Coronary Artery Disease is the single leading cause of death in America today. Twice each minute an American suffers a coronary event half are fatal. – American Heart Association.
ABILITY‘s Chet Cooper spoke with Dr. Subbarao Myla, Director of Cardiovascular Research at Hoag Hospital in Newport Beach, California.
Chet Cooper: What is a heart attack?
Subbarao Myla: A heart attack happens when the arteries supplying blood to the heart suddenly shut down. Then, the downstream heart muscle doesn’t get the blood supply and if that blood flow is not restored with in a certain time (usually six hours) then permanent damage takes place in the heart muscle. It’s almost like a wave front phenomenon. A heart attack, unlike what most lay people think, is not a light switch effect where a heart attack happens and then it is all complete. It is more like dropping a stone into a quiet pond. Like the waves reaching the shore, there is only a certain amount of time until you damage more heart muscle. That’s why we use the term “Time is muscle.” Some patients, even the patients with a known heart attack or known angina, think they can keep taking nitroglycerin and not get attention. A distinction needs to be made between the pain of angina and the pain of a heart attack.
CC: Angina being…?
SM: Angina is the term we use when someone gets a pressure, tightness in the chest, neck or jaw. It’s very unique for that person. A common mistake, the stereo type, is that the pain is on the left side of the chest and then travels to the left arm and heart. They say, “Well, I’m having pain in my right arm so it is not a heart attack.” That is a dangerous denial. When we did large scale studies, population-based, the pain travels down both arms with equal frequency. Jaw pain is common. We get, quite often, calls from dentist’s offices. The patient goes to the dentist thinking there is something wrong with a tooth. But, when the dentist checks it out and finds there is nothing wrong with the teeth, the patient gets referred to us. The heart is a deep structure. It’s not a superficial organ. Deep structures share nerve tracks with other organs of the body. All pain perception is in the brain. As a layperson, how do I tell which pain is heartburn, which pain is a muscle ache, and which one is a heart attack? The way to tell is to see if you can point a finger at one spot and see if that is exactly where the pain is. A heart attack pain, being a deep sensation, is never one small area. It is usually a big, wide area and it is not superficial, it’s deep inside. The most important thing is to be smart. When in doubt, don’t play doctor. Just go to the doctor and let him be the objective person.
CC: When does angina occur?
SM: Angina is a warning that the heart muscle is not getting blood flow in relation to what it is demanding. It comes on with exertion. Typically, angina would affect someone who is physically active-playing two sets of tennis, running or jogging, etc. During intense exercise they feel the deep pressure in the chest, arms, neck or jaw-any of these locations or all of the above. When they stop the activity, the pain subsides within minutes. That’s a classic, worrisome symptom. It is a warning signal saying, “Hey. I’m not getting enough flow here, back off.” So, the individuals learn to adapt. For example, people who play tennis, they don’t push that hard. They may even switch to doubles, where the intensity is less. We see that in a lot in active people. They get the warning signs. That’s why we tell recommend not being a couch potato. Your heart disease will get detected so late.
CC: Why is that?
SM: When people exercise, they increase their heart rate. This causes the heart to demand more blood. So, if there is a small blockage then the symptoms can be detected early. Take the example of someone who is a couch potato. The most exercise that he would probably do is to lift his legs when the vacuum cleaner is coming his way. We have patients like that. Their biggest exercise is the right hand pushing the remote control but tons. The heart rate never goes up. The blockage will go on to progress to complete occlusion. We have people with all the three major arteries to the heart completely blocked.
CC: They don’t have any of the symptoms, so therefore it would be an instant surprise?
SM: Exactly right. As we age, we inevitably develop some blockage. Nobody will have absolutely unaffected arteries. There is data now that shows the earliest sign of the plaque (what we call the fatty streak) is already forming in the fetus. What separates the majority of people that don’t develop a heart attack, as opposed to the minority whose blockage has just blossomed? That is the big mystery. If a heart blockage is progressive, obviously you want to know early on. When angina occurs, you go and get treated, rather than suffer a heart attack. Or even worse, like the unfortunate ones, including my father, at 67, his first symptom of a heart disease was sudden death. 650,000 people, every year, die in this country suddenly. When we interview the surviving spouses, they turn out to be not so sudden. A lot of denial exists. We call it the “executive syndrome.” We get patients who are corporate executives, who hop from airport to airport. They are doing a fairly large amount of exercise hustling through the escalators and hallways with their laptops and bags. They get a sudden tightness in the chest that feels like heartburn It is denial They attribute it to the late night liquor, a little wine, or a greasy burger. They blame it on that and take Mylanta We typically see these executives…they have this thin white lining around the lips. It is actually Mylanta or the antacids. So, what happens? When someone gets severe chest pain, they stop their activity and the pain goes away. They may have taken this Mylanta or what have you, but the pain was going to go away anyway because their activity level stopped. They falsely attribute the pain cessation to the Mylanta. In some East Asian com munities, like Westminster (“Litle Salgon” in Southern Caledonia), they have a coin rubbing practice, where they take a coin and then they rub the coin on their chest. They believe this makes the pain go away. The fact of the matter is that angina pain goes away after a few minutes. This denial plays a role. It is important to see that angina is in relation to exertion and emotional exercise.
CC: Who are the people at risk?
SM Family history is the number one risk factor. Patients need to know their parents’ history-uncles; aunts, any relative. Did they have any premature heart disease? Premature meaning before the age of sixty. Or, more importantly, before the age of fifty. If they have a family member with heart disease before the age of fifty, they must get a thorough check-up. Therefore, we have hope. We have the data to support aggressively treating the patient. Other risk factors are high blood pressure, heavy smoking, diabetes and, of course, elevated cholesterol levels. The amount of cholesterol that is considered normal keeps going down. I remember in the 80s when was taking a course at Harvard, calling my father and he would gleefully tell me, “I broke the barrier. I got my cholesterol down below 300.” You see, 300 was considered normal then. I told him, “Dad, we dropped the normal.” It was 240 at that time. The conventional wisdom now says that normal should be 200 New data is coming out and I think the normal should be less than 170. In someone who already has heart dis ease, it probably should be under 140.
Let’s talk a little bit about the heart scans or the calcium scans. These are very good tests. If someone has these risk factors, it is a reasonably good test and Medicare is starting to pay for this. There is enough data to support that a growing blockage develops an aging phenome non. A calcium build-up in the blockage is a sign that it is aging and the CAT scans don’t pick up the blockage. They pick up the calcium. Look at the copper drainage rain gutters that are out there. You can’t tell the age by the shape. You can tell by the patina that it develops That’s the same thing. This calcium build up is a patina Based on that patina, you estimate how long that it has been there. But, the new generation CAT scan, and the MRIs that are going to come out in a couple of years. most likely will actually tell us how bad the blockage is. But, more importantly, which blockage will cause a heart attack. We are installing that kind of unit here at Hoag Hospital right now. I also do stroke prevention technique. The blockage that builds up in the heart arteries causing the potential for a heart attack is different from the blockage that causes a stroke. The cholesterol doesn’t have to build up to a point of closure to get a stroke. That is a common misconception. The blood flow is usually anywhere from 50-80% blocked. There is still plenty of flow but the torrential flow that is coming will rip through tiny particles of the blockage. Think of tree on the east coast in the fall season. You go under the tree and shake it and these leaves fall and just like that the cholesterol particles break loose into the brain and cause the stroke. There may be warning signals. Just like angina for the heart, there is a term for the brain called TIA (transient ischemic attack). Morning is the most likely time to have a heart attack or stroke.
CC: Why is that?
SM: The tiny little blood elements called platelets tend to be stickier in the morning. Blood pressure tends to be higher in the morning. Heart rate tends to go up in the morning around 5:30-6am. So, when someone says, “I checked my pressure at home. I should have no risk.” I tell them to check it twice a day. Once in a while, check your pressure in the morning. Early morning blood pressure control is very important. Most medications will cover blood pressure control twenty-four hours a day. Most people believe that aspirin therapy is the first line of defense for prevention of a heart attack or stroke. The problem is that the data is not strong. We still don’t know what dose of aspirin one should take. There is more solid evidence that, at least in men, taking a mini mum of two aspirin a day will give good protection. It has been in the newspapers lately that if you take Ibuprofen or Motrin your heart attack protection from aspirin will be gone, so don’t take those. I think the data is very sketchy, but it is still usually safe to take aspirin. The most important risk of aspirin is the potential for bleeding in the stomach. So, that’s why I don’t make a blanket recommendation. If someone has a history of stomach pain, acid reflux or if they have arthritis and they are taking other pain medications, it is important that they consult their doctor. Taking the aspirin in the morning is preferable to taking aspirin at night. A lot of us leave the pills to the early morning hours or in the late evening hours.
CC What is the danger of taking aspirin at night?
SM: You have a meal and then you take the aspirin. The stomach doesn’t empty as much after you go to bed. The aspirin sits in the stomach for a lot longer. There fore, it has more potential to cause ulcers and other things. But, if you take it in the morning with a meal, the risk of aspirin damage in the stomach is very limit ed. There is a new medicine called Pletal that may replace aspirin, except for the cost. Pletal is about three dollars a pill. You can probably buy about a hundred aspirin for three dollars. In women, if they have significant risk factors, I tend to favor Pletal.
CC What is the difference between men and women?
SM: We don’t know very well. We do know that in women the estrogen hormone protects them from cardiovascular events. That explains why before menopause the risk of a heart attack is very low. In fact, if we see heart disease before menopause, it is typically somebody who has diabetes, a very strong family history of heart disease, or they are smokers. But, after menopause, a woman’s risk is the same as a man’s. In general, women have about a decade of advantage. A sixty-year-old woman’s risk of heart attack is about the same as a fifty-year-old man. So, we think that it has to do with the female hormone estrogen. Estrogen causes the arteries to relax and causes good cholesterol levels to stay up. In the past, the stereotype argument was that women are not exposed the same stress that men are. That is no longer considered to be true. I mean, most of the American families are dual income families. Plus, women take care of the children. How many men actually go home and help the wife take care of the children? The gender issue is still largely unexplained. There is no question that the interventions we do like sophisticated plumbing of the arteries are not as effective for women. We think it may have something to do with the body size. The size of the arteries correlates to the body size. The average woman is smaller than the average man. These techniques don’t work as good in smaller arteries. It is not so much that it is hard to work on small arteries, but when scar tissue builds up there is less room to deal with and you may actually block that artery with scar tissue.
CC Have there been studies done with different size women?
SM: The studies show that women with big arteries react the same as men. So, we think, to a degree, it has to do with the size of the arteries. The other difference is that when a woman is presented with a heart problem she is usually older. So, generally, we are dealing with an older person. The risks are always higher for older people, male or female,
CC Tell me about the latest treatments.
SM: The traditional method of treating the arteries that are blocked has been nitroglycerin and nitrates. They have been life savers for almost half a century. The discovery of those pills was by sheer accident. Factory workers in New York were getting angina pains on weekends, when they were away from the factory, When they came back to the factories they didn’t get the angina pains. It is because they were inhaling nitrate fumes. That dilates the arteries. So, nitrate has the ability to increase blood flow. Now, fifty years later, we find that the lining of the arteries in healthy bodies produces nitrous oxide which is a chemical that keeps the arteries healthy, open and relaxed. So, it is a natural consequence, that when someone has angina you put a tablet under the tongue and within minutes the angina pain goes away.
CC: Does it absorb better under the tongue?
SM: Any pill that you swallow has to go through the liver. The pill gets broken down. Ninety percent of the drug is removed. The liver is a big scavenger, cleaning house. So, very little amount of the drug remains available. The blood supply under the tongue can directly get to the heart arteries. We take advantage of that. Of course, now there is nitro spray which is few seconds faster. It is more expensive. A simple pill will do the same.
CC: Aren’t those more like quick fixes? Are they solving any problems?
SM: They are band-aids. The real problem is heavily blocked up cholesterol calcium plaque. The permanent solution is removing it or relieving the obstruction. Angioplasty started in the early 80s and is now more or less replaced by stenting. Angioplasty is where we insert a thin plastic tube with a balloon at the end. We position the balloon right in the middle of the blockage and we inflate the balloon. It pushes the blockage into the walls. Most of the time it stays up there in the walls and then you take the balloon out and the plaque is settled there. But, there is nothing stopping the cholesterol plaque from coming down. Intuitively, it is almost like a coal mining tunnel that the ceiling caved in and you need to come up with a method to lift the ceiling up and find a prop or a scaffold that holds it in place to allow the traffic to go through. And that’s what a stent is. A stent is a round metal tubing somewhat similar to a spring coil in a ballpoint pen. This is made of a high-tech nickel titanium alloy. You could have 20 stents go through the airport security gates and not trigger a metal detector. Magnetic fields cannot detect them. They are also MRI safe.
CC: You don’t use plastics for that?
SM: No. We are looking towards biodegradable stents in the future. A prototype is now available in Japan. They have a biodegradable material called collagen and other materials. They are made of a tough fiber, but within six months they dissolve.
CC If the stents dissolve how can they support the artery?
SM: It has to do with how the body reacts to the stent. On both ends of the stent, a lining or reinforcement is formed that incorporates the stent into the wall of the artery. So, about three months later, if you were to look for the stent you wouldn’t see it. You may see shadows of the stent. The body has a natural way of healing and isolating the foreign material. Think of a room under construction with insulation sticking out of the walls. That insulation is the plaque and the stent is the drywall that covers it. Then the body makes wallpaper on top of that, making it smooth. So, the circulating blood elements don’t come into contact with the stent.
CC: So the biodegradable type will be there….
SM:…long enough for the body’s healing mechanism to strengthen itself. Unfortunately, it is not easy to develop durable biodegradable material. So, the research goes on. The real nemesis of the stent is the exuberant scar tissue that builds up within the stent as part of the body’s healing process.
C: Too much wallpaper?
SM: Too much wallpaper or, if you look at in other construction terms, picture somebody putting in tile with spacers for grout to seal them together. The scar tissue would be like if it was sloppy with too much grout. Think of that in a round tunnel. Too much scar tissue will block the flow. The heart muscle doesn’t care what is blocking the plumbing, whether it is cholesterol or calcium or scar tissue. It only suffers the consequence of not getting enough blood. So, we have techniques now that use a drill bit to get rid of the scar or we use a cutting balloon-a balloon that has blades on the top (we have that available here at Hoag Hospital.) A little bit of scar is important, but not a lot. Almost like Goldilocks not too much and not too little, but just the right amount. Too much scar, blockage forms. Too little scar. the stent is too close to the blood and that may cause a clog and a heart attack. So, it takes fine tuning to get that Goldilocks stent.
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