Shortness of breath may require a stent as well as heart meds

Dear Dr. Roach: I am a male in my late 50s and have recently been diagnosed with coronary artery disease, hypertrophic cardiomyopathy and high blood pressure. A cardiac catheterization procedure revealed four blockages in my arteries, with blockage percentages of 40% to 60%.

I was informed that stents were not necessary and that my condition could be managed with medication. My doctors have prescribed the following medications as part of my daily treatment plan: aspirin, bisoprolol, rosuvastatin and 2.5 mg of ramipril.

I understand that these medications are intended to slow down future plaque buildup and better manage my cholesterol and blood pressure levels. However, I am curious to know if these medications will also help reduce the existing plaque and lower the blockage percentages over time. My primary concern at the moment is my persistent shortness of breath. Could you please provide advice on this matter?

– G.B.

Answer: Although these treatments are based firmly in cardiac physiology, it’s a bit complicated to explain.

Starting with the blockages, rosuvastatin stabilizes the plaques and possibly reduces them. There is now extremely strong evidence that medicines like rosuvastatin reduce the risk of heart attack and improve life spans in people with blockages.

Statin drugs (in combination with a prudent, mostly plant-based diet and regular exercise) may reduce the blockages and help keep them from rupturing and causing a heart attack. Similarly, aspirin helps prevent a heart attack by reducing the likelihood of blood clotting in the coronary artery near one of the blockages.

Bisoprolol, a beta blocker, is doing at least three good things for you. It reduces the blood pressure, which means that the heart doesn’t have to work as hard. It does this by directly working on the heart muscle to keep it from squeezing so hard and by slowing the heart rate. Together, these make the heart require less blood. In people with coronary blockages, one major goal is to make sure that the demand for blood does not exceed the supply, and bisoprolol helps accomplish that very well. Also, because you have hypertrophic cardiomyopathy, bisoprolol helps remodel the heart and reduce the outflow obstruction, which is the hallmark of this condition.

Ramipril, an ACE inhibitor, works by relaxing the small arteries, further reducing the amount of work that the heart has to do. In people with blockages in the arteries, ramipril was shown to improve life expectancy, even on top of beta blockers, aspirin and a statin.

Shortness of breath can come from angina (a condition where the heart isn’t getting adequate blood supply) or from heart failure (where the heart isn’t pumping enough blood and pressures inside the heart). I don’t know which is the more likely possibility. It does take time for these medicines to reach their full effect.

If your cardiologist feels that your shortness of breath is due to blockages, a stent may be recommended after all, since opening the blockages and placing a stent to keep them open has recently been shown to reduce symptoms of angina and improve exercise tolerance.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Drive, Orlando, FL 32803.