Ask the Doctors September 2014 Issue

Ask The Doctors: September 2014

Q. My daughter is a sedentary 51 year-old, with normal BP (105/60), whose recent mammogram showed extensive vascular calcification. She has no history of cardiovascular disease (CVD) other than leg swelling caused by peripheral venous insufficiency. Her grandfather died of a stroke/heart attack. Should we be concerned about the arterial calcification? Is treatment indicated only if she has serious coronary artery disease (CAD)?

A. Yes, you should be concerned. Vascular calcifications (abundant calcium deposits in the walls of blood vessels) are never normal. And despite the fact that they are commonly seen in elderly and diabetic individuals, finding them in a 51 year-old woman is unexpected and premature. One of the most compelling pieces of evidence we have is from 1998, when Dutch researchers published a study evaluating the relationship between breast arterial calcification (BAC) and death due to cardiovascular causes in a group of more than 12,000 women aged 50-68 years undergoing screening mammography. At baseline, BAC had been detected in just nine percent of this population, and only four percent of those in your daughter’s younger age group of 50-55 years. Women with BAC were 60 percent more likely than those without BAC to already have an established history of CVD. After adjustment for the risk factors of age, diabetes, hypertension and smoking, individuals with BAC were about 30 percent more likely to die of CV causes, and 44 percent more likely to die of CAD during the followup period, than those without BAC. Even their total mortality risk (death from any cause) was about 30 percent higher. Although other studies have produced conflicting results, most evaluating this topic have had similar findings. Research published in 2012 found that BAC predicted a 60 percent greater risk of obstructive CAD than for those without BAC.

While these data would appear to paint a rather grim picture, bear in mind that the Dutch study evaluated women primarily before 1990, when drug therapy of cardiovascular disease was much less effective than it is today. Given the lack of smoking and significant family history (grandfather does not count given that he is a 2nd degree relative), she has less genetic and environmental CV risk to combat. I recommend that your daughter see her primary care physician, obtaining a referral to a cardiologist or vascular medicine specialist, who could then assess her total cardiovascular risk. He or she could then institute aggressive preventive therapy, which is indicated whether she has obstructive CAD or not.

Q. Can you reverse heart failure? I know there are new procedures, pumps and medications used to treat it. But can you actually undo damage that has weakened the heart?

A. Unfortunately, the direct answer to your question is no. Given our current understanding of the disease, from a molecular level up to whole-body physiology, damage done to the heart’s muscle tissue (myocardium) is not reversible. Treatments are focused upon maximizing residual heart function, and preventing it from getting worse (which will inevitably happen if heart failure is left untreated). Appropriate medications, including a beta-blocker, ACE-inhibitor or ARB, vasodilator and other drugs are the most helpful treatments we know to help improve symptoms and prolong life. Equally important is lifestyle therapy, which includes a low-sodium diet and daily exercise. Finally, an implantable cardioverter-defibrillator (ICD) to prevent sudden cardiac death is known to benefit many types of heart failure patients. If felt necessary by one’s cardiologist, the ICD can also provide pacing to both ventricles, which in most cases will lead to an improved clinical scenario. One investigative treatment which holds promise to rejuvenate injured myocardium is stem cell therapy, which is still undergoing further study and improvement.

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