Monday, February 1, 2010
Benico Barzilai, MD
Head of the Section of Clinical Cardiology in the Robert and Suzanne Tomsich Department of Cardiovascular Medicine in the Heart and Vascular Institute.
Heart disease is the No. 1 killer in United State’s. Cleveland Clinic is recognized as the world leader in the diagnosis and treatment of cardiovascular disease. As we kick-off “American Heart Month”, Cleveland Clinic cardiologist Benico Barzilai, MD will answer your questions and learn more about your heart.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Barzilai. Today we kick-off "Heart Month" so take advantage of this opportunity and get your questions answered about heart disease. Dr. Barzilai, thank you for joining us and taking our questions.
Speaker_-_Dr__Barzilai: I am happy to be here.
Coronary Artery Disease
clara: I had open heart surgery 3 years ago. Five months ago I had a problem and they did a cath. A stent was placed in the right posterior descending artery. It was 90% blocked. Also the left anterior descending artery is 50% diffuse blocked / the distal circumflex is 80% obstructed by diffuse disease / the grafts are now 80% blocked . the posterolateral segment is 40% obstructed by a single discrete lesion. I was told that I am a difficult case and not to exercise beyond 2.2 on a treadmill. Is there anyway any of this can be fixed?
Speaker_-_Dr__Barzilai: Without looking at your films I cannot give specific advice. Sometimes we entertain repeat bypass surgery. It would be best to evaluate you further.
JG: I have a question for the Dr Barzilai: I have 50% blockage of the 3 main arteries. My dad passed away MI 1992 at the age 56(smoker) I am 52 currently what is the normal amount of narrowing in the arteries for my age. What would you recommend? I know that I have been told I have this condition. What are the options going forward… the reason I am sending this email I registered for this chat I do have Java and I was unable to connect to your server....can you have the doctor respond I am able to print the live web chat… thanks John
Speaker_-_Dr__Barzilai: I know that it is somewhat scary to realize you have 50 percent blockages. However, with good aggressive medical therapy it is possible to retard or even stop the progression of the disease. It is imperative that you lower LDL as low as possible, that you not smoke, and try to lose weight as much as possible. I have seen many patients who have changed their lifestyle and have lived many years with these blockages.
kimG: is there any benefit re; heart disease -atherosclerosis-etc from bioidentical hormone replacement therapy
Speaker_-_Dr__Barzilai: Hormone replacement therapy in heart disease is a good example of our changes in understanding over time. When I was a junior cardiologist we all thought that estrogen was going to be beneficial. However, large multi-center trials have shown the detrimental effects of estrogen replacement therapy. Unfortunately it requires large trials to determine whether "hormone" therapy is beneficial - I would be therefore very cautious about using any hormone therapy that has not been rigorously tested.
bigmike: 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?
Speaker_-_Dr__Barzilai: It is difficult to answer this question without knowing more particulars. However, stents are very effective in reducing angina but do not necessarily reduce future heart attacks.
martinl: Is it possible to decrease plaques in arteries through diet, exercise, and cholesterol lowering drugs such as simvastatins?
Speaker_-_Dr__Barzilai: It is possible to reduce plaque in arteries however, it requires VERY aggressive reduction in cholesterol (LDL). It has only been recently shown with very aggressive reduction in cholesterol with rouvastatin that we have started to see regression of plaque.
Peppy: My friend is diabetic and had six bypasses. Three graphs closed and she has three still open and was told they are too small to stent the closed graphs. Is there anything else that can be done? She has a lot of angina.
Speaker_-_Dr__Barzilai: In general in a diabetic patient who has already undergone bypass surgery and three of the bypass grafts have closed down because of very small vessels we usually recommend aggressive medical therapy. A repeat bypass surgery could be entertained but the likelihood of the bypass grafts remaining open is very low. Therefore we try to be as aggressive as possible with medical therapy including the addition of new anti-anginal medicines such as Ranolazine.
Irregular Heart Rhythm
mb: I have been having heart palpitations on and off, mostly due to caffeine. However, recently, I have been getting them randomly. What is the cause of this? Should I be concerned?
Speaker_-_Dr__Barzilai: We need to know the specific arrhythmia to give you definitive advice. However in general, I find that palpitations are very episodic - there can be periods of calm followed by periods of extreme palpitations. No one really understands the cause of the fluctuation.
janetsf: my father has an irregular heart beat. the doctors haven't been able to find the root cause. what can we do aside from help him lower his stress to keep the heart beating regularly?
Speaker_-_Dr__Barzilai: The important question is the type of arrhythmia. I find that sometimes the most difficult problem is catching the abnormal heart rhythm is catching the rhythm on a monitor so we know how to treat it. Without knowing the specific rhythm, it is impossible to treat the irregular heart beat effectively.
Janerww: Can left bundle block be resultant from cardiomyopathy/ventricular enlargement?
Speaker_-_Dr__Barzilai: Sometimes the first sign of a cardiomyopathy is a bundle branch block. There is no question that patients with cardiomyopathies have higher incidence of bundle branch block.
naturelady: Hello Dr. Barzilai: What is trace mitral valve leakage and what can be done to keep it from progressing?
Speaker_-_Dr__Barzilai: Modern echocardiographic equipment finds a very small amount of leakage in many patients. In the vast majority of these patients there is no progression of this leakage over time. It is almost like a normal finding.
WKThune: 55 year old male with a calcified aortic valve from Rheumatic fever, but no symptoms associated with condition yet. I have been recommended to get replaced. Is better to wait for symptoms to appear to replace valve or proceed before symptoms appear?
Speaker_-_Dr__Barzilai: It depends on the severity of the aortic valve stenosis and leakage as to when a replacement is needed. The key is to follow patients closely and to operate before damage to the ventricles occurs. Symptoms may occur very late in the disease process
lcnelson: I am being treated for a leaking valve and atrial fibrillation I am 89 years old Is it possible for me to have my valve repaired>
Speaker_-_Dr__Barzilai: In general, we evaluate the risk of surgery in a patient of your age by looking at your other medical problems including history of stroke, history of renal failure, history of liver failure, and history of lung disease.
Murphy: With multi-valve regurgitation, should surgery be held off as long as possible? All valves regurgitate.
Speaker_-_Dr__Barzilai: Patients with multi valve regurgitation must be followed very closely. We are trying to make sure that they do not develop damage to the left or right ventricle. In patients with damage to the ventricle the risk of surgery is increased. Therefore it is important to operate before this damage occurs.
Symptoms of Heart Disease
Murphy: Dr. Barzilai: This has been followed every six months for 2 years and I keep landing in emergency - 2x last week. AV mod. - severe regurg., TV mild-mod., PV trace and MV trace regurg. I have been sitting up sleeping due to chest discomfort lying down, have shortness of breath upon exertion, and recently have started yawning marathons. My ECG was abnormal yesterday and white blood cell count is up. Blood pressure readings are from 170/83 P 80 - 94/51 P 41. I sleep alot - sometimes 3 days. I also have Fibromyalgia and an undiagnosed peripheral neuropathy. Thank you
Speaker_-_Dr__Barzilai: Unfortunately with the information presented I do not have a good explanation for your symptoms. You may need another opinion - we would need to review your actual films to provide you with more information.
opermom: I have had a triple by-pass, two medicated stents and a pace maker at this time. I am on plavix since the bypass and 81 mg aspirin since the stents including coreg. I also have a bundle branch block. I have had valve and aorta repair in the beginning of this. I had been on phen fen. My pain physician has recommended neurontin for nerve pain. Where does that leave me. I also take thyroid and prevacid zocor and cozaar.
Speaker_-_Dr__Barzilai: Without knowing particulars - due to all your problems - it is too difficult to provide any recommendations without further review. We would be happy to see you at the Cleveland Clinic or we also have an econsult over the web as another option.
bkctennis: on 10/09/2009 I had myocardial ischemia anomalous coronary arterial anatomy, we did off-pump lima diagonal branch surgery. I since am still having sensation of someone sitting on my chest and loss of breath, I am doing cardio rehab and trying to work out at the gym 5 days a week to build this up but it just seem to be getting better any suggestions
Speaker_-_Dr__Barzilai: In general, all we can do in patients such as you is to first document that the bypasses are working. Over time, I suspect that some of the tightness will slowly resolve.
Imaging for Heart Disease
MikeBar: Is there any coronary imaging Without the use of iodine?
Speaker_-_Dr__Barzilai: Yes there is - there are both invasive and noninvasive imaging modalities. Intravascular ultrasound looks at the wall of the vessel and does not use any iodine although it requires that the probe be placed directly in the vessel (invasive).
MRI is starting to be applied to look at vessels non-invasively without the use of iodine dyes. This is a technology in evolution and hopefully in the next 5 - 10 years we will be able to non-invasively view the coronary arteries without the use of iodinated dyes.
Medications and Heart Disease
Peppy: Does Metropolol tartrate affect lipid levels? Does it cause weight gain?
Speaker_-_Dr__Barzilai: It has been shown in a very small number of patients that Metoprolol tartrate can increase Triglycerides particularly in patients who have abnormal glucose metabolism. However, this needs to be monitored on a case by case basis and usually is not a problem. As far as weight gain, again it is described but usually is not a problem. Since Metoprolol can cause people to be somewhat sluggish it is feasible that people do not exercise as much when on the Metoprolol tartrate and consequently may have weight gain as a result of reduced activity.
Janerww: Could you speak to the use of beta blockers with someone who is asthmatic? What is the "target dose" for this population?
Speaker_-_Dr__Barzilai: Beta blockers must be used very cautiously in patients with asthma (reactive airway disease). I personally use beta blockers in this population at very low doses and titrate them up very slowly. However, in some patients with bad asthma it is impossible to use this class of medicine.
jason0226: I have heard about a newer drug on the market as a replacement for Plavix, do you know anything about this, or data that might show benefits?
Speaker_-_Dr__Barzilai: The drug is called Prasugrel. In some studies it has been showed to be more effective than Plavix. However it almost all studies it has shown to increase bleeding. Therefore it has to be used as a substitute for Plavix in a case by case basis.
JJAltoona: Hello Dr. Barzilai. I recently had my second MI in just over three years. It necessitated the implanting of my sixth coated stent including four in the LAD artery. I have two questions related to Plavix and aspirin (325 mg) therapy. The first question is; what is the current thinking on the length of time that the Plavix will be required since I've been told that I seem to have an aggressive form of CAD? The second question concerns the relationship between Plavix, Aspirin and PPI's such as Prilosec OTC. I have GERD which has required dilation of the esophagus on numerous occasions due to strictures and the Ranitidine that I am currently taking doesn't seem to help as well. Is the current thinking still that the risk of interaction between Plavix and PPI's is too high to recommend taking something such as Prilosec or Nexium? Thank you.
Speaker_-_Dr__Barzilai: The recommendation at the present time is for a minimum of Plavix for one year after placement of a drug eluting stent. However, many of us including myself are recommending three years of therapy.
The question of the interaction with the PPI's is very interesting. The FDA recently advised all cardiologist that they believe that the interaction between Plavix and protein pump inhibitors (PPI's) is significant and that we should take this into account when prescribing the protein pump inhibitors. My interpretation of the data is that we need to develop new strategies to deal with interactions. Therefore, at the present time I am very reluctant to use the protein pump inhibitors in the first year after the implantation of drug eluting stents. After the initial 12 months I think you can start the protein pump inhibitor very cautiously to treat any GI symptoms.
However, strategies will be forth coming in the near future related to this interaction. It is possible that higher doses of Plavix may be required or agents such as Prasugrel will be substituted.
martinl: Can beta blockers such as atenolol cause shortness of breath under demanding physical activity such as hiking?
Speaker_-_Dr__Barzilai: It is possible that you have a version of exercise induced asthma which has been exacerbated by the beta blocker.
High Blood Pressure
Marchi: Hello Dr Barzilai: When my Blood Pressure go high I get a lot of palpitations, I taking Metoprolol 25 ml 2 times but I want to find the cause do you thing I have to go to see the cardiologist?
Speaker_-_Dr__Barzilai: Unfortunately in many patients we do not find the specific cause of high blood pressure with palpitations. In a small minority there may be a tumor which secretes high doses of adrenaline. This is a rare condition and I find that it is probably better to treat people with metropolol rather than finding the specific cause.
tirreno: I am also on Metorpolol 25mgs twice a day and 165mg of Diovan a day. I take my metoprolol at night before I go to bed and in the morning. I take my Diovan in mid afternoon to balance my blood pressure. I have heart disease and my blood pressure is 125/75 in the morning. 135/70 in the afternoon, but goes up to 145/80 in the evening. My pulse is about 47-51 throughout the day. Is there anything I can do to lower my pressure in the evening?
Speaker_-_Dr__Barzilai: It may be worth trying taking the Diovan a little earlier in the day since it does take a while to reach maximum effect after it is taken.
babaruda: I have very erratic systolic blood pressure. It can vary from normal to over 160. What causes this
Speaker_-_Dr__Barzilai: Minute to minute variation in blood pressure is related to the autonomic nervous system. It is normal for individuals to have fluctuations in blood pressure. However your blood pressure fluctuations is somewhat exaggerated. Sometimes it is useful to use drugs such as beta blockers to treat these wide fluctuations.
kristine: My husband and I are planning to have children as soon as possible but need help controlling my blood pressure. I’ve had hypertension since my early 20s (I’m 36 now). I quit my job to see if quitting my stressful job can fix my uncontrollable hypertension problem. I am currently taking baby friendly meds for this issue hoping that we could kill 2 birds with one stone: 1) fix my hypertension, and 2) find baby friendly meds that would work. So that when my hypertension gets fixed, we won’t have to switch meds (again!). Unfortunately, my blood pressure is still up and down like a yo-yo (I don’t experience any symptoms at all). I have see several doctors in Toronto and we are hitting a roadblock. We were hoping to get an answer from the Cleveland Clinic in Ohio since it has been rated #1 in the Cardiology dept! Need some advice or direction in this as soon as possible. I can't wait any longer.
Speaker_-_Dr__Barzilai: Without knowing more specifics - in general - young people with hard to controlled blood pressure need an extensive evaluation for secondary causes of high blood pressure. We have a group of doctors in our vascular medicine department that specialize in treating blood pressure in young individuals - Dr. Gornik and Dr. Bartholomew - if you would like further evaluation.
Peppy: My bp can be very low in the morning with readings like 86/59. It hovers around a 110/60 mid-day and in the evening may even go to 120/70. I monitor daily at home. Take my readings to the cardiologist appointment. It can go up at her office as well as the GP. Makes me feel like a liar. The monitor has been calibrated twice and is right on. I am on Metorpolol Tartrate 25mgs. twice a day and have a two year old DES in the diagonal. One doctor told me it is not safe to have my bp going so low as it does in the mornings. Where should bp be? I've always heard 120/80.
Speaker_-_Dr__Barzilai: In general we would like to see blood pressure of about 90/60 as a minimum in patient's with heart disease. However many patients have a lower blood pressure and do not seem to have any long term side effects.
If the patient does not have any symptoms of dizziness on arising with the blood pressure of 86/59 I usually do not recommend any changes in therapy. However it is possible that a change in the schedule of medications could alter the low blood pressure in the morning.
Cholesterol, Lipids, LDL, and Statins
Mike_G: Should HDL be viewed in absolute terms or relative to LDL? For example, if directly measured LDL is 39 and is HDL of 34 as too low? I understand that the higher, the better when it comes to HDL. However, how relevant is HDL when LDL is this low?
Speaker_-_Dr__Barzilai: I personally look at HDL both on the absolute value as well as the relative value related to LDL. In patients such as you where the LDL is extremely low and the HDL is also low I do not believe that there is any value in trying to raise the HDL itself. However, at higher levels of LDL such as 70 or 80 there does seem to be some additional value in raising the HDL over 40 in those patients. However, this is an excellent question since there are really not very many good medicines available to increase HDL. I suspect as we get better medicines in the future that improve HDL we will probably use the absolute values of HDL levels as a target for therapy.
osiag: So, in my example where LDL direct is 68 and LDL indirect is 85, I would consider the LDL target of 70 as being met. Is that correct?
Speaker_-_Dr__Barzilai: I would use your direct measurement - therefore your LDL target of 70 has been met.
osiag: When we refer to LDL targets like 70, is that number determined directly or by indirect calculation? I understand that the indirect method captures IDL. So, if a lab reports real LDL of 68 and indirectly measured LDL of 85 with the difference being IDL and some noise because of tris, which do you go by in terms of determining whether the target of 70 is met?
Speaker_-_Dr__Barzilai: Most labs use a calculated measurement of LDL from the total cholesterol, the HDL and the triglycerides. However, we are increasingly moving to direct measurement of LDL for the reasons you stated. The target is LDL.
osiag: When switching from Lipitor to another statin, is there a washout period or can you begin the next day with the other statin?
Speaker_-_Dr__Barzilai: I would recommend waiting at least a few days.
osiag: Do we think that the reversal in plaque recently seen using rouvastatin is do to properties of the rouvastatin itself, the percentage decrease in LDL or the low level to which LDL was reduced (e.g., 60mg/dl)?
Speaker_-_Dr__Barzilai: I think it is probably the level to which it is reduced. However, Zetia which also reduces LDL has not been shown to reduce plaque. Therefore, at the present time we can only say that statins are the best way to reduce LDL.
jason0226: Can you please explain the differences between HDL and LDL cholesterol and how should I monitor this? What range is acceptable for both types?
Speaker_-_Dr__Barzilai: HDL is the "good" cholesterol. In general we would like to see values over 45 in males and over 55 in females. However, the higher the better.
LDL is the "bad" cholesterol. During my career I have seen the desirable values for LDL decrease over time. We would like to see it below 100 in most patients and below 70 in patients with coronary heart disease.
tirreno: I have excellent LDL approximately at 70. However, I exercise 3 days per week and eat healthy and can only get my HDL up to 40 at best. What do you recommend for improved HDL levels? A
Speaker_-_Dr__Barzilai: At the present time, we have very few drugs that increase HDL. Niaspan has been used with some success however it must be started at low dose and titrated up slowly due to the side effects.
krisbern: To lower my cholesterol, I did a lot of research and found that the primary cause is land animal fat. Also in my research, I discovered that shellfish (shrimp) is high in cholesterol, but it's high density. The high density is supposed to clear out your arteries, so I quit eating meat and bulked up on shrimp. Is this a healthful approach? I also ramped up my exercise.
Speaker_-_Dr__Barzilai: Certainly by reducing animal fat you probably have reduced your cholesterol - however - I am not sure that the shrimp is all that helpful - we usually recommend Omega 3 rich foods. Here is a great article for you regarding omega 3 rich foods - my.clevelandclinic.org/heart/prevention/nutrition/omega3.aspx
Peppy: My cardiologist wants to try me on Niaspan. My GP says no it will cause my migraine headaches to return. I can't tolerate statins as they cause me migraines. I am able to tolerate 10 mgs. of Pravastatin only without the headaches. We've tried them all. I need more help than that. With diet and exercise I have gotten down to a total cholesterol of 176 with and HDL of 131. Tri's were under 150 and HDL was 38. Some blood tests I have been under 150 total and down to 80 HDL. It fluctuates. With one stent places two years ago I need to do everything that I can to control risk factors. What do you suggest?
Speaker_-_Dr__Barzilai: This is a very specific question - I would recommend a visit to our Preventive Cardiology Group.
Mike_G: If a LDL is below 70 mg/dl, do LDL partcile numbers, LDL pattern type,. or Lp(a) really provide any useful information?
Speaker_-_Dr__Barzilai: The vast majority of cardiologist would argue that an LDL below 70 mg/dl is sufficient. I personally see very little additional information in the LDL particle number of the LDL pattern in patients with an LDL below 70. However, Lipoprotein ( Lp(a) ) may provide useful information in a small segment of patients who continue to have events despite aggressive therapy of the LDL.
Exercise, Cardiac Rehabilitation and Heart Disease
osiag: are there parameters that can be set around wieghtlifting to prevent further progression of aortic value regurg?
Speaker_-_Dr__Barzilai: In general I do not like to see the blood pressure go up excessively with weight training since it can aggravate the aortic valve regurgitation. I would rather see someone do more reps with a lower weight.
martinlaurence: What about weightlifting (dumbbells) and mitral valve regurgitation?
Speaker_-_Dr__Barzilai: Dumbbells are fine as they are not as heavy. I would still have you watch your blood pressure.
mom4331: My Dad has CHF and has really been quite sedentary. He recently turned 80 and has had some recent health issues. He is bouncing back from his surgery, but I think he would benefit from Cardiac Rehab. Is it too late for him to start a rehab program? What things can we do so his quality of life does not suffer?
Speaker_-_Dr__Barzilai: I am a big fan of cardiac rehab in patients such as your father. Not only are there physical effects of the exercise but there are incredible psychological benefits of cardiac rehab programs. It is not too late for him to pursue this.
ajay11: I am an Indian male of 44 years-residing in u.k. I had a heart attack in india in may 2003, and angioplasty and stenting was done in proximal lad. My lvef came down to 32%. After this five years passed without a single problem, though I was taking the recommended medicines. In nov 2008, I had a cardiac arrest without any warning and was lucky to be revived by the ambulance team.in this process I got brain injury also. after one month I was discharged from the hospital with icd implanted to me. My lvef has now come down to 21%. I am taking-asprin/carvidilol/clopidogrel/atorvastatin/ amioderone/ramipril/lansoprazole. My queries are: Why did this cardiac arrest happen after 5 years? How did the lvef go down from 32% to 21% over five years despite taking regular medication? Is icd enough safe guard for the future? What does life hold for me regarding the progress of my heart condition? what and when new problems will/can come, are these avoidable? Are there some more treatments(lvad or crt or eecp) etc. can these be good for me? is stem cell treatment right for me?
Speaker_-_Dr__Barzilai: Unfortunately despite best knowledge the only predictor of sudden death seems to be ejection fraction (EF). Consequently in a patient such as you with a reduced EF, it is very difficult to predict when events may occur. At the present time, our best approach is to prophylactically place defibrillators in individuals with EF less than 35 percent.
It is difficult to predict your future course. However, due to new technologies, we may have a lot to offer you in the future. Stem cell therapy is being aggressively studied and likely will benefit individuals like you in the next couple years. Alternatively, you may be a good candidate for heart transplant if you should develop intractable heart failure or angina. We would be happy to evaluate you.
Janerww: What are the risks for implantation of a biventricular pacemaker with debrillator?
Speaker_-_Dr__Barzilai: In general, the risks involve infection, the risk of perforation (low), and rarely stroke.
Auto-immune Disease and Cardiovascular Disease
naturelady: Have there ever been any studies regarding autoimmune diseases playing a roll with white blood cells activated by inflammation involved in the production of plaque in artery walls?
Speaker_-_Dr__Barzilai: It is known that patients with rheumatoid arthritis have increase incidence of heart disease. Patients with lupus also have many cardiac problems. Therefore it can be said that most patients with autoimmune disease probably have increased propensity to heart disease.
Carotid Artery Disease
naturelady: Five years ago, I was diagnosed with a 50% blockage in one carotid artery. Now I have blockages of 55% and 69%. My cholesterol numbers are good. I am on a statin and aspirin daily. I am 60 years old, never smoked, lost weight and exercise the best I can with spinal stenosis and oa. My father had many tia incidents and frankly I am very anxious. My cardiologist orders a doppler and echocardiogram every 6 months. Can you tell me the risk numbers for a stroke with the present medication protocol versus some type of surgical intervention? Should additional medication be added to ensure that the clotting risk is kept to minimum? Is sustained anxiety a factor in progressing blockages? Thank you for your time and advice.
Speaker_-_Dr__Barzilai: A number of studies have looked at the role of surgery or stents for blockages in the carotid arteries of 50-69%. There has never been any studies that have shown any benefit from the surgical procedures.
Every surgical procedure has some inherent risk of stroke and since the stroke rate with medical therapy is low we at this time do not recommend prophylactic surgical therapy. The question of sustained anxiety is a good one. I do not believe we have any evidence to show that sustained anxiety has a definite effect. It is a difficult problem to quantify and hence the studies are difficult to interpret. Finally there is no recommendation at this time for any additional antiplatelet agents but studies are on going about the use of drugs such as Plavix or Dipyridamole.
gem947: Does the fibrous tissue encapsulation that covers a Dacron graft add structural strenght to fixing of the graft to the heart structures to which the graft is originally sutured? How long does it take for this encapsultation to cover the graft completely?
Speaker_-_Dr__Barzilai: The body's response to foreign bodies that are implanted is to cover them with its own tissue. This increases the strength and reduces the propensity for clotting on top of these foreign materials. We usually say that it takes at least 6 weeks for this process to occur but it continues for months thereafter.
janetsf: are there any books you would recommend on understanding heart disease/conditions? or books that describe alternative treatments?
Speaker_-_Dr__Barzilai: Dr. Roizen has some pretty good books on the therapies - there are several books by Dr. Roizen. Dr. Rimmerman also has books that are good if you have heart disease
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Benico Barzilai is now over. Thank you again for taking the time to answer our questions about heart disease. Happy Heart Month!
Speaker_-_Dr__Barzilai: Thank you for having me today.
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