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Interactive Learning : HealthCast Transcripts

Episode 5 :Carotid Artery Disease; FAQ's about Travel and Blood Clots

Release Date: November 6, 2006

Dr. David Meyerson: Hi, I'm Dr. David Meyerson, cardiologist at Johns Hopkins and your host for this edition of Vascular Disease Foundation's HealthCast. We're so very excited to be able to bring excellent, easy to understand science to you on all topics relating to heart and blood vessel diseases as a public service. As a public education forum, the Vascular Disease Foundation is made up of representatives of the premiere medical and science advisory groups in the country that related to vascular diseases. These are groups that use peer-reviewed science to verify that the information that you're getting is nationally recognized as the very best and most reliable data available. Prior episodes of this series have dealt with the parent organizations of the VDF, noninvasive laboratory, those tests that are done without needles, catheters or discomfort. We've spoken about peripheral vascular disease and critical limb ischemia and today we're going to be talking with a very, very special guest in a few minutes about diseases of the carotid arteries. How to prevent stroke, how to prevent transient ischemic attacks. Something that's very, very exciting, again, really preventable diseases. Carotid artery disease, the narrowing of the arteries in the neck that nourish the brain which can cause stroke and threatened strokes, some people call transient ischemic attacks. Recall, we've spoke about coronary artery disease, narrowings of the arteries that nourish the heart muscle that can cause angina, the chest pain you get when too little blood supply and oxygen gets to your heart muscle and it can also cause heart attacks. Abdominal aortic aneurysms are on a list of things to discuss in the future. These are the bulging and weakenings of the major blood vessel of the abdomen which can cause life threatening blood loss and pain and finally we have spoken about and will again, talk about peripheral arterial disease. The narrowings or the blockages of the arteries that nourish the legs which can limit your ability to walk which cause pain, ulcers of the leg, and in extreme situations, can even cause risk of amputation. The most important thing, this is the message for all of you. These are largely preventable diseases. Once developed they are very treatable diseases and the early recognition and treatments can promote your physical ability, promote your well being, prevent disability and allow you to maintain the healthiest and most active lifestyle you possibly can.

Before we get to our very special guest this evening, I want to bring back to the HealthCast microphones, Dr. Kerry Stewart. Dr. Stewart is the Director of Clinical Research Exercise Physiology at Johns Hopkins. He's a member of the Vascular Disease Foundation's Board of Directors and we have a new segment called frequently asked questions. And you actually can write in, you can go to our website, www.vdf -- that vdf stands for Vascular Disease Foundation,, O-R-G and you can submit questions for Dr. Stewart and he just might answer them in this format. So, Dr. Stewart, welcome back to the HealthCast microphones. Tell me about the frequently asked questions for tonight.

Dr. Kerry Stewart: Well, as you said Dr. Meyerson, in an attempt to be as interactive as possible with our listeners and with the visitors to our website, we'd like to answer your questions, those issues that you need clarification on so that you can be a better informed patient. And today, I thought I'd take a little bit of time answering two questions related to travel, given that it's coming up on holiday season. A lot of questions that people have sent us and here are two related to travel. The first question is, "I have P.A.D. My friends say I should wear compression stockings when traveling by air to prevent clots. Is this true?" Well, compression stockings are often used after surgery or trauma to prevent deep vein thrombosis or DVT. These stockings help prevent the pooling of blood in the legs when someone is not active. The stockings are also used to reduce swelling and help the blood return to the heart and lungs after a DVT and help to prevent swelling and varicose veins and venous insufficiency. Compression stockings are not used for P.A.D. however. In fact, they may make your arterial circulation worse. And one final question for tonight is, "Is air travel safe for people with P.A.D.?" Well, there's no known connection between P.A.D. and air travel. P.A.D. as you've heard on many episodes now is a decreased blood flow through the arteries to the legs and although it's relatively uncommon, air travel has in fact, has been associated with clots occurring in the veins. To reduce the risk of clots during lengthy flights, flex your feet and calves several times every hour or get up and walk up and down the aisle. Also, drink plenty of non- alcoholic fluids before and during the flight. I guess this will make you walk and down the aisle very quickly if you do that. And if you've had a history of blood clotting problems, you should discuss your risks with your healthcare provider before you take a long flight. And again, for more information about issues related to vascular disease, visit our website at

Dr. David Meyerson: That's Dr. Kerry Stewart, Director of Clinical and Research Exercise Physiology at Johns Hopkins. He's a member of the Vascular Disease Foundation's Board of Directors and let me also suggest of behalf of the Vascular Disease Foundation that as Dr. Stewart mentioned, walking up and down the aisles is reasonable unless you are stopped by an Air Marshall, in which case we suggest you submit immediately. I'd like now to bring to our HealthCast microphones a very special guest, Dr. Michael Jaff is Assistant Professor of Medicine, Director of Vascular Medicine at Massachusetts General Hospital, one of the best hospitals in the United States. He is a past president of the Society for Vascular Medicine and Biology and a true expert in vascular diseases. Dr. Jaff, thanks so much for spending the time with us today.

Dr. Michael Jaff: Thank you Dr. Meyerson, it's a pleasure to be here with you.

Dr. David Meyerson: Thank you. Dr. Jaff, I want to -- we've met before so if I by accident call you Michael, no disrespect. I think our audience already knows that you are a well-trained and senior person at a major medical center in the United States. There are few places better than Massachusetts General Hospital, so Dr. Jaff does come with a portfolio of wonderful training and wonderful information. I almost feel, Dr. Jaff, that this is going to be more like an edition of This Old House. We talked briefly about our analogy, our listeners have heard this before. If you had a seventy-year-old house and the plumber said that there was corrosion in one of the pipes in the bathroom on the second floor, it wouldn't for the moment, for any moment surprise you if there was a similar defect in the pipe in the middle floor or in the basement for that matter. And vascular disease is a generalized vascular process. Is it not?

Dr. Michael Jaff: It is and we certainly know that if you find artery disease in one artery in the body, it is very likely that you're going to find it in others as well. I mean, you talked about peripheral arterial disease before and there have been good studies that have shown that people who have peripheral arterial disease have a sixty to seventy percent chance of having coronary disease and about a forty to fifty percent chance of having carotid artery disease leading to stroke, so it is a common system problem.

Dr. David Meyerson: One of the things that as a cardiologist here at Johns Hopkins, also a superior medical institution I might, if you'll forgive me that, we get asked on a frequent basis to evaluate those people who are not known to have coronary or heart disease, but they're being evaluated because they have known vascular disease, terribly narrowings of the lower extremities that might require surgery. And we're often asked because one coexist with the other, again when the plumbing is bad in one area of the house, the plumbing can also be bad in another. Why I thought Dr. Jaff was such a special guest to bring to the HealthCast microphones today is to talk about carotid artery disease. Again, these are the arteries that bring blood to the brain and these arteries when they get clogged, either small pieces of plaque can break off and go up to the brain and cause stroke, you can have blood clots form. Take us into the area of carotid artery disease if you will, Dr. Jaff. I stepped on your toes a little bit, but let's take it from the top. How do you get carotid artery and why is it so important to recognize?

Dr. Michael Jaff: Well, first of all let's remember that contrary to other blood vessel problems where discomfort is often the only symptoms, so in people who have narrowing of the arteries to the heart, they can get angina as you said, or chest discomfort. If they get leg artery blockage, they can get calf or leg discomfort when they walk. Carotid artery disease doesn't hurt. And most people don't know they have it and unfortunately the first sign or symptom of carotid artery disease can be a devastating stroke. And quite honestly, most of my patients are worried more about a stroke and the ill effects of that than any other manifestation of hardening of the arteries.

Dr. David Meyerson: I would agree with that. Our patients tell us the same. They don't want to be incompacitated. They could live with little bit less heart function if they had a heart attack and we think we can treat them fairly well. They can live if they have some disability where their legs aren't working very well. We obviously like to maximize their function, but they just don't want the risk, the process of stroke and things like that of not being able to speak, of not being able to participate in their own care, not be able to communicate. It's devastating, don't you think?

Dr. Michael Jaff: It is and you know, stroke is the number one cause of adult disability in the United States. Seven hundred and fifty thousand strokes a year. It's estimated by the year 2050, there will be a million strokes every year in the United States and probably about twenty to twenty-five percent of all strokes are due to large artery blockage from the carotid arteries in the neck.

Dr. David Meyerson: Let me then go take a back door into this topic, if you will, Dr. Jaff. If you are diagnosed as having peripheral arterial disease and you either have intermittent claudication, meaning you walk half a block and all of a sudden you have to stop right in your tracks because that calf is pinching so tight, it feels like a vice grip plier that's sticking your calf. If you have that and if you're being treated for that or if you have had coronary artery disease, you've had angina, you've had angioplasty, you've had a stent, maybe you've had a bypass. Should those same people because of the prevalence of coexistent disease be asking their doctors to screen them for carotid artery disease, especially since you just told us that the first event for carotid disease is sometimes a nasty clinical event?

Dr. Michael Jaff: Yeah I think that's a great question and certainly all things being equal, patients should absolutely ask their doctor, if I've got heart artery blockage or leg artery blockage, how do you know that I don't have carotid artery blockage? Unfortunately, it's hard in today's medicine in the United States to get screened for carotid artery disease due to reimbursement climates, but in somebody who has multiple risk factors, extensive artery blockage in other vascular beds like the heart, or the legs, or they have what we hear on exam is a turbulent sound in the neck, we call a bruit. Those are the patients that absolutely should be screened for carotid artery disease.

Dr. David Meyerson: For those of our patients that like to look things up on the web. The word that Dr. Jaff just used is spelled B-R-U-I-T. It's a French word and I've forgotten what it means, but it probably means turbulence, or noise, or something like that.

Dr. Michael Jaff: Right it means noise, right.

Dr. David Meyerson: And so you would insist then, you would tell the patient if they've had an abdominal aortic aneurysmal problem, if they have peripheral vascular disease, or carotid disease, at least make sure the doctor listens to the carotid arteries, and if they can -- what do you think about the screenings that you hear in the community sometimes, about where they bring doppler studies and other types of equipment and do screenings. Are you a fan of those?

 Dr. Michael Jaff: I'm a fan of those if the people doing the test are skilled, and the patient who's having the test really needs to have it. For example, you wouldn't want to screen for carotid artery disease in an eighteen-year-old healthy, strapping person, who's never smoked, has no family history, doesn't have diabetes. That's not the kind of person where the screening is going to be of much use.

Dr. David Meyerson: The so-called pretest probability is so low that you'd probably never find it.

Dr. Michael Jaff: Exactly, but in somebody who's got coronary artery disease, and high blood pressure, and smokes, those are the people in which screening could be very effective, and if done by the right person, it can be lifesaving.

Dr. David Meyerson: Again, the very same process that causes acceleration of the hardening of the arteries, blockages, the laying down of calcium, and plaque, and cholesterol in the artery walls. That very same process that caused it to happen in the arteries that nourish the heart muscle, the coronary arteries, that happens in the peripheral arteries, the arteries that nourish the legs. That's the very same process that happens in the arteries, the carotid arteries. Isn't that true?

Dr. Michael Jaff: Absolutely true. We know that the risk factors for carotid artery disease are similar to those of artery blockage elsewhere.

Dr. David Meyerson: So tell us. If somebody says to you, I get the message Dr. Jaff. You've finally convinced me that again, we're in this seventy- year-old house, and if there's something, someplace, I need to have the plumber look in other areas. And they talk to their doctor, and they agree to get some testing. What kind of testing is done on carotid arteries to see if a blockage is there because a lot of people can have very significant disease, and generally don't have to have that vascular noise that we talked about, the bruit.

Dr. Michael Jaff: That's absolutely true, so the tests that most people do right now to look for this is a simple ultrasound test. Painless, no needles, no dye. Where a probe is placed right on the skin lightly, and pictures are taken using sound waves, and it gives us very accurate prediction of the severity of blockage that might be present.

Dr. David Meyerson: So again, this is an absolutely painless, totally comfortable, and it's based on similar technology. I guess that a lot of people are aware that, when a woman is going to have a baby she can have a sonogram. And it doesn't hurt the baby, it doesn't hurt the mother, and in fact everybody looks forward to it because it's the first baby pictures. And, through a very similar technique, the sound and radio waves can be focused on the arteries of the neck, and actually show you what the lining of the blood vessel looks like?

Dr. Michael Jaff: That is absolutely true. We can -- it's become very sophisticated. We can tell you how narrow the artery might be, we can tell you what type of blockage there is, whether there's a lot of calcium, a lot of cholesterol, and sometimes we can even predict the likelihood that that plaque may break off and go to the brain.

Dr. David Meyerson: The brain is lucky in a matter of speaking. I guess we're lucky that whoever designed the system did a very good job. But the brain has almost a threefold blood supply, doesn't it?

Dr. Michael Jaff: It does. There's a very rich blood supply to the brain that allows us to tolerate this degree of blockage over a long period of time without even knowing that you have it, so it's a big advantage for us. But on the other side of the coin, it may be a disadvantage, in that it never hurts. So people won't go to a doctor because of this necessarily.

Dr. David Meyerson: Dr. Jaff, let me bring up something that I mentioned in one of our past podcasts, and that was I mentioned the possibility of a transient ischemic attack which was almost like a threatened mini-stroke, but it didn't last. It's almost like angina is to a heart attack. Angina, you get some chest pain, you stop what you're doing, it goes away. It generally doesn't leave you with heart muscle damage. A heart attack, actually a segment of heart muscle is deprived of blood and oxygen for long enough that that segment of heart muscle actually dies and ultimately gets replaced by scar tissue. And the more scar tissue you have, the less functional heart muscle you have. With a stroke, you actually lose brain tissue, some brain tissue dies. With a transient ischemic attack, you have a threatened event. You have an event where your mouth may droop, you may have garbled speech for a while, you may not understand things. One side of your body may not work for a few minutes or your or your leg might be clumsy. We mentioned on our program that the last thing in the world that you do when you get one of those symptoms is to go to sleep at night and call your doctor the next day. That's something you want to act on right away, is it not?

Dr. Michael Jaff: Yeah, we try and tell our patients, don't just think you're having a bad day. This is a warning sign. You're one of the lucky ones quite frankly who's been given a chance to prevent the next catastrophic event and that's only going to be done if you call your doctor and get into a place where they know what you had, they know how to diagnose it and they know how to figure out how to prevent the next major event.

Dr. David Meyerson: So again, we're agreeing and what we need to emphasize to our listeners is that if you have a threatened neurologic event, you do not sit on that information. You get evaluated right away because you may have one warning, the next one might be that catastrophic event. And the Vascular Disease Foundation is all about maximizing function, taking things that could be warnings and turning them into success stories and we want to prevent amputations, we want to prevent strokes, we want to prevent heart attacks. We want people to be living active well into their nineties and that's possible. Let me ask you then Dr. Jaff, if somebody -- what can our listeners do between today and tomorrow which would make a major difference in their blood vessel biology? What message must they really get?

Dr. Michael Jaff: Well, there are a number of healthy things that they can do, but I think it's really a matter of asking the right questions of your doctor. For example, is your blood pressure really normal? Of all the risk factors that can lead to stroke, high blood pressure is potentially the most dangerous. Now, I'm not including things like irregular rhythms of the heart and blood clots comingfrom the heart, but if we're looking at risk factors for artery blockage, getting your blood pressure down to normal is of critical importance and that's got to start today. Other things, we now have very good data that says that avoiding any exposure to cigarette smoking can have a major reduction in events of future strokes. We know that taking cholesterol lowering medication, getting your cholesterol really low, especially with the statin class of drugs and really lower the risk of stroke. It's very impressive. It also lowers the risk of need for surgery or revascularization procedure.

Dr. David Meyerson: So you're saying that therapy with the statin group of medications, for example if you take the worldwide data, I could suggest that we can prevent about forty percent. We could lower heart attacks by forty percent and I believe we can lower stroke by close to thirty-five percent. Is that not right?

Dr. Michael Jaff: It is correct.

Dr. David Meyerson: And so, it's the very same process that we can use to prevent heart attacks, can also be used to prevent strokes and peripheral arterial disease, --

Dr. Michael Jaff: Absolutely.

Dr. David Meyerson: -- so you get a triple bang for the buck. How can somebody not take advantage of that? Hit smoking for us again because smoking -- I've never seen in my practice at Johns Hopkins, every day of my professional life, I see lives that have just been decimated by tobacco smoking.

Dr. Michael Jaff: It is horrible and I must tell you that, it's such an addictive drug. We can't over emphasize the fact that patient's need help to be successful, but it's probably the single most important thing that they can modify in their lives. But we as doctors, we as healthcare professionals need to reach out to our patients and be there for them. Don't judge them, but be helpful to get them to stop smoking.

Dr. David Meyerson: Now I want to hit one point before we go on. People have heard perhaps of carotid endarterectomies which is a surgical procedure where you actually take out the core of the corroded lining of the artery that nourishes the brain and sew it up again. That's a surgical procedure, but I understand that we have now a very excellent techniques of putting stents in carotid arteries similar to the way we open up blockages in the arteries that nourish the heart muscle. Tell us about that, Dr. Jaff.

Dr. Michael Jaff: It's true. The interesting thing is that the operation that you mentioned carotid endarterectomy is actually a very safe and very effective operation, but nonetheless, it is an operation and the trend has been to go away from operations towards less invasive procedures and sure enough, there are now ways to put those metallic scaffolding devices, those stents into the narrowed carotid artery and one of the obvious questions that people are asking is, well what happens to all that blockage when you press it up against the wall, you crack that plaque? Isn't there a risk of some of that debris going up to the brain and sure enough, there is. So, companies have come up with very novel devices called filters that protect the brain during the procedure, catches any debris that might end up in the brain before it gets there.

Dr. David Meyerson: So it's almost like a little umbrella in the circulation that catches any of the pieces that come from the doctor working on the inside lining of the blood vessel. Isn't that correct?

Dr. Michael Jaff: That's correct and these are not permanent devices. The stent stays there permanently, but that little umbrella gets pulled out at the end of the procedure.

Dr. David Meyerson: And then if they say that an open endarterectomy procedure is the right one for that patient then they should probably avail themselves of it because this is important and truthfully, it's excellent surgery as a rule.

Dr. Michael Jaff: Excellent surgery, certainly by a surgeon who does a lot o f them. I know that one of the leaders in the country in carotid endarterectomy is at your institution. We have some at our place as well. So the key is going to somebody who does a lot of these, who's got experience seeing these operations and doing them. But you're right. If the doctor says to you, here are the reasons I think the operation is better for you, then that's a good thing to consider. It's a good, safe, effective operation.

Dr. David Meyerson: The message here Dr. Jaff, and you've helped it so eloquently drive it home is that there are some areas of the body where we get more warning signs. There are sometimes when we don't get warnings. In areas where we are less likely to get warnings, you have to be especially vigilant and that's one of your messages regarding the carotid circulation and preventing transient ischemic attacks and stroke.

Dr. Michael Jaff: Yeah, I think that this is a clear example of how you as a patient work with your doctor as a team. Don't let anybody get in the way of you asking appropriate questions and be your best advocate. And your doctor's there to help you achieve that so that you can live a long, healthy, fruitful life.

Dr. David Meyerson: My special guest has been Dr. Michael Jaff, Assistant Professor of Medicine, Director of Vascular Medicine at the Massachusetts General Hospital in Boston. He's past president of the Society of Vascular Medicine and Biology, an eloquent spokesperson and Dr. Jaff, I'd like you to agree to come on and do another podcast with us at some point because the information that you have is just so important, it's so critical for our listeners. I thank you so much for being here.

Dr. Michael Jaff: Thank you. I'd love to be back with you.

Dr. David Meyerson: And for the Vascular Disease Foundation, I'm Dr. David Meyerson, thank you so much for listening, till next time.


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