Ask the Doctor-Cardiovascular

Q: I recently had a heart attack and was successfully treated with stents. My cardiologist has prescribed Plavix and aspirin, and I'm wondering how important are these drugs?

Q: I've been told I snore very loudly and often I find myself waking up in the middle of the night. Do I suffer from sleep apnea and can it be cured?

Q: My father died of a ruptured blood vessel located in his belly.  Is that something I need to be worried about?

Q: Can too much exercise be bad for the heart?

Q: I recently had a heart attack and was successfully treated with stents. My cardiologist has prescribed Plavix and aspirin, and I’m wondering how important are these drugs?

During a cardiac catheterization procedure, a stent is placed in a blocked coronary artery. The stent, which looks like a small wire mesh tube, helps to keep the artery open allowing blood to flow to the heart. It may be either bare metal or a drug eluting stent, which releases medication on a time-release basis. As cardiac catheterization and the placement of stents become more common in the treatment of heart attacks, we are learning more about post treatment drug therapies. Patients who have undergone this procedure should take aspirin and/or Plavix™ or both drugs in combination. These drugs keep blood from clotting in the stents and keep a healthy blood flow to the heart.

In the last three years, clinical studies have shown that Plavix™ should be taken for longer time periods compared to previous findings. The FDA recommends that patients with bare metal stents should take Plavix™ for at least three months. Those with drug eluting stents should take Plavix™ for at least one year or longer as tolerated. The FDA does recognize every patient should be assessed on a case by case basis, and these recommendations may be even longer depending on how complex the intervention was, the number of stents placed, and other factors.

The recommendations for aspirin have also been adjusted. For those with bare metal stents, the FDA recommends taking 325 mg aspirin for at least one month followed by taking baby aspirin indefinitely. Patients with drug eluting stents should take 325 mg of aspirin for three to six months and then baby aspirin indefinitely.

The predominant side effect for aspirin is gastrointestinal distress such as stomach upset or propensity for ulcers. However, coated aspirin does help patients with stomach issues. Side effects are less intense for patients taking only Plavix™. Patients may suffer from similar GI side effects when taking Plavix™, as well as bruise easier. These side effects are worsened when aspirin and Plavix™ are taken in combination, which is usually the case.

Plavix™ and aspirin are extremely important medications that should not be stopped without consulting your cardiologist first. Your primary care physician or other specialist may not have a complete picture of your coronary disease. For example, many physicians may want to stop administering Plavix™ or aspirin before a surgical procedure due to the risks of oozing or bleeding. But it’s important to consult with the cardiologist to weigh these risks against the potential of a heart attack.

If a patient stops taking these medications, the risk of the stents closing up is high, bringing with it the potential of an acute heart attack. This is often not a gradual change in the individual's angina over time. Unfortunately, there are case reports of individuals who stop their Plavix™ and aspirin medications and in a matter of days have a heart attack. For this reason, it is very important to consult your cardiologist if you have any questions about these prescriptions.

Dr. Karthik Sheka is an interventional cardiologist at Pocono Medical Center’s ESSA Heart and Vascular Institute. He is board certified in Internal Medicine, Cardiology, and Interventional Cardiology.

Q: I've been told I snore very loudly and often I find myself waking up in the middle of the night. Do I suffer from sleep apnea and can it be cured?

Sleep apnea is a sleep disorder during which breathing repeatedly stops and starts. There are two main types. Obstructive sleep apnea, the more common form, occurs when the throat muscles relax. Central sleep apnea occurs when the brain doesn’t send the correct signals to the muscles controlling breathing. Central sleep apnea is less common, and more prevalent in patients with heart disease such as atrial fibrillation and congestive heart failure as well as stroke. The symptoms of both types are similar and include the following: daytime sleepiness, loud snoring and observed periods of breathing cessation during sleep. Patients may also experience morning headaches and awakening with a dry mouth or sore throat.

The causes of obstructive sleep apnea are physical such as relaxation of the muscles in the back of the throat, causing the airway to narrow. This may lower the oxygen level in the blood which sends a signal to the brain to awaken you from sleep so you may reopen your airway. This is so brief that most people don’t realize they may be awakening frequently during the night.

Risk factors for obstructive sleep apnea include excess weight, but it is not only the overweight who are afflicted with this disorder. Neck circumference may predict your risk for sleep apnea, because a thick neck may narrow your airway. Other risk factors include high blood pressure. Males are two times as likely as women to have sleep apnea. In addition, overweight women and those past menopause are also at increased risk. People over age 65 are two to three times more likely to have sleep apnea. Smokers are also three times more likely to have obstructive sleep apnea than non-smokers, yet another good reason to stop smoking or never start.

Complications from sleep apnea can be quite serious and include cardiovascular problems due to the strain on the cardiovascular system caused by the reduced oxygen levels. This can also increase your chances of developing hypertension by two to three times. If you already have underlying heart disease, multiple episodes of low blood oxygen can lead to sudden death from a cardiac event. Obstructive sleep apnea can also increase your risk of stroke whether or not you have high blood pressure.

Additional complications include significant daytime fatigue, difficulty concentrating, as well as increased irritability. Patients with obstructive sleep apnea are more likely to experience complications following major surgery once they have been sedated. Memory impairment and esophageal reflux disease may be more prevalent in patients with sleep apnea.

If you suspect that you may have sleep apnea, there are formal ways of diagnosing this condition. An evaluation will usually involve overnight monitoring of your breathing in a sleep lab where you will be monitored for heart, lung, and brain activity.

There are some simple things you can do on your own. Avoid alcohol, which can worsen the condition. Also avoid sleeping on your back, as sleeping on your side may reduce the severity of sleep apnea. Once the condition is diagnosed, treatment modalities can be prescribed and may include CPAP (continuous positive airway pressure), which involves wearing a mask which delivers air pressure to your throat and may keep the airway open. Some patients benefit from an oral appliance designed to keep the airway open, bringing the jaw forward.

Surgery to remove excess tissue from your nose or throat may be an option for certain patients. Any therapy must be tailored to the individual’s specific case and what works well for one person may not be an option for another.

If you suspect that you or a family member may have sleep apnea, the place to start is with your family doctor. Appropriate work up and treatment will reduce or eliminate the likelihood of developing any of the above complications.

Patricia Rylko, M.D., F.A.C.C., is a cardiologist who is Board-certified in cardiovascular diseases.

Q: My father died of a ruptured blood vessel located in his belly.  Is that something I need to be worried about?

Most likely your father had a ruptured abdominal aortic aneurysm, also referred to as AAA (“triple A”).  AAA’s are a relatively common condition occurring in 5 percent of people over the age of 65. In most cases the patient has a history of smoking and high blood pressure.  Over time, the aorta, the largest blood vessel in the body, becomes diseased and weak, and ultimately starts to bulge at its weakest part, usually just above the level of the bellybutton.  One of the biggest contributing factors to developing AAA is a family history of a parent or sibling with an aneurysm.  Unfortunately, AAA’s rarely cause any symptoms until they rupture, and when they do, it has a 90 percent fatality rate.  This makes finding an aneurysm when it is small (less than 2 inches) and monitoring it, or large (2 inches or more) and repairing it, very important.  Many famous people have died of ruptured aneurysms, including Albert Einstein and Lucille Ball!

Your doctor should provide a complete physical examination, which includes pressing on your belly, trying to feel for the aortic pulse.  In larger folks, the best way to identify if there is AAA present is with a safe and painless ultrasound.  In fact, many new Medicare enrollees will qualify for a free screening.  If the ultrasound shows evidence of AAA, it may be followed up with a CT scan which is the best way to accurately measure a AAA when it gets large enough to fix.  Although for many years open abdominal surgery was the only way, 80 percent of people we see qualify for a less invasive procedure called stent-grafting or EVAR.  This newer technique has made repairing AAA very safe, with only an overnight stay in the hospital, and a quick return to normal activity.  Ask your doctor if he or she thinks you might have AAA…it could save your life!                 

Eric P. Wilson, MD, FACS is Board Certified by the American Board of Surgery. He specializes in vascular and endovascular surgery and practices at PMC Physicians Associate located in Bartonsville. He can be reached at 570-426-2900.

Q: Can too much exercise be bad for the heart?

While exercise has been shown to provide many health benefits, including reducing body fat, lowering the risk of various diseases and fighting off emotional strains like stress, anxiety and depression, there are some caveats to its use. This is especially true for individuals who may have an underlying cardiovascular disease. Therefore, it is always best to consult with your physician before starting an exercise program. Exercising in extreme weather conditions, under the influence of certain medications or in excess (i.e., to the point of experiencing injury or physical pain) should be avoided.

Normally, people who are perfectly healthy and have no family history of heart disease should be able to exercise without any risk of heart damage. However, if you have any risk factors for coronary artery disease (i.e., if you have a strong family history of heart disease, diabetes, high blood pressure, are obese or if you are a smoker), you should check with your doctor before starting an exercise regimen.

This is also the case for individuals who have heart disease and wish to start an exercise program. Knowing that exercise reduces future cardiovascular disease, there are many people who have heart disease and want to start exercising. With the right training and education about their conditions, it is very possible for those individuals to exercise on a regular basis. Again, it is important that they consult their physician and/or cardiologist before they begin an exercise routine.

At Pocono Medical Center, we’ve seen many cardiac patients recover and go on to jog, play tennis, and do various other types of exercises daily—exercises that even some people thirty or forty years younger do not do. Thus, it is possible for individuals who have heart disease to exercise. The key is ensuring these patients receive the right education and rehabilitation for their conditions. That way, they will learn how to gradually—and safely—increase their physical activity without overexerting themselves or putting themselves at risk for future cardiovascular disease.

In the vast majority of cases, however, exercise is rarely harmful to one’s heart. To be safe, if you have any risk factors for heart disease or if you have a history of heart disease, you should consult your doctor before you begin exercising. This will help ensure that your heart can enjoy the benefits of regular exercise without being at risk.

Mark Indzonka, MD is Board-certified in Cardiovascular Diseases and Interventional Cardiology. Dr. Indzonka is a member of the Medical Staff at Pocono Medical Center and practices at Heart Care of the Poconos in East Stroudsburg.


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