Stephen Ellis, M.D.
Section Head, Invasive Cardiology
Cleveland Clinic Department of Cardiovascular Medicine

Identification of plaque

lpmulligan: is identification of the plaque as vulnerable important, and what are the prospects for such identification

Speaker_-_Dr__Ellis: Careful studies have shown that blockages leading to heart attacks are often not that severe if studied several months earlier, but rather arise from moderate stenoses in areas of the artery that have positively remodeled or enlarged to accommodate a large amount of plaque. The difficulty is, however, that at least in some patients there are many such plaques. Studies have shown that plaques most prone to rupture have large areas of inflammation or necrosis that are only thinly covered by fibrous tissue. We don't yet have a reliable way of identifying plaques at very high risk of rupture, but there are promising early studies utilizing magnetic resonance imaging or macrophage-tagged imaging that need confirmation.

Speaker_-_Dr__Ellis: In the meantime, the best prevention of rupture is an aggressive lipid lowering treatment regimen with aspirin in addition to minimize the buildup of a blood clot should a plaque rupture (recall that usually requires a blood clot to completely block the artery to cause a heart attack)

Stents - drug eluting stents, bare metal stents, and other types of stents

setexan1: I had a bare metal stent placement, but due to restenosis a coated stent was used the second time, is this a standard procedure on restenosis?

Speaker_-_Dr__Ellis: Blockages within stents, unless they are particularly long, are often amenable to treatment with drug eluting stents

setexan1: Is there a life expectancy on the effectiveness of drug-coated stents, and if so what would that be?

Speaker_-_Dr__Ellis: After the placement of a stent, the body begins the healing process which generally takes about six months to complete. This is somewhat different than the process related to the buildup of the original blockage which is largely related to cholesterol and inflammation. Healing around the stent involves the production of scar tissue to variable degree. It has nothing to do with cholesterol but can be adversely influenced by smoking.

Speaker_-_Dr__Ellis: If there is a large amount of scar tissue the stent is likely to reblock. If there is no important reblockage by six months or so is quite uncommon to have a stent reblock later. Blockages within stents, unless they are particularly long, are often amenable to treatment with drug eluting stents.

bornagain100306: Why would arteries clog after metal stents were installed in the coronary arteries if my diet is healthy and never suspended the medicines?

Speaker_-_Dr__Ellis: After the placement of a stent, the body begins the healing process which generally takes about six months to complete. This is somewhat different than the process related to the buildup of the original blockage which is largely related to cholesterol and inflammation. Healing around the stent involves the production of scar tissue to variable degree. It has nothing to do with diet or cholesterol but can be adversely influenced by smoking. It is still important to follow a healthy diet so you do not develop blockages elsewhere.

mary_beth: I have heard of magnesium absorbable stents, what are your thoughts

Speaker_-_Dr__Ellis: In large part, because of concern about delayed blood clotting on stents due either to the polymer or the drug, there has been a lot of interest in bioabsorbable stents.

Speaker_-_Dr__Ellis: It is hard to know which of these are most promising, but among them are the magnesium stents. Initial results have been a little disappointing but we are early in the process of understanding the healing process associated with these stents.

Speaker_-_Dr__Ellis: I suspect that within 5 - 8 years, most coronary stents may be bioabsorbable.

MaryJ: Any thoughts on this week's news release on Medtronic's endeavor stent and Abott's Xience Stent?

Speaker_-_Dr__Ellis: There are two especially promising next generation drug eluting stents that will likely be available in the United States at the end of 2007 or more likely the beginning of 2008. The Medtronic Endeavor stent appears to have somewhat less risk of blood clots but slightly higher risk of restenosis in comparison with currently available drug eluting stents. Physicians may choose to use it accordingly.

Speaker_-_Dr__Ellis: The Abbott Xience Stent is somewhat similar to the currently available Cordis Cypher Stent except the stent itself is more flexible and deliverable. Current data do not allow us to know whether it has more or less or the same risk of blood clots in comparison to the Cordis Stent.

Speaker_-_Dr__Ellis: Market analysts predict heavy usage for both new stents when they become available, but we will need to follow patients long term to really be able to understand how they should be used.

frankem: Is there a limit to the number of stents a person can have?

Speaker_-_Dr__Ellis: In concept, there is no limit to the number of stents a patient can have. But, judgment needs to be used especially if you have a large number of blockages or if your blockages repeatedly reoccur.

Coronary artery disease and prevention of progression

pszych_2: I had a 90% LAD blockage and one stent. How can I improve CAD or at least prevent further buildup at age 64 years.

Speaker_-_Dr__Ellis: The proper approach to minimizing the risk of new blockages has some features common to all patients, but also must be individualized. Working toward an ideal body weight with a combination of diet and exercise is important for all of us.

Speaker_-_Dr__Ellis: There has been some debate recently about the best type of diet -- in particular whether proteins and fats need to be restricted, but in my opinion a low-calorie diet without a large amount of processed or simple sugars, and without the concept of a "crash" diet, but rather one that can be sustained, is best. Exercise with the equivalent of a brisk walk at least 30 minutes five times a week is ideal. Aspirin and almost always a statin are also required to minimize the risk of a blood clot and plaque buildup respectively. The approach beyond this needs to be individualized depending on which of the particular heart disease risk factors a patient might have -- diabetes, smoking, high cholesterol, obesity, or hypertension. Other studies such as CRP and genetic tests are being evaluated for their predictive importance, also.

whickey58: I am age 69 have just had one coated stent put in and am very interested in preventative programs such as diet and exercise.How do I find the best most experienced doctor at the clinic in these areas to see for a consult.

Speaker_-_Dr__Ellis: We have a group of physicians who specialize in the prevention of atherosclerosis and coronary artery blockages. The Section of Preventive Cardiology can be reached by calling 216-444-9353. You can also learn about those physicians in our staff directory on the website at http://www.clevelandclinic.org/heart

TMR (Transmyocardial Revascularization) and EECP (enhanced external counterpulsation)

GaryL: Please discuss TMR and it's efficacy for people who have had multiple interventions (stents, CABG), but have been told no more interventions are possible, but still have disabling angina.

Speaker_-_Dr__Ellis: TMR (Transmyocardial Revascularization) involves using a laser to place holes partially through the heart muscle in an attempt to generate new blood vessels via the healing process. It has been largely discredited and seldom used any more. Occasionally, by damaging the local nerve endings of the heart, it may provide benefit.

GaryL: Besides TMR, and the failed GENASIS trial, are there other promising treatments to promote angiogenesis?

Speaker_-_Dr__Ellis: Angiogenesis or the induced generation of new blood vessels to the heart has long been a research goal. Many modalities to accomplish this haven't really panned out. Stem cell therapy is presently being evaluated and may provide benefit in the future.

Speaker_-_Dr__Ellis: Some people also think that the benefit of EECP (enhanced external counterpulsation) may be due to angiogenesis.

Cardiac catheterization

vjk: I was told I need a cath and I have allergy to cath dye, what should I do? Can I have CTA?

Speaker_-_Dr__Ellis: Unless you had a severe anaphylactic response to contrast dye, pretreatment with antihistamines and steroids is generally sufficient to allow you to proceed with minimal risk with cardiac catheterization.

Speaker_-_Dr__Ellis: CTA uses the same contrast dye, hence poses the same risk. If you had an anaphylactic response you need to discuss the pros and cons with proceeding given the somewhat heightened risk.

maryj: My mother requires a catheterization and has poor kidney function - she is on dialysis. What should she do ?

Speaker_-_Dr__Ellis: Dialysis itself is certainly not a contraindication to cardiac catheterization, although dialysis should usually be performed at the day before or early on the day of catheterization. For patients with impaired kidney function who are not on dialysis there is some risk of further kidney damage. This can be minimized by making sure that the patient is well hydrated and that the amount of x-ray dye utilized is minimized.

Speaker_-_Dr__Ellis: Biplane angiography, or taking two pictures at the same time, can usually result in using about 1/2 the amount of dye otherwise necessary. The blood test usually used to assess kidney function, serum creatinine, can be somewhat misleading if used alone, especially in small patients or the elderly. Creatinine clearance is a much better measure of kidney function.

Nickel allergies

sunwayhomes: Stainless steel stents contain 14% nickel, most doctors do not know this. The manufactures warn not to place if a person has a metal allergy. No one askes or tests. Stents are FDA approved but there has been no Human testing regarding Nickel only rats. I have all the same problems as the rats on a CDC study but the rats did not have directly in blood stream like me. Thanks Your comments?

Speaker_-_Dr__Ellis: You are quite correct that stainless steel has a large component of nickel. There are largely anecdotal reports that patients with nickel allergies have a greater risk of restenosis. We are presently completing a 100 patient study of skin testing for metal allergies as a risk for restenosis. Stay tuned.

sunwayhomes: Nickel allergies and stents. I was in much better shape before the stent. Your comments

Speaker_-_Dr__Ellis: I have already begun to answer the question about nickel allergies and problems. This particular question raises the issue as to whether or not there are certain circumstances when a stent should actually be surgically removed. This is a major operation that is only rarely justified. However, if your allergist or rheumatologist is convinced that your symptoms are severe and stem from your stent removal can be discussed with a thoracic surgeon.

Total coronary artery blockage

jason521: i have 100% blockage, my doctor said I need bypass. Can I have an angioplasty instead?

Speaker_-_Dr__Ellis: With recent improvements in both techniques and equipment, many high volume experienced centers have begun to report much higher success rates than before in treating 100% blockages. The estimated likelihood of success depends on the details of your anatomy and may likely range from 50 - 80%, possibly offering you an alternative to bypass surgery.

Restenosis after angioplasty or stents

dj7643: I have restenosis with a stent. Can they do laser or radiation to treat it?

Speaker_-_Dr__Ellis: Restenosis within a bare metal stent, as long as it is relatively short (less than 10 - 15 mm) can usually be successfully treated with a drug eluting stent with the likelihood of restenosis being 15 - 20%. Longer blockages pose more of a problem and your physician will have to weigh the likelihood of restenosis with placement of a drug eluting stent in comparison with other treatment options (increasing your medications or bypass surgery).

Speaker_-_Dr__Ellis: Laser therapy has generally proved ineffective. Radiation therapy, or brachytherapy, used to be the best treatment but has been supplanted by drug eluting stents and is rarely used any more.

marks: Why is brachytherapy no longer used?

Speaker_-_Dr__Ellis: Brachytherapy is no longer used because the associated risks of blood clots were higher than with drug eluting stents and because the initial benefit in reducing restenosis was lost over time.

Bifurcation blockage

frank: I have a complex blockage, involving a part of my artery where it branches. My local cardiologist has offered angioplasty, but it might be challenging. Should I seek a second opinion?

Speaker_-_Dr__Ellis: With improvements in technology over the last 5 to 10 years, most interventionalists can achieve high quality results with many, but not all, types of blockages.

Speaker_-_Dr__Ellis: Although it is difficult to be certain in your case, if your physician indicates some reluctance or states the procedure will be difficult, it would probably be best to seek a second opinion from an interventionalist from a very high volume center. For example, the rate of complications leading to emergency bypass surgery after interventional procedures (PCI) at the Cleveland Clinic is half the national average.

hg498: I was told I have a blockage at a bifurcated artery. Are there stents that can handle this?

Speaker_-_Dr__Ellis: Stents can often be used to treat blockages in bifurcated arteries. The exact technique used depends on the anatomic details of your blockage.

Speaker_-_Dr__Ellis: Sometimes, however, the technique is challenging and you should seek out an experienced interventionalist.

Plavix and aspirin therapy after angioplasty or stent

rebecca: I have a drug coated stent my doctor put me on plavix for 3 months, then told me to stop. Should I?

Speaker_-_Dr__Ellis: Because drug eluting stents by their very nature delay healing of the artery after stent placement, the inner lining or endothelium of the blood vessel is slow to reform. This makes it more prone to blood clot formation, particularly if the patient forgets to take their blood thinners (aspirin and plavix [Coumadin is not a good preventive for this particular process]) and under the stress of surgery. People heal at different rates, but most Cleveland Clinic physicians recommend aspirin indefinitely and plavix for at least two years. Newer tests that can detect exactly how well individual patients respond to both aspirin and plavix are often utilized to fine tune the dose of these medications.

GaryL: I recently saw an article that says people on aspirin therapy should not use ibuprofen (which I do for arthritis) as it defeats the benefits of the aspirin. Can you comment?

Speaker_-_Dr__Ellis: You are correct that ibuprofen (motrin or advil) partially opposes the beneficial effect of aspirin. On the other hand, most nonsteroidal antiinflammatory medications, except possibly naprosyn, modestly increase the risk of a heart attack. You and your cardiologist and internist/rheumatologist should discuss the best options for you. Newly available blood testing allows physicians to detect exactly how well aspirin is working for individual patients and may be of help in your case

Jailed artery blockage

pak70: I was told I have jailed artery blockage causing chest pain. I have had a stent, what should I do now?

Speaker_-_Dr__Ellis: "Jailing" of a branch blood vessel refers to the placement of a stent in the main vessel across the branch such that access to the branch may be difficult. More recently however, we describe this as "minimal security" jailing, because experienced interventionalists can almost always access the side branch unless it comes off a very sharp angle from the main branch.

Speaker_-_Dr__Ellis: Once the side branch is accessed, if the blockage is at the very beginning of a side branch, often rotational atherectomy or other advanced procedures provide a better result than balloon angioplasty. Due to somewhat higher risk of restenosis and blood clots we generally try not to place stents in a y configuration

Medication - Ranexa

GaryL: Do you have any comments on the (relatively new?) anti-anginal drug Ranexa?

Speaker_-_Dr__Ellis: Ranexa is a recently released medication for patients whose angina is refractory to other medical therapy. It works by altering metabolism of the heart so it requires less energy. The benefits tend to be modest and the drug itself interacts with many other commonly used medications, so you and your physician need to be careful about its use.

Hybrid rooms

sharonp: I have been reading about "hybrid rooms" where interventions are done and heart surgery can be done in the same room if needed. Will the new Cleveland Clinic Heart Center have this? What do you think of these rooms?

Speaker_-_Dr__Ellis: We also have an avid interest in hybrid labs and will have three of these in the new heart center. They are probably best used for very complicated percutaneous (catheter based) procedures that occasionally require conversion to open surgical procedures.

Neck arteries - carotid artery disease

roaminghermit: What is best treatment for 100% blockage left and 45-50% right side after operation on neck arteries

Speaker_-_Dr__Ellis: I am sorry, but I do not do carotid procedures and this would be best answered by an interventionalist who does them often

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Ellis is up. Dr. Ellis thank you again for taking the time to answer our questions today.

Cleveland_Clinic_Host: Thanks for joining us everyone. If you missed any part of this chat, please check back soon for the full transcript. And join us for our next chat with Dr. Stanly Hazen on 5/30/07. if we did not get to your question. If you have additional questions after the chat, please use our "Contact Us" link (www.clevelandclinic.org/contactus) to submit your questions.

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