NOT EVERYONE WITH AN ABNORMAL STRESS TEST NEEDS AN ANGIOGRAM OR REVASCULARIZATION
It may seem logical that opening a narrowed artery or bypassing it would prevent heart attacks and prolong life. However, recent clinical trials in stable patients, such as COURAGE and BARI-2D, show differently. Stents and bypass surgery did not prolong life or prevent heart attacks in the stable patients studied. Most heart attacks are triggered by plaques which did not cause severe narrowing before the event.
Most angina is caused by plaques which cause significant narrowing. There is then a disconnect between the treatment of symptoms and the prevention of death and heart attack. The “rusty pipe” concept is not the best one for patients to understand coronary artery disease. In fact, soft plaque rather than “hardening of the arteries” may be the bigger concern. Medications and lifestyle changes change plaque on a microscopic level to make it less dangerous – this is a major focus of treatment. Those with moderate to severe ischemia on a stress test may be eligible for the ISCHEMIA trial. The ISCHEMIA trial tests a routine invasive strategy of cardiac cath and revascularization plus medical therapy vs. a conservative strategy of medical therapy alone, with cath reserved for worsening symptoms or acute coronary syndromes. Learn more at www.ischemiatrial.org
WHEN WOMEN HAVE ACUTE CARDIAC COMPLAINTS, DON’T MISS THE OPPORTUNITY TO ADDRESS LONG-TERM RISK REDUCTION
Many women who complain of symptoms that may be cardiac in origin turn out to have a non-cardiac problem. Still, heart disease is the leading killer of women and attention to risk factor modification is important for everyone. Take the opportunity while she is thinking about her heart to educate your patient about the risk factors for heart attack and stroke. Give her concrete ideas about how to make changes in diet and lifestyle. This is some of the most important work we do as physicians! The woman who avoids a heart attack because of the time you spent telling her how to eat healthy and exercise may not know to thank you. But we all know what a big impact this one-on-one attention can have.
WOMEN CAN HAVE HEART ATTACKS THAT DON’T SHOW UP IN AN ANGIOGRAM OR IN ST SEGMENT ELEVATION
Twenty-five percent of the heart attacks that women experience show no ST segment elevation or blockage. In contrast, only 3-10% of men have heart attacks without ST elevation or blockage. One explanation is that there was obstruction temporarily, with a totally blocked artery, but then the woman’s body was able to open it up again, but only after damage occurred.
Another possibility is that damage occurred due to do a temporary blockage caused by vascular spasms that no longer show up by the time the angiogram is done. Still another possibility is that in women, the blood clot that forms on an active plaque may break up into the smaller vessels. That is, a level that’s too small for an angiogram to pick up. An angiogram that can show the trunk of the vascular tree and the big branches may not be fine-grained enough to show what’s going on at the microvascular level.
YOUR PATIENT SHOULD KNOW THAT A HEART ATTACK THAT DOESN’T REGISTER ON AN ANGIOGRAM OR IN ST SEGMENT ELEVATION IS NOT A BENIGN CONDITION
While this is not quite as serious as more overt forms of heart attack, roughly 2% of women who have a heart attack without blockage or ST elevation will experience another attack in the next 1-12 months. There’s a temptation for her to dismiss this kind of attack, not taking it as seriously as she should. However, she should know that even if she didn’t have the typical symptoms in the hospital, she nevertheless did have a heart attack and that her treatment should include, as appropriate, the same medications and lifestyle changes that would accompany a more typical heart attack.
WOMEN NEED TO BE EDUCATED THAT WHEN THEY HAVE HEART ATTACK SYMPTOMS, MINUTES COUNT
There are many cases of women experiencing heart attack symptoms who delay going to the hospital. Instead, they first take care of their loved ones, or even try to clean the house before they leave for the hospital! Women need to learn that when it comes to the possibility of a damaged heart muscle or increased risk of death, the minutes really do count. There can be false alarms, but doctors and emergency rooms are ready for this and women are not “bothering” anyone by coming in with chest pain even if they are not sure if it is a heart attack. Given the seriousness of possible outcomes, this is what to recommend.
OF THE SEVEN MAJOR LIFESTYLE MODIFICATIONS, WORK WITH HER ON THE ONES SHE’S MOST LIKELY TO CHANGE
The American Heart Association lists seven health factors that can help prevent heart attacks. The Simple Seven are: Get Active; Eat Better; Manage Blood Pressure; Lose Weight; Reduce Blood Sugar; and Stop Smoking. However, asking her to take on all of these at once may be too hard for her.
Instead, we recommend trying to discover which of the seven health factors she is most motivated to change. If she is not motivated to change a particular factor, you’re not going to get very far with her. Spend a couple of minutes with her finding the area where she is most motivated to change. Then help her set an easy goal; one so that she can achieve by the next visit. When she’s achieved that goal, go to the next step. Then the next. After a while, she will have achieved big changes in small increments.
RECOMMEND THE WEB SITE “MY LIFE CHECK” TO YOUR PATIENTS
The American Heart Association and the American Stroke Association have created a helpful website that’s consumer-friendly, easy to understand, and motivational. It’s called “My Life Check– Life’s Simple 7,” and your patient can find it at: http://mylifecheck.heart.org/Multitab.aspx?NavID=3&CultureCode=en-US.
Recommend that she visit it for additional encouragement and understanding.