Matters of the Heart
JOSEPH DANIEL FIEDLER ILLUSTRATION
The heart is an energy-hogging muscular pump fueled by oxygen-infused blood flowing through four small coronary arteries. Its electrical, pumping, valve and distribution systems have more backups than the pumps at the Sewerage and Water Board. Any infrastructure is susceptible to decay and breakdown over time; the human heart is no exception.
If the heart’s electrical conduction system is disrupted, an artificial pacemaker can be inserted to generate the needed impulses. Diseased and faulty heart valves can be replaced with valves from animals and man-made substitutes. If a critical blockage clogs a coronary artery, bypasses and stents come to the rescue. And just as a plumber can inspect pipes with a fiberoptic camera, cardiologists can probe arteries from the neck to the legs to correct many problems previously corrected only by surgery.
No specialty in medicine seems as blessed or maybe cursed with so many breakthroughs as is cardiology. New drugs, new ways of using older drugs, so-called less invasive procedures, other tests and disease management protocols aimed at the heart and the body’s circulation appear with the regularity of a Monday morning. The time lapse between an academic study touting the worth of some new approach and press reports is measured in hours. Television networks and newspapers allocate specific time and space in advance timed to the weekly press releases from prestigious medical journals such as the Journal of the American Medical Association.
Many medical practice changes do not stand the test of time. Overly zealous guidelines to lower glucose in Type 2 diabetes in an effort to prevent adverse cardiovascular events were based on studies of Type 1 diabetes and the energetic support of pharmaceutical companies. It doesn’t take a Tulane MBA to figure out that increased prescriptions for diabetic drug combinations fueled drug company bottom lines. Subsequent analyses showed more intense drug treatments caused more complications than benefits, especially for older persons with diabetes.
Coronary angiograms in the 1960s and ’70s were pre-diagnostic tests – the appetizer before the entrée of definitive surgery to increase blood supply to the heart. Surgeons use short segments of redundant blood vessels from the chest and legs to bypass coronary arteries occluded by cholesterol and calcium deposits of plaque. Coronary artery bypass surgery, abbreviated CABG and called “cabbages” around hospitals, kept operating rooms humming and built many mansions for cardiovascular surgeons through the ’90s.
As the angiogram catheters, the long slender tubes used to inject dye into the coronary arteries, became smaller, cardiologists became more daring. They threaded these miniature, deflated balloons fitted on the business end of a long catheter into the arteries supplying the heart. When positioning appears perfect, the cardiologist inflates the tiny balloon to break up discrete blockages in the larger caliber coronary arteries. These percutaneous transluminal coronary angioplasties (PTCA) marked the transition from simply invasive cardiology into interventional cardiology. Early failures and complications were common, but the success rates rapidly improved with experience and technology innovations.
By the early 1990s, cardiovascular surgeons were quickly losing ground as cardiologists “intervened” more and referred fewer patients for actual surgery. Catheter attached devices including lasers to chop away at plaque deposits were the rage for a few years, but complications were common. The development of the coronary stent really transformed interventional cardiology. A stent is a small circular device that serves as a scaffold inside the coronary artery keeping it open after a balloon angioplasty. Stents can also become occluded or clogged and design flaws appear with regularity.
“The gold standard for treating triple vessel coronary disease, as well as much single and double vessel disease, is still the CABG,” says Dr. Morrison Bethea, a cardiovascular surgeon and co-author of the best-seller Sugar Busters!
who’s currently covering the globe as a health consultant for Freeport-McMoRan.
“It provides longer benefits with less mortality,” Bethea says. “Ochsner did a one-year look back at some 400 patients who had either bypasses or stents. There were almost no readmits in patients who had CABG; the readmit rate for persons who had stents was 25 to 30 percent.”
While interventional cardiology has become more and more technically advanced, premature coronary heart disease mortality in the United States is on the wane for other reasons. Cigarette smoking has declined. Physicians are treating hypertension and abnormally high cholesterol levels more aggressively thanks to improved drugs. The next preventive border to cross is the rising obesity rate in the United States. Experimental mice fed less and exercised more live longer. Thin folks live longer on average than their overweight counterparts. The target in the gunsight of tomorrow’s interventional cardiologist is the overweight couch potato tethered to a computer with a soft drink in one hand and potato chips in the other.
With the blessing of good genes and a healthy lifestyle, most folks reading this article will never need heart surgery or what the cardiologists call an intervention. Like everything in medicine, the treatment of heart disease is an art based on science. Medical practitioners interrupt this science in different ways. In my biased opinion, a good internist is the best impartial guide.
Common Questions Different Perspectives
We put the same heart related questions to Brobson Lutz, an internist, and to David Elizardi, consultative cardiologist and director of the Cardiovascular Disease Training Program at Ochsner Medical Center. Here are their answers:
What vitamins should I be taking for my heart? Lutz: Vitamins are popular, but in the absence of any specific deficiency you are helping the companies that sell such substances and not yourself. Eat a varied, balanced diet in moderation, don’t skip breakfast and donate the money you would have spent on vitamins to the Louisiana SPCA.
A glass or two of red wine or a short toddy of another alcoholic beverage in the absence of any alcohol contraindications is much more heart friendly than supplemental vitamins. Elizardi: In general, I agree. There is increasing evidence that omega-3 fatty acids, which can be found in fish oils, may have broad reaching benefits in both prevention and treatment of heart disease, but there are no definite guidelines in place to dictate their use currently.
Should I take an aspirin every day? Lutz: Yes, if it doesn’t upset your tummy and you’re of a certain age. A single daily low dose aspirin around 81 milligrams reduces the incidence of heart attacks in men 45 to 79 years old. This protection doesn’t extend to women, but the same dose does reduce the incidence of strokes in women 45 to 79 years old. For older persons, the benefits decrease due to an increase in gastrointestinal bleeding. Elizardi: I agree.
How often should I get my blood pressure and cholesterol checked? Lutz: In the absence of any known health problems, I advise individuals to get a baseline check around age 30 or so. If both are normal, it is a good idea to recheck with a physician every five to 10 years with more frequent testing beginning at age 50. Beware of home blood pressure devices as user and equipment errors are common. On the other hand, the free blood pressure devices in larger drug stores are usually very accurate. For healthy persons, donating blood is an excellent way to get your blood pressure and cholesterol tested for free in addition to a slew of other tests for blood transmissible diseases. Elizardi: I agree and strongly endorse a lipid panel at age 30 to include HDL and LDL cholesterol levels. Coronary artery deposits begin at least in teen years, and many subsequent victims of heart attacks have missed 20 plus years of therapy that could have prevented the progression of their blockage that leads to heart attacks. The data is very convincing that lowering LDL levels with diet and drugs translates into many fewer heart attacks, strokes, and episodes of sudden cardiac death in as few as three to four years of beginning the medication.
What is my ideal blood pressure? Lutz: Normal blood pressure is usually cited as 120/80, but a person’s blood pressure normally fluctuates both up and down depending on many factors including activity. Many healthy persons have systolic pressures lower than 120, which is no cause for concern unless the lower pressure is causing adverse symptoms of some sort. If the systolic pressure rises above 130 to 140 or if the lower diastolic number goes above 90, treatment with blood pressure lowering medications should be considered. Systolic blood pressures below 130 are ideal for most folks, but the optimal systolic for many older folks can be much higher. Elizardi: In general, I agree. However, there’s a myth, especially among older individuals, that elevated systolic blood pressure is OK; unfortunately, the incidence of stroke and diminished cognitive functioning is directly related to the level of blood pressure elevation above ideal levels in elderly people, so I remain aggressive in management of these folks who are special risks for life-altering complications.
Do I need any medication if I only have white coat hypertension? Lutz: White coat hypertension refers to the situation when a person believes their blood pressure is elevated only in the physician’s office. My bias is that persons with labile hypertension and wide fluctuations in blood pressure are best treated to prevent hypertensive complications. Elizardi: I agree. I challenge anyone whose blood pressure is elevated in my office to prove to me that it is normal under normal circumstances, and they must provide a log of readings over several weeks taken at home that documents this. I usually find that the home blood pressure is too high, and the people who have documented this themselves are usually convinced and are quite willing to begin medication.
Once I start it, will I have to take blood pressure medication forever? Lutz: Some over weight persons can stop or reduce antihypertensive medications if they lose weight. I never tell a person they will have to take a particular medication forever. Science advances in ways impossible to predict. It is important to remember that the adverse effects from an elevated blood pressure can take decades to develop. The blood pressure lowering medication a person takes at age 45 will substantially reduce the lifelong risk of premature heart attacks, strokes, and kidney failure. Elizardi: Also, avoidance of salt and alcohol may obviate the need for long-term therapy. I tell people that we have excellent blood pressure medicines these days and can almost certainly find a combination that will be free of side effects and yet have all of the benefits of avoiding the devastating problems that so adversely affect our quality of life in later years.
What is a normal cholesterol level? Should I be on cholesterol lowering medication? Lutz: The average total cholesterol for patients of all ages in my practice is about 240. On the other hand, the optimal total cholesterol is less than 200 and the optimal LDL or low-density cholesterol level is less than 100. The decision to initiate cholesterol-lowering medication depends on the history and other risk factors. For a 30 year old with LDL 150, hypertension, and diabetes, I would strongly recommend treatment. For an otherwise healthy 85 year old with an LDL of 150, I probably would not recommend drug therapy. Elizardi: Unfortunately, my new patient population also has LDL levels well above the published guidelines that all physicians should follow. We have excellent medications that have very low side effect profiles and can be taken for decades, with prevention of the life-altering complications such as heart attack, stroke and the need for bypass surgery and coronary artery stenting. Prevention is so much more effective than waiting to treat advanced problems!
Do I need a yearly electrocardiogram? Lutz: No. A baseline EKG every 10 years or so might be in order, but there is no reason for a well person without symptoms of some sort to need a yearly EKG. Elizardi: I agree. Spend your health care dollars on being sure your cholesterol is ideal.
Should I get a routine stress test as part of an annual physical examination? Lutz: Unless you have an intermediate or higher risk of cardiovascular disease, I don’t recommend a routine cardiac stress test. Persons with specific symptoms that could be caused by coronary artery disease are the only ones who usually need these tests. One exception might be a sedentary person who decides to begin some sort of vigorous exercise program. Another exception might be a diabetic with other risk factors. Elizardi: I agree. Routine stress tests aren’t good predictors of coronary events in the truly asymptomatic person.
How can I figure out if my cardiovascular risk suggests I need a stress test? Lutz: Most experienced primary care provides can pinpoint cardiac risk categories as low, average, or higher than average informally based on long-term knowledge of the patient, the family history, and cholesterol values. There are several established formulas that can calculate cardiac risks more accurately and precisely. To use one Internet based calculator, you plug in your age, gender, total cholesterol, high density or good cholesterol level, smoking status and blood pressure, and out comes your 10-year risk of having or dying from a heart attack. Elizardi: I agree that risk stratification is important, as early intervention with lifestyle modifications and medications is an investment with great favorable outcomes. Sadly, by the time I see many people, they have missed years or decades of proper care that might have prevented serious problems.
If I do need a stress test, what kind should I get? Lutz: This is a decision I usually leave to the cardiologist. The injection of a radioisotope in conjunction with a stress test can improve its accuracy. Such perfusion scans are usually not needed for adults with low to intermediate cardiac risks. These radioactive isotope scans are best reserved for persons with suspected advanced cardiovascular disease, diabetics or a strong family history of premature coronary artery disease. Elizardi: I agree, especially with the last sentence. The fancy, more expensive and cumbersome stress tests are otherwise best used when there are equivocal results from simpler studies or in diabetics. I perform a stress echo treadmill on most people, as it is quick and does have better accuracy than a simple stress test that depends only on electrocardiogram changes to determine problems.
Should I get a routine high-sensitivity CPR blood test along with checking my cholesterol? Lutz: Probably not. The C-reactive protein (CRP) is very nonspecific marker of inflammation that may or may not be cardiac in etiology.
Some experts believe it can be useful in better accessing cardiac risk. I have not found that it changed anyone’s outlook, behavior or clinical management. Unless a potential test result leads to some specific change or intervention, I don’t usually recommend it. Elizardi: I agree.
Should I get a routine CT heart scan to see if I have heart disease? Lutz: No, I agree with the American Heart Association that generally recommends against these scans, which can expose you to as much radiation as 33 chest X-rays, if you don’t have any symptoms of heart disease. If a person has symptoms of heart disease, other tests are usually preferred. Besides, Medicare and most insurance companies usually will not pay for this test. Elizardi: I believe there’s a role for CT coronary calcium scoring in some people. About 60 percent of Americans, not already diagnosed with coronary artery disease, are “at risk” for its development. If we can identify those over the age of 50 who will most benefit from aggressive medical therapy for their blood pressure, LDL cholesterol, and blood sugar, it’s worth the $100 that insurance doesn’t cover. Many of these folks can be sorted out without the test, but many cannot, and the actual dose of radiation is low when we consider what all of us are exposed to under normal daily activities and with airline travel.
Should I have a routine angiogram just to make sure I do not have some sort of coronary disease? Lutz: No. There is nothing routine about an angiogram. You shouldn’t have one in the absence of very suspicious symptoms or specific indications. Even worse is a screening angiogram that results in the insertion of a cardiac stent. Current data is clear – stents have an important place in treating the person who’s having an acute heart attack; however, insertion of stents is not recommended just because an angiogram shows an asymptomatic blockage or area of reduced blood flow. Elizardi: I agree. Stents have come a long way and can be very useful in the symptomatic patient and those having a heart attack, but they have been overused in many people. Just as we believed that bypass surgery would make people live longer by “fixing” the problem 35 years ago, so have we believed this about stents. However, in both cases, the real benefits occur only in the really symptomatic or very high-risk people.
What’s best – a stent or heart surgery? Lutz: It depends. If you’re having a heart attack and a blockage can be opened with a stent, the stent is usually best. If you have progressive heart disease and/or several blocked coronary arteries, surgery with bypass grafting grafts gives better longterm results. Elizardi: Diabetics also often do better with bypass surgery. There are centers in the United States, which have particular expertise and high volume with stenting, and their results are often similar to bypass surgery, but this doesn’t translate into the same benefits in many community hospitals.
What happens if I get a heart attack on a cruise line? Lutz: A Cleveland Clinic outpost serves as the cardiology consultants for several large cruise lines operating out of Florida. Whenever a person on a cruise developed any chest symptoms, the ship doctors performed an EKG and called the Cleveland Clinic for advice. During a two-year period they called for 76 men and 24 women. Only three persons actually died on the ship, but 73 others were evacuated to hospitals. Elizardi: The best advice I can give my patients is to be certain you aren’t having increasing symptoms before you travel, and if you have a heart problem you should discuss this with your physician before you purchase tickets. It is rare for otherwise healthy people to develop new heart attacks on a cruise.
My doctor started me on Plavix after I got a stent. How long should I be on it? Lutz: Sometimes it’s just easier for a physician to keep somebody on a drug than to get him or her off of it. I have sent notes or called cardiologists about six times in the last year about this. About half the time, I was told the patient could stop Plavix if they stayed on aspirin. Some cardiologists are more likely to keep patients on it longer like until it causes a serious gastrointestinal bleed. Elizardi: Stents, for all of their benefits, have presented us with new challenges. Often, the best long-term results are achieved with drug-coated stents in which Plavix therapy for at least one year is mandated. However, all of us have experienced, and the literature has supported, acute closure of these stents well beyond the one-year mark. Since the consequences can be fatal, and are not negligible, many of us are reluctant to stop the Plavix in folks with these types of stents, unless extenuating circumstances arise.
White coat hypertension refers to the situation when a person believes their blood pressure is elevated only in the physician’s office. My bias is that persons with labile hypertension and wide fluctuations in blood pressure are best treated to prevent hypertensive complications.
Stents have come a long way and can be very useful in the symptomatic patient and those having a heart attack, but they have been overused in many people. Just as we believed that bypass surgery would make people live longer by “fixing” the problem 35 years ago, so have we believed this about stents. However, in both cases, the real benefits occur only in the really symptomatic or very high-risk people.