DR. SALGO: SQUEEZING SENSATION IN YOUR CHEST, SHOOTING PAIN IN YOUR LEFT ARM.  CLASSIC SIGNS OF A HEART ATTACK, RIGHT? WELL, NOT NECESSARILY. FIND OUT WHAT WE ALL NEED TO KNOW ABOUT HEART ATTACK AND HEART HEALTH, NEXT ON SECOND OPINION.   

MAJOR FUNDING FOR SECOND OPINION IS PROVIDED BY THE GUIDANT FOUNDATION.  THROUGH PHILANTHROPIC PARTNERSHIPS, THE GUIDANT FOUNDATION IS COMMITTED TO INCREASING PATIENT AWARENESS AND ACCESS TO ADVANCEMENTS IN CARDIOVASCULAR CARE. WITH ADDITIONAL SUPPORT FROM THE FOLLOWING: THE JOSIAH MACY JR. FOUNDATION AND THE PARK FOUNDATION.

DR. SALGO: WELCOME TO SECOND OPINION, WHERE EACH WEEK WE SOLVE A REAL MEDICAL MYSTERY.  WHEN WE CLOSE THIS CASE FILE A HALF AN HOUR FROM NOW, YOU'LL NOT ONLY KNOW THE OUTCOME OF THIS WEEK'S CASE, BUT YOU'LL BE BETTER ABLE TO TAKE CHARGE OF YOUR OWN HEALTH CARE.  I'M YOUR HOST, DR. PETER SALGO AND TODAY OUR CASE FILE CONTAINS THE STORY OF MARY.  AS ALWAYS, WE'VE ASSEMBLED A HEALTH CARE TEAM TO TACKLE THE CASE.  SOME ARE DOCTORS, SOME ARE NOT.  NO ONE ON THE PANEL KNOWS THE CASE EXCEPT FOR ELISSA ORLANDO, OUR CIVILIAN. NICE TO HAVE YOU BACK.

DR. SALGO: THIS WEEK'S PRIMARY CARE PHYSICIAN IS DR. LISA HARRIS.  LISA, NICE TO SEE YOU AGAIN. 

DR. HARRIS: DR. SALGO. 

DR. SALGO: AND NOW IT'S TIME TO LOOK INTO THE CASE OF MARY.  HERE'S HER CASE FILE.  MARY IS A WOMAN OF 58 YEARS.  SHE IS MARRIED, SHE HAS TWO GROWN CHILDREN AND SHE IS RETIRED.  IN RETIREMENT, SHE FINDS THAT SHE'S EATING OUT MORE, SHE'S PUT ON A LITTLE WEIGHT IN THE MEANTIME.  SHE IS BOTHERED, HOWEVER, BY RECURRING HEARTBURN AND THE HISTORY OF AN ULCER.  OTHER THAN THAT, SHE CONSIDERS HERSELF VERY HEALTHY.  UP UNTIL THIS MOMENT, WHEN SHE WAKES UP IN THE MIDDLE OF THE NIGHT WITH PRESSURE IN WHAT SHE CALLS HER SOLAR PLEXUS, WHICH IS WHAT I GET FROM PATIENTS FROM TIME TO TIME AND I'M ASSUMING SHE MEANS PRESSURE RIGHT HERE, SOMEWHERE IN HER MIDDLE ABDOMEN.  ASSUMING IT'S HER HEARTBURN, SHE TAKES AN ANTACID, BUT TWO HOURS LATER THE PAIN IS STILL THERE.  HER SYMPTOMS ARE SIMPLY NOT GOING AWAY AND EVEN THOUGH HER INSTINCTS ARE TELLING HER THIS IS NOT HER USUAL GI STOMACH PAIN, SHE'S TRYING HARD TO BELIEVE THAT HER PAIN IS SIMPLY HEARTBURN.  SO SHE CALLS A DOCTOR AFTER AN HOUR MORE. LISA, YOU'RE MARY'S DOCTOR AT THIS POINT.  SHE CALLS YOU IN THE MIDDLE OF THE NIGHT.  WHAT DO YOU DO? 

DR. HARRIS:  I MEAN, THERE ARE SEVERAL QUESTIONS THAT JUMP INTO YOUR MIND.  AND SOMEONE HAVING DISCOMFORT IN THE SOLAR PLEXUS IN THE MIDDLE OF THE NIGHT STRIKES A LOT OF FEAR TO THE HEART OF THE PHYSICIAN.  AND I WANT TO MAKE SURE THIS IS NOT SOMETHING THAT COULD POTENTIALLY RESULT IN HER DEMISE.  SO WHAT I WANT TO KNOW IS, HAVE YOU BEEN SHORT OF BREATH WITH THIS? DID IT MAKE YOU

DR. SALGO: NOT YET, NO.

DR. HARRIS:  DID IT MAKE YOU SWEATY WHEN YOU GOT IT? 

DR. SALGO:  NOT PARTICULARLY.

DR. HARRIS:  IT WOKE YOU UP OUT OF YOUR SLEEP?

DR. SALGO:  THAT IT DID.  AND IT FEELS SUBLIMINALLY DIFFERENT.  IT'S NOT--THIS IS MARY--MY USUAL STOMACH GASTROINTESTINAL PAIN. 

DR. HARRIS:  THAT'S A GET TO THE EMERGENCY ROOM RIGHT AWAY.

DR. SALGO:  I'M HEARING CONCERN HERE OVER A LIFE-THREATENING ILLNESS.  THAT'S WHAT YOU SAID, LISA. 

DR. HARRIS:  YES.

DR. SALGO:  BUT I'M NOT HEARING WHAT'S WORRYING YOU.  WHY ISN'T THIS JUST A TUMMY ACHE? 

DR. COVE:  I THINK SHE SAID IT HERSELF.  SHE SAID THIS IS DIFFERENT THAN HER USUAL INDIGESTION AND IT WOKE HER UP FROM SLEEP, WHICH WOULD BE A LITTLE ATYPICAL FOR A TUMMY ACHE.

DR. SALGO: OK.

DR. COVE:  AND I THINK WE'RE ALL CONCERNED THAT THIS IS MYOCARDIAL INFARCTION, OR A HEART ATTACK THAT'S PRESENTING AS A GI SYMPTOM.  AND IT'S VERY COMMON FOR HEART DISEASE TO PRESENT AS GI SYMPTOMS.

DR. GOLDSCHLAGER: AND EVEN IF IT'S WRONG AS A DIAGNOSIS, IT IS A DIAGNOSIS THAT HAS TO BE EXCLUDED.

ORLANDO:  WELL IF I WAS MARY, TOO, I WOULD REALLY WANT THIS TO BE MY ULCER. A LOT.  I MEAN, I MIGHT BE TELLING YOU WHAT MY SYMPTOMS ARE, I MIGHT SAY THAT IT FEELS DIFFERENT BECAUSE MY GUT INSTINCT IS TO KNOW THAT THERE'S PROBABLY SOMETHING DEEPLY WRONG.  BUT IF I'M MARY, I PROBABLY REALLY WANT THIS TO BE MY ULCER AND I REALLY WANT SOMEBODY TO TELL ME, "NO, DON'T GO, THIS IS GOING TO GET BETTER IN A COUPLE OF HOURS."

DR. SALGO:  I'LL TELL YOU WHAT DOES HAPPEN IS THAT THE PAIN CONTINUES.  SHE GETS MORE AND MORE WORRIED ABOUT IT.  SHE HAS HER HUSBAND DRIVE HER TO THE HOSPITAL AND SHE ARRIVES.  WHAT CAN SHE EXPECT WHEN SHE GETS THERE? 

DR. COVE:  SHE'S GOING TO EXPECT TO BE SEEN BY A NURSE, WHICH IS USUALLY A TRIAGE NURSE WHO WILL TAKE A SHORT HISTORY AND HOPEFULLY, IF THE PHYSICIAN'S CALLED IN, BE PUT INTO A CHEST PAIN PROTOCOL, WHICH MOST ER'S AT THIS POINT SHOULD HAVE A CHEST PAIN PROTOCOL. 

DR. SALGO: YOU'RE ALL TALKING ABOUT A HEART ATTACK, AND THIS IS ABDOMINAL PAIN.

DR. GOLDSCHLAGER:  THAT'S FINE.

DR. SALGO: WHY IS IT FINE?

ORLANDO:  WHY IS IT FINE?

DR. GOLDSCHLAGER:  BECAUSE MYOCARDIAL ISCHEMIC PAIN, ISCHEMIC--NOT ENOUGH BLOOD FLOW TO THE HEART MUSCLE--CAN PRESENT AS ABDOMINAL PAIN, ESPECIALLY IN THE EPIGASTRIUM, RIGHT HERE IN THE SOLAR PLEXUS.  IT CAN PRESENT AS JAW PAIN, TOOTH PAIN, SHOULDER PAIN, BACK PAIN, ARM PAIN, OR WEAKNESS. 

DR. SALGO:  WHY IS THAT?  IS THAT BECAUSE SHE'S A WOMAN OR SIMPLY BECAUSE HEART PAIN DOES THAT?

GOLDCHLAGER:  HEART PAIN DOES THAT.

DR. SALGO:  BUT IN WOMEN ISN'T IT MORE LIKELY TO DO IT THAN IN MEN?  IS IT A DIFFERENT SYNDROME IN WOMEN SOMETIMES?

DR. MOSS:  IT TENDS TO BE MORE ATYPICAL IN WOMEN. IT TENDS TO BE MORE ATYPICAL IN THE OLDER PATIENT.  SO SHE COULD CERTAINLY HAVE A CORONARY PROBLEM.  SHE COULD HAVE AN ANEURYSM.  SHE COULD HAVE THE ULCER, WHICH, ON EXAM, ONE'S GOING TO GET THE VITAL SIGNS AND DO A PHYSICAL EXAM, IT'S NOT GOING TO TAKE VERY LONG TO FIND OUT WHETHER THE ABDOMEN IS BENIGN AND SHE HAS SOME RAPID HEARTBEAT OR IRREGULAR HEARTBEAT AND AN ABNORMAL ELECTROCARDIOGRAM, WE'LL FIND OUT IN A VERY SHORT PERIOD OF TIME WHAT'S GOING ON.

DR. COVE:  I THINK ART BRINGS UP A GOOD POINT.  IT'S A VERY SIMPLE THING TO DO TO GET AN EKG.  IT'S QUICK, IT'S EASY.

DR. SALGO:  OH, SO YOU WANT TO DO A CARDIOGRAM?    

DR. COVE:  ABSOLUTELY, IT'S THE FIRST THING I WANT TO DO BECAUSE IF THERE'S CERTAIN CHANGES ON THE EKG, THAT COMPLETELY CHANGES HOW YOU'RE GOING TO TREAT HER.

DR. SALGO:  WHAT I NOW SEE IN THE CHART, BEFORE SHE CAME TO THE HOSPITAL SHE POPPED AN ASPIRIN.  SOMEONE SAID THAT WAS PROBABLY A GOOD IDEA.  MUST'VE BEEN WORRIED ABOUT HER HEART.  IS THAT A GOOD IDEA IN SOMEBODY WITH AN ULCER BY THE WAY, CHRIS? 

DR. COVE:  NOT IF YOU'RE SURE THE DIAGNOSIS OF ULCER.

DR. SALGO:  THEY'RE SURE, AREN'T THEY?  THEY'RE ON THE PHONE.

DR. COVE:  I THINK...UNSURE THESE SYMPTOMS SHE'S HAVING IS AN ULCER.  I THINK A SINGLE ASPIRIN IN THIS CASE IS NOT A BAD IDEA. 

DR. SALGO:  WHY AN ASPIRIN THOUGH, ART? 

DR. MOSS:  WELL, AN ASPIRIN'S VERY INTERESTING.  THERE'S EVIDENCE THAT THE ASPIRIN AFFECTS THE CLOTTING SYSTEM JUST ENOUGH THAT WHAT'S CALLED THE PLATELETS, THESE ARE THE LITTLE CIRCULATING ELEMENTS IN THE BLOOD THAT CONTRIBUTE TO CLOTTING, AND IF YOU CAN GET ASPIRIN ON BOARD, IF THE PERSON'S HAVING A CORONARY EVENT, YOU'RE GOING TO SLOW DOWN THE CLOTTING PROCESS. 

DR. SALGO:  THEY DID TWO THINGS. THEY GAVE HER A PHYSICAL EXAM AND THEY GET HER CARDIOGRAM.  ON PHYSICAL EXAM SHE IS TACHYCARDIC, SHE HAS A VERY RAPID HEART RATE.  HER PULSE IS IN FACT 170.  HER BLOOD PRESSURE IS ALSO LOW.  HER BLOOD PRESSURE'S DOWN TO ABOUT 85/50.  THEY GET HER CARDIOGRAM AND HER CARDIOGRAM REALLY DOESN'T SHOW VERY MUCH EXCEPT THE TACHYCARDIA.  THERE'S NO OTHER EVIDENCE ON THE CARDIOGRAM RIGHT NOW THAT SHE'S HAVING A HEART ATTACK.  THEY ALSO SENT OFF SOME BLOOD TESTS. WHERE'S THE CHICKEN AND WHERE'S THE EGG HERE?  IS THE TACHYCARDIA CAUSING HER HEART TROUBLE OR IS HER HEART TROUBLE CAUSING THE TACHYCARDIA?

DR. MOSS:  WE'RE NOT SURE AT THIS POINT.  IF WE SAW SIGNIFICANT CHANGES ON THE ELECTROCARDIOGRAM WE WOULD HAVE A BETTER IDEA OF THE CHICKEN OR THE EGG ANALOGY.  BUT WITH SHOWING NO ACUTE CHANGES, HER SYMPTOMS COULD BE DUE TO THE TACHYCARDIA.

DR. COVE:  I THINK THE OTHER THING THAT CONCERNS ME IS HER BLOOD PRESSURE.  WHEN YOU HAVE A TACHYCARDIA AND YOU'RE BLOOD PRESSURE'S LOW, THAT TO ME MORE SUGGESTS THAT THE TACHYCARDIA IS A PATHOLOGIC TACHYCARDIA RATHER THAN A RESPONSE TO A STIMULUS.  BECAUSE YOU'D EXPECT, IF YOU WERE RESPONDING TO A PAIN OR RESPONDING TO SOMETHING, YOUR BLOOD PRESSURE WOULD BE UP AS WELL.  AND SO TO ME THE FAST HEART RATE WITH LOW BLOOD PRESSURE IS A BAD COMBINATION.

DR. SALGO:  THEY DECIDE TO EXAMINE HER AGAIN AND NOW WHEN THEY LOOK AT HER, THEY DESCRIBE SOMETHING CALLED "SIGNS OF EARLY FAILURE" ON HER LUNG EXAM TO THEIR EARS AND ON HER CHEST X-RAY WHICH THEY GOT BACK VERY QUICKLY.  SO THEY DECIDE THAT SHE'S GETTING INTO TROUBLE.  ART, WHAT ARE YOU THINKING ABOUT THIS NOW?

DR. MOSS:  WELL, WHAT YOU'RE DESCRIBING WITH THE SOUNDS IN THE LUNGS--THESE ARE USUALLY REFERRED TO AS RAILS, OR CREPITATIONS AND  THEY'RE FREQUENTLY A SIGN OF SOME FAILURE OF THE HEART.  THERE'S A BUILDUP OF SOME FLUID INTO THE CHEST, INTO THE LUNGS, WHICH COULD OCCUR AS THE RESULT OF A VERY RAPID HEART ACTION.

ORLANDO:  I'M DIZZY!  I'M REALLY DIZZY.  I'VE HEARD GI PROBLEMS, I'VE HEARD LUNGS, I'VE HEARD HEART, I'VE HEARD TACHYCARDIA.  I'M NOT QUITE SURE EXACTLY WHAT THAT MEANS, AND THAT TIME IS REALLY CRITICAL.  SO WHAT ARE YOU SAYING TO ME AS THE PATIENT IF I'M LYING THERE, OR TO MY HUSBAND?

DR. HARRIS:  SOMEONE WHO'S NOT A CARDIOLOGIST AND IS DEFERRING THE READING OF THE EKG TO THEM WOULD COME AND SPEAK TO THE PATIENT AND SAY, "WE'RE NOT SURE WHAT'S CAUSING THIS.  YOUR HEART IS BEATING VERY FAST AND WHEN IT BEATS THAT FAST, BLOOD IS NOT GETTING OUT TO THE ORGANS THE WAY IT NEEDS TO.  SO WE'RE GOING TO DO SOME TESTS TO SEE WHY YOUR HEART IS BEATING THAT FAST.  WE DON'T KNOW IF THERE'S A PROBLEM WITH THE HEART THAT'S CAUSING IT TO BEAT FAST OR IF IT'S BEATING FAST WHICH IS CAUSING A PROBLEM FOR YOU."

DR. SALGO:  ALL RIGHT, SO NOW TIME IS RUNNING OUT.  THEY WANT TO GET HER HEART RATE DOWN QUICKLY.  TICK-TOCK, TICK-TOCK, TICK-TOCK.  CHRIS, WHAT ARE YOU GOING TO DO? 

DR. COVE:  WELL I MEAN IT'S DIFFICULT BECAUSE A LOT OF THE DRUGS YOU USE TO LOWER HEART RATE LOWER BLOOD PRESSURE, SO I THINK THE FIRST THING I'M GOING TO DO IS GIVE HER SOME IV FLUIDS.

DR. SALGO:  WHAT FLUIDS YOU GOING TO GIVE HER?

DR. COVE:  JUST SOME NORMAL SALINE.

DR. SALGO:  YOU'RE GOING TO PUT SALT WATER IN HER BODY THOUGH HER LUNGS ARE FILLING UP WITH SALT WATER. 

DR. COVE:  I DON'T KNOW IF THEY'RE FILLING UP.  YOU DESCRIBED MILD, EARLY CONGESTION.  SO I THINK THAT IT'S PROBABLY SAFE TO GIVE SOME FLUIDS. 

DR. SALGO:  OK.  ART, YOU GOING TO DO THAT?

DR. MOSS:  WELL, I'M NOT SURE I WOULD DO THAT BECAUSE OF THE FLUID SITUATION.  I'M MORE CONCERNED THAT THIS IS A PRIMARY, RAPID HEART ACTION OF THE UPPER CHAMBER.

DR. HARRIS:  I'M GOING TO THIS IS A PATIENT THAT IS NOW HYPOTENSIVE AND IS GOING

DR. SALGO:  HYPOTENSIVE, MEANING LOW BLOOD PRESSURE.

DR. HARRIS:  LOW BLOOD PRESSURE.

DR. MOSS:  YOU DIDN'T LET ME FINISH MY TRAIN OF THOUGHT HERE.  I'M THINKING OUT LOUD ON THIS.  BUT IT DOESN'T TAKE VERY LONG IF YOU'RE AT THE BEDSIDE TO SIMPLY PRESS ON THE CAROTID SINUS AND IF HER HEART RATE WERE SUDDENLY TO GO FROM 170 TO 80, THIS WOULD CORRECT THE WHOLE SITUATION VERY QUICKLY. 

DR. GOLDSCHLAGER:  BUT YOU DON'T HAVE A WHOLE LOT OF TIME TO SLOW THIS RATE OR CONVERT IT TO NORMAL BEFORE SHE COULD DECOMPENSATE--GO BAD. GO REALLY BAD.

DR. SALGO: I'M GOING TO TELL YOU WHAT THEY DID.  AND WE'LL SHORT-CIRCUIT SOME OF THIS DISCUSSION.  THEY WENT AHEAD AND THEY GAVE HER AN INTRAVENOUS CALCIUM CHANNEL BLOCKER BECAUSE THEY WERE CONCERNED THAT HER HEART RATE WAS GOING TOO FAST.  SLOW IT DOWN.  THIS SOUND OK TO YOU GUYS?

DR. COVE:  WE DON'T REALLY HAVE A DIAGNOSIS AND THERE ARE SOME DOWNSIDES TO A CALCIUM CHANNEL BLOCKER.  CERTAINLY IT CAN LOWER YOUR BLOOD PRESSURE EVEN MORE IN

DR. GOLDSCHLAGER: WHICH IS WHY YOU'RE GIVING IT WITH FLUIDS.

DR. COVE: CORRECT.  IT CAN ALSO--IN THE SETTING OF A HEART ATTACK, THERE ARE CERTAIN CALCIUM CHANNEL BLOCKERS YOU DON'T WANT TO GIVE.  AND WE HAVEN'T RULED OUT

DR. SALGO: WHAT IS A CALCIUM CHANNEL BLOCKER ANYWAY?  WE'RE ALL THROWING THIS TERM AROUND.

DR. COVE: A CALCIUM CHANNEL BLOCKER IS A MEDICATION THAT WILL SLOW THE HEART RATE, LOWER THE BLOOD PRESSURE. COMMONLY USED IN HIGH BLOOD PRESSURE, COMMONLY USED IN PEOPLE WHO HAVE CERTAIN TACHYCARDIAS.        

DR. SALGO: ALL RIGHT, I'LL TELL YOU WHAT THEY DID.  THEY GAVE HER SOME CALCIUM CHANNEL BLOCKER AND IN FACT, THEY SKATED ON THIS ONE, AND HER BLOOD PRESSURE STAYED OK.  HER HEART RATE CAME DOWN, NOW WITH THE HEART RATE HERE THAT I'M LOOKING AT IT, ABOUT 100.  THEY LOOKED AT HER CARDIOGRAM AGAIN AND THIS TIME THEY SAID THAT MARY IS HAVING A HEART ATTACK.  WHAT DO YOU DO NOW?  WHAT IS A HEART ATTACK ANYWAY, ART?

DR. MOSS: WELL A HEART ATTACK IS DUE TO COMPROMISE OF THE CIRCULATION TO THE HEART MUSCLE, WHAT WE CALL THE CORONARY ARTERIES.  USUALLY IT'S A RUPTURE OF A PLAQUE THAT OCCLUDES A VESSEL.

DR. SALGO: WHAT'S A PLAQUE?

DR. MOSS: A PLAQUE IS THE LINING, THE ARTHLEROSCLEROSIS, THE BUILDUP OF CHOLESTEROL ON THE INNER LINING OF THE CORONARY ARTERY. 

DR. SALGO: SHE'S HAVING A HEART ATTACK.

DR. MOSS: THAT IS CORRECT. 

DR. SALGO: IF HER HEART MUSCLE, IF I UNDERSTAND IT RIGHT NOW, WHAT YOU'RE TELLING ME, HER HEART MUSCLE IS DYING AS SHE'S LYING THERE ON THE STRETCHER.

DR. GOLDSCHLAGER: WE'RE NOT SURE ABOUT THAT YET.  WHAT WE KNOW FROM WHAT YOU SAID IS THAT SHE IS HAVING INSUFFICIENT BLOOD SUPPLY.  

DR. SALGO:  THE CARDIOGRAM NOW SAYS SHE'S HAD A HEART ATTACK, SHE'S GOT HER CALCIUM CHANNEL BLOCKER.  WHAT DO YOU DO?  YOU CALL IN CHRIS?

DR. MOSS: ABSOLUTELY.  FIRST OF ALL YOU CALL IN THE CARDIOLOGIST,  IN THIS CASE IT WOULD BE CHRIS.  THIS PATIENT IS GOING TO NEED A CARDIAC CATHETERIZATION AND TO SEE EXACTLY WHICH BLOOD VESSEL IS BLOCKED OR NEARLY OCCLUDED AND IT CAN BE OPENED UP AND YOU HAVE MAYBE SIX HOURS FROM THE BEGINNING TO THE TIME TO SALVAGE THE HEART MUSCLE SO THERE IS NO RESIDUAL DAMAGE. 

DR. SALGO:  THE PHRASE HERE IS WHAT, ART?  TIME IS MUSCLE. 

DR. MOSS: TIME IS MUSCLE.

DR. SALGO: FOR EVERY SECOND YOU LOSE YOU LOSE MORE MUSCLE.

DR. HARRIS: SO THE PATIENT WHO'S LYING HERE WONDERING WHAT'S GOING ON, WE ARE DOING THINGS OTHER THAN JUST THINKING.  WE'RE ALSO GIVING A LITTLE BIT OF FLUIDS, WE'RE GIVING PAIN MEDICATION TO EASE THE DISCOMFORT SO THEY'RE NOT LYING THERE IN PAIN.

DR. SALGO: SHE'S ON IV FLUIDS, SHE'S ON OXYGEN. 

DR. HARRIS: THAT'S RIGHT.

ORLANDO: SO HAVE YOU TOLD ME YET, "YOU'RE HAVING A HEART ATTACK?"  THAT'S MY FIRST QUESTION.  AND THE SECOND QUESTION IS,  A CATHETERIZATION IS A LOOK AT WHAT'S HAPPENING INSIDE YOUR ARTERIES?

DR. MOSS: AND TO CORRECT IT IF IT'S...DEPENDING UPON WHAT WE FIND.

DR. GOLDSCHLAGER: WITH INTENT TO OPEN THE VESSEL IF IT'S OBSTRUCTED.

DR. HARRIS: CATHETERIZATION IS WHERE THEY TAKE A SMALL WIRE, LIKE A SMALL CAMERA, AND THEY GO IN THROUGH YOUR GROIN AND THREAD IT UP THROUGH THE VEINS IN YOUR GROIN INTO YOUR HEART MUSCLE, THAT'S ONE OF THE MAJOR WAYS THAT THEY'RE GOING INTO THE ARTERIES OF THE HEART TO TAKE A LOOK AND SEE WHERE THE BLOCKAGE MIGHT BE.  SO IT'S KIND OF LIKE USING THE SNAKE ON YOUR PLUMBING.

ORLANDO:  IN THE VERY BEGINNING OF THE CASE SHE WAS THINKING MAYBE IT WAS HER ULCER AND MAYBE WANTED IT TO BE HER ULCER.  COULD SHE HAVE DONE ANYTHING TO SAVE TIME BY REALLY UNDERSTANDING SOME OF THE THINGS THAT WE'VE BEEN HEARING ABOUT WHAT THE SYMPTOMS ARE AND MAYBE UNDERSTANDING HER OWN HISTORY BETTER? 

DR. GOLDSCHLAGER: IF THE PATIENT HAD AN APPRECIATION OF THE KINDS OF THINGS SHE NEEDED TO KNOW, WHAT ARE THE POSSIBLE SYMPTOMS OF HEART ATTACK, ETC, AND SHE RECOGNIZED HERSELF THAT THESE WERE NOT HER ULCER SYMPTOMS, SHE WOULD'VE COME IN EARLIER.

DR. COVE:  50% OF PATIENTS WHO HAVE HEART DISEASE, THEIR FIRST SYMPTOM IS EITHER A HEART ATTACK OR DYING. 

DR. SALGO: THAT'S A SOBERING NUMBER. 

ORLANDO: WOW!

DR. SALGO:  SO LET ME JUST PAUSE FOR A MINUTE HERE TO SUM UP SOME KEY THINGS--I'LL GET BACK TO YOU.  HEART ATTACK SYMPTOMS MAY PRESENT DIFFERENTLY IN WOMEN THAN IN MEN.  EARLY INTERVENTION TO PROTECT THE HEART IS CRITICAL.  SEEKING HELP QUICKLY, BEING ABLE TO DESCRIBE YOUR SYMPTOMS ACCURATELY, WILL LEAD TO A FASTER DIAGNOSIS AND A FASTER TREATMENT.  HEART ATTACKS DON'T ALWAYS PRESENT THE WAY YOU'VE HEARD THAT THEY WILL WITH CHEST PAIN, ARM PAIN, SOMETIMES IT CAN BE ABDOMINAL PAIN AS WELL, PERHAPS MORE FREQUENTLY IN WOMEN THAN IN MEN, BUT BOTH SEXES NEED TO HAVE THEIR ANTENNAE UP WHEN THEY BEGIN FEELING FUNNY IN THE MIDDLE OF THE NIGHT.  LET ME MOVE THE CASE ALONG A LITTLE BIT.  MARY IS HAVING A HEART ATTACK, HER DOCTORS WANT TO DO SOMETHING TO STOP IT.  THEY'RE GOING TO CALL YOU.  WHAT ARE YOU GOING TO TELL MARY?  RIGHT NOW?

DR. COVE: I'M GOING TO EXPLAIN TO MARY THAT SHE HAS AN ARTERY THAT'S COMPLETELY BLOCKED AND THAT THIS IS PREDOMINANTLY A BLOOD CLOT AND THAT THE FASTER WE CAN OPEN THIS ARTERY UP, THE BETTER CHANCE SHE'S GOING TO HAVE TO SURVIVE AND THE BETTER CHANCE SHE'S GOING TO HAVE TO HAVE BETTER HEART FUNCTION.

DR. SALGO: ALL RIGHT I'LL TELL YOU WHAT.  HER EMERGENCY ROOM DOCTORS HAVE DECIDED--JUST AS YOU DID, JUST AS WE DID--THAT MARY IS HAVING A HEART ATTACK.  SO, THEY GIVE HER SOME MEDICATION, THEY CALL YOU, THE CATH LAB GUY, THEY GIVE HER A BETA BLOCKER, THEY GIVE HER NITROGLYCERIN, THEY OF COURSE HAVE HER ON OXYGEN.  THEY DO NOT GIVE HER ANY THROMBOLYTICS, NONE OF THESE BLOOD-THINNING, CLOT-BUSTING DRUGS AT THE TIME.

DR. COVE: GOOD.

DR. SALGO: THE CATH REPORT SHOWS THAT IN FACT THERE'S A BLOCKAGE IN HER LEFT ANTERIOR DESCENDING CORONARY ARTERY. WHAT DOES THAT MEAN ON THE CATH REPORT, WHAT HAS CAUSED THIS BLOCK CHRIS?

DR. COVE:  BASICALLY, THE LEFT ANTERIOR DESCENDING IS THE ARTERY THAT GOES TO THE FRONT OF YOUR HEART.  THERE ARE THREE MAIN ARTERIES, AND IT BASICALLY MEANS THAT THIS IS WHAT'S CAUSING HER PROBLEM. IT MEANS THAT TO GET THIS ARTERY OPEN, IT'S GOING TO MAKE HER BETTER. THE GOAL HERE IS TO THREAD THIS SMALL WIRE, WE PUT IN A BALLOON, INFLATE THE BALLOON, IN SOME CASES, NOW, WE'LL ACTUALLY EXTRACT THE BLOOD CLOT, WE'LL GO IN WITH A CATHETER, WE CAN ACTUALLY PULL THE BLOOD CLOT OUT AND AGAIN WHAT WE FIND, AS NORA SAID, IS WE'LL FIND THAT THERE'S A LARGE AMOUNT OF BLOOD CLOT AND A SMALL AMOUNT OF BLOCKAGE.

DR. SALGO:  YOU'RE GOING TO ANGIOPLASTY HER?

DR. COVE:  YES.

DR. SALGO: WHAT DOES THAT MEAN?

ORLANDO: WHAT IS ANGIOPLASTY?

DR. COVE:  ANGIOPLASTY IS A BALLOON, A SMALL SAUSAGE-LIKE BALLOON THAT'S INFLATED, IT KIND OF SQUISHES THE BLOCKAGE BACK INTO THE WALLS OF THE ARTERY, THAT WORKS VERY WELL FOR OPENING THE ARTERY, BUT A LOT OF TIMES, THAT ARTERY WILL KIND OF COLLAPSE BACK DOWN, SO WE PUT IN WHAT'S CALLED A STENT, WHICH IS A METAL SCAFFOLDING. IT'S LIKE A SPRING ON THE INSIDE OF A PEN.

ORLANDO:  HOLDS IT OPEN?

DR. COVE:  AND IT HOLDS IT OPEN. THESE STENTS STAY IN THERE, THEY'RE PERMANENT.

ORLANDO:  SO THAT ALL HAPPENS DURING...

DR. HARRIS:  THAT'S WHY WE CALL THEM ROTO-ROOTERS.

ORLANDO:  ROTO-ROOTER. SO THAT ALL HAPPENS IN THE COURSE OF THE CATHETERIZATION, THOUGH, RIGHT? SO IT HAPPENS ONE RIGHT AFTER THE OTHER, IF THEY NEED TO DO IT, THEY JUST DO IT?

DR. GOLDSCHLAGER & DR. COVE:  RIGHT.

HARRIS: AT THE SAME TIME.

DR. SALGO: WELL IN MARY'S CASE, THEY DID FIND A BLOCKADE IN HER CORONARY ARTERY. YOU WENT IN, OR YOUR EQUIVALENT WENT IN AND ANGIOPLASTIED HER, THEN YOU PUT IN THIS STENT TO KEEP IT OPEN. SO NOW MARY'S GOT THIS GREAT CORONARY ARTERY, YOU KNOW, THERE'S THAT COMMERCIAL THAT SAYS, MUCH, MUCH BETTER THAN YOU. SHE'S FINE RIGHT, SHE CAN GO HOME, NO PROBLEM.

DR. COVE: NO, I THINK YOU'RE STILL DEALING WITH, ALL THE...YOU'VE TREATED THE SYMPTOM, WHICH IS THE BLOCKAGE, YOU STILL HAVE THE DISEASE OF ARTERIOSCLEROSIS.

DR. SALGO: SO WHAT DOES THAT MEAN?

DR. COVE: WHICH IS A LIFELONG DISEASE.

ORLANDO: SO SHE HAS IS THAT LIKE CORONARY ARTERY DISEASE?

DR. COVE:  CORRECT.

DR. SALGO: THEY DID FIND THAT THE MUSCLE THAT SEEMED TO BE AFFECTED BY THE ARTERY THAT WAS OBSTRUCTED WASN'T MOVING VERY WELL AT THE BEGINNING OF THE CATH, BUT BY THE END OF THE CATH, IT WAS MOVING A LOT BETTER.  AND I CAN TELL YOU THAT IT'S ALL-TOGETHER LIKELY THAT BASED ON THIS CHART, MOST OF THE SYMPTOMS THAT YOU GUYS WERE CALLING "HEART FAILURE" GOT BETTER.  NOW WHAT DO YOU WANT TO SEND HER HOME ON?  WHAT MEDICATIONS DO YOU WANT HER TO HAVE?  WHAT ABOUT HER LIFESTYLE?  WHAT ABOUT HER DIET? GIVE ME SOMETHING TO LATCH ONTO HERE THAT MARY CAN USE.

DR. MOSS: WELL, THERE'S A LOT OF VERY GOOD MEDICATIONS THAT ARE USED TO TRY AND IMPROVE SHORT AND LONG-TERM OUTCOMES.  SO ONE OF THE VERY CLASSIC MEDICATIONS THAT SHE WOULD BE PUT ON IS WHAT'S CALLED A BETA BLOCKER.  THIS WOULD BE THE VERY FIRST THING.  IF HER, WHAT WE CALL HER MECHANICAL FUNCTION RETURNS TO NORMAL, SHE MIGHT NOT REQUIRE SOME MEDICATIONS TO DIALATE THE BLOOD VESSELS BUT ALMOST SURELY IN HER AGE GROUP--SHE WAS WHAT, 57, 58--SHE PROBABLY HAS SOME CHOLESTEROL ELEVATION.  SHE WOULD CERTAINLY END UP WITH A LIPID-LOWERING DRUG, WHAT WE CALL A STATIN GROUP OF DRUGS.  SO AS WE GET MORE INFORMATION, THERE'S A WHOLE SERIES OF MEDICATIONS SHE CERTAINLY ONE WOULD CONSIDER ASPIRIN, BUT IT WOULD BE DEPENDENT UPON HOW ACTIVE HER ULCER MIGHT'VE BEEN. 

DR. SALGO: I'LL TELL YOU WHAT THEY DID.  HER DOCTORS DID SEND HER HOME ON A STATIN FOR WHATEVER REASON.  THEY SENT HER HOME ON A BETA BLOCKER.  SO FAR THEY'RE IN AGREEMENT WITH YOU GUYS.  IT SAYS HERE THEY PUT HER ON ASPIRIN AND THEY PUT HER ON AN ACE INHIBITOR.  WHAT THE HECK IS THAT?

DR. GOLDSCHLAGER: IT'S A DRUG THAT PREVENTS THE DISTORTION.  IN A PATIENT LIKE THIS, WHERE WE'RE NOT GIVING IT FOR BLOOD PRESSURE, WHERE IT'S AN EXCELLENT DRUG ALSO--IT'S GOING TO PREVENT THE DISTORTION AND SHAPE CHANGES IN THAT LOWER PUMPING CHAMBER SUPPLIED BY THAT OBSTRUCTED ARTERY THAT CAN RESULT IN HEART FAILURE.

DR. SALGO: THEY ALSO GIVE HER A DIET, A LOW-CHOLESTEROL DIET, AND THEY TELL HER TO EXERCISE.  NOW MARY'S JUST HAD A HEART ATTACK.  CAN SHE EXERCISE AND WILL DIET AND EXERCISE DO HER ANY GOOD AT ALL, LISA?

DR. HARRIS: SURE SHE CAN EXERCISE AND IN FACT SHE SHOULD BE IN A CARDIAC REHABILITATION PROGRAM WHERE SHE GETS SPECIFIC DIRECTED EXERCISES UNDER THE CARE OF A PHYSICIAN AND/OR A NURSE.

DR. SALGO: WELL SHE'S GOING HOME WITH A BUNCH OF DRUGS.

DR. HARRIS: THAT'S RIGHT.

DR. SALGO: I MEAN, WE'VE GOT--WELL, COUNT THEM UP!  1, 2, 3 ,4...

DR. COVE: SHE SHOULD BE ON ONE OTHER DRUG, ACTUALLY.

DR. SALGO: WHAT'S THAT?

DR. COVE: PLAVIX.

DR. HARRIS: RIGHT.

DR. SALGO: I WAS GOING TO ASK YOU ABOUT PLAVIX.  I'M GLAD YOU BROUGHT THAT UP.         

ORLANDO: WHAT'S PLAVIX?

DR. COVE: BECAUSE IF SHE HAS A STENT PUT IN, THE STENT'S A PIECE OF METAL IN AN ARTERY, THESE STENTS CAN CLOT, AND PLAVIX IS A MEDICINE THAT CAN PREVENT IT.

DR. HARRIS: IT HELPS REDUCE CLOTTING BY AFFECTING THE WAY THE PLATELETS WORK. 

DR. COVE: IT ALSO HAS THE BENEFIT TOO IN THAT AFTER THESE ACUTE CORONARY EVENTS, IT CAN REDUCE SECOND CORONARY EVENTS.

DR. SALGO: OK.  SOMEBODY ELSE IN THE CHART LATER ON, I CAN TELL YOU, I READ THE NURSE'S NOTES HERE, SUGGESTED PLAVIX AND THEY ADDED IT. 

DR. HARRIS: WHAT OFTEN HAPPENS IS THAT WE START THIS ARMAMENTARIA OF MEDICATIONS, WE THINK WE'VE DONE OUR JOB, WE SEND THE PATIENT HOME.

DR. SALGO: SHE'S ON FIVE DRUGS HERE!

DR. HARRIS: IT'S GOING TO BE IMPORTANT TO MAKE SURE THAT SHE HAS A COMMUNITY HEALTH AGENCY THAT'S INVOLVED IN HER CARE TO MAKE SURE THAT HER QUESTIONS ARE ANSWERED ABOUT HER DIET AND HER EXERCISE, A CARDIAC REHABILITATION PROGRAM, THAT HER PRIMARY CARE PHYSICIAN IS INVOLVED, AND THAT SHE GETS REGULAR CHECK-UPS WITH HER PRIMARY CARE PHYSICIAN.

DR. SALGO: I COME BACK TO THE POINT. YOU JUST PUT HER ON A COCKTAIL.  WE JUST PUT HER ON A COCKTAIL OF FIVE DIFFERENT DRUGS.  ACE INHIBITOR, BETA BLOCKER, STATIN, ASPIRIN, AND PLAVIX.

ORLANDO: HOW WOULD SHE KNOW THE SCHEDULE?

DR. SALGO: IS SHE GOING TO TAKE THIS STUFF?
       
DR. MOSS: LET ME MAKE A COMMENT ON THIS.  YOUR IMPLICATION IS THAT, WHY DOES SHE NEED ALL THESE MEDICATIONS?  SHE'S HAD A SERIOUS HEART EVENT.  POTENTIALLY LIFE-THREATENING.  IT CAN RECUR.

DR. SALGO: LISA, WHAT ARE YOU GOING TO DO?  WE'RE IN YOUR OFFICE, IT'S 10 O'CLOCK IN THE MORNING AND THERE'S MARY IN YOUR WAITING ROOM.  SHE LOOKS AWFUL.  REALLY UPSET.  AND SHE SAYS, "I'VE GOT TO TALK TO YOU IN PRIVATE." WE GO BACK IN YOUR OFFICE, YOU CLOSE THE DOOR AND SHE LOOKS AT YOU AND SHE SAYS, "I CAN'T AFFORD IT.  IT'S $500.  PLEASE HELP ME."  SHE LOOKS AT YOU JUST LIKE THIS.  $500.  CAN YOU HELP?  

DR. HARRIS: SURE, SURE.

DR. SALGO: THAT'S A LOT OF MONEY.

DR. HARRIS: THERE'S A VARIETY OF THINGS ALMOST ALL THE PHARMACEUTICAL COMPANIES HAVE PROGRAMS WHERE THEY CAN ASSIST INDIGENT PATIENTS OR PATIENTS THAT ARE HAVING DIFFICULTY PAYING FOR THEIR MEDICATIONS.  AND THEN THERE'S A WONDERFUL THING CALLED YOUR SAMPLE CLOSET [LAUGHTER] AND YOU ASSIST THE PATIENT OUT OF YOUR SAMPLE CLOSET AND/OR YOU REASSESS THE MEDICATIONS THAT YOU HAVE PLACED HER ON AND SEE IF THERE'S A LESS EXPENSIVE COCKTAIL THAT YOU CAN PUT HER ON.

DR. GOLDSCHLAGER: AND THEN YOU WRITE YOUR CONGRESSMAN.

DR. SALGO: YOU WRITE YOUR CONGRESSMAN, YOUR SENATOR. LET ME SUM UP A FEW KEY THINGS TO REMEMBER HERE.  SECONDARY PREVENTION, WHICH IS WHAT WE HAVE BEEN TALKING ABOUT OVER HERE, IT MEANS DRUGS, DIET AND EXERCISE, DOES WORK.  SECONDARY PREVENTION REDUCES THE RISK OF A SECOND HEART ATTACK.  FASTEN YOUR SEATBELTS HERE, NOT BY A LITTLE BIT, BUT BY BETWEEN 50% AND 80%.  THAN IS AN ENORMOUS EFFECT.  THESE DRUGS ARE IMPORTANT, LIFESTYLE IS IMPORTANT, DIET IS IMPORTANT, EXERCISE AND CARDIAC REHAB IS ABSOLUTELY CRITICAL.  I'M SURE EVERYBODY HERE IS GOING TO AGREE WITH THAT.  WE'RE GOING TO STOP THE CASE FOR A SECOND AND GO BACK.  YOU ASKED WHAT WAS HER CHOLESTEROL BEFORE ALL OF THIS BEGAN.  WELL I'VE GOT NEWS FOR YOU.  HER LDL, THE BAD CHOLESTEROL, WAS HIGH.  HER HDL CHOLESTEROL, WHICH IS THE GOOD CHOLESTEROL, WAS NORMAL.  AND UPON REFLECTION, MARY SAYS, "I WASN'T PUT ON A CHOLESTEROL-LOWERING DRUG BECAUSE MY DOCTORS TOLD ME THAT MY HDL CHOLESTEROL WAS OK AND I DIDN'T NEED IT."

DR. MOSS: .  I DON'T KNOW THAT THERE'S AN ABSOLUTE RIGHT ANSWER, PETER.  I THINK THAT THERE ARE MANY PHYSICIANS WHO WOULD PUT SUCH A PATIENT, AS WHAT WE CALL PRIMARY PREVENTION, WHO HAS AN ELEVATED LDL, THE BAD CHOLESTEROL, ON A STATIN DRUG.  THERE ARE MANY PHYSICIANS WHO WOULD.  THERE ARE ALSO MANY PHYSICIANS WHO WOULDN'T BECAUSE OF THE COST, ETC.  AND SO THIS IS A GRAY AREA IN MEDICINE. 

DR. HARRIS: BUT I THINK THE BOTTOM LINE IS WE HAVE TO ENCOURAGE OUR PATIENTS TO TAKE CHARGE OF THEIR OWN HEALTH CARE AND THEIR OWN DESTINY AND THAT YOU ABSOLUTELY HAVE TO TEACH PATIENTS TO EAT APPROPRIATELY, TO LOSE WEIGHT, TO EXERCISE, TO DO ALL OF THOSE THINGS BECAUSE STATINS ARE NOT PANACEAS.

DR. SALGO: WE WERE TALKING ABOUT SECONDARY PREVENTION FOR MARY WHO'D ALREADY HAD A HEART ATTACK.  NOW WE'RE TALKING ABOUT SOMETHING ELSE, WHICH IS PRIMARY PREVENTION, TO KEEP HER FROM HAVING A HEART ATTACK IN THE FIRST PLACE. 

DR. COVE: IF YOU LOOK AT PRIMARY PREVENTION, SOME OF THE SIMPLE THINGS ARE THE BEST THINGS--DIET, EXERCISE AND NOT SMOKING.  IF WE COULD STRESS THOSE AS MUCH AS WE TRY TO PUSH DRUGS SOMETIMES, WE COULD BE BETTER OFF. 

DR. SALGO: IT'S IMPORTANT TO SUM SOME OF THIS UP.  PRIMARY PREVENTION DOES WORK WITH DRUGS AND EXERCISE AND DIET.  IT MAY PREVENT YOU FROM HAVING A HEART ATTACK IN THE FIRST PLACE AND ALSO PREVENT YOU FROM HAVING TO TAKE THAT COCKTAIL OF DRUGS THAT MARY'S GOING TO HAVE TO TAKE FOR THE REST OF HER LIFE.  PRIMARY PREVENTION INCLUDES EATING A HEART-HEALTHY DIET, EXERCISING REGULARLY, MANAGING YOUR CHOLESTEROL AND BLOOD PRESSURE, STOPPING SMOKING. PERHAPS IT MEANS EVERYBODY'S TAKING A STATIN DRUG.  IT'S NOT ENTIRELY CLEAR.  BUT ISN'T IT BETTER TO KEEP YOURSELF FROM GETTING SICK IN THE FIRST PLACE?  ALL RIGHT, I WANT TO GO BACK TO THE CASE.  9 MONTHS LATER, I CAN TELL YOU THE CHART, ALMOST TO THE DAY, 9 MONTHS LATER SHE'S BACK IN THE HOSPITAL THIS TIME WITH CHEST PAIN.  I'LL SPARE YOU ALL OF THE RIGMAROLE WE WENT THROUGH THE FIRST TIME.  BACK TO THE CATH LAB.  SHE HAS OCCLUSION AT, IN, OR AROUND THE STENT THAT ONE OF YOUR FRIENDS PUT IN. 

DR. COVE: MY STENTS NEVER BLOCK, BY THE WAY.
[LAUGHTER]

DR. SALGO: IS THIS A SIGNIFICANT PROBLEM HERE?  WHAT'RE YOU GOING TO DO ABOUT IT?

DR. COVE: IT'S A COMMON PROBLEM.  STENTS RE-NARROWING HAPPENS ABOUT 20% OF THE TIME IN WHAT WE CALL BARE METAL STENTS, WHICH ARE THE ROUTINE NORMAL STENTS WE USED PRIOR TO SEVERAL YEARS AGO.  AND USUALLY WHEN THESE PEOPLE PRESENT, THEY USUALLY DON'T PRESENT AS A HEART ATTACK.  THEY PRESENT MORE WITH TYPICAL ANGINA OR CHEST PAINS WITH EXERTION. 

DR. SALGO: CAN YOU FIX IT?

DR. COVE: YES. 

DR. SALGO: YOU GOING TO GO TO THE CATH LAB AND OPEN IT UP?

DR. COVE: RIGHT, YOU OPEN IT UP AND THEN YOU DO YOU RADIATE.  YOU DO RADIATION ON THE INSIDE OF THE STENT.

DR. SALGO:  NOW, WE COVERED A LOT OF GROUND TODAY.  IS THERE ANYTHING ELSE THAT MARY NEEDS TO KNOW BEFORE WE BID HER FAREWELL?  I CAN TELL YOU THAT SHE TOOK HER DRUGS AND SHE DID WELL FOR AS LONG AS SHE WAS FOLLOWED UP HERE.  ANY LAST WORD?  IN THAT CASE WHAT I'M GOING TO SAY--I WANT TO REVIEW THE INFORMATION THAT YOU AT HOME NEED TO REMEMBER.  HEART ATTACK SYMPTOMS MAY PRESENT DIFFERENTLY IN WOMEN THAN IN MEN.  EARLY INTERVENTION TO PROTECT THE HEART IS CRITICAL.  SEEKING HELP AND BEING ABLE TO DESCRIBE YOUR SYMPTOMS ACCURATELY WHEN YOU GET TO SOMEBODY WHO CAN HELP YOU WILL LEAD TO A FASTER DIAGNOSIS AND FASTER TREATMENT.  SECONDARY PREVENTION, WHICH IS PREVENTION AFTER A HEART ATTACK, MEANING DRUGS, DIET AND EXERCISE, DOES WORK AND IT WORKS VERY WELL.  SECONDARY PREVENTION REDUCES THE RISK OF A SECOND HEART ATTACK BY A WHOPPING 50% TO 80%.  PRIMARY PREVENTION, PREVENTION THAT WILL KEEP YOU FROM HAVING A HEART ATTACK IN THE FIRST PLACE, ALSO WORKS. IT ALSO PREVENTS YOU FROM HAVING TO TAKE THAT COCKTAIL OF DRUGS FOR THE REST OF YOUR LIFE.  PRIMARY PREVENTION INCLUDES EATING A HEALTHY DIET, EXERCISING, MANAGING YOUR CHOLESTEROL--PERHAPS WITH MEDICATION--AND MANAGING YOUR BLOOD PRESSURE AND STOPPING SMOKING.  IT'S A LOT TO REMEMBER, BUT YOUR LIFE IS HANGING IN THE BALANCE.  THIS IS IMPORTANT STUFF.  OUR FINAL MESSAGE IS THIS: TAKING CHARGE OF YOUR HEALTH MEANS BEING INFORMED AND HAVING QUALITY COMMUNICATION WITH YOUR DOCTOR.  I'M DR. PETER SALGO AND I'LL SEE YOU NEXT TIME FOR ANOTHER SECOND OPINION.

SEARCH FOR HEALTH INFORMATION AND LEARN MORE ABOUT DOCTOR/PATIENT COMMUNICATION ON THE SECOND OPINION WEB SITE.  THE ADDRESS IS PBS.ORG.

MAJOR FUNDING FOR SECOND OPINION IS PROVIDED BY THE GUIDANT FOUNDATION.  THROUGH PHILANTHROPIC PARTNERSHIPS, THE GUIDANT FOUNDATION IS COMMITTED TO INCREASING PATIENT AWARENESS AND ACCESS TO ADVANCEMENTS IN CARDIOVASCULAR CARE, WITH ADDITIONAL SUPPORT FROM THE FOLLOWING: THE JOSIAH MACY JR. FOUNDATION AND THE PARK FOUNDATION.

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