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Have COURAGE! By James H. O'Keefe, M.D. We used to believe that heart disease was just a plumbing problem, where the gradual build-up of plaque in the coronary arteries eventually chokes off the blood supply to the heart muscle, much the same way that sludge accumulation gradually clogs up the pipes from your kitchen sink. The intuitively obvious solution to both of these problems is to simply unclog the pipes. Indeed, balloon angioplasty and stents unclog the blockages, and bypass surgery re-routes the blood around the blockages, restoring normal blood flow to the heart muscle and fixing the problem-or so we thought. Unfortunately, fixing your coronary arteries is not as simple as unclogging the pipes to your sink. It turns out that most heart attacks are caused by smaller plaques that are much like pimples on your skin. These plaques can become filled with pus and cholesterol, causing them to become inflamed and prone to tear or rupture. Rarely, this can stimulate a clot to form, suddenly transforming the previously innocent looking plaque into a life-threatening complete coronary occlusion. While it is still important to seek out and eliminate the tight blockages, it is equally important to get the pus, cholesterol, and inflammation out of those hidden pimples just under the inner lining of the heart's arteries. The right diet, exercise, and medications can quickly heal the complexion of vessel walls, and restore your arteries to their naturally smooth, soft, and supple state, which markedly reduces your risk of heart attack and cardiac death. Here at Cardiovascular Consultants, we were part of the COURAGE study, a large trial of 2,287 patients from the U.S. and Canada with stable angina (chest discomfort caused by significant blockages in the coronary arteries). The patients were randomly assigned to receive either a stent procedure and aggressive medical therapy, or aggressive control of their risk factors with medications, diet and lifestyle alone. At the end of the five-year study, almost the same number of patients in both groups had died, suffered a heart attack, stroke or continued to have chest pain. This study suggests that many people with stable coronary artery disease can be safely managed without resorting immediately to invasive therapies like stents or coronary bypass surgery. However, about 30 percent of the patients who were originally assigned to medical therapy ended up needing a stent during the five-year study. The COURAGE study affirms our approach at Cardiovascular Consultants to patients with stable coronary disease. We place a strong emphasis on aggressive medical therapy for risk factors using safe, effective, and life-saving medications like statins (for cholesterol), ACE inhibitors, ARBs, beta blockers (for blood pressure), aspirin, and fish oil. We also emphasize the importance of diet, daily exercise and regular check-ups to make sure your numbers are in the ideal ranges that will keep your arteries unclogged. Ideally, we like to check your heart periodically to ensure that your arteries stay open. As in the COURAGE trial, if problems come up, we may need to consider doing an angioplasty to eliminate tight blockages. By combining aggressive medical therapy with focused interventions when needed, we can make sure that you and your heart continue to thrive. Importantly, if you develop unstable symptoms, like suddenly worsening or unrelenting chest discomfort, that go along with an acutely blocked coronary artery, you need to seek immediate medical attention. Urgent cardiac catheterization and stenting for an evolving or threatened heart attack is a dramatic life-saving therapy that was invented right here at the Mid America Heart Institute of Saint Luke's Hospital in Kansas City. In 1980, Drs. Geoffrey Hartzler and Barry Rutherford, working for Cardiovascular Consultants, used a balloon catheter to open a coronary artery of a man who happened to have a heart attack while he was in the hospital. That man remains alive and well today, and since then we have been using urgent balloon and stent therapy to treat heart attacks. That treatment has evolved to become the gold standard for treating heart attack patients around the modern world. Do I Have to Take These Medicines for the Rest of My Life? To this, one of the most common questions I hear from my patients, I often reply, "No, only until about a year before you die. At that point you won't need them anymore. When you get that date on your calendar, let us know and we can simplify your medication regimen." But seriously, who knows what we'll be using to treat your cardiac risk factors in five, 10, or 20 years? For now, this is the best we've got, and it will keep you alive and well, especially if you also do your best to eat right, exercise daily and don't smoke. Scientists estimate that it took humans about 100,000 years to develop spoken language. Another 25,000 years went by before we invented written language. The printing press came along 4,500 hundred years later; and then the pace of progress really started to pick up. The computer was developed 350 years later, and then the Internet (maybe the most profound human invention thus far) sprouted into existence just 20 years ago. The pace of technological progress has been accelerating with exponential speed, especially now that information moves around the globe instantaneously and continuously. By some estimates, the world's total scientific knowledge has doubled just since 1997. Things change so quickly, especially in a dynamic field like cardiology. Robert, who had a stent placed in one of his coronary arteries three years ago, learned first-hand how quickly things can change. When I saw him last year his blood pressure was 134/84, and his LDL (bad) cholesterol was 90. I told him, "Your numbers are great, so stick with the same medications and keep working on your diet and exercise." This year's numbers were even better with a blood pressure of 132/83 and an LDL of 85, yet I had to tell him that his numbers were not good enough-he was understandably a bit confused and irritated. I told him, "With what we know today, it looks as though you will need to get your blood pressure to less than 130/80; your bad cholesterol to less than 70; and your blood sugar to less 100 if you want to avoid heart attacks, strokes and death from cardiovascular disease." |
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