[music plays] [no dialogue] >>Lori Banks: Carotid stenosis is the leading cause of stroke, yet the symptoms can be subtle.

On this edition of Being Well, Interventional Cardiologist Dr. Ash Al-Dadah will be here to explain this disease.

Risk factors such as age, high blood pressure, and high cholesterol can lead to carotid stenosis.

Dr. Al-Dadah will talk to us about how it's diagnosed and the treatment options available.

Finally we'll get some heart healthy advice we can all follow right now.

Don't go away, Being Well starts now.

[music plays] Production of Being Well is made possible in part by: Sarah Bush Lincoln Health System, supporting healthy lifestyles.

Eating a heart healthy diet, staying active, managing stress, and regular checkups are ways of reducing your health risks.

Proper health is important to all at Sarah Bush Lincoln Health System.

Information available at sarahbush.org.

Dr. Ruben Boyajian, located at 904 Medical Park Drive in Effingham, specializing in breast care, surgical oncology, as well as general and laparoscopic surgery.

More information online, or at 347-2255.

>>Singing Voices: Rediscover Paris.

>>Lori Banks: Our patient care and investments in medical technology show our ongoing commitment to the communities of East Central Illinois.

Paris Community Hospital Family Medical Center.

HSHS St. Anthony'’’s Memorial Hospital, delivering health care close to home.

From advanced surgical techniques and testing, to convenient care for your family.

HSHS St. Anthony?s makes a difference each and every day.

St. Anthony'’’s.

Where you come first.

[no dialogue] Welcome back to this edition of Being Well.

I'm Lori Banks, and today we have an interventional cardiologist with us from Prairie Heart Institute, Dr. Ash Al-Dadah joins us.

Thanks for coming over.

>>Dr.

Ash Al-Dadah: Thank you for having me.

>>Lori Banks: So, tell us a little bit about your practice and the kinds of cases that you see.

>>Dr.

Ash Al-Dadah: Well, I'm an interventional cardiovascular specialist, so my speciality involves the heart as well as the vascular beds of the body.

And I treat narrowing of the blood vessels in the body, whether it's within the heart muscle itself or outside the heart muscle.

That includes the carotids as well as the leg arteries.

And essentially we utilize modern technology, modern information to help the sequelae of these diseases.

Not so much as just because we saw the disease, we want to go ahead and treat it.

No, it's if it's causing problems, if it's causing symptoms for the patient, we will go ahead and treat.

And we have numerous types of technologies that we can utilize to treat these patients.

>>Lori Banks: So, are you seeing as you've been in this field, are you seeing more and more patients come in with issues, heart issues, carotid stenosis, which we're going to talk about in just a little bit?

>>Dr.

Ash Al-Dadah: We do see an increase of coronary disease, as well as peripheral vascular disease and carotid stenosis, to be specific.

And I think a lot of this, why we're seeing more and more of these patients, is because we're seeing more and more aging Americans.

And that's why we're picking up a lot more signal, so to speak, of these patients.

>>Lori Banks: Okay, well when we talked to you about what topics you wanted to cover, you said, "I'd like to talk about carotid stenosis."

And when I heard the word stenosis, you think of spinal stenosis, which is a back issue.

So, what's carotid stenosis?

>>Dr.

Ash Al-Dadah: Stenosis is basically a narrowing of a lumen.

So, when you hear it within the spinal realm, it's the spinal canal, where the spinal cord runs through.

And it has neurological sequelae different than the neurological sequelae that we see with carotid artery stenosis.

Carotid artery stenosis is the narrowing of the blood vessels that give nourishment and blood supply to the brain.

The obstruction of the flow results in strokes and neurological deficit.

And how does it come about?

It's plaque buildup.

>>Lori Banks: Plaque is cholesterol.

>>Dr.

Ash Al-Dadah: Cholesterol and scarring, and so forth.

It's multi-components that make up this plaque that ends up narrowing the lumen of the artery that supplies the brain with the nourishment and oxygen.

In addition to that, it's the jagged edges of that plaque that could rupture and shower upstream into the brain, and result in disruption of the blood flow and neurological deficit.

>>Lori Banks: Okay, so carotid artery is right here.

I mean, that's where you take your pulse.

Do you have one on either side, or just... where is it?

>>Dr.

Ash Al-Dadah: So, we have two carotid arteries.

And both carotid arteries actually, they arise from the aorta directly or indirectly.

So, on the right side the majority of us, not all of us, will have a trunk called the brachiocephalic trunk that comes out from the aorta, and will divide into the right arm artery and the common carotid artery.

On the left side the majority of us will have it arise directly from the aorta.

And some of us, not so much, we all have normal variants.

And both of them will traverse internally within the thorax, meaning the chest, and will come up into the neck and will subdivide further into an internal carotid and an external carotid.

The internal carotid will go to the brain and supply the brain tissues, as well as the vision vs. the external carotids will supply the external structures of the head and neck, the face and the neck.

>>Lori Banks: What is the connection between stroke and carotid stenosis?

You'd talked about that earlier.

>>Dr.

Ash Al-Dadah: The connection is the plaque buildup.

Carotid stenosis is a leading cause of strokes.

And strokes are a leading cause of death in the United States, about the fourth leading cause to be specific.

And it is a leading cause of morbidity and debility in the United States for patients that suffer from carotid artery stenosis and subsequent deleterious effects, and that is strokes.

>>Lori Banks: Okay, so let's talk about who's at the highest risk for carotid stenosis.

>>Dr.

Ash Al-Dadah: You have to have multi-factor.

Sometimes you could be a high risk, and you only have one risk factor.

But the risk factors, the more they build up, the higher the risk for strokes.

And who is at risk?

The older you get, the higher the risk.

As with aging comes scaring in the arteries.

High blood pressure is a major risk factor.

Tobacco smoking is a major risk factor.

Diabetes is a major risk factor.

Other risk factors tend to be a little more obscure.

Exposure to radiation therapy to your neck, and that's for folks that suffer from head and neck tumors that require radiation therapy to treat their tumors.

So, we see that sometimes in that patient population.

But that's a little bit more obscure.

The traditional risk factors, it's age, high blood pressure, high cholesterol and diabetes.

>>Lori Banks: The same things that cause all the other heart issues, as well.

>>Dr.

Ash Al-Dadah: They inflict similar damage into different vascular beds in our body, whether it's in the heart, the legs or the carotids.

The resultant deleterious effect is different from one organ to the other.

>>Lori Banks: So, does the carotid tend to, are there arteries that tend to build up with plaque faster than others?

>>Dr.

Ash Al-Dadah: You could look at it this way.

High mileage arteries tend to have more buildup: the coronaries, the carotids and the legs.

>>Lori Banks: Okay, because you've got more blood going through them, and that makes a lot of sense.

So, if you have carotid stenosis, how do you even know you have it?

Are there any outward symptoms at all?

>>Dr.

Ash Al-Dadah: Unfortunately the majority of carotid stenosis patients are asymptomatic.

They don't know they have the disease, they don't know they have narrowing of their of their lumens.

And when we find out it's either it's been picked up on a routine exam or it expressed itself, presented itself.

And how does it present itself/ There's three manifestations for carotid artery stenosis.

The first is the worst, and that's strokes, which results in either prolonged or permanent neurological deficit.

The second is what we call TIA, or transient ischemic attacks, another common name for it is mini-strokes.

And this is a neurological deficit that lasts less than 24 hours.

Finally, Latin term is amaurosis fugax, which is temporary loss of vision, and it lasts less than 24 hours.

It's a subtype of mini-strokes, but this is a warning symptom.

And a lot of people would experience the symptoms and not pay too much attention to it because it's a loss of field of vision, not of total blindness.

>>Lori Banks: So, like you might not be able to see these sort of out here, okay.

>>Dr.

Ash Al-Dadah: Exactly, and it is a warning shot that an impending stroke is about to happen.

>>Lori Banks: Yeah, we've done a program on stroke, and we have gone through the signs and the symptoms of it because, as you know, if you can catch it early your chances of surviving and recovering are a lot better.

So, if the symptoms are rather vague and you don't know, are people with those risk factors, are they regularly tested for it?

Or what kinds of things should you be asking your doctor about if you're worried?

>>Dr.

Ash Al-Dadah: Well the first and the simplest, if you have multiple risk factors, a simple carotid exam with a stethoscope can suffice.

And what you would listen for is a harsh sound of the turbulent blood flow going through the carotid because of a narrowing, or just a plaque buildup and hardening of the artery.

And you would hear a swish as a provider.

So, a carotid exam by your healthcare provider is the first to start off with.

But not all narrowing will produce that harsh sound.

And therefore, if you have the risk factors, some guidelines from the American Heart Association do recommend screening, utilizing an ultrasound or doppler methodology to detect the flow across the carotid by measuring the velocities.

And that could give us a very good idea of how narrowed the carotid artery is.

But you have to have of course multiple risk factors and you're considered high risk for developing that kind of disease.

>>Lori Banks: Okay, so at what point does someone end up seeing a specialist such as yourself for carotid stenosis?

>>Dr.

Ash Al-Dadah: Majority of the time it's picked up as a carotid bruit, is the term that we utilize.

>>Lori Banks: Bruit?

>>Dr.

Ash Al-Dadah: Bruit, and that's the turbulent flow of the carotid artery.

And it sounds like a swish sound, to be specific.

The majority of the time it's the healthcare providers picking it up, and basically referring to the specialists.

The other part, unfortunately when it's too late, when you have a stroke symptom and the patients present themselves to the emergency department, and so forth, and they're worked up for this.

And we evaluate their carotids to see if it is the source of their strokes.

And that's what we call a symptomatic patient.

They've already expressed themselves as somebody that has carotid stenosis.

>>Dr.

Ash Al-Dadah: Okay, so carotid stenosis, I always make sure I have this right, that causes strokes.

But when you have a blockage in your heart, that's what causes the heart attack, correct?

It's the same mechanism, just happening in a different place?

>>Dr.

Ash Al-Dadah: Yes.

>>Lori Banks: Okay.

>>Dr.

Ash Al-Dadah: But there are other causes of strokes that could rise up.

But the majority of the time it's the carotid stenosis that we encounter.

>>Lori Banks: So, do you, what's kind of the course of treatment that you go through?

Do you automatically go in and do a procedure, or can medication like cholesterol lowering medication help first?

>>Dr.

Ash Al-Dadah: We do risk stratify patients.

So, what you have is a symptomatic and asymptomatic patient.

And it's the level of narrowing that determines the next course of action.

So, for symptomatic patients, those are folks that have either a stroke, mini-stroke or amaurosis fugax, temporary loss of vision, we aggressively treat it medically period, irrespective.

And that's utilization of Aspirin, utilization of cholesterol lowering agents in a drug class called statins.

And in addition to that, we modify the risk with respect to diabetes, with respect to high blood pressure.

If they have with imaging, whether utilizing CAT scanning, MRA's or an actual angiogram, if we demonstrate that there's a 50% reduction of the lumen of the carotid, they're considered high risk.

You don't leave these patients alone, and you actually offer them, in addition to their aggressive medical strategy, you offer them an invasive strategy.

And we'll get into that part a little bit later.

And that's either stenting or a surgical procedure.

Now patients that don't have symptoms, and we incidentally found that they have narrowing of their carotid arteries, we look at their risk factors.

And if they have more than 70% reduction of the lumen, so they're basically hanging on by 30% of their original lumen size, then those patients are offered an invasive strategy in addition to aggressive medical strategy to treat their carotid artery stenosis.

>>Lori Banks: So, you rate the narrowing by percentage.

So, at kind of, you know, if it's 10%, 20, at what point does it really get serious?

>>Dr.

Ash Al-Dadah: 50% with patients that have strokes, 70% that are asymptomatic.

>>Lori Banks: Okay, so do we all at some point have some cholesterol and some plaque buildup?

Does everybody, unless you've eaten perfectly your whole life, do we all have some level of cholesterol in our arteries?

>>Dr.

Ash Al-Dadah: We do, and there actually has been an older study from 15, 20 years ago, it's not that old, and it actually looked at juvenile autopsies.

These are young kids that underwent an autopsy, and they looked at their arteries.

And they found that obese kids that had plaque in their arteries, there was a direct correlation, the obesity and the plaque buildup in their arteries.

It was not significant, did not cause narrowing, but there was a plaque deposition and cholesterol deposition in their arteries if they were obese.

So, there is a correlation.

Can you be walking around, young, and still have plaque buildup?

Yeah.

>>Lori Banks: Does the plaque buildup in arteries come from the fat that we eat, and the types of fats like high cholesterol foods?

Is that primarily where it's coming from?

>>Dr.

Ash Al-Dadah: This is a direct source, yes, but not the primary source.

I think all of it has to be put in together.

It's the type of fat, like you said, makes a huge difference.

But in addition to that it's a sedentary lifestyle, you know?

There's never been a direct correlation with high cholesterol level and strokes, or high cholesterol level and heart attacks.

It's been always considered a risk factor.

>>Lori Banks: It's all that whole combination of everything sort of work-- and genetics, too.

I mean, I know people that eat right and have really high cholesterol-- >>Dr.

Ash Al-Dadah: And exercise.

>>Lori Banks: Yeah, and people who eat whatever they want and have really low cholesterol.

So, yeah, you're right.

It's not just one thing.

>>Dr.

Ash Al-Dadah: It's multiple.

>>Lori Banks: Alright, so let's get into if you have a patient and their percentage of blockage is high enough that you need to go in and do something surgically.

>>Dr.

Ash Al-Dadah: So, if medical management is exhausted and you do have a high risk feature for a patient, and you actually start recommending an invasive strategy.

And the reason why we'd recommend that, in spite of aggressive medical management, if you have the high risk features your chances of a stroke are still high.

And you mitigate that risk of stroke by offering them a re-vascularization strategy, meaning you modify the plaque.

Either you get rid of it altogether, and that's a surgical incision across the neck.

And you actually scoop up the plaque and stitch the artery back, and you close it up.

Or the alternative is a puncture wound in the common femoral artery, and basically access the arterial system as a highway system to get within the artery on the inside, and you implant a stint.

And the stent's function here is to actually modify the plaque.

How?

By shielding it inside of the lumen of the artery, and opening up the artery farther so you can actually supply more robust blood.

But most importantly is you're excluding that plaque from the inner lumen of the artery, and therefore it won't shower and cause strokes.

>>Lori Banks: So, which is the, how do you decide if, I mean to do the stent vs. going in there and, as you said, scoop it out?

>>Dr.

Ash Al-Dadah: Stenting is a more modern procedure, and it has not gained a ton of traction to become mainstream.

It is gaining more traction.

More trials have been published to compare it to the more traditional treatment, and that's the surgical incision and scooping up the plaque out.

And the data is actually straightforward, showing very comparable results.

The difference is the surgical procedure is invasive, and it comes with risks of infection, recurrent laryngeal damage, and that's the nerve that comes and supplies the vocal cords.

But it's a lower risk of stroke, but a higher risk of heart attack.

So, you have to weigh your options, and risks and benefits.

On the other hand, stenting, it's a higher risk of stroke, but it's a puncture wound.

It's not a major incision, nor risk of infection, negligible risk of infection, and so forth.

And no risk of a heart attack.

So, you have to weigh your risks and benefits.

And if you go with the tailored guidelines, there are a subset of patients that right off the bat they're considered too high risk for any surgery whatsoever, and we offer them stenting.

At the Prairie Heart Institute, we do have trials at this point that we run.

And we basically recruit the patients, and we give them the option for stenting vs. an arterectomy, or even medical treatment as well.

So, it's on trial basis, as opposed to a mainstream treatment modality.

>>Lori Banks: So, which one of those are you doing?

Are you doing more of the minimally invasive method?

>>Dr.

Ash Al-Dadah: We do stenting as interventional cardiologists.

I do not do the surgical procedure.

We do have partners within the Prairie Heart Institute that do offer the surgical procedure.

And the majority of the time, we offer the patient both procedures simultaneously, and offer them consultation with an interventional cardiologist and a vascular surgeon so they can be well-informed from both ends before deciding to go one way or another.

>>Lori Banks: So, what's the, I would imagine just the minimally invasive, the recovery time is a lot faster than having an incision.

>>Dr.

Ash Al-Dadah: The recovery time is about a day, 24 hours from the time of the procedure, and patients go home.

And their recovery's based on the puncture would itself.

We give them restrictions for not heavy lifting, and so forth.

But it's about, it's a one-day procedure on average.

The surgery itself, and it depends on the surgical center, our center we tend to keep patients for 48 hours or so, maybe less.

it depends on how fast we control the blood pressure afterwards.

Some centers go up to 72 hours where they keep their patients.

The recovery is a little longer because of the incision and having to turn your neck sideways.

And it's a little bit more rigid with the restrictions and the blood pressure management.

>>Lori Banks: So, if you have the stenting, stent process done, is that permanent?

Or do you have to sometimes go in and do a little preventative or maintenance a few years down the road?

>>Dr.

Ash Al-Dadah: Hopefully you don't have to have maintenance.

But if you have patients that have multiple risk factors, and the risk factors continue to be uncontrolled and unchecked, and this goes for both arterectomy and stenting, the disease can recur.

And you would actually have to go in and alter the plaque again.

Unfortunately if you go the stenting route, you cannot go the surgical route later.

>>Lori Banks: Oh, okay.

And why is that?

>>Dr.

Ash Al-Dadah: Because the stent is a permanent part of the carotid artery, and you cannot cut through it.

>>Lori Banks: So, does that stent, we had a physician here that brought one.

It looks like little mesh.

Does that, it actually starts to kind of grow into the artery?

>>Dr.

Ash Al-Dadah: Basically the body forms some scar tissue within it, and it becomes embedded within the arterial wall.

>>Lori Banks: Okay, is it the same kind of stent material that's used in the heart?

Are they all sort of the same, or are they a little bit different?

>>Dr.

Ash Al-Dadah: Mechanically they're different because they have to have a certain what we call radial strength to them.

In addition to that, the common stents that we use in the heart are medicated and drug-coated.

We don't use that in the carotids, and the reason is lumen size makes a difference.

>>Lori Banks: Okay, I was going to ask, is it lumen, L-U-M-E-N?

And that's the inside of the artery, or what is that?

>>Dr.

Ash Al-Dadah: That's basically the diameter of the artery, kind of like a cross-section.

>>Lori Banks: Okay, so that's interesting.

We're learning all sorts of stuff today.

You know, I host a medical show.

Sometimes I think I am a doctor because I ask these questions for so long.

But it's great for us as patients or potential patients to be informed about-- >>Dr.

Ash Al-Dadah: Well hopefully you won't be a potential patient.

>>Lori Banks: I hope not.

>>Dr.

Ash Al-Dadah: And prevention is the cure.

It's modifying the risk factors and not allowing them to take over your body, let them take over your health.

Exercise, eat healthy, check your cholesterol, check your blood pressure.

If you screen for these early, then you don't have to worry about a problem later.

>>Lori Banks: Do you have, the patients that you're treating, do most of them, are they good patients, and you don't have to do repeat processes on them?

Do they follow the doctor's advice and direction?

>>Dr.

Ash Al-Dadah: I'll put it this way, it is a rare occurrence to have the recurrence of the disease.

And a lot of times undergoing a procedure itself is really enlightening to the patient.

And they become more educated, more empowered.

And therefore, the lifestyle modifications are taken upon them, and they're empowered, they're in charge of their own health because they don't want to come back.

>>Lori Banks: Yeah, so do these people go through like cardiac rehab, the way if you had a heart stent put in?

Do they go through that same kind of process or not?

>>Dr.

Ash Al-Dadah: They don't have to.

But about 40% of patients that have carotid artery disease, they actually have concomitant coronary artery disease.

And somehow, someway we figured out a way to plug them into the cardiac rehab side of things.

And that's how they, we gained their attention in respect to cardiac rehab.

But do they require cardiac rehab?

No.

It's the symptomatic patients that have suffered a stroke that will require a rehab, but not cardiac.

It's more of a neurological rehab.

>>Lori Banks: So, when you have carotid stenosis, you don't generally have the shortness of breath and the weakness.

It's more the stroke kinds of warning signs, like you do with the heart.

>>Dr.

Ash Al-Dadah: Yes.

>>Lori Banks: Okay, so I wanted to talk to you real quick about just some general heart health things that you yourself follow as a cardiologist.

What advice would you give to all of our viewers out there for just good cardiac health, so that we, you know, hopefully don't have to come see you at some point?

>>Dr.

Ash Al-Dadah: I try to exercise regularly.

And I'm not doing it as robustly as I should.

I think with having kids and having a career, it's a little difficult.

And I'm not making excuses, but at least three times, for me.

But what I would recommend, four times a week of moderate intensity exercise.

That is jogging.

Not walking, jogging.

>>Lori Banks: Not just strolling around the neighborhood.

[laughing] >>Dr.

Ash Al-Dadah: If you do it in a more robust fashion and a brisk pace, and that'll help you actually achieve the moderate intensity.

If you break a sweat, that was a good exercise.

>>Lori Banks: What did you, you said something before we started the show that that's, use those, get the blood pumping through the system, that that's really beneficial.

>>Dr.

Ash Al-Dadah: Circulating the blood is kind of like a healing process, an internal healing process.

You circulate the blood, you heal these vascular beds, and you mitigate some of that disease that could occur.

>>Lori Banks: So, regular exercise.

Any great foods that you think are great heart health foods?

>>Dr.

Ash Al-Dadah: Well I prescribe to a Mediterranean diet.

And the primary choice of oil is olive oil.

And in addition to that, believe it or not, carbs are a major source of energy.

Red meat is out of the picture for the most part.

It's twice a month that I actually consume red meat.

I try to stay away from it as much as possible.

It is difficult.

It's everywhere, though.

Prescribe to white meat, mostly fish and chicken, and lots of fruits and vegetables as fillers, so to speak, you know, between the bread and the meats.

And dessert is a fruit, is a fruit.

I'm glad my daughter is a big fan of that because she loves her fruits, ever since she was a baby.

And we do not consume as much cake or pie.

It's mostly the fruits that we consume for dessert.

>>Lori Banks: Alright, well Dr. Al-Dadah, thank you so much for coming by the show and letting us become more knowledgeable about carotid stenosis, and hopefully prevent some of these things from occurring in the future for us.

>>Dr.

Ash Al-Dadah: Thank you.

>>Lori Banks: Thank you.

>>Dr.

Ash Al-Dadah: Alright.

>>Lori Banks: Production of Being Well is made possible in part by: Sarah Bush Lincoln Health System, supporting healthy lifestyles.

Eating a heart healthy diet, staying active, managing stress, and regular checkups are ways of reducing your health risks.

Proper health is important to all at Sarah Bush Lincoln Health System.

Information available at sarahbush.org.

Dr. Ruben Boyajian, located at 904 Medical Park Drive in Effingham, specializing in breast care, surgical oncology, as well as general and laparoscopic surgery.

More information online, or at 347-2255.

>>Singing Voices: Rediscover Paris.

>>Lori Banks: Our patient care and investments in medical technology show our ongoing commitment to the communities of East Central Illinois.

Paris Community Hospital Family Medical Center.

HSHS St. Anthony'’’s Memorial Hospital, delivering health care close to home.

From advanced surgical techniques and testing, to convenient care for your family.

HSHS St. Anthony?s makes a difference each and every day.

St. Anthony'’’s.

Where you come first.

[no dialogue] [music plays]