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| The nation's #1 heart program by U.S. News & World Report for 13 years in a row! |
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| Live Web Chat Transcript: Latest Treatments and Research: Report from the American Heart Association Scientific Sessions — November 14, 2007
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Cleveland_Clinic_Host: Welcome Dr.Lincoff and thank you for being with us today. Let's begin! Speaker_-_Dr__Lincoff: I am happy to be here today |
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Cardiovascular Disease jojo: How long after bypass surgery do you feel better. I had surgery about 4 weeks ago and I am still tired and don’t feel great. Speaker_-_Dr__Lincoff: We typically tell patients that they won't feel "themself" for 6 to 8 weeks after surgery. At that point, many can resume work and their regular activities. They may need to wait longer for heavy work. This varies depending on the patient however. some patients who have had very extensive surgery or have other medical problems may take longer to recover. Generally if one is feeling better as a gradual trend over the weeks, that should be encouraging.Carl: I wonder if at American Heart Association anyone reported any new treatments like HDL Apo A1 Milano that would clean out arteries that are blocked. I have coronary artery disease and disease in my legs too. I could use a drug that could clean out my arteries. Speaker_-_Dr__Lincoff: There are no new therapies yet although there is much work going on in this field. One encouraging piece of research showed that although the Pfizer drug torcetrapib was not effective in reducing heart disease, raising HDL (which was the effect of torcetrapib) probably will be an effective therapy if the right drug can be found. Speaker_-_Dr__Lincoff: There were side effects of torcetrapib that likely explain its lack of benefit. BUt, the patients who had the highest HDL levels actually showed evidence of reduction of heart disease. This is important because it will encourage other companies with drugs under development to raise HDL to continue their research. |
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Symptoms of Heart Disease gary : What does heart disease feel like? Speaker_-_Dr__Lincoff: This is actually a very important question. Because the broad variability in the way patients present with heart disease is in part responsible for why many delay coming to medical attention. Speaker_-_Dr__Lincoff: We talk of "angina" being chest pain, but in fact many people's angina is not typical. They may feel shortness of breath only. Or indigestion, or vague heaviness in the chest. Or heart burn. Perhaps one of the key features of typical heart symptoms is that they are related to physical activity or mental stress and tend to resolve with rest and relaxation. Even this pattern may not be the case if a patient is having a heart attack, which can occur at rest. Particularly for patients that have the typical risk factors for heart disease, which include smoking, hypertension, diabetes, high cholesterol, or a family history of early heart disease, one should be suspicious of any symptoms that fit this pattern and get medical attention.sue: what do you do if you get chest pain? Speaker_-_Dr__Lincoff: This is difficult to answer in general because all chest pain isn't necessarily due to the heart. However, in particular if pain occurs during exercise, it is reasonable to be concerned about a heart problem. Speaker_-_Dr__Lincoff: If pain occurs during exercise, one should stop the exercise and see if the pain goes away. I would avoid further exercise until seeing a physician under those circumstances. Speaker_-_Dr__Lincoff: Pain occurring during rest may be a heart attack. In particular, pain associated with shortness of breath, sweating, lightheadedness, radiation to the arm or neck is concerning. One should take a full dose aspirin. If the pain lasts 10 minutes or so, one should call 911. Speaker_-_Dr__Lincoff: If the pain resolves spontaneously then still best to consult your physician sooner rather than later. All of these recommendations are for patients without known heart disease. Speaker_-_Dr__Lincoff: Those who have known heart disease should have received recommendations regarding use of nitroglycerin and what is an acceptable level of exercise. MaryW: I am 45 years old and was just diagnosed with a new murmur. My doctor said it is a "flow" murmur - what does that mean? Should I be worried? I am seeing a cardiologist at the end of the week and I am not sure what to ask. Speaker_-_Dr__Lincoff: Most murmurs are benign - harmless. If the murmur is truly "new" it might signify a narrowing or leakage of one of the valves of the heart. Never the less, most murmurs are just the sound made by blood flow as it goes through the heart. These are usually of no significance and may just represent a bit of roughening ("sclerosis") of the valve surface. If a cardiologist thinks that the murmur may be of concern after listening to it, a non-invasive ultrasound (echocardiogram) can nearly always determine the cause and importance. In many cases though, the examination by a cardiologist is reassuring enough that an echo is not necessary. |
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Diagnostic Testing kile44: What is an adenosine stress test? Speaker_-_Dr__Lincoff: This is a non-exercise stress test. Ideally we like to exercise a patient to stress their heart to determine if they have blockages in the arteries that feed the heart, and thus a limited blood supply. Many patients however, aren't able to exercise sufficiently to stress the heart either due to orthopedic problems or arthritis - or general disability. Speaker_-_Dr__Lincoff: The adenosine is an intravenous medicine given to the patient that in effect, "fools the heart" into thinking it is exercising. We can then image the heart with a nuclear camera to see how the blood supply is under that stress.tudi: If you are on a blood thinner and have to get tested – what are the desired rates? Speaker_-_Dr__Lincoff: By blood thinner, I assume you mean warfarin or coumadin. Other blood thinners do not require testing. For coumadin, the desired range depends upon the disease being treated as well as the patient's risk for bleeding. In general, we look for the measurement called "INR" to be in the range of 2.0 to 3.0 for some conditions and 2.5 to 3.5 for conditions of high clotting risk. Your physicians should be able to tell you what your desired range is for your specific condition.Jonathan: I have heard a lot about CT angiography? But I had a stress test last week and my doctor said I need a cath. When is it ok to have a CT test and when do you need a cath? Speaker_-_Dr__Lincoff: There is a lot of controversy regarding the role and usefulness of CT angiography (CTA). What is clear is that CTA does not see the detail that catheterization shows. It is very reliable if it shows no heart disease at all. But, it is not particularly accurate in determining the degree of narrowing of the arteries. So, for a person with an abnormal stress test or clear angina-like chest pain, a cTA may only add to the uncertainty. In most cases a catheterization would be required to definitively evaluate whether or not there are significant blockages of the arteries. Let's not forget that CTA, while not invasive, does require use of dye and is a significant radiation dose. There are therefore slight risks associated with CTA and it should not be used unless it is likely to provide a clear answer. |
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Abnormal Heartbeats: Atrial Fibrillation and Sinus Tachycardia corki98: Diagnosed Atrial Fib-Heartbeats about 70-90 pm-no shortness of breath or tiredness-taking drugs for high blood pressure-scheduled for CARDIOVERSION-What are possibilities of: not able to stop abnormal heart beat? Development of a more dangerous dysrhythmia? Damage to heart? Possibility of stroke? death? How can I discover more about my cardiologist record of cardioversions? Thanks Speaker_-_Dr__Lincoff: Cardioversion is successful in the vast majority of cases, particularly if it is relatively recent in onset and the patient does not have extensive heart disease. The development of more serious rhythms is very rare and can usually be corrected immediately with another electric shock. Some patients will have the atrial fibrillation recur however and will need additional therapy. Stroke is the major concern, although the risk is low. You should be on blood thinners prior to and for a few months after cardioversion - at least. In some cases, blood thinners before the cardioversion are not necessary if a transesophageal echo (TEE - ultrasound of the heart performed using a tube down the throat in the esophagus) is performed and shows no clot. Death or damage to the heart is very rare associated with cardioversion.GoDBacks: I asked this question at your last chat, however, I guess that chat was more for surgical questions. I am 43 yo and have been put on Atenolol 25 mg a day for sinus tachycardia. I have been on this since the end of August 2007. Stress test was done, ultrasound of my heart, halter was worn, and blood sample looked okay. I have read that using medication to slow the heart is not the best option. Exercise and blood lipid control is best, so I have read. Recently, I have split the dose, 1/2 in the morning, the other half at night (when was taking all at once previously, my arm was falling asleep a lot at night and fingers were starting to feel tingly). Resting heart rate now is about 85 (can go lower) to 90. What is your opinion of this treatment? I am kind of young and when I talked to PA at cardiologist office, he stated I may have to stay on this for the rest of my life. Thank you. Speaker_-_Dr__Lincoff: Sinus tachycardia is benign - it poses no danger to you or your heart. In some people it is symptomatic - that is they feel palpitations and it is uncomfortable. If that is the case in your situation, then atenolol is perfectly appropriate. I cannot make recommendations regarding drug dosing. You need to discuss this with the physician that prescribed the medication. |
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Stents Stents Vs. Bypass Surgery robertS: if someone has coronary artery disease when do they decide that bypass surgery is necessary vs. a stent? Speaker_-_Dr__Lincoff: There is no one general answer to this. It depends upon the individual patient, his or her other illnesses, and the extent and locations of the blockages in the heart arteries. In many or most patients, surgery can be avoided entirely. In some multiple angioplasty procedures may be required. But in others, the extent or severity of disease indicates they will do better with surgery. For all patients, the preventive measures (smoking cessation, diet, exercise, cholesterol control, blood pressure control, diabetes control) are of paramount importance in preventing progression and reducing the risk of needing surgery.Stents: Left Main Trunk marybeth: Can a left main trunk be stented? Speaker_-_Dr__Lincoff: We traditionally have considered blockages in the left main trunk to be an indication for surgery rather than stenting. This is because the left main trunk provides blood flow to so much of the heart muscle that closure of the artery as a complication of stenting would likely be catastrophic. Speaker_-_Dr__Lincoff: It is controversial whether modern stenting techniques allow the left main to be approached safely with stents. This is an ongoing topic of research. The decision must be individualized to the patient and to the location and actual severity of the blockage. Stents: The risk of surgery after previously having a stent BobK: I read the news article about the risk of surgery after having a stent. I heard that if you have restenosis in a stent after you get a stent that radiation doesn't work anymore. If you have a drug eluting stent and have blockage in the stent, what are your options? What if you need surgery again? Speaker_-_Dr__Lincoff: This is a very complex question. It is really multiple questions. Let me take this one at a time. Speaker_-_Dr__Lincoff: Drug eluting stents effectively reduce the risk of renarrowing ("restenosis") from about 15 to 20 percent for a bare metal stent to about 5 to 8 percent for a drug coated stent. The down side is that the drug eluting stent is slightly more prone to clotting, which if it happens can cause a heart attack or death. That risk is about 2 out of 1000 excess for drug coated stents. That risk is reduced if a patient stays on aspirin and plavix for at least one year and probably for several years after the stent has been placed.Speaker_-_Dr__Lincoff: This brings up the issue of what happens if a person needs surgery and the surgeon wants to take him off aspirin and plavix to minimize the risk of bleeding from the surgery. If that is happening within the first 6 to 12 months after the stent was placed, there is some concern that the clot may form on the stent when the aspirin and plavix are stopped. We don't know the best approach to this. Ideally, the aspirin and plavix if at all only a few days before the surgery and restarted as soon as possible thereafter. Some doctors will admit the patient to the hospital and use intravenous blood thinners while off the aspirin and plavix. This approach as all others is unproven as we do not have enough information. Speaker_-_Dr__Lincoff: After 6 months to one year, the risk of stopping the aspirin and plavix is likely very low. Speaker_-_Dr__Lincoff: Regarding the question of radiation, this is a somewhat obsolete technology for stents. Before we had drug eluting stents, we would treat a restenosis in a stent with radiation to prevent regrowth of the scar tissue. Over the years, we found that the radiation lost its effectiveness as time progressed and some patients developed restenosis years later.Now that we have drug coated stents, they are the preferred method of preventing or treating restenosis. Speaker_-_Dr__Lincoff: Even with a drug coated stent, some patients will experience restenosis or renarrowing (5 to 8 percent). For those patients we can do a balloon procedure or even place another stent. Alternatively bypass surgery may be a better option. The choice of therapy would depend on a lot of factors and cannot be generalized. Stents: 100% Blocked Artery marybeth: I saw a TV show last night that showed a coronary artery stented when it was 100% occluded. Can a totally occluded coronary artery be stented? Speaker_-_Dr__Lincoff: Yes under some circumstances a totally occluded artery can be stented. It is much more difficult to open a totally occluded artery compared with one that is not completely blocked. It is often very difficult to get equipment such as a guidewire or balloon or stent to even cross a total blockage. In particular, blockages that are old (more than a few months) or very long or in bypasses are unlikely to be successfully treated with balloons or stents. Speaker_-_Dr__Lincoff: There is also the question of whether or not a total blockage SHOULD be treated at all. In many cases the body builds its own blood supply to that area (collaterals) or the muscle fed by the artery is already scarred. In those cases, there would be little benefit to opening the artery but there would be the risk of attempting it. Speaker_-_Dr__Lincoff: So, the best treatment has to be individualized to the patient. Some cardiologists have particular skill in techniques of opening total blockages and would be available for consultation. |
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Cardiovascular Risk Factors (cholesterol) marybeth: Can your cholesterol level (LDL or Total) be too low? I heard about recent studies that show low cholesterol levels being associated with Alzheimer's disease, decreased immunity and even greater Cancer risk. Speaker_-_Dr__Lincoff: There is no evidence of a "too low" cholesterol level. No study of cholesterol treatment has suggested risk with reducing the cholesterol. What you may be seeing are studies looking at groups of patients and looking for associations between their cholesterol levels and other illnesses. The problem with those studies is that they cannot show that the cholesterol is the CAUSE of the other diseases. The other diseases may reflect poor health in general which could also cause low cholesterol. The only way anyone could conclude that low cholesterol causes other diseases would be to treat with cholesterol lowering medicine and observe what happens. There have been trials that have done just that, enrolling tens of thousands of patients in total, and we have seen no evidence of negative effects of low cholesterol. |
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Research Research: Transplant dlafond: I have been sent some research information from UCLA, an a test they are conducting about transplant recipients that have had certain tests done and are able to stop taking anti-rejection medication. Has the Cleveland Clinic been involved in any studies of that nature? Speaker_-_Dr__Lincoff: The manager of Heart Failure Research stated that we do not have the study that you have described however there is a study in which patients take a blood test and then may not need a biopsy. You may want to go to http://www.clinicaltrials.gov to do a focused search on your topic for studies across the country.Research: Stem Cell Therapy KarenM: I am interested in stem cell therapy. I had a heart attack 5 years ago and my heart is not functioning well. Is there any new research on stem cells? Are you planning anything at Cleveland Clinic? Speaker_-_Dr__Lincoff: Stem cell therapy is promising but in very early stages of development. At this moment we do not have any studies going on at the Cleveland Clinic with stem cells although there may be studies in the future. In any case, I think that a widely available stem cell therapy is at least several years off.Research: Angiogenesis GaryI: what exactly is angiogenesis? Is that something that is available? Speaker_-_Dr__Lincoff: Angiogenesis refers to techniques to try to stimulate the body to create a new blood supply to areas of blocked arteries. In our field this has been applied to the heart and to the legs. This is still only an experimental technique and thus far most studies have not shown benefit with the different approaches. We currently are not performing angiogenesis studies although again, there may be new studies in the future. |
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New Innovations – Future Medical Care Cleveland_Clinic_Host: American Heart Association Conference is a very important conference for highlighting research and new innovations. Dr. Lincoff can you describe any interesting subjects brought up at the conference? Speaker_-_Dr__Lincoff: Two studies that may have impact on common medical problems at some point in the future included vaccines to treat high blood pressure (hypertension) and to help stop smoking. Investigators reported very early studies using a vaccine which may be effective for up to four months after each injection to reduce blood pressure. If ultimately safe and effective, this might be easier to take than a daily medication. Speaker_-_Dr__Lincoff: Similarly, another group reported an early study with a vaccine against nicotine. For six to twelve months after taking the vaccine, smokers would not experience the pleasurable effect of nicotine and thus may find it easier to quit smoking. Speaker_-_Dr__Lincoff: I emphasize neither of these vaccines will be available for several years. But they are an interesting direction of research for chronic problems. Speaker_-_Dr__Lincoff: Another study reported on 17,000 patients that had gotten drug eluting stents and were followed for two years or more. This is important for the reasons discussed previously in this web chat. They showed that despite the clotting risk of drug coated stents they were safe overall and may even decrease the risk of death under some circumstances compared to bare metal stents. This is reassuring given the concerns regarding stent clotting. |
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| Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Lincoff. Dr. Lincoff, thank you again for taking the time to answer our questions today. Speaker_-_Dr__Lincoff: Thank you for having me today. Technology for web chats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC). © Copyright 2007 The Cleveland Clinic Foundation. All rights reserved 11/07 |
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