DEAR DR. ROACH: I am a 64-year-old man who has been having periodic shortness of breath for the past six months or so. This happens mostly upon exertion but sometimes occurs when I stand up.

I do have a family history of coronary artery disease. After a CT angiogram (my calcium score was 617) and an echocardiogram (all good), my interventional cardiologist recommended an angiogram. This showed mild-to-moderate stenosis with blockages of 30% to 40% in my right coronary artery and 30% in my left anterior descending artery.

He also mentioned “mild bridging” of the LAD artery, with the possible cause being periodic shortness of breath coupled with mild-to-moderate stenosis.” He placed me on 81 mg of aspirin per day for blood flow even though I’ve had esophagitis in the past that is now controlled via the proton-pump inhibitor Voquezna (10 mg per day).

I’ve taken 40 mg of Crestor for the past 10 years (and Lipitor for 13 years prior to this). While my total cholesterol score has been 170-180 mg/dL for the past 10 years, my LDL/HDL cholesterol levels have not been great. He has recommended that I add 10 mg of Zetia per day to my Crestor regimen in order to further reduce my cholesterol score and improve my HDL/LDL levels.

The doctor also said that there is some data to support Crestor and Zetia, which can possibly reduce the stenosis I have going forward and help make the unstable lesions more stable. From your perspective, does adding 81 mg of aspirin and Zetia make sense given my history and current health status? — D.B.

ANSWER: It sounds to me that your cardiologist is recommending exactly the right management, and I agree. Before I talk about managing your cholesterol, let me explain “bridging.” This is when the part of the artery that normally goes outside the muscle wall of the heart is partially tunneled through the heart muscle. When the heart contracts, the blood flow through this artery can partially or completely stop.

A few people have atherosclerotic plaque in the area of bridging, which sounds like the case with you. Beta blockers are sometimes given to help keep the heart muscle from squeezing so hard that it stops blood flow. Surgery can even be considered if symptoms are severe and haven’t responded to medical treatment.

Aspirin has recently been questioned as a preventive for heart attacks, even though we have been using it for decades. Statin drugs like Crestor and Lipitor are more effective and less dangerous than aspirin, so aspirin is used much less for prevention now that statins are widely available.

However, for people with coronary artery disease, even with blockages of 30%, aspirin is clearly indicated to prevent a heart attack. Low-dose aspirin is unlikely to cause bleeding, and esophagitis is not a reason to withhold aspirin.

The issue of how aggressively to treat cholesterol remains debated. Most cardiologists use the LDL level, and although all experts would agree that a level below 70 mg/dL is best, some experts would push it down to 50 or even 40 mg/dL. The fact is that you developed blockages despite statin drugs, so in my opinion, additional therapy is warranted to protect you.

Zetia keeps your body from absorbing cholesterol in your diet, and it is generally safe and well-tolerated. So, it’s a good recommendation that has recently had new studies supporting its use. Another option would be a PCSK-9 inhibitor drug, like Praluent, which is highly effective at lowering LDL levels and reducing the risk of a heart attack.

Finally, never minimize the effect of a healthier diet and regular exercise, which are helpful regardless of medication.

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. (c) 2025 North America Syndicate Inc. All Rights Reserved