Carotid Artery Stenosis and Stroke, Part 2

Someone asked me to wrote more about carotid artery disease, so here goes.  We see a large number of patients with carotid artery stenosis.  Next to aneurysms, I don’t think that there is any other medical condition that raises more anxious feelings for patients.  The paired carotid arteries supply  the left and right side of the brain.  There are ale smaller arteries that supply the back of the brain named the vertebral arteries, and there is a communication between the 2 systems within the brain called the Circle of Willis.  But the dominant supply to each side of the brain is via the carotid artery.  Blockages in the carotid artery can lead to strokes.  The typical symptom of a stroke are loss of motor control on one side of the body versus the other, loss of speech ability, and loss of vision in one eye versus the other.  Stroke symptoms do not cause pain, and vague symptoms such as dizziness and vertigo are not typical of strokes (unless it occurs in a certain area of the brain that control balance).

The typical risk factors for carotid artery disease are the same as for other cardiovascular diseases, namely cigarette smoking, high blood pressure, high blood sugar, high cholesterol, age and family history. Age and family history you are stuck with.  If Dad or Mom had heart disease and strokes at an early age, then unfortunately you are probably at a higher risk.  But the other risk factors are able to be controlled with medication if needed, or diet and exercise and smoking cession.

Most people with carotid artery disease never have symptoms.  In general, the higher the degree of narrowing, the greater the risk of symptoms.  Sometimes, you can have what is called a Transient Ischemic Attack (TIA) or mini-stroke, and at other times you might have a full blown stroke.  The difference between the two is that a TIA resolves within 24 hours, while a stroke last greater than 24 hours.  We don’t know which event is going to occur, if it does occur. We just know if you have a TIA, and you have significant carotid artery narrowing, your risk for a full blown stroke is a lot higher.

Most patients with carotid artery stenosis do not need surgery.  We emphasize controlling the risk factors, as well as smoking cessation.  I advocate an anti-platelet agent such as Plavix or aspirin, and close follow-up.  We used to be much more aggressive with carotid stenosis in terms of surgical management years ago.  However, in the era of anti-platelet agents such as Plavix, as well as statin drugs to control cholesterol level, and much better management of diabetic patients by our family practice and medical colleagues, the role for carotid artery intervention has diminished.  The options for management of carotid stenosis include carotid surgery where the blockage is cleaned out versus carotid artery stenting where the blockage is essentially reopened with a stent.  There is an ongoing debate about which technique is better for patients.  I suspect the answer is going to be dependent on the patients age, and anatomy, as well as other cardiovascular issues such as heart disease.

I dont think there is any doubt that if you have a TIA or a stroke with good recovery, and you have severe carotid artery narrowing on the side of the stroke, that you would benefit from carotid artery intervention to reduce further strokes.  What is less settled to me in the modern era is what should be done for patients with moderate to severe carotid artery disease (greater than 60% narrowing) who do not have symptoms of TIA’s or strokes.  There are carotid stents or carotid surgeries being performed for that condition (so called asymptomatic carotid stenosis), but the data is not clear in my mind of the benefits of the intervention versus the risks.  Thats what this whole business is about, balancing the risks versus benefits of every intervention we do.

Eating Right

I was trained the same way most physicians are trained in nutrition, and I suspect the same way that most other people in the health care industry are indoctrinated.  For years, I thought the equation for weight was simple.  Input equals output.  If your input in terms of calories are greater than your output, then you gain weight.  If your output was greater than your input, you lost weight.  Simple.  I recited the food pyramid to my patients diligently, and suspected that most people who thought they were following the correct diet and who did not lose weight were really not as strict as they thought.  If they only counted calories, they would lose weight.  I was the typical 35% cards, 35% protein, 30% fat diet guy.  When I started to hack my own diet and exercise, I discovered that at least for me, what I had been taught was all wrong.  Now I eat at least 50% of my calories from fat, and approximately 30-35% protein, with the rest being carbs.  I don’t eat bread or pasta.  I eat sweet potatoes only on a leg or back workout day (large muscle groups).  I have lost body fat, my waist size is less than 30 inches, and I am 56 years old (soon to be 57). Turns out there is new science validating some of this information.  As we get older, the body does not like to let go of fat.  You have to trick it into thinking there is lots of fat around.  It really works.  If you are a male in your 40’s or older, change the way you eat.  Combine it with variations of high intensity interval training.  You will feel better, and you will lose the body fat.  I should add I suspect the situation is more complex for women.

Maktub-Air of Resignation or Sound Advice?

One of the words that really interested me in The Alchemist by Paulo Cuehlo was the Arabic word “Maktub” which apparently means “so it is written.”  I think it really loses it full flavor when translated from the Arabic.  Even the pronunciation of the word gives it more meaning than you can get by literal translation, but I guess thats what you lose when you translate one language to another.  All the pronunciations of the word I can find on the internet sound like an American or European reading the word MACK-TUB.  I would love to hear it from an Arabic speaking person to get the full flavor.

Does the word mean “so it is written” as in “there’s nothing you can do about it” or does it imply “young man or women, take life one step at a time.”  I would prefer it to imply the latter, but thats probably my own personal bias.  Life seems much more hectic than it used to be.  Every event and statement has taken on an air of so much importance and relevance.  But perhaps as Charlie Munger might ask “what is the incentive for these peoples motivation and behavior?” I tell my kids there are only 3 or 4 really important things or events in life, kind of like the 10X inflection points that Andy Grove wrote about.  These include controlling your mind and thinking, when and to whom you get married, and when and if you have children.  A loving atmosphere at home is the foundation for your life.  The rest of it is probably nonsense.  The other thing I tell my kids is what my Dad told me years ago, and it has always stuck in my mind.  He said “I can tell you about a man by the people he hangs out with.”  Thanks Dad, that was good advice.

Carotid Artery Disease and Strokes

The carotid arteries are the main blood supply to most of the brain.  The right carotid artery supplies the right side of the brain.  A right sided stroke  symptom will include loss of vision in the right eye, kid of like those old movie theaters where a curtain comes down over part of the eye or all of it.  This event is called Amaurosis Fugax.  Another potential symptom of a right brain stroke is loss of motor control of the left side of your body.  You may be stirring a cup of coffee with your left hand, and all of a sudden you can lift your hand.  There is no pain associated with these events.  A left brain stroke will cause the opposite event to the right side, namely amaurosis fugax of the left eye and loss of right sided motor control.  In addition, most peoples speech centers are on the left side of the brain, so you may lose your ability to speak even though you know what you want to say, or it may come out as a string of non-sense words.

Carotid artery blockages are one of the many potential reasons for a stroke.  The risk factors for carotid artery disease are the same as the risk factors for other cardiovascular diseases.  These include   1.  Cigarette smoking

2.  Diabetes

3.  High blood pressure

4.  High cholesterol or triglycerides

5.  Age

6.  Family history of circulation problems

Most people with carotid artery narrowing do not know they have it.  If you have had a heart attack or has peripheral vascular disease, then you have a higher risk for carotid artery narrowing.  Most patients with carotid artery stenosis do not need surgery.  Age and family history you are stuck with!  Our goal is to prevent the narrowing becoming worse but making sure that your blood pressure, blood sugars, and cholesterol levels are well controlled, and that you stop smoking.

If you have been diagnosed as having carotid artery narrowing, the prognosis is really quite good.  Most people will never need their carotid artery repaired.  Th old standard for treatment of carotid artery narrowing that was 60% or greater was surgical intervention based on a study published in the New England Journal of Medicine.  However, this study was prior to the current era where we have Plavix which is like a super aspirin, and statin drugs.  Therefore, the management of carotid artery disease has changed somewhat to a more conservative approach, as outlined by the writings of Dr. Frank Veith, one of the most thoughtful and smart vascular surgeons who has been around a long time and seen  it all.  I personally discuss surgery in patients who have had a TIA or ministroke and carotid artery narrowing on the side of the TIA.  A TIA is a stroke like symptom, but by definition, you recover function within 24 hours.  If you have a TIA, and have severe carotid artery narrowing on the side that caused the TIA, then you have a high risk for a full blown stroke, and really should have intervention for the carotid artery narrowing.

In terms of treatment for carotid artery stenosis, as I mentioned most people do not need intervention, and can be managed with anti-platelet agents that thin out the blood such as aspirin or Plavix, as well as control of their cardiovascular risk factors, statin drugs as necessary, and smoking cessation.  Why not fix all carotid artery narrowing when it’s present?  Because the intervention itself carries a risk for stroke and even heart problems.  This business is all about balancing the risks versus benefits of everything we do.  If the risk of stroke is low with carotid artery narrowing, then it is better managed conservatively.  If intervention is required, the options are to either have a surgical intervention or a carotid artery stent.  There are advantages and disadvantages of both. I personally do not do carotid artery stenting; I think that is better left to someone who has experience in doing the procedure, but also in fixing problems that may arise both during and after the procedure.  If I think a patient is better served by a carotid artery stent rather than surgery, I will ask them to see a friend of mine who is a neurointerventional radiologist, basically a specialist in all things related to the blood flow to the brain.  He might come back and tell me “no, I think this case would be better served by surgery, or yes I think carotid artery stenting would be a good option.”  Remember the old adage “if your only tool is a hammer, the whole world looks like a nail.”

 

High Intensity Intervals For Old People Like Me Part II

Monday was my leg day, and after testing the out limits of my quadriceps weight bearing abilities, the last thing I wanted to do was to get on the stair stepper or treadmill and run.  So I experimented with the incline and speed on the treadmill.  I took my baseline heart both with a stop watch and the machine and it correlated well at around 68 beats per minutes (bpm).  Then I started off at 3 degrees incline and at 2.5 miles per hour (mph) on the treadmill.  With each change in the variables, I correlated the machine readout of my heart rate with my stopwatch, and they were actually quite comparable.  I increased my incline sequentially by a few degrees, and increased my walking rate to 3 mph.  at 15 degrees incline and 3 mph, my heart rate was persistently in the 130+ range.  At 10 degrees, it was in the 120 range.  So I varied the incline every 2-3 minutes, and kept the speed at a comfortable constant 3 mph for 40 minutes.  At the end, my legs did not hurt, and I had a good cardio workout.  It also did not seem as onerous as pushing myself hard on the treadmill or stair stepper for 30 minutes, and I achieved the same calculated calorie goal.  For those who say that they don’t have 40 minutes to do this type of experiment, you can split it up into 2 20 minute sessions, one in the morning and the second at night.  In fact, there is research that suggests splitting up cardio into 2 shorter sessions rather than 1 long session boosts your metabolic rate higher than just one session.

Principles of Life

I looked through my old notes that I had taken on my laptop this morning, as I thought about what I was grateful for.  I try and start out the day by spending a few minutes being grateful, it really does change something inside me, no matter how I feel when the alarm rings at 5 am.  I found some old notes that I forgot I had made.  Instead of writing something about medicine, I have copied them down here.  My apologies if they are plagiarized from someone, I don’t know what I was reading or thinking or even when exactly I made these notes, but they are just listed below

THE FOUR OVER-RIDING PRINCIPLES TO LIFE

  1. There is only one important time, and that time is NOW. The present moment is the only time over which we have dominion
  2. The most important person is always the person you are with, who is right there before you (including yourself if you are alone), for who knows if you will have dealings with any other person in the future
  3. The most important pursuit is making the person standing at your side happy, for that alone is the meaning of life
  4. In whatever situation you are in, whether good or bad, have fun and be happy. That is a conscious decision we all make, for in between any stimulus and response there is an infinite time period; it is up to us and us alone to decide that response

High Intensity Intervals for the Elderly!

So sometimes I get out of work, and my legs just don’t want to cooperate in terms of running or doing significant cardiovascular work.  So how to get my cardio in and keep my heart rate above 130 for one minute intervals at least 10 times?  I find that if I try and grind it out by running fast on days like this, I get discouraged.  Its not my heart rate and shortness of breath withe exercise that limits my running on days tike this, it my legs that just feel tight and fatigued.  For example, every Tuesday I am in the clinic all day, on my feet seeing patients.  I have been in practice for 25 years, and I see 50-60 patients on Tuesday.  So my hack is when I get on the treadmill, I get my heart rate up by running slower on a steep incline, say 5-8 degrees at 4 mph.  I usually cycle every 2 minutes, meaning I run at 4 mph at 8 degrees incline, then 4 mph at 1 degree for 2 minutes.  I repeat this cycle for 40 minutes, and get a nice work-out.  I vary the incline on how I feel.  Usually, I will start off at 5 degrees incline, but as I run longer and feel better, I increase the incline on my higher intensity segments.  Try it, it really does work.