Lowell Satler, M.D. and Ron Waksman, M.D.
Director of Interventional Cardiology and Associate Director of Cardiology, Washington Hospital Center
Friday, February 12, 2010; 2:00 PM
Former president Bill Clinton was released Friday morning from a New York hospital, where he stayed overnight after doctors inserted two stents into a clogged coronary artery after he complained of chest pains. The one-hour procedure went smoothly, according to his cardiologist.
Clinton underwent the procedure at the same hospital where he underwent quadruple heart bypass surgery in 2004. The former president had recurring episodes of chest pain over the past several days, a Clinton aide said, and he could have suffered a heart attack if the condition had gone untreated.
Lowell Satler, M.D., director of Interventional Cardiology at Washington Hospital Center and Ron Waksman, M.D., also with the hospital, were online Friday, Feb. 12, at 2 p.m. ET to discuss Bill Clinton's medical condition and coronary heart disease.
Lowell Satler, M.D.: Welcome to a discussion regarding coronary heart disease. My name is Dr. Lowell Satler and I am the Director of Interventional Cardiology at the Washington Hospital Center. We perform over 4500 angioplasties with stents as well as 2000 open heart procedures each year. I will be happy to discuss these procedures as they relate to the recent problems of former President Clinton.
Kansas City, Mo.: Dr Satler - I am three years out from a 5X CABG and doing great (after an initial graft failure and another MI plus stents) What are the 2-3 most important things I can do to try to maintain the integrity of these grafts? My cardiologist only performs a nuclear stress test once a year now. Is this the most appropriate testing if one is asymptomatic? Thanks for your time -- we CABG patients love our cardiologists.
Lowell Satler, M.D.: 1. It is important to continue strict risk factor modification, including blood pressure control, abstinence from smoking, eating properly, and exercising daily.
2. Optimal medical therapy is equally important and includes the use of cholesterol lowering medications, beta-blockers, and aspirin.
Chevy Chase, Md.: How long will a stent be effective? (I had one put in 5 years ago -- I am 71), and how long should you take Plavix after the stent put in?
Lowell Satler, M.D.: After the 1st nine months, if you have been stable, the likelihood of a problem occurring in the stented segment is extremely low. It is important, however, to continue life-style modifications combined with medical therapy to prevent the progression of blockages occurring in other segments of the heart arteries.
Clopidogrel (Plavix)is generally recommended only for the 1st year after a new stent has been placed. Studies are in progress to determine if the extended use of the drug is beneficial.
Arlington, Va.: At what age should someone start getting regular physical checkups by a doctor for detecting early onset of heart disease?
Lowell Satler, M.D.: The need to evaluate for coronary heart disease is related to an individual's risk factors. If someone has diabetes, smokes, has hypertension, has elevated cholesterol, or a family history of premature heart disease, an early evaluation is warranted.
Henderson, Nev.: Atrial fibrillation greatly increases the risk of stroke. I take 5 mg Warfarin and 5 mg Bystolic per day. Does this significantly reduce the risk?
Lowell Satler, M.D.: Coumadin is the most effective anti-coagulant to reduce the risk of stroke in patients with atrial fibrillation. Blood pressure control is additionally imperative.
White Plains, N.Y.: Do we know the long-term benefits of stenting, since it's a relatively new treatment compared to CABG? Can you live a normal and fairly active life with a stent...and possibly even drop your required medication after a while?
Lowell Satler, M.D.: Effective treatments for coronary artery disease include medications, coronary stenting, and CABG. The selection of the treatment is based on a combination of a individual's symptoms, stress test, age, and coronary anatomy.
Once coronary disease has been identified, patient's will benefit from medical therapy indefinitely. When medical therapy is ineffective, coronary stenting or CABG are often recommended based on the location and severity of the blockages. Both coronary stenting and CABG will often allow one to return to a normal and active life.
Glen Burnie, Md.: Dr, Satler -- What is your experience with incidence of continued coronary disease affecting bypass vessels, even though diet, exercise and blood pressure along with cholesterol levels are maintained at recommended ideal levels? Does genetics trump all precautions and life style?
Lowell Satler, M.D.: With good medical therapy, it is often possible to prevent the progression of blockages in both the bypass grafts as well as in the patient's own coronary arteries.
The impact of genetics is important, but is only one of several factors involved with long-term outcome. One should not use this as an excuse to avoid modifying other risk factors.
Owings, Md.: I received a stent two years ago at WHC. My concern is: how do I know when a chest pain is serious? Like most my age, I have occasional indigestion, muscle aches, etc. Is there any definitive symptom I need to watch for to know when to declare and emergency?
Lowell Satler, M.D.: The symptoms of coronary disease include chest pain, shortness of breath, unexplained fatigue, arm pain, and/or jaw pain. Physicians become particularly concerned when these symptoms increase in frequency with minimal activity or occur at rest or night-time. When one is uncertain, it always best to be seen by your health-care provider. When these symptoms are sustained, a more urgent evaluation is necessary.
New Orleans, La.: Was it a drug emoting stent that was inserted? What are the risks?
Lowell Satler, M.D.: There are two different types of stents:
1. Bare metal
The 1st generation of stents were bare metal. These stents improved outcomes compared to balloon angioplasty but were associated with a chance of renarrowing. In order to reduce the incidence of renarrowing, the stents were re-designed to deliver a drug to suppress inflammation.
The risk of the stent after implantation include the renarrowing as well as closure. Aspirin and Plavix are useful to prevent closure.
washingtonpost.com: Dr. Satler has to leave now and we are awaiting another heart specialist from Washington Hospital Center to continue with the chat. Please stand by.
Washington, D.C.: Insertion of stents has become almost an outpatient procedure? Is this safe?
Ron Waksman, M.D.: Hi, This is Dr. Ron Waksman, associate director of cardiology at Washington Hospital Center. Dr. Satler had to take care of patients.
washingtonpost.com: Ron Waksman, M.D., associate director of Cardiology at Washington Hospital Center, will continue with the discussion.
Huntington, W.Va.: What are the dangers of cognitive dysfunction associated with coronary bypass surgery? Do you think heart patients are made sufficiently aware of these dangers as well as the alternative therapies related to diet and lifestyle that might allow them to avoid surgery?
Ron Waksman, M.D.: With CABG stroke rates are low around 1%.
Cognitive impairment is usually transient.
Stents are an alternative but for multivessel disease CABG is still the preferred strategy of revascularization.
Cabin John, Md.: Heart disease reversal is possible. I have read about it and seen it with a friend. Have you ever known anyone to get rid of blockages, lower cholesterol below 150, and get rid of angina?
Ron Waksman, M.D.: Reversal is rar.e Aggressive lipid management can prevent progression of disease.
Washington, D.C.: Is there any merit to the idea of using fish oil supplements as a tool in the fight against heart disease?
Ron Waksman M.D.: It can help on the prevention side to certain population but improving the lipid profile.
Washington, D.C.: Recent research shows that greater awareness is needed of heart disease as it relates to women. For example, heart disease may occur later in life and may present with different symptoms than men. Is there merit to this?
Ron Waksman, M.D.: There is a lack of awareness to heart disease in women. Watch the video: Women at Risk.
Manassas, Va.: Can the graft sites weaken the aorta?
Ron Waksman, M.D.: No.
Huntington, W.Va.: Is "coronary stenting" the same as "angioplasty"? If so, has it really shown to be effective at reducing mortality?
Ron Waksman, M.D.: Not much in reduction of mortality mainly, reduction in chest pain (angina).
Boston, Mass.: I have a 100 percent clogged artery near where it exits the heart. Fortunately, I developed collaterals that prevented a heart attack. What is the life span of these collaterals? Is a bypass in my future?
Ron Waksman, M.D.: Colatterals can be helpful and avoid the need for bypass. Need to check with your cardiologist with a stress test to see if there are sufficient to alleviate ischemia.
Washington, D.C.: What's CABG?
Ron Waksman, M.D.: Coronary artery bypass grafting.
Taking a vein form the leg or artery from the chest to bypass the blockage in the native artery.
Washington, D.C.: I'm a 53-year-old female with a family history of heart disease. My GP recommends an arterial scan. Is this an effective tool? What exactly can it show?
Ron Waksman, M.D.: Prefer stress test.
Bethesda, Md.: Is cholesterol consumption related to heart disease? How much impact would totally removing cholesterol from your diet have? Thank you!
Ron Waksman, M.D.: Avoiding cholesterol can halt the progression of the disease.
Ron Waksman, M.D.: We have lots of patients to take care of so we need to go. Thank you for your interest.
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