Page 15 - Boca Club News - May '23

Boca Club News, Page 15
Medical Matters: Cardiovascular Disease,

Updated (Part Three)

By Richard Nagler, M.D., a member disease. It is described as pressure, tightness, a burning or of stable angina who, even with angiography, demonstrate
of Broken Sound Club and retired squeezing pain in the center of the chest, which usually no evidence of significant narrowing of the main coronary
physician. After graduating from the radiates to the left side of the neck, jaw or down the inner arteries. This is due to inadequate blood flow with non-
University of Pennsylvania and New aspect of the left arm. It is not present at rest, when demand obstructive coronary arteries. It comes in two main forms,
York University’s School of Medicine, for oxygenated blood is minimal, but as the patient engages one of which is microvascular angina, where the inner walls
Dr. Nagler served his internship and in physical activity—including walking, especially up a hill of the tiniest branches of a coronary artery become thickened
residency at Baltimore City Hospital or a flight of stairs—the demand for a significant increase in and lose their ability to expand and contract in response to
and Johns Hopkins. He followed that blood flow cannot be met and angina will develop and then demand for increased blood flow during exercise,
with a Fellowship in Gastroenterology ease as the resting state is resumed. The other, less common, type is vasospastic angina,
at Yale University School of Medicine, and was then Chief A sublingual nitroglycerine tablet, which rapidly dilates where muscles in these vessels suddenly clamp down causing
of Gastroenterology at Fitzimmons General Army Hospital the coronary arteries and increases blood flow, will bring coronary spasm, which block blood flow to heart muscle. The
in Denver. He returned to the Yale Medical School for one about immediate relief. Variations of angina are seen, diagnosis can be made by more sophisticated tests such as a
year as an Assistant Professor of Medicine before opening especially in women with unexplained shortness of breath, coronary flow reserve (CFR) or non-invasively with a nuclear
his own successful private practice in Internal Medicine fatigue, palpitations or indigestion. This is associated with stress test with a PET scan, which measures how well the
and Gastroenterology. During that time, he also served for worse outcomes due to delayed diagnosis and treatment. An heart’s circulation can deliver blood under stress versus rest,
ten years as Chief of Medicine at Huntington Hospital in EKG will invariably be normal if it is done in the resting state. by placing a wire in the heart’s main coronary arteries and a
Huntington, N.Y. A stress test will be helpful as classical changes appear on the drug administered that dilates them and mimics the effects
People with no symptoms suggestive of coronary artery tracing concomitant with the development of angina as the of exercise. These patients should be treated medically in the
disease are often erroneously advised to have a stress test. exercise level increases. Medical treatment is often the first same manner as those patients with the stable angina.
As many as 20% turn out to be false positives, requiring choice. It involves a beta blocker such as Inderal, Tenormin, In contrast to stable angina there is unstable angina,
invasive tests to confirm. Those who are at high risk should Atenenol and Lopressor, which slow the heart rate in response which is an emergency situation. Symptoms are similar to
have a nuclear stress Thallium test, or a CCTA9 (coronary to exercise, lowers systolic blood pressure and enables heart stable angina, but more intense, occur at rest and there is
computerized tomography) to confirm whether there is any muscle to utilize available oxygen more efficiently. no response to nitroglycerine. Unstable angina is caused
significant coronary artery disease present. An angiogram A long-acting vasodilator, such as Isordil or Cardizem, is by rupture of plaque with the formation of a blood clot that
may be recommended based on a patient’s age, a family added along with low-dose aspirin and statins. While statins has not as yet completely obstructed a coronary artery but is
history, some vague non-specific symptoms and a risk factor lower LDL cholesterol, a more beneficial effect is that they threatening to do so. After being given an aspirin if available,
or two to justify this invasive procedure. Most experts agree are potent anti-inflammatory agents that can prevent both the the patient should be rushed to an ER where a clot buster
that doing an angiogram in these asymptomatic people is the formation of plaque and the breakdown of existing plaque like TPA, Streptokinase or Urokinase is given intravenously
major reason that, of the more than 1.5 million angioplasties leading to rupture. When medical therapy is ineffective or to dissolve the clot. This can be lifesaving, but serious side
and stents performed in this country each year, more than poorly tolerated, an angiogram to identify the offending effects, especially from excessive bleeding—including a
50% are not indicated. If an angiogram was done on the plaque followed by an angioplasty and stent opening up stroke—can occur.
entire population of men over 55 and women over 65, the that area to normal blood flow, will eliminate angina. When A better option is to send the patient up to a cath lab,
vast majority would have one or more narrowed areas in the for technical reasons stents are not feasible, coronary artery where an angiogram can identify the location of the offending
coronary arteries due to plaque build-up. bypass surgery may be required. clot. An angioplasty and stent can follow, which will restore
There is overwhelming evidence that in asymptomatic Both medical and surgical treatments can successfully normal blood flow and prevent an imminent heart attack.
people angioplasty and stenting coronary arteries with less return the patient to a normal quality of life. Neither method An actual heart attack is called a myocardial infarction
than 70% obstruction does not prevent a heart attack, does will prevent a future heart attack nor prolong life, because and presents with a similar picture to unstable angina.
not improve lifestyle, nor does it prolong life. In addition, the risk factors involved with the development of the disease However, the pain is more intense and is associated with
this invasive procedure is not without risk. Four percent can remain after any treatment has been administered and existing profound sweating, dizziness, weakness and often a sensation
have a heart attack during the procedure, an embolus may non-obstructing plaque will continue to grow and more of impending doom. There may be no symptoms at all,
be dislodged and travel to the brain and cause a stroke, the dangerous new soft plaque more susceptible to rupture is referred to as a silent heart attack. This is more common than
catheter used can tear a coronary artery (which would be likely to develop. That is why in every person with or without appreciated. Plaque has ruptured and a clot has completely
catastrophic), a dangerous arrhythmia may be provoked symptoms of coronary artery disease it is essential to identify obstructed a coronary artery. Shock and ventricular
from irritation of the catheter, and an adverse reaction to the any risk factors they may have, and then do everything fibrillation often complicate matters, resulting in cardiac
dye used can damage the kidneys. When plaque is very hard possible to modify or eliminate them. arrest and death. Emergency intervention is essential with a
it can defy efforts to deploy artery-widening stents to open In most cases of a heart attack, aspirin has proven to be defibrillator, if available. Giving an aspirin can help reduce
up a narrowed artery. A new technique called intravascular of benefit in reducing the damage to the heart muscle by clot expansion. If the patient has survived to this point, it
lithotripsy uses shock waves to break up these hardened preventing the expansion of a clot or helping to dissolve it. is imperative to restore blood flow to the affected heart
deposits deep within plaque, followed by a stent. However, in normal people regardless of age who have no muscle within 90 minutes before permanent damage occurs
When a patient has symptoms of stable angina the significant risk factors, the risk of bleeding from even low- resulting in subsequent congestive heart failure. Emergency
situation is completely different. Stable angina is the major dose aspirin outweighs any benefit and it should be avoided. angioplasties and stents and coronary artery bypass surgery
consistent reliable indicator of significant coronary artery There is a subset of patients who have classical symptoms have resulted in a significant reduction of deaths from heart
attacks over the past 60 years.
If we can significantly make inroads into the epidemic
of obesity in this country, and simultaneously reduce the
incidence of type 2 diabetes, identify and successfully treat
high systolic blood pressure in more people, further reduce
smoking tobacco and vaping, encourage a Mediterranean-
style diet, utilize statins in many more individuals, defeat
obesity, encourage heart-healthy diets and continue to push
for more participation in aerobic physical activity, we will
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