Subtitle File Mark:1C:\Samples\z.vob
00:00:05:25&00:00:08:20#Our medical director, Dr. C. Everett Koop. 
00:00:10:01&00:00:11:17#We can plan for and anticipate
00:00:12:03&00:00:13:05#many things in life,
00:00:13:17&00:00:15:15#but illness is usually not one of them.  
00:00:16:04&00:00:17:10#What I have learned over the years
00:00:17:25&00:00:18:10#as a physician,
00:00:18:26&00:00:20:24#as the Surgeon General of the United States,
00:00:21:08&00:00:22:06#and as a patient,
00:00:22:22&00:00:24:08#is that understanding a health problem
00:00:24:22&00:00:25:20#can make a real difference. 
00:00:26:27&00:00:27:23#Over the next thirty minutes,
00:00:28:08&00:00:29:22#we will take you through the very issues
00:00:30:08&00:00:32:05#you are probably wondering about right now.  
00:00:32:22&00:00:33:26#By the end of our program,
00:00:34:16&00:00:36:05#you will have the knowledge you need to
00:00:36:21&00:00:37:23#better understand what you or
00:00:38:11&00:00:38:27#a loved one is faced with,
00:00:39:11&00:00:40:13#and what can be done about it.  
00:00:41:00&00:00:45:26#No matter what challenges lie ahead,
00:00:43:18&00:00:44:28#it helps to be knowledgeable
00:00:45:14&00:00:46:07#and to stay informed.   
00:00:48:08&00:00:48:27#So, stay with us,
00:00:49:09&00:00:51:08#because we are going to help you do just that.  
00:01:10:14&00:01:11:11#Hello, I'm Mike Schneider.
00:01:11:27&00:01:14:12#There is no question that coronary artery disease
00:01:14:29&00:01:17:03#is serious and it can get worse over time,
00:01:17:21&00:01:19:09#but it is also a disease that response
00:01:19:21&00:01:20:16#both to medical treatment
00:01:21:03&00:01:22:03#and to life style changes.
00:01:22:09&00:01:24:02#Our program is made up of
00:01:24:16&00:01:25:13#four different reports
00:01:26:01&00:01:27:02#about coronary artery disease.
00:01:27:12&00:01:28:22#In report one,
00:01:29:07&00:01:30:14#we look at how the diagnosis is made
00:01:30:22&00:01:32:20#and what is going on inside the body.
00:01:33:06&00:01:35:00#In report two, we discuss what happens next,
00:01:35:16&00:01:37:23#you will learn about what kinds of
00:01:38:08&00:01:39:08#follow up tests to expect,
00:01:39:25&00:01:41:07#what kinds of health professionals
00:01:41:15&00:01:41:28#you may encounter.
00:01:42:15&00:01:44:23#Report three explores options for treatment
00:01:45:10&00:01:46:01#and management,
00:01:46:16&00:01:48:05#and finally in report four we address issues
00:01:48:23&00:01:49:09#that frequently arise.
00:01:49:28&00:01:51:13#We'll be giving you a lot of information,
00:01:52:01&00:01:53:27#to review it, use the booklet
00:01:54:13&00:01:55:12#that comes with this program.
 In it you will find a place to write down questions
and take notes when you are with your doctor
and a list of other resources that are available.
Now our first report.
Imagine designing a pump
that would perform around the clock,
day in, day out, for decade after decade,
with no maintenance.
 The human heart is a marvel of engineering,
to do its job, it requires oxygen and nourishment,
that's where the coronary arteries come in.
Coronary from a Latin word meaning encircling.
The coronary arteries are the blood vessels that
encircle the heart and they are vitally important
to its well being.
The coronary arteries are basically pipes or
tubes that supply blood to the heart muscle,
and so the heart muscle can get the oxygen
and nutrition it needs to do its work,
which is to pump blood around
the rest of the body.
And if there is any lack of blood supply to
the heart muscle cells, then the heart muscle
is not able to squeeze as
forcefully enough to pump
the blood forward.
Coronary artery disease is a condition
in which the arteries of
the heart become narrow.
Usually as a result of being clogged with
a fatty substance called plaque,
your doctor might also use the word
"atherosclerosis" to describe the process.
The heart is a pump that is made up of muscle
called the "myocardium".
The heart muscle or myocardium contracts,
causing the heart to beat and pump blood to
all the tissues of the body.
Blood vessels encircling the heart called
"coronary arteries", deliver blood
to the myocardium.
Inside the coronary arteries,
blood carries oxygen and nutrients,
which the myocardium needs to function.
Coronary artery disease begins when fat,
cholesterol, and minerals in the blood are
deposited in the artery wall.
These deposits form fatty streaks,
which may develop into plaque.
 The process can occur slowly
over a period of years,
but eventually the artery may begin to close.
The flow of blood is constricted and
the heart muscle does not
get enough oxygen,
a condition called "coronary ischemia".
When this occurs the patient may feel
chest tightness or pain, a symptom called
"angina pectoris", or simply angina.
If someone has a funny chest pain,
they should not overlook it,
but really should seek advice as to
whether or not is
has to do with their heart,
because in fact then the next symptom
maybe a heart attack.
A heart attack could happen if a blood clot
called a "thrombus" forms
on the surface of the plaque.
If it suddenly blocks the flow of blood
to the myocardium, a heart attack occurs,
this is also called a "myocardial infarction"
or "MI",
it may result in permanent damage
to the heart muscle.
A heart attack as you know can be fatal,
it can also be a frightening wake up call,
as it was for Stanley Welch.  
I was healthy as a horse,
until 1975 when I had what
the doctors call anterior MI.
Certain job pressures had
got the best of me,
and I was really stressed out
and I tried to pick up the piece of
metal out of the snow,
and that's when it happened. 
Doctors don't know exactly what
causes one person to develop
the disease while others don't,
but they do talk about risk factors,
for example if someone in your
family's had it,
doctors also consider your age
and your race,
African-Americans are more likely
to develop coronary artery disease.
The chances of getting the disease
also arise if you have
high blood pressure,
a high cholesterol level,
if you're over weight,
or have diabetes,
and if you smoke cigarettes you are
dramatically increasing the risk.
Thirty to forty percent of deaths
due to heart attacks,
are linked to smoking.
Now lets take a moment
to review some of the words
you may have come across,
cholesterol is a fatty substance
that can deposit in the wall
of the artery, and may develop into plaque.
This build up of plaque can lead to
a condition called "atherosclerosis",
your doctor may refer to the blockage
in the artery as a "lesion".
When less blood and therefore
less oxygen get through to the
heart muscle, you have "ischemia",
which causes a painful feeling
called "angina pectoris",
those are two Latin words
that mean choking and chest.
But the pain is not always just
in the chest, it can also feel like
and upset stomach, lower back pain,
or even a pain in the jaw.
When a clogged artery is closed off
by a thrombus or a clot,
a myocardial infarction or
a heat attack can occur.
Preventing one is the primary goal.
The severity of your condition
and your overall health will
determine what happens next,
after the diagnosis.
The truth is, some things in your
day to day life may change,
you will need to take personal
responsibility for scheduling
doctors appointments or
remembering treatment plans,
and you will want to know
what may lie ahead for you.  
The severity of your disease
and how you're feeling play a role
in what happens after
coronary artery disease is suspected
or diagnosed.
You may have already undergone
or about to undergo a stress test.
The electrical changes in you heart,
can be recorded with a electrocardiogram,
known as an ECG or EKG.
Tests like these can give your doctor
a more complete picture of the health
of your heart.
In general, there is a sequence of tests
the patients go through,
usually starting with the simplest,
working up to the more complicated
and evasive procedure.
Often deciding how to treat
coronary artery disease requires
inside information,
from coronary arteriography
also called an angiogram.  
The angiogram supplies a physician
with very important information regarding
the anatomy of his heart.
It in essence creates a roadmap telling
the physician where the blockages are
in the arteries
and how severe they are,
and which arteries are involved.  
The other thing it tells you about is
what has been the consequence to
coronary insufficiency over time,
has the heart muscle been hurt.
The angiography is done in the cauterization
laboratory or cauth lab of a hospital
 A cautheritor is a very thin tube,
it is usually inserted into an artery
in the groin or the arm.
It is threaded through the blood vessels
into the coronary arteries.
A dye is injected that shows up on a x-ray,
so your doctor can see what's going on
inside the coronary arteries.
The angiogram shows how well
blood is flowing through the arteries,
because the dye seen on the x-rays
travels in the blood.
A normal artery allows blood to flow easily.
On this film you can see
where the flow of the dye and
therefore the blood is pinched off
 you can't see the plaque that's closing the artery,
but interrupted blood flow reveals its location.
In this way, your doctor learns precisely
where your artery is clogged.  
As with all procedures,
you should discuss with your doctor
the risks involved.  
So far we've heard for several cardiologists,
but along the way you might be referred to
other specialists as well.
From a nutritionist to a cardiothorasic surgeon
who is a chest surgeon.
Your primary care doctor may also play
an important role,
coordinating your care with specialists,
then continuing to over see it as you recover.  
One of the rules as a family physician
 is trying to help the patient to get back to
their quote normal status in life,
as soon as it's reasonable.  
Whether you're recovering from a heart attack
or trying to prevent one
 important decisions about treatment and
management need to be made.
That's the subject of our next report.  
Your doctor will advise you on what
treatment or management approach is
recommended for you,
it is important that once you have decided on
a strategy with you doctor,
that you do your best to stick with it.
Make sure to take notes on how your
treatment seems to be working for you,
and let your doctor know how
you feel about your progress.  
Once your doctor knows how seriously
your coronary arteries are clogged,
he or she can decide what to do about it.
Sometimes the need for treatment is immediate.
When Ernest Willms had his heart attack
his family doctor told paramedics to administer
a drug to dissolve the clot,
even before he got to the hospital.
When just about time we got to the hospital
the pain quit all at once,
and doc says well that's when the clot started to open
and let the blood through,
he says, when you were having that
pain it was doing damage to your heart.
The clot dissolving agent
and a nitroglycerin patch to relieve
his angina saw Ernest through his crisis.
After angiography,
his cardiologist decided the disease could be treated
with medication for the time being.
Your doctor might prescribe one or
more kinds or medications.
Nitrates or nitroglycerin to open the vessels,
beta blockers to slow the heart rate,
or calcium channel blockers to relax
the muscles in the artery walls.
Your doctor might also want you to take
an anticoagulants to help prevent a clot from forming,
and other drugs might be prescribe for
lowering cholesterol levels or blood pressure.
Medications cannot cure coronary artery disease,
but for many patients, they can help control it.  
So persons who are taking medications,
many of them could be followed for many,
 many years and depending on the risk factor profile
of the progression of the disease,
they may never require open heart surgery or
angioplasty.
Open heart surgery and angioplasty are the two most
commonly used procedures
when it's necessary to go beyond medication.
Angioplasty starts out just like an angiogram,
the doctor inflates a balloon, just like this one,
inside the artery to open it up.
The balloon is placed on a catheter
and positioned inside the diseased artery.
Once inflated the balloon compresses
the plaque opening the artery,
then it is deflated and retracted leaving
the artery open so blood can flow more freely.
Some doctors follow the balloon angioplasty by
inserting a stainless steel mesh frame called a "stent",
this works as a scaffolding to help hold the artery open.
It is common for patients to feel
some chest discomfort,
I also tell them to try to reassure them know
when that happens,
so they can anticipate.
Number one that it is going to happen,
they will have pain and also that they know
that it is normal,
and thirdly that know it will be short lived,
that I'm going to deflate balloon,
blood flow will return and they will feel better promptly. 
While relief is immediate,
the affects of balloon angioplasty don't always last,
sometimes the procedure has to be repeated
because the artery gets clogged again,
or plaque builds up in another location.
For some of those patients
and for many others whose blockages
can't be treated with angioplasty,
it might be necessary to consider
coronary artery bypass surgery.    
Coronary artery bypass graph surgery uses
a blood vessel from the leg or
chest to form a bridge over
a clogged coronary artery.
The substitute blood vessel is graphed,
attached above and below the side of the blockage,
allowing the blood to bypass the obstruction.
As for double, triple, or quadruple bypass operations,
the term refers to the number of
blood vessel bridges the surgeon builds.
Whether one bypass or four, it's a serious operation.
It requires patients to stay in the hospital
about one week, after that,
several weeks of recuperation time at home
are also necessary.  
We are not actually curing the disease per sack,
it means therefore; they have to be very religious
in their rehabilitative efforts, diet,
hypertension control, exercise,
avoidance of smoking,
very careful control of their diabetes,
and control their blood pressure.
All of these things are extremely important
and should be done indefinitely in patients
following the coronary bypass surgery.  
I had no problem adjusting to the life style change,
cause as the result of the changes, I felt so good.     
It has been four years since Stanley Welch
had bypass surgery.
With his wife's help,
he watches his diet and gets regular exercise.
The doctors say you shouldn't wait
until you've had a heart attack or
surgery to make changes.
A healthful lifestyle is a must for
all coronary disease patients.
That means if you smoke,
your number one priority is to stop
immediately and completely.  
I think it is very important to understand
that if you smoke, as little as two cigarettes
a day it will put you at increase risk of
having a heart attack,
so when we talk about stopping smoking,
we really mean stop.  
A healthier lifestyle might also include
joining a cardio-fitness program in your area.
It might be at the local "Y",
or at a high-tech heart enhancement center,
like this one at Emory University.
The important thing is to have a health care
professional monitoring your new approach
to exercise and diet.
In the beginning,
when a patient comes into our program,
we see fear as one of the first things that
they have to deal with.
Now they've been diagnosed with
a heart condition,
and they don't really know how much
they're able to do.
Their family member may be saying,
"oh, you shouldn't do that because of your heart",
and that kind of thing.          
After his heart attack eight years ago,
Tom Norton had to get used to the idea of exercising.
He also had to adjust to a new way of eating.
They put me on a sixteen-hundred calorie diet,
and I was, I used to eat sixteen-hundred calories for
breakfast, but I stuck with it,
and I was determined to stick with it.
I even wanted to drink skin milk,
and don't eat any ice cream.
My wife steamed all the vegetables and fish,
chicken and turkey and no fried foods.
By bringing his weight down,
Tom's diet reduces the strain on his heart;
it's also designed to lower the amount of cholesterol
in his blood stream.
The goal for most adults is
a total blood cholesterol level
of less than two-hundred.
It's also important to know the balance between
two kinds of cholesterol.  HDLs and LDLs
 high density, and low density micro-proteins.
Think of them as little packages in the blood stream
carrying cholesterol.
Those LDLs could be carrying trouble.  
The LDL cholesterol is the bad cholesterol,
it gets deposited in the blood vessel walls
and it causes cholesterol build-ups
and hardens the arteries and potentially a heart attack.
The good cholesterol,
the HDL is like PAC-man,
it goes to the arterial walls and
chews up the bad cholesterol and brings it back to
the liver for further metabolism.
So in some way you want high levels of the high density,
the good cholesterol, you want low levels of
the low density or the bad cholesterol.
So here are two more numbers you may hear
when you get your cholesterol checked, the HDLs,
or good cholesterol should be above thirty-five,
the LDLs should be below one-hundred.
Your blood might also be checked for
high levels of triglycerides,
that's a kind of fat that is believed to contribute
to the build-up of plaque in the arteries.  
Your doctor will be keeping track of your
blood pressure as well.
Noreen Miller takes medication to control
her high blood pressure.
After two heart attacks,
and an angioplasty,
Noreen is exercising and avoiding fat
and cholesterol in her diet.  
I could say for my stand point,
that there isn't any reason why you can't carry on,
a fairly normal life with using good common sense.  
Good common sense backed up by knowledge
that's a powerful combination to have
that you share the responsibility for managing
your coronary artery disease with your doctor.  
The secret is to work with a physician
and understand that this is a chronic process,
it's a disease,
a pattern that will need chronic attention,
but with proper medical care
and proper responsibility on the patient's part,
you can return to a very active, normal, healthy,
productive life that you started with.  
Making the best of your future
means stopping smoking,
controlling your blood pressure, eating a low fat diet,
and exercising.
It also means being alert to the changes that may indicate its time to get in touch with your doctor
 or even an emergency room.
There's no question that if a change in symptoms is not understood as being a bad sign, that's just 
as dangerous as ignoring the initial symptoms, because a change in symptoms means something inside t
he coronary artery is changing, something inside our muscle is changing, and you're heading for trou
ble.  It needs to be treated.  
We're not here to recommend any particular treatment, but we can whole-heartedly endorse a healthy l
ifestyle and good communication with your doctor.  
By asking questions and discussing things
you give your doctor a better understanding
of your specific concerns,
and that's important.
Do not hesitate to ask questions,
in fact it might help to write them down
before hand.
You are not the first person in your situation
to have those questions,
and you won't be the last.  
While we were preparing this program,
some issues came up repeatedly.
So, while we encourage you to talk to
your doctor about your specific concerns,
we would like to take this opportunity to
address some of those issues.
Here to help us with that,
is Dr. Sidney Smith,
chief of cardiology at the
University of North Carolina.
Dr. Smith, good to have you with us.
Thank you Mike.
First of all, let's talk about something
that we've heard so much about,
and that is that people with
coronary artery disease should take
an aspirin a day, is that true,
does it really help prevent heart attacks?  
Absolutely, aspirin can make a difference.
If you have documented heart disease,
first of all during a heart attack or
unstable angina, it cuts mortality;
it can save your life.
Secondly, we believe now,
based on recent evidence,
that patients with heart disease taking
as little a one aspirin a day
will have fewer heart attacks and live longer.
Now there are a couple of things to remember,
the first is, you may have an allergy to aspirin,
the second is, you may have problems with
bleeding or ulcer disease.
Under those circumstances,
ask your doctor first,
but in general aspirin is good news
for patients with heart disease.  
In contrast to something as old as aspirin,
what can you tell us about some of
the new cutting edge techniques?
Well, there are some good developments there
that are worth talking about.
We've mentioned balloon angioplasty,
but there are three other areas,
where we're able to improve blood flow
in these arteries that are diseased.
The first technique are the stents.
Now a stent is like a scaffolding,
which is on a balloon catheter and
can be expanded to hold the artery open.
The second is atherectomy,
these are mechanical cutting devices
that go in and cut away the narrowing.
And the third is the use of laser technology,
initially laser technology,
we thought helped great promise,
we understand now that lasers
are good with very specific situations,
smaller arteries and what
they can do is really limited.
I think that the opportunities for stents
and atherectomy are substantial and
will make a significance difference
over the coming years.
Now there's another issue
we should address,
and that is the different kinds of fats.
There's a lot of confusing information
in the news about fats these days,
so we asked a registered dietitian,
Carol Thomason what kinds of fats
should be avoided and
what kinds of food contain them.     
The type of fat that a person with
coronary heart disease should be
aware of and try to decrease in
their diet is saturated fat.
Saturated fat is solid at room temperature;
it primarily comes from animal products
and it does cause cholesterol levels to go up
if it's an excess in the diet.
Examples of saturated fats are meats,
the fat around meats, cheeses, sour cream,
butter, lard, shortening, those types of things.
There's also an exception to that;
there's two types of oils that are from
a vegetable source yet they're highly saturated,
and those are what we call the tropical oils,
palm and coconut oil,
those are highly saturated fats even though
they're not solid, and they come from
a plant versus an animal.  
Dr. Smith, anything you care to add to that?  
Good advice there Mike,
everyone knows that cholesterol needs to be lowered.
Most people don't understand that it's fat
that raises cholesterol as well as cholesterol itself.
Average American eats thirty-seven percent fat;
we need to get it down below thirty percent.
The bag of potato chips you see,
that says no cholesterol,
actually has fifty percent fat,
and can raise your cholesterol.
So it's very important to listen to the message
and avoid fat in your diet.
Another issue patients with coronary disease often face,
is depression.
To get more information about that,
we spoke to psychologist James Bloomenthal,
who does research on depression and coronary disease.  
It's been estimated that people,
who are depressed after a heart attack,
may have up to five times the risk of dying
compared to cardiac patients who are not depressed.
So this is something that we are very concerned about,
and fortunately there are treatments out there
that are available of the cardiac patient
who is depressed.
There are a number of newer medications
that are proven to be extremely effective
in reducing depression.
And also there are a number of psychotherapies
that are available, newer psychotherapies,
cognitive therapy for example,
that are successful in reducing depression is
cardiac patients.
So there is help available to patients who need it.  
Here's one question I'm sure
you hear all the time these days,
can you actually reverse
coronary artery disease,
can the arteries actually clear up?
The answer is yes.
It's good news for patients with
coronary disease, we can't make all of
the blockages go away,
but by taking the right therapy,
by reducing fat, by not smoking,
we can keep the disease from progressing,
we can make small blockages begin
to get smaller, and we can keep patients
from having heart attacks.
We can cut the mortality from heart disease
by forty percent.  Great news
for patients with heart disease,
Mike.  
Thank you for joining us, Dr. Smith.
And thank you for joining us.
Remember, you can use the booklet that
came with this program to review key points
and to take notes.
You'll also find a resource guide
and a glossary of terms
that may be helpful.
And that concludes our series
of reports on coronary artery disease.
We wish you well!
I hope we have done our job,
and that you feel more comfortable
with the diagnosis.
The knowledge you have gained
should help you prepare for
the decisions you ma have to make.
It can also help you sort out any
additional information you receive,
whether it is from well meaning friends,
or the evening news.
Facing medical conditions involves
taking personal responsibility.
Responsibility for keeping in touch
with your doctor,
and other health professionals,
and for following their instructions.
And of course responsibility for
getting the support you need to
cope with certain issues.  
For all of us with Time Life Medical,
thank you for turning to us
at the time of diagnosis.
To help you access important information
that was covered in this program,
you may refer to your personal workbook.
You may also find additional information
related to your situation is other
Time Life medical videos.