Medical Issues published by the Daily Dish

[ami]

Q: I've heard there are new guidelines about taking aspirin for prevention of a heart attack or stroke. As a preventive cardiologist, what's your opinion on this?
— Judy, New Jersey
Dr. Arthur Agatston A:

Many of my cardiology patients ask about the value of taking daily aspirin to prevent a heart attack and stroke. Now the updated guidelines from the U.S. Preventive Services Task Force, published in the March 17 issue of the Annals of Internal Medicine, have shed some new light on the subject. The revised guidelines, which recommend aspirin use for the primary prevention of heart attack and stroke, are more specific than earlier guidelines:

* Men ages 45 to 79 should take aspirin if the chance of preventing a heart attack outweighs the potential harm of an increase in gastrointestinal (GI) bleeding.
* Women ages 55 to 79 should take aspirin if the chance of reducing an ischemic stroke outweighs the potential harm of an increase in gastrointestinal bleeding.
* Women younger than 55 and men younger than 45 who have never had a stroke or heart attack should not take aspirin for prevention.
* In men and women 80 or older, current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention.

As far as what dosage works best, the jury is still out on this. But we should learn more when the results of the ongoing CURRENT-OASIS 7 clinical trial, the first large-scale randomized trial to directly compare high-dose vs. low-dose aspirin, become available later this year. For now I recommend 162 milligrams daily (two low-dose, or baby, aspirin) to patients who already have coronary heart disease or who are at risk for a heart attack and aren’t at risk for a GI hemorrhage. And I sometimes recommend one low-dose aspirin (or 81 milligrams) to those who are at low risk for heart disease and prefer not to take the stronger dosage.

Proactive as the above guidelines may seem, you should never take any form of aspirin regularly without consulting your own doctor. As noted above, aspirin can cause stomach bleeding, and it should not be used by those who have or are prone to gastrointestinal ulcers. According to the U.S. Food and Drug Administration (FDA), if you take aspirin regularly, you should not drink alcohol because it can also irritate the stomach lining. Because aspirin is a nonsteroidal anti-inflammatory drug (NSAID), it should not be taken with other NSAIDs, such as ibuprofen or naproxen. And because it can thin the blood, avoid taking aspirin with anticlotting medications, such as Coumadin (warfarin) or Plavix (clopidogrel), unless advised to do so by your doctor.

Last Updated: 05/13/2009
Arthur Agatston, MD, is a practicing cardiologist and an associate professor of medicine at the University of Miami Miller School of Medicine. He is also the creator of The South Beach Diet

[ami]

Bringing your cholesterol numbers down is an important part of improving your heart health.
By Arthur Agatston, MD, Everyday Health heart expert

If you have established heart disease or are at high risk, aggressive cholesterol lowering is beneficial no matter what cholesterol levels you start with. There are a number of studies that demonstrate this.

The 1998 Air Force/Texas Atherosclerosis Coronary Prevention Study was different from prior statin investigations. In this study, the participants started with normal levels of total and LDL ("bad") cholesterol and no obvious signs of cardiovascular disease. Understandably, many people thought that giving statins to people with normal LDL cholesterol was "overkill." In truth, it turned out to be lifesaving. Compared to people who were given a sugar pill (placebo), those who took a statin had a 37 percent lower risk of having a heart attack, unstable angina, or sudden cardiac death.

A more recent study, the 5-year Heart Protection Study, reported in 2002, backed up these results. In this study, a statin was given to half of 20,536 subjects with risk factors for heart disease other than a bad LDL cholesterol level. In fact, some of the study volunteers had a relatively good level of LDL (below 116) to begin with. The results showed that cholesterol-lowering statin therapy decreased heart attacks equally in those starting with an LDL level of less than 116 and in those who had a higher initial level of LDL.

In yet another study, published in 2005 and known as the "PROVE-IT trial," more than 4,000 patients with an elevated LDL cholesterol level who were hospitalized for either a heart attack or unstable angina were given one of two statin drugs and followed for up to 2 years. In one group, LDL levels were decreased to less than 70 mg/dL, as compared with a decrease to about 100 mg/dL in the other group. Those who had their LDL lowered to at least 70 had significantly fewer cardiac events, and there was even further incremental benefit as the LDL was lowered into the 50s and 40s.

Despite these studies, some physicians and researchers believe that using medications to lower cholesterol to very low levels may be dangerous. As far as I'm concerned, there is a danger, but it is from the high levels of cholesterol caused by our modern lifestyle, not the low levels we get by using cholesterol-lowering drugs. Newborns and people living in most preindustrial societies have a "normal" total cholesterol level of 120 mg/dL or less. In the United States, our "normal" is about 200 mg/dL. From my perspective, one could say that aggressive statin therapy simply reduces cholesterol to "natural" levels.

Would You Benefit from Taking a Statin?
How do you know if you would benefit from taking a statin or another cholesterol-lowering medication? This is something you will need to discuss with your doctor. In my practice, I lower my patients' cholesterol levels until I believe I have arrested or reversed the underlying disease. The ultimate level, of course, varies from patient to patient. One patient with an LDL cholesterol of 160 mg/dL might have little or no plaque and not require a statin. Another with the very same cholesterol level but a more significant amount of plaque might benefit from aggressive statin treatment.

However, you can get some idea of what your doctor might advise by referring to the NCEP guidelines for LDL cholesterol. The higher your LDL level, the greater your risk of having a heart attack or stroke. (You are at the highest risk if you have diabetes or known heart disease.)
Last Updated: 11/14/2008
Reprinted from: THE SOUTH BEACH HEART PROGRAM by Arthur Agatston, MD. © 2007 by Arthur Agatston, MD. Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800)

[ami]

Q: My husband had a heart attack last year, and since then, he barely leaves the house. He doesn't want to do anything active and spends all of his time watching TV or surfing the Internet. How can I help him participate in life again?
— Gail, New York
Dr. Arthur Agatston A:

Although you didn’t use the term, your husband’s lack of action is a classic sign of depression, which is very common after a heart attack or stroke. I'm glad that you are determined to help him. Depression after a heart attack has been linked to abnormal heart rhythms, inflammation, increased blood pressure, high cholesterol levels, and increased plaque buildup, all of which significantly increase the risk of another heart attack.

There are certainly plenty of reasons why your husband might be depressed. Worrying about having another heart attack and fear of dying are probably paramount, but he may also be concerned about caring for you and the rest family, when he can return to work, or if he can ever play full-out basketball or 18 holes of golf again.

It's very common for depressed people to lose interest in their self-care and to give up the activities that once made them happy. Just like your husband, those who are depressed are more likely to be sedentary, eat poorly, and start smoking and/or drinking alcohol. They may also skip their medications.

The good news is that treatment helps between 80 and 90 percent of people with depression. The place to start is with your husband’s cardiologist to discuss the problem and re-evaluate the medications he’s on (sometimes beta-blockers, which are often given after a heart attack to slow heart rate, can cause or aggravate depression). Depending on the depth of his depression, it may be that he will need to be prescribed an antidepressant. Beginning talk therapy with a psychotherapist or family counselor can also help.

I would also recommend that your husband get back to exercising (in consultation with his doctor, of course). Many people fear that exercising will cause another heart attack, but it's actually beneficial. Begin with short daily walks and gradually work up to longer walks and more strenuous cardiovascular and core-strengthening exercises if his doctor permits. Not only will regular exercise stimulate the mood-boosting brain chemicals called endorphins, it will also boost his energy and strengthen his heart muscle.

Interacting with supportive people outside the home can also help. Consider contacting a support group for heart attack survivors and their families, such as Mended Hearts, which is sponsored by the American Heart Association and has chapters in communities throughout the United States and Canada.

Last Updated: 05/29/2009
Arthur Agatston, MD, is a practicing cardiologist and an associate professor of medicine at the University of Miami Miller School of Medicine. He is also the creator of The South Beach Diet.

[ami]

When diet and lifestyle changes aren't enough to lower your cholesterol, medications may be necessary.
By Arthur Agatston, MD, Everyday Health heart expert

When I tell high-risk patients that I think they should take a statin drug and explain why it will help to improve their cholesterol levels, they usually agree. But it is not unusual to get some resistance from patients who aren't well informed about the potential benefits or side effects of these drugs.

The following are some typical patient reactions:
"No! I don't want to take any medications. I want to lower my cholesterol naturally, without drugs and their side effects. Won't drugs fry my liver?"
"Sign me up! I'd rather take a pill than worry about my diet or bother with exercise!"

In both cases, these patients are just cheating themselves.

Patients who reject medications because they think they're not "natural" are missing out on some of the best tools in aggressive prevention. Statin drugs alone can slash the risk of having a heart attack by more than 30 percent — and by much more than that when taken in combination with other drugs such as niacin, aspirin, and/or certain blood pressure medications.

I am quick to remind patients who make remarks about drugs not being "natural" that there is nothing "natural" about having a sick artery that is burdened with plaque. I also tell them that statin drugs can actually help to restore the artery to its youthful, flexible state — the way that nature intended it to be. And I remind them that a truly "natural" cholesterol level is in the low 100s. At least that is the level found in populations with unprocessed, non-Western diets.

Patients who think that popping a pill renders diet and exercise unnecessary are also making a deadly mistake. Drugs are meant to work together with these lifestyle changes; they are not meant to replace them. Even if a combination of drugs can reduce your risk of having a heart attack by 50 percent, half of all people taking these drugs who were destined for a heart attack will still have one. That's why making lifestyle changes is so essential to further reduce risk.

Although I am a passionate believer in the power of diet and exercise, given what we know today about the effectiveness of statins and other drugs, it makes no sense at all for at-risk patients not to take them. I made this point recently when I was lecturing at a major medical center about the benefits of good fats, good carbs, and lean protein to a group of physicians. At the end of my talk, after having built a strong case for the role of diet in heart disease prevention, one doctor asked if I would be willing to conduct a study that tested the principles of the South Beach Diet as a sole therapy for patients with coronary artery disease. I was adamant that I would not. Using diet alone to treat heart disease would be ignoring 30 years of lifesaving medical advances.

So does that mean that statins should be universally prescribed in a manner akin to adding fluoride to drinking water to reduce tooth decay? That would be going too far. But statins have generally been underprescribed.

Despite numerous excellent studies documenting their effectiveness, millions of people who should be taking these cholesterol-lowering drugs are not. This means that millions of Americans have an unnecessarily high risk of suffering a heart attack, stroke, or sudden death.

A Word of Caution:
Tell your doctor about all the medications and dietary supplements you take regularly, whether they're prescription or over-the-counter. When taken in combination with other drugs, many otherwise safe medications can interact, causing potentially dangerous side effects. Never stop taking a heart medication without consulting your doctor.

Last Updated: 12/01/2008
Reprinted from: THE SOUTH BEACH HEART PROGRAM by Arthur Agatston, MD. © 2007 by Arthur Agatston, MD. Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800) 848-4735.

[ami]

The heart serves a vital purpose in the body.
By Arthur Agatston, MD, Everyday Health heart expert

The heart is not an inanimate pump: It is a living, dynamic community of millions of hardworking cells. Its job is to deliver blood to organs that would die without it. Blood contains oxygen and nutrients necessary for the functioning of every cell in the body, including heart cells.

Everyone's heart beats around 70 times per minute, or 100,000 times per day, or about 2.5 billion times in the average lifetime. This vital organ is programmed to work automatically for every second of every day for as long as you live, no matter what else you're doing mentally or physically. In other words, your heart never rests.

Your heart is located just about in the center of your chest and is divided into four chambers: The two smaller upper chambers are known as the left atrium and right atrium and the two larger lower chambers are the left ventricle and right ventricle. Oxygen-poor blood enters the right atrium and is then pumped into the right ventricle and through the pulmonary artery to the lungs, where it is enriched with oxygen (and loses carbon dioxide).

The oxygenated blood is then carried to the left atrium via the pulmonary veins, from where it enters the left ventricle, the main pumping chamber of the heart. It is the thick, powerful muscle of the left ventricle that pumps blood to all the organs of the body via the aorta. From a cardiologist's point of view, it is the left ventricle that is the most important chamber because it is the area of the heart most likely to be affected by a heart attack.

As blood enters the aorta, some is immediately directed to the coronary arteries. The left main coronary artery divides into two major coronary arteries — the left circumflex artery (LCx) and the left anterior descending artery (LAD). A third major artery, the right coronary artery (RCA), has its own point of origin from the aorta. All of these arteries have branches, which are also known as coronary arteries. They supply the beating heart muscle with blood and oxygen. If anything obstructs the flow of blood through one of these arteries for more than 20 to 30 minutes, the heart will likely not receive enough oxygen, and the part of the heart muscle fed by that artery will die. This is what happens when you have a heart attack.

Heart failure occurs when your heart muscle is damaged to the point that your heart can no longer pump sufficient blood to the rest of your organs. When your heart is damaged and can no longer pump efficiently, blood also tends to back up into the lungs, making them heavier, which results in difficulty breathing.

Learn how to eat to improve your health.
Last Updated: 11/14/2008
Reprinted from: THE SOUTH BEACH HEART PROGRAM by Arthur Agatston, MD. © 2007 by Arthur Agatston, MD. Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800) 848-4735.

[ami]

Q: I live in an area with poor air quality, and I have asthma. Should I be worried that this will affect my heart?
— Samuel, Alabama
Dr. Arthur Agatston A:

Unless you already have heart disease, Samuel, I would be more concerned about how an asthma attack is affecting your lungs rather than what it is doing to your heart.

When you have asthma, your immune system overreacts to substances in the environment, including smog, and this triggers a full-scale alarm, or an asthma attack. When this happens, immune system defenders called mast cells, located in tiny passageways in your lungs, release chemicals, including histamines. Your airways then become inflamed and constricted, causing your breathing tubes to produce extra mucous and making it even more difficult for air to get through.

While it would seem like an asthma attack, with its attendant coughing and wheezing, would be hard on your heart, asthma is not a risk factor per se for heart disease. In fact, some pulmonary specialists believe that the histaminic response that your body has to such an attack can actually help protect the heart, because the histamines may counter the release of excessive amounts of the neurotransmitter noradrenaline. This is the “fight or flight” chemical that your body produces when under stress, including the stress of a heart attack.

That said, a few studies that have found a possible association between asthma and stroke, and there have been associations made between compromised lung function and coronary heart disease (mainly in women). But more research is needed in both of these areas, so I wouldn’t be too concerned.

For someone who already has heart disease, however, it is possible that certain drugs used to treat asthma could precipitate an acute coronary event. Beta-agonist drugs that are commonly used as quick-acting bronchodilators tend to have stimulatory side effects similar to those of adrenaline. Generally, these effects are slight, but occasionally, people with certain types of heart disease, such as angina or arrhythmia, are sensitive to even these minor effects.

On the flip side, certain beta-blockers, such as Inderal (propranolol), which are used to treat high blood pressure, can have particularly strong effects on the bronchial tubes, causing constriction and triggering an asthma attack.

Since I don’t know your personal situation, I suggest that you discuss any concerns you have with your own physician.
Last Updated: 05/06/2009
Arthur Agatston, MD, is a practicing cardiologist and an associate professor of medicine at the University of Miami Miller School of Medicine. He is also the creator of The South Beach Diet.

[ami]

Q: My husband has a high-pressure job and works long hours. I'm worried that his work, combined with a less-than-ideal diet, may lead him to have a heart attack. What can I do to get him to make his health a priority?
— Annabelle, California
Dr. Arthur Agatston A:

Your husband’s case sounds familiar. I see it all the time. In my book The South Beach Heart Health Revolution (now available in paperback), I tell a story about a wife who literally drags her overweight and sedentary husband into my office for tests because she’s worried he’s at high risk for heart attack or stroke. She wants me to read him the riot act about his health.

But, while dragging a workaholic husband into a doctor’s office might seem like a great way get him to focus on his health, it isn’t ideal because the patient is basically against the idea from the get-go. Even so, for many couples, visiting a doctor is the only way to start the process, and I would highly recommend that they see a preventive cardiologist.

For some resistant patients, I’ve found that “shock and awe” is the only thing that works; for others, it may be instituting a series of small steps toward better health. When I say shock and awe, I mean that one of the quickest ways to get a person to understand his or her risk for heart attack is to do a heart scan for coronary calcium (which I typically do after some advanced blood work and a carotid ultrasound). This noninvasive procedure shows the amount of calcified plaque in the person’s coronary arteries. If there’s a lot of plaque, the arteries will light up like an airport runway at night on the scan. Seeing this firsthand can often shock the person into wanting to take immediate action to improve matters. I’ve found that putting the scan up on the fridge is also a potent reminder.

For people who prefer not to have such a test or who turn out to have a moderate amount of plaque after the scan is done, I typically recommend changes in diet and exercise. It’s unrealistic to tell a person who enjoys his work to cut back, but you can tell him that simply getting 20 minutes of vigorous aerobic exercise every other day — either before or after he heads for the office or during his lunch hour — can go a long way toward beating stress, strengthening the heart muscle, and preventing a heart attack or stroke. Since most workaholics won’t go to the gym (no time), I tell them to buy the most expensive treadmill or elliptical machine available, since they’re more likely to use it if it costs a lot of money!

Making simple dietary changes like eating more antioxidant-rich, high-fiber fruits, vegetables, whole grains, and legumes, and eating at least two nutritious snacks a day at the office (rather than chowing down on empty-calorie fast food) can also help.

And if your husband smokes (which many workaholics do), I would definitely read him the riot act. I tell my patients who smoke that I think they’ll be lucky if they do die quickly from a heart attack, because a long and lingering death from emphysema or lung cancer is far worse!
Last Updated: 03/17/2009
Arthur Agatston, MD, is a practicing cardiologist and an associate professor of medicine at the University of Miami Miller School of Medicine. He is also the creator of The South Beach Diet.

[ami]

The Huffington PostAugust 1, 2009
Arthur Agatston, M.D.

The Real Cost of Obesity

No matter what health care delivery system this country adopts, no matter what plan or series of plans are enacted, it will be bankrupted in no time by the ongoing obesity epidemic if we don't act now. President Obama talks about adopting a plan that's revenue neutral. But no current cost model could ever compete with this frightening trend.

This week we learned that spending on obesity-related medical issues jumped 82 percent from 2001 to 2006, with the current price tag $147 billion a year.

But these startling stats really aren't that startling when you also learn that two-thirds of American adults and one-third of the children in this country are either overweight or obese. Today, the typical baby boomer male weighs just shy of 200 pounds and the average baby boomer female weighs more than 170. I'm afraid this isn't news for us preventive cardiologists. Unfortunately, we treat obese patients with heart disease, prediabetes and diabetes, and dozens of other obesity-related ailments in our practices every day.

And it's not just cardiologists who deal with these issues. Many people with weight problems look to their primary-care doctors to solve this burgeoning battle of the bulge. But the sad fact is that most doctors don't have the practical experience to make a dent in this epidemic, as much as they'd like to.

Fighting obesity is really a public health issue that must be centered in individual communities, workplaces, and schools and involve grassroots action and education. And the initiative must get into high gear now.

We need to create communities where fresh and healthier food, not just fast food, is within easy access, where there are paved sidewalks and bike paths that encourage physical activity, where the opportunity to exercise is more widely available in the workplace. We need schools where physical education is mandatory and playgrounds are plentiful. We need schools that teach our children about healthy eating at an early age (with hands-on vegetable garden "science labs" that excite kids about eating what they grow). And in those same schools we need healthier cafeteria meals and nutritious snacks in the vending machines. Furthermore, we need to encourage busy families to sit down at the dinner table together, even if it's only once a week.

And we can't stop there. There's no argument that fresh vegetables are better for kids than potato chips and that regular exercise is essential for maintaining a healthy body. But while we know these ideas work, we should never become complacent. We should always be evaluating their efficacy. Even in this difficult economic climate, we need to continually be investing research dollars (and perhaps some of that stimulus money) to determine what's most untactful. And we must never stop looking for new ways to make our nation healthier.

Unless we do something soon, the billions we're currently paying in weight-related medical bills will seem like a drop in the bucket. Ultimately the escalating obesity-related costs alone can sink any health care system we put into place in this country.

[ami]

Skipping Heart Medication While Exercising

Q: My boyfriend intentionally skips his blood pressure medication before heavy exercise (bike riding 40-50 miles) because he says it makes him lethargic on his rides. I believe he is placing himself at risk during these high-exertion times. Am I right?
— Maria, California
Dr. Arthur Agatston A:

Given the scenario you have provided, I don’t believe your boyfriend is placing himself at risk. Since controlled blood pressure is achieved over many months to years, and blood pressure drugs stay in the body when taken daily, there shouldn’t be a problem if he chooses to take his medication at a different time of day on occasion. Furthermore, it is not uncommon for systolic blood pressure (the top number in the reading) to safely go above 200 in a trained athlete.

There are a number of reasons why your boyfriend could be feeling lethargic on his rides.

1. His medication dose could be too high, which he should discuss with his doctor.

2. He could be dehydrated, a more likely reason. If he’s not keeping up his fluid intake as he exercises, he could be subject to low — rather than high — blood pressure, which could make him feel tired.

3. He could have too little salt in his system. Often people with high blood pressure are told to go easy on the salt, and this can contribute to dehydration. I tell my patients with high blood pressure who exercise in hot weather to be more, not less, generous with the saltshaker on the morning of exercise days.

4. He’s not cooling down properly. If he’s exercising hard and stops abruptly without cooling down adequately, his blood pressure could drop quickly and make him feel more tired after the ride.


Last Updated: 01/21/2009
Arthur Agatston, MD, is a practicing cardiologist and an associate professor of medicine at the University of Miami Miller School of Medicine. He is also the creator of The South Beach Diet.

[ami]

Triglyceride levels provide insight into your heart disease risk.
By Arthur Agatston, MD, Everyday Health heart expert

Triglycerides are the form in which fat is stored in your body's fat cells. Your triglyceride level is almost always strongly influenced by lifestyle. A low-fat, high-refined carbohydrate actually elevates your triglycerides. Two decades ago, when I first began putting my patients on this type of diet, which was recommended back then, I was often dismayed to see their triglycerides go up. This, of course, was the opposite of what I was hoping to achieve. We now know that it was not the carbohydrates per se that raised the triglycerides, but the bad carbohydrates — sugars and starches devoid of fiber and other nutrients — that did it.

The same thing happened when I experimented with an extremely low fat diet that was also popular at the time. When I put one patient with a moderately high triglyceride level of 220 mg/dL on it to lose weight, he did not lose weight, and his triglycerides soared to over 500. His was just one of many cases like this that made me begin to question the conventional dietary wisdom of the time. Today, I recommend a diet that contains lean protein and moderate amounts of good fats (those found in oily fish, olive oil, and nuts) and good carbs (those found in vegetables, fruits, and whole grains). If patients follow this plan, reductions in triglycerides can be dramatic.

If you have high triglycerides (over 150 mg/dL is borderline high) and low HDL (less than 40 mg/dL if you're a man and less than 50 mg/dL if you're a woman), your risk of heart disease is compounded. To find out if you have this added risk, divide your triglyceride count by your HDL count. Ideally, the resulting number will be 2 or lower. For example, if your triglyceride level is 200 and your HDL is 40, divide 200 by 40 and you get 5. This is much higher than the desirable ratio, and it tells you that you have a heightened risk of a heart attack that will need to be addressed.

Your triglyceride level can also give you insight into your LDL particle size. In general, the higher your triglycerides and the lower your HDL, the smaller and denser your LDL and the greater your risk of heart disease. If your triglycerides are higher than 200 and your HDL is lower than 45, it is very likely that you have too much small, dense LDL.

There are a number of ways to lower your triglycerides. In addition to eating the healthy diet that I describe in Step 1, losing weight and getting more exercise can help. Medications such as niacin and fibrates are also effective at lowering triglycerides, increasing HDL, and enlarging LDL particle size.

THE NCEP GUIDELINES FOR TRIGLYCERIDES
149 mg/dL or under is normal.
150–199 mg/dL is borderline high.
200–499 mg/dL is high.
500 mg/dL is very high.
Last Updated: 11/18/2008
Reprinted from: THE SOUTH BEACH HEART PROGRAM by Arthur Agatston, MD. © 2007 by Arthur Agatston, MD. Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800) 848-4735.

[ami]

Q: I had a heart catheterization in August 2006 and had three stents placed in a heart artery. I started taking Plavix at that time. Is it possible to ever stop taking Plavix once you've started?
— Diane, South Carolina
Dr. Arthur Agatston A:

Your question is a common one from people who have had one or more stents put in after angioplasty or heart bypass surgery to keep a problem vessel open. Like you, nearly all these individuals with stents implanted are told to take the antiplatelet drug clopidogrel (Plavix), often along with daily aspirin, to discourage the formation of blood clots and to prevent a resultant heart attack.

I don’t know which type of stent you have, but since 2003 the majority of stents are made of stainless steel and coated with medication (so-called drug-eluting stents). These have all but replaced the bare-metal stents that had been widely used since 1994, when they were first approved for use in the United States.

A concern with all metal stents, medicated or unmedicated, is that the stainless steel can cause recurrent narrowing of the stented area as a result of scar-tissue forming at the site of the stent. The drug-eluting stents were specifically designed to prevent this scar tissue formation.

Normally, when a stent is put in, the body naturally covers the stent with a protective coating formed from cells that line the heart and blood vessels (called the endothelial lining). This then serves as a barrier to blood clotting. What recent research has shown, however, is that the drug coating on the medicated stents may actually prevent the protective endothelial lining from healing completely, leaving sections of the metal stent exposed. If this happens, then the chance of blood clots, and possible a heart attack, is greater. Indeed, while rare, there have been cases of what is known as late stent thrombosis (heart attack) with drug-eluting stents, when the blood-clotting inside the stent occurred even a year or more after the implant.

To prevent this, most cardiologists are erring on the side of caution and keeping patients with stents on Plavix far longer than the few months originally thought to be protective. In fact, depending on a person’s risk profile, taking the drug for 12 months or longer is not uncommon.

As a preventive cardiologist, I think the most important thing you can do to avoid a heart attack in the future (in addition to taking your Plavix) is to make sure you work aggressively to get your lipids (blood fats), blood pressure, and other risk factors for heart disease under control through diet, exercise, and other medications, such as statins or prescription niacin as necessary.

But even if a blood test shows that you have perfect lipids, there is always a chance that your endothelium may not have healed properly with the medicated stent. Therefore, it is very important that you not stop taking Plavix, or even tapering it off, without consulting your cardiologist. Until the long-term risks of medicated stents have been clarified, and your doctor feels confident that you can go off the Plavix, you need to stick with this medication indefinitely.

Learn how to eat to improve your health.
Last Updated: 01/05/2009
Arthur Agatston, MD, is a practicing cardiologist and an associate professor of medicine at the University of Miami Miller School of Medicine. He is also the creator of The South Beach Diet.

[ami]

These advanced blood test take a closer look at your cholesterol.
By Arthur Agatston, MD, Everyday Health heart expert
Liprotein Subfraction Test
This is an exacting blood test that divides your cholesterol into a variety of subparticles based on their size and density. While the Standard Lipid Profile tells you the quantity of total cholesterol, LDL, HDL, and triglycerides, this test will tell you the quality of your cholesterol. In particular, you will learn whether you have large amounts of small, dense LDL and/or small HDL particles, both of which put you at risk of having a heart attack or stroke.

The rate at which cholesterol gets into your vessel walls depends on the number and size of your LDL cholesterol particles. Small LDL particles containing less cholesterol per particle move into vessel walls more easily than larger particles. The smaller the particle, the more easily it moves in. That's why patients who have low total cholesterol levels and even low total LDL levels can still be at high risk for coronary disease if they have lots of small LDL. Patients with increased numbers of small LDL particles are classified as being pattern B. Those with large LDL particles are classified as pattern A.

Like small LDL, small HDL also has less cholesterol per particle. Patients with predominantly small HDL particles do not clear cholesterol from vessel walls as well as those with larger HDL particles. Small HDL also reduces the total cholesterol number, and this is another reason why patients with low total cholesterol may still be at risk for coronary disease. That's why it is important to know not just your total cholesterol and LDL numbers, but also the size of your particles.

People who have small LDL and HDL along with high triglycerides have what is called the atherogenic lipid profile and must be treated aggressively. These lipid factors are associated with a sedentary lifestyle, obesity, prediabetes, and diabetes — and will accelerate the development of atherosclerosis. A program of weight loss and regular exercise can help to reverse these lipid abnormalities. Taking medications such as Niaspan (prescription niacin), TriCor (fenofibrate), or one of the so-called TZD agents, Avandia (rosiglitazone maleate) or Actos (pioglitazone hydrochloride), can also help.

Lipoprotein (a) Test
Lipoprotein (a), or Lp(a), is a type of LDL particle with a protein called "little a" attached. An increased number of these particles is associated with an increased risk of coronary disease when Lp(a) is greater than 30 mg/dL. (This number could be slightly higher or lower depending on the lab that analyzes the blood test.) This risk is multiplied when Lp(a) is associated with other blood lipid abnormalities, such as elevated LDL.

How Lp(a) actually affects your blood vessels is still not well understood, but you can think of it as making the endothelial lining of the arterial walls more porous to LDL particles. Thus, Lp(a) facilitates the development of plaque, which can lead to heart attacks. Lp(a) is unique in that it does not respond to lifestyle changes. Niacin is the only medication that effectively lowers Lp(a), though it often requires high doses.

Follow-up. When the results of the lipoprotein subclass and Lp(a) tests are abnormal, I treat a patient with lifestyle changes and medications accordingly and repeat the tests every 2 to 6 months depending on the patient's overall level of risk. Once the therapeutic goals are reached, I repeat the tests twice a year.

Everyday Health Network Copyright © 2009 Waterfront Media, Inc.
The material on this web site is provided for educational purposes only, and is not to be used for medical advice, diagnosis or treatment. See additional information. Use of this site is subject to our terms of service and privacy policy.

[ami]

Q: I am having a heart catheterization done, and I want the doctor to knock me out so I do not know anything that is happening. He will not do it and says he will use a local anesthetic. Why won't he knock me out for this procedure?
— Deborah, Alabama
Dr. Arthur Agatston A:

I know it must be a bit scary to think about being awake for a heart catheterization (also known as coronary angiography), in which a long, thin, hollow plastic tube (the catheter) is inserted into your body to examine and possibly treat your heart’s blood vessels. But let me reassure you that most patients breeze through this procedure with minimal or no pain or discomfort.

The reason that doctors don’t knock you out during coronary angiography is that they need your cooperation. You will be asked to take deep breaths, to hold your breath, cough, or place your arms in various positions. This is important, because it is necessary for the doctor to see your heart vessels properly during the procedure.

In short, the way angiography works is this: You will be given an intravenous sedative, such as diazepam (Valium), about a half an hour before the procedure to relax you. Then you’ll receive an injection of local aesthetic in the area where the catheter will be inserted. Once your skin is numbed, a small needle is passed into one of your blood vessels, and a tiny wire is threaded in place. The needle is removed, and a short plastic tube (the sheath) is inserted into your artery. A catheter is then inserted through the sheath and into your blood vessel and carefully threaded to your coronary arteries, guided by an X-ray machine. Threading the catheter should not cause any pain, and you won’t even feel it moving through your body. Your heart rhythm and oxygen intake will be monitored throughout the procedure.

Once the catheter is in place, dye is injected through it so the structures and vessels of the heart can be clearly seen. You may have a brief sensation of flushing or warmth when the dye is injected; this is normal. An X-ray machine then takes pictures (angiograms) of your heart and blood vessels. Don’t be alarmed if you feel your heart skipping a few beats; this too is a normal occurrence during angiography. The procedure can last from an hour to several hours.

Remember, your doctor is not suggesting anything out of the ordinary by saying that you don’t need general anesthesia. In fact, there is a slightly greater risk of death when anesthesia is taken. Also, keep in mind that cardiologists perform more than 800,000 of these procedures every year in the United States. And during the vast majority of them, patients are nearly always sedated but awake.

Learn how to eat to improve your health.
Last Updated: 12/23/2008
Arthur Agatston, MD, is a practicing cardiologist and an associate professor of medicine at the University of Miami Miller School of Medicine. He is also the creator of The South Beach Diet.

[ami]

Q: I have an irregular heartbeat. Recently, after I missed a dose of medication (atenolol), my heart was pounding for about an hour. Could there be damage?
— Jeanne, Englewood, NJ
Dr. Arthur Agatston A:

No doubt your heart rate did go up after you missed a dose of your beta-blocker medication (beta-blockers work, in part, by slowing the heart rate). But it’s extremely unlikely that missing one dose would cause damage to your heart. That’s because there would still be plenty of atenolol in your system, assuming you’ve been taking the drug for a while. If you have a structurally normal heart, then palpitations, even if they continued for a period of time, would not cause damage.

That said, if your heart palpitations are sustained for any length of time when you are taking your medicine, or if they are associated with other symptoms such as chest pain or light-headedness, contact your doctor and then relax. Most of the time, heart palpitations are nothing to worry about.
Last Updated: 12/23/2008
Arthur Agatston, MD, is a practicing cardiologist and an associate professor of medicine at the University of Miami Miller School of Medicine. He is also the creator of The South Beach Diet.

[ami]

Hopping on a bike or treadmill can help your doctor find the source of your symptoms.
By Arthur Agatston, MD, Everyday Health heart expert

What is it? The primary purpose of an exercise stress test is to determine your ability to increase blood flow through your coronary arteries to your heart muscle when your heart is beating faster and/or harder, demanding two to five times the blood flow it gets at rest.

If you have been feeling symptoms such as chest pain or shortness of breath with exertion, an exercise stress test will help your doctor figure out whether these symptoms are coming from sluggish blood flow due to a blockage in one or more of your coronary arteries. The stress test will also indicate how severely the blockage is limiting the blood flow, which is crucial information in deciding whether to recommend an invasive or noninvasive approach to treatment.

Doctors also get other valuable information from a stress test. From watching a patient exercise, we get a good sense of whether the person's symptoms are heart or lung related. For instance, some patients complain of shortness of breath even while they are demonstrating outstanding exercise capacity on the treadmill or bike. And yet they don't appear short of breath to me. These people may have the benign "sighing" type of shortness of breath. Other patients demonstrate limited exercise capacity with extreme shortness of breath, and yet they still insist they are doing fine. These are the patients I look at much more closely.

Studies from Steven N. Blair, PED, of the Cooper Institute in Dallas, as well as others, have indicated that overall exercise capacity is an excellent predictor of future health and longevity. The blood pressure response to exercise is a helpful sign of the risk of future complications from hypertension, such as heart attack and stroke. The two most common types of exercise stress tests are the plain EKG test and the nuclear (or thallium) test. During both tests, you walk on a treadmill or ride a bike, which increases in elevation and/or speed every few minutes. In the plain EKG stress test, leads are applied to your chest, as they are for the basic EKG, and tracings are similarly produced. We look for changes on the tracings that indicate compromised blood flow to the heart muscle. This test takes about 20 minutes.

In the nuclear exercise stress test, two sets of images are taken. The first is taken after a small amount of a radioactive tracer (such as thallium) is injected when you are at rest. This is not a dye, so allergic reactions are not a problem. The second set is done after the tracer is re-injected when you are at peak exercise on the treadmill or bike. The radioactive substance travels to the heart muscle in proportion to the flow of blood. If there is a blockage in one or more of the coronary arteries supplying blood to the bottom of your heart, this area will accumulate less thallium during exercise than other areas with normal blood flow. The resting and exercise images are then compared and significant blockage will almost always be apparent.

In younger patients in whom I do not suspect heart disease, I use the plain EKG exercise stress test. In older patients, in those with abnormal resting EKGs, and in patients in whom I strongly suspect coronary artery disease, I prefer the nuclear stress test because it gives a better quantification of heart muscle areas with compromised blood flow. For patients who cannot exercise, there is a third type of stress test called a pharmaceutical stress test. In this test, a drug is injected to dilate the coronary arteries, which allows increased blood flow unless there is a blockage. Nuclear images are obtained in the same manner described for the nuclear stress test to reflect relative blood flow during rest and during exercise.

A stress test is a good indicator of the state of a patient's coronary blood flow at the time of the test. But its ability to predict the future does have limitations. You can accumulate a lot of plaque in your coronary arteries, and even have blockages, yet still maintain normal blood flow at rest and during exercise. This is because your body may have produced the protective network of collateral blood vessels.

While a stress test is valuable for women as well as men, studies have shown that women have more abnormal stress tests without necessarily having obstructive coronary disease. These women may have a disease of their smaller vessels, which can limit blood flow and cause chest pain but not necessarily cause a heart attack. Having a nuclear stress test rather than a plain EKG stress test helps to reduce the number of false positives for women.

Follow-up. If a patient's initial stress test is fine, I normally do not repeat it unless there is a change in the person's symptoms or risk factors. In high-risk patients, including those with known coronary artery disease, I repeat a stress test on a more regular basis.
Everyday Health Network Copyright © 2009 Waterfront Media, Inc.
The material on this web site is provided for educational purposes only, and is not to be used for medical advice, diagnosis or treatment. See additional information. Use of this site is subject to our terms of service and privacy policy.