Prevention of Secondary Heart Attack
Guest: Dr. John Kratz – Department of Surgery, MUSC
Host: Dr. Linda Austin – Psychiatry, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m talking, today, with Dr. John Kratz, who is Professor of Surgery in the Division of Cardiothoracic Surgery here at the MUSC, working out of our beautiful new building, the ART building. Dr. Kratz, let’s talk, in this podcast, if we could, please, about prevention of what you would call a secondary heart attack, or complications that can come in the months and years after a patient has had bypass surgery. I understand that the way we manage patients; the way we advise patients, after bypass surgery has really changed over the last few years. Can you describe some of those changes?
Dr. John Kratz: Yes. I think that this is, really, a quiet revolution that, perhaps, everybody isn’t aware of, but has been going on steadily, in the background, over the last several years. People who present for coronary bypass surgery frequently had no concept, or idea, prior to a month or two before their illness that they had a problem with cardiovascular disease, or that they were growing atherosclerotic disease.
We all know we’re supposed to lead a healthy lifestyle, but many folks feel like they’re doing well, and they’re not having a problem, only to find out they’ve developed such a severe problem that they have to have a bypass operation to correct all the blockages from atherosclerosis that have developed in their arteries. At that point, with all those blockages there, many times there’s no choice but to go on and correct all the blockages with bypass surgery. Coronary bypass surgery does that very successfully, with graft patencies that run 95 to 98 percent.
Dr. Linda Austin: When you say patencies, you mean?
Dr. John Kratz: Grafts that stay open and work, and correct the problem. So, in the vast majority of people, we can correct all the blockages and get lots of blood going to the heart. But, we’ve really only fixed the secondary problem, which was the blockages. We haven’t fixed the underlying problem, which is why they developed those blockages. And that’s important. If we don’t interrupt this process, then they’re going to develop blockages in other arteries in the heart, or arteries that go to the brain, or to the leg. So, the first step is to fix the heart; get the blood going to it like it needs to. The second step is to prevent this process from continuing to destroy the blood vessels that are in the body.
The great news is that we now, today, in 2008, have all sorts of tools that, when I started this work 20 years ago, we didn’t have. So, today, we can stop the progression of this disease. We can prevent further blockages. And, these concepts, we talk about, but we need to keep reminding ourselves, because they do as much to enhance the patient’s long-term survival and quality of life as the initial operation did.
Dr. Linda Austin: So, in other words, what’s important to underline, I think, in what you said, is that when you get a bypass graft, it’s not exactly correct to think of it as, well, you’ve taken the arteries back to the state they were in when you were a baby. It’s more that you’ve turned the clock back. And now you get a new start, but a start on a disease process that tends to be chronic and progressive, unless you take pretty active steps to slow that down. Is that correct?
Dr. John Kratz: I think that’s right. And, you know, unfortunately, you can have a situation where two folks have the same cholesterol, for instance. One person has lots of blockages in the heart and has to have surgery. The other fellow didn’t have any blockages at all. So, there’s more to this than we understand. But, we now know that once you’ve had a problem, you’re clearly identified as a person who needs to alter that underlying disease process that’s causing these blockages. And, again, there are lots of opportunities to do that, to really turn things around.
Dr. Linda Austin: And, what are some of the most important ways to alter that process?
Dr. John Kratz: Well, some of them are fairly obvious, and we all know about them, although we might not take them too seriously. One thing the community, as a whole, has done is really begin to take, I think, cigarette smoking seriously. We still need to get the message out to a lot of folks. We still need to get the message out to teenagers, unfortunately, that cigarettes damage arteries and destroy the inside of our bodies. This is a first step that I talk to my patients about, which is that they have to quite smoking completely, because the nicotine will continue to cause constriction and damage to arteries. And, it’s something that, at least, you can identify; here’s part of the problem, I can fix this. It’s not easy. I think nicotine addiction is probably one of the most difficult addictive processes in our country today. I feel deeply for people who do have a nicotine problem, because it’s tough to break. But, it can be broken, with a lot of help, and it’s terribly important that they do so.
Dr. Linda Austin: And, I would underline, we have some new medications that are very helpful with that too.
Dr. John Kratz: We do. There are lots of new things coming along, and there’s lots of help available. If you’re a smoker, whether you’ve had heart surgery or not, see your family doctor today and work on that problem.
The next most obvious problem is probably high cholesterol. Again, we’re not too clear on why one person with a somewhat elevated cholesterol has a problem and somebody else doesn’t. But, nevertheless, once you’re identified as having heart disease from artery blockage, it’s terribly important to bring that down. Our guidelines for what’s low enough in cholesterol have changed over the last few years. There are lots of various components of cholesterol. But the two biggies we talk about are HDL cholesterol and LDL cholesterol. HDL is good for you. The more you have, the better. LDL is bad for you. So, we want to get that LDL cholesterol down.
Most people, untreated, have LDL cholesterols at about 100 or 130, around the country. We used to recommend cholesterol being down to 100. We now say that everybody with any known cholesterol; coronary artery, problem ought to be down to 70 or less. So, the guideline is lower. The good news is that we now have medicines with very few side effects that can do that for you, with diet. So, it can be done. It can be done without being miserable and having all the side effects of the older medicines we had available. So, step number two is to get that LDL cholesterol down to 70 or less; really work on your lipids.
High blood pressure is terribly important, especially in South Carolina. One of the great epidemics in South Carolina today is high blood pressure. We have way too many people walking around with either partially or untreated high blood pressure. And this is terribly important. So often I see somebody who says, well I just have “white coat” high blood pressure. Every time I’m in the office, it’s 150, 160, but I’m really okay, doc. You’re not okay! If you’ve got a blood pressure of 150 in the doctor’s office, you’ve got a blood pressure of 150 when your boss yells at you, or some car passes you too fast. And it’s bad for your blood vessels. People need to get their blood pressure down to normal levels, which is 120 or 110/70, and they need to work with their family doctor to do this. It’s terribly important to get the blood pressure under control.
Diabetes, everybody knows that diabetes is a longstanding disease in the country, and that there are lots of folks with it, and lots of problems. But, the one thing we’ve learned about diabetes in the last several years is that you truly can control the number of side effects of diabetes; coronary artery disease being one of them, if you meticulously manage the diabetes. The old days of just lowering your blood pressure a little bit are, now, over. You need very tight control of your diabetes to keep that blood sugar at very normal levels if you’re going to avoid these vascular complications. So, we need to spread that word even more, and get people really fired up about really fine tuning and controlling their diabetes.
But, again, the good news is that almost every year a new medication, or a new treatment, for diabetes control comes out. There’s a bewildering display of various drugs and treatments available. So, if you have diabetes, you need to work with your local physician to bring that blood sugar down into really tight control, not just sort of okay control.
Dr. Linda Austin: And how about medications like Plavix, Aggrenox, and so forth?
Dr. John Kratz: Right. They have a place, and we should understand why they’re important. There are things in your bloodstream called platelets. Platelets are, actually, even much smaller than a red blood cell. They’re job is, when you cut your finger, to swim up and plug up the hole. And then they call your clotting mechanism in to seal off the hole so you don’t bleed to death. These same platelets can stick in the arteries of your heart, on a rough spot, or a narrow spot, and call in the clotting factors, and cause a blood clot in your heart. That’s what causes a heart attack; the platelets causing a clot on top of an already narrowed area.
So, we’ve found, over the years, that things that make the platelets slippery, so that they don’t stick to the heart and cause these blood clots, prevent heart attacks. Everybody who has coronary artery disease; unless there’s a really good reason, needs to be on an aspirin a day. Aspirin causes your platelets to become slippery, and not stick together. There are a lot of drugs on the market now that work in addition to aspirin to make your platelets even more slippery. Plavix is one of the more famous ones.
As we get into these stronger drugs, they can have the side effect of bleeding. So, it’s not generally that everybody in the world who has coronary artery disease needs to be on one of these stronger, expensive, platelet inhibitors. There are certain classes of people, in certain situations, where these drugs can be terribly helpful in preventing further problems. Usually, you don’t have to take them forever, but for, perhaps, a year or so, depending on your clinical situation. So, your physician will advise you when these things are necessary in addition to the daily aspirin, which is the first line of defense.
Dr. Linda Austin: And, the punch line being that the outlook, following coronary artery bypass surgery, is far brighter than 10 or 15 years ago because of the knowledge we now have about the importance of taking these various long-term preventive measures.
Dr. John Kratz: It really is. Twenty years ago, a fellow who had a coronary bypass could look forward to more trouble in eight to ten years with his heart. Today, with the management we have available, it’s completely possible that this same patient will live 20 or 30 years before any other major interventions in his heart need to be done, which is just fantastic. We can, now, begin to think about pushing people to the point where coronary artery disease, or heart disease, is no longer an important factor in how long they’re going to live.
Dr. Linda Austin: Dr. Kratz, thank you so much for talking with us today.
Dr. John Kratz: Thank you, Linda.
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