Monday, January 21, 2013 - 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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clara: I have had open heart surgery / aortic valve replaced / 8 stents in all the major arteries. I am now told that the tricuspid valve is severe and the mitral valve has gone to moderate. Would I experience swelling in the stomach / shortness of breath/ and some weight gain?
Dr__Cho: Severe tricuspid regurgitation can lead to right sided heart failure. We recommend that you follow up with your cardiologist regarding treatment. Most tricuspid regurgitation can be treated with medication.
Lsuso-Linda-W: My chest seems to buzz. Vibrate rather than beat. This doesn't happen all of the time but I wake up in the night with the feeling along with weakness in my left arm and a slight nausea. I normally sleep in one spot and never disturb the other side of the bed but lately I wake up to a bed in total disarray. I don't want to over react and go to the ER if it’s nothing. So far on-line it seemed it was more of an anxiety issue and after taking a Xanax I was able to fall back asleep for a couple of hours. This has happened three times in the past week long period.
Dr__Cho: You should see your doctor if you are concerned about these new symptoms.
Coronary Artery Disease
browna20: Is CAD with 100% stenosis a chronic total occlusion?
Dr__Cho: Yes. Chronic total occlusion is a coronary artery that is 100% blocked.
browna20: What is angina?
Dr__Cho: Angina is usually described as chest pressure or tightness from the heart not getting enough blood flow or oxygen. It usually occurs during times of exercise or stress, when the heart requires more oxygen. Sometimes they have angina-equivalent - such as jaw pain or arm pain. This is not "classic angina" but is still coming from lack of oxygen to the heart.
Irregular Heart Beats (Arrhythmia)
charlee09: I am 25 years old. I feel a lot of skipped beats and sometimes a sharp pain in my chest. It feels like a thud and lasts a few minutes and then will go away - it is right under my left breast. I am very scared. A couple years ago I fainted and had an ekg and the doctor said it was normal. Should I go for another check?
Dr__Cho: The most common cause of palpitation in women is due to hormonal changes and is very benign. These palpitations are caused by extra heart beats and rarely lead to fainting spells. It is unclear whether your fainting spell previously was related to extra heart beats or not - so it is best to be evaluated.
As far as your sharp chest pain, it sounds musculoskeletal in nature. Usually cardiac pain is exacerbated with exertion.
Kor24: I get heart palpitations or irregular beats and it correlates with my period. Is that common? Will it go away with menopause?
Dr__Cho: Yes it is common. Sometimes it is worsened with menopause but after fully done with menopause, can improve. It is worsened by caffeine, dehydration, alcohol and over the counter decongestants.
emoeller: I have a pacemaker/defibrillator that was part of the recall due to faulty leads several years back; is there any new information that I should be aware of?
Dr__Cho: Have you had your lead extracted? Are you following up with your electrophysiologist? Normally they would monitor your device with pacemaker interrogator and x-ray.
Rebecca-S: My heart has an irregular beat two or three in a row, then will not have one for a couple of minutes. I had my aortic valve replaced and my and a section of my descending aorta replaced with mesh about a year and a half ago. (My valve is an congenital defect). I am taking warfarin and metoprolol. Should I be concerned about this irregular beat?
Dr__Cho: Not if it is one - two beats only. The kind of beats we are concerned about lasts about 10 minutes. However, you should talk to your doctor about your new symptoms.
Mary_Ellen_T: What arrhythmia feels like: regular rhythm not terribly fast, but very strong beats, lasts about 10 seconds, makes me feel very lightheaded, like I am going to pass out? These episodes really scare me.
Dr__Cho: You should see a doctor. He or she would most likely look at your heart with a 24 hour monitor that can see what is occurring when you feel these symptoms.
eadler1220: You mentioned earlier that palpitations in women are usually a side-effect of hormonal changes. I am 57 and experienced severe palpitations about 5-7 years ago, and as a result was put on beta-blockers, which I've been taking ever since. I am now in menopause, so I'm wondering if I should try stopping the beta-blocker and see if my palpitations are gone? Also, are there certain ones more highly recommended than others? I'm on Propranolol, which I understand is not selective like Metoprolol for example. Is that a disadvantage?
Dr__Cho: For most people palpitations are totally benign. We only start beta blockers on patients who are highly symptomatic. You can try to wean yourself off with your doctor's permission.
suzanneLen: Can microvascular disease show up on a nuclear stress test?
Dr__Cho: Yes. In some instances it can show up on a stress test however the most sensitive test for microvascular disease is coronary flow reserve test (as part of a cardiac cath, therefore invasive) or a perfusion cardiac MRI. The best way to diagnose Microvessel disease is not by a stress test.
whatcouldbewrong_: I am an active, healthy 51 year-old who doesn't smoke or drink alcohol or caffeine. I take a warm water exercise class, which helps my Fibro symptoms. I’ve been having symptoms in which everything excites my heart. Sweeping, doing laundry, vacuuming; my heart starts beating really hard and fast, and it feels like I just can't seem to get enough air. I saw my G.P. Thursday. H.r. was 136, which is weird, because it's usually in the low 70s. My b.p was really high: 168 (it’s usually 100). Also, the doctor heard a "pronounced S-gallop" and a "significant murmur". He said that my E.K.G. concerned him (something about "S & T elevations" and "low voltage") and chest x-ray showed that my heart was enlarged and that I have fluid around my heart. He sent me for labs ...and an echo. The tech. wouldn't give me much info, but she did say that my heart was "very swollen". My h.r. was between 130 - 140 the whole time; she said that I had a lot of “extra beats". What could be going on?
Dr__Cho: Please speak to your doctor about the results of your test. There are cases where continued fast heart rate can lead to heart failure by enlarging the heart. It is called tachycardia induced cardiomyopathy. Treatment sometimes is very simple in that patient population. You need to speak to your doctor.
sarahNY: I have two questions: one - what is the best test for a woman to determine if they have heart disease or not. I have been having some chest discomfort the past couple weeks and have an appointment with my doctor on Wednesday. Wonder what I should make sure I get to determine what is going on.
Dr__Cho: The best test is actually dependent on the type of symptoms you have. Whether your symptoms are truly related to coronary artery disease or not helps to determine the correct test. Some patients have valvular disease or arrhythmia which would not benefit from a stress test for example.
sarahNY: My second question is this. My older sister also has had symptoms in the past, on a statin and beta blocker and aspirin. She had a cath and it showed disease but "not enough." I just wonder how much narrowing on cath does it take to intervene and second what do you do to get rid of the blockage you have?
Dr__Cho: Usually the blockage has to be around 70 - 80% angiographically with symptoms or corresponding stress test before we think about intervention. There are a couple of studies that show if your bad cholesterol (LDL) is less than 60 that it may reduce plaque. The best data is that if your LDL is less than 70 it can stop the progression of further plaque formation. That is why it is important to talk to your doctor about best ways to lower cholesterol, blood pressure and other risk factors.
There are ways to lower your cholesterol even for patients who have been intolerant to statins in the past. We have great success with this and would be happy to see you.
lara2569: My mom went to the emergency room about a month ago with chest pain. They did an ekg blood work and all ok. They sent her home. Then, last week she had a heart attack. Wondering if they missed something a month ago.
Dr__Cho: Did they do a stress test on your mom before she went home?
Mollee: My heart attack and symptoms leading up to it were so slight that it went unrecognized by me and 2 doctors - for someone with slight symptoms that are difficult to pin down (with established CAD) is there any value to periodic stress testing?
Dr__Cho: There was a study that doing routine stress test vs. symptomatic follow up in patients with CAD. Patients who had routine stress tests had more events, such as more cath, more revascularization and heart attacks, etc. Therefore, the AHA and the ACC do not recommend routine stress testing.
Peppy: I suffered from menstrual migraine premenopausal. I had aura with them. After menopause they continued once in a while. I am reading that migraine with aura seems to lead or contribute to CAD and vascular events. Mine always seemed to be linked to hormone fluctuations premenstrually. Now, in menopause for 6 years they still appear every so often. This concerns me. What is known about this condition?
Dr__Cho: Migraine with aura does increase risk of cardiovascular events that is why in those patients it is important to control blood pressure, control cholesterol, maintain healthy body weight and not smoke. We recommend for our patients with migraine to get an annual cholesterol test, blood pressure check and fasting glucose.
Peppy: I understand Beta Blockers lead to diabetes, have little use in stable CAD patients and will shorten life. How long should we take these drugs after a stent placement or a nonstemi?
Dr__Cho: Beta blockers leads to diabetes probably because it leads to weight gain. Not because inherently bad for you. We usually recommend beta blockers one to two years after a heart attack.
eadler1220: Does long-term use of beta-blockers such as Propranolol have a negative impact on the heart? Specifically, not being able to get your heart rate up when exercising?
Dr__Cho: No, there are no long term cardiac harmful effect of beta blocker usage. Getting your heart rate up is a marker for how hard you are exercising. By blunting your heart rate response with beta blocker, as long as you are exercising vigorously, you are still getting the exercise benefit.
clara: I forgot to ask you if I should see someone else, because I was told I would need surgery on the tricuspid valve and probably the mitral valve since it has changed. I was also informed that I would have to wait until the year was up so I could go off Plavix. I had the last stent in Sept. 2012. I think I read that the CC does more valves than anyone else. Can I mail the tests to them before making a trip? I get lightheaded also with these other symptoms.
Dr__Cho: Ideally you should be on plavix for one year if you had a DES would be one year - so the earliest would be September 2013. However, don't wait to send your records for evaluation. We have a method to send in records for surgical review - Contact the nurses at www.clevelandclinic.org/heartnurse for instructions. Depending on your valves, there are times when we need to shorten the plavix use to get the valves done. It would depend on your case.
Mollee: I had 2 overlapping drug eluding stents for 100% blokced LAD in 2009 ( I was 62 years old at the tine, with only risk factor of mother with CAD at age 69.) My doctor recently changed his advice about taking plavix, saying I could go off now. Should I taper gradually? What is your opinion about plavix? Should I add tumeric to my diet if I go off? I had a mild heart attack at the time with little to no damage, but only symptoms were being tired and muscle aches.
Dr__Cho: There is no good data about how long you should be on plavix with overlapping stents. Most people recommend 1 - 2 years however randomized control studies are lacking.
Taking tumeric has never been shown to decrease events therefore I would advise you to take aspirin; and continue with your other medications such as cholesterol lowering medicine, controlling blood pressure and other risk factor reduction.
Mollee: In going off plavix is there such a thing as a rebound effect - is there any benefit in taking it every other day - or gradually reducing use?
Dr__Cho: No - there is no rebound effect. Most people just stop the medication, no need to gradually reduce. Make sure you are always on aspirin if you have had a stent. Talk to your doctor about dosage.
eadler1220: At what point do you recommend taking statins? What indicator is the most conclusive (HDL, LDL, non-HDL) and what are the thresholds?
Dr__Cho: Whether patients start on statins or not depend on diabetes, coronary artery disease, other risk factors. The NCEP guideline suggest a certain LDL number based on if you have disease or not.
Heart Disease Prevention
eadler1220: What is the best way to PREVENT heart disease in women, especially those with a family history of HD?
Dr__Cho: The best way to prevent heart disease is to lead a heart healthy life with diet and exercise. Do not smoke and keep a healthy weight. Also, check your cholesterol, blood pressure and fasting sugar checked annually. There are novel risk markers that are predictive of premature heart disease such as lipoprotein a that should be checked in family with significant premature (less than 55 yrs of age for men and less than 65 years of age) CAD history.
emoeller: What are good levels to have of triglycerides, HDL and LDL cholesterol?
Dr__Cho: If you don't have heart disease:
- Your triglycerides should be less than 150
- LDL ideally should be less than 100 (to 130)
- HDL should be greater than 50 if you are a woman and greater than 45 if you are a man.
- We do not look at total cholesterol. We look at the components of the cholesterol test.
eadler1220: What are the NCEP guidelines? Where do I find them?
Dr__Cho: Here is information on the guidelines: my.clevelandclinic.org/heart/prevention/nutrition/atp3.aspx.
eadler1220: What is the lipoprotein test? Is CRP a good indicator of heart disease?
Dr__Cho: Ultrasensitive or high-sensitivity CRP is a predictor for heart disease. However, hs-crp can be elevated with cold or infection or inflammation so 2 separate testing is best to determine your risk. There are many types of lipoprotein tests so I am unsure of what you are referring to.
eadler1220: The lipoprotein test I am referring to is this one, mentioned by you earlier: " There are novel risk markers that are predictive of premature heart disease such as lipoprotein a that should be checked in family with significant premature (less than 55 yrs of age for men and less than 65 years of age) CAD history."
Dr__Cho: lipoprotein (a) is a blood test that can be ordered by your doctor. It is a predictor for early heart disease and stroke.
linda-p: How much can diet influence cholesterol: LDL, HDL and triglycerides and how long does it take to make an impact?
Dr__Cho: There is some data that if you lose 10 pounds you can reduce your LDL by 10%. If your diet is horrendous, of course diet can make big impact. For those who are already following a healthy diet - you would need to go completely vegan to make changes in your lab work. Vegan diet means absolutely no animal product or byproduct - no dairy, no animal meat, no milk, no cheese, no chicken, no fish, etc.
Cheryl65: Can you tell me what the biggest things are that influence triglycerides. My triglycerides went up to over 300 this year. Wondering what to do to bring them down - I started to watch the fat and salt in my diet.
Dr__Cho: Triglyceride - number one cause of high triglyceride is dietary indiscretions. Things that are high in triglycerides are high in carbohydrates. These include anything sweet tasting, including alcohol, bread, rice, pasta, any fruit juice, cookies, cake, and candy. Even condiments such as syrup, honey and others cause high triglycerides.
Dr__Cho: Often we look for secondary causes of high triglycerides such as diabetes and hypothyroidism.
Mollee: I am trying to follow the Esselstyne diet which is difficult. Do you recommend it for patients with CAD? Any new research on its effectiveness?
Dr__Cho: For patients who want to be on a vegan diet we recommend either the Esselstyne diet or Ornish diet or a modified form. I think a diet that is difficult to follow is not realistic for a lot of patients. There are definite benefits to Esselstyne diet however it has never been proven in large studies to reduce cardiovascular events. The claim of coronary artery disease reversal is overstated and one that is not endorsed by the Cleveland Clinic.
SaraF: I have heard great things about the gluten-free diet and am thinking about giving it a try. What are your thoughts?
Dr__Cho: Gluten free diet has been very popular over the past couple years. Unfortunately there is no data about gluten free diet and reduction of coronary artery disease. Also - patients with gluten free diet tend to gain about 10 pounds when starting the diet - so make sure you watch your calorie intake. Traditionally gluten free diet is reserved for patients with celiac disease, however lately many different patient groups are on the gluten free diet without much data.
JaneS: What's the least amount of exercise needed to gain cardiovascular benefit?
Dr__Cho: I hate to exercise too but after exercise always makes me feel better. The least amount is probably 20 minutes 3 - 5 times a week. It is important to get your heart rate up and to exercise vigorously to have benefit. Walking around the mall all day at a leisurely pace with your friends does not really help with cardiovascular fitness, so start slow but try to get in a moderate intensity exercise most days of the week.
For weight loss we recommend low to moderate exercise intensity for 45 minutes to an hour 5 days a week. It turns out the exercise maintains weight loss - while calorie reduction helps with weight loss.
asgalian: How Likely is it that someone in the early 50s will need to be on the same bp med for the rest of their lives?
Dr__Cho: Blood pressure increases with age so most patients if they start on blood pressure meds in their 50s may need to be on additional medication in their 70s. One can combat that with aggressive lifestyle modification.
CHERJU: I am a 69 yr. old very active woman. I have controlled high blood pressure. When I went in for my yearly physical in October my blood work revealed that my potassium level was too low around 2.8. Since then my primary care physician has prescribed several different blood pressure medications, different potassium pill regiments and different water pills. I am eating potassium rich foods. My blood is about 130/75 and my potassium is still had 3.0. I am concerned because my mom died from congestive heart failure and low potassium was one of her problems. Should I continue with my primary care or should I see a specialist? If so could you make some recommendations as to a doctor might be able prescribe something else.
Dr__Cho: Hypokalemia without associated other disease should be evaluated with 24 hour collection of urine to determine urinary excretion of potassium. Also, we also test for acid-base status to determine the cause. Ideally, a cause for hypokalemia should be found so that treatment can be tailored.
Bundle Branch Block
symphony: Hello, I am a 53 year old woman with left branch bundle block that was just diagnosed in October. I don't smoke, am not overweight and exercise regularly. One Dr. thought I should go on a low dose of beta blocker to protect the heart over time. I do not have any symptoms. Echo and chemical stress test did not find heart disease and my ejection fraction was 55. Would you recommend a beta blocker for a woman with this condition? Thank you.
Dr__Cho: Left bundle branch block with normal ejection fraction does not warrant a beta blocker. Sometimes left bundle branch block can occur due to rate induced bundle branch block - others have a fixed bundle branch block. since your ejection fraction is normal, we would recommend yearly follow up with your cardiologist.
symphony: I have a left branch bundle block, diagnosed last Oct when I had knee surgery. I am 52, I am not overweight, and I exercise, and have never had any symptoms. Before the knee surgery I underwent an echo and chemical stress test and all was ok. My ejection fraction was 155. The cardiologist I was said don't worry, but cut down on caffeine, salt alcohol, and he wanted to start me on a low-dose beta blocker. He said that he has seen hearts weaken over time with LBBB. I am getting a second opinion. What do you think?
Dr__Cho: It is important to get an annual follow up appointment with your cardiologist. There is no data that shows that beta blockers with LBBB - however you may have had other indicators that warranted starting a beta blockers. We are happy to provide you with a second opinion.
symphony: Thank you for your answer. Just a follow-up...are there any other tests I should be having as a fairly young person to have a left branch bundle block. I had the chemical stress test. Would you recommend a treadmill stress test? My cholesterol is too high, LdL is 148, and probably the combination of LBB and high cholesterol isn't good. Thank you.
Dr__Cho: For baseline LBBB, we normally get an echo to assess heart pumping function, right ventricular pumping and the heart valves. It is always better to get a functional stress test rather than a chemical stress test to assess your baseline exercise capacity.
As for your cholesterol, just because you have LBBB, does not mean that you need to lower cholesterol with meds, we recommend you start with diet and exercise. However - if you have LBBB and heart disease, that LDL is just too high.
iltham: Hi I have CT scan done: 38 years old Male with echo demonstrating aortic root of 4.1 cm and ascending aorta of 4.9 cm. Ct scan Impression as1- there is dilatation of the aortic root as well as the ascending aorta. Remainder of the thoracic aorta is normal in caliber. No other significant thoracic abnormalities noted. 2-Fatty liver do I need surgery? Aortic root of 4.1 cm and ascending aorta of 4.9 cm. impression: fat...
Dr__Cho: For Patients with ascending aortic aneurysm, size of the aneurysm is very important determinant of surgical repair. Most data support intervening with surgical repair when aneurysm is >5.0cm. It is important to be seen at a center where there is large experience dealing with aneurysm.
Also, it is important to control your blood pressure and to have your aneurysm monitored with serial imaging test. Usually, these aneurysms go with valvular heart disease or family history in most cases so it is also important to have an echocardiogram and do a thorough evaluation.
We, at Cleveland Clinic, have one of the world's largest experience with aneurysm and would be happy to provide you with a surgical review. Please contact our heart and vascular resource nurses to discuss: www.clevelandclinic.org/heartnurse
This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.