Asked and Answered with General and Interventional Cardiologist Dr. Alexander Postalian

On this episode of Asked and Answered, general and interventional cardiologist Dr. Alexander Postalian answers some of the most common questions that he gets from patients regarding cardiovascular health.

The questions in this podcast are related to the following topics:

• Assessing chest pain and discomfort
• Medical procedure
• Medications 

Read more about our specialties: texasheartmedical.org/edu

Watch the video here.

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Visit Our Website: texasheart.org

Chapters

• 0:20 Heart Health & Tests
• 3:22 Medications & Procedures
• 6:47 Surgery and Symptoms
• 12:05 Stress Tests & Medication

Transcript

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Hello, my name is Alexander Ian.

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I'm an interventional cardiologist here at the Texas Art Institute in Houston,

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Texas. And welcome to Asked and Answered,

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where we try to answer, uh,

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patient questions that are common and some that are not so common. And, uh,

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hopefully we can make sense of, uh, some problems that some folks are having.

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So, question number one,

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I used to get a stress test every year,

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but my new doctor doesn't wanna order it. We get that relatively often.

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What's going on? Well, um, first of all,

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what is a stress test? Uh,

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a stress test is a way for your doctor, usually a cardiologist,

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to assess if there are blockages in the arteries that feed your heart muscle.

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Um, and to actually get to that diagnosis,

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we have to simulate a situation of stress, which can be being on a treadmill,

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being on a bike, or sometimes with a medication injection.

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In the past we used to do those

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regularly, even if a patient felt okay.

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Right now we're moving a little bit away from that and doing,

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doing it only in patients that are at high risk of issues or if they have

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symptoms like chest pain or shortness of breath. Um,

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so even though your doctor did it every year,

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you may not need it done every year going forward.

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Next up,

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I always get random chest pains and I going to drop dead.

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The only thing certain in life is death and taxes. So, you know,

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we're all gonna die, but chest pains are quite common,

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even though we pay attention to them, they're a common issue.

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And if you think about it, there's a lot of stuff in your chest.

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There's the things that we care about, like your heart, your big vessels, uh,

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but also other things like bone, cartilage, nerves,

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lining of organs, et cetera. So even though chest pain can be dangerous,

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the majority of the time somebody has pain in their chest is usually a low risk

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condition. So we're very good, uh, at ruling out dangerous things.

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We are not as good as determining exactly what caused your chest pain.

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So it depends, but most likely, no,

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you're not gonna drop dead immediately, but if you're having chest pain,

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go get checked out. And next up, when I'm in bed at night,

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I could swear I feel my heart stop for a few seconds and restart with a thump.

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Should I be worried? Okay, well, at night something interesting happens.

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There's silence.

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So you are a little bit more aware of sounds and sensations.

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So palpitations,

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which is the feeling of irregular heartbeats or pounding heartbeats are more

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common at night, not necessarily because they happen at night,

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but because because you're more aware of them. Um, palpitations can be many,

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many things causing them.

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The thing that you seem to be describing stop for a few seconds is most likely

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ectopic beats or premature ventricular or atrial contractions.

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The common word for is skipped beats, which the majority of the time are benign.

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But we do some tests to make sure they are not of the not benign kind,

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and that there's nothing else going on. Next question.

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I had a stent put in my heart about two years ago,

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and my doctor told me I could stop my Plavix. Is it safe? Okay,

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so first off, what's a stent?

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I'm assuming they are referring to a coronary stent,

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which is a stent that we place in the coronary arteries to open a blood flow to

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the heart muscle. It's a metal scaffold that we use to open up blockages.

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And Plavix is the brand name of a medication called Clore,

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which blocks platelet activity.

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And what happens is whenever we place a stent inside a vessel,

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it is a foreign body, okay? So your body wants to attack it,

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wants to shut it down,

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and what we do is we use medications to prevent that from happening.

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And Plavix is an clopidogrel or their sister

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medications, uh,

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are a very important part of preventing the stent from shutting. However,

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that the risk of the stent shutting down is much higher early after the

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procedure. 'cause over time, your own,

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your body lines that that stent with its own cells and the risk of shutting it

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down comes down significantly. So after two years,

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it is probably safe to stop the oppi grill.

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There are things that we look at like how long was the stent?

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Have you had any bad events in the past? Is the stent across a bifurcation,

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another branch coming off? So it's not a simple decision,

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but if your cardiologist thinks you can stop it after two years,

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it is probably safe.

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My mom is scheduled to have a heart calf next week. Should I be scared?

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Okay.

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A heart catheterization in general is going in your arteries

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or veins with a calf,

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advancing it to your heart and either taking pictures of the arteries or

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checking the pressures inside your heart,

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which can be important to decide what medications you should be on and make some

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diagnoses. So it's a relatively common procedure.

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We do it in the hospital every day, so the overall risks are low.

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However, there are some risks. Um, and I think, uh,

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if you haven't had the discussion with your doctor,

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you should probably sit down and talk in detail about what the risks are,

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even though again, it's something we do almost every day.

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Next question.

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I'm 65 and I have been taking aspirin for a long time.

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I read aspirin doesn't do anything. Can I stop it? Great question.

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So in the past we used to give aspirin to everybody above the age of

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55. It was a common thing. You turn 55, you get an aspirin, boom, boom, boom,

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done. Now, over time,

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we've learned that that isn't necessarily the way to go.

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Um, overall, patients weren't benefiting as much as we thought they would,

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and we've done a lot of studies to confirm that. And in fact,

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they showed shows that aspirin doesn't really do benefit for everybody.

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Um, and that got published relatively recently,

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so it made some strides in big journals and stuff.

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So people are talking about it. However,

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some patients still benefit from aspirin, okay?

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Patients that have had stents implanted, patients that have had strokes,

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heart attacks, patients with diabetes and some other risk factors,

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patients with high calcium count in the arteries of the heart.

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So even though not everybody needs aspirin, some patients need aspirin,

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uh, I think that's an individualized decision that you need to have with,

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with your doctor. My doctor told me I need my aortic valve replaced,

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and he tells me they have to crack me open.

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A friend of mine had the valve replaced through the groin.

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Why is this not an option for me? Okay,

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so the aortic valve is a valve that sits between the

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left ventricle,

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which is one of the main heart chambers of the heart and the aorta,

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which is the big vessel that comes out, this one right here.

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So blood comes from there into the aorta out,

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and the aortic valve opens to allow the blood to come out,

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and then it closes to prevent it from going back. So drip, chop, chop, chop,

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drip chop.

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In some patients over time because of genetic factors or some other reasons,

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the aortic valve becomes stiff and it opens less,

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and then it gets to a point where it barely opens and the heart has to, uh,

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pump hard to open it up. That is called aortic stenosis.

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And that is the most common reason for needing an aortic valve replaced.

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It may not be that for you who ask the question,

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but is the most common reason in the past.

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The only way we could do that is open up the chest or crack me open as

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he's saying. And that's still necessary for or he or she. Uh,

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that's still necessary for some people. But now we have another option,

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which is going through the groin minimally in invasively and putting the valve

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in place. Uh, that procedure,

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the the groin one transcatheter is called tavr,

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has gotten better over time and has grown.

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We used to only do it in patients that were really old and you couldn't do

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surgery.

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Now we are doing the transcatheter one more than the surgical one.

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But again, not everybody's a candidate for the transcatheter one.

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There are anatomical limitations, uh,

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and a a list of things that we have to make sure that you do have or don't have

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to be able to do it with a catheter. So it might be an option for you. Um,

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it is worth investigating if you're interested.

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And what we do here is when somebody has an a valve problem,

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we all get together in a room, cardiologists, surgeons, uh,

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some other doctors, and we decide what is the best way to, to move forward.

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So it seems like something like that may have to be done with you.

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Next question. My father had a quadruple bypass when he was 46. Mm-hmm.

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Pretty young.

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My doctor tells me that I have the same problem and wants me to have surgery as

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well. Why can't I have stents instead? Yeah,

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difficult question. We've been trying to answer that one for a long time.

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We've done many, many studies. So

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stents do very well if the blockage

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is of a certain characteristic that allows the stent to stay open.

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If you have many blockages or the blockages are very long, very tough,

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et cetera, et cetera. Bypasses, which is surgical fix,

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can last longer.

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So we have a set of scores and the things that we look at to decide who needs

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stents and who needs bypass.

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Sometimes it's obvious you would do better with a stent.

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Sometimes it's obvious you would do better with surgery and there's a lot of

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gray, uh, area. So again,

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and I feel like I'm saying the same thing over and over again,

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but it is what it is. There's depends on your specific case. So, uh,

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this is something that you should talk to your cardiologist, your surgeon,

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and if you have questions, you can always look for a second opinion.

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We never get offended when those happen. Okay?

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I'm a 38 year old woman and I have stomach cramps that move to my chest all the

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time.

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My cardiologist did a CT scan of my chest and told me there's nothing to worry

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about, but I know heart attacks can present differently in women.

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What should I do? Okay? Um,

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we know from past experience that heart attacks

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not always present the way you'd expect.

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The the classic way is a pressure leg sensation in your chest that is worse with

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physical activity, better with rest,

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and it kind of may go to your arm or shoulder may go to your neck, but you know,

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it comes from the chest little dull pain that is the classic angina pectus,

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uh, as we call it now, it can sometimes be a stomach pain,

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can sometimes be back pain, can sometimes be shortness of breath.

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So it's hard to definitively rule out a heart attack sometimes.

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And these atypical or not normal presentations of

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heart attacks are more common in women than in men. So yes,

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if you're a woman, you may present differently and also if you're a man,

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now, 38 is pretty young,

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so the risk of a heart attack just based on age is relatively low. Um,

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I would say that sitting down with a cardiologist

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discussing the details of your chest pain plus some

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workup like lab work and perhaps some imaging can probably answer,

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uh, this question. Hmm. So it depends. Okay.

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Most likely it's not a heart attack. There is a small, small chance.

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It could be if they did some imaging tests and it was negative,

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that would be reassuring. But of course, if you keep having issues,

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you go back to them. Okay,

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I had one type of nuclear stress test one year ago in which they had me running

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on the treadmill this year. They tell me no running, just an injection.

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I can still run just fine. Why is this? Okay,

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so this patient could run,

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he used to get stress tests running and now they're telling him to get a stress

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test that doesn't involve running even though they can still run. Okay?

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There's multiple types of stress tests. Um,

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the classic one is we put you on a treadmill and we hook you up to an E K G and

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we see if there's any electrical evidence of injury while you're exercising.

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And then sometimes after that we can inject you with a radiopharmaceutical,

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put you under a camera and see if all areas of your heart are getting equal

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blood flow to suggest if there's a blockage or not. Now,

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some patients cannot exercise, so we simulate stress with an injection.

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It's not really simulating stress, it's more like a vasodilator,

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but it simulates the conditions of stress.

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And we can still inject you with a radiopharmaceutical,

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put under the camera and see findings similar to what we would've seen with the

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exercise. So that would suggest that, okay, if you can exercise,

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you don't need the medication. However, some of the stress machines,

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particularly some of the newer ones, the way they are set up, um, and the,

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some of the medications that we use do not allow for the running on the

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treadmill part. So that means that we can only do it with the injection,

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the simulation, the vasodilator. And coincidentally,

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some of these machines have better image quality than some of the older ones.

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So sometimes we're doing tests with injection even though the patient can run

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because the image quality is gonna be much better. Now,

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what I would do is I would make sure that you talk to your cardiologist,

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make sure they know you can run just fine before they decide,

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finally decide on the test. But if they tell you, Hey, no,

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I wanna do it with the injection,

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then it's probably because it's the better machine. Uh,

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I would just go with the recommendations. I had a heart attack three years ago.

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My doctor has tried to put me on three different statins and I can't take them

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because of horrible leg pain and insomnia. How concerned should I be?

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I am already following a healthy diet and hope that's enough. Okay,

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well, cholesterol medications and are, are a big, big topic. We talk about it,

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I talk about it multiple times a day. I almost have, you know,

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speech number four in my brain ready to go. And, uh,

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we're talking about cholesterol medications. So you had a heart attack.

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If you had a heart attack, then you are in a different category.

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It's not like somebody going on the street, Hey,

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you need to control your cholesterol. Isn't that it? It's,

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it is a much higher risk situation.

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We're much more strict with cholesterol control, blood pressure control,

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medications, et cetera. Uh,

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and statins are classic well-studied medications to lower cholesterol

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and lower the risk of heart attacks. In the past,

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we used to think that statins caused bad side effects in

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about 30% of people. Um, and over the years,

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if I were to summarize the evidence,

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somehow what we've done is essentially, it's not exactly this,

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but if you add them all together,

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we took a bunch of people and we gave them a statin and told them,

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here is a statin.

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And then we took a bunch of people and we gave 'em a tic-tac and told them,

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here is a statin. And a lot of people taking the tic-tac,

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almost as many as the ones taking the statin, you know,

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above 20% had to stop the tic-tac because of unbearable side effects.

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So that's called the nocebo effect. You think something's gonna harm you.

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And because there's so much, you know,

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evidence out there and you're aware of the issues with the medication.

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So that means that the, the side effects are not really 30%. It's much,

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much lower than that. That's important.

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The other side of the coin is some patients do get really bad side effects from

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cholesterol medication. And fortunately we have alternatives.

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And lately we've had some more, for example, PCSK nine inhibitors,

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which are injections every two weeks. Uh, a medication called lyran,

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which is an injection every six months. We have other oral drugs like bemed,

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doic acid, ezetimibe,

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and some others coming down the line that can be used in patients that cannot

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tolerate statins. So if you have a, if you've had a heart attack,

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I would be very, very,

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very careful with stopping drugs unless it's under

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supervision. And just know that if you haven't tolerated statins,

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doesn't mean that you won't tolerate them now,

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but if you truly cannot tolerate them, there's alternatives.

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I just wouldn't go untreated and let you cholesterol run high and increase the

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risk of having another heart attack. Okay, well, this has been great.

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This has been a pleasure to be here. You know, I, I love doing this.

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So please send any questions. It can be anything cardiology related,

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high blood pressure, diet, medications, testing,

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valve issues, pacemaker issues, heart failure issues, uh, exercise,

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you know, questions about limitation or what can you do, et cetera. Um,

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just send it all. We'll be happy to look it over.

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Maybe they'll feature in our next, uh, session here. And again,

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this is a general discussion, so if you have any symptoms like chest pain,

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shortness of breath,

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it's always good to talk to your doctor and remember that every patient is an

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individual. So while we can make general recommendations in the end,

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we always make an individual recommendation for a specific patient.

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So when you're watching something, asking a question,

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just keep keep that in mind. We're giving you a general recommendation,

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but if you want a specific one, talk to your doctor.