Despite many significant advances, heart disease is still the leading cause of death among men and women. Cardiovascular disease and its management can be complicated, and as a result, lends to common misconceptions.
In talking with patients, the most common heart-related misunderstanding is the impact of “blockages.” With rare exception, a patient’s response to learning of a blockage is intense fear and a sense of impending doom. The typical reaction is to emphatically focus on opening the blockage, somewhat akin to the saying: “If it’s broken, it should be fixed.” But that is not necessarily true.
The hard part is trying to explain to a patient that, even if there is a 50 percent blockage in your artery, we are not going to do anything as extreme as stents or surgery. In this setting, there are two important facts to consider: 1) there are no clinical data that demonstrate a benefit to opening this degree of blockage and 2) in the absence of benefit, such a procedure can only cause harm. For example, stents can clog; they are foreign objects, so your body can have an adverse reaction to them. Even if we were to find a patient with a 70 percent blockage, we probably would treat that with medication, unless we believe symptoms are definitely related to the blockage and would improve with stents.
We know that for the majority of patients with stable heart disease, the true lifesavers are not stents and bypass procedures. They are healthy lifestyles and medications, if indicated. Those are the things that save the most lives over time.
When considering death rates from heart disease, we see mortality take a big turn around the 1970s, when we gained a better understanding of the effects of lifestyle and learned of drugs that can help prevent heart attacks, such as aspirin. It was also during that period that public health policies started promoting the idea that individuals are responsible for their own health and have a responsibility to embrace healthy lifestyles. With these as a backdrop, we have seen even steeper declines in mortality with the advent of cholesterol lowering medications, such as statins.
To emphasize these points, I would like to highlight the findings of the COURAGE Trial (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) to consider. Published in 2007, these results stated that, for people with stable coronary artery disease, artery-opening angioplasty did not extend life and was no better than medications and lifestyle changes at preventing future heart attacks or strokes. As with most things in life, there are rare exceptions (such as the location and extent of blood flow limited by a blockage), but your cardiologist now is armed with information to help guide decisions that maximize benefit while limiting potential harm.
Another common misconception is in the area of screening for heart disease. I have found that nearly everyone wants to know what his or her arteries look like. Do they have a blockage? Are they at risk for a fatal heart event? However, when patients come to the Alaska Heart Institute for screening, we aren’t just checking to see if you have blockages. We are screening to evaluate a patient’s overall risk of having heart attacks or dying from heart attacks — pretty important stuff. I often look at my role as a prevention cardiologist much like a risk manager.
We don’t use any one screening tool in isolation; we use them together. It is equally important to meet with a cardiologist and discuss background risk factors as it is to have high quality images taken of the heart using our top-of-the-line imaging equipment, such as a coronary calcium score. We want to understand the patient’s family history of heart disease just as we want to know what his or her blood pressure is. It’s when we have each piece of the puzzle that we can determine risk level and develop the best plan to combat that risk moving forward.
It can take a lot of time and education for us to help patients understand the concepts of cardiovascular health, but the beauty is that we do have time to sit with patients and help them comprehend the reasoning behind our proposed treatment plan. When patients understand their diagnosis and why they are taking a certain medication or making a particular lifestyle change, it can be a big first step toward success.
Dr. Christopher Dyke is a cardiologist at the Alaska Heart Institute, which treats patients in a number of communities around the state.