Category: Patient Education

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High Blood Pressure: the basics

Hypertension, or high blood pressure, increases the amount of work the heart has to do. It’s like going to the gym and lifting heavier weights. Just like when you lift heavier weights at the gym to get bigger biceps, when your heart beats against a higher pressure it compensates by getting thicker. However, this compensatory mechanism can actually weaken the heart over time making it harder to perfuse the heart with blood and over time increases your risk of heart failure, heart attack, and stroke.

Some of my patients tell me, “but I feel fine”. And that’s the thing- high blood pressure is a silent killer. You can have elevated blood pressure for many years and not even ‘feel’ it. That doesn’t mean it can’t cause serious harm and increase your risk of future heart attack or stroke.

Defining Hypertension (high blood pressure)

A ‘normal’ blood pressure is <120/80. That means both the systolic (top number) and diastolic (bottom number) need to be below 120 and 80, respectively. Some people have lower blood pressures and that can be completely normal. The short and skinny of it is that you want your blood pressure less than 120/80.

Below are the different stages of hypertension. How we treat blood pressure depends on your individual circumstances and medical history. It is based on robust data summarized in a the 2017 ACC/AHA (American College of Cardiology/American Heart Association) guidelines.

If you have a normal blood pressure reading (<120/80) that doesn’t mean you’re off the hook. You should still get a yearly blood pressure reading. Sometimes you just hit a certain age where your blood pressure starts to creep up a little bit. This is a good reminder that having high blood pressure, like many things in medicine, is both genetic predisposition as well as some behavioral and lifestyle choices that can impact it. Having high blood pressure doesn’t mean you did anything wrong. Some of my patients are the healthiest individuals I’ve ever met. Except that hypertension runs in their family. We will get into some behavioral and nutritional choices you can make to help bring down your blood pressure in another post.

Elevated blood pressure is 120-129/<80. Notice the different goals for the systolic and diastolic (i.e. top and bottom numbers). Essentially, if your bottom number goes above 80 you are considered hypertensive. But if your diastolic remains <80 but your systolic is 120-129 we generally recommend rechecking your blood pressure in 3-6 months. This doesn’t mean you need medications but it does mean that we want to ensure you don’t develop high blood pressure. It’s also another chance to make some positive lifestyle habits and nutritional choices that can pay off over time. As many of my patients can attest, one of my favorite sayings is that many of the choices we make today can pay off over time. Like building a strong retirement fund with a good interest rate. In contrast, ignoring high blood pressure is like having bad debt. Either way- the interest is going to compound. So it’s always better to know if you have high blood pressure than to ignore it.

Stage 1 hypertension is either a systolic between 130-139 or a diastolic between 80-89. This is where working with your physician is important. In patients at higher risk of heart disease, like those who already have clinical evidence of atherosclerotic cardiovascular disease (i.e. prior stroke, heart attack) we often will initiate both lifestyle modifications and treatment with blood pressure medications. If you are a low risk patient we can consider lifestyle modifications alone and rechecking your blood pressure in a few months. If lifestyle modifications do the trick and bring down your blood pressure we can avoid using medications. But if you are doing all the right things and your blood pressure won’t budge then you likely will require medications to lower your blood pressure. Regardless, patients with stage 1 hypertension should be reassessed in 1 month.

Stage 2 hypertension is either a systolic >140 or a diastolic >90. In these patients we often jump to use medications while also initiating lifestyle modifications because the degree that lifestyle modifications will impact your blood pressure likely won’t be enough. Just like how you wouldn’t ignore a leak under your sink you should also not ignore high blood pressure-both will cause damage over time. This is where talking with your physician is important because not all patients are alike. If you want to avoid using medications I certainly don’t think it’s unreasonable to hold off if you are right on the borderline of stage 1 and stage 2 of hypertension as long as we have a plan in place and you continue to follow up. However, a blood pressure of 142/88 for instance is very different than a blood pressure of 180/100. For latter blood pressure (i.e. 180/100) would likely require initiation of medications right away. All patients with stage 2 hypertension should be also reassessed in 1 month (just like those with stage 1 hypertension).

The more uncontrolled your blood pressure is and the greater the period of time that it remains uncontrolled the greater your risk of heart disease (e.g. heart attack, stroke). Just because you have high blood pressure doesn’t mean you will have a heart attack and just because we treat your high blood pressure doesn’t mean you won’t. It’s all about decreasing that intrinsic risk.

Why you should check your blood pressure at home

In my clinical practice I like when my patients take their blood pressure at home for a few reasons. First, if you’ve ever been to a doctor’s office you know it can be a little anxiety inducing. That’s why I never make drastic changes based on a single blood pressure reading. Some patients can have white coat hypertension– when the blood pressure readings at your doctor’s office are always elevated but when you take them at home they are normal. These patients don’t need to be treated for high blood pressure!

Second, you can only go the doctor’s office so many times. Taking your blood pressure at home gives us additional data points to use to estimate your average blood pressure. Generally, I care the most about the your blood pressure trend. Let’s look at two patients as an example. ‘Patient 1’ consistently gets systolic blood pressure readings in the 140-150’s but occasionally gets a systolic blood pressure of 118. ‘Patient 2’ on the other hand gets consistent systolic blood pressure readings in the 120’s but occasionally gets a systolic blood pressure reading in the 140’s. In both patients I won’t ignore the occasionally high or low reading but I care more about where your blood pressure average tends to be.

How to take your blood pressure at home

Type of blood pressure cuff

Generally, arm cuffs are better than wrist cuffs. However the most important thing is that you use an appropriately sized cuff. Using the wrong size blood pressure cuff can give you falsely high or falsely low readings (shown below).

If you want to be accurate, the American Heart Association recommends a cuff bladder width 40% of the arm circumference and a bladder length 80% of the arm circumference. Use the middle part of your arm to check the circumference (shown below).

How to actually measure your blood pressure

If you don’t like reading I made a short TikTok video explaining how to actually check your blood pressure (shown below). The following tips aren’t to torture you- they are so we get accurate readings. The important things to remember are:

  • Blood pressure cuff should be bare to skin (not over clothing)
  • Keep your arm supported (don’t elevate it in the air)
  • Keep your feet flat on the ground
  • Don’t cross your legs
  • 30 minutes before taking your blood pressure do not smoke, drink caffeine, or exercise (life hack- take it first thing in the morning before your first cup of coffee or if you smoke before your first cigarette)
  • You can repeat the reading after waiting 5 minutes. I typically tell patients to take it once in the morning and once in the evening
  • WRITE DOWN YOUR READINGS IN YOUR PHONE OR NOTE PAD AND BRING THE READINGS TO YOUR NEXT DOCTOR’S VISIT
@marckatzmd

How to accurately take your blood pressure at home #Cardiology #Hypertension #Medicine #MedicineExplained #fyp #PepsiApplePieChallenge

♬ Roxanne – Instrumental – Califa Azul

Don’t forget to bring your readings to your next doctor’s appointment

Every day after work when I leave the hospital I put my hospital identification card in my car. That way I don’t have to remember to take it with me to work the next day. Because believe me there’s nothing worse than getting to work and having to turn around and drive home to pick up your ID badge. Similarly, remove road blocks from bringing your blood pressure readings to your next doctor’s appointment by putting the information directly into your phone. This way you don’t have to remember to bring the notepad you’ve been writing your blood pressure readings in. If you choose to do it the old fashioned way with pen and paper that is perfectly fine. Just remember to bring it to your next visit. Remember to document both the top and bottom number in addition to your heart rate. Lastly, please do not rely on your memory to serve as a blood pressure log. I want to know what blood pressure readings you are getting at home and not just that it was ‘high’ or ‘normal’.

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Most Commonly Used Tools Cardiologists Use For Palpitations

Palpitations are one of the most common reasons that I see patients in the inpatient and outpatient setting. Palpitations are abnormal the sensation of your heart beating. I explain them briefly in this TikTok video:

@marckatzmd

What are palpitations and other questions explained in greater detail on my 15min YouTube video #Cardiology #MedicalTikTok #Cardiologist #Palpitations

♬ original sound – Marc Katz, M.D.

Depending on the underlying diagnosis they can be completely benign or potentially life-threatening. I go into much greater detail in a much longer separate YouTube video here:

To understand the common tools we use to diagnose and treat palpitations you have to find out how frequently they occur. So let’s review the most common tools cardiologists use to evaluate palpitations.

If they’re happening right now- get an ECG! Sometimes an Apple Watch can even diagnose some abnormal heart rhythms like atrial fibrillation. But if palpitations are not happening when you get the ECG then you will not catch the rhythm. In the inpatient setting we often also use telemetry. This also underpins the importance of talking to patients to evaluate how frequent palpitations occur as different tools can be used for different durations of time. Sometimes even when we diagnose certain abnormal heart rhythms we use the next few tools to quantify the ectopic burden (how many extra beats are there) as this may influence treatment.

Holter Monitor: 24 – 48 hours

Holter Monitoring - SND Hospital Ropar

Holter monitors are 24-48 hour mini ECG’s, as depicted above. Patients wear them and document when they feel symptoms and we correlate the information we collect from the monitor. This can also help quantify how frequently someone is having a known abnormal heart rhythm to help guide other treatment choices.

ZioPatch Event monitor: 1 – 2 weeks

How Zio works | iRhythm

Event monitors are the next step up in duration. They can be worn for extended period of time, typically for 1-2 weeks. My favorite is the ZioPatch, shown above. It can be worn for weeks at a time (again, typically 1-2) and is small, goes on the chest, and records everything while being worn, and patients can even shower with this device. They click a button on the device to note when symptoms occur and then we go back to see what rhythm was happening at that time when we receive the report. It does not get transmitted in real time. Instead, as shown below, patients actually take it off at home and send it back to the company in the mail who then forward a report to the ordering physician.

The wireless future of medicine | zhiyaobme

Implantable Loop Recorder: up to 3 years

Implantable Loop Recorder

Lastly are implantable loop recorders (ILR). ILRs are less than 2 inches long and quite thin, as depicted below.ILRs are the only monitoring device that is actually implanted under the skin on the chest. They record everything and have up to a 3 year battery life! The ILR automatically records certain fast and slow rhythms but patients can also use an activator to save rhythms if they’re having symptoms. We often use these when the palpitations are infrequent or if we have a high suspicion of an underlying arrhythmia without a documented diagnosis that might change management. For example, I frequently use these in tandem with neurologists in stroke patients in whom we suspect but have not diagnosed atrial fibrillation (AF). If we see AF on an ILR then we would start a blood thinner but sometimes don’t want to treat empirically.  The location these are placed is shown below and often can be safely removed.

Just like any test these tools aren’t perfect. First, patients can have palpitations a few days a week but for whatever reason don’t have any symptoms when wearing the monitor. Depending on the clinical scenario sometimes we will redo the test. Second, these monitors should not be ordered unless clearly indicated. If you were to place Holter monitors on 100 random individuals you are certain to find some abnormal heart rhythms that are completely benign. Thus ordering unnecessary cardiac monitoring for patients can lead to unnecessary follow up procedures, testing, and possible harm.

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Lyme Carditis | How Lyme Disease Can Involve the Heart

I’m starting a new section on my blog and YouTube channel bringing you some cool cardiology related topics that you might not have heard about. To kick things off I wanted to talk about Lyme disease- and more specifically a possible complication of Lyme disease known as Lyme carditis. And if you prefer videos to reading check out my YouTube video on the topic and be sure to give it a like and subscribe!

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Background: what is Lyme Disease?

Lyme disease is caused by the bacterium Borrelia burgdorferi (and rarely Borrelia mayonii). It is transmitted to humans through the bite of an infected tick, as depicted below.

Lyme Disease: Borrelia burgdorferi - YouTube

Why is it called Lyme Disease?

Lyme disease got it’s name from the small coastal town in Connecticut back in 1977 when Yale researchers identified clusters of what they initially called Lyme arthritis but then changed the name 2 years later to Lyme disease (1).

What are typical symptoms?

Classic Lyme disease typically causes a ‘bullseye-like rash’ on the skin on average 7 days after the initial tick bite but can happen anywhere between 3-30 days after the initial tick bite known. The medical term for this is erythema migrans. Erythema migrans can manifest differently, as below (2). It is rarely itchy or painful and can have a variable appearance. Additionally in dark skinned individuals it can be difficult to appreciate or visualize well.

  • Left posteriorthigh, popliteal fossa

Other symptoms that can happen anywhere from days to months after the initial tick bite include headache, neck stiffness, and severe joint pain and swelling that normally involve the knees and other large joints. So why is a cardiology fellow talkign about Lyme disease? Because a potentially serious and life threatening complication of Lyme disease is Lyme carditis.

What is Lyme carditis?

Lyme carditis occurs when the bacterium infects the heart tissue and disrupts the normal electrical conduction system of the heart. This can have a variable clinical expression. The most serious complication is complete heart block.

What is complete heart block?

To understand the complete heart block let’s look at what normal conduction of the heart looks like. To create a coordinated heart beat your heart conducts electrical impulses down a network of nerves. It goes from the SA (sino-atrial) node to the AV (atrio-ventricualar) node, then down to both ventricles, as below.

In complete heart block the top and bottom chambers of the heart are unable to communicate with one another and beat independently. This is also why complete heart block is also referred to as third degree AV block because the electrical impulses are unable to get through the AV node.

Why is complete heart block a big?

Normally the top chamber of the heart is in charge. It sends impulses down the electrical system of the heart and the ventricle does as its told. So what happens when the ventricle never receives any of those electrical signals? Your heart has a backup system for these very instances but it is far from perfect. This back-up system is normally inhibited by electrical impulses received from the SA or AV node but when it never receives those impulses it generates a ventricular rate of about 20-40 beats per minute. This means that you might only be able to sustain a heart rate of about 20-40 beats per minute! Additionally this back-up system isn’t always 100% and in Lyme carditis can lead to a fatal arrhythmia. It is serious and should be treated in the hospital.

What are the symptoms of complete heart block?

A slow heart rate also explains symptoms of complete heart block. Think about what happens everyday of your life when you stand up to walk around- your heart beats faster. If your heart can’t increase the rate that your ventricle beats then your brain is not going to get enough blood and you will feel faint, lightheaded, dizzy, and could even pass out. Passing out, or syncope, is your body’s way of making the heart not have to work against gravity but can also seriously hurt you or somebody else depending on how you fall. Other symptoms of complete heart block can include symptoms severe shortness of breath, palpitations, or chest pain.

How do we treat Lyme carditis?

The first thing we do is treat empirically for Lyme disease with antibiotics. The confirmatory lab tests can take a while to get back and some people don’t develop antibodies until a few weeks after infection. So we don’t waste any time and start treating as the benefit fo treatment often far outweigh the risk of the antibiotics. In the hospital we typically use Ceftriaxone and then switch to oral Doxycycline for a typical duration of about 21 days.

Not everyone who develops Lyme carditis develops complete heart block. There are varying degrees of heart block. About 4-10% of patients with Lyme disease develop some form of Lyme carditis (3). Out of the 4-10% of patients who develop Lyme carditis, about 90% of those only develop 1st degree atrioventricular block (AVB). 1st degree AVB is a benign form of AV block and can often be seen in normal otherwise healthy patients in the general population. However patients who develop new 1st degree AVB in the setting of Lyme disease infection should be watched in the hospital on continuous cardiac telemetry monitoring because it is a good predictor of those who might develop complete heart block.

If you develop hemodynamically significant heart block we often use a temporary pacemaker to ensure that your heart rate is adequate. We place place these through the jugular vein and depending on the type of temporary pacemaker that your receive are either floated to sit in the right ventricle or are screwed into the heart to ensure adequate electrical transmission. Depending on the type, temporary pacemakers are only able to stay in place between 2-7 days and are not a permanent solution.

The good news is that most people who develop complete heart block due to Lyme carditis fully recover with antibiotics and do not require a permanent pacemaker.

How do you prevent Lyme disease and where is it found?

The last teaching point I’ll make for is the importance of checking for ticks after you leave a heavily wooded area. Lyme disease is endemic to the northeast, north-central, and mid-Atlantic regions of the US but can be found elsewhere, as below.

U.S. map reported cases of Lyme Disease at a county-wide level

How do you remove a tick safely?

Now let’s say you notice a tick attached to you. What do you do? Try to get a small tweezers if you can and grasp it from as close to your skin surface as you can, as below.

Unfortunately if you just grab it from the body you can potentially rip off the body and leave its mouth stuck on you. The goal is to get the tick off you ASAP! So don’t use remedies like paints, nail polish, or petroleum jelly to wait for it to fall off. After you remove the tick you can flush it down the toilet, kill it in alcohol, or drop it in a sealed bag.

Then call your doctor

Questions we will ask will attempt to narrow the timeline of when the tick attached to you. Interestingly it takes about 36 hours being attached to you for the tick to transmit the bacterium to you. The reason for this is that the bacteria lives inside the tick gut and it takes about 36 hours for the tick to get so engorged on your blood that it actually vomits and in doing so transmits the bacteria before detaching and falling off.

So technically if you went hiking and noticed a tick one hour later then you might not need any treatment for Lyme disease. The reason why it’s important to call your doctor is that a prophylactic treatment for Lyme disease is a single dose of oral doxycycline which typically outweigh the risks of possible contracting and developing complications of Lyme disease.

Works Cited

  1. Delaware, T. (2020). Lyme Disease Information – Delaware Health and Social Services – State of Delaware. Retrieved 28 July 2020, from https://www.dhss.delaware.gov/dhss/dph/epi/lyme.html#:~:text=Lyme%20disease%20gets%20its%20name,the%20attention%20of%20Yale%20researchers
  2. Lyme disease rashes and look-alikes | CDC. (2020). Retrieved 28 July 2020, from https://www.cdc.gov/lyme/signs_symptoms/rashes.html
  3. Scheffold N, Herkommer B, Kandolf R, May AE. Lyme carditis–diagnosis, treatment and prognosis. Dtsch Arztebl Int. 2015;112(12):202-208. doi:10.3238/arztebl.2015.0202
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I hope you guys enjoyed this post. If you liked this post drop a comment below and subscribe so you don’t miss my next post or drop a comment below if there’s something cardiology related that you think would make a cool post or YouTube video and I’ll see if I can make one for yah.

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Marijuana Use and Cardiovascular Disease

Marijuana Use and Cardiovascular Disease 🍃♥️

Yesterday was 4/20 so let’s take a look at a review article on marijuana’s effect on cardiovascular disease (CVD) published in the Journal of American College of Cardiolgoy in January 2020. Here are the highlights (no pun intended)

💔 Epidemiological studies have shown a temporal link between marijuana use and heart attacks. In 3,882 patients who had a heart attack, 3% smoked weed within the past year. 37 of that 3% smoked within 24 hours and 9 within 1 hour of suffering a heart attack, respectively

💓Abnormal heart rhythms, or arrhythmias, can occur with marijuana use. Weed can increase the heart rate and release catecholamines (adrenaline). One observational study of 2,459,856 marijuana users found 3% had arrhythmias- mostly atrial fibrillation (AF)

🧠 It has also been associated with increased stroke risk, peripheral artery disease, and cardiomyopathy (weak heart muscle)

💊 Weed (i.e. the marijuana) can also interact with medications by inhibiting the CYP 450 family

✅ Ultimately, observational studies suggest potential associations with marijuana use and CVD but lack robust levels of evidence. Hence I am weary of anyone who touts marijuana or CBD as a miracle cure for anything. It may have specific uses but with regard to CVD the jury is out. We need more robust studies but few randomized control trials (RCT) have or will likely occur due to its Schedule I federal drug designation as a controlled substance and a general lack of homogeneity of the drug itself

🔑 Patients at high-risk of CVD should avoid or minimize marijuana use

To view the original journal article click here: http://www.onlinejacc.org/content/accj/75/3/320.full.pdf?download=true

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General Medicine | how to talk to your family about code status

In medicine we colloquially say someone ‘codes’ if their heart stops requiring cardiopulmonary resuscitation (CPR) or if they can’t breath on their own requiring intubation. So ‘code status’ refers to the level of medical interventions a patient wishes to have if their heart or breathing stops. Unfortunately the worst time to discuss something as important as you or your loved one’s code status is when a patient is in critical condition requiring life saving measures. The COVID-19 pandemic is the perfect opportunity to talk to your doctor and loved ones about your code status. Here’s some basic information about code status, how I talk to my patients about it, and how you can talk to your family so you’re all on the same page.

Main categories of code status

There are generally two main categories. The first is ‘full code’ which generally means to perform all life saving measures. We will perform CPR and intubate. The second main category is ‘DNR/DNI’ which stands for ‘do not resuscitate/do not intubate’. So when we say ‘DNR’ we generally mean ‘do not perform CPR’ and when we say ‘DNI’ we generally mean ‘do not place the patient on a ventilator’.

These two terms, DNR and DNI, are separate but interconnected entities. If your heart stops beating then you are technically dead and, as such, will need a ventilator to help you breath too. However if you stop breathing or are having trouble breathing requiring you to be intubated your heart very well may continue to beat on its own. This can happen for a number of reasons, including COVID-19. However even just explaining this situation breads multiple different variables and gets us bogged down in the weeds. For now, let’s focus on intubation since this is more important to understand than ever during the COVID-19 pandemic.

Misconseptions

Before I go any further I want to address one of the most common misconceptions with regard to code status that I have observed in my short career in medicine. Just because someone is DNR/DNI it does not mean that we stop treating the patient. If they are sick, have an infection, or are in pain we continue to treat those issues. Being DNR/DNI is not the same thing as withdrawing or stopping care.

Why does someone need to be intubated?

Generally we intubate patients if they cannot breath on their own. This can happen in a number of clinical scenarios. In COVID-19 we are seeing that patients who have increasing oxygen requirements often deteriorate quickly. Meaning they go from needing a little bit of oxygen via a nasal cannula to potentially being intubated within a day. Sometimes we choose to intubate patients in a controlled setting when a patient is getting worse before the

How long do patients stay intubated?

It depends. It depends on each clinical situation and the reason for intubation. In COVID-19 some patients have required 2 weeks of ventilator support and others are able to be extubated much quicker.

So why would anyone choose to be DNI?

This is the crux of the code status discussion. Generally, people who are more sick with more comobidities (greater number of other medical health problems) have more difficulty being extubated successfully. They have trouble regaining the strength to breath. If someone cannot be successfully extubated the options are limited to tracheostomy (an incision in the neck where the ventilator can then be connected to) or terminal extubation (we remove the breathing tube anticipating that the patient won’t be able to breath on their own and will ultimately die).

Clinically with regard to severe illnesses like COVID-19, intubation is only one piece of the overall puzzle. A patient can be successfully intubated but still have a long battle ahead of them and intubation does not guarantee that they will survive. It is impossible to know with 100% certainty which patients will be intubated, improve, and be extubated, which patients will be intubated and unfortunately still pass away, and which will be intubated and have difficulty breathing on their own again.

Changing the terminolgy

Professionally speaking I don’t like using the term ‘DNI’. I prefer the term ‘allow natural death to occur’ because that is precisely what we are doing when we choose not to intubate someone who needs it.

End of life care

Again, just because someone is ‘DNR/DNI’ does not mean we do not treat their symptoms or other illnesses. In any illness when a patient might require intubation but they choose to allow natural death to occur by avoiding intubation we change our clinical focus to other aspects of a patients care. I’ve been at bedside with families whose loved ones are DNR/DNI after a long battle with cancer or other diseases and don’t want to prolong their suffering any longer. It’s not an easy decision to make at first but one that is so much easier to make when everyone in a family knows the patients wishes.

How can you talk to your family and/or doctor about your code status?

If you have the time I highly recommend reading Atul Gawande’s Being Mortal. It’s an amazing book about death and dying in the United States and he puts it more eloquently than I ever could.

When I talk to patients about code status most common delineation they are able to make is if (1) they would want to be intubated no matter what and all life saving measures performed or (2) that they would not want to be intubated if they did not have a good chance at surviving with a good quality of life. Notice I said ‘survive with a good quality of life’ and not just ‘survive’. This is an important distinction.

What would a good quality of life look like to you? This might seem abstract but it helps doctors guide their medical decisions if we can understand what is important to you. What makes you happy on a day to day basis? What would be a quality of life and what would not be worth living? It means that code status is not always cut and dry. Its not black or white but instead shaded with areas of grey. It also illustrates how important it is to have this type of conversation not only with your family but also with your doctor. So I encourage you to please talk to your physician about you or your loved one’s code status the next time you can with your physician.

I know this is not an easy conversation. The first time I talked to a patient about their code status they literally asked me point blank ‘is this the first time you’ve talked to someone about this?’. So if you want to start the conversation about code status with your family about your or their code status you can use the following script to get the ball rolling.

“I want to talk about your/my code status. This is difficult to talk about but it is important to know what you/I would want done in the unfortunate event that your/my heart would stop beating or if you/I would stop breathing on our own.”

Conclusion

I have seen patients die surrounded by loving family members at bedside who disagreed with their loved one’s decision but respected it and made the patient’s last days or hours occur with less pain and suffering. I’ve also seen the opposite.

This is by no means an exhaustive conversation about code status but please talk to your doctor and family members about your and their code status. Additionally, make sure everyone in the family knows their wishes and not just a few people as it is far more difficult to make these tough decisions when some family members are left out of the loop of communication.

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Medications After a Heart Attack| Why Dual Anti Platelet Therapy Is So Important

When you have a heart attack, or a myocardial infarction (MI), one of the most common outcomes is the placement of a stent inside your coronary arteries, or the arteries that supply the heart itself. The most common type of stent we use today are drug eluting stents (DES). Two medications cardiologists routinely prescribe together after DES placement are dual anti platelet therapy (DAPT).

DAPT is composed of two medications. The first is aspirin and the second is either Plavix (Clopidogrel), Brilinta (Ticagrelor), or Effient (Prasugrel). They are supremely important after a having a stent placed in the heart because they keep the stent open. DAPT keeps stents open by preventing clots from forming inside the stents.

The history behind coronary stents starts several decades ago when balloon angiography was the only direct mechanism we had to combat sudden heart attacks. We used to insert a balloon inside the clogged artery and open it up. However this only worked for a short period of time and at 6 months the artery was often narrowed again almost 50% of the time. Additionally when we deflated the balloon the natural physiology and physics of the balloon angiography would cause the artery to recoil and often would be even more narrow than before. This is visualized below on the left hand side

Elastic recoil and neointimal hyperplasia after stent placement

That’s why bare metal stents were created. The metal inside a stent kept the artery wall from recoiling. However these stents also closed up with time. The reason they closed or narrowed over time was due to neointimal hyperplasia. Neointimal hyperplasia is shown above on the right hand side. It is the process of normal smooth muscle cells inside of the coronary arteries abnormally being deposited inside the inner layer of the artery wall. That’s why drug eluting stents (DES) were created.

DES are the same metal stents but they are coated in a drug that slowly seeps into the artery wall and prevents neointimal hyperplasia and thus prevents the slow narrowing of the artery from happening. However this causes the metal struts of the stent itself to be exposed to the bloodstream for a longer period of time and results in an increased risk of in-stent thrombosis- or clots to form inside the stent. This is where dual anti platelet therapy (DAPT) comes in. DAPT keeps stents from having clots form inside the stent itself.

In the video below I go into greater detail about what happens during a heart attack inside the coronary arteries, a brief history on how heart attacks previously used to be treated, why we developed new types of coronary stents, and ultimately the importance of taking your dual anti platelet therapy after a heart attack and stent placement, and possible side effects of the medications to watch out for I also briefly explain the duration of DAPT therapy, side effects patients should look out for, other medications to avoid after a heart attack, and I stress the importance of never stopping your medications without first talking with your cardiologist.

Dual Anti Platelet Therapy After Myocardial Infarction and Coronary Stenting

***This video is intended for educational purposes only. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have heard or read online***

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