Amanda Wilde (Host): Welcome to DocTalk, presented by Montefiore Saint Luke's Cornwall. Today, we'll focus on what patients and families need to know about coronary artery disease with Dr. Ahmad A. Hadid. Dr. Hadid is Medical Director of the Kaplan Family Center for Cardiovascular Medicine and Interventional Radiology at Montefiore St. Luke's Cornwall. I'm Amanda Wilde, your host. Dr. Hadid, thank you so much for being here.

Ahmad A. Hadid, MD: Thank you.

Host: Can you tell us in plain terms, what is coronary artery disease?

Ahmad A. Hadid, MD: Coronary artery disease is a chronic disease of the artery of the heart causing blockages in the artery of the heart, preventing blood flow to the muscle, causing lack of oxygen, obviously, to the heart muscle in a chronic way. And it has two manifestations: chronic coronary artery disease, that slow process going for years and years and actually decades, and acute coronary disease where that buildup causes suddenly the plaque to rupture and clot to form, preventing blood supply acutely to the heart muscle and causing what we know as like heart attack and unstable angina and acute coronary syndrome.

Host: So, the blockage can be acute, it can be chronic. But this is obviously not something you catch like a cold. What causes someone to get coronary artery disease?

Ahmad A. Hadid, MD: Risk factors for coronary artery disease are multiple. We like to divide it by modifiable risk factor for coronary artery disease and non-modifiable coronary artery disease. Modifiable risk factors are like diabetes, if it is controlled or uncontrolled, hypertension, where the blood pressures are elevated and, most of the time, really silent. We don't feel it. It's called silent killer. Hypercholesterolemia, where the bad cholesterol, LDL, is high, et cetera. Smoking. Smoking is a major risk factor for coronary artery disease. Obesity, overweight.

And non-modifiable, like age and sex and family history and genetic predisposition for coronary artery disease. These risk factor ares mostly established since the Framingham study in the '40s, which was one of the longest study for almost 30 years, to find out those risk factors are the causes of coronary artery disease. The higher the risk factor, obviously, the more likelihood of the coronary artery disease. The better controlled, the better the outcome.

Host: And if it doesn't manifest as acute, how do you diagnose coronary artery disease?

Ahmad A. Hadid, MD: In the last really like thirty years or so, there's been a huge advance in coronary artery disease. An important thing that, you know, an adult to check routine, check the blood pressure, check diabetes, do a blood test, go through the family history, obviously, follow healthy lifestyle, especially for people with coronary artery disease.

There has been also added—it's called calcium scoring. We do it for a certain population, where we do a CAT scan of the chest, really looking for calcification in the coronary artery. It's a simple test, has little radiation exposure, but it really gives us a number of calcium score.

Coronary artery disease is a chronic disease that anything chronic in the body gets calcium deposit, and CAT scan is excellent to detect that, and it gives us a number from zero to like a thousand. The higher the number, the more likelihood the cholesterol builds up and the coronary artery disease.

So, we define or how we find coronary artery disease, there are certain tests we do, from EKG, from stress test, et cetera, we do that to diagnose. Obviously, it's very important, like, symptomatic versus asymptomatic. And as I mentioned earlier, asymptomatic coronary artery disease is much more common, and it's very prevalent. It's actually one of the leading cause of death in the United States, up to 22% of death in the United States caused by coronary artery disease. It's definitely more than cancers, accident, stroke, et cetera.

Host: That's a sobering statistic. So, you do have a variety of diagnostic tools. When someone is diagnosed, what does treatment look like day to day?

Ahmad A. Hadid, MD: The treatment, it's really from relieving symptoms if patient has angina. Angina is any discomfort in the chest that's brought on by exercise or by mental stress. From relieving symptoms to preventing heart attack, to improve heart function, to obviously reduce complicationsand prolong life, it mainly really again and again goes back to the risk factors, that modifiable lifestyle changes like stop smoking. Regular exercise, obviously advised by a doctor, recommended to do like seventy-five minutes or so a week, two, three times a week, thirty to forty minutes, moderate exercise. Heart-healthy diet, low saturated fat, more fruit, more vegetables, more grain, less salt, less sugar.

In the last, ten, twenty years, we're going to, like, lower carbohydrate diet. Weight control is very important. Overweight and obesity is an epidemic in the United States. And it's interesting to see the data, like reviewing the average adult weight in the United States in the last 30, 40 years has gone up, average in the whole population gone up in the last forty years. Recently, obviously, there's data that is maybe changing with the new use and utilization for some of the medicine, that we are all aware of the Ozempic, Wegovy, et cetera.

The other thing is stress management. Stress is really kind of semi-quantitative risk factor for heart disease. And obviously, the other risk factor, controlling blood pressure, make sure the blood pressure is good and, as I mentioned earlier, is a, like, silent killer because we really don't feel our blood pressure. And if we feel blood pressure, that's really not good because that's really significantly high.

And this kind of like misconception and, you know, I get a lot of patient tell me, "Oh, I feel when my blood pressure is up,' it's usually not. Diabetes, controlling diabetes is really a cornerstone of treating coronary artery disease, getting the diabetes better. They are kind of like really interconnected, diabetes, the weight, the exercise, the diet, obviously the cholesterol lowering. We know cholesterol is a major risk factor for coronary artery disease, bad cholesterol.

The LDL, I always use it like HDL, like the happy HDL is the positive cholesterol or good cholesterol, the one that clear cholesterol. And that's really from lifestyle changes, obviously, to come to medication and procedure, et cetera, et cetera.

Host: You're describing a lot of things that can relieve symptoms and improve heart function, lifestyle, including stress management and diet, and taming other conditions with medications like diabetes. How effective is this? A lot of people have heard of stents and bypass surgery. So, how often do you have to go to that step?

Ahmad A. Hadid, MD: In acute coronary syndrome, that is a totally different, obviously, scenario. When that applies to somebody who's having we call it crescendo angina or chest pain that is not relieved by rest or sometimes with medication, nitroglycerin, et cetera. We always, always advise patient if he has symptom that is really not getting better concerning like a crushing chest pain, sometimes nausea, et cetera, to seek medical help to find out if it is due to acute coronary syndrome or no.

Acute coronary syndrome, a patient with coronary artery disease for a long time, usually they get reproducible chest pain that comes with the stress or exercise, and when they rest, they feel better. They have it for a long, long time, and it's kind of predictable. This is one totally different category than patient who comes with a chest pain that does not go away. Those patients, we really advise them to go be evaluated, get an EKG, go to emergency room, and be tested because it saves life. It saves lives to stop the acute coronary syndrome, to bring the blood supply back to the heart muscle to save it.

Those are the people that need to go to the hospital to be evaluated to make sure they're not having a heart attack. Well, that's a major thing. In St. Luke's Hospital, we've been doing cardiac cath and angioplasty for almost two decades. We started the angioplasty program there, after in New York State there was like a couple of studies showing that it could be done safely and effectively in a hospital without backup bypass surgery.

Traditionally, for the catheterization and angioplasty, actually angioplasty is done in a hospital where they have bypass surgery. And that used to be a requirement because angioplasty at one time was more dangerous. Currently, angioplasty could be done safely with a very low complication risk if it is done obviously, correctly. You know, certain selection protocol and quality control, et cetera, et cetera.

So for the last almost 20 years, we've been doing that in St. Luke's Hospital and, obviously, serving the community. But again and again, the treatment of coronary artery disease is very important. The chronic stable coronary artery disease versus acute coronary artery disease, major, major difference.

Host: And I just want to mention for listeners that we have another podcast with you that is more in depth on angioplasty. Should people be interested, you can look for that. Once someone has had a heart attack or a stent placed, what does recovery and long-term management look like? Is this something they manage forever?

Ahmad A. Hadid, MD: prevention of coronary artery disease, it is a lifelong process. Acutely, once patient has heart attack or has an evidence, you know, showing the coronary artery disease, it's really lifelong process and management. And we talk about the risk factor, and lifestyle earlier.

There's obviously also medication, which is definitely additional benefit. As simple as aspirin, you know, a lot of time if somebody's having even acute coronary syndrome, we ask them to take four baby aspirins. It's been traditionally used 162 to 325 milligram of aspirin, do it acutely and it helps actually.

It's been shown in a study of acute myocardial infarction that it prolonged life, it decreased mortality since the 80s. It was used at one time when we did not know aspirin was as effective as thrombolytic therapy, the clot buster. It was done, international study in Italy where they used a thousands of patient and aspirin decreased mortality, prolonged life in patient with acute coronary syndrome and that what established it in the '80s.

And as I said, it's as effective as thrombolytic therapy. And, even after that, there was we call with the study, we use certain arm aspirin versus no aspirin, thrombolytic like streptokinase, the oldest one, versus no streptokinase, and both of them together versus not. And that really established the treatment in the '80s for heart attack patients to give them aspirin and streptokinase. This is one of the simple medicines.

The other medicine really the statin. Statin, the cholesterol medicine like atorvastatin, the brand name called Lipitor. Statin has been also a cornerstone in the treatment. It's called 4S study, the Scandinavian study, when they use, actually, brand name Zocor, or simvastatin. And it did show that it decreased heart attack incidence, prolonged life, decreased stroke, decreased bypass. So, these are one of the cornerstones of the treatment for coronary artery disease. And obviously, we give medicine to improve symptoms like nitroglycerin, which opens up the artery and give more blood supply to the heart and also decrease the heart work because it works magically. And it clearly works, nitroglycerin.

Also, some other medicine, we use it after heart attack and damage in the heart muscle, we call it ACE inhibitor like ramipril or altace. Those medications, all of them, they've been studied and proved they prolonged survival in patient with coronary artery disease and decrease heart function. As what we know, a heart attack makes the heart weaker, and it cause heart failure, et cetera. And other medications like beta blockers and calcium channel blockers. These are the medications before we talk more about obviously procedure.

Host: Dr. Hadid, you've touched on what's new in how we treat this disease as a result of studies that have been done. Are there any recent breakthroughs that patients should know about?

Ahmad A. Hadid, MD: heart disease and coronary disease is ever important and evolving process. The guideline and the standard therapy, as I said, it is really evolving and we are utilizing it actually in St. Luke's Hospital. So, the guideline, if patient comes with heart attack and, you know, special set of heart attacks called ST-elevation myocardial infarction, where the heart artery is totally 100% blocked, and it showed on the electrocardiogram, EKG, where we call it ST elevation myocardial infarction, the best treatment and decreased mortality really we call it reperfusion therapy.

Reperfusion is where the blood supply to the heart is reestablished. And this guideline has been standard if it's available to open the blocked artery with balloon and angioplasty. And this is since 2000 or 2004 or so. It's been the standard therapy. Before, and I've been here for 30 years, before we used to give thrombolytic therapy in the '90s. And actually, thrombolytic therapy is definitely improve survival, but it has risk of bleeding and bleeding into the brain, et cetera. And it's better obviously than no thrombolytic therapy. But however, the angioplasty, it's a safer way, more effective way to restore good flow to the heart muscle faster, sooner, and safer.

If we look into the study of thrombolytics clot buster versus the balloon angioplasty and stenting, clearly stenting will win and, clearly, is a standard therapy nowadays in a place where they do angioplasty, like in St. Luke's Hospital.

And time is really the essence. You know, with those therapy, the heart muscle, you know, time is a muscle, we call it. The sooner we restore flow to the heart muscle, the better the outcome. Obviously, the chest pain stops, the heart necrosis or dying of the heart muscle stops. It improves the heart function, decreases heart failure, save life our patients feel better, all those good outcomes from that. and we've been doing that for like almost two decades in St. Luke's Hospital

Host: It's encouraging that we keep perfecting and understanding treatment of this disease. If someone listening right now has a loved one, a parent or sibling with heart disease, what's the single most important thing they can do for themselves today?

Ahmad A. Hadid, MD: To check themselves, obviously check their loved one. As we know, family history is a risk factor for coronary artery disease. You know, like recently, I had a patient, his grandfather died at age 55, or their father died at age so and so young age. And that, you know, really should prompt them to be checked and to look for the risk factors, and try to modify that because it could be modified. We could help the patient. We do that all the time, and it makes all the difference. it's a very, very important thing. That's what we do, and that's how obviously we help our patients and community.

Host: Well, Dr. Hadid, thank you for this comprehensive overview of the facts and treatment of coronary artery disease. Really appreciate it.

Ahmad A. Hadid, MD: Thank you very much. Thank you. It's been my pleasure. As I said, I've been working here for 30 years in the community. I'm happy to help and happy to be part of this community.

Host: That was Dr. Ahmad A. Hadid. To learn more about Montefiore St. Luke's Cornwall's cardiac services, visit montefioreslc.org. Please remember to subscribe, rate, and review this podcast and all other Montefiore St. Luke's Cornwall podcasts. This is DocTalk, presented by Montefiore St. Luke's Cornwall. Thanks for listening.