Ask the Doctors December 2011 Issue

Ask The Doctors: December 2011

I had some bleeding in my leg when I had a stent put in the first time. I have to get another soon. How does a doctor decide to go in through the leg or the arm?

The cardiology community has been engaged in considerable discussion lately regarding the possible advantages of performing heart catheterization procedures, or “caths,” through the arm.  The first step in a heart cath, getting into a major artery, is known to doctors as “vascular access.” This can be obtained either through the groin, via the femoral artery, or through the arm, via the radial artery in the wrist or the brachial artery in the elbow.  The main goal of a cath is to inject contrast dye into the coronary arteries and create an X-ray movie of them, to see if severe narrowings are present. Sometimes, as in your case, stents need to be placed to open them up.

While femoral artery access is the mostly widely used approach, during the past 10 to 15 years, especially outside America, there has been a resurgence of interest in arm access. Catheterization through the radial artery can be achieved with tiny needles, small catheters, and without an incision. Published data from several hospitals suggest that radial caths are equally successful to femoral caths, but at the same time lead to fewer complications, including bleeding. It is also reasonably argued that patient comfort and convenience are improved, since bedrest after the cath is not required. Some downsides of radial artery caths are that they are more technically challenging, can take longer to perform and result in more radiation exposure, and that permanent blockage of the radial artery occurs in a small percentage of patients. This last complication is generally not clinically significant, since all persons undergoing radial cath are first checked to make sure a dual blood supply to the hand (via the radial and ulnar arteries) is present.

Two factors determine if radial artery access is chosen by the cardiologist: 1) the cardiologist’s experience and comfort level doing the procedure by that route; and 2) whether the patient sustained a complication by an alternate route. In your case, it would certainly be reasonable to consider radial access, given your past bleeding complications in the groin.

I was told I’m “pre-hypertensive.” How often should I see my doctor and check my blood pressure. And how often should I have my cholesterol levels or glucose levels checked?

In general, the frequency that you should undergo medical evaluation for blood pressure (BP), cholesterol, and glucose levels is inversely correlated to their degree of control.  Translation? The worse the numbers, the more often you should be getting a checkup. Your doctor mentioned that you were “pre-hypertensive,” a term used to describe someone whose systolic BP is between 120 and 139 mmHg, or whose diastolic BP is between 80 and 89 mmHg. All such patients should pursue therapeutic lifestyle changes in order to bring their BP down, including weight loss, dietary modification (eating a low-fat, low-sodium diet rich in fruits and vegetables), exercise, and moderate alcohol intake. People in the pre-hypertensive range, who are not being treated with BP medications, can generally followup every three to six months with their doctor. Those taking meds should be evaluated monthly, until their pressures are under better control. With a home BP monitor, it is reasonable to check the BP twice a day: once in the morning, and again in the evening. Each time you check, it is useful to take three measurements, and obtain an average, to ensure the values are consistent.  It is important that you bring your home BP monitor to your doctor’s office to verify its accuracy.

Regarding blood glucose levels, diabetic patients will, of course, check their levels several times a day. Nondiabetics can have their fasting blood glucose checked every three to six months. The same is usually true for checking cholesterol, depending on whether or not drug treatment, such as statin therapy is being used, and whether or not the dose has recently been changed.