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Melanie Cole (Host): Coronary artery disease is one of the most prevalent, serious, progressive conditions in the population. It is the basis for many heart attacks and heart disease. My guest today is Dr. Adam Levine. He’s an interventional cardiologist at Lourdes Health System. Welcome to the show, Dr. Levine. What is coronary heart disease?

Dr. Adam Levine (Guest): Thanks for having me on the show. Coronary heart disease can be multiple different entities, but specifically coronary artery disease, which is what I’m seeing the majority of the time, which is blockages of the arteries that feed blood to the heart muscle itself.

Melanie: So who’s at risk for coronary artery disease?

Dr. Levine: Patients at risk – definitely tobacco abuse is the number one reversible risk factor in the country. However, there’s definitely other risks including diabetes, high blood pressure, high cholesterol, as well as obesity.

Melanie: So if people have these risk factors, are there any tests that would find coronary artery disease? Is it something they would know that they have?

Dr. Levine: A lot of it is driven based on your symptoms. The testing for coronary artery disease, which classically is the stress test, shows severe plaque buildup typically of the heart, but stress tests aren’t given to the whole population, so, therefore, symptoms such as chest pain or pressure, shortness of breath, or very bad sweating, things along those lines – sometimes bad fatigue – can lead your doctor to want to order a stress test to assess for coronary artery disease.

Melanie: Is there any part of the population that would have a stress test just as a matter of course?

Dr. Levine: A lot of patients prior to surgeries would have stress tests done as a risk predictor for surgery, however, even in the diabetic population, which is the highest risk population, routine stress testing has kind of gone away.

Melanie: So what about blood tests? Would they show anything? If people get their annual physical and they get a CRP, or they have their cholesterol checked, any of these numbers, would that contribute or let somebody know that they might be at higher risk?

Dr. Levine: That’s a great question. Definitely, cholesterol has been the mainstay of blood testing and if your cholesterol is elevated, medications to bring it down to reduce your risk. The high sensitivity CRP has been a great tool for a lot of us, and when it is elevated we know, we need to be very aggressive with that patient to reduce their risk of having heart attacks in the future. There’s a lot of other tests out there like lipoproteins and whatnot, but not as much data – the CRP has been a great tool to help us identify people at high risk.

Melanie: So if you do identify somebody or you diagnose that they do have coronary artery disease, then what do you do for them? What’s the first line of defense?

Dr. Levine: Most of the time, the first line of defense is medication, so we’re going to use medicine to reduce blood pressure, reduce cholesterol and reduce the strain on someone’s heart with a beta blocker. Aspirin therapy is recommended to reduce the risk of heart attack. If the patient is symptomatic, meaning they’re having a lot of the symptoms of chest discomfort or severe fatigue, then heart catheterization where we look at the arteries that supply blood to the heart with X-ray and contrast dye would then be done to assess how severe and what the further therapy would need to be.

Melanie: Tell us about that catheterization. What are you doing in that type of procedure, Dr. Levine?

Dr. Levine: The patient would have anesthesia -- although not general anesthesia, so would be made comfortable – and then the catheter can either go through the wrist or through the groin artery, up to the heart, and injections of contrast dye and pictures with an X-ray machine to look at how narrow or how much plaque buildup is in the arteries.

Typically, there’s three outcomes after a heart catheterization. Either there’s very little plaque buildup, or plaque buildup only needing medications, then plaque buildup requiring a stent, which is a piece of metal to open up the plaque, and then the worst case scenario would be the need for bypass surgery – open-heart surgery.

Melanie: Now, I want to jump back just a minute, Dr. Levine, you mentioned aspirin. People have a lot of questions about should they be taking a prophylactic aspirin? What do you recommend to people and if they’re not at high risk, do you recommend people of a certain age take an aspirin a day?

Dr. Levine: Definitely risk factors play a big role so people that are at higher risk should be on, and baby aspirin would suffice – the 81mg or low-dose aspirin would be enough for most of the patients. Patients at low risk, then – if every patient at low risk was taking aspirin, they would increase their risk for potential bleeding with aspirin, so that’s not typically recommended. Really, the higher risk population like diabetics, high blood pressure, known coronary artery disease, the peripheral vascular disease would be a definite need for aspirin. That’s been shown to reduce heart attacks in those appetites

Melanie: And what about cholesterol medications? If somebody is at a higher risk of atherosclerosis, coronary artery disease or as you mentioned, peripheral vascular disease, are we keeping pretty close track of their cholesterol?

Dr. Levine: Yes, there should be – after the first visit if the cholesterol is elevated, the institution of medications to reduce it and then follow-up testing to make sure that the drugs are working and there’s no side-effects. As long as that’s the case, then routine blood tests usually every six months to check on the progress.

Melanie: So then what about exercise or cardiac rehab if you’ve identified this person as high risk? What do you recommend for people? Can this be reversed if you do identify it?

Dr. Levine: Typically, not reversed, but stabilized, so the lack of progression is the key, but diet and exercise is the best therapy over medicines to reduce heart attacks and strokes going forward in that population. Diet is just as important as exercise, but exercise is typically three to four times a week in 30-minute intervals of a cardiac-type exercise like walking or running.

Melanie: If somebody does have coronary artery disease, what do you tell them about living with it and managing it and if they have something like peripheral vascular disease, sometimes even exercise can be a limiting factor – pain in the legs – and so for them it might be hard to exercise, but yet they want to to help to keep that blood flow. What do you tell them about some of these things?

Dr. Levine: For the peripheral vascular patients specifically, exercise is also a therapy for peripheral vascular disease, so trying to increase the amount of exercise you can do by pushing yourself a little further each day or muscle-type conditioning exercise can really improve the distance that those patients can walk and at the same time will also improve their cardiac health.

Melanie: So then give us your best advice about prevention. You mentioned healthy lifestyle and eating, but tell people what you want them to eat, what you want them to steer clear of. Give them some of your best prevention advice.

Dr. Levine: For prevention from the dietary perspective, I usually recommend the Mediterranean diet, which is a low-carbohydrate-type diet, as well as a low saturated fat diet, so more lean meats like chicken and fish and trying to stay away from the beef and prime ribs. On top of that, we know that white bread and heavy carbohydrate sugars and soft drinks are really wasted calories and only going to make things worse so staying on a low carb and plenty of fruits and vegetables. Really no restrictions in that realm and even one glass of red wine a day is even recommended.

Melanie: And then what about some of the other things that you might want to tell them like stress-related – does stress contribute to coronary artery disease?

Dr. Levine: Stress can contribute to overall heart attacks, and there’s actually a stress-induced heart attack that can occur, so you do want to try to reduce stress. Stress is a source of inflammation in the whole body, so if you can – I can’t tell people to quit their jobs, but you should reduce the stress as best you can.

Melanie: Now give us some heart attack warning signs. If somebody does know that they have coronary artery disease, atherosclerosis, or peripheral vascular disease, any of this kind of coronary heart diseases and they’re worried about actually having a heart attack, just go through a few red flags that you would want them to know about and even for women that may be a little different than men.

Dr. Levine: So the women and diabetics definitely do not have the classic signs. The classic heart attack signs are chest pressure, like an elephant sitting on your chest with potential shortness of breath or frank sweating out of nowhere, cold sweats. For women and diabetics, they typically don’t get that classic symptom. Women may have jaw or tooth pain, maybe shoulder pain, left arm pain or numbness is common. Those may be signs of heart attack in that population, especially if they’re not going away, as well as with exercise. Exercise—induced discomfort of these types is definitely a sign that there may be something wrong.

Melanie: So is there anything you’d like to add to tell listeners about coronary artery disease, heart disease in general, Dr. Levine, as a cardiologist that you tell people every day and that you really want the listeners to hear?

Dr. Levine: The way to prevent heart disease and heart attacks is by eating well, exercising, no smoking – smoking is again, the number one reversible risk factor and I see a lot of patients that smoke. The worst thing you could do as a diabetic is to smoke. If you do have diabetes, make sure you’re watching your diet, watching your blood sugar, and are on the correct medications. Make sure you visit your doctors to make sure that they’ve checked your cholesterol and blood pressure to keep you on the straight path.

Melanie: That’s great advice and so important for listeners to hear. Thank you, so much, Dr. Levine, for being with us today. You’re listening to Lourdes Health Talk, and for more information, you can go to LourdesNet.org, that’s LourdesNet.org. This is Melanie Cole. Thanks, so much, for listening.