Affairs of the Heart

MARY CHEN of the Sunday Mail  has an intimate look at modern cardiovascular care and the age-old saying that prevention is better than cure

For 20 years, Dr James Adams, an invasive cardiologist based in California, has been performing angiograms and angioplasties on heart patients as part of cardiovascular medicine procedures.

And during this time, one question remains uppermost in his mind - why are doctors treating a disease that had developed many years before instead of preventing it from happening?

"It is so much harder to treat cardiovascular diseases after symptoms surface, particularly in a heart attack, and what the cardiologists can do then is often too little and too late.

"We were treating the problem from the wrong end, when we should be looking at prevention," he said.

Today as medical director of HeartScan San Francisco, California, Dr Adams no longer performs angioplasties (a procedure where special balloons or stents - tiny mesh tubes – are inserted into the heart to open up block arteries). Instead, he devotes his time to help prevent people from developing life-threatening cardiovascular disease.

Coronary artery disease begins in most individuals when they are in their early 20s , some times even during adolescence. This process, called atherosclerosis, usually starts with cholesterol build-up in the wall of the artery. By the time they are 40 years old, 90 per cent of people will have some form of atherosclerosis in their heart vessels.

"We are more interested in identifying coronary atherosclerosis in apparently individuals aged 45 and above with no standard cardiovascular risk factors," he said.

"When you came in with symptoms such as chest pain, you are already suffering from obstructive coronary artery disease, with clogged heart arteries."

He feels cardiologists are currently, are in focusing at the lumen (the opening) when the disease lies in the wall of the arteries.

"When we see a stenosis (narrowing in the artery), our first reaction is to stent it out and that is the continuing battle when treating atherosclerosis (thickening of the blood vessel, because cholesterol build-up or plaque is still going to occur in some other sites," he said.

The electron beam computed tomography (EBCT) scan may help doctors gauge the risk for coronary artery disease, even before symptoms appear.

The EBCT scan reveals whether you have calcium in your coronary arteries, an indicator that plaque may be building up and narrowing arteries. The greater the quantity of calcium deposited the greater the risk of blockage. However, having a high calcium score is not a risk factor. It is just an indicator of atherosclerosis.

Calcium scores are classified into four standard categories:

0-10                  insignificant atherosclerosis

11-99                mild atherosclerosis

100-399           moderate atherosclerosis

400 or more     advance atherosclerosis

" If you can identify the people who are at the highest risk of getting a cardiac arrest and target them for treatment you can lower their risk of getting a heart attack.

"When we detect a person with atherosclerosis, and modify their risk factors, aggressively, it is possible to reduce their plaque buildup," said Dr Adams.

He added that having a high cholesterol level doesn’t need not necessary mean that a person would have coronary artery disease (CAD). A normal or slight cholesterol level also did not mean that you would have a lower risk of developing CAD.

Apart from high level of cholesterol, other risk factors such as smoking, high-blood pressure and diabetes can contribute to the rapid development of cholesterol plaques in heart arteries.

Studies have shown that annually, seven percent of the asymptomatic population in the age range of 50 is likely to have a heart attack.

"If you have 100 people, we do not want to treat them all. It makes more sense to narrow that population into the high risk group and treat them instead," said Dr Adams.

"If you don’t treat those in the high risk group, their atherosclerosis will progress by 30% annually and the plaque score doubles every two years. " If you treat coronary atherosclerosis aggressively, you can stop the plaques from growing and reverse the progress."

Dr Adams said the same medicine that was used to prevent a second heart attack could be used on a person who had not had a heart attack but was at high risk of developing one.

Dr Adams advised an EBCT for men above the age of 40 and postmenopausal women aged 50 and above. If you have a strong family history of heart attacks or other risks factors, you should have an EBCT five years earlier.

If the scan were normal, you can monitor your atherosclerosis with an EBCT every 5 years. If it is abnormal, then you may need to follow up more regularly.