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Ask the Heart Doctor (Dr. Nissen 2/21/12)

Tuesday, February 21, 2012 - Noon


Cleveland Clinic is recognized as the world leader in diagnosis and treatment of cardiovascular disease and has been ranked No. 1 in the nation for cardiac care by U.S. News & World Report every year since 1995. Dr. Steven Nissen answers your questions about the latest treatments and diagnostic tests for cardiovascular disease.

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Coronary Artery Disease and Heart Attack

hadaheartattack: how long does it take to recover from a heart attack? and is there 100% recovery?

Dr__Nissen: Generally people are feeling pretty normal 4-6 weeks after a heart attack, however, the heart muscle is permanently damaged to some extent. There will always be at least some reduction in the ability of the heart to perform.

ekandef: I just had two stents put in last week R-PDA 3mmX16mm And 3mmX12 mm during a heart attack another narrowing of the LAD has been found at 80 % narrowing how long before I need to get another stent put in ?and what are the risk of getting another stent right away or waiting a month or two ?

Dr__Nissen: There is no special risk to receive a second stent (if you really need it). I assume that you have chest pain no manageable with medications. We usually reserve stents for patients with unstable symptoms or difficult to manage angina.

clara: I had bypass surgery & aortic valve replacement 2006. I have had 6 stents 2009, 2010, and fall 2011. All major arteries have stents. My question is how many stents can I keep getting? I was told that I have very aggressive heart disease that is not connected to cholesterol. I exercise and am thin. Open heart surgery is a concern for me.

Dr__Nissen: There are some other causes of aggressive coronary disease that should be explored. Several of these are discussed in our book Hear411. There is no precise limit on the number of stents you can receive, but it is always better to prevent blockages than treat them. A second opinion may be useful.

mooreke126: How long does it take for plaque to form? 54 yo f with excellent blood work numbers. I follow a vegan diet. controlled by BP meds and statin. found <50% calcified plaque in LAD during CT. following heart healthy ways. no symptoms. extensive family history.

Dr__Nissen: We do not recommend extreme low-fat diets. We also do not recommend calcium scanning. Treat your risk factors (cholesterol, BP). Do not expect any particular benefits from the vegan diet.

ekandef: during my heart attack there were two stents put into the RDA and I was told that because I got treatment so quickly that there was no heart damage that shows up on a ekg but the LDA artery showed a narrowing of the artery toward the bottom of the heart and there are no symptoms or pain because of this but it has been recommended that I have another stent inserted it that artery. I was about 2 week ago that I had the first two stents put in. My question is when should that be done you said that you do NOT recommend stent unless it is un manageable, I do not even know its there except by looking at the cath pictures that were taken during the last heart attack.

Dr__Nissen: We do not recommend another stent, unless you have symptoms.

KY67LH: If a stent can't be placed for one reason or another, does this mean that there is a greater chance of a heart attack?

Dr__Nissen: No necessarily. Most heart attacks do not occur at the site of a coronary narrowing that might receive a stent.

Kalen: Is it possible to have a myocardial infarction with normal coronary arteries without blockage of any kind?

Dr__Nissen: Yes. There is a syndrome known as Broken Heart Syndrome where a heart attack occurs in a patient with normally coronaries.


kcatgrg: My 75yo mother, with no heart of other medical problems was told by her doctor to get her LDL level to 75 or lower. I thought 100 or less LDL level was the standard for non heart patients. Why would they recommend that? What is your opinion?

Dr__Nissen: You are right.

crisispro: Can you please speak to the ACCORD study, specifically its findings on the effects of various heart medications on heart disease. If it within the scope of this session, I would also appreciate hearing what the study showed re blood sugar levels in diabetics.

Dr__Nissen: ACCORD showed that moderate control of blood sugar (HbA1c of 7 to 7.5%) was just as good (and possibly better) than extremely tight control. (HbA1c < 6.5%). The lipid study showed that fenofibrate (Tricor) had no benefits for diabetes when given on top of standard treatment (statins).

kcatgrg: My husband, 52 yo, had a baseline treadmill stress test and during the testing the techs mentioned that he showed a right bundle block. What is it and is it something to be concerned about?

Dr__Nissen: First of all, we do not recommend stress testing unless patients have symptoms. A RBBB is relatively common and does not necessarily mean that he has heart disease. It is a slight delay in the conduction of the electrical impulses of the heart


mreen721: Is it true that aerobic exercise normalizes cholesterol levels?

Dr__Nissen: No, exercise can help with cholesterol but the effect is small. Generally, exercise raises the good cholesterol (HDL), but minimal effects on the bad cholesterol (LDL).

mreen721: Is strength training 2-3 times a week good for the heart?

Dr__Nissen: We prefer aerobic training, but strength training several times a week is reasonable for most patients. See Heart411: The Only Guide to Heart Health You Every Need, for more details.

dliving41: As a 71 year old male, who exercises daily, is a heart rate of 150 dangerous? There is no chest pain involved.

Dr__Nissen: I assume that your heart rate is during exercise. It is not a problem.

mikert: I have been having some kind of heartburn for the last two weeks and a small pain on my the right side of my chest as well as some pressure on the center of my chest. I went to Urgent care last week and an ECG showed normal. Also blood work eliminated a heart attack at the moment. Am I suffering from Angina?

Dr__Nissen: It is possible. You should seek care from a cardiologist promptly.


mreen721: Is consistently eating too much salt in the diet a concern for an otherwise healthy person?

Dr__Nissen: Very controversial. If you do not have high blood pressure, there is not strong evidence of a harmful effect from salt, but most experts think that moderating salt intake is reasonable for everybody.

kcatgrg: Are there any heart benefits in drinking tart cherry juice?

Dr__Nissen: No. There are no magic foods.

dliving41: Can you comment on the relationship of alcohol to heart disease?

Dr__Nissen: In general, a moderate intake of alcohol is associated with a lower risk of heart disease. It does not appear to matter what type of alcohol. There are no special benefits of red wine. Please see the chapter in our book Heart411.

mreen721: Are pesticides from produce harmful to the heart?

Dr__Nissen: We have no specific information about pesticides and heart disease.

kcatgrg: Can the calcium in milk, if you drink 3 or more glasses during the day, affect the calcium plaque buildup in the arteries?

Dr__Nissen: No.

Diagnostic Testing

mreen721: What are the best tests to identify artery blockage?

Dr__Nissen: There are no recommended tests to identify coronary blockages. The commonly used test such as stress testing or coronary calcium scores are NOT recommended for patients without symptoms. The best defense for preventing coronary disease is heart-healthy habits.

ekr0214: I had a calcium scan 15 years ago. My score was o. Should I be concerned reference radiation exposure? I am now 56 years old. I am the female with the 15 episodes of afib who has been submitting questions.

Dr__Nissen: You can't go back in time. We recommend avoiding future radiation exposure if possible

dliving41: I have advised to have a stress test. I have had one before where I was on a tread mill. Now I understand the procedure has changed. Had you explain?

Dr__Nissen: We do not recommend treadmill testing unless you are having symptoms. The procedure has not changed.

David100: What special circumstance would be reserved for HRV? Is HRV practical?

Dr__Nissen: Are you referring to Heart Rate Variability testing?

David100: Yes, Heart Rate Variability Testing, frequency and time measures

Dr__Nissen: This is not a test that we routinely use in patients with heart disease.

David100: I have your Heart 411. I searched the book and did not find Heart Rate Variability. I am not being critical in any way. My interest is preventative maintenance of my heart. I hope to make personal HRV measurements to determine if the care I am providing is working, i.e. much like your Cleveland Clinic’s McKee, Moravec Phd’s use of BioFeedbackStressManagement in the treatment of heart disease, only I am not going to have my heart transplanted. How does HRV fit into the cardiology field?

Dr__Nissen: We don't recommend HRV testing as a matter of routine. It's reserved for special circumstances. You may want to consult with one of our heart rhythm specialists (electrophysiologists).

beatright: What is a calcium scam? Is this the same as a bone density scan?

Dr__Nissen: No, it is not the same. It is a scan of the heart to look for calcium. We do not recommend this test.

dliving41: I don't have symptoms but a CT Scan done before and after my ablation showed a fair amount of calcification. Could a stress test be in order?

Dr__Nissen: We only recommend stress testing if you are having chest pain with exertion. You should be receiving appropriate preventive therapies for coronary disease such as statins and/or blood pressure medications.

Sw_William: What is your opinion about the new 320-line CT-MRI machine? Does it afford enough resolution to substitute for the relatively invasive catheterization procedure in preparation for aortic valve replacement?

Dr__Nissen: The answer is no. We do not believe that CT scanning is an acceptable substitute for coronary angiography in most cases, although, if it is completely normal, the odds of having a blockage are very small.

crisispro: Do you ever suggest calcium scanning? Even in someone with high numbers (before heart meds) and overwhelming family history of premature heart disease?

Dr__Nissen: Absolutely never! The radiation dose is unacceptable for use in prevention.

Forward: Is there any coronary imaging without the use of iodine

Dr__Nissen: Yes. MRI can be used but the image quality is not very good and we, therefore, do not routinely use this test.


tlg43: What are some of the long term effects of taking Coumadin? Can a person who had a successful single bypass and a maze procedure for AF, two years with no problems ever be able to stop taking Coumadin. Can he be evaluated by a electrophysiologist about this problem?

Dr__Nissen: You may be able to stop Coumadin, but you should definitely consult with an electrophysiologist.

crisispro: I cannot take hydrochlorothiazide because of a Whipple procedure. I am currently on lozartan, 50 mg/day. Do you consider this an acceptable regimen?

Dr__Nissen: It is acceptable if it is controlling your blood pressure.

Valve Disease

movshuk: Do you expect that future developments in the tissue engendering will change the practice of aortic valve surgery? Thank you!

Dr__Nissen: I don't understand what you mean by "tissue engendering." There are major developments underway toward less invasive methods for replacing the aortic valve.

kcatgrg: Is it still recommended to take antibiotics before a dental cleaning after mitral valve repair?

Dr__Nissen: No.

kcatgrg: In 2010 at the age of 49, I had isolated mitral valve repair at Cleveland Clinic and am doing excellent. I have no issues and I am not on any medications. My follow up echo in 2011 was perfect. Do I still have to continue to have echos in the future and if so at what intervals?

Dr__Nissen: We are very pleased that you are doing so well! An echo every few years is probably reasonable.

kcatgrg: Has there been any advancements in stem cell created valves for use in patients?

Dr__Nissen: Work on stem cells is proceeding, but at a very slow pace.

Sw_William: What is your opinion about the recently revised Ross procedure, whereby the pulmonary valve is reinforced after replacing the aortic? What is your opinion about the femoral access method for aortic valve replacement?

Dr__Nissen: One, we do not recommend the Ross procedure at the Cleveland Clinic. Two, the percutaneous valve replacement is not recommended unless the patient is too sick for surgical valve replacement. Three, do not consider the 320 line CT scan to be equivalent to CT angiography.

movshuk: I have bicuspid aortic valve with combined aortic stenosis and regurgitation. Is it possible that regular aerobic exercise (30-40 minutes on stationary bicycle 3-4 times a week) may increase the mean pressure gradient, and make the aortic stenosis worse? And how much anaerobic exercise is not detrimental in my case of BAV with combined (and asymptotic) AR and AS? Thank you very much for kindly sharing your expertise.

Dr__Nissen: It all depends on the severity of your AS. We would need to know much more about your situation to advise about exercise. If you would like to get further advice, one of our heart valve specialist would be pleased to see you


Dorsey: When sleeping at night, if I lay on my left side, I sometimes am awakened by a sharp pain in my chest. When I asked my family Dr about this years ago, he referred me to a cardiologist. An EKG was preformed & after asking me several questions, he dismissed me, saying it wasn't anything serious. I try to sleep on my right side or back, but if I happen to switch to my left side, I am usually awakened & have to sit up until the pain subsides. What could be causing this?

Dr__Nissen: Uncertain. It's not typical of coronary heart disease. May be musculoskeletal problem. If you are still worried, get a second opinion. It's always good advice.

noravas: I am experiencing constant upper back pain and some tightening of the chest. Is this a matter of immediate concern?

Dr__Nissen: yes. These symptoms can indicate coronary disease or diseases involving the large blood vessels in the chest. Please see you doctor promptly.

Heart Failure

clw73: Two part question: 1) Have you ever heard of a heart device called The Optimizer by Impulse Dynamics for heart failure patients? It focuses on Cardiac Contractility Modulation of the heart. 2)What other treatment options are out there for patients with familia DCM and EV of 35% but no symptoms? Thank you

Dr__Nissen: 1) This is NOT an approved device. I would be extremely skeptical. 2) You should be taking several types of heart failure medications shown to preserve your ejection fraction. If you need further advice, one of our heart failure specialist may be able to help.

Irregular Heart Beats

ekr0214: I’ve had 15 episodes of afib in my lifetime where I have converted on my own within a few hours. Is my heart muscle being weakened with each episode? It started when I was 22 yrs old. I am now 56 yrs old.

Dr__Nissen: The answer is no. I am assuming that you have no problem with your heart valves causing you to have a-fib.

jillrn: In March of '04, I had the maze ablation at CC along with two valves repaired. I have been visited intermittently by a-fib/a-flutter in the last year +. It seems to be related to altitude. Last week, while trying again to go to my home (7900') the a-fib returned violently while descending vail pass, and is remaining with me. I was forced to move in with my son at 5500'.QUESTION: while pursuing fixes, will it be to my advantage to go to much lower elevation (sea level)? and if it is good to be lower, will I be able to return to this new home-elevation of 5500'?

Dr__Nissen: It is difficult to say for certain, but you should seek advise from one of our electrophysiologists. We may be able to find a way to keep you out of a-fib.

witter123: I have a dual chamber pacemaker (slow heart beat) and recently have a quiver feeling inside my chest which does not show outside the chest. Is this my pacer program that needs adjustment?

Dr__Nissen: There is no way to tell. Please consult your cardiologist who will interrogate your pacemaker electronically.

beatright: I am a sixty-seven year old female in a-fib since August 2010. After having my heart rhythm controlled for the past ten years on a 200 mg daily dose of tambocor I went into a-fib. A cat-scan and TEE were conducted in mid-January at Straub Hospital on Oahu, HI, to determine if an ablation could be performed. The cat-scan detected a clot, which seems to be encapsulated, in the LAA and the ablation was cancelled. Upon returning to Kauai, HI, my cardiologist indicated that nothing could be done, and that I would have to live with this a-fib. The a-fid has affected my life severely with lack of energy, shortness of breath and a generally feeling overwhelmed. My own web research indicates that there are some procedures which can isolate the LAA, making it possible to conduct an ablation. Do you concur? Of the available procedures, which is most successful? Should other medications be considered first?

Dr__Nissen: Yes, I concur that you may be a candidate for one of the new procedures available to isolate the LAA. This is a very tricky area and I recommend that you consult an experienced electrophysiologist at a major medical center. You may benefit with an electronic consultation with one of our electrophysiologists at Cleveland Clinic who can review all your records and make a recommendation.

mclaypool: I have been diagnosed with tachycardia. I am on no meds but have been having that fluttering feeling more often. What should I be watching out for?

Dr__Nissen: Tachycardia can be caused by many different rhythm disturbances. You will need a more precise diagnosis for us to recommend preventive therapy.

ekr0214: Reference the above question I asked you on the 15 episodes of afib.. I do have some prolapsing of the mitral valve leaflets and I just discovered that I have a patent foramen ovale in my heart. I am on a beta blocker but I think that I need a more aggressive intervention to be taken. I’m seeking a second opinion. Do you think that is warranted?

Dr__Nissen: Absolutely. There are many options to be considered.

PaulK: Could a pinched nerve in the spine that connects to the heart cause the heart to skip a beat?

Dr__Nissen: No

Marker: I have an irregular heart beat. the doctors haven't been able to find the root cause. what can I do aside from lowering stress to keep the heart beating regularly?

Dr__Nissen: It depends on the type of rhythm problem. There are a variety of medications that can be used, but it all depends on the exact diagnosis.

beatright: What procedure do you feel is better to remove or close off a LAA? AtriClip or Lariat?

Dr__Nissen: They both work. Our experience is only with AtriClip.


Francois: My systolic blood pressure can go as high as 200 without my feeling anything abnormal not only in a doctor's office but also in other places including my home in response to average stressors of life and living. However it returns to normal within an hour or so. Ambulatory Blood Pressure monitoring shows that I do not suffer from hypertension. Am I at risk of getting a stroke when my blood pressure like this? I am male, 74 years old and in otherwise excellent health.

Dr__Nissen: Episodic hypertension, such as you describe, is associated with increased risk of heart attack and stroke. This type of pattern often precedes sustained hypertension. We sometimes treat patients like yourself with low dosages of anti-hypertensive medications, but it's best to discuss with your doctor.

crisispro: At what blood pressure levels do you recommend medication? Do you have a preferred hypertensive med?

Dr__Nissen: We treat most patients if they exceed 140/90. The first line medications are diuretics. We strongly discourage use of beta blockers such as atenolol in the first line treatment of hypertension.

firefly50: Last November I was diagnosed with AFib. Put on Pradaxa, Propafenone, (450mg 2x's day) and Diovan, along with Lipitor, Xanax and Ambian. I know now I had this for 9 years after one of the most stressful weeks of my life. In Nov. 2011 I had a seizure and a possible mini stroke. I am afraid to leave the house, visit friends and family or even go to sleep. When I thought it was anxiety I went about my business but now that it is AFib I am totally afraid to do anything. Is there any chance this is curable and will go away totally? I will take any suggestion to my cardiologist.

Dr__Nissen: There may be alternatives, but we would need to know more about your situation. Your current therapy is fairly routine. Occasionally, we find patients with long-standing atrial fibrillation who can benefit from an ablation, but if you've really been in a-fib for 9 years, it's likely that you will stay in a-fib. There are many other issues, so you might seek a second opinion.

General Questions

ekr0214: I live in southern Florida... If I go to a Cleveland clinic near me and get that evaluation forwarded to the Cleveland Clinic in Ohio for a joint consultation on what course of treatment should be pursued?

Dr__Nissen: This can be arranged if it would be helpful to you.

David100: Do I have a chance of finding a cardiologist to work with me, an 83 year old male patient who makes his own ECG measurements and has his own software for developing time and frequency HRV measures.

Dr__Nissen: Of course. We see all types of patients, even those who choose to self-treat. A reasonable doctor will partner with you to try to assist.

mooreke126: Dr. Nissen I am half way thru your book and it is excellent. I've ready many books on this topic and yours explains topics for the lay person to understand.

Dr__Nissen: Thank you so much and I hope you use the book to improve your health!

clara: where can I buy the book Heart 411? I also want to thank you for you help.

Dr__Nissen: Thank you! It is available on the Amazon and Barnes and Noble web sites and in your local bookstore.

mreen721: Thank you for your help, Dr. Nissen. I am looking forward to reading your book!

Dr__Nissen: Thank you!

Reviewed: 02/12

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