.

Donna Kimmaliardjuk, MD, FRCSC:

I'm Dr. Donna Kimmaliardjuk, and I'm a cardiac surgeon with a special interest and focus on coronary artery disease and bypass grafting.

Christine Jellis, MD, PhD:

I'm Christine Jellis. I'm an imaging cardiologist with a special interest in advanced imaging. I'm one of the detectives and we use this imaging to figure out how bad heart disease is, so that we can send them across to Donna if people need surgery.

Leslie Cho, MD:

Perfect.

So, we're going to start with some basic questions, and I know you have been so generous and asked us tons of questions. We're going to get through some of the common ones. So, why don't we start out with coronary artery disease, which is blockages in the heart. And we're going to start with Christine first and ask you, what are some of the diagnostic tests we do for women for coronary artery disease?

Christine Jellis, MD, PhD:

Absolutely. Great question. And I think we always start simple. A good thorough history and examination is the first step. Often women will present with traditional symptoms, but sometimes they can be atypical. So, I'm wanting to ask people, are they having shortness of breath? Are they having heavy central chest pain? Sometimes people can feel it as a pressure or discomfort, particularly when they're exerting themselves walking up a hill or walking long distances that's relieved with rest.

And then based on that assessment, I'm looking at my diagnostic tools. So, things like an ECG, sometimes called an EKG, same thing, or an echocardiogram. Now an echocardiogram is an ultrasound of the heart similar to an ultrasound people have when they're having a baby. It's telling us what the structure of the heart looks like, but it's only telling us the structure and function of the heart at rest. And as I mentioned, some of these symptoms occur with exertion, which is when the heart needs additional blood flow and oxygen. So, what we often then do, Leslie, as you know, is go on and do stress testing. And there are several different types of stress testing that we can do, which we really try and stratify depending on the suitability of each of the types of stress test for the specific patient.

Leslie Cho, MD:

Perfect. Let's say the patient flunks their stress test, and they go get a cardiac cath and they are found to have disease. Now, Donna, please explain when do we think about bypass surgery, versus medical therapy, versus getting a cardiac stent?

Donna Kimmaliardjuk, MD, FRCSC:

Another excellent question. So, it really comes down to patient factors, but also blockage factors when deciding medication, versus stenting, versus surgery. So, I think all of us would be in favor of good medical therapy. That's your first approach. I always tell patients, when you come to see me for bypass surgery, you're still going to be on all the same heart medication afterwards, same with the stent, because it's going to help keep those stents and those bypasses open, help prevent new disease from forming. So, that's always in the background, but then when looking at blockages, it really depends on the number of blockages, where those blockages are, how severe those blockages are in terms of deciding stenting versus surgery, but also looking at the patient overall themselves. There's a lot of things we'll take into consideration, anything from age to other comorbidities, to goals of care, or goals in terms of quality of life and expectations of recovery and getting through a recovery after surgery versus stenting. So, it really should be a shared decision-making process between the patient, the cardiologist and the surgeon.

Leslie Cho, MD:

There's a lot of questions about what recovery looks like. One of the questions is, do women have more prolonged recovery? Do they have similar outcome as men and women? So, what do you tell your female patients?

Donna Kimmaliardjuk, MD, FRCSC:

So, I actually tell my female patients, you're going to find recovery easier than the men, I find, because our traditional approach for open-heart surgery is what we call a sternotomy, where we go in the middle of the breastbone. So, it's a common misconception of breaking ribs. No, it's a cut in the middle of the breastbone. And I do find women, I'm not sure why, but we find this much easier compared to men. And by day three, most folks only need Tylenol to help with the pain, but like any broken bone, it needs time to heal. So, the recovery process really is around allowing that sternum, that breastbone to heal properly. So, the certain restrictions come into play of no driving for the first weeks. And I always tell patients, it's not because of the heart. It's because of the bone, we need that to heal. And then as well, no heavy lifting, nothing more than 10 pounds, which includes yourself if you think about it. Again, not because of the heart. The heart can handle it. It's, we need that bone to fully heal back together, and that takes six weeks.

So, it's the six weeks of just walking. That's really all we want you to do before you can get back to regular activities, but before you feel a 100% great, in all honesty, can take a few months. That's going to be different from person to person, again, depending on other health issues, how mobile you were before surgery, how your recovery was in hospital, if there were any major complications. But for it to take a few months even for our healthiest and fittest patients is not unheard of. But the whole beauty and goal of bypass surgery and, well, an open heart surgery is, we get you back to doing everything you did beforehand without restrictions and without having pains, or pressures, or shortness of breath or a heart attack. So, I always say, the payoff is real. It's just that price to pay of recovery for a few weeks or potentially a couple of months before you feel really perfect again.

Leslie Cho, MD:

There are patients in whom bypass surgery is preferred, like diabetics, people with low ejection fraction, and for bypass surgery is superior than stent. And then there are people in whom stent and bypass surgery is pretty equivalent.

Donna Kimmaliardjuk, MD, FRCSC:

Yes. Absolutely.

Leslie Cho, MD:

So, I think one of the things that we always, I think, struggle with when we try to explain is, in some patients really surgery is by far a better option for longevity, for durability.

Donna Kimmaliardjuk, MD, FRCSC:

Yes. So, something that I'll often say to my patients, maybe you can like this analogy or not, but I think of it with bypass surgery and stents, if I'm meeting a patient that I know the evidence supports surgery is going to give you better, longer lasting results of having fewer chest pains in the future, less need for repeat intervention in terms of either stenting or bypasses, being free from symptoms and free from heart attack, it's like you get what you pay for in life. So, let's say you want really high quality, expensive appliance, or car, well, it's really expensive, but it's going to last you a really long time as opposed to something that's really cheap and you can get it right now, but it's not going to last as long.

So, that is sometimes that analogy I use between bypass surgery. So, it's going to last you, hopefully, a really, really, really long time, but the price to pay is the recovery with that surgery and the initial early days and weeks after surgery, but the payoff’s better. Whereas the stents in some patients, we know they're going to be really high risk that those stents could close up and you're back again with more chest pain, shortness of breath, or, heaven forbid, a heart attack. So, that's really how I think I try to view it, that the payoff sometimes is really, really worth it.

Leslie Cho, MD:

Yeah. And then there are patients in whom surgery can't be. We can't have surgery, because their lungs are too poor, or their comorbidities are too high, in whom, I think, intervention is good.

Donna Kimmaliardjuk, MD, FRCSC:

Correct.

Leslie Cho, MD:

Well, thank you so much for joining us today and we look forward to seeing you again in the future.

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