Pumping up the heart
Healthy habits, high-tech treatments help fight coronary artery disease and keep a heart strong
Richard Bartholomew’s massive heart attack hit him out of the blue. A trim and fit 68-year-old man, he never had chest pains, never smoked and had no family history of heart disease.
But none of that mattered one Saturday last August. The day began with a leisurely breakfast with his sister at their Watertown home, but ended with emergency open-heart surgery at the Hospital of Saint Raphael.
"I was never in the hospital in my life," says Bartholomew, who’s been driving a 30-ton truck for 40 years. "I never, ever thought in my life that this would happen to me."
No one does, experts say. In fact, about 60 percent of those with heart disease don’t know they have the condition until they have a heart attack — or worse, says Thomas Donohue, M.D., section chief of cardiology at the Hospital of Saint Raphael. "About 40 percent of heart disease sufferers have a heart attack," adds Donohue, who’s board-certified in internal medicine and cardiovascular disease. "Another 20 percent die of one."
"Heart disease" is a general term that encompasses valvular disease, cardiomyopathy and coronary artery disease, which is by far the most common and most deadly form. Also called atherosclerosis, coronary artery disease occurs when fat and cholesterol build up inside the three arteries that supply the heart with oxygenated blood. As these deposits thicken over time, it gets harder for the heart to pump normally. This can lead to fluid buildup in the lungs, angina (chest pain), or a full-blown heart attack.
Since heart disease is still the nation’s No. 1 killer — about 500,000 people die of coronary artery disease each year, says the American Heart Association — chances are that you, or someone you love, may one day be in the same position as Richard Bartholomew.
Although following a healthy lifestyle is the best way to prevent heart disease, sometimes more than preventive measures are needed to keep a heart strong. Medication, or invasive procedures like angioplasty or bypass surgery, may be necessary. "But unfortunately, a lot of people don’t know much about the treatments available, or what they do, because they don’t want to have to know them," says Roger Crevier, assistant regional director of the New England Mended Hearts, Inc., a national support group for heart surgery patients.
In recognition of American Heart Month in February — and, of course, to encourage the better health of our readers and their loved ones — here’s an overview of the most common, yet sophisticated, treatments for coronary artery disease today. (Although your best source of health information is always your own physician.)
Medications
Many people are fortunate, so to speak, that their bodies give a warning sign of heart disease. This warning sign is called "angina," more commonly referred to as chest pain. It’s characterized by an aching or burning, or a sensation of pressure or squeezing, in the middle of the chest wall. In women, angina is often accompanied by nausea or shortness of breath, with pain or pressure that sits in the middle of the sternum, rather than radiating out, explains cardiologist Lisa Freed, M.D., who’s board-certified in internal medicine. Angina often flares up during exercise, in moments of stress, after a big meal, or following exposure to cold.
In many cases, angina can be relieved and managed with medication. Nitroglycerin, which dilates blood vessels, is one heart drug with which many people may be familiar. Taken under the tongue, it can subdue an angina attack within minutes. It can also be administered intravenously or through a patch on the arm.
Other heart drugs used to control blood pressure, slow the heart rate and relieve pain include beta blockers, calcium channel blockers, ACE inhibitors and IIBIIIA inhibitors. To stop a heart attack that is already under way, doctors may prescribe anti-platelet drugs alone or in combination with thrombolytic drugs, also called clot busters. And many, if not most people with heart disease, take a daily dose of aspirin, which prevents platelets from sticking inside the arteries.
"Our whole pharmaceutical war chest has gotten broader and better," says cardiologist John Chandler, M.D., who’s board-certified in internal medicine and cardiovascular disease.
Cholesterol reducers, or statins, are also important drugs for people trying to prevent heart disease, or at least stop it from getting worse. "The statins are the most powerful, most effective drugs we have today," Chandler adds. "Overwhelming data show that these drugs save lives."
Because they lower the amount of low-density lipoprotein (LDL), the so-called "bad" cholesterol, statins reduce the chance of heart attack, stroke and the need for an invasive procedure like angioplasty or bypass surgery.
Unfortunately, however, not all patients can tolerate these medications, nor is every patient even a candidate for drugs alone. In these cases, or if stable angina suddenly becomes erratic, angioplasty may be needed.
Balloon angioplasty
Angioplasty is a general term for procedures done to clear blocked blood vessels. For blocked coronary arteries, it’s common for people to have "balloon angioplasty." In fact, about 500,000 are performed each year in the United States. The first balloon angioplasty performed at Saint Raphael’s was done in September 1981 on Archie Krampitz, a 72-year-old farmer from Cheshire who was experiencing chest pain. The procedure was performed by Chandler and cardiologist Philip Fazzone, M.D., who’s board-certified in cardiology and internal medicine.
In a balloon angioplasty, a catheter with a special device and a deflated balloon on the tip is inserted into the patient’s femoral artery in the thigh, and from there is threaded up to the heart. Once the device reaches the blockage, the doctor quickly inflates the balloon, which stretches and reshapes the artery and allows blood to flow more easily. Since typically only local anesthesia is used, most patients are awake and talking throughout the procedure.
One drawback to balloon angioplasty is that in about one-third of the cases, the artery closes back up within three to six months. "You can’t look at it like it’s the pipes in your house," Donohue explains. "Your arteries are living things. They can renarrow." And when this happens, the procedure must be repeated.
That’s precisely what happened to Krampitz. When his artery clogged a second time, he had another angioplasty in January 1982. But since then, it’s been clear sailing. "I never had chest pain after the second procedure," says Krampitz, now 90, who lives with his sister on the four acres that remain of their family’s farm.
As one of the first in the state to undergo balloon angioplasty, Krampitz is believed to be the oldest surviving patient, Chandler says. And he continues to feel well. "I have a nitro patch, and take half an aspirin a day. I have a good appetite, and I get plenty of exercise," he says with a chuckle, adding that he enjoys tending his large garden.
Stents
Although the artery-renarrowing rate remains frustrating to cardiologists, they now have a tool that can make balloon angioplasty work better the first time around. That tool is a tiny metal coil, about a half-inch long, called a stent, which was approved by the federal Food and Drug Administration about five years ago.
"The biggest advance in the past 24 to 36 months has been an explosion in the use of stents," says Eugene Caracciolo, M.D., director of cardiology research at the Hospital of Saint Raphael and a practicing cardiologist. "We now use stents in about 75 percent to 80 percent of all our angioplasties."
The stent is fitted over the tip of a catheter and threaded up to a blockage during balloon angioplasty. When the balloon is inflated, the stent springs open and permanently into place within the artery wall, compressing plaque and other deposits in the process. "It acts like a scaffold," says Caracciolo, helping to keep the artery open for good. "Stenting is revolutionary because it gets at the Achilles’ heel of angioplasty, which is the renarrowing. With a stent in place, the chances for renarrowing come down to 20 percent to 30 percent."
People with extremely twisted or narrow arteries are not good candidates for stents. But aside from these cases, stents are being used with great success. "This has become the No. 1 procedure for coronary artery disease," says Caracciolo, who’s board-certified in internal medicine and cardiology.
Other forms of angioplasty
In very rare cases, doctors may recommend one of a variety of other types of angioplasty (all of which are done at Saint Raphael’s), which employ several different devices at the tip of the catheter. "These are really niche procedures," explains Caracciolo. They include the following:
n Rotational, or rotoblator, atherectomy, in which a special diamond-tipped burr, or shaver, spinning at about 200,000 revolutions per second (twice as fast as a dentist’s drill) pulverizes the arterial plaque, which is then washed away by the bloodstream;
n Directional atherectomy (DCA), which shaves deposits off an artery wall and then stores the shavings in the nose of the device being used, until it is taken back out; and
n Extractional atherectomy, in which a blood clot can be sucked from a large vessel.
Once doctors stopped Bartholomew’s heart attack on that Saturday afternoon last August, they discovered what caused it: Plaque had completely closed off two of his three coronary arteries, and the third was 96 percent blocked. They immediately scheduled him for an open-heart surgery called "coronary artery bypass graft." (A procedure often referred to as CABG, or "cabbage.")
Bartholomew’s bypass operation was one of about 500,000 performed across the country last year on patients for whom medications or angioplasty would not have been enough. Typically, these are people with several blocked arteries, an obstruction in the left main artery, or a damaged heart.
Although bypass surgery occurs as often as angioplasty, it is much more complex. Patients are under general anesthesia, which carries its own risks. In most cases, their hearts are stopped during surgery and they rely on a heart-lung machine, or "pumper," while the surgeon works on the heart. Then, the heart must be started again.
As its name suggests, bypass surgery involves the creation of a detour, or bypass, around a blockage in an artery. The surgeon takes a vein or an artery from another part of the body and grafts it onto the heart artery that’s clogged. Usually, the internal mammary artery, which runs down the middle of the chest, is used. Others commonly used are the radial artery from the forearm, or the saphenous vein from the leg.
"The mammary artery is really preferred; it’s a wonderful conduit," explains Donohue, adding that veins degenerate more quickly because they cannot withstand the relatively intense pressure of blood coursing in and out of the heart. Since most people have at least three (and usually four or five) bypasses done at one time, doctors must sometimes resort to using veins.
Barring complications, most bypass patients go home within four to five days of the operation. "This is an incredibly oft-performed procedure, and for people in their 60s, the mortality rate is less than 1 percent" says Donohue. "The most common complaint is pain — not in the chest area, but from the leg where they got the vein."
Remarkably, there is now a way for some patients to recover from bypass surgery even more quickly. And that is by having the operation done on their heart while it is still beating. Vasant Khachane, M.D., section chief of cardiothoracic surgery at Saint Raphael’s, was one of the first surgeons in Connecticut to perform this revolutionary procedure, which is called "beating heart bypass." In fact, he has performed almost half of all the beating heart bypass surgeries done in Connecticut during the last 12 months.
In this operation, the patient is not put on the heart-lung machine. Instead, the surgery is performed with special instruments that allow the heart to keep beating. While it is undeniably trickier for a doctor to work on a beating organ, the benefits to patients are clear: less anesthesia, fewer blood transfusions, fewer medications, a much smaller chance of complications and a shorter recovery time. "It offers nothing but positives," says Khachane, who’s board-certified in cardiothoracic and vascular surgery.
For patients like Tony Anastasio of Bethany, who had a beating heart bypass at Saint Raphael’s, technological and medical advances like this mean the world. "There’s something calming about the fact that your heart will never stop beating in this operation," he says.
Although Bartholomew’s bypass was the traditional type, he is no less grateful for the procedure that mended both his heart and his life. "It’s like a miracle," he says. "I feel real good now. I walk two miles a day, around the track at a local school, and I can really feel the difference. I’m on the road to recovery."
Sidebars:
Stop heart disease before it starts
It’s a conundrum worthy of the game show "Jeopardy." We all know the answer: The best way to prevent heart disease is to change behavior. Specifically: Quit smoking, reduce cholesterol, lose weight and start exercising. So, the real question isn’t "How can heart disease be avoided?" But rather, "Why don’t more people do it?"
"There are so many people out there with obvious risk factors who aren’t taking care of themselves," says Eugene Caracciolo, M.D., director of cardiology research at the Hospital of Saint Raphael. "But how do I convince you, if you don’t feel bad, to do something you don’t want to do, like modify your diet or possibly take medication? This is a tremendous public health problem. The cure is seen as worse than the condition itself."
"It’s very frustrating," agrees Thomas Donohue, M.D., section chief of cardiology at the Hospital of Saint Raphael. "Half the people in this country die of cardiovascular disease. But it’s still very hard to get through. If people feel well, it’s hard to get them to change their lifestyle."
Granted, there are certain risk factors, such as a strong family history of heart disease, about which absolutely nothing can be done. But most of the others — including smoking, high blood pressure, high cholesterol and being overweight and sedentary — are completely controllable.
"The main thing people can do to prevent heart disease is not smoke," Donohue stresses. "You can’t fix your genes. But smoking is a purely voluntary thing. Not smoking has a tremendous impact on preventing heart disease."
"Limiting the amount of fats we eat each day is also tremendously beneficial," adds Caracciolo. "Diet and exercise are the cornerstones."
One myth about heart patients is that they aren’t supposed to move, that they should be resting all the time, explains Donohue. But just the opposite is true — under a doctor’s supervision, of course. "In my experience, when folks move, when they begin to exercise, they have remarkable improvement," he says. This doesn’t mean people should begin lifting weights or training for a marathon. But taking a 20-minute walk, swimming a lap or two at the YMCA or bicycling around your neighborhood can do a world of good.
"Anything’s better than nothing," Donohue says. "I don’t think people should be satisfied with just anything. But doing anything is better than lying on the couch, eating Doritos and watching TV.
"Exercise is unbelievable," he concludes. "When you exercise, everything is easier to manage — diabetes, blood pressure, weight, and the list goes on. For the 20 minutes you might put in, you get an awful lot out on the back end."
Did you know?
As a leader in cardiac care, the Hospital of Saint Raphael is:
- Ranked as one of the "100 Top Hospitals" in the U.S. for cardiac bypass surgery by HCIA, Inc., a Baltimore-based healthcare provider consulting practice that rates hospitals nationwide.
- Ranked 38th nationwide by U.S. News and World Report as one of "America’s Best Hospitals" for cardiology and heart surgery.
- A pioneer of many cardiac procedures, including beating heart bypass surgery and endoscopic vein harvesting.
- Home to one of the most technologically sophisticated cardiothoracic intensive care units in the state.
- Sponsor of one of the only cardiac rehabilitation programs in the area, TakeHeart, which assists those recovering from heart disease and other cardiac problems, as well as the All Heart Club support group and referral service for cardiac patients. Both can be reached by calling (203) 789-3325.
Pioneering procedure helps eliminate pain
One of the ironic things about traditional heart bypass surgery — a major operation that requires surgeons to crack open a patient’s chest — is that the worst pain during recovery is not near the heart, but in the leg from which the doctors take the vein used for the graft.
But thanks to a procedure called "endoscopic vein harvesting," this pain has been greatly reduced in many patients. The technique is being pioneered at Saint Raphael’s by cardiothoracic surgeon Richard Shaw, M.D., who is board-certified in cardiothoracic surgery.
Until now, Shaw says, leg veins were always removed for use in bypass surgery through the "open technique," which requires an incision that often extends from the groin to the ankle and can leave a patient vulnerable to incision-related complications. "A significant number would become infected, and there would be a lot of swelling and discomfort, especially around the knee," Shaw explains. "We would also see a lot of circulation problems, especially in people with peripheral vascular disease."
With the new procedure, there is only a tiny, 2-centimeter incision near the knee. The doctor inserts a small endoscope (a long rod with a clear tip) into that incision, and with the help of an optical instrument isolates the vein to be harvested. After dividing the branches of that vein, the doctor makes another incision in the groin, only 3 or 4 millimeters long, and pulls out the vein.
Sterile strips are then used to close the groin incision, with dissolving stitches and gauze to close near the knee. "The great benefit to patients is that there is virtually no pain, and no complications. We often ask them, after their surgery, if they know where we got the vein we used — and they say no," Shaw adds. "This procedure allows us to harvest veins well, with minimal trauma to the vein, and all the benefits to the patient. The end result is that patients do great."