Scott Webb: Coronary artery disease is common and treatable if we recognize the signs and symptoms and reach out to our providers. Joining me today to tell us about CAD, the signs, symptoms, and treatment options is Dr. David Prutzman. He's a cardiologist with Elliot Cardiovascular Consultants. This is your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth.

I'm Scott Webb. So, doctor, thanks so much for your time today. We were just kinda shooting the breeze a little bit before we got started here, and there are some things we're going to get to, like some of the cool technologies available now at Elliot Hospital. But before we get there, let's talk about coronary artery disease, right? What is that, or what causes it?

Dr. David Prutzman: Coronary artery disease is really this kind of umbrella term for the syndrome that is associated in a general sense of having plaque that builds up inside the coronary arteries. What causes the disease is really, we used to think that this was kind of a passive process where you are putting plaque or developing plaque inside the coronary arteries, which are the arteries that are delivering blood flow to the heart muscle. But we've really come to understand through new technology, that it's much more of an intricate process.

And without going into too much detail, there are a couple of points that people really need to understand, which get into why you end up having symptoms associated with coronary disease or certain conditions that can accelerate coronary disease and how we end up treating them. Really it understands that there's a process that begins at the endothelium, which is the interlining of the coronary arteries, and it is constantly getting these insults or repetitive things that are promoting injury, such as deposition of LDL or bad cholesterol, reactive oxygen species, and chronic inflammation, that leads to this endothelial dysfunction.

This injury to the artery and plaque formation when plaque formation develops over a long period of time, you end up calcifying through mineralization in these, you know what originally starts out as a small fatty streak ends up becoming this very much complex organized plaque that's inside of the wall of the artery that now starts protruding into the lumen or where the blood is. And when you start limiting that space that's available, that's where you start impinging on blood flow. And that's where you start running into the mechanism of the demand and supply mismatch, which is where people end up getting symptoms associated with it. And it's the understanding that this repeated episode of this disruption of plaque, this rebuilding of plaque and healing process where you get this gradual progression that leads to this narrowing.

Scott Webb: Yeah, what you said there, the supply and demand issue, I think that that's one that we can all sort of identify with, whether it's the grocery stores or our bodies and our arteries and our hearts and all those things. So, who's at the highest risk for coronary artery disease? How common is it?

Dr. David Prutzman: People who are generally at risk for coronary artery disease, it's going to come down to, there's never one specific answer for something like this. There are always multiple things that come into play and, multiple hits, as you call it. There is always lifestyle that is contributing to the formation of plaque, but also chronic diseases, and as I mentioned before, coronary artery disease is really this chronic inflammatory process. And so people have these underlying medical conditions like diabetes, high blood pressure, even high cholesterol, you're having this chronic inflammation.

As I mentioned about coronary disease and how it develops, these are all things that are creating this plaque or this environment, where you end up having this impingement of blood flow and worsening of coronary disease. But aside from chronic medical conditions, it's other things that you're doing outside of your chronic medical history, like smoking. Tobacco abuse is single-handedly the leading, preventable cause of morbidity and mortality in the United States and, in particular, in relationship to coronary artery disease in the development of plaque.

But aside from that, you also look at lifestyle diet patients who are overweight, who eat poorly, and who are relatively sedentary. These are all things that promote plaque formation and end up worsening coronary disease over time.

As far as how prevalent coronary artery disease is, well, coronary artery disease has been around for a long time, and it is something that has been the leading cause of mortality in the United States, and coronary artery disease by itself is the most common type of heart disease.

But by far and away it's the most common cause of death, and it's been that way for decades. You know, it’s estimated that every 40 seconds, one patient has a heart attack, and about every 34 seconds, one patient dies from an event from coronary artery disease, and you're estimating probably every year of over 800,000 people who have a heart attack. And that's a lot of patient care that we are giving here in terms of acute onset of symptoms. It's also important to understand that this is a large portion that ends up leading to medical expenses, hospitalizations, and overall patient care.

Especially when you're dealing with other things in this country, particularly in the United States, where mortality or chronic medical conditions that end up causing death, like stroke or cancer, that something like coronary artery disease, which is something that maybe some people don't think about, is actually the leading cause of all of these things.

Scott Webb: Yeah, I think you're so right. It's not easy being a patient or even a provider, right? There's dealing with family history, genetics, behavior, lifestyle, and chronic medical conditions. It's a lot, right? But there are definitely things that folks do smoking, as you say, is really at the top of the list. What's one or some of the biggest misconceptions that people have about coronary artery disease?

Dr. David Prutzman: So I think that with the patients that I see in my own practice, I think that there are not just one, but I'm gonna say two misconceptions about coronary artery disease. Number one would be the symptoms associated with coronary disease, and number two is the age of onset and the overall prevention of coronary disease. Because most people look at CAD, people think that this is something that only elderly patients get somebody in their sixties, seventies, or older. But in reality, this is something that is developing over a very long period of time.

It takes years to develop plaque. I mean, they can rupture at any time and cause acute coronary events, but the actual process of developing plaque inside of the coronary arteries develops as early as in your teenage years. So, this is something that is slowly accumulating over a long period of time and where people may think that, well, I can do what I want now. I can eat what I want, I can exercise how I want, etcetera, and it's not really going to affect me until later. But it's the prevention that you end up making early on in life that ends up reducing the chance of having obstructive coronary artery disease and the complications associated with that.

So, the idea that only elderly patients can be affected by this clinical syndrome is misinformation. I mean, we do see young patients who, you know, especially ones who have underlying medical conditions like diabetes, they're more prone to, plaque formation and the aggressiveness that you get with coronary artery disease. Young patients can also be affected by the complications associated with blockages within the arteries of the heart. And that brings up a second point, which is really the symptoms related to it. This is something that most people, especially when you're watching television, it becomes a little bit dramatized.

And I think that that's what television is supposed to do. It is not always presenting as something where you get the elephant sitting on your chest that's radiating into your arm and jaw, especially in patients who have chronic coronary artery disease, meaning that they have blockages; it's obstructing blood flow. But it's not maybe critical, or it hasn't acutely ruptured, and now you have a clot inside the artery, and it's been narrowed down to 99% or completely occluded. People live with these symptoms every single day, and it's predominantly exertional.

This is what we would call typical symptoms. If it is substernal, if it's related to exertion, and it's better with rest or with nitroglycerine, but most people don't describe pain. Most people would also describe symptoms such as having pressure in their chest, or a heaviness, or a feeling like something is squeezing them, or a band like sensation around their chest. Patients also get other symptoms like shortness of breath. They feel fatigued and weak. They used to be able to go long distances, being able to walk, or do mild levels of exertion.

And slowly they've gradually noticed this decline, whether it's over a few months or over a few years. Coronary artery disease is not something that's just acute, and it's not this one typical pattern. There's a wide variety of symptoms that people can experience, and again, it's not something that happens so acutely. This is something that can be progressively happening over a long period of time.

Scott Webb: Yeah, and I think you're right. When we think about reducing our risk, is it really more about being better about things like behavior, lifestyle, quitting smoking, those kinds of things? Or is it a whole sort of bundle of things that we need to do?

Dr. David Prutzman: So, I think that this is something that like most things in medicine, there's multiple answers. There's never just one thing that ends up causing the problem and you can definitively put your finger on it and say, I'm gonna treat that and things are gonna go away. There are, what I would say are modifiable risk factors, but there are also unmodifiable risk factors, and the one thing that you cannot change is your genetics.

There is no doubt that there is a genetic role, especially with cholesterol. Familial conditions cause an increase in cholesterol levels and plaque. People are more prone to certain diseases and conditions that are gonna ultimately end up leading to coronary artery disease down the line. For some of those things you cannot control, there are medications and things that end up being used to try and slow progression, reduce progression, etcetera. Then, on the other side of that coin really are the modifiable risk factors or things that we've already talked about.

And when we talk about those things, hinting really again at diet, lifestyle, and even going a little bit into detail, there are certain things that people do from a preventative standpoint, especially in the United States. Because we're accustomed to this western diet that's very high in fat and sugar and things that end up just significantly accelerating coronary artery disease. But there are different things specifically, and there's a lot of information that can be found. And when I mention one thing, let's just say diet.

It's recommended people should follow more of a Mediterranean style diet, which is plant based. This is higher in fruits and vegetables and whole grains, which is getting away from things like processed meats, refined sugars, beverages, specifically soda things that are very sweet. And these are things that. You can do on a daily basis that don't involve medical therapy. And one of the best things, if not the best thing to prevent coronary artery disease is exactly that. It's prevention. Like in real estate, it's location, location, location. Well, in coronary artery disease, it's prevention, prevention, prevention.

Not ending up with the complications down the line. Again, even coming back to younger people having coronary artery disease, it's the understanding that what you do now affects who you become and what you have later. And when you're talking about lifestyle, this is something that I stress personally. It's very, very important to make sure that lifestyle, maintaining an adequate, healthy body weight, keeping up with exercise. Over 40% of patients in the United States are categorized into what we would call an obese category. Keeping a normal healthy lifestyle, exercising, at least for right now, the recommendation of at least 150 minutes during the week of aerobic exercise.

Really helps to minimize the risk of developing coronary disease by keeping your blood pressure lower and helping with the stresses that you would normally get on your heart from other underlying conditions. This is all part of the multifactorial things that help to reduce the chance of coronary artery disease, but also treatment. And I will say that, even for patients who do have coronary artery disease, if you're looking into even some mild form of plaque regression. It's not just medications that we give people. Even if you have coronary artery disease, these are things that you should be doing on a daily basis to try and prevent the progression of what you already have. So, to speak.

Scott Webb: Yeah, I mean, as you say, some things are modifiable, things within our control, and some things that even if we've done our best with all these things, we might still end up in the office with you. So, let's talk about treatment options, technologies, how they work, and really ultimately the benefits to patients.

Dr. David Prutzman: So treatment options, we try and look from two different perspectives. One side of the coin is looking at, well, what are things that I can do that are non-invasive? And the other side of the coin is looking at things that we can do in terms of what is invasive. Noninvasive therapy would really include, risk factor modification, things that we've already really talked about, trying to treat underlying conditions and things that prevent coronary disease. The other thing that you're looking at is in terms of medical therapy, there are a wide range of what we call antianginal.

These are medications, different classes of drugs that help to reduce the stress on the heart, increase the amount of blood flow going to an area or another, reducing blood pressure, and just overall reducing that demand that your heart gets. We go back to the supply and demand mismatch you get with your heart when you have blockages in the coronary arteries and you cannot deliver blood flow. For a vessel that is trying to dilate and get more blood flow, it's being restricted. These medications are trying to allow that process to happen just a little bit easier.

Common medications that we use, or that people may have heard of, or even for what people are on are beta blockers, or nitrates, and calcium channel blockers. These are the pillars of treating coronary artery disease. But there are other medications that we use such as statins. These are cholesterol lowering medications that also help to reduce inflammation inside of plaque that promotes plaque rupture, that leads to acute coronary events and the necessity of emergent treatment. We also use different medications to control after people have a heart attack and there's remodeling of the heart, there are other medications we use, like ace inhibitors, or aldosterone receptor blockers, aldosterone antagonists.

These are all medications that we use to help with the remodeling of the heart, decreasing scar tissue formation, helping with the pumping function of the heart, and trying to reduce that overall stress with delivering more blood flow. On the other side of that is looking at what we do in terms of a more invasive, treatment for coronary artery disease. And that really comes into minimally invasive and more invasive strategy, which I would say is what I do as an interventional cardiologist is more of a minimally invasive treatment, which is through cardiac catheterization versus going through coronary artery bypass grafting.

Both of these are strategies of revascularization or trying to create new channels of blood flow or opening up blood vessels that are severely blocked. Obviously, one has potentially more risk than the other, but each one of these comes at its own risk, depending on what type of coronary artery disease you're dealing with. And it is truly unique working in interventional cardiology because, no two patients are the same. People have different anatomy and different plaque morphologies, and that's part of what is so interesting about doing interventional cardiology is that everybody's different. What is true for one person is not true for everybody.

Scott Webb: Well, as you and I were talking about before we got started here, you know, one of the things that sort of drew you to this specialty is that it's always changing. Right. There's always emerging and new technologies. You're speaking the buzz words there for patients, minimally invasive, right? So, smaller scars, faster recovery, less time in the operating room and all of that. Lots of benefits for patients, obviously. And it would be great if we could all do our part as well. I think I just wanna wrap up here and finish up by just talking about the benefits to patients doing their part, right?

So, reducing their risks, addressing their chronic medical conditions, reaching out to providers, all of that. So, in your words, your best advice, why should we take this seriously, and what are the benefits to taking it more seriously and not waiting till we're perhaps elderly, as you were saying earlier?

Dr. David Prutzman: It's so important to take it seriously. It's not only from the standpoint that you know, it can be a very heavy cost burden for what you're going through, especially in today's climate, where we're dealing with inflation and increased prices and whatnot. I mean, it is very well known that patients with coronary disease and underlying medical conditions are going to have higher medical expenses and bills and things that they're going to have to be able to cover for. But one of the most important things, at least that I think about, really comes down to the lifestyle, and this is one of the things that draws me to interventional cardiology.

It's the ability to do something like, you know what you said from being a minimally invasive standpoint, that dramatically changes somebody's life, and by that, I don't mean just in an acute setting. I mean also in a chronic setting. So, people who are living with shortness of breath, people who are living with chest pain, people who feel exhausted, they're falling asleep all the time, they just can't live the life that they feel like they want to live or that they should be living. This is why prevention is so important, but also taking care of yourself.

Trying to recognize symptoms in which you need to seek help because overall, it's not just what we do from a treatment standpoint, but if you are not happy with how you are and how you feel, it's a matter of changing that trajectory of your life, your symptoms and letting you get back to doing what you want to do and not inhibiting yourself from something that potentially is treatable. At the end of the day, if it is something that can be fixed, why would you not take the chance on doing it? Really it comes down to the understanding that there are treatment strategies that they can do, number one, that is local to where they're living.

They don't need to go to these really big centers that are really far away thinking that that's the only place where they can get this treatment. That’s the benefit of doing interventional cardiology minimally invasive surgery procedures, if you will, is that there are faster recovery times. They are minimizing the risk associated with it. Now, granted no interventional procedure comes without risk. There's always risk, but you're talking about being able to get back to your daily living and getting back to work faster and rapid improvement in symptoms.

I mean, it's dynamic what you do from these different technologies because before we would think that patients with very complex coronary artery disease need to go to surgery. Now we realize that there are many different things that we can do, especially through advancing technology where maybe you don't have to go through open heart surgery. Maybe there is a procedure that you can do where, and a lot of times we end up doing these procedures through the radial artery, which is in the wrist.

So the recovery time is much faster, the bleeding is much lower, and you're getting these different types of high-risk interventional type procedures, but you're being able to do that without having to stay in the hospital for a week or more at a time with an open sternum wound and things where you're dealing with a completely different aspect of complications than what you would do where you're really just doing a procedure through a blood vessel- a very small blood vessel, whether it's coming from the wrist or the leg.

So, I think that is one really important aspect for people who are searching for answers for coronary artery disease and what they can do. Because not everything is black or white. Not everything is just, well, it's medical therapy or surgery. There is something in between and that something in between can be life.

Scott Webb: Yeah, that's perfect, doctor. This has been so educational today. I love it. Thank you so much. You stay well.

Dr. David Prutzman: Thank you. You take care and have a great day.

Scott Webb: And if you enjoyed this podcast, please be sure to tell a friend and share on social media. This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Stay well, and we'll talk again next time.