Dr. Roach

Dr. Keith Roach

DEAR DR. ROACH: I am a 79-year-old female who was scheduled for a carotid endarterectomy. The artery was occluded, and the procedure was unsuccessful. The surgeon did not recommend further carotid surgery.
I take warfarin and diltiazem for paroxysmal atrial fibrillation (AFib); losartan and hydrochlorothiazide for controlled high blood pressure; and atorvastatin for high cholesterol. I do cardio exercise three hours a week, walk frequently and have an active social life. I recently lost 10 pounds and have begun a plant-based diet.
Will a plant-based diet cause the current plaque in my arteries to dissipate? Can some of the plaque break away and cause a stroke as the arteries clear? What do you think about not pursuing further carotid surgery? — P.F.
ANSWER: Blockages in the carotid arteries are a common cause of stroke, and partial occlusions of these arteries are often treated by surgery. The indications are precise and depend on the degree of occlusion and the presence of symptoms. Surgery isn’t indicated for a 100% occlusion, so I certainly do not recommend pursuing surgery further.
Intensive medical therapy is the key, and blockages can lessen over time with the appropriate treatment. You have outlined many of the crucial parts of treatment. The most important are:
— Control of blood pressure: High-risk people, such as those with blockages, benefit from strict control, less than 120 over less than 80 mm Hg.
— Statin medication: High-dose atorvastatin (and possibly additional medication) is used to get the LDL level below 70 mg/dL, possibly below 50 or even 40 mg/dL.
— Diet: A plant-based diet has been shown to help reduce risk. Several types of diets have been proven to be helpful, but all include small amounts of meat, processed foods and sugar, while emphasizing vegetables, legumes, fruit, whole grains, nuts and fatty fish. You have to find a diet that works for you.
— Exercise: Cardio exercise and muscle-training exercise each have unique benefits in reducing heart risk.
— Smoking cessation is mandatory.
— Weight reduction provides a small benefit for most, coupled with diet and exercise.
— Control of diabetes is appropriate if applicable.
— Anticoagulation or antiplatelet drugs: Aspirin is recommended for most, but people with AFib, like yourself, need an individualized approach.
All of these together can dramatically reduce the risk of both stroke and heart attack. These treatments do not increase the risk of embolus (plaque breaking off and causing a stroke).
DEAR DR. ROACH: I started taking lisinopril in the evening based on an article I read. However, I check my blood pressure twice daily, and it is always higher in the morning. I question whether I should take lisinopril when my blood pressure is at its lowest. I also find that my blood pressure is lower after a workout.
I would like to know if this is unusual, what is causing this and when should I be taking lisinopril. — E.U.
ANSWER: The normal pattern of blood pressure shows it rising sharply upon awakening, and going down before and during sleep. What you are seeing is normal physiology. Lisinopril lasts a long time in the body, so this likely isn’t an effect of the lisinopril.
A study a few years ago did seem to show a dramatic benefit in taking blood pressure medicine in the evening compared to the morning, but further studies did not show this benefit.
You can take lisinopril at any time that’s convenient, preferably at the same time each day.
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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 Dr., Orlando, FL 32803.
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