February 2009: Managing Heart Disease
01 Feb 2009
Dr. Ian Cohen is a board-certified fellowship-trained cardiologist at Weiss Memorial Hospital. His specialties include coronary interventions, peripheral vascular interventions, valvular heart disease and secondary prevention. Dr. Cohen is chief of cardiology at Weiss.
Managing Heart Disease in 2009: A Patient’s Guide to New Developments
Dr. Ian Cohen
Chief of Cardiology
Weiss Memorial Hospital
Cardiovascular disease remains the leading cause of death in the United States and most other developed nations despite significant advances in prevention, detection and treatment. Cardiovascular disease is caused mainly by atherosclerosis, a hardening of the arteries due to deposits of cholesterol debris (plaques) in the lining of blood vessels. These atherosclerotic plaques cause heart attacks, strokes and limb loss.
Public health awareness campaigns and medications targeted against modifiable atherosclerotic risk factors have resulted in improvements. These modifiable risk factors include controlling blood pressure, blood sugar and cholesterol as well as smoking cessation. Medications, along with lifestyle modification such as weight loss, regular exercise and a heart healthy diet are key weapons in the fight against the disease.
Steps for early detection
Early detection is critical to preventing heart disease, especially for people with risk factors. Persons with a family history of heart disease should consult a physician to be evaluated. A physical exam together with an electrocardiogram (ECG or EKG) is the usual starting point in an evaluation. Other diagnostic tests that may be ordered include a stress test and an echocardiogram. If the investigations lead to a diagnosis of atherosclerosis in the heart arteries (coronary artery disease), the patient is referred to a cardiologist for an angiogram.
An angiogram is an evaluation of coronary artery blood flow by injecting an iodine-based dye into the arteries to create a moving X-ray of the artery. Angiograms are performed in a specialized suite called a cardiac catheterization lab (the procedure is often called a cardiac cath). Under sedation and local anesthesia, a special IV is inserted in a leg artery and specialized catheters are advanced by the cardiologist to the heart under X-ray guidance. Once the dye is injected, the cardiologist has an immediate real-time look at the arteries and can assess whether the blockages need to be opened.
In some cases, the blockages may only require medical therapy. In other instances, they may be severe enough to require referral to a cardiac surgeon for open-heart bypass surgery. In many cases, the blockages can be fixed right away by angioplasty, the opening of the artery in the cath lab using specialized balloons. In most cases, angioplasty is performed using stents—metal coils that remain inside the artery keeping it open.
Angiograms and angioplasties are now performed routinely in most hospitals with a high success rate and a low complication rate. In most cases, patients who have stents placed are discharged the next day.
Understanding your options
Unfortunately during the last few months, confusing information has been published in the media regarding the efficacy of cardiac stenting. The confusion has raised doubts among patients about the safety of newer “coated” stents and whether stenting is indeed indicated. The following summary is a consensus from most expert opinions regarding these matters.
The data regarding the safety of the newer coated stents is clear. Newer coated stents are safe and have a much lower tendency to re-narrow than the older generation non-coated “bare metal” stents. As a result, patients who receive coated stents are thus much less likely to require a repeat procedure for stent narrowing. With the older bare metal stents, approximately 20 percent of patients need a second procedure on the same artery within six months. With the newer coated stents, the rate is now less than 5 percent. These newer generational stents are coated with drugs that inhibit the treated artery from re-narrowing by preventing scar tissue inside the stent. The tradeoff for this reduction in re-narrowing is that patients have to take both Aspirin and Plavix—drugs that prevent platelets from suddenly blocking the stents—continuously, for at least one year.
The issue regarding the indication for stent placement is also clear. For patients presenting with heart attacks caused by sudden blockages in arteries (a condition known as acute coronary syndrome), stenting is superior to treatment with medications. In fact, the more serious the heart attack, the better the outcome with stenting. In the most serious form of heart attack, known as STEMI, not only is stenting essential, but it must be done within 90 minutes of presenting to the hospital. It is important for patients to know whether their hospital offers emergency stenting and what the hospital times are for STEMI cases. In fact, it will soon be mandated that hospitals make this data available to the general public.
The major controversy regarding stent placement is in cases where patients have long-standing blockages and a stable chest pain syndrome known as chronic stable angina. In these cases, the benefits of stenting are less clear cut. It is essential that these patients meet with their physician and cardiologist to discuss the benefits of undergoing a stent procedure. Medications are often an adequate solution for patients who are functioning with minimal chest pain or symptoms of congestive heart failure. However, stenting is preferred if medications lose their effect or if it is determined that the patient’s blockages are more severe than symptoms suggest. Cardiologists rely on several tools to perform cardiac testing, including stress tests, echocardiograms and cardiac CT scanning to determine which approach to follow.
As I often tell my patients, the key to good cardiac care is the combination of an educated patient and an experienced cardiologist in a longstanding relationship.
For more information
If you would like more information about managing heart disease or would like to schedule an appointment, call Dr. Cohen’s office at (773) 564-6060.