The procedures that we’ve been discussing are usually performed in cases where only one or two arteries are blocked, though there are exceptions. It’s important for you to realize that such procedures are palliative-that is, they relieve the condition, they avoid heart surgery, but they do not free the patient of coronary artery disease. These procedures are more likely to be effective when patients are ready to take charge of their own destiny by giving up cigarettes, by exercising daily, by reducing stress when possible, and by learning better methods of stress management. And, of course, lowering cholesterol is important.
Even under the best of circumstances, these procedures

require, before you submit to them, that you talk openly with your doctor about an alternative plan. Once again, if the doctor is offended or evasive in response to such questions, or if you have the impression that the doctor is too busy to answer your questions, you may need to find another doctor. Again, it’s your job to be courteous, open, and nonthreatening. It’s the doctor’s job to give you all the information you ask for.

It’s true that some patients don’t want to know. But if you were one of them, you wouldn’t be reading this book. In general, the better informed you are about a procedure and about what may follow, the less worried and the less anxious you’ll be. And the less worried you are, the better for your heart.

One patient who had refused angioplasty treatment later explained: “It wasn’t that I didn’t want the angioplasty. But the doctor seemed in such a big hurry, like I wasn’t important to him, I guess I was just scared. I wish I had asked more questions.” Take those words to heart. If things are moving faster than you’re comfortable with, slow them down. Ask your questions. (You’ll find more on this subject in Appendix 1, “Your Rights as a Patient.”)

Procedures involving the heart-coronary bypass surgery. angioplasty, stenting, or atherectomy-can be stressful anc even scary. Ease your mind by asking questions and gaining knowledge. Besides relaxing you and relaxing your doctor, this tactic lets the doctor know that, as an inquiring and informed patient, you have high expectations of him or her and of the hospital.

Now let’s look at a slightly different angle. Because Dr. Schaeffer doesn’t consider Bigger’s condition immediately threatening, and because Bigger is a cooperative and smart patient, the doctor has decided to begin treatment with methods that aren’t invasive. If after a few months the improvement isn’t what Dr. Schaeffer has hoped for, he still has several resources he can turn to instead of surgery. Remember that coronary disease means that the arteries are dogged and therefore the heart isn’t getting enough oxygen-rich blood. Whatever the treatment, it must address that basic problem. In the case of a patient for whom exercise, diet, and stress- relief measures don’t bring about the necessary improvements or stability, there remain several options for nonsurgical treatment. These include angioplasty, stenting of an artery, and atherectomy.

Angioplasty

The most common of the treatments we’ve named is angioplasty. It’s an outpatient procedure-that is, you usually go home the same day the procedure is performed or the next morning-pc formed by a cardiologist, in the cardiac catheterization lab 0= hospital.

The procedure itself begins with the insertion of a sn: wire, called a catheter, into the blocked coronary arteries. A c. loon is attached to the end of the catheter and the catheter advanced into the arteries that surround the heart. The cardio. gist can monitor the progress of the catheter on a TV sere called a fluoroscope. With the heart and the blood vessels t. surround it always in view, the cardiologist steers the balloor; the center of the blocked artery. Then the balloon is infla.. causing the blocked vessel to reopen.How does the catheter find its way to the blood vessels of the heart? \Nell, it’s a little bit like following the yellow brick road. The catheter is inserted in any large blood vessel-usually in the groin area-that leads to the heart. From there, the catheter just follows the path back to the heart.
Angioplasty is usually recommended for patients who have one, or sometimes two, severely blocked coronary arteries. It is also performed in situations where, for whatever reason, heart surgery is considered dangerous or impractical. Generally, angioplasty is painless and straightforward. The patient is mildly sedated with a local anesthetic (that is, the area to be treated is numbed, just as it is in your dentist’s office). Angioplasty is a common procedure, performed in university hospitals, teaching hospitals, and community hospitals all over the country.
Naturally, in this treatment as in all medical treatments, there can be a downside. In this case, the risk is that the blood vessel that’s been opened can close again, or the blood vessels can tear open (rupture). You can playa significant part in raising your odds of having a successful procedure by finding out as much as you can about the product,
which, in this case, is your doctor’s competence and experience, and the reputation of the hospital in which the procedure will be performed.
You need to ask your doctor how many angioplasties he or she has done and the success rate of these procedures. Don’t be embarrassed. You have an absolute right to know. So ask the following questions, politely but firmly, and expect answers:

•    How many angioplasties have you personally perform- .
•    In what percentage of the angioplasties you perform d
the arteries close again?
•    What is your success rate?
•    What happens if the angioplasty doesn’t work?
•    What complications are possible, and how do you deal
with them?

Most well-trained board-certified cardiologists will have no tr: ble answering these questions freely and openly. If your docto: defensive, refuses to answer your questions, or seems offended, t should raise a red flag. You need to what you can to keep the commun.: tion going, and that means asking: questions again, if necessary, in most friendly and unthreatenin~ ” you can. If you still don’t get a satisf: tory response, you’d be wise to ref the procedure with that particular c. diologist. You can find a better more open to his or her patients, more likely to win your cor dence. You want no less. After all, next to God, the cardiologis: the person who will carry your life in his or her hands.

Stenting

A second nonsurgical procedure for opening blockages in a y;; sel, and which is used in conjunction with angioplasty, is stenti A stent is a very small coil that keeps a blood vessel open once has been cleared by angioplasty. The cardiologist first locates t. “culprit” artery-the one where the trouble is. He or she opens that vessel with an angioplasty procedure. The cardiologist then inserts the stent. It’s that simple. Although the results vary, depending on the extent of the damage and on the cardiologist’s experience, in general, angioplasty with stents works even better
than angioplasty alone.

Atherectomv

Finally, your cardiologist may suggest, rather than angioplasty or stenting, a procedure called atherectomy. Here, a small device is inserted into the blocked artery and cuts through the blockage. Atherectomy is only performed by the most experienced cardiologists and, in general, it’s less effective than angioplasty or angie-
plasty with a stent.

Exercise is an essential part of heart treatment. Exercising regularly lowers blood pressure and cholesterol. It lowers cholesterol by allowing your body to metabolize it more effectively-that is, to burn it off. We often forget that the heart is a muscle and that it needs exercise just as other muscles do in order to remain efficient and strong.

Excess weight means more work for your heart-more wear and tear. Talk to anyone who works out at a gym or at homeabout how exercise lowers stress lev-els. Life is stressful, and it can be especially stressful for African Americans. Although we can’t always eliminate the causes of stress, we can do something about the effects. In chapters 5 and 10, we describe exercise routines that are easy, fun, and uiat relieve stress and bring about the other good things we’ve described.Maybe you’re going to tell us that you know lots of people who exercise regularly and still have heart attacks. Maybe you even remember the famous Flo To, who died of a heart problem despite being in ultimate shape. It’s true: Life isn’t always fair, and life isn’t always consistent. We know a lot about the heart, but mysteries remain.

What isn’t a mystery are the odds. For every ten people whc keep in shape and nevertheless die of heart disease, thousands die due to lack of exercise, and because they don’t control their cholesterol and blood pressure levels. You’re smart enough tc play the odds. Exceptional cases like that of Flo Io aside, if you have a strong heart as a result of exercise and conditioning, even if you have the misfortune to suffer a heart attack, your chances of surviving are greatly increased. Do you want to live longer and live better? Play the odds.

WE’VE BEEN TALKING ABOUT what the symptoms of coronary artery disease( CAD) tell you if you listen to them. We haven’t said much about what happens
after the doctor tells you that you have coronary artery disease. Is surgery the only solution? And, if not, how do you and the doctor choose between treatment options?

Let us introduce you to Bigger Gordon. Bigger has a lot going for him. He’s bright, energetic, and takes pretty good care of himself. He doesn’t drink, and he plays basketball once a week in his church league. True, he smokes-”a little,” according to Bigger, and “a lot,” according to his wife. But, he says, his work has its tensions, and cigarettes and an occasional CIgar help him to handle stress.

Bigger is a well-educated man who graduated at the top of his class from Hampton University in Virginia, and his life has been good so far. He’s an excellent father to his two kids, and: and his wife are the best of companions. As for his job, it’s the je he was born for, as he often says. As the first African American ~ hold the position of vice president of finance in a multi-rnillio:’. dollar company, he’s determined to be better than the best. Tl.. means some stress, but he seems to thrive on it. There’s nothi-’. Bigger has looked forward to more than going to work ea, mornmg.

But all that has changed for Bigger since the spring of 199 when, after two weeks of slight pressure in his chest, he awo. one morning with alarming chest pain and presented himself L examination at the local emergency room. Bigger had a pret: good idea of what he was in for. Coronary artery disease runs : his family. He saw his mother die from it, and his father becan: . a semi-invalid because of congestive heart disease.

In the emergency room Bigger was put through a full cardia: workup: physical examination, lab work, chest x-ray, and electrc cardiogram (EKG). Meanwhile, the emergency doctor called in cardiologist, who, on the basis of the examination and test; agreed with the diagnosis of unstable angina.

“Tell you what, Mr. Gordon. Let’s do one more test-a corenary angiogram. That’ll give us a closer look at the arteries ar; help us to evaluate any potential damage. From there, we C2know better what we have to do.”

What the cardiologist, Dr. Schaeffer, came up with wasn’t “l. ~ best of news, but it wasn’t the worst either. He found that tl: ~ main artery that feeds the heart was 20 percent blocked, and ther: was blockage in several minor arteries. But Dr. Schaeffer didr: recommend surgery. “I think that this can be satisfactorily treate : without that,” he said. Bigger took the news with mixed feelings. Nobody loves the idea of going under the knife. At the same time, the analytical part of his mind was uneasy. “Look, Dr. Schaeffer, I certainly don’t want surgery if I don’t need it, but I need to get this fixed, I don’t like the idea of messing around with it for years, waiting for the other shoe to fall. Maybe it would be better to go in and get the whole thing taken care of now-you know, to have the surgery and get this all behind me.” ”I’ll tell you what, Mr. Gordon. You listen to what I have to say. Then, if you still feel uneasy about my recommendation, we’ll call in another cardiologist.” Bigger knew how to listen. And what he heard was roughly this: In a sense, heart issues are lifestyle issues. The way we eat, the way we spend our days, the substances we ingest, the way we manage the inescapable stress in our lives-it all bears on the health of our heart. If all Americans consciously controlled their cholesterol, their blood pressure, their diabetes, if they smoked and drank less and exercised more, coronary artery disease would be much less of a problem than it is.
Much of what hurts the heart is avoidable. And, though most people aren’t ready to hear this until after they’ve had heart trouble, even after the heart has suffered injury it’s not too late to change habits, and, by changing them, to help the heart to heal. The patient is in large part his or her own doctor. For instance, before he even mentioned medication, Dr. Schaeffer told Bigger at once that an essential part of his treatment was to stop smoking. “It’s up to you, Bigger;’ he said. “I can only give you the facts, and the facts are these. Cigarette smoking is dangerous and can be lethal to every organ in the body, and especially to the heart. The chemicals in cigarettes directly cause damage to coronary arteries-damage that will eventually lead to blockage, heart attacks, and strokes.” “Yeah, well, I don’t want to sound cynical, but what’s the difference now, when the damage has already happened?” Bigger asked.
“Let me give you another fact,” said Dr. Schaeffer. If you keep smoking, whether you are treatec medically or surgically, your chance of recovery is decreased. Ii you have bypass surgery, smoking will lead to premature closure of the bypass grafts and will leave you as bad off as when yotstarted. I know, you hear a lot of people say, smoking’s not the worst thing in the world. They’ll tell you about friends and relatives who lived to be eighty and smoked down to their last dai Sure, it happens. But for everyone of those, thousands die of hear: attacks or heart failure for which smoking was a primary cause Those are the facts. You make the choice.”

Okay,” Bigger said. “You’ve convinced me. I’ve always tole myself I could quit when I chose to. Now I choose to. But SOlI: of this other stuff isn’t under my control. You tell me my bloc pressure is high. Well, so was my mother’s and my father’s an ~ their mother’s and father’s before them. Not much I can do abor that, is there?” “I don’t want to sound smug,” Dr. Schaeffer said, “but tl.. answer is: ‘Actually, quite a lot.’ For example, you can exercise.” “But I do, once a week-basketball in the church league. You should see me go at it. They call me “Air Bigger.”
Dr. Schaeffer agreed that was fine. “But it’s not enough,” he said. He explained that they could bring Bigger’s blood pressure down with medication, but it was more important in the long run for Bigger to bring it down by himself.
“I’ve got patients who swear by meditation. Not only do they swear by it, but as far as I can tell, it works for them. It’s one way of getting in touch with the part of yourself that isn’t stressed and that doesn’t need to run at full throttle all the time.
“We also have to look more closely at your exercise regime.

Playing basketball once a week is fine-or was fine-we won’t have you doing that until we get your heart in better shape. But the point here is that you need something regular-say three times a week in a gym, with at least 20 minutes of aerobics each time. Regular exercise lowers blood pressure. Once we have you fixed, that’s something you need to make time for. “Your cholesterol is too high. If we don’t change that, it won’t do us
much good to correct the damage that’s already been done. For you, high cholesterol means more damage to the arteries.” “So you’re going to put me on a diet of fish and broccoli for the rest of my life. Man, that’s going to be tough. I love to barbecue on the weekends.” Nothing that bad. My view is, if you’re not eating some of the things you enjoy, you may cut the cholesterol, but you’ll add to your stress,” explained Dr. Schaeffer. “The diet I’m going to recommend allows you to eat a variety of tasty things, but it requires you to keep mental tabs on how much cholesterol you take in. [The reader can find out more about this diet”I’m not saying that this isn’t a drag. vVe all want to eat what we want to eat when we want to eat it. But you’ve got to think about the trade-off. What you’re going to find, Bigger, is that, if you stick to the regime we’re plotting out here, you’ll feel better than you have for years.

“I have to say that for you it isn’t all going to be lifestyle remedies. Your blood pressure is too high, and we have to address this immediately. For a while, at least, I’m going to put you on medication. Then, when we lower your blood pressure to where it should be, we’ll see if we can gradually control it without medication.

“My guess is that if you watch what you eat, stop smoking get into a regular exercise routine, and, if it suits you, some meditation as well, we can get you in reasonably good shape. I don’t want to kid you on this. You do have coronary artery disease, and nothing can make it entirely undone. But we can have you living a healthy, normal life, and playing as much basketball as you want, but you have to stick to the plan we’ve talkec about here.

“Let me sum this all up. You have coronary artery disease that your smoking and high blood pressure have contributed tc I’m going to treat this in two ways. First, I’ll give you medicatior, nitroglycerin, that will help increase the blood flow to your heal’ when your heart is stressed. It does that by opening up the arte:ies around the heart whenever the heart needs extra blood.

“I’m also going to put you on medication to help contrr your blood pressure. [The reader can find out more about hit blood pressure, also called hypertension, in chapter 8.] But, as I’ve said, medication can’t do the whole job. You have to support it. And you do that by, first, not smoking; second, by exercising three times a week; third, by keeping your weight down; and, fourth, by eating low-fat and low-sodium foods. You’d be surprised at how tasty and varied such a diet can be-and I speak from experience. And on Sundays I’ll give you time off for good behavior and you can barbecue and eat what you want, but in moderation.
“You stick to this plan and we’ll stop the progression of your coronary artery disease-maybe we’ll even reverse some of it. I’d like you to make an appointment for a month from now. At that time, I’ll examine you and check your blood pressure and cholesterol levels, and we’ll see if you’re really in shape, Air Bigger.” Dr. Schaeffer smiled at Bigger. Bigger was lucky in one respect. He didn’t have a serious weight problem and he knew something about exercise. What if he hadn’t? Dr. Schaeffer would have told him much the same thing, but he might have had a harder time convincing him. Excess weight, or obesity, which is disproportionately high among African Americans, and especially
among African American women, is a major risk factor in matters of the heart. Often, overweight people have stopped exercising, or never did exercise.