Q: After heart surgery, when can I drive again?

A: After coronary artery bypass surgery or open heart surgery when the sternum has to be cut and then resewn together, most surgeons recommend 8 weeks after the surgery. This is the minimum time required for bone to heal. Some surgeons are more conservative. You should consult your own cardiac surgeon before resuming driving. Also, with my patients, I ask that they not drive if they feel weak, dizziness or lightheaded, any visual problems like blurred vision, double vision, you cannot walk, having chest pain or shortness of breath. In fact, if you are experiencing any of these symptoms after open heart surgery, you need to seek out your Cardiologist or primary physician as soon as possible.

Q: I had a stress test just last month. My Doctor said it was fine. Can I consider myself safe from a heart attack?

A: No. A heart attack is rarely caused from a stable plaque within the coronary artery. It is when the stable plaque becomes unstable that the heart attack results. Dr. Ambrose found in his study during the 1980s of heart attack victims, that the cause of the heart attack was not the high-grade blockages but the less than 50% blockages which became unstable and ruptured. Once the plaques ruptures, the contents of the plaque, lipid rich cholesterol becomes exposed to blood. The blood recognizes this as foreign substance and initiates the clotting cascade. This results in a clot within the coronary artery resulting in total occlusion of the artery. The heart no longer gets blood to that distribution and if not reopened within 15 minute, irreversible damage results. Up to 30-50% of victims of heart attack never make it to the hospital alive. This is what happened to Tim Russert.

Mr. Russert had a stress test in April 2008 and was told he did fine. However, he died suddenly while at work on June 13, 2008.

Q: So why bother with a stress test if it is not predictive of future events?

A: Stress tests are critical in allowing us to detect significant coronary blockages and prognosticating cardiac risk. There are four basic types of stress tests:

1. EKG stress test alone

2. EKG stress test with nuclear imaging before and after exercise.

3. EKG stress test with Echocardiogram imaging before and after exercise.

4. EKG test with pharmacologic or drug induced ischemia.

Of all the above testing types, the most sensitive is nuclear imaging performed in conjunction with EKG exercise stress test. The least sensitive to detect a significant blockage is the EKG exercise stress test alone.

There are other factors that make stress testing less sensitive:

1. the patient didn’t walk long enough or get his/her heart rate high enough.

2. the patient’s EKG is nondiagnostic or uninterpretable for detection of changes that Doctors need to diagnose a significant blockage.

If you already have coronary artery disease an exercise stress test with nuclear or Echocardiogram imaging is recommended. This allows your Doctor to obtain risk assessment over time.

If you don’t have coronary disease, but have multiple heart attack risk factors like strong family history of heart disease, smoking cigarettes, recent chest pains, abnormal EKG or elevated cholesterol or lipids, an exercise stress test performed with adequate exercise (you walked as long and as hard as you possible can), can provide crucial information about the presence or absence of a significant coronary blockage.

Stress tests alone aren’t good enough to prognosticate heart attack risk. There are other tests which can be done which will allow or enhance your Doctors ability to determine if you are at higher risk for a heart attack in the next 6 months to one year (see: What’s New in Heart Treatment). The Doctors’s own clinical judgement must be allowed to integrate all of these tests into a meaningful prognosis of your heart attack risk. Doctors are Scientists first. As such, physicians all like to have a formula we can plug certain numbers in and get a clear answer: Yes or No. But Medicine is rarely ever so black and white. Sometimes, it comes down to the suspicion of the Doctor who takes all of these tests into consideration and makes a final judgement.

The other major tip I have as a practicing Cardiologist can give you: if you have anything like chest pain, heart burn, shoulder pain (not directly attributable to trauma or athletic strain), jaw pain or tooth pain: directly seek out Medical attention. DO NOT WAIT.

If it is going on right now: CALL 911 and let the paramedics get some baseline information that they can then fax directly to the Emergency Dept. Doctor (see my section on the 411 on calling 911).

I tell my patients, I would rather have them wait 5-8 hours at the Emergency room, rather than lose the rest of the years, days, hours and minutes of your life.