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Five Crucial Questions to Ask Your Doctor About New Heart Disease Treatments

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Patient and Cardiologist
What might the latest research on new heart disease treatments mean for patients? Recent innovations include a less invasive diagnostic test, technologies that improve stent placement, and more patient-friendly angiography done via the wrist. But not all physicians utilize these emerging approaches, so patients seeking out the best possible treatment for coronary artery disease would benefit from asking their cardiologists some key questions about the newest tests and treatments.

While patients might assume that good cardiologists all recommend the same diagnostic tests, drug regimens and surgeries (medicine is a science, after all), this is an evolving field and the heart disease treatment an individual receives depends on their doctor's experience, opinions and access to technology. Each physician will draw his or her own conclusions about the pros and cons of new therapies, what new skills to seek out, what technologies to try to convince their hospital to purchase, and which new approaches to incorporate into their practice.

In fact, a recent study showed a large variation in the treatment heart patients receive depending on where they live and who their doctors are.

Here are five key technologies or heart disease treatments that can be of major benefit to patients, but are not yet universally available:

    1. Less invasive diagnostic imaging tests for heart disease;
    2. More effective non-surgical management of stable angina;
    3. Increasingly precise ways to determine when and where to place cardiac stents;
    4. A more patient-friendly via-the-wrist approach to catheterization and stenting;
    5. Changing recommendations on medication after stenting.

All five of these areas have been subject to headline grabbing media controversy, resulting in confusion among patients and physicians alike. Heart patients interested in making sure they are benefiting from the most up-to-date knowledge and getting the treatment that best fits their preferences, can ask their cardiologist the following questions:

1) Am I a candidate for non-invasive CT Angiography (CTA) to determine if I need heart disease treatment?
Patients with chest pain have traditionally been sent for nuclear stress testing followed, if deemed necessary, by cardiac catheterization. However, studies suggest that the newest non-invasive CT scans may help prevent large numbers of patients from receiving unnecessary catheterization (an invasive procedure with some risk). Studies show that at least 37% of patients who undergo cardiac catheterization are found to have no coronary artery disease.

When conducted with currently available low-dose protocols, CT angiography exposes patients to less radiation than nuclear stress tests and produces less "false positive" results. CTA is much more effective than other available tests at ruling out arterial disease and avoiding unnecessary intervention, 98-99% accurate in some studies.

If patients choose CTA, they should make sure the facility where their tests are done specializes in cardiac CT, does a large volume and monitors radiation dose levels on its machines. CT angiograms are typically done with a radiation dose of anywhere from 5 to 15 mSv (millisieverts), although some centers have reduced the dose down to 2 mSv. By comparison, a nuclear stress test averages 16 mSv. While CT angiography is painless and easy on patients, it is not yet widely used as a first line diagnostic test for symptomatic heart disease and it is not universally reimbursed, so patients need to seek it out.

2) If I have stable angina, in addition to drugs, will I receive help to change my lifestyle?
Patients with stable angina (activity-related chest pain that is not life threatening) will be advised to take a number of medications used in heart disease treatment, and to change their diet and lifestyle. Studies suggest that pain can be controlled without interventions (like bypass and stents), but only if major changes are made – too often doctors prescribe the drugs without the on-going support that lifestyle changes require. If you want to control your pain and slow progression of heart disease, ask about supervised cardiac exercise, facilitated stress reduction and support groups, smoking-cessation programs, nutrition education and nurse-educator outreach.

3) If I need a catheterization or stent, am I a candidate for wrist angioplasty (a.k.a. the radial approach)?
Traditionally the catheter used in imaging tests, balloon angioplasty, and stenting is introduced into the body and threaded into the heart via the femoral artery in the groin - this involves a small incision in the groin area that can sometimes lead to complications such as bleeding or nerve problems. Increasingly, cardiologists are reaching the heart by way of a catheter introduced through the radial artery in the wrist.

The wrist approach has fewer complications and entails a faster, more comfortable recovery for the patient. Individuals with small arteries or other contraindications may not be candidates for the radial approach, but it is widely used in Europe and Asia where it has been highly successful, and it is increasingly being utilized by U.S. cardiologists.

Switching to the radial approach requires additional training on the part of the cardiologist, so interested patients need to seek out centers where cardiologists experienced in the radial approach are practicing. For more about radial, visit the Wrist Angioplasty FAQ in our Patient Center.

4) If I need a stent, do you use IVUS and/or FFR in addition to angiography?
When doctors put in a stent, they look at an X-ray screen to guide the placement of the device. There are new technologies available to see more precisely where the stent is going. Intravascular Ultrasound (IVUS) is an additional imaging technology that has proven to facilitate optimal stent placement. .

Fractional Flow Reserve, or FFR, is a measurement technology that can be used during angioplasty to better determine which areas of the artery will best benefit from a stent. FFR more accurately measures blood flow through the affected area.

Studies of drug-eluting stent effectiveness suggest that FFR may decrease the use of stents by as much as a third, because it allows cardiologists to identify which narrowings in the arteries are actually restricting blood flow to the heart, something which is not possible with angiography alone. IVUS and FFR are only being used by some interventional cardiologists – but the more patients ask for these technologies, the more they will become available.

5) What kind of stents do you use and how long will I need to take antiplatelet medications like Plavix (clopidogrel) or Effient (prasugrel)?
One of the biggest issues in heart disease treatment today is how long patients who receive drug-eluting stents need to take antiplatelet medications to prevent blood clots. There are several on-going studies looking at different antiplatelet regimens, but no clear data yet. Current recommendations are to take such medications for 12 months or more.

Before you get a stent, discuss this issue with your cardiologist – these drugs are expensive and they may have side effects and risks. If you will not be able to afford a full year of antiplatelet medicine, your cardiologist might suggest a bare metal stent instead – these require a shorter period of antiplatelet medicines, although they have a higher incidence of reblocking.

Researchers are finding that some patients only partially benefit from clopidogrel (Plavix), the most commonly-used antiplatelet drug. An emerging approach is to test a patient's blood platelet function before stenting, to determine whether clopidogrel will work for them – ask your cardiologist whether he does platelet function testing. Patients should know that the decision to get a stent is a decision to commit to taking anti-clotting medication (like Plavix) as well.

Patients: Ask Questions! It’s Your Health and Your Decision
The days of "whatever you say doc" are over. There is often no one right answer, especially for chronic conditions like heart disease, for which there is no cure. Heart disease patients really need to take responsibility for their own health, since everyone agrees that lifestyle change is key to managing coronary artery disease.

With the complexity of modern medicine there is a broad movement toward active patient participation in decision-making. The best medicine is individualized medicine, with doctor and patient working as a team, examining treatment choices and making decisions based on each individual's medical situation and preferences. In fact, the federal Affordable Care Act mandates funding for patient decision-making aids, to help people navigate their options. Being an educated health care consumer benefits patients, and enlightened cardiologists are coming to expect patients to take an active role in their own health, including asking lots of questions, and seeking out the best science has to offer them.

For more information on heart disease treatment, visit our Patient Center.

Reported by Deborah Shaw, Patient Education Editor, April 14, 2011, revised December, 10, 2012