Things to know about Coronary Atherosclerosis

CORONARY ATHEROSCLEROSIS (CAD) is “hardening of the arteries” involving the arterial blood supply to the heart. This condition is the usual cause of heart attacks, and often causes weakening of the heart, heart failure, and heart rhythm abnormalities, all of which can be very serious conditions. Atherosclerosis is caused by a combination of factors in most cases. The risk of getting coronary atherosclerosis and the complications mentioned above increases especially with age, being a man or woman after menopause, cigarette smoking, elevated cholesterol, hypertension (high blood pressure), diabetes, physical inactivity, a history of heart attack or CAD in the family, and many other factors to a lesser extent. Proper management of patients with CAD is one of the most important aspects of the practice of cardiology. First of all, an APPROPRIATE CARDIOVASCULAR EVALUATION including assessment of the possibility of restoring normal blood supply to the heart, improving the pumping function of the heart, maintaining a stable heart rhythm, and controlling any signs or symptoms that may be present must be addressed. After that is accomplished, preventive measures and careful monitoring of the condition are very important since CAD often tends to be a progressive condition with more problems in the future to be expected unless prevented and dealt with early when they are first detected. These are the primary goals in dealing with coronary atherosclerosis. We need the continuing assistance of a primary care physician at all times involved in the management of our patients, since heart disease is only a part of the overall health status of our patients and medical conditions all interact and influence one another.

Your cardiologist may recommend tests like ultrasonic imaging of the heart, nuclear heart scan, ultrasound or nuclear exercise stress test, ECG rhythm monitor or “Holter monitor”, or other non-invasive tests to determine the character and severity of the problem. Many times a cardiac catheterization test and X-ray images of the pumping function of the heart and the blood vessels to the heart (angiograms) are needed if unanswered questions remain after non-invasive tests are performed. Nuclear and ultrasound exercise testing are accurate in 85% of patients in detecting CAD. Therefore, even with a normal exercise test your cardiologist may recommend a cardiac catheterization if your symptoms warrant it.

Treatment for coronary atherosclerosis may include REVASCULARIZATION PROCEDURES such as surgery, balloon angioplasty (PTCA), and coronary stent procedures to improve the blood supply to the heart as deemed appropriate. MEDICATIONS AND SOMETIMES DEVICES like pacemakers or defibrillators are needed to deal with heart rhythm problems if they occur. Medications and lifestyle changes are recommended to help the strength of the heart if weakness is present. In many cases it is possible to take very serious conditions and accomplish dramatic improvement with all the therapeutic options available today.

Once your problem with CAD has been addressed, PREVENTION OF FUTURE PROBLEMS becomes one of our most important goals and concerns. SURVEILLANCE OF THE HEART CONDITION WITH PERIODIC TESTING is necessary since symptoms and signs alone are not adequate to allow the cardiologist to know enough about what is going on with the heart. Our recommendations for most patients with CAD will depend on the medical history and the exact nature of the patient’s heart condition. The type of monitoring recommended is usually dependent on whether revascularization has been necessary. This educational material is intended to allow our patients to understand these recommendations in the context of their own particular cardiac condition and medical history of heart problems, events, and revascularization procedures.

STRAIGHT FORWARD ADVICE FOR PATIENTS WITH CORONARY ATHEROSCLEROSIS:

1. DO NOT SMOKE OR USE TOBACCO PRODUCTS. NOT ANY. NOT AT ALL. Cutting down on smoking is not good enough. You must quit entirely and permanently. If you have difficulty doing this, your primary care physician should be consulted to make recommendation regarding appropriate measures to help you quit and stay off cigarettes.
2. CHOLESTEROL IS IMPORTANT. Get your cholesterol and the cholesterol subfractions under optimal control and keep them there. Either your cardiologist or your primary physician can help you do this with dietary recommendations and medications. Blood tests for monitoring are usually needed about twice a year once the therapeutic goal is reached.
3. BLOOD PRESSURE IS IMPORTANT. Optimal treatment of hypertension (High Blood Pressure) is very important for all kinds of heart disease. If you have hypertension, you should get your blood pressure checked frequently in a non-medical situation such as in the pharmacy or the grocery. Having a home blood pressure kit is a very good idea also. Please get your blood pressure checked at least once a week, write down the readings, and bring them with you when you come to see your cardiologist or your primary care physician. This is highly superior to having the blood pressure checked only in the doctor’s office, where the readings may not be representative of your usual blood pressure values.
4. DIABETES MELLITUS MUST BE TREATED OPTIMALLY. Optimal management of Diabetes if present is extremely important and must be managed or coordinated by your primary care physician.
5. DIET IS IMPORTANT. Your cardiologist will make dietary recommendations to you after the details of you heart condition and laboratory information are known. For most patients restriction in dietary fat is the most important thing in treating coronary atherosclerosis. There are many excellent books on restricted fat diets available in the local book stores and from the American Heart Association. You need to understand the kind of diet that is recommended for you and make the PERMANENT changes in your eating habits necessary to accomplish your dietary goals.
6. EXERCISE AND WEIGHT CONTOL ARE IMPORTANT. Your cardiologist will make recommendations about appropriate exercise and weight management goals. You need to establish a daily routine in your life that will allow you to get the necessary exercise of the type and intensity recommended. Physical deconditioning and being overweight are something you need to avoid. It puts a strain on your heart and makes everything worse.
7. ALL MEDICATIONS ARE IMPORTANT. TAKE YOUR MEDICATIONS AS PRESCRIBED AND BRING THEM TO EVERY OFFICE VISIT. We could make serious errors in the management of you heart condition if we do not know exactly what medications and the doses and frequency with which you actually take them. Tell us if there is any medication that you are taking in some way different from the directions on the bottle and get the directions changed. There is no other way we can know what medications you are actually taking. Lists made by our patients are often inaccurate, incomplete, or misleading. Get a plastic bag and put all the medication bottles in the bag and remember to bring it with you when you come to see us.
8. COMMUNICATION IS IMPORTANT. If you are having symptoms that suggest things are not going well with your heart condition, we need to know about it. Call our office and let the nurse know what is going on. If there is some urgency involved, one of our cardiologists is always available through the medical exchange in Austin. If an emergency is involved or if you are having persistent chest discomfort, call 911 and they will take immediate action to evaluate your condition and pursue appropriate treatment.
9. YOUR MENTAL STATE IS IMPORTANT. A great number of heart patients suffer from depression, anxiety, sleep disturbance, problems with potency, and other important difficulties that are not directly due to heart disease. Do not allow depression to go untreated. Contact your primary physician to get on a plan of treatment to deal with these problems if they occur.

MONITORING YOUR HEART CONDITION:

SURVEILLANCE IS IMPORTANT. Once a year your cardiologist will want to perform some kind of non-invasive testing, probably including a stress test (not all stress tests involve exercise) or other imaging procedure. This will allow us to get some reasonable assessment of the condition of your heart with objective measurements and imaging procedures that are far more accurate and complete than the information that can be derived from reported symptoms and physical examinations. Periodic objective evaluation with non-invasive tests allows your cardiologist to know what is going on with your heart and to be sure nothing is going wrong or remaining untreated. This is extremely important since the blood supply to the heart, the strength of the heart, and the stability of the heart rhythm can all change with no signs or symptoms whatsoever. The tests that your cardiologist recommends will be selected personally for you. However, in general patients will fall into one of several categories, and therefore pathways as described here.

1. Known Coronary Atherosclerosis with NO HISTORY OF REVASCULARIZATION
Surveillance for patients in this category usually involves a once a year non-invasive test to evaluate the strength of the heart and the blood supply to the heart. Either a stress (exercise or chemical) nuclear scan or a stress (exercise or chemical) echocardiogram (ultrasound) will usually be our choice.

2. Known Coronary Atherosclerosis with a HISTORY OF A CORONARY BALLOON OR STENT PROCEDURE
When a balloon procedure (PTCA) with or without a coronary artery stent is performed, there is a possibility of tissue growth into the stent with in the first 6 to 12 months, sometimes resulting in occlusion or substantial narrowing of the opening. After 12 months time this no longer occurs. Once the vessel is properly opened with a balloon or stent, a stress (exercise or chemical) nuclear scan is done about 4- 6 weeks after the procedure. The stress nuclear scan is superior to other choices in its ability to localize and quantify areas of the heart muscle that demonstrate impairment of blood supply at rest or with stress and to allow differentiation between these two types of abnormalities. This test is done after revascularization to establish a new baseline and to insure that the procedure has indeed been successful. If any suspicious recurrent symptoms are noted the stress (exercise or chemical) nuclear study may be repeated and compared to the 6 week study. If the results still look good, a long lasting success has probably been achieved. If not, or if symptoms are highly disturbing, another cardiac catheterization with coronary angiograms is usually recommended to see how the blood vessels actually look and to decide whether anything further needs to be done at that point in time. Once we get things looking good and staying that way, the plan for surveillance is just as in number 1 above.

3. Known Coronary Atherosclerosis with a HISTORY OF CORONARY BYPASS SURGERY
Aortocoronary bypass surgery is a very major operation in which bypass grafts are placed by the surgeon to reconnect the supply of oxygenated blood in the aorta to the blood vessels to the heart, the coronary arteries. The grafts have a certain probability of becoming occluded per year, approximately 10 to 15% per graft in the first year and about 5% per graft per year thereafter, increasing at 10 years post surgery. We want to do everything possible to prevent this and to detect it in its early stages if possible, when it may still be possible to reopen the graft with a balloon or stent instead of repeating the bypass operation. For this reason, the stress (exercise or chemical) nuclear study is usually recommended on an annual basis so that if some part of the heart begins to show evidence of new impairment in blood supply, a cardiac catheterization and coronary angiograms can be performed with the intent of opening any blockages possible with a balloon or stent without delay. Once a graft becomes closed completely for even a relatively short time it may be neither safe nor even possible to reopen it. Additional surgery then may become necessary, but could potentially have been avoided if the graft had been kept open with a coronary stent before becoming occluded. This is the goal of close surveillance in patients after coronary bypass surgery.