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Heart Healthy Living (Dr. Blackburn and Kate Patton, MEd, RD, CSSD, LD 3/25/13)

Monday, March 25, 2013 - Noon

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The Cleveland Clinic Section of Preventive Cardiology & Rehabilitation helps patients by designing lifestyle modification strategies to improve cardiovascular health. Take advantage of this unique opportunity to get tips on heart healthy strategies and have your questions answered in a secure online setting with Cleveland Clinic experts, Dr. Gordon Blackburn Director of Cardiac Rehabilitation, Preventive Cardiology and Kate Patton, MEd, RD, CSSD, LD.

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Exercise - Activity

Sara2238: My mom has CHF. Her EF is 23%. I am wondering if she would improve her heart function if she exercised. How much should she do? Can she get better with diet and exercise?

Gordon Blackburn PhD: Normal ejection fraction (EF) ranges between 50 and 65%. At an ejection fraction of 23% exercise may be beneficial in improving her exercise capacity, quality of life and reduced cardiovascular risk however exercise has no direct impact on ejection fraction.

Kate – Her diet will not improve her ejection fraction, however, following a low sodium diet is highly encouraged in order to maintain your driest weight (usual body weight).

Gordon Blackburn PhD: Following her medical regimen as prescribed by her cardiologist is critical.

jennie-hoop: I am a 50 yo woman with no history of heart disease at all. I have good lab values and good blood pressure - no risk factors for heart disease. I exercise pretty regularly and also eat a healthy diet. When I exercise occas. I get sort of a numbness in my left arm or a feeling in my chest but then it goes away even if I continue to exercise. I don't feel like it is my heart but then I feel like maybe I am ignoring something. What do you think?

Gordon Blackburn PhD: Although you have no known heart disease and no significant risk factors the symptoms should not be ignored . I think you should discuss this with your cardiologist. The nature, location, frequency, intensity, duration and triggers of your symptoms are all critical pieces of information to better understand the potential causes of your chest and arm discomfort.

There is a phenomenon known as walk through angina. The chest discomfort can occur early in exercise but as the vessels dilate, blood flow improves, cardiac demand decreases and the symptoms may resolve.

rdelone: Is there a certain pulse rate you should achieve when doing cardio to strengthen your heart? If so, what length of time should this pulse rate be maintained?

Gordon Blackburn PhD: To gain the benefits of exercise, the intensity should be maintained at a moderate level. This can be measured using heart rate but the heart rate is very individualized especially if certain medications are being taken such as beta blockers. Your specific heart rate range is best determined based on the results of a symptom limited exercise test. Rather than time, the key focus is the number of calories expended per session at the appropriate intensity level. A threshold of 1000 expended per week has been identified but benefits continue to improve as caloric expenditure reaches 2000 calories per week. Beyond that level the cardiovascular benefits seem to level out.

GeorgeBMac: Hi, Everyone "knows" that exercise is good for the heart and the vascular system -- but why is AEROBIC exercise good for that system? Physiologically, what does it do that is good for the cardio/cerebral vascular system?

Gordon Blackburn PhD: Exercise and improvement in functional capacity have a strong impact in reducing risk for developing heart disease, in both the primary and secondary settings, and reducing mortality. For every 1 MET increase in functional capacity there is a 9 – 12 percent reduction in cardiovascular and all cause death. (Exercise intensity can be described in units of METS. 1 MET=1 kcal/kg body wt/hr).

Some of the direct effects of exercise include improved endothelial function (protective lining of the artery); increased capillary density; improved blood pressure control; improved glucose control; and slight improvement in HDL. All of these directly and indirectly decrease the risk of developing and progressing heart disease.

GeorgeBMac: After vigorous or semi-vigorous aerobic excercise such as running or cycling I will often feel weak and kind of woozy -- maybe even a little light headed -- even though my muscles do not feel tired. As I become more and more fit, this is less of a problem, but it is always there and it seems to limit how hard I am able to excerise. I am not aware of any health related issues (except for a probable hypo active thyroid for which I will be retested in a couple weeks)... Is this something to be concerned about? Should I seek a consult with a cardiologist?

Gordon Blackburn PhD: Congratulations on setting up a regular activity plan. You describe your aerobic exercise as 'vigorous or semi-vigorous'. The health benefits of aerobic exercise are best achieved with MODERATE intensity activity. If your exercise intensity is relatively too high you may be triggering a 'vasovagal' response. This response is more likely to occur immediately following a vigorous exercise session as a result of the sudden withdrawal of sympathetic tone when exercise is stopped and the 'wooziness' may be secondary to a resulting drop in blood pressure. A person is more likely to experience this if exercise is stopped abruptly and they stand still.

In addition to setting a MODERATE intensity exercise stimulus, a light level of continued activity for several minutes following an exercise session will reduce the likelihood of a vasovagal response. Dehydration and some medications (especially antihypertensive medications) also increase the likelihood of vasovagal/hypotensive responses following exercise.

If your post-exercise symptoms persist despite an active cool-down, adequate hydration and a moderate exercise intensity.... or if you experience the weakness and 'wooziness' during activity... follow-up with your personal physician or a cardiologist should be considered. Your physician may also be able to assist you in determining the appropriate exercise intensity to optimize your personal health benefits.

steelguy: 59 years old - 13 stents (12 since 2008) - excellent lipids (Crestor / diet) diabetes well under control (metformin / diet) Diavan, toprol, & aspirin rounds out the meds. 20# overweight - Pain in chest/shoulder with cold weather exertion. Thoughts on how hard to exercise (until pain or into pain etc) and what types of exercise would be best? Thanks.

Gordon Blackburn PhD: You report a history of coronary aretery disease with multiple interventions in the past. You also list several risk factors for the progression of CAD. My first concern is for the symptoms you are having with cold weather and exercise. Before addressing the specifics of exercise, please discuss your symptoms of chest and shoulder discomfort with exercise with your doctor.

fstoner: About 2 1/2 years ago I had quadruple bypass surgery with the Maze procedure. I try to maintain a heart healthy diet and exercise 3 times a week at our hospitals cardiac rehab group. Because of painful arthritis in my hands and feet I only exercise for 15 minutes each on a recumbent bike, a Nu-Step machine and a exercycle. Because I was left with continuous afib after surgery, I seldom sweat or reach a maximum heart rate. I'm 74 years old and wondered if this is sufficient exercise for my heart?

Gordon Blackburn PhD: With the chronic atrial fibrillation, you cannot rely on heart rate to guide the intensity of your exercise program. Heart rates for individulas with atrial fibrillation can vary from hour to hour, day to day with exercise and at rest. You could guide your exercise based on a Rating of Perceived Exertion and/or METs, if you had a recent exercise stress test. However, if your arthritis limits your ability to exercise this may be a submaximal study and the arthritic discomfort may be the limiting factor to your exercise, rather than your heart. Although the limitations from the arthritis may not allow you optimal cardiovascular benefit, you will continue to burn calories which will help with weight management and moderate exercise may be beneficial for the management of your arthritic symptoms.

My3kids: My husband was recently diagnosed with an aortic aneurysm. His doctor told him to watch his blood pressure and lose weight. He needs to lose about 30 pounds. What do you suggest for exercise and how to monitor exercise?

Gordon Blackburn PhD: I am often asked the question: ‘which exercise is best’. There is no one best exercise for weight management or health benefits. The key is to find an activity that you enjoy doing and do it on a regular basis. Although exercise can increase caloric expenditure and aid with weight management, the best strategy is a combined program of regular, moderate intensity aerobic exercise and dietary modification to control dietary intake.

SamB: I have paroxysmal atrial fib - treated with metoprolol. I am an active person by history - skiing, running, cycling. But sometimes I get very over tired with exercise; sometimes I am ok. I am wondering if I am in afib when I feel that way. I am wondering if it is ok to exercise as much as I do. Should I be concerned?

Gordon Blackburn PhD: Paroxysmal atrial fibrillation is an intermittent and often unpredictable arrhythmia originating in the upper chambers of the heart. From your question it appears that you are not aware of when you are in atrial fibrillation or a normal rhythm. Atrial fibrillation may lead to decreased cardiac output which can affect your exercise tolerance and contribute to a feeling of fatigue during normal activities. However, rather than assuming that it is the atrial fibrillation that is the cause of your intermittent fatigue with your usual levels of activity, I would encourage you to follow up with your cardiologist for more evaluation regarding the frequency and possible triggers of your atrial fibrillation. If your symptoms of being tired during activity are linked with the occurance of the atrial fibrillation, you may be able to continue activity but with a reduction in the exercise intensity.

CharlesWA: I had stents put in 3 months ago. I am in cardiac rehab in Washington. The other day while I was exercising, my BP during exercise was 86/52. Afterward it went up to my normal BP which is around 120/80ish? Is this a cause for concern?

Gordon Blackburn PhD: Going to a cardiac rehabilitation program following your stents was a wise decision. Recent studies have demonstrated approximately a 50% reduction in mortality for patients who participate in and complete cardiac rehab as compared to those who do not attend these programs. In this environment your exercise responses can be closely monitored and guidance for appropriate follow care can be identified in a timely fashion.

Blood pressures are routinely monitored at rest and during activity in a cardiac rehab program. Accurate measurement of blood pressure during activity requires some additional skill but can be performed efficiently by trained cardiac rehab staff. If your blood pressure did fall with exercise this may be a sign that the heart cannot tolerate the level of exercise you are performing. Systolic BP should climb with exercise and return toward resting levels at the end of exercise. The reverse pattern, a fall in systolic blood pressure with exercise and climb in recovery post exercise may indicate a decrease in left ventricular function, an arrhythmia or an obstruction to cardiac output. If you routinely have a drop in systolic blood pressure with activity it requires further evaluation by your cardiologist.


Diet

Katelynn: Are omega-3 fatty acids still considered beneficial for heart health? Is one source better than another?

Kate Patton RD: Yes; they are still considered beneficial – EPA and DHA are two forms of omega three fatty acids that elicit cardiovascular benefits. EPA and DHA is better than ALA which is the plant based source.

Charla23: I am interested in omega 3 and flax seed and chia. Which one is better for you? How much do you need to be beneficial?

Kate Patton RD: Research shows that the omega 3 fatty acids DHA and EPA, which are found in fatty fish, such as tuna, salmon, sardines, mackerel) provide the strongest cardioprotective benefit. Plant based sources such as flax and chia seeds contain the omega 3 ALA which is a precursor to EPA in the body. Therefore, it is not as strong of a source as the fish related omega 3. We usually recommend a serving size of 2 tbs of flax or 1 tbs of chia for patients.

Quest: I am 60 yrs old, have 3 stents in a heart artery, and am a Type II diabetic. My meds are Novo log, Lantos, Miscarries, Clodigpril, Synthroid, Lipitor. My meds are controlling my blood work. However, I am 100+ pounds overweight. I cannot seem to find any sustainable results with weight loss. Can you recommend an eating plan that would satisfy my heart and diabetes. I have considered many, Weight Watchers, Atkins, Mediterranean, 1500 cal. Any advice would be so appreciated.

Kate Patton RD: have you considered working with a registered dietitian to create an optimal meal plan to help support weight loss?

Gordon Blackburn PhD: Many of the diets listed can be beneficial with weight loss and managing diabetes in addition to diet consider a regular activity program performed most if not all days of the week. With insulin therapy, close attention to post exercise blood sugars to minimize hypoglycemic risk should also be performed.

Mary-OH: I have a lot of friends making drinks in the morning with Kale, flax, apple or other "green" ingredients. Have you heard of this? If you were to suggest a smoothie with the best ingredients, what would you include? Seems like everyone thinks Kale is the answer - what do you think?

Kate Patton RD: Kale is a very anti oxidant rich vegetable. However for a meal replacement shake you would want it to include some carbohydrate, protein and fat. To reach this combination include fat free plain Greek yogurt; any fresh favorite fruit; ground flax seed and veggies as desired.

NancyGA: For the dietitian: What is the best way to prepare foods to keep their nutrient level? For example, does boiling boil out the vitamins?

Kate Patton RD: Boiling does not boil out 100% of the vitamins however some are lost. I would encourage a variety of cooking methods such as steaming, baking, grilling and broiling in order to offer different flavors and textures.

KarenH: I have high cholesterol and follow a low fat diet - recently my doctor said I am borderline diabetes so I am reading labels to make sure my fat content and sugar content are not too high. When reading the label what is a good amount of "sugar" or amount that is ok? A lot of foods, like low fat yogurt has a lot of sugar in it - I am trying to find the balance.

Kate Patton RD: That is a great question. To start off, keep with in mind, yogurt does have some natural sugar in the form of lactose. 6 oz of plain yogurt has 12 g of sugar. Any amount of sugar greater than that typically comes from added sugar or fruit. The best choice for yogurt would be to choose a plain nonfat yogurt and add your own fruit. The AHA recommends no more than 36 grams of sugar a day for men and 20 g for women. Therefore, be conscious of added sugars in the foods you are eating to prevent exceeding this recommendation.

BethS: I am following a whole food/plant based diet from Dr. Esselstyn to reverse the heart disease. My recent blood test results show a good total cholesterol of 130 and LDL was 68, triglycerides 155. Does a diet of lots of beans, grains, and whole vegetables increase triglycerides?

Kate Patton RD: They can. Excess intake of any form of carbohydrate can increase triglycerides. Whole grains and legumes are the ideal source of starch or grain in your diet because of their slow digesting ability however, too much of these can still be stored as triglycerides.

there4jsweetie: I am currently eating a diet following Caldwell Esselstyn's vegan fat free recommendations. I am a 65 year old male currently taking Lipitor with hopes of stopping the meds and allow the diet to take control of my cholesterol problem. I also have pulmonary hypertension secondary to sleep apnea, which is currently under control with the use of a CPAP machine and blood pressure meds. I have not had any other cardiac issues. Can you state if there are any risks associated with my current diet. I have read that there is a possible higher risk of stroke if I don't get enough protein.

Gordon Blackburn PhD: Congratulations for the dietary changes you have made and the use of the CPAP and compliance with meds to control blood pressure. These plus the appropriate medications to optimize your risk factors are essential to reducing your risk of heart disease as much as possible.

Kate Patton RD: Be aware that excess caloric intake even on this fat free vegan diet can still result in weight gain which therefore being overweight is a risk factor to diabetes and cardiovascular health and can aggravate your sleep apnea.

KathleenCK: I have a daughter going to college. We have a strong family history of heart disease and high cholesterol. I am worried that she will go to college and then eat foods that are not good for her. Do you have any advice or resources I can give her about eating away and snack foods that would be helpful to her.

Kate Patton RD: Encourage her to minimize the amount of animal fat in her diet by avoiding high fat meats, full fat dairy products, cheese, butter, fried foods and desserts and sweets. Inquire with her school’s food service company if on her meal plan they allow for special diets or have food ingredient information.

SandraH: I have read a lot on the internet about the benefits of coconut oil. Is that a good option for cooking or using in dressings - similar or better than olive oil?

Kate Patton RD: Coconut oil is high in saturated fat which is a type of fat you want to minimize in your diet to protect heart health. Olive oil on the other hand is rich in monounsaturated fat which has plenty of research to support its heart protective benefits. It has very little saturated fat. Coconut oil is safe to use in moderation; it is sweeter; it can be used within baking. For dressings, I would stick to olive oil.


Medications

Yless1: Tell us something about the use of Statin Drugs. I am on Cardizem CD and Digoxin and it seems like there are warning flags about adding Lipitor to the mix. My LDL is at 141. Is it worth the risk and what monitoring needs to be done for the digoxin?

Gordon Blackburn PhD: All medications have some level of risk associated with them and medications can and do interact with each other. While there is no obvious absolute contraindication to adding a statin agent with the other medications listed and depending on your cardiac risk profile there may be significant benefits to a lower LDL level, this is a question you should be discussing with your cardiologist.

Sue in WDC: Hi. I have paroxysmal a-fib and a-flutter. I also have labile hypertension, but I'm otherwise healthy. I'm 66, watch my diet and walk what seems like a million miles a day. I'm down to the last of the antiarrhythmics, Amiodarone (200 mg/day), which so far is very effective. Amio is a potassium channel blocker, and my question pertains to potassium "intake." Since January, I've been tracking my nutrients from food and now come close to the daily RDA for potassium (4,700 mg). Since I'm on a potassium channel blocker, am I running around in circles eating potassium-rich foods or should I cut back? Thanks for any advice.

Drug Information Pharmacist: It makes sense to assume that a medication called a potassium channel blocker may cause changes in your body’s potassium level; however this is not the case with amiodarone.

Amiodarone works by blocking potassium channels in the heart because the heart beat depends on the flow of sodium, calcium, and potassium in and out of tissues. Amiodarone's effect on blocking potassium going into the heart tissue should not significantly affect the potassium level in your body. Futhermore, changes in potassium levels are not listed as a common side effect of amiodarone therapy.

You should continue to try to obtain the recommended daily allowance (RDA) of potassium through your food intake, unless your physician tells you differently. If you have any further questions about this matter, please consult your physician.


Vitamins – Supplements

nene619: Is it possible that taking calcium pills could cause calcium buildup in arteries? I never had any buildup (at one time the doc said my arteries were like a teenager's). A few years ago I had a bone scan and they said I had osteopenia so they advised me to take calcium supplements (1500 mg. per day). A couple of years later they said my carotid arteries were 20 some % blocked. I stopped the calcium pills since they were the only thing that I had done differently. When I had my last scan of the carotid arteries (about a year after the previous one) they said nothing had become any worse.

Gordon Blackburn PhD: There is a mixed message at this point regarding benefits and risks of calcium supplements. Study published in 2010 in Menopause Journal finds no significant elevated risk of taking calcium supplements and heart attacks or developing heart disease.


Heart Disease

Furgoodkara: Hi. I have a history of heart disease in my family. I do exercise and eat pretty healthy. I had a perfusion exercise stress test and it showed 25 percent reversibility. What does that mean? I also have a small area 15% of old infarct, which I new about. I am wondering if I can exercise - the tech kind of scared me and said I shouldn't do anything until I talk to my doctor.

Gordon Blackburn PhD: Exercise perfusion studies can be used to identify areas of transient perfusion defects (ischemia)and fixed perfusion deficits (scar/prior heart attack).

If the reversible defect is a new finding the results should be reviewed with your cardiologist to determine its significance. It would be prudent to avoid vigorous exercise until that time, especially if you are having any exercise induced symptoms such as chest pressure, indigestion, chest tightness, that may be indicative of ischemia.

pri.kris: My husband's family has a really bad history of heart attacks and blockages including death. During an yearly exam even after his total cholesterol being under 200 he was asked to go in for an angiogram. He is 33 and works out. When is a good time to worry about things like this?

Gordon Blackburn PhD: Coronary artery disease can start in the late teens and early 20’s. A family history of premature CAD (before age 55 in a first degree male relative or befor age 65 in a first degree female relative) is a very strong predictor of premature heart disease. If several first degree family members have experienced heart disease in their 30s and 40s , I strongly encourage aggressive management of all modifiable risk factors, not just cholesterol. Based on the family history provided, age 33 is not too early to focus on his risk factors. The decision regarding a catheterization is one that should be made in consultation with a cardiologist who has more detail regarding his case.

Reviewed: 3/13

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