Four Areas of Controversy – Coronary Artery Disease

by Joseph Alpert, MD

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    00:01 Well, let’s look at controversies now. I've given you six areas where pretty much the cardiology community is in agreement.

    00:09 There are four areas where there's some debate. Number one, does revascularization - either angioplasty, new vessels, opening vessels again or having new vessels with coronary bypass put into your heart, does it save lives? Well, it turns out that there have been a number of trials that have looked at this. In fact, there's a decrease in mortality, if you have severe three-vessel disease and reduced heart function. But, in all other settings, medical therapy has been shown to be just as good as surgical or catheter intervention therapy as long as the patients follow through with their medical therapy.

    00:51 A recent trial, the COURAGE trial done in the Veterans Administration in the United States showed that when the patients adhere to their medicines and if their symptoms got worse then of course, they jumped over to coronary bypass or angioplasty. The group that started out with medicines did just as well as the group that started out with angioplasty or surgery. Again, confirming the point I said before, a good doctor and a good cardiac rehab program make a huge difference even in the absence of an intervention such as bypass or angioplasty. A little diagram that you've seen before demonstrating a coronary bypass graft going into a blood vessel and I already showed you earlier in this talk an example of an angioplasty with the balloon opening up an occluded artery. These days we place a little metal stent in after the balloon opens the artery in order to keep it open and of course, that means you have to take your Anti-platelet agents to prevent blood clots from forming. Just to reiterate on revascularization not saving lives in the vast majority of patients with chronic ischemic heart disease, then medical therapy and lifestyle intervention works just as well in terms of preventing another myocardial infarction or dying from coronary heart disease as does the intervention when chosen as the initial strategy for taking care of these patients. However, there are the settings - acute ischemic heart disease or three vessel disease with reduced left ventricular function, those patients are pushed in the direction of an intervention such as bypass or angioplasty and the studies have shown that when those settings are there, acute ischemic heart disease or the three vessel disease with decreased left ventricular function, those patients will do better… a little bit better with the intervention than with just medical therapy.

    02:53 By the way, after intervention, the patients have to stick with medical therapy as well.

    02:57 So, it’s really intervention plus medical therapy versus medical therapy alone. But, the vast majority of stable patients with ischemic heart disease that represents the overwhelming majority of patients do just as well with medical therapy from the start as they would with an intervention like bypass or angioplasty from the start.

    03:18 Second area of controversy is that all patients with coronary disease should have a cardiac catheterization with an angiogram, which you see a little diagram of on the right hand side. If you believe that an intervention makes a difference in terms of preventing death, why then all patients should have an angiogram. But, as I've just demonstrated, really for the vast majority of patients with coronary disease, intervention should only be done when the patients develop acute symptoms or very severe symptoms with minimal exertion.

    03:51 So, really cardiac catheterization is not necessary and usually, we can do a non-invasive stress test which will give us a sense of how much ischemia - how much lack of blood flow there is in the heart and the patients, again, can be followed on medical therapy.

    04:06 Again, the importance of the doctor and the cardiac rehab program, lifestyle changes and taking your medication. These things are very important as we've talked about in the areas of consensus, not everybody needs an urgent coronary angiogram.

    04:23 Now, let’s talk about another controversy and that is that older patients with coronary disease should never undergo revascularization. In fact, its been shown, yes, the older you are, there is higher risk as you can see from the diagram here when they do angioplasty or bypass, there is a higher risk of death. But, in fact, the overwhelming majority of very elderly patients and I've seen individuals who are vigorous and active in their 90s, who developed a non-ST elevation or even an ST-elevation myocardial infarct have angioplasty and do extremely well. Now, I live in an area in Arizona where there's a lot of very vigorous retired people. They move to Arizona because they want to be playing tennis, they want to be hiking, they want to maintain a very active lifestyle and the weather allows them to do that in Arizona. We have done a number of these older patients who are vigorous and active. We don’t hesitate to do an intervention in them when the indications are there, that is they have an acute ischemic event or their symptom of angina becomes so severe that they're having a hard time doing their normal activity. Intervention does reduce the anginal episodes and therefore, in an active person, the intervention such as bypass or angioplasty does help to reduce angina and at least make people’s quality of life a little better.

    05:51 Although, medicines are not far behind when the patient is not interested in having an angioplasty or bypass. In patients who are very symptomatic, as you can see from these two diagrams, there is an improvement when intervention is used, but you can see that long term, the difference is really not very much. So, again, emphasizing that good medical therapy really works and that in patients who are very symptomatic, there is a little bit of an improvement with intervention, but long-term, the difference is, on the right hand side, not very much. Another area of debate, of controversy is whether patients with coronary artery disease should be seen as occurring only in the elderly population and never occurring in the younger population. Where you can see from the diagram here on the right hand side that yes, coronary disease, the manifestations of it, angina, myocardial infarction are more common in individuals who are elderly. But, look at the left hand side of the diagram, there are still a substantial number of younger people who developed this and it is not uncommon for us to see in a week in our hospital, individuals in their 40s and early 50s with clinical manifestations of coronary disease, for example, myocardial infarction. So, although this disease is much more common in the elderly and of course, the mortality is higher in the elderly, just as with all diseases the mortality is higher in the elderly, there is less vigor of resistance. On the other hand, this is not just a disease of old folks, it is definitely something that is seen in younger individuals as well.

    07:37 Well, so, in summary, coronary artery disease is extremely common, but in fact, it appears that at least in the US and in Western Europe and Canada, there is a decrease in mortality and even a decrease in atherosclerosis as reflected by autopsy studies and a declining average serum cholesterol in the country. There is excellent evidence based therapy for acute ischemic heart disease that is myocardial infarction, unstable angina as well as chronic ischemic heart disease that is exertional angina and that patients usually will do just as well with medicines as they will with intervention as long as they're not acutely ischemic or as long as they don’t have three vessel disease and reduced left ventricular function.

    08:29 Effective medicine, as delivered by good doctors, and good cardiac rehab programs make a huge difference. Lifestyle changes are just as important as the medicines that one takes in reducing the risk for recurrent events and death.

    About the Lecture

    The lecture Four Areas of Controversy – Coronary Artery Disease by Joseph Alpert, MD is from the course Cardiac Diseases.

    Included Quiz Questions

    1. Cirrhosis of the liver
    2. Elevated blood cholesterol
    3. Cigarette smoking
    4. Diabetes mellitus
    5. Hypertension
    1. High levels of HDL cholesterol can cause coronary artery disease.
    2. Obese individuals often have elevated blood pressure.
    3. Diabetics develop coronary artery disease more frequently than non-diabetics.
    4. Myocardial infarction occurs in patients with coronary artery disease.
    5. Statins are effective therapy for patients with coronary artery disease.
    1. Sudden death
    2. Gastrointestinal bleeding
    3. Dehydration
    4. Diarrhea
    5. Pneumonia
    1. Blood transfusion
    2. Statins
    3. Coronary bypass surgery
    4. Coronary arterial angioplasty
    5. Anti-hypertensive drugs
    1. CAD patients often have mitral stenosis.
    2. Statins decrease mortality rate in patients with CAD.
    3. Cigarette smoking is a major risk factor for CAD.
    4. Sudden death is a feared complication of CAD.
    5. Myocardial infarction is much less likely to be fatal than it was 50 years ago.
    1. Antiplatelets
    2. Antihistamines
    3. Sodium channel blockers
    4. Beta blockers
    5. Calcium channel blockers
    1. It can be performed in elderly patients.
    2. It is most often performed in young patients.
    3. Medical therapy is not indicated after angioplasty.
    4. Patients are hospitalized for at least 3 days.
    5. Diet modification is not indicated after angioplasty.
    1. Diabetes mellitus
    2. Young age
    3. Old age
    4. Female
    5. Multiparity
    1. Family history
    2. Physical inactivity
    3. Obesity
    4. Hypertension
    5. Cigarette smoking

    Author of lecture Four Areas of Controversy – Coronary Artery Disease

     Joseph Alpert, MD

    Joseph Alpert, MD

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