Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, MD
 17 May 2006

“I AM NOT HAVING SURGERY”

            The gentleman was 72 years old and a very active individual.  He owned and operated a substantial cattle ranch.  Fortunately, he was not a smoker but he had never bothered to address health maintenance.  He was one of the standard South Dakota males who took wonderful care of his ranch equipment and cattle but didn’t pay a hoot of attention to himself.

            I met him in 2004, about two years ago.  He sought medical attention at his wife’s insistance because he was having chest pain when he exerted.  The event that got his attention was branding day.  Normally, he could brand calves with the best of them but in the spring of 2004 when he would get cranked up and working he would develop chest pain and recognize that he needed to stop for awhile. After five or ten minutes of rest, the pain would go away and he could go back to branding again for another short period before the chest pain recurred.  Then he would stop again.  His son working with him noticed his father’s unusual resting and also made the observation that “dad just didn’t look good”.

            It was a classical story for what is called “angina pectoris”.  This is chest pain that comes on with exertion and is due to the heart not getting enough blood to satisfy its work needs when a person exerts.  This is due to “plaque” (rust and corrosion) that builds up on the inside of arteries and blocks the normal blood flow to the heart.  This plaque is made up of cholesterol and scar tissue.  Until recently, we thought was irreversible.  We believed once plaque got laid down in an artery’ it was going be there forever.  That is really not true as the rest of this story will show.

            When I met this gentleman, the usual tests were done and it was seen that his cholesterol was 280 mg% (normal less than 200 mg%) with the bad cholesterol of 170 mg% (normal less than 100 mg%).  His blood pressure was very slightly high at 135/85.  He was not diabetic.  A stress test was done and was distinctly positive indicating that he had significant blocks in the arteries that supply blood to his heart.  He was advised that he needed to see a cardiologist to have an angiogram done to visualize where these blockages were, how extensive they were and what might be done to deal with them.

            On visiting the cardiologist, it was seen that this gentleman had “triple artery involvement” with significant plaques on the right coronary artery, on the left anterior descending coronary artery, and the circumflex coronary artery.  These arteries are the three major arteries that supply the heart with the blood it needs to do its work.  Each of them had over 70% blocks and one had a 90% block.  He was strongly advised that he needed to have triple coronary artery bypass surgery as soon as possible.  Fortunately, there had been no damage to his heart to this time.

            Against advice, he elected not to proceed with any surgery at that time.  He wanted to go home and think about it.  What he really did was go home and use his computer and the Internet to research for himself.  He had a relative in Oklahoma who had had bypass surgery done.  Following the bypass surgery that his relative in Oklahoma had, that man’s mind didn’t work well.  He was much more forgetful and really not able to carry on his occupation as he had previously.  This 72-year-old patient of mine considering surgery on himself was in no way going to take a chance on not being able to think.  When he reviewed this on the Internet, he found out that brain damage is not that unusual following bypass surgery in elderly individuals. That cinched it.  HE WAS NOT GOING TO HAVE SURGERY.

            When he visited with the cardiologist, he was told to be taking an aspirin a day. This was something that he had never done before.  It was also suggested that he have a medicine to protect his heart while he went home to think.  He was given a pill called a beta-blocker.  He was also strongly advised to get his cholesterol down and was started on a “statin” drug to lower his cholesterol.  About two week later, he came back to visit me again, stating that he was not going to have any surgery and he wondered what else could be done to deal with the blocks in his coronary arteries.

I reviewed with him the medical literature showing that if a person’s bad cholesterol (LDL) could be lowered to a value under 70 mg% or less, there actually seemed to be melting of the cholesterol plaque in the arteries.  He said that he wanted to try that and he was started on a higher than usual dose of the statin drug called rosuvastatin (Crestor).  The normal dose of this drug is 5 or 10 mg.  He was placed on 10 mg for the first two months but his bad cholesterol only came down to around 100 mg% from the previous high of 170 mg%.  The dose was increased to 20 mg per day.  This lowered this cholesterol further to around 80 mg% in an additional 2 months.  He was then started on a drug called Zetia which blocks cholesterol absorption from the bowel.  This lowered his bad cholesterol to 60 mg% by October of 2004.  At that time, he still had chest pain with exertion but he had learned to adjust his activity.  He learned to use Nitroglycerin under his tongue if the chest pain came on and didn’t go away very quickly.  He seemed adjusted to the situation and happy with his choices.

            He recently came in for his six month check up and remarked that he had gone through calving season this spring without one episode of chest pain the whole spring.  He was a very proud individual at this point.  We did a stress test and all of the ugly changes that were present previously were gone.  He was able to walk quite extensively on an uphill grade and not get chest pain before the test was stopped because he had reached the maximum pulse for his age.  This was the success story of the year and it is only April.

            In the April 5^th issue of the Journal of the American Medical Association, there is an article describing the “ASTROID TRIAL”.  This was a trial in multiple centers across the country.  They have examined 340 people who have the amount of plaque in their coronary arteries measured prior to starting the cholesterol medicine mentioned above.  Those 340 people then had the amount of cholesterol in their arteries measured again two years later.  It was seen that the amount of cholesterol in the plaque in these patient’s arteries had actually decreased substantially.

            Another trial several years ago used a statin drug called atorvastatin (Lipitor) at a very high dose of 80 mg daily.  That trial using the very high dose of Lipitor also resulted in a decreased incidence of heart attacks, sudden death and angina pectoris in the patients with the high Lipitor dose.

            Animal studies have now shown that new lay-down of cholesterol plaque in arteries probably will not occur if the bad cholesterol is 70 mg% or less.  To me, the message of these studies says that health maintenance means getting your bad cholesterol below 70 mg% to prevent progression of the atherosclerotic process.  In the long run, this prevents heart attacks and strokes.  In my personal opinion, the most important benefit will be the prevention of the progression of Alzheimer’s disease that comes from poor circulation to the brain.  The healthcare professionals at your local clinics are aware of this information and can help a person get the right combination of medications to get the bad cholesterol below 70 mg%.