The 5 Signs of Heart Attack and What to Do

1) Chest pain or discomfort;
2) Pain or discomfort in the jaw, neck or back;
3) Feeling weak, lightheaded, or faint;
4) Pain or discomfort in the arms or shoulder;
5) Shortness of breath.

Additional Signs, Particularly Common Among Women

1) Shoulder or neck pain,
2) Stomach upset,
3) Unusual tiredness.

WHAT TO DO: Call for emergency medical help immediately. Do not wait. Do not drive yourself or have your family drive you. Call 9-1-1. In a heart attack, every second counts!

In looking back at my term as President of the Society for Cardiovascular Angiography and Interventions (SCAI), I cannot help but ponder how far we have come in this field — and how far we have yet to go. We have made great advances in stopping heart attacks, especially with the development and continued improvements of the stent, which props open blocked arteries after they have been reopened by angioplasty. From the introduction of angioplasty 30 years ago to the bright prospects for the bioabsorbable stent and the non-surgical treatment of structural heart disease, we see interventional cardiology getting better and better at improving health and saving lives.

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There is increasing evidence that we can do to strokes what we’ve done to heart attacks — stop them in their tracks. Just as it has been proven that angioplasty and stents can open and keep open major blood vessels near the heart, more research is showing they can do the same for the major blood vessels in the neck called carotid arteries. A long-term study called SAPPHIRE recently published in the New England Journal of Medicine shows carotid artery stenting is an effective option for high-risk patients who are at high risk or otherwise not eligible for surgery.

Carotid artery disease (CAD) may not be that well known among the general public, but it is a significant risk factor for stroke. CAD occurs when the arteries in the neck that provide blood to the brain become clogged. When there is no blood flow to the brain, strokes may occur.

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We sometimes tend to over-react to the early test results on promising new procedures, either becoming too excited when results are positive or too disappointed when results are neutral or negative.

 So when we hear, as we did last month at the SCAI Annual Scientific Sessions in Partnership with ACCi2 Summit (SCAI-ACCi2) in Chicago, that when a small number of patients with narrowed kidney arteries were studied and responded no better to treatment by angioplasty and stent plus medication than they did to drug therapy alone after only one year, we need to put that information in perspective.

 The study, called ASTRAL (Angioplasty and Stenting for Renal Artery Lesions), was one of the largest studies so far to look at renal (kidney) stents. It showed that the implantation of stents – tiny wire mesh devices inside blood vessels that work like a scaffolding to prop open blockages – successfully opened kidney (or renal) arteries blocked by cholesterol and fatty plaques. But after a year, patients with the renal stents showed the same levels of kidney failure, blood pressure control and major heart disease as a comparison group treated with drugs, but not stents. Importantly, the patients who received stents did not have worsening of their kidney function.

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As an interventional cardiologist and the current president of the Society for Cardiovascular Angiography and Interventions (SCAI), it doesn’t get much more exciting than our annual meeting, which is set to begin this Saturday in Chicago. This year, SCAI will combine its Annual Scientific Sessions with the American College of Cardiology’s (ACC) Innovation in Intervention: i2 Summit, in a single combined meeting also called SCAI-ACCi2.

 While the annual meeting is always a thrill for me and many of my colleagues, patients can be excited about what it has to offer as well. The goal of our meeting is to help physicians learn about new treatments and how to improve existing therapies for heart disease, helping them to deliver optimal care to their patients. We come away from this meeting with the latest information on how to apply break-through techniques and data in our daily care of patients whose lives and well-being may be seriously jeopardized by heart disease.

 I encourage you to return regularly to Seconds-Count.org, both on this blog and in the “Latest News,” section, as we’ll be working hard to deliver the important news from the meeting and analyze, interpret, and contextualize it for you in lay terms. We often hear about a “new study” on the evening news, but so often a 60-second segment leaves us worried, bewildered, frustrated, or confused. We’re trying to change that by offering you another way to hear the news – straight from interventional cardiologists.

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As a guest blogger and the Immediate Past President of the Society for Cardiovascular Angiography and Interventions (SCAI), I believe this is one of the most critical and contentious issues looming today. The safety of percutaneous coronary intervention (PCI) in hospitals not equipped for cardiac surgery has been hotly debated for years.  

Those of you in the health care community may already know about the ongoing debate around this issue, but for those of you who are heart patients, this may be the first you are hearing of it.

 PCI is a therapeutic medical procedure performed by threading a catheter through a main artery to unclog a clogged blood vessel. PCI is less invasive than bypass surgery, a major operation that involves opening up the chest, stopping the heart from beating, and using the heart-lung machine to sustain life during the bypass. 

 The safety of performing PCI has improved dramatically since the procedure was introduced just over 30 years ago. Today, only two to three PCI patients out of every 1,000 experience a complication during PCI that requires an emergency bypass operation.  Since this is an “emergency,” some believe that all centers performing PCI should have cardiac surgery “on-site” so the operation can be performed as quickly as possible,  moving the patient from the cath lab (where PCI is performed) to the operating room (OR) in the same facility. That makes perfect sense, if the OR is held open and ready to accept such a patient if the need develops. However, in part because this so rarely happens, ORs are no longer “held open” and the rare emergency patient is usually stabilized and waits for the next available OR and cardiac surgeon. In reality, that can take as much as 60 and even 90 minutes if the ORs are occupied and all of the heart surgeons are busy operating. Since patients nowadays frequently have to wait some time before actually going to the OR, those in favor of PCI without on-site surgery have argued that it takes no longer to transfer an emergency patient to a surgical hospital, where they can go to the OR directly upon their arrival because the cardiologist has called ahead. If only lower-risk patients have PCI at facilities without on-site surgery, then the risk should be even lower than 2-3 per 1000. 

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All the talk and confusion about the relative benefits of cholesterol-lowering drugs is enough to, well, raise my blood pressure. 

Recent studies seem to create doubt about whether drugs that lower bad cholesterol (LDL) offer a net clinical benefit for those at low risk or for women. For my part, I would be very careful about reading too much into those studies.

 First, in attempt to sort through the confusion, it’s important to remember a few points that are not at issue:

• There is no debate that if you are at high risk for heart or vascular disease, you should be on cholesterol-lowering drugs like statins. High-risk patients include those who had a prior event, (such as a stroke or heart attack), have diabetes, or have pain in your legs due to blockages (the presence of peripheral artery disease, also known as PAD).
• When it comes to lowering risks, doctors agree that they want all heart and vascular patients to take the very first step of lifestyle changes. This means you need to stop smoking and get exercise every day. You should also change your diet and achieve your ideal body weight. That said, there is irrefutable research to show that lowering LDL cholesterol reduces your risk for asubsequent adverse event. There is also solid evidence that there are other steps you can take, such as taking statins, to lower your risk.
• Most important of all is this: If you have any questions about statins or other drugs you are taking for your heart, you should always talk to your doctor, preferably your heart specialist. Moreover, never stop taking a prescribed medication without first consulting with your heart specialist.

The recent study – ENHANCE – that sparked much of the discussion looked at a cholesterol-lowering drug called Vytorin that combines a statin called Zocor (its generic name is simvastatin) and a non-statin called Zetia (or ezetamibe) into one pill. The study finds that Vytorin was no better than Zocor alone in keeping fatty plaque from building up in the arteries in the neck – which is associated with elevating the risk for heart attack and other adverse events. Read all »

As interventional cardiologists, my colleagues and I frequently prescribe what are known as anti-platelet medications to cardiovascular patients. Anti-platelet medications are frequently given to patients to help prevent blood clots from forming in the arteries we are working to keep open. These anti-platelet medications are especially important when a patient has received a stent, but they are also important for patients who are being treated with a regimen of medications-only and in some patients with other artery diseases such as narrowing in the carotid arteries (arteries to the brain). The most commonly used anti-platelet medication, other than aspirin, is called clopidogrel (or Plavix). It was the focus of a study published this week in the Journal of the American Medical Association (JAMA). 

 In our field, there is ongoing discussion about how long patients need to take an anti-platelet medication after it is prescribed. The common thinking is that no less than one year is the most appropriate amount of time, to maximize each patient’s chances of avoiding formation of clots. Regardless of this length of time, however, it is of utmost importance that patients taking anti-platelet therapy do not stop taking the medication prescribed to them without first discussing doing so with their doctor.  Read all »

It’s one thing for media reports to inadvertently spread confusion based on highly scientific, complex reports and conflicting experts. It’s quite another to spread fear and distrust based on lopsided reporting derived upon unsubstantiated and misleading information.

One such example was published on MSNBC.com on Tuesday, January 29: “Conveyor-belt cardiology puts profits first,” by Robert Bazell, NBC’s chief science and health correspondent. The story’s sub-headline reads: “In the battle of stents vs. bypass surgery, the best care may be neither.”

In his latest story, Bazell cites an anecdotal example of Miami doctors bragging about implanting stents “knowing full well it was unnecessary.” He says he “overheard” the doctors while he was in “incognito” (dressed in scrubs). The implication was that the conversation he heard was common among physicians when no one else was around. We don’t know what the rest of the conversation was. Nor do we know the context of what he supposedly heard. He acknowledges these interventional cardiologists are the exception, that most interventional cardiologists are “honest and caring.” If he really believes this of interventional cardiologists, why even mention this event?

Bazell makes another accusation that disturbs me even more because he claims it is a common practice. He writes that “all too often” interventional cardiologists urge “lightly sedated patients” to have an immediate angioplasty, allowing “no opportunity for the patient to weigh other options; no chance for a second opinion.”

This is flat-out wrong. Informed consent is at the center of how we practice. Patients who undergo angioplasty have been thoroughly briefed by the interventional cardiologist, and have given their consent before they are sedated and tested. For patients in non-emergency situations, this frequently occurs in the doctor’s office. In more acute settings, physicians still explain what they are recommending to the patient (or his or family members) and obtain consent prior to any invasive diagnostic procedure or medications. This is standard practice and is done because once the interventional cardiologist sees the results of the diagnostic procedure, it may make the most sense to proceed directly with an intervention in the best interest of the patient. Even with prior consent, interventional cardiologists may stop after the diagnostic procedure to go over their options once again in a more specific manner based on the additional information provided by the angiogram, particularly if the decisions or risks are not straighforward. Bazell, in his reporting, does not tell his Web readers of this important informed consent process, instead distorting the reality of patient care . Read all »

A story in the New York Times on Jan. 21 about an upcoming article in the American Journal of Therapeutics on the use of peripheral stents – stents used in the arms and legs, primarily – was alarming to some patients who have received stents in their peripheral arteries. The story talked about “off-label” use of peripheral stents. If you are patient who has received a stent and wonder if it was “off-label,” the first thing you should know is that you do not need to be alarmed or afraid.  Following the New York Times story, many physicians like me received numerous calls from patients wondering if “off-label” meant the stents they received were unsafe, or even illegal. I’d like to explain what “off-label” means and why doctors often choose to use medications, devices, and treatments “off-label” to achieve the best outcomes for our patients.

 Let me start by stressing that I, like all of my colleagues, want my patients to get the best results from my care. That is the goal of every aspect of the care we provide and it is fundamental to understanding why “off-label” treatments are used thousands of times every day.

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If you are a cardiovascular patient, you can rest assured that there is no lack of research being done on the various therapies available to you! Just this week, two studies focused on drug-eluting stents and an accompanying commentary piece on the findings appeared in the New England Journal of Medicine. Like other recent cardiovascular research, these two studies have received a good amount of media coverage, and justifiably so – cardiovascular disease is the number one cause of death in America and the treatments used in these studies are performed on millions of our patients each year. Just as patients are always on the look-out for news related to their condition, physicians are always eager to have solid research to help us provide the best possible patient care.

Here is my take on the two studies publicized this week. If you are interested in learning more about them, we’ve posted some additional information in Latest News.

Drug-eluting stents are just as safe and are significantly more effective than bare metal stents, particularly in sicker patients. Although patients have improved results with drug-eluting stents, patients with two or more blocked arteries appear to do somewhat better with a major surgical operation on the heart called a coronary artery bypass graft (many of you know it simply as “bypass surgery”). It is important that you realize this comes from the early experience with drug-eluting stents and, like many other similar studies, the results may be reversed as we look further into this issue. Despite this issue, in these studies, patients who have diabetes did not show this difference and may, therefore, do even better than we expected with stents.

Considering the two studies together, I’ve come to a broader, and perhaps more basic conclusion: At a time when communication is often on overload and information to guide our decision making is seemingly everywhere, so-called ‘old-fashioned’ face-to-face conversation between patient and doctor results in the best outcomes and the most satisfaction for patients. As you’re viewing health reports on the medical news or reading the headlines in your newspaper of choice, I’d ask you to keep this in mind – the best reason to be a well-informed patient is that you’ll be ready to ask your doctor good questions and you’ll more likely to feel good about the answers and the treatment you receive.