Thursday, November 29, 2012 - Noon
In "The Cleveland Clinic Guide to Heart Attacks", Curtis Rimmerman, MD, one of America’s foremost authorities on heart health, reveals important information for patients and their families on how to avoid a heart attack or survive and thrive after one. Dr. Rimmerman answers your questions about heart attacks, including risk factors, diagnostic tests and treatments.
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Symptoms of Coronary Artery Disease and Heart Attack
robertlA: I am 23 years old and occasionally get chest pain. Is it possible this is coming from heart and I could be having coronary disease and possible heart attack?
Dr__Rimmerman: Given your age, unlikely. I would recommend you see a doctor, have them perform an exam and assess your heart risk factors - particularly your cholesterol. I also suggest an EKG. That is an excellent start.
KL22139: I went to the emergency room for chest pain. They did an ekg, chest xray and blood work and said I wasn’t having a heart attack. Now I keep having chest and left arm pain on and off but not sure what to do. Should I go back to the ER?
Dr__Rimmerman: Very difficult to advise over the computer. In the setting of your history of coronary artery disease, I would recommend a repeat visit to the ER.
Whils35: If you suspect you are having a heart attack, what should someone do?
Dr__Rimmerman: First thing - chew an aspirin and simultaneously call 911.
Driving yourself to the hospital is potentially dangerous to you and also the general public. Optimally you will be transported to your closest hospital to confirm or hopefully refute the diagnosis of heart attack. If confirmed, chances are you will be taken to the heart catheterization lab immediately. If a heart cath lab is not available, you may be administered powerful IV blood thinners and transported simultaneously to the closest hospital with a cath lab.
There is a saying - time is heart muscle - and that is why it is so important to quickly recognize your symptoms and quickly seek help. Driving yourself to a distant hospital with a cath lab vs. calling 911 and being treated to the closest hospital introduces greater risk than benefit. Let the medical professionals guide you after their prompt evaluation with their prompt evaluation with an exam, blood work and EKG.
When in doubt, or when you have any concern about a heart attack please call 911 - that is the best approach.
CalvinKL28: I had a heart attack 3 years ago. No symptoms but my doctor after my annual said he wants to do a nuclear stress test. I am wondering given all the press about unnecessary testing if 1. I need a stress test without symptoms or does my history warrant it and 2. Is nuclear necessary? What is the added value? Or - could there be something in the physical that could have caused him to say I need a stress test?
Dr__Rimmerman: In the absence of symptoms, I do favor an annual stress test. I would advocate for an exercise echo/similar information without radiation exposure.
marilynmann: The ACC "Choosing Wisely" list discourages stress testing in asymptomatic people, but they make an exception for patients with diabetes who are over 40, patients with 2% or more annual risk of an event, and patients with peripheral artery disease. Is there data showing that stress testing improves outcomes in those patients? I am concerned that stress testing can lead to false positives, referrals for cardiac catheterization, and unnecessary stenting.
Dr__Rimmerman: Great question. I am not aware of specific data in this patient population. 100% agree with the possibility of unnecessary testing, thus choosing patients for a stress test is exceedingly important and I tend to lean at a minimum toward the moderate risk population such as you describe. I also invariably utilize cardiac imaging in addition to stress ECG and preference echo imaging that in my experience has less likely false positive results.
charlene: Dr. Rimmerman, My friend recently was in the emergency room for a mild heart attack. When he was tested by cath later in the week, they found no blockage. Is it possible to have heart damage or a heart attack with no blockage?
Dr__Rimmerman: Yes. Especially in the case of coronary vasospasm or minimal blockage not visible on the cath which can still result in a ruptured plaque and transient blood clot formation.
Caroline527: Can you tell me what to do if you can not feel you have a heart attack to know you are having one in the future? My husband had a heart attack which showed up when he had a doctor check him out. He wasn't feeling well, went to the doctor and he said his EKG showed he had had a heart attack. He swears he had no symptoms.
Dr__Rimmerman: Tricky situation. About 30% of patients have no symptoms. I would advocate at a minimum a yearly stress test for surveillance; coupled with excellent dietary modification, regular exercise, blood pressure and lipid control.
Suzzztp: I'm a 40 year old female who had a heart attack. They told me it was a NSTEMI. It was diagnosed with enzymes. I was lucky and have no damage. Can you tell me 1. what does NSTEMI mean? 2. What are enzymes and how do they tell if you have a heart attack? 3. How do you have a heart attack and no damage? Feeling lucky.
Dr__Rimmerman: NSTEMI is an EKG pattern description only. With the enzymes in the blood are due to damaged heart muscle cells in the presence of a heart attack are released into the blood stream. Under normal circumstances, they are not detectable.
I suspect your heart attack was very small and not visible to the naked eye on, for instance an echocardiogram. You are fortunate but at the same time this is serious and your cardiac risk factors need to be optimized - such as lowering your cholesterol; making sure your blood pressure is well controlled; a regular exercise program; daily aspirin; daily statin; possibly a beta blocker; weight control and no tobacco.
lowres: If I have had one heart attack, am I more prone to another one?
Dr__Rimmerman: The short answer is yes - since you have been diagnosed with coronary artery disease presumably. The great news is that you should be much more informed patient and if you were not living an optimal lifestyle with regard to diet, exercise, etc, this is a fantastic opportunity to get those aspects of your life inline.
Additionally you should be on new medications - such as aspirin or statin and these medications in combination with your lifestyle efforts will lower your future heart attack risk to a level approaching that of a patient without a history of prior heart attack.
BarbaraB22: I have had chest pains on and off. The doctor said I have a spasm problem. He said there was not much to do for that. What do you do for a spasm in your heart? Is it dangerous? Can I get a heart attack from it?
Dr__Rimmerman: I presume you have had a heart catheterization to exclude significant blockage. If not, you may consider a treadmill based stress test and echo to make sure everything is ok. If that test comes out satisfactorily consider discussing addition of one of the following medications:
- long acting nitroglycerin
- amlodipine (The latter being a calcium channel blocker)
Infrequently heart attacks can occur from prolonged spasm, thus the above recommended investigation.
Lynda: Is endothelial dysfunction the same as coronary Microvascular disease? How it diagnosed and what is is the treatment?
Dr__Rimmerman: Endothelial dysfunction represents abnormal blood vessel response especially dilation in the face of stress/exercise and can be an adverse indicator of the beginnings of atherosclerotic disease. Endothelial dysfunction falls under the category of endovascular disease. Taking a hard look at your cardiac risk factors and making sure your lifestyle efforts are optimized in this situation.
Prevention of Cardiovascular Artery Disease Progression
RayMC: I am 65 and have been diagnosed with both mild heart and carotid artery disease. I am completely asymptomatic with lipids in line and absolutely no physical discomforts. I exercise strenuously for an hour, 5 days a week but have moved away as a safety precaution from the 95% max heart rate cardio I had been doing and now concentrate on strength training almost exclusively. I recently had a positive exercise stress echo but refused the suggested angiogram because of the high false positives and because my doctor said the likelihood of the necessity for angioplasty appeared to be only 30%.I am mindful of my diet, take low dose aspiring + statin daily. My sense is that there is nothing more to be done from a preventative point of view unless I want the angiogram. What are your thoughts on my situations? Thanks.
Dr__Rimmerman: Excellent question. Aim for an LDL less than 70, optimally HDL greater than LDL and this can often be obtained by one of the excellent food programs out there such a plant based diet.
Peppy: Is a plant based diet better for the heart with or w/o the addition of some wild salmon?
Dr__Rimmerman: You are asking a lot of questions about nutrition. Nutrition is a very important topic for the general population especially for people with atherosclerotic heart disease. I am a firm believer that with the combination of excellent medications available and a disciplined diet atherosclerosis can be stabilized and most importantly, reduction of heart endpoints such as stroke and heart attack can be achieved via the reduction of vascular inflammation and plaque rupture.
Diet is one component of a multi-pronged approach including statins, aspirin, blood sugar and blood pressure control, and tobacco cessation. Regular exercise confers outstanding physical and emotional benefit.
Kendar: After a heart attack, what type of exercise program do you recommend?
Dr__Rimmerman: Shortly after a heart attack it is best to enroll in an outpatient hospital based cardiac rehabilitation program. The benefit of this type of program is that it is highly supervised with medical professionals focusing on optimizing your cardiac health.
Dr__Rimmerman: This type of program will closely monitor your blood pressure, heart rhythm and heart rate and also for adverse symptoms as your program is gradually advanced. Most typically there is also a dietary educational component and also a support system of patients with similar diagnoses.
Once this program is completed, typically lasting 6 weeks you have the option of continuing with a similar program in a similar setting which is less supervised but creates the discipline for you should you deviate from your exercise routine. I equate exercise with other essentials such as eating, sleeping, brushing your teeth - in terms of its positive impact on your physical and emotional health it is a great way to lower blood pressure and it helps maintain a stable and excellent weight.
When starting an exercise program realize it is a journey and not a destination; thus reaching gold medal status on day one will not happen. Thirty minutes of continuous aerobic activity daily should be your goal and gradually increase your level of exercise as you tolerate.
Peppy: I was told my carotids are about 50% occluded and watching. I don't want surgery. Been on a plant based diet and statin, exercise for five years now. What else can be done to keep the stent and surgeon away? I'd rather medically manage or diet management.
Dr__Rimmerman: What you describe is perfect.
Medications and Supplements
JoyD: I recently read that beta blockers carry certain side effects that may elevate cholesterol and triglyceride levels in some patients. I was placed on a beta blocker after having one episode of angina. Should I contact my cardiologist about making a change or wait until my one year visit?
Dr__Rimmerman: What I would suggest would be a repeat lipid profile 3 months after starting the beta blocker. If your results are not adversely impacted, there is no cause for concern.
carmenvelez: Is plavix routinely prescribed after post cardiac cath procedure? Any other meds recommended?
Dr__Rimmerman: It depends on what is found at the time of cardiac cath. Most frequently plavix is prescribed after stent placement. Other medications such as statins and aspirin are typically recommended if coronary artery disease is confirmed.
songcanary: Is there any comparable substitute for low dose aspirin if a person is prone to gastritis? No prior problems, just as prevention because of family history.
Dr__Rimmerman: The only alternative would be clopidogrel (plavix). This is most typically recommended as an alternative to aspirin when a true aspirin allergy exists. What you are describing is a side effect of aspirin. For instance, an allergy would represent a serious side effect such as hives or tongue swelling. Please discuss with your physician.
luker: What about stomach and intestinal bleeding with aspirin?
Dr__Rimmerman: It is a possibility and that is why I recommend using enteric coated aspirin and taking it with food. I prefer in the morning and should you have significant stomach upset, consider an antacid or over the counter medication.
Dr__Rimmerman: In heart patients, aspirin is as important a medication as other medicines such as statins and just because it is over the counter, its importance should not be minimized.
luker: Any recommendations for vitamins or nutrients, such as Vit E or D?
Dr__Rimmerman: Vitamin E has not proven to benefit cardiac outcomes. Vitamin D should be replaced if you are truly deficient. The only way to find this out is a blood level.
Interventions – Angioplasty and Stent
Peppy: How is the TAXUS II Express DES performing after five years in clinical studies? Restenosis high? Stent thrombosis risk increase or decrease? Mortality affected positively or?
Dr__Rimmerman: The TAXUS stent has been an excellent performing stent for many years.
tscan: I was diagnosed with MVP and regurgitation about 3 yrs ago and it has gotten worse. I am 51 yrs old and I am getting a HIDA Scan done this Friday for a nuclear stress test. If I need MVP surgery, do I have to make any special arrangements to come to the Cleveland Clinic to have that surgery performed?
Dr__Rimmerman: It depends on how much mitral valve leakage you have and certainly if significant a call to our Heart Center Resource Nurses at 866-289-6911 will help you with the steps for a surgical review.
clara: I had bypass surgery and aortic valve 2006. From 2009 - 2012 I have had 8 stents in all the major arteries; None due to restenosis. I was recently told that the tricuspid valve is severe and will need to have it fixed once I can go off Plavix. The mitral valve has changed some too. I think it was mild moderate and now moderate. I was also told that I have a genetic problem. I know that the tricuspid valve is not done often, also I wonder if I need to seek CC for advice. I do not have a cholesterol problem or high blood pressure.
Dr__Rimmerman: I am sorry to hear about your cardiac history and you sound like a complex situation. With this in mind, you would be an ideal patient for an experienced medical center such as Cleveland Clinic. We have many valvular heart disease specialists who are exceedingly qualified to see a patient such as you. You can go to www.clevelandclinic.org/heartnurse for contact information to speak to a nurse or call our appointment line at 800-223-2273, extension 46697.
rks1131: How serious a condition is it for someone having a low ef of 15%.
Dr__Rimmerman: It can be potentially very serious. However there are many excellent treatment options available. It is my sincere hope that you are in contact with an excellent cardiologist who has evaluated the cause of your heart dysfunction and placed you on the appropriate medications. We have excellent physicians at Cleveland Clinic who specifically specialize in taking care of patients with low ejection fractions.
ch2727: can CoQ10 used for heart patients, especially dilated cardiomyopathy? Also can a patient with cardiomyopathy and a defibrillator maintain a BP of 88/50? This patient is 31 years old.
Dr__Rimmerman: I am not aware of any interaction between CoQ10 and heart function. A low BP with reduced heart function is common and generally is a combination of low heart output and required medications.
Talking with your Cardiologist
Cleveland_Clinic_Host: Dr. Rimmerman, you also wrote the book "Speaking with Your Cardiologist", what are some take home points?
Dr__Rimmerman: It is hard to summarize the entire book, but I would strongly suggest if you have the time to carefully prepare for your visit with the cardiologist.
Consider collecting the following information prior to your visit:
- A narrative of your symptoms and why you are visiting.
- A list of your cardiac risk factors especially family history.
- An accurate list of your medications.
- If you have undergone prior cardiac testing both paper reports and images, including images or testing on CD-rom can be invaluable for review, preferably sent to the cardiologist in advance of your visit.
- Should you have specific questions for your doctor - again - writing them out ahead of time can be extremely time efficient and maximize the outcome of your visit.