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After a coronary stent procedure, exercise is important but it is imperative what type of exercise is performed. For the first four to six weeks, after undergoing a stent procedure (eight weeks after implantation of DES), patients should refrain from any weight lifting, climbing, TAEBO, contact sports, baseball, softball and Tennis. Aerobic exercise like jogging, walking, or biking is acceptable.
For a complete discussion, please click to INSTRUCTIONS FOR PATIENTS under PRECAUTIONS. The list of medications to avoid for heart patients is growing every day. The short list is: Vioxx, Inapsine, Actos, Imitrex, Viagra, Levitra, Cialis, Sudafed, Erythromycin, Levaquin and other Quinolone Antibiotics, Tricylic Antidepressants, chemotherapeutic agents
(Adriamycin and their related chemotherapeutic drugs), and Pletal.
If you are not experiencing any chest discomfort or any symptoms, you need not go to your Cardiologist more than once a year. However, you must follow up with your primary care physician for following cholesterol and lipid panels especially if the cholesterol was elevated in the past. You should get a stress test of some type 3 months after your stent implantation procedure and then annually thereafter. Even though the current drug eluting stents (DES) have a restenosis rate after one year of 3.1%, after 3 years (even with DES stents), the restenosis rates can rise up to 8% (TAXUS 3 year data for long coronary blockages).
I recommend Plavix or Ticlid for one year after implantation of a stent (see PCI-CURE trial, NEJM, 2002). If the stent implanted is a Drug Eluting type (DES), I recommend continuing Plavix or Ticlid for at least one year. If a surgery is required, it must be an of an emergent life threatening nature. However, with Plavix or Ticlid on board, the patient undergoing surgery is at significantly higher risk of post-operative bleeding complications. That is why I recommend elective surgeries be postponed for at least one year after implantation of a drug eluting stent (DES).
I recommend waiting at least 8 weeks before starting to drive. Driving requires the use of pectoralis muscles of the chest. The chest muscles insert into the sternum. The sternum is the bone the surgeon cut in order to access the heart for the open heart surgery procedure. Bones including the sternum require at least 6 weeks to heal properly.
If only one vessel was diseased and that vessel was successfully stinted, I recommend waiting at least one week before engaging in sexual relations. The leg artery called the femoral artery needs also to heal adequately. Also, I don’t recommend Viagra or similar agents in any patient with heart disease especially coronary artery disease.
In general, that’s a good plan. There is no need to proceed with any surgery with its attendant risks if you don’t have symptoms. However, this is one of those very few times I make an exception to that rule. People with heart failure often don’t have any symptom. In fact in the SPAF trial in the early 1990s, up to 30% of people with documented low heart function did not notice any symptoms. People with weak hearts (with heart failure where their heart is not able to pump greater than 30% of the blood it receives from the lungs), have a high likelihood within the next hear of dying from a fatal rhythm disturbance called Ventricular fibrillation or Ventricular tachycardia. So far we have not been able to isolate any factor that can successfully prognosticate who with low heart failure with develop this fatal heart rhythm disturbance. The one factor that was identified is low heart function. Remember, you must be having heart failure for at least 3 months before you are allowed to get the AICD. You must be on heart failure medications for 3 months and only if the heart medications fail to correct the heart failure can you receive the AICD. The AICD implantation is not a small surgery and must be performed by a Board Certified Eleoctrophysiologist (a Doctor that specializes in Heart Rhythm disturbances).
This is the challenge of cardiologists today. We as Cardiologists can fix (or open) the most blocked artery with a balloon angioplasty (PTCA) or stent, but what about the not so critical <50% blockages? Medicines presently at our disposal are powerful enough to stabilize these <50% blockages if not cause some regression of the plaques. These drugs are statins and antiplatelet drugs. Statins have shown in multiple different trials (PLAQUE, 4-S, WOS, AFS-CAP, etc) that even though coronary angiograms do not show little or no change in plaque morphology, patients on these statin drugs require 35-40% less hospitalization for heart catheterization, PTCA or bypass surgery. “Clot busting” drugs consist of TPA, retavase, and tenectaplase and are used to open acutely blocked arteries during an acute heart attack. They are given via injection or via IV and are not approved as oral agents to be given as “prophylaxis” in the prevention of heart attacks in people without symptoms even though they may have known coronary blockages. Aspirin, Plavix or Ticlid are anti-platelet “blood thinner” type drugs presently approved for use in the prevention of heart attacks in patients with known coronary blockages.
After coronary artery bypass surgery or open heart surgery when the sternum has to be cut and then resewn together, most surgeons recommend 8 weeks after the surgery. This is the minimum time required for bone to heal. Some surgeons are more conservative. You should consult your own cardiac surgeon before resuming driving. Also, with my patients, I ask that they not drive if they feel weak, dizziness or lightheaded, any visual problems like blurred vision, double vision, you cannot walk, having chest pain or shortness of breath. In fact, if you are experiencing any of these symptoms after open heart surgery, you need to seek out your Cardiologist or primary physician as soon as possible.
No. A heart attack is rarely caused from a stable plaque within the coronary artery. It is when the stable plaque becomes unstable that the heart attack results. Dr. Ambrose found in his study during the 1980s of heart attack victims, that the cause of the heart attack was not the high-grade blockages but the less than 50% blockages which became unstable and ruptured. Once the plaques ruptures, the contents of the plaque, lipid rich cholesterol becomes exposed to blood. The blood recognizes this as foreign substance and initiates the clotting cascade. This results in a clot within the coronary artery resulting in total occlusion of the artery. The heart no longer gets blood to that distribution and if not reopened within 15-minute, irreversible damage results. Up to 30-50% of victims of heart attack never make it to the hospital alive. This is what happened to Tim Russert.
Mr. Russert had a stress test in April 2008 and was told he did fine. However, he died suddenly while at work on June 13, 2008.
Stress tests are critical in allowing us to detect significant coronary blockages and prognosticating cardiac risk. There are four basic types of stress tests:
Of all the above testing types, the most sensitive is nuclear imaging performed in conjunction with EKG exercise stress test. The least sensitive to detect a significant blockage is the EKG exercise stress test alone.
There are other factors that make stress testing less sensitive:
If you already have coronary artery disease an exercise stress test with nuclear or Echocardiogram imaging is recommended. This allows your Doctor to obtain risk assessment over time.
If you don’t have coronary disease but have multiple heart attack risk factors like strong family history of heart disease, smoking cigarettes, recent chest pains, abnormal EKG or elevated cholesterol or lipids, an exercise stress test performed with adequate exercise (you walked as long and as hard as you possible can), can provide crucial information about the presence or absence of a significant coronary blockage.
Stress tests alone aren’t good enough to prognosticate heart attack risk. There are other tests which can be done which will allow or enhance your Doctors ability to determine if you are at higher risk for a heart attack in the next 6 months to one year (see: What’s New in Heart Treatment). The Doctor’s own clinical judgement must be allowed to integrate all of these tests into a meaningful prognosis of your heart attack risk. Doctors are Scientists first. As such, physicians all like to have a formula we can plug certain numbers in and get a clear answer: Yes or No. But Medicine is rarely ever so black and white. Sometimes, it comes down to the suspicion of the Doctor who takes all of these tests into consideration and makes a final judgement.
The other major tip I have as a practicing Cardiologist can give you: if you have anything like chest pain, heart burn, shoulder pain (not directly attributable to trauma or athletic strain), jaw pain or tooth pain: directly seek out Medical attention. DO NOT WAIT.
If it is going on right now: CALL 911 and let the paramedics get some baseline information that they can then fax directly to the Emergency Dept. Doctor (see my section on the 411 on calling 911).
I tell my patients, I would rather have them wait 5-8 hours at the Emergency room, rather than lose the rest of the years, days, hours and minutes of your life.
There is no absolute value considered to be too low simply because blood pressures vary by person and concomitant disease processes. First I need to know what your blood pressure is usually ( at baseline when you are doing fine). If your blood pressure usually runs 110 to 120 systolic (the top number), then blood pressures less than 90mmHg are considered low. The common denominator is the presence or absence of symptoms. If you feel light headed, whatever the measured BP, it is too low. The usual causes of low BP are medications. Other causes include anemia, heart attack, heart failure, endocrine problems.
People with hypertension can run blood pressures as high as 200/100 in the resting state. If their blood pressure drops down to 120/80, considered “normal” BP in most people, would be considered catastrophically low in people with hypertension and this would cause the person to be light-headed or even have a stroke! Therefore, what blood pressure is considered “too low” depends upon the individual clinical state of the patient with their underlying disease process. There is, unfortunately, no absolute number for all patients that can be universally be considered too low. That is why a doctor’s prompt input is so important when a person gets dizzy or lightheaded. Get a blood pressure first and then call the doctor. Know what your usual blood pressure is at the baseline state.
Coronary Artery Bypass Surgery, although an extremely useful technique, is not a permanent solution to coronary artery disease. In fact, it is a palliative procedure that is able to prolong life. The underlying problem of coronary artery disease is atheroclerosis, an insidious process that starts in childhood and continues through life in a progressive, often inexorable fashion culminating in heart attack, stroke or peripheral artery disease if not aggressively treated.
We used to think that the fundamental process is abnormal lipid deposition in heart arteries. Research has shown it is more complex than this: the heart arteries are inflamed and result in blood cells reacting to the initial inflammation resulting in further injury to the artery. The heart artery, to protect itself, tries to rebuild itself, resulting in abnormal growth within the artery wall. The damage to the wall causes abnormal lipid accumulation which we call atherosclerosis. Bypass surgery simply bypasses the most severely blocked areas in the artery but the process of atherosclerosis is not addressed with surgery. So what can we do to arrest if not ameliorate this process? Intensive dietary restriction (little to no fat/cholesterol intake), daily and regular exercise program, stopping smoking, and anti-lipid medications have shown to stop, if not reverse the atherosclerotic process. These measures remain the mainstay of my treatment advice to my patients. “An ounce of prevention is worth a pound of cure.”
Despite these measures, however, many patients continue to develop arterial disease. Some of these patients, unfortunately, end up requiring another bypass operation. This is the frustration of cardiologists and their patients. This means we have not isolated all the factors involved in this exceedingly complex disease: atherosclerotic heart disease. Consequently, the doctors work only begins after a heart bypass operation. A patient should follow up closely with his internist or family physician and cardiologist as required. Regular cholesterol and lipid panel checks and dietary counseling are only a part of the intensive follow-up process required after bypass surgery. If close follow-up is not done and if the patient does not follow the doctor’s recommendation closely, the unfortunate and almost certain outcome is another bypass operation, heart attack or death. It is my fervent hope as doctors that our patients don’t fall prey to these unfortunate consequences of this deadly, yet silent disease called atherosclerosis.
According to the FDA, drug-related adverse events are responsible for 4 million Emergency room visits per year. The cost of these visits exceed $4 billion per year. More important, these medication errors can prove fatal.
How Medication Errors Occur
Medication errors can occur in many ways:
How can this happen? Most heart patients have other Doctors also involved in their care for other ailments. If you wind up in the Hospital for anything, invariably a new medication is started or a change in dose of medications you were already taking. Hospitals routinely give a list of medications for the patient at the time of discharge.
Tips To Avoid Medication Errors
Here are some tips to avoid these medication errors:
AT HOME
AT THE PHARMACY
AT THE HOSPITAL (PATIENT OR SURROGATE)
Watch Dr. Nanavati talk about the six things that you should know before and during your doctor visit.
1. Reports
2. Medications
3. Allergies
4. Hospital visits
5. Examination
6. See Your Doctor
The Surgeon General Regina Benjamin declared on December 9, 2010 that smoking can kill. We all have known this for many years back in the 1970s when C.Evert Coop was the Surgeon General. What’s new in this report is how damaging cigarette smoking can be to a person, particularly a heart patient. “In someone with heart disease, one cigarette can cause a heart attack.” This makes cigarette smoking as harmful as a gunshot to the heart.
Until this report came out, this degree of potency was never previously declared.
What makes cigarettes so much more harmful than decades ago?
Cigarettes primary ingredient is Nicotine, a highly addictive drug that causes the heart rate to go up and causes the heart to contract more vigorously. It acts as a stimulant like caffeine. But it has harmful effects on the heart as well as the lungs. In fact, all the organs of the body are negatively affected by cigarette smoke. Cigarettes in recent years have been redesigned to maximize the delivery of Nicotine in as minimum period of time.
How has this been accomplished?
1. Ammonia added to tobacco converts the nicotine into a form that gets to the brain faster.
2. Filter holes that allow people to inhale smoke deeply into the lungs without coughing.
3. Sugar and “moisture enhancers” to reduce the burning sensation of smoking. This enhances the pleasure of smoking especially for new cigarette smokers.
If nicotine and all the other toxic and carcinogenic ingredients in cigarettes can be delivered in just one puff, its no wonder that smoking just one cigarette (15 to 20 puffs) can cause a heart attack!
This report does not come as news to most Heart Doctors. How? Nicotine and its neurostimulants cause disruption of the lining of the inside of the coronary artery. Nicotine can also promote clot formation thereby leading to a heart attack. The main mechanism of heart attack is the formation of clot inside of a coronary artery whose lining is damaged and thereby allows lipids and foreign substances to be exposed to blood. Blood then clots in response. Clotting outside in the skin is good so you don’t bleed out from a nick or cut. But clotting inside a closed space like a coronary artery can entirely occlude an artery thereby causing a heart attack.
Its been known that smoking cigarettes can increase the risk of heart attack in patient with known coronary artery disease by four to five fold over those heart patients that don’t smoke. This new report describes how cigarettes are now redesigned to maximize the exposure of nicotine in as short of time as possible therefore accelerating the risk of heart attack even more than we had previously thought.
Nicotine is highly addictive and therefore very difficult to quit. With the help of your Doctor, use Nicotine substitutes such as gum or patch and quit smoking. If you’re a heart patient, smoking cigarettes is like putting a loaded gun to your head. No amount of medications can ameliorate or negate the effect of inhaled Nicotine. There are counseling programs available. In the State of California there is a stop smoking help line: 1-800-NO-BUTTS.
The harmful effects of cigarettes are not limited just to the one holding the cigarettes. Everyone around the smoker inhales the smoke. It’s the smoke in the cigarettes that contain the Nicotine, ammonia and other carcinogenic substances. Cigarette smoke affecting others around the primary smoker is termed Secondhand Smoking.
Don’t smoke around children especially because they are also adversely affected by the substances emitted from cigarettes. They can get premature asthma, bronchitis. Cigarette smoke can affect their brain and vascular tissue as well. Children’s’ organs are especially sensitive because they are still growing and developing. Children and others can be affected even if you don’t smoke in front of them. Consider this: the ventilation system blows cigarette smoke through your apartments ventilation duct into another apartment in which children and others are present. This cigarettes smoke penetrates other peoples’ lungs as well as furniture, clothing and anything else in the room. Have you ever walked into a room where a person was smoking? You instantly know with one breath that the room was occupied by a smoker. Everything reeks of cigarette smoke; the curtains, the bed linen, the carpet and even the towels. These toxic substances emitted from cigarette smoke penetrate every fabric and can thus emit them slowly over time long after the smoker has left the room. This is called Third hand smoking.
Here are some sobering statistics for you to consider before you consider picking up your next cigarette:
1. 1 in 5: deaths are attributed to tobacco annually.
2. 443,000 Americans are killed by tobacco per year.
3. $193 billion: is the annual cost in health care and lost productivity in the US due to cigarette smoking.
4. 4,100 teenagers smoke their first cigarette each day.
5. 85% of Lung Cancers are due to cigarette smoking.
In short, if you’re a heart patient, don’t smoke. If you are not a heart patient, don’t smoke around others: they could be heart patients.
Eating out has become an unavoidable and in some households a regular event. As a Cardiologist, I strongly encourage my patients to dine at home and eat home cooked meals. There are volumes of books on diet and “heart healthy eating.” Before going to bookstore and purchasing all these titles, try reading these dining out tips. I have compiled a few practical tips when I as a necessity must eat out.
All fine restaurants have certain common dishes that are invariably on the menu. Based on this observation, I make the following recommendations on how to maintain a heart healthy diet even when dining out:
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