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Women and Heart Disease (Dr. Cho 5/7/12)

Monday, May 7, 2012 - Noon


Heart disease is the Number 1 killer of women over age 25 in the United States. It claims the lives of more women than all forms of cancer combined. At the Women’s Cardiovascular Center at Cleveland Clinic, women can get comprehensive heart care, designed to meet their unique needs. Dr. Cho answers your questions about heart disease in women.

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Cleveland_Clinic_Host: Let's begin with the questions.

Dr__Cho: Thank you for having me today.

Coronary Artery Disease in Women

Peppy: As a woman with a stent in my diagonal, what questions should I be asking my cardiologist?

Dr_Cho: The first question to ask yourself is why did I have heart disease? Then, what are my risk factors and how well am I controlling them? Am I on medications that optimally control my risk factors? Last, is my lifestyle truly a healthy heart lifestyle?

hoagie0013: what do you think of dr. pauling's theory about why we get coronary heart disease and other mammals don’t. Could it really be a vitamin deficiency that could be related to heart disease?

Dr_Cho: I am not sure about vitamin deficiency causing heart disease. I think the western diet together with sedentary lifestyle is the biggest contributor of heart disease.

Peppy: What is research telling us about women and heart disease? How should we be treated long term if we have heart disease? Do we respond to traditional heart medications differently than men and which medications are best for us? I've heard women don't respond as well to statins for instance.

Dr_Cho: Women do respond to statins just as well as men. There are studies that show that older women that are small in size have more muscle aches on certain cholesterol medications - however the benefit of cholesterol lowering medications is still the same if you are a man or a woman.

In general, women tend to have more side effects on anti-hypertensive medications than men. As far as bypass and stents - women and men have similar benefit.

Frankie: What are some good resources for women to use (besides our doctors) to obtain information for prevention and intervention of heart disease?

Dr_Cho: Our website has a lot of great information on prevention and women and heart disease - please go to

Coronary Dissection

charlene-pa: I was diagnosed with a coronary dissection after a heart attack. I cannot find very much about it except that it is more common with women. Can you talk about this? what is the risk? if you have one, are you at risk for more? I am very worried about this. what is the overall treatment for this?

Dr_Cho: Coronary dissections in the third trimester of pregnancy or post partum are well described. It has to due to hormonal changes and fluctuations. However, now we also know that patients with fibromuscular dysplasia also have increased risk for coronary dissection. Fibromuscular dysplasia (FMD) can be diagnosed with a renal ultrasound and a carotid ultrasound. If you have FMD you should be seen by a physician and monitored.

If your dissection is due to pregnancy, then usually it is situational and the likelihood that another event will occur is less unless you are pregnant again. We would not want you to get pregnant again.

Small Arteries and Micro Vessel Disease

chris66: Hi, I am a 45 yr old female with known heart disease. I have lesion through out my vessels. My LAD is very small and diffused. I have had pain that goes across my chest and down my left arm, the pain only happens when I walk and will stop when I stop. I have had stress (nuclear) that show no ischemia. One stress test stated that there was a small reversible are at the mid point of my lad but it was thought it could be poor coronary flow reserve. I am not sure I understand what this is. Does this have to do with the smaller vessels? Or is the blood flow between the lesion on the LAD? I have been trying to find help for this pain with no luck. My regular will not do any thing because he said it is my heart and after testing done by my heart Dr and finding no ischemia it becomes a dead in there .Thank You , Chris

Dr_Cho: You may have ischemia in the mid portion due to small artery and not enough blood flow through some vessel. LAD is an artery that gives off many branches and you may have couple of branches that are not getting enough blood flow. Positive stress test means that you are not getting enough blood flow; however, it is not so good at saying exact location.

Unfortunately, if your artery is too small, it may not be amenable to bypass, stent or balloon angioplasty and medical therapy maybe the only option. The classes of medication that treat angina are beta blockers (such as metoprolol/lopressor/ Toprol); calcium channel blockers (such as amlodipine/norvasc); long acting nitroglycerine in a patch and pill format; and ranexa (which is an artery dilator). Also, one of the best treatments is exercise which also helps with angina but maybe building collateral vessels. Also, if the cardiac muscle is "dead" it shows up as an "infarction or scar" on your nuclear stress test which is different than ischemia. Maybe you should talk to your cardiologist.

Colleen: My mom has had chest pain. Her stress test showed that she is having decreased blood supply with exercise but her doctor said there is nothing they can do because she has "microvascular disease." What is that? Is it true there is no treatment for it? Can she have a heart attack? I am worried about her.

Dr_Cho: Micro vessel disease usually does not cause heart attacks. If your mother has small coronary arteries with diffuse disease then that can cause heart attack. Symptoms for treating microvessel disease and diffuse coronary artery disease revolve around treatment for risk factors as well as symptom relief.

It is important to keep bad cholesterol less than 70mg/dl; control diabetes and blood pressure; and stop smoking. As for medicine, there are anti-anginal medications including beta blockers, calcium channel blockers, nitrates and ranexa.

Symptoms of Heart Disease in Women

Grannyscott: Dr. Cho, women are often told that our symptoms may differ from men's, and that we should take seriously, for example, such symptoms as excessive sweating and pain in an arm. Does this mean that if we experience one of those symptoms, for example, but no other apparent "signs" of a heart attack, we should call 911 and go to an emergency room?

Dr_Cho: If you are feeling fine otherwise but have excessive sweating and pain in an arm that is not heart attack symptoms. Usually patients who are having heart attack feel terrible AND they have other symptoms such as chest pain, SOB, nausea, sweating etc. Not all pain is related to the heart. Usually heart pain is accompanied by shortness of breath or chest pain accompanied by feeling unwell.

lorettaK: I have had chest pain for a year and also shortness of breath with exercise. I have had a stress test, ekg and an event monitor. And - the doctor said he does not know what else to do. Do you have any suggestions?

Dr_Cho: Most likely your chest pain is not from the heart if all your tests were normal. Sometimes chest pain can be musculoskeletal or sometimes a stomach problem. In rare cases, patients can have microvessel disease which is still diagnosed in experienced centers with perfusion cardiac MRI or invasively using coronary flow reserve tests.

cyndi: I had chest pains and some shortness of breath. went to the ER and left - they told me the ekg was fairly normal. went home and kept having the chest pains. went back to the ER and asked them if they compared my tests to any prior tests - so then they saw some changes to my prior ekg and tested my blood and my enzymes were up. Thank goodness I went back. the doctor in the ER told me it was anxiety. I think that we need to really be assertive and know your body and make sure they test you when you have chest pain - I could have stayed home the second time but felt like something was wrong and was persistent.

Dr_Cho: Good for you for being proactive. Yes - women do sometimes have unusual symptoms and that is the reason why educational efforts are being made for patients as well as physicians to look for atypical symptoms in women.

Diagnostic Testing in Women

MaryAnn: The supplement to "Women's Heart Advisor", April 2012 states on page 8 that the nuclear stress test can expose a patient to radiation levels equivalent to 900 chest x-rays. Would you know from where this information was obtained and/or whether it is true? Also, the same publication recommends that women have a stress echo instead. Do you know whether this advice also pertains to men? If it doesn't pertain to men, what advantage does the stress echo have for women in particular? Can you help? Thanks, Maryann

Dr_Cho: This information about nuclear stress test and amount of radiation is readily available in medical literature. Unfortunately, nuclear stress test has very high radiation exposure 600-900 Chest x-ray. Therefore, for our female patients we generally recommend stress echo to avoid radiation exposure

Aquarius: Does a Lexiscan stress test produce a false positive result?

Dr_Cho: The false positive rate for most nuclear stress test and stress echo is around 15%. False positive means that your stress test says you have ischemia but you really don't. The number one cause of a false positive test in women is large breasts and diaphragmatic attenuation (means diaphragm is in way of heart). Most good centers do post acquired imaging modification, however, the false positive rate still continues to be high. It is important to go to a cardiologist or get the scan where they have had a lot of experience.

mooreke126: 54 yo female, normal weight, exercise, eat very well. I had a CT 64 slice scan 2.5 years ago that showed the LAD had a <50% calcification. Should I have it redone to see progression or hopefully stabilization?

Dr_Cho: No. There is no evidence of repeat CT scan in your case. The recommendations continues to be controlling risk factors. As we age, calcium scores go up. This information may not be helpful

Peppy: How often should we have an ekg and stress test after an angioplasty/stent procedure? I haven't had one in six years now but see the cardiologist every six months.

Dr_Cho: The American Heart Association and American College of Cardiology do not recommend routine stress tests. The stress testing should be guided by symptoms. If you have been doing well then you do not need another stress test.

ritchreg: I've had bypass surgery, am stented and still have shortness of breath, chest pain and rapid fatigue when I exercise or go up a flight of stairs. I had a heart cath which showed good blood flow, is there another test I should possibly have done? My doctors are suggesting exercise induced asthma but the daily inhaler is not working.

Dr_Cho: There is a test called metabolic stress test where we test both the heart and lung to determine which organ is most affected in exercise limitations. That may be a good test for you.

Diabetes and Coronary Artery Disease

ritchreg: I'm 57, diagnosed CAD, already had surgery and stents (still having some issues). I exercise regularly as hard as I am able and watch my diet very carefully. I've gotten very "pudgy" around the middle (it's a new "pudginess") and it won't go away. Am I in danger of developing diabetes even though I exercise and watch my diet?

Dr_Cho: There is always a risk of developing diabetes but exercise and diet is a very good way to prevent the onset of diabetes. Frequently patients complain in mid age about pudginess in the mid section. However it is really intra-abdominal fat - not so much the subcutaneous fat under the skin - that is a risk factor for poor outcome. Fasting glucose, Hgb A1-C and 2 hour fasting glucose tolerance test are all blood tests you can have to determine if you have diabetes.

Lipids and Coronary Artery Disease

mooreke126: Hi Dr. Cho. I am a 54 yo female with extensive family history of heart disease, diagnosed with CSD due to <50% calcium in LAD. I am normal weight, exercise 5x week, take 20 mg of simvistatin and BP meds. Follow a plant based diet. All my numbers are excellent per my cardiologist except my trig will spike to 150. Could fruit be the culprit? What else could I do to improve my current condition?

Dr_Cho: As far as triglycerides, they may be elevated due to secondary causes such as diabetes, hypothyroidism or kidney disease. Other times medications can increase triglycerides. If all these things are not your case, then yes, diet is a culprit. Anything that tastes sweet to the mouth or high carbs affects triglycerides. Fruits definitely have lots of sugar and when consumed in excess can lead to increased triglycerides. Fruit consumption should be done in moderation just like other food consumption.

We normally recommend patients to increase their vegetable and fiber and avoid sugar when dealing with high triglycerides. Also remember - Your LDL should be less than 70.

Grannyscott: Is a high (4+) CRP rate still considered a risk for a heart attack - and is Crestor still supposed to be the best statin for taking down the inflammation rate?

Dr_Cho: Usually we recommend high sensitivity (HS) CRP or US-CRP not just regular CRP. HS-CRP or US-CRP is still considered a risk for heart disease. Crestor and other cholesterol lowering medications lower the inflammation rate. In addition to statins another way to decrease inflammation rate is weight loss, controlling other risk factors such as stopping smoking, controlling blood pressure, etc.

Nancy: How is it possible that statin drugs have a possible side effect of causing muscle pain and/or damage but do not damage the heart MUSCLE?

Dr_Cho: Statins do not damage heart muscle. Also, your overall body has a lot of muscles and heart muscle is only a very small part of that. The statins usually affect large muscle groups not small ones. Statins have been tested in over 1 million patients and it does not cause heart damage.

Also, I think you may be confusing muscle ache with muscle damage. Muscle ache without blood level rise of muscle enzyme is found in 2-10% of patient and is associated at times with genetic predisposition, other medications or build up of the statin in the muscle. Muscle damage from statin which is where the blood level of muscle enzyme rises is extremely rare and found in 0.1-0.5% of the population. Most people do not have this.

NJJ: But statins can cause rhabdomyolosis....

Dr_Cho: Yes – it occurs in one in a million patients who take statins. The benefit of statin therapy outweighs the risk.

pananny: can statins and thyroid meds mask a heart disease?

Dr_Cho: No.

MadelineR: What about the latest information on statin drugs, like lipitor. The article was very critical of long term medications. I have been on lipitor for 20 years and have had quadruple heart bypass surgery 10 years ago. Do you give your patients statin drugs for their heart disease and for how long.

Dr_Cho: As far as patients with bypass surgery, prior stent and heart attack are concerned, they should be on statin for a long time and it is very safe. Your bad cholesterol LDL should be less than 70. The likelihood that you will have recurrent bypass surgery, heart attack, stroke or death is much higher if you stop taking your statin medication.

NJJ: I had an 89 and 90% blockage in mid LAD which was stented with one DES. I have no other quantifiable blockages in other coronary arteries. It took me 62 years to get these blockages. Do I REALLY need to take statins? Theoretically I have fibromyalgia and hence, plenty of muscle pain. I read somewhere that statins can cause chf. I forgot to mention that I had only 2% damage to my heart and my resting ekg looks like I have never had a heart attack.,

Dr_Cho: Yes. You still need to take statins. Statins stabilize the plaque in the coronary arteries and can prevent heart attack. Muscle aches with statins can occur and so maybe talking to your doctor about taking a cholesterol lowering medication that has the least affect on muscles may be a good idea.

nance: Your opinion on a cholesterol of 200, HDL 50 and LDL 115. I had to stop taking statins which really controlled Lipitor controlled my cholesterol numbers well, however caused much muscular pain so I had to stop them. For 6 mo. I have taken red yeast rice,, policosanol and krill oil and my numbers are: cholesterol 200, triglycerides 121, HDL 50, LDL 115. What is your opinion? Should I try a different statin due to LDL number?

Dr_Cho: It depends on your risk factor profile. Do you have established coronary disease? Then, your LDL should be less than 70 and your levels are too high. If you have no heart disease - a primary prevention patient - then LDL of 100 might be ok.

As for red yeast rice, the FDA has issued two warning letters against the medicine for being contaminated and causing liver dysfunction. Please have your liver function checked by your doctor.

VickiP: I am a 60 year old female with a 1-2% risk by the Framingham Risk Tool- no family history, low blood pressure (no meds) and pulse, healthy weight, daily vigorous exercise, etc. The only risk factor I have is high total cholesterol (230-240, no meds), but my HDL is 65-70. A cardiac cath in April 2011 (preparatory to mitral valve repair) showed no blockage. Following CCF's website it appears I do not currently fit in a category that requires cholesterol-lowering drugs (but, the risk model makes no mention of valve repair; is that a risk factor?). I have read both pro and con arguments on statins and would like to hear how you would recommend a patient with these data should manage cholesterol levels. Thank you.

Dr_Cho: Valve surgery is not an indicator of atherosclerotic disease. That is why the risk score does not include it. Your total cholesterol is high because your HDL is high. This is a good thing. If your LDL (bad cholesterol) is less than 130, then I would not start you on medication. You can also measure ultra sensitivity CRP or other novel risk markers to assess your risk. As your get older, your LDL will increase and at that time you may need statins.

Heart Rate and Rhythm

LendaB: What is a safe normal resting heart rate for a 64 year old woman - 230 lbs. "7"?

Dr_Cho: Resting Heart rate should be around 50-100. When someone is in good shape, their resting heart rate is very low. They say Lance Armstrong's resting heart rate is 29. I don’t think your resting heart rate can be 7. I think it is an error.

sally77: heart rate 129-- no serious problems other than some shortness of breath and tiredness

Dr_Cho: Is your heart rate 129 after exercise or at rest?

sally77: 129 at rest

Dr_Cho: 129 at rest is high. Sometimes some people have naturally high rate due to metabolic problems, or dehydrated or anemic (low blood count). I would go and talk to your doctor about your heart rate because high heart rate for prolonged period of time may not be good for the heart and lead to heart failure.

Brenda_S: how serious is ventricular tachycardia for a women who's 52 and has episode about 5 x a year that can last anywhere from 45min. to 4hrs.? Internist says it's caffeine and anxiety, but when I had my colonoscopy the nurse said I should do something about it. I am worried I am hurting my heart My mothers side of the family all died in there 40's and 50' from strokes (not my mother) uncle, grandmother, grandaunt, great grandmother

Dr_Cho: I am not sure if you mean ventricular tachycardia or premature ventricular contraction (PVC). You cannot have ventricular tachycardia for 45 minutes to 4 hours. Usually that is life threatening.

If your internist said it was caffeine or anxiety, then it sounds like premature ventricular contraction. Usually these are very common in women 40-60s and it is often caused by dehydration, caffeine, stress, decongestants or alcohol. Sometimes when patients have a lot of PVCs, they can get it ablated. But it should be 10% of the total heart beat over 24 hours.

dragonfly: I am a 34 yo female who experiences heart "flutters" some more mild than others. This has been happening for about 10 years or a little longer. I have had an ultrasound, worn a holter monitor for a week, and tried a beta blocker (in which I felt absolutely horrible and stopped taking it). I was also diagnosed with hypothyroidism almost 6 yrs ago. Are the two health issues related? Many time w/ the flutters, I pray it's not the last time my heart will beat! Is this more anxiety? Is there a specific test I should request? Is this something "normal" to live with?

Dr_Cho: Usually hyperthyroidism causes palpitations (flutters) and not hypothyroidism. The number one reason why young women see a cardiologist is due to palpitations. It is completely benign and is related to hormonal fluctuations. Women often complain they get flutters with rest and not with exercise and worse when they are quiet or in bed. They often say they feel thumping and we don't like to treat with medications unless they are very very frequent. Avoiding caffeine, alcohol, over the counter decongestants, and dehydration are key to preventing more episodes.

CLSTAR: I was a young woman with "flutters and ignored. It turned out to be a BIG deal, do not ignore them!

Dr_Cho: Your fluttering may have been due to stiffness of the heart which is different than most people. Best to go see your doctor so they can see what you have.

[Editor’s note: Here are two great articles on palpitations and abnormal heart rhythms in women that may help you]

Valve Disease

nance: I underwent annuloplasty at the Cleveland Clinic in 1998 to help correct a 4+ mitral valve regurgitation. I am now 80 and during a recent echo, the valve continued to be supported. Can I expect this to be a permanent "fix" through my 80s and 90's, if I live that long?

Dr_Cho: Sounds like you had a great result from your annuloplasty. You still need an annual echo.

nance: Is it possible that hyperthyroidism can cause damage to heart valves?

Dr_Cho: Hyperthyroid can cause heart disease by damaging heart muscle. Thus it is important to treat your hyperthyroidism.

Diastolic Dysfunction or “Stiff Heart”

CLSTAR: What causes the heart to become "stiff"?

Dr_Cho: Heart stiffness is called diastolic dysfunction. The most common cause is age. The other causes is high blood pressure, diabetes and probably coronary artery disease to some extent. Controlling your risk factors can sometimes make your heart become less stiff. Diastolic dysfunction has been linked to poor cardiovascular outcomes including lower survival.

Calcium Supplements

Aquarius: What is the safety of calcium supplements on post menopausal women?

Dr__Cho: The British medical journal published a paper last year which suggests that taking calcium supplements may increase the risk of heart disease and heart attacks. These are compelling data and for our patients with established heart disease we have been recommending dietary calcium supplementation and not medications.

Peppy: What? I think the dietary calcium supplements ARE NOT recommended and medications are. Is that correct?

Dr_Cho: What I mean is eating calcium in your diet is best- not medications, such as - drinking milk, eating yogurt, eating foods rich in calcium.

Anticoagulants: Plavix, Warfarin

Peppy: I have the old Taxus II DES in my diagonal. I have heard they are performing so well and patients should stay on Plavix for life. I was on for three years and then the cardiologist wanted me to stop. I did but feel uneasy about a late stent thrombosis.

Dr_Cho: The risk of stent thrombosis with the first generation of DES is 0.5% per year indefinitely. Evidence suggests that being on dual antiplatelet therapy (aspirin and plavix) for one year is mandatory but thereafter the data is murky. The risk of stent thrombosis increases with the length of the stent; whether you have diabetes; kidney disease; and how many stents you have. If you only have one diagonal artery stent and you do not have other risk factors then your risk for stent thrombosis is lower.

You have to be on aspirin forever. Plavix is a good medicine but it can increase the risk of bleeding.

Aquarius: I just discontinued Warfarin and have started with 15mg of Xarelto. What is the safety and effectiveness of this medication?

Dr_Cho: Dr. Bartholomew will be hosting a web chat on this topic June 27th. He will be answering questions about all blood thinners.

Women’s Cardiovascular Center at Cleveland Clinic

Cleveland_Clinic_Host: Dr. Cho, can you tell us a little more about the Women's Cardiovascular Center and why someone should go?

Dr_Cho: Women's cardiovascular center treats women with heart disease for primary and secondary prevention. The unique aspect of our center is that we treat patients comprehensively. We have nutritionists, endocrinologists, exercise physiologists, psychologists as well as cardiologists who treat women with heart and vascular disease. There are unique medical conditions that affect women's hearts; including post partum cardiomyopathy; microvessel disease; coronary dissection; high risk pregnancy in heart disease patients; FMD, etc. The Center has patients from all over the country as well as the world who seek our opinion regarding complex medical conditions for women with heart disease.

Reviewed: 05/12

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