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Ask the Heart Doctor (Dr. Barzilai 2/21/11)

Monday, February 21, 2011 - Noon

Benico Barzilai, MD
Section Head, Clinical Cardiology, Department of Cardiovascular Medicine, Miller Family Heart & Vascular Institute

Description

Heart diseases are United State’s No. 1 killer and Cleveland Clinic is recognized as the world leader in diagnosis and treatment of cardiovascular disease. Cleveland Clinic has been ranked No. 1 in the nation for cardiac care by U.S. News & World Report every year since 1995. Cleveland Clinic cardiologist and Section Head of Clinical Cardiology, Benico Barzilai, MD answers your questions.

More Information

Cleveland_Clinic_Host: Welcome to our "Ask the Heart Doctor" online health chat with Benico Barzilai, MD. He will be answering a variety of questions on the topic. We are very excited to have him here today! Thank you for joining us Dr. Barzilai, let's begin with the questions.


Medications

horace8: What are the benefits of the new drug Pradaxa vs. Coumadin? 2. What about the control of afib heart rate at 80 vs. a higher rate?

Dr_Benico_Barzilai: Pradaxa is the first of a new class of drugs (direct thrombin inhibitors). As opposed to Coumadin it works within hours (Coumadin needs days to become therapeutic), is much more predictable and does not need blood tests for monitoring. It may be best for patients who are more prone to bleeding as some groups in the studies had less bleeding on pradaxa. It does not have a long track record so we do not know whether any rare side effects may occur. It is only approved for atrial fibrillation at this point. Unfortunately it is very expensive at least 6-7 dollars a day. We are very excited about this drug but only time and experience will clarify its role.

As far as rate control for atrial fibrillation—A recent study suggested that maybe we do not need to be as aggressive as we had been before. I try to keep the heart rate around 80 at rest and try to keep it controlled with exercise. However sometimes it takes multiple medications to slow the heart rate down with exercise and patients feel over medicated at rest. We are now taking a more moderate position. We certainly do not want the heart rate over 100 all of the time but we will accept an occasional increase into the low 100s.

Mary606: Does Pradaxa react with Multaq the same as it does with Amiodarone?

Dr_Benico_Barzilai: I just called our pharmacy line and we do not have sufficient data as of yet to give you an honest answer to this question.

Pradaxa has only been out a few months and we are still learning about its drug interactions. I suspect we will have much more data in the next few months.

Mary606: Is there any way to keep tabs on the anticoagulant ability of Pradaxa

Dr_Benico_Barzilai: Not at the present time.

MonaB: I have been taking simvastatin for 3 years and in the past 6 months have begun a vegan diet. I have also been rigorously exercising for more than a year and am presently at a desirable weight, 5'5" and 129 lbs. I am continuing to exercise regularly. My GP said I could go off simvastatin and see if the numbers were still good. Right now my cholesterol is 123, LDL 55, HDL 48, and triglycerides 95. However I have just been reading about statin rebound and am very nervous. Do those studies just pertain to patients with coronary disease? Am I safe to stop?

Dr_Benico_Barzilai: You should be congratulated on your lifestyle changes. I would have no trouble having you stop the simvastatin and following you very closely—the statin rebound that you describe usually pertains to patients with known coronary artery disease and I see no evidence that you have coronary artery disease.

MARTINL86: How long should a patient be kept on a simvastatin?

Dr_Benico_Barzilai: In general, we continue it indefinitely unless there are substantial lifestyle changes that allow you to reduce your dosage.

roadams: I am taking 1500 mg of Niaspan a day with 20mg of Novastatin. On Feb. 2 my LDL cholesterol was measured at 68. Is this too low? Am I taking too much Niaspan?

Dr_Benico_Barzilai: The LDL of 68 is not thought to be too low.

Peppy: Could you clarify the aspirin issue for stent patients and those with diabetes? I was told 81mgs. is sufficient. A friend was just told if you have a stent and diabetes you should have 325mgs. Should stent patients take the higher amount with or w/o diabetes?

Dr_Benico_Barzilai: Clearly right after the stent procedure you use higher doses. In diabetics I tend to continue the full dose of aspirin for at least a year, thought this is not necessarily the dose that all cardiologists use.

MARTINL86: How long should a patient be on low-dose aspirin? I have been experiencing frequent nose bleeds and have taken myself off low-does aspirin. This stopped the nose bleeding.

Dr_Benico_Barzilai: I am not sure why you are on the low dose aspirin. Not everyone can take it for primary prevention—you have to do a risk benefit analysis. It sounds like the risk is greater than the benefit in your situation.

Laurie: I have gained a lot of weight (50#) after cabg in November 07. Weight decreased after surgery to return to normal and stayed very stable until I stopped taking Digoxin, about 3.5 months after surgery. Then I experienced rapid, inexplicable weight gain, especially in upper body and belly. I have relayed this info to cardiologist and family doctor but I don't feel like they take me seriously. It is a very depressing situation. Can you offer any insights?

Dr_Benico_Barzilai: It is possible that digoxin was causing some suppression of your appetite—certainly at toxic levels; one of the side effects is nausea. In addition, it is possible that the digoxin was causing your heart to work a little better and you may be retaining fluid. You need to be evaluated before we can provide you with an assessment of your situation.


Abnormal Heart Rhythm

Gary: I have been diagnosed with A fib and A flutter... I have a lot of chest pain... Recently my left breast has been vibrating... I have had a lot of "roller coaster syndrome" as well as pounding... I had a cath procedure a couple of years ago and had no visible problems... I ended up with a rather severe pseudoaneurysm... My last several blood tests have had a low platelet count, i.e. from 55 to 100. No one seems concerned... Except me...What can I do???

Dr_Benico_Barzilai: There are a lot of new options for atrial fibrillation including possibly a procedure to eradicate it (ablation). I would suggest that you see an atrial fibrillation specialist (electrophysiologist) who would evaluate you for more advanced therapy for afib. Clearly you are bothered by the irregular heart beat and you need something to help you become more regular.

Julie: Does a normal heart look different than a heart that has arrhythmia? How can you tell the difference?

Dr_Benico_Barzilai: In most patients the heart of patients with arrhythmias looks structurally normal. However, every patient with arrhythmias should have a test such as an echocardiogram to prove that their hearts are structurally normal. We are looking for abnormalities in the heart valves and abnormalities of the muscle.

n39wc: Is the risk of stroke higher with Paroxysmal AF or Persistent/Chronic AF?

Dr_Benico_Barzilai: The risk of stroke is probably a little higher in persistent afib however; I want to make it clear that the risk of stroke in paroxysmal afib is significant and I always treat my patients with paroxysmal afib with some sort of anticoagulation.  Particularly since many patients with paroxysmal afib can develop persistent afib.

PaulJ: I am an 82 year old male patient who had a heart attack in July of 2006 and had two stents placed at that time. and had a recovery. I have been diagnosed with Atrial Fibrillation and have been treated with Coumadin since the time of the heart attack. Dosage is 5 Mg for 5 days of the week and 2.5 mg for two days of the week. I am concerned with having to take Coumadin the rest of my life which seems to sap my energy as I would like to have an active lifestyle with daily exercise and golf. Is the Ablation procedure recommended for people of my age and condition and if so, would having it negate the necessity for taking a blood thinner forever? Thank you.

Dr_Benico_Barzilai: Most patients after an ablation still take Coumadin until it can be proven that there is no recurrence of the atrial fibrillation. Unfortunately in many patients there are still occasional episodes and they still will require Coumadin. You may want to investigate a new anticoagulant called pradaxa, which may not have the same effect on your energy level.

Honnie: I had open heart surgery in Phila in 1991. In 2001 I had quadruplet open heart surgery at Cleveland Clinic with Dr. Sabik & (Sidell consultation). Everything has been great until recently following a bout with pneumonia, I developed A-Fib. After 2 Cardioversions & on Coumadin, Lasix & Amiodarone.  The A-fib is worse. My cardiologist does not think I could undergo surgery again. What other medications could help me? I really need your opinion, as I am very tired & uncomfortable. Don’t know which way to turn. Thank you

Dr_Benico_Barzilai: There are other medications which could be used but amiodarone tends to be the most successful. I wonder whether you would be a candidate for a catheter procedure such as an ablation to try to eradicate the source of the atrial fibrillation.

We would be glad to have our electrical specialists here see you if you want to pursue that.

skippy: What are the side effects or potential post problems with heart ablation?

Dr_Benico_Barzilai: Post ablation, in general there are very few problems. However, there is about 1 percent risk of procedural complications. In recent times these complications seem to be becoming less frequent. However, the complications we look for include problems with the esophagus, stroke or threatened stroke, and bleeding into the space around the heart. I must emphasize that the complication rate has really declined over the last decade.

stevedon41: can you have a low heart rate ( in the 40's ) and still experience A-fib ???

Dr_Benico_Barzilai: Yes—it is possible to have a low heart rate and still have atrial fib. It usually implies that you have disease of the conduction system of the heart as normally you would have a much higher heart rate with atrial fib.  Sometimes individuals with a low heart rate and afib need a pacemaker

Charlene858: Please help me. My son had a major heart attack in 05-in 09 he had a ICD implanted-in the last two months he has had two firings. His Dr gave him the option of taking MEXILETINE without any counseling. He is very fit. We don't know who to turn to for advice. Thank You for your concern.

Dr_Benico_Barzilai: He needs to be followed closely by an electrophysiologist. We would be happy to see him here. He could also go to hrsonline.org for a listing. There are many options other than mexilitine, however he needs to be evaluated.

n39wc: Can esophagitis trigger AF? Can heart burn cause AF?

Dr_Benico_Barzilai: I do not consider esophageal pathology as a major precipitator of atrial fibrillation however since the esophagus is directly behind the left atrial it is feasible that inflammation of the esophagus can trigger afib.

stevedon41: Are there any new advances / medicines for treating A-fib and what are the typical tests required for someone with A-fib ? Thank you.

Dr_Benico_Barzilai: There has not been many new medicines. There are some medicines in development but we are unsure when they will reach clinical use.  The typical tests we use are monitors to detect the frequency of atrial fibrillation, echocardiograms to look at the heart and valves and blood tests to look for any electrolyte disturbances or thyroid problems.

rkchuey: I was diagnosed with A fib in December 2010 at age 55. The echo showed no structural problems and no evidence of a heart attack. I have been taking cardizem (240 mg daily), along with Coumadin. I am scheduled for cardioversion. I have persistent A fib. I read that there is a new ablation technique from Medtronics that has been successful in eliminating gaps that the normal ablation leaves. Is this procedure available at the Cleveland Clinic? Is it recommended for patients with persistent A fib?

Dr_Benico_Barzilai: I would proceed with the cardioversion. Many patients after cardioversions do not have a recurrence in quite some time. If you indeed have a recurrence then you would need to see an electrophysiologist who is competent in afib ablation.

javier: can the atrial arrhythmia I was given a medicine to lower my heart rate to 55 or 52 is that ok?

Dr_Benico_Barzilai: There is no problem with a resting heart rate of 52 provided you do not have dizziness or marked fatigue (over tired).


Women and Heart Disease

Adam: All I ever hear is Heart Disease is the #1 killer of Women in the United States, though it seems more Men have and die from Heart Attacks. Everything I read says Women aren't at an equal risk until they start menopause. Why are men more likely to develop Heart Disease 10+ years before Women? Is Heart Disease the #1 killer of men as well?

Dr_Benico_Barzilai: Heart disease is the number one killer of both men and women. Heart disease affects men earlier due to the difference in hormones, particularly testosterone. In some studies, estrogen is thought to be protective for women.


Heart Valve Disease

Cindi: A question regarding prosthetic heart valves, hemolytic anemia, and exercise: How does a daily 30 min. easy-to- moderate work-out effect an individual who has a St. Jude's aortic valve, hematocrit level of 26 and hemoglobin level of 8.7? Is it helpful or harmful? Of course the body isn't exactly excited about doing it, but if exercise is helpful, it can be convinced to cooperate . . .

Dr_Benico_Barzilai: I assume that the hemolytic anemia that you have is due to the "waring blender" effect of the heart valve. Strenuous exercise would increase the shear forces which might further damage the blood cells.  However, aerobic moderate exercise would probably not have a marked effect. I would therefore suggest aerobic exercise such as treadmill or elliptical training.

Hafs: I was diagnosed with mild mitral valve prolapse I get a lot of palpitations and I get startled quite easily. I've become very anxious n jittery and its seriously affecting my quality of life. I have so many un connected symptoms that either there's something really physically wrong with me or am going nuts. I have bad aches that once lasted for a month I did ct but nothing turned up, lately my feet get numb and the left one the toes keep twitching uncomfortably sometimes even waking me from sleep, I hardly get 4hrs sleep every night cause I keep waking and can't go back. I suffer excruciating ovulation pain. I reside in Nigeria and that's where I've been seeing doctors so am not too confident by the test results cause of outdated equip. Please what could be wrong with me and what kind of doctor do I need to talk to. Am 30yrs old with 1 child

Dr_Benico_Barzilai: You have many different symptoms—therefore I feel it is probably a good idea to see a very good internist who could direct you to the proper specialists. It is a mistake to see many specialists without a coordinated effort.

chaumont: I have SVT-exercise induced by a stress test. I also have 3 mildly prolapsed heart valves. Did they contribute to the problem or just electrical. I am on cardizem 180 mg. My heart goes off sometimes, not fast just seems off-maybe extra beat. Most of the time it is okay. My Dr. said that rather then increase the medicine if needed-would have to have that procedure. What do you think about the valves-they say don't worry about them and cardizem etc. thanks

Dr_Benico_Barzilai: Mild prolapse of the heart valves is extremely common. In some studies it is as prevalent as 10 percent in some populations. I therefore do not feel you need to be too concerned about them if they maintain a mild prolapse.

beancounter4: Can low hemoglobin (red blood cell count) be attributed to leaky valves?

Dr_Benico_Barzilai: It is possible that the leaky valve is causing the red cells to be injured or resulting in a hemolytic anemia. However, other causes of anemia need to clarified as well such as low iron or low b12.

mymvp: I have recently been diagnosed with severe regurgitation ( MVP ) though the only symptom I am having is extreme fatigue. My doctor mentioned valve replacement, though after reading all the info on valve repair, I am a bit skeptical on replacement, what % of valve repair does your hospital do compared to replacement?

Dr_Benico_Barzilai: The Cleveland Clinic has been a champion in mitral valve repair. Our data suggests that patients do better with repair vs. replacement and we would suggest you go to a center that does a very high rate of repair—over 90%.

roullac: Dr Barzilai what do you think should be as maximum heart rate after having undergone Mitral valve repair (18 months since repair)? Also what would be the maximum caffeine that we could have in day?

Dr_Benico_Barzilai: Max heart rate should be about 85% of your predicted maximum heart rate (220 - age).  After mitral repair you may be prone to atrial arrhythmias—so I would be reluctant to allow you to have more than 3 cups of coffee per day.

kathync: Have 20 yr old daughter with Aortic Valve Stenosis. Had balloon done 3 times now needs surgery. Pig valve or Ross method?

Dr_Benico_Barzilai: This is a complicated question - as patients are individually evaluated for the best surgery to meet their needs. We had a webchat two weeks ago that our heart surgeons answered many question about heart surgery, including many questions about aortic valve surgery—we also had a web chat last week with Dr. Pettersson who is an expert in congenital heart valve surgery—these two transcripts will be posted this week. I would suggest you look at those questions and answers.


Diagnostic Testing

Mary: PLEASE share thoughts.. Cardiac Angiogram? or better test (CT Scan?). 52 active/eat well. OK stress tests and EKG. Under much stress. High cholesterol. Creeping BP -nervous about med procedures due to past events. Told very minor/WNL regurg in 3 valves. Sometimes SOB, racy.. Overnight in hospital - showed nothing. Issue: Allergic to many meds, Iv dye, iodine, adhesives, sulfa, penicillin, fungal = anaphylaxis, (brief) atrial afib, rashes, hives, aches, mental fog. Read CA procedure may be contraindicated for those with fungal issues - having something to do with prednisone? Am OK with Benadryl. Worth the other risks? Hmmm Your thoughts? Thanks.

Dr_Benico_Barzilai: I believe you are asking about the relative worth of coronary ct angiography vs. cardiac catheterization. Cardiac cath remains the gold standard but it requires IV dye and you would have to be premedicated with prednisone and Benadryl to avoid a contrast allergy. Unfortunately you would have to get IV contrast for a full ct scan study as well. You could get a coronary calcium score which tells us how much calcium is in your vessels. This does not require any contrast but it really does not answer the question about the per cent blockage in your vessel. Coronary ct scan is quick—takes a few minutes and with the newer scan protocols the radiation has been reduced, However the doctor will have to address the risks of IV contrast with you specifically.

Rodgers: I am 55 years old. I recently had a physical (Dec.). My dad died of a stroke at the age of 77 (also had diabetes). My mom died at the age of 67 of lung cancer, but she too had congestive heart failure. I have not had a stress test. Would it be advisable for me to get one?

Dr_Benico_Barzilai: Before proceeding to a stress test I feel it is essential that we get an estimate of your cardiovascular risk. This usually requires measuring the risk factors (blood pressure, diabetes, smoking, family history, cholesterol)—we then use the Framingham risk estimator to assess your risk. If you are in the intermediate category it may be reasonable to proceed to a stress test (you can find this calculator on our website).

GW656610: I had two ECG's two months apart and both showed inverted T Wave. After the first ECG I was taken straight to the cath lab and I had six blockages, 60% ostial D1, 40% mid LAD X 2, 40% proximal LAD, Diffuse 30% disease in proximal / mid RCA X2. I was told blockage had to be 70% are more before any stents or bypass could be done. Two months later I was having same symptoms and a stress test was ordered, it was non diagnostic with heart rate only 62% of target rate. Treatment was to change medicine. Question is does blockage have to be 70% or above before treatment can be done.

Dr_Benico_Barzilai: Determining the exact significance of a blockage can sometimes be tricky. Remember the cardiac cath only shows the size of the vessels - it really does not tell the true effect on blood flow. You need a good "functional study"—Stress tests with imaging can be used to answer this. We usually assume that a 70% blockage is significant but I use a stress test to make an assessment. A good example is a nuclear stress test using adenosine (avoids the need to get your heart rate up to a certain level). PET scans can also be used to answer theses questions.

slick49: T wave inversion anteriorly

Dr_Benico_Barzilai: This is a non-specific finding but it always requires further evaluation to make sure that you do not have blockages in your blood vessels or that you do not have weakness in the front of your heart. However, this may be your normal pattern.

nellie: What screening tests do you need to find out if your heart is healthy? Is it more than just a stress test?

Dr_Benico_Barzilai: When a patient comes in to see me for an evaluation, I start with looking at the risk factors. This includes lab work for cholesterol, diabetes, kidney function. I also look at the electrocardiogram (EKG), and do a physical examination to look for high blood pressure and any heart murmurs. That is the first step. If I am suspicious of any further problems I tend to proceed to an echocardiogram to look at the heart muscle and the heart valves.

MARTINL86: Is LDL of 45 too low?

Dr_Benico_Barzilai: I personally do not feel that an LDL of 45 is too low but there are some authorities that are worried that such a low LDL may reflect an underlying disease. If you are taking medications to reduce your LDL, it may be worthwhile to reduce your dose.

rogelio2754: I have a stress test and echocardiogram scheduled for next Monday, what data do I need to pay attention to regarding the severity of aortic valve regurgitation?

Dr_Benico_Barzilai: During the echocardiogram, they will use Doppler echocardiography to try to estimate the severity of the regurgitation. In addition, we will look at the aortic size, the size of the left ventricle and the contractility of the left ventricle. Patients with severe aortic regurgitation tend to develop dilated left ventricles and over time, the heart may become weak.

steve656: In four years my CT Calcium score on my heart arteries went from 41 to 231. My cholesterol also rose from 180 to 230 in four years and my LDL rose from 130 to 166. My HDL remains the same at 45. I am now 55 years old. My diet is not very fat intensive and exercise is not daily but I do exercise. What can cause an increase like this in just four years? Also, my doctor said that with a CT Calcium score of 231, this indicates that I have around 70% blockage in my heart's arteries. Is that true that I only have 30% of an opening in my arteries? Can my arteries really be that "clogged" now? Thanks for your help in addressing my concerns.

Dr_Benico_Barzilai: CT calcium scores do not really measure percent stenosis (blockage). Another test such as CT Angio or cardiac cath would be required to really determine the extent of blockage. However, the increase in calcium score is somewhat concerning. I was wondering whether you have attempted to decrease your LDL to much lower levels (even as low as 70). Also do we know whether you have an increase in CRP (c-reactive protein) which would indicate inflammation. Finally, is there any indication of diabetes or pre-diabetes, which are strong risk factors.

cdamewood: 4 years ago. I had a cardiac cath and stent placement after having chest pains. 3 months after the procedure, I had a cardiac stress test since I continued to experience chest pains after the stent placement. That stress test result and every one each year were "normal" as well as every ECG taken. However, a cardiac CT scan done about a year after my stent showed 9 additional blockages of varying degrees from 39% to 87%. The original cath only detected 2 blockages, one 98% which was stented and one 47% which was not. Since cardiac echo stress tests never show anything, why should I continue to rely upon them as the only indication of whether my CAD is progressing, halted or regressed. Given that the stress tests missed 9 blockages, wouldn't a cardiac CT scan or some other diagnostic tool better serve to determine my continued course of treatment?

Dr_Benico_Barzilai: There is a reluctance to rely exclusively on ct scans since early generation scanners require very high levels of radiation for diagnostic purposes.  However, there are some new machines and new protocols which allow much less radiation to be used. It may be safe to do repeated scans under these circumstances. However, the presence of stents can make the diagnosis of new blockages difficult. I still tend to use stress tests such as stress echo or nuclear stress tests to follow most of my patients at this time.


Aneurysm

Diogie: My husband is 56 yrs old & was just diagnosed with an ascending aortic aneurysm just above the heart. It is 5cm & we are in the process of cardiac/ thoracic surgeon appts. We live in Pa & want to go out of the area for the surgical procedure. How do I go about getting an appt with the Cleveland clinic & what doctor should we see?

Dr_Benico_Barzilai: Please send an email with these details to heartcenter@ccf.org and the nurses will assist you.

FORQUER: Had 5 stents at CCF in 2006; can CVD be reversed by exercise and drugs?

Dr_Benico_Barzilai: Until recently there is little evidence that CVD can be reversed, however a recent trial of rouvastatin at high doses might cause regression of plaque.

clara: I had open heart surgery 4 years ago - aortic valve and 2 by pass. 2009 I had to have a stent 2x5mmx18mm -RT PLA. In 2010 I had to have 3 more stents - circumflex and LAD. These were not the grafts. They have filled up 60%. My question is can they stent inside of the stents.

Dr_Benico_Barzilai: Sure they can. However, they would reserve stenting the lesions for only high grade blockages. Probably over 70 percent.

Other Cardiovascular Disease Questions

vikram: HELLO DOCTOR--I AM AN ASIAN / INDIAN MALE OF 45 YEARS AGE LIVING IN U.K. AND MY MEDICAL HISTORY IN BRIEF IS--- 1) M.I. IN 2003 +ANGEOPLASTY & STENTING IN THE PROXIMAL LAD. EF 32% ---2) AFTER FIVE YEARS IN 2008-CARDIAC ARREST +ICD IMPLANTED+ EF IS NOW 21%- MY QUERRIES ARE--HOW DID THE EF GO DOWN FROM 32 TO 21 IN FIVE YEARS WHEN I WAS TAKING REGULAR MEDICINES.---WHY/HOW DID THE CARDIC ARREST HAPPEN IN 2008 --AND NOW IN 2011- I HAVE BEEN DIAGNOSED A CLOT IN MY LV- I HAVE STARTED WARFRIN. PLEASE CAN YOU TELL ME WHAT I CAN DO NOW- REG. MY LV CLOT AND OVERALL HEART CONDITION.

Dr_Benico_Barzilai: I would continue Coumadin for at least 6 weeks and then repeat the echocardiogram to see if the clot has disappeared. Sometimes it takes 6-12 months before the clot disappears. Continue close follow up with your doctor and make sure you are taking your beta blockers and ace inhibitors.

MaryR: I had the H1N1 Flu Shot last year and several hours later I started to have a lot of palpitations that lasted approx. 3 days. This was my first flu shot. I am prone to palpitations but they are usually very mild. The palpitations after the flu shot were moderate to severe at times. I do have trouble with palpitations with the drugs Azithromycin and Metronidazole Vagl. I have several underlying conditions including a PFO, Chronic Rt. Transverse Sinus Venous Thrombosis, Bochdalek Hernia, Thornwaldt Cyst (in Nasopharynx) and multiple drug allergies. Several of my doctors said I should get the flu shot regardless of the fact that I had palpitations after it last year. However, my primary care physician is more conservative and feels that I should not get it. Are palpitations a side effect of the flu shot? What is your professional recommendation on whether I should get the flu shot in the future? Thank you!

Dr_Benico_Barzilai: In general, patients with the type of heart disease that you describe are strongly recommended to get a flu shot. However, I am a little concerned about your reaction, which is certainly not a typical one and I think it should be investigated more fully. Is it possible that you are allergic to one of the components of the flu shot?

Suzanne: my husband has had numerous blood clots and has been hospitalized 3 times since May 2010. He is on Coumadin and does get his I&R checked. He also has clots that occasionally come out when he urinates. Why is he getting these?

Dr_Benico_Barzilai: When I see patients who are having bleeding while on Coumadin I am aggressive in trying to find the cause of the bleeding. In your case, if you really are having blood in your urinary tract you should be seen by an urologist to make sure there is not a structural lesion.  I do not like to assume that the Coumadin is the sole cause of the bleeding as many times the Coumadin is just unmasking an underlying problem.

wrigley: I am a 47 yr old female with Lyme disease and I have been experiencing complex migraines immediately after having strange arrhythmias and "Flip-flop" heartbeats- my heart has been fluttering very erratically and causing heart pain when I have a bowel movement. I’ve never had this before, but I was diagnosed with MVP about 25 yrs ago. I do not have panic attacks or anxiety and my weird heart beats tend to get much worse when I am lying on my belly trying to sleep- I've also been getting very faint lately and feeling dizzy- like I'm going to pass out. Is this serious or just a Lyme thing?

Dr_Benico_Barzilai: When I see a patient in the office I try and identify flip flops you describe. I usually will place some type of monitor(e.g. Halter) so that we can record the heart beats when you are having the symptoms. I also usually order an echocardiogram to look at the structure of the heart and to see whether your heart and valves are normal.  I would not attribute your symptoms to Lyme disease without a much more detailed evaluation of the heart.

leon: I had an aortic valve replacement at CCF and doing great. When I do really active exercise such as basketball or racquetball I get very server pain in right groin where catheters and stand by bypass during surgery. It hurts so much I have to stop the exercise. It has been checked for scarring and aneurysm and ok. Is there anything I can do to get rid of this pain.

Dr_Benico_Barzilai: You may want to see a vascular medicine specialist to evaluate your symptoms. It still sounds like you are not getting enough blood flow when you exercise.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Barzilai is now over. Thank you again for taking the time to answer our questions about heart disease.

Dr_Benico_Barzilai: Thank you for having me today.

Reviewed: 02/11


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