Ask the Doctors September 2011 Issue

Ask The Doctors: September 2011

I have two coronary stents, but recently my doctor said I may need stents in a different artery soon. Does having multiple stent procedures harm the heart? How does a doctor determine the timing of stent placement? And are their advantages to waiting?

You pose some important questions which are frequently encountered by patients and their cardiologists. One factor which helps determine if a stent should be placed is the patient’s clinical presentation. For example, if someone is experiencing an “unstable coronary syndrome,” such as a heart attack or unstable angina (in which chest discomfort or equivalent symptoms are present at rest, or are worsening rapidly over a period of days to weeks), then there is a definite advantage to undergoing stent placement. Patients with unstable coronary syndromes who get a stent are less likely to experience heart attacks in the future, and are more likely to live longer. However, those with stable or very slowly progressing symptoms represent a more complex situation. Study data indicates that stenting such individuals can improve symptoms better than medication and lifestyle changes, but does not tend to reduce risk of future heart attacks, and does not prolong life. We refer to this type of stent placement as “elective,” because the patient (guided by their doctor) is choosing to get the procedure done, rather than being forced to do so by an emergency.

Cardiologists should not place coronary stents based solely upon the percent blockage of the artery. The severity of patient symptoms (which may include chest discomfort, shortness of breath, fatigue, or other complaints) helps determine if elective stent placement is desirable, and how soon it should be done. Patients with concerning symptoms and an abnormal stress test have a reasonable indication to undergo stenting – to relieve their symptoms. However, placing stents in individuals with an abnormal stress test but without symptoms is more controversial, and an argument can be made for treating such patients with medications and lifestyle modifications. Elective stenting can often be delayed, since the major indication to perform it is symptom-based. Finally, multiple stent procedures do not harm the heart. However, the more invasive procedures one undergoes, the higher the likelihood of experiencing complications. I would recommend you discuss the relative risks and benefits of elective coronary stenting with your cardiologist.

Exercise guidelines seem to be geared toward people younger than 65. I’m 78. What are the exercise recommendations for those of us who are older?

The American College of Sports Medicine (ACSM) and the American Heart Association (AHA) have published exercise recommendations for various age groups. Older persons should engage in moderate-intensity aerobic activity at least five days per week, or vigorous-intensity aerobic activity at least three days per week. On a subjective 10-point exertion scale where 0 is sitting and 10 is maximal effort, “moderate” is defined as a 5 or 6, and causes noticeable increases in heart rate and breathing. “Vigorous” is a 7 or 8 and produces large increases in heart rate and breathing. Moderate exercise should be performed for a total of at least 30 minutes per day, and can be split into bouts of at least 10 minutes each. Vigorous exercise should be continuous for at least 20 minutes per day.

Also recommended is muscle-strengthening activity with weights at least two days per week, with at least 8 to 10 different exercises involving the major muscle groups, using 10-15 repetitions per cycle. Flexibility and balance exercises a minimum of two days per week are suggested. If you are unfamiliar with regular exercise, you should seek the help of an exercise physiologist or personal trainer to help tailor the type, level, and duration of exercises that best suit your needs. The exercises described above can lead to improved health and sense of well-being.