December 9, 2009
Dr. Julie Huang
Tomsich Family Department of Cardiovascular Medicine
Cardiovascular disease is NOT just a man’s disease. Cardiovascular disease is the Number 1 killer of women over age 25 in the United States. The death rate from cardiovascular diseases has decreased among men, but continues to increase in women. There are 8,000,000 American women living with heart disease today. Dr. Huang, a Cleveland Clinic cardiologist answers your questions about heart disease in women.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with cardiologist Julie Huang, MD. Thank you for joining us Dr. Huang. Let’s begin with the questions.
Speaker_-_Dr__Huang: Thank you for having me today.
Medications in Women
Mari: Will be participating in the online chat on 12/9 regarding women's heart health. I'm very frustrated because I am a "woman of childbearing age" and there are very, very few options in terms of medications to lower my cholesterol. I went to Preventive Cardiology for several years and the only thing they could come up with was diet, exercise, and Niaspan, which didn't help very much. I'm turning 38 this month. Is any research being done to find drugs that more women can actually take? You hear all the news about how heart disease is so prevalent in women, but if you are genetically predisposed, it doesn't seem like there's much you can do! Thanks.
Speaker_-_Dr__Huang: All the medications that are traditionally prescribed for hyperlipidemia can be used for women of child bearing age - but should not be used while pregnant.
Specifically the statin medications such as lipitor and zocor are known to be associated with fetal anomalies - or birth defects. However if you are not currently pregnant or plan to get pregnant, statin medications may be your best option for lipid control.
JoyD: I am a 58 y.o. female and have CAD and am on Zocor 80 mg but my internist has suggested that Crestor may be a better alternative as it is more potent and could reduce my numbers even more. (Current LDL-64 and HDL 72) Is there a potentially significant reduction for me to incur the cost of paying a large amount out-of-pocket for the drug?
Speaker_-_Dr__Huang: Your current lipid values - the LDL of 64 and HDL of 72 - are at favorable levels. For somebody with a history of CAD - as you mentioned - the goal LDL level is less than 70 mg/dl, which you have achieved with Zocor 80 mg. In my opinion, I would continue with your current regimen.
Peppy: I have read the research on statins and it appears that intense statin therapy for stent owners conveys better outcomes. What to do if you can just not tolerate them? Everyone I have tried has given me daily migraine headaches.
Speaker_-_Dr__Huang: The philosophy of our preventive cardiology clinic is to try statin therapy in whatever dose is tolerated with the thought that some statin is better than none. We will often recommend low doses in "atypical dosing" regimens such as every other day or twice a week. If statins are truly impossible for you to tolerate, alternate lipid lowering medications like niacin could be tried.
ut23: What do they mean when they talk about aspirin therapy for heart health? Is there a good dose – are there certain brands – what about coated?
Speaker_-_Dr__Huang: Aspirin is one of the fundamental medications used for prevention of heart attack and stroke. It is commonly prescribed in patients with heart attack risk factors and for patients who already have coronary artery disease. No brand is better than any other - I commonly prescribe generic. The usual dose is 81 mg - 162 mg daily. Most people tolerate the coated version better than the uncoated because of gastric side effects. You should discuss with your physician is aspirin therapy is appropriate to you.
JoyD: Once you are taking Plavix, are you on the drug for life?
Speaker_-_Dr__Huang: This depends on the indications for which you are taking the plavix. In most cases after angioplasty and stenting - patients are recommended to take plavix for at least one year and often times longer. Some patients encounter complications such as bleeding or low platelet counts on plavix and in that case, the medication needs to be stopped earlier.
smith_s: I have high blood pressure – I read in an article that some medications work better in women than men – what medications should I look for.
Speaker_-_Dr__Huang: We use similar medications for both men and women for hypertension. Often times because of smaller body size or different metabolism, women may require lower doses than men.
Palpitations in Women
carol20: I have palpitations all the time – not sure what they are, feels like my heart is running away – especially at night. Is that serious?
Speaker_-_Dr__Huang: Palpitations is a very common complaint especially in women. In most cases, they are benign and can be caused by extra or skipped beats also called PACs or PVCs. Sometimes palpitations can be associated with thyroid disease or excess caffeine or alcohol. In some cases, palpitations can be more ominous and be caused by actual heart disease. You should discuss your symptoms with a cardiologist to determine if more evaluation is needed.
blasebacc: Do palpitations in someone with heart disease mean anything significant?
Speaker_-_Dr__Huang: If you are feeling palpitations this can signify many different things from benign etiology to arrhythmias such as atrial fibrillation or others. You should be evaluated more thoroughly with your cardiologist. They may order an event monitor - or holter monitor.
Triglycerides in Women
cad16: I have triglycerides of 420 – I am overweight and borderline diabetic. My dad had heart disease – I am worried – can I get back to good levels with diet and exercise alone. How long should I try the diet first – are there special diets I should be on?
Speaker_-_Dr__Huang: High triglycerides are defined as a level over 150 mg/dl. A level of 420 would be considered moderately elevated and is commonly seen in patients with diabetes and excess weight. You are right to be concerned as elevated triglycerides has been shown to be an especially bad risk factor in women because of the association with metabolic syndrome.
The first step in treating elevated triglycerides is diet and exercise. Specifically - we recommend at least 30 minutes of moderate intensity exercise on most days of the week and 60 - 90 minutes if needed for weight loss. Diet should be low in fat and carbohydrates and high in fiber and vegetables. I would usually allow 3 - 6 months to see if lifestyle changes affect the triglycerides. If you are not seeing a significant decrease, it is probably time to start medication. Your borderline diabetes makes it very likely that you will need medications for lipid lowering.
Symptoms of Heart Disease in Women
k_mich: I am a 40 year old woman who had a hysterectomy last year. This is the only problem I have ever had – very healthy otherwise. I started having chest discomfort on and off last week – I am seeking a cardiologist on Friday. Do you think this could be heart disease?
Speaker_-_Dr__Huang: Any time a patient presents with new chest pain we are always concerned about the possibility of heart disease. Your age of 40 is a bit on the low side for heart disease but we are increasingly seeing young women present with symptoms and disease. Good luck with your evaluation.
jonesh: I am 50 years old – good cholesterol. Follow a healthy diet. Exercise a few times a week. Lately I have been having pain in my left chest around the breast – but it is there for a very long period of time. It is not like what is described as angina – that only lasts for a few minutes. It occurred for 3 days in a row.
Speaker_-_Dr__Huang: Any new or unusual chest pain is worth discussing with your regular doctor and may require further evaluation. Frequently women may experience "unusual" symptoms for angina which they may not attribute to heart disease. Nevertheless - this should be reviewed with your doctor in the context of your other risk factors.
567td: I went to my doctor and had a physical. I feel fine – maybe a little tired. He took an EKG and said it looks like I had some damage to my heart – next week I am going for a stress echo. Is it possible to have heart damage without knowing it.
Speaker_-_Dr__Huang: It is definitely possible to have sustained heart damage without being aware of it. sometimes when people are in very good shape to begin with, or alternative or if they are not very active, they may not notice a mild degree of heart damage. Silent heart attacks are more common in diabetic patients. Women may have unusual symptoms such as fatigue or breathlessness or nausea and may not come to attention right away. Campaigns to increase awareness of heart disease in women and men are helping.
Treatment of Cardiovascular Disease in women
Peppy: How well are women living with stents as compared to men?
Speaker_-_Dr__Huang: After angioplasty and stenting, women frequently have more problems with chest discomfort than men. However - with appropriate ongoing medical therapy such as blood pressure control, cholesterol control, diet and exercise, women can do very well long term with stents.
mc_505: I am a 50 year old woman with a new stent placed in an artery October. I am in cardiac rehab – taking medications and following a low fat diet. How long do stents normally stay open. Is there anything special I can do to insure it stays open forever? What are the signs of stent closing?
Speaker_-_Dr__Huang: Both drug eluting and bare metal stents have very good long term patency rates though drug eluting stents seem to be a little better in this regard. Making sure you follow your cardiologist's recommendations for blood pressure control, cholesterol medications, and antiplatelet therapy (aspirin and clopidogrel) will insure that your stent will stay open as long as possible.
For signs of stent closing - Be on the look out for symptoms similar to those that brought you to the stenting to begin with - whether these be chest pain, fatigue, breathlessness. Make sure you follow regularly with your cardiologist - many will perform follow up stress testing to test the quality of blood flow in your heart.
Jane: I need bypass surgery – three of my arteries are blocked – are there issues with women and bypass surgery that I should know about for recovery?
Speaker_-_Dr__Huang: Women often have smaller arteries than men and may have poorer outcomes with bypass surgery in terms of long term patency of grafts and increased rates of complication with surgery such as bleeding. Talk to your cardiologist about any concerns that you have going into surgery.
Hormone Replacement Therapy
ng_349: I have been going through menopause and have symptoms all the time – I am miserable – my doctor won’t give me any hormones because of the risk of heart disease? Can you talk about that?
Speaker_-_Dr__Huang: You didn't mention whether or not you already have a history of heart disease. Let's assume that you do not at this time. There has been a lot of controversy about the use of hormone therapy especially after the large Women's Health Initiative Study results were released several years ago. In this study, women had a higher risk of heart attack and blood clotting within a few years of starting hormone therapy. For this reason, prominent cardiology society guidelines strongly recommend against using hormone therapy for prevention of heart disease. However, for patients with severe menopause symptoms without heart disease - consideration can be given to short term hormone therapy. You may want to try other non-hormonal remedies first - such as - soy supplements; antidepressant therapy, which can help with hormonal changes.
desi111: Perhaps ng_349 could use low dose transdermal hormones that bypass first pass hepatic metabolism and therefore do not carry the risks of increasing TGY and clotting factors?
Speaker_-_Dr__Huang: It would be best to speak to a women's hormone specialist - such as in our Women's Health Institute.
Diagnostic Testing in women
blasebacc: What findings do a Holter Monitor show?
Speaker_-_Dr__Huang: A holter monitor is a continuous recording of your cardiac rhythm usually worn for 24 or 48 hours. If you are having frequent palpitations, they can often be picked up and diagnosed from the holter monitor. If your symptoms are less frequent (not daily) an event monitor - which is worn for up to 30 days - may provide a better yield for diagnosis.
JoyD: I have heard that heart attacks are more likely to occur in the morning, so should I wait until afternoon to do cardio. I have not had a heart attack but am just wondering if one time is better than another.
Speaker_-_Dr__Huang: I think the best time to exercise is a time that fits into your schedule and you can do consistently. Don't let fear of morning heart attacks stop your morning workout.
Peppy: Do recommend Interval Training for women after stents? Does this form of exercise keep a stent working long-term?
Speaker_-_Dr__Huang: Any type of aerobic exercise following diagnosis of heart disease or the placement of stents is highly recommended - at least 30 minutes 5 or more days a week. I know no particular advantage to interval training.
You seem to have many questions that you would like addressed - you might consider an appointment for a personal consultation in Preventive Cardiology or the Women's Cardiovascular Center.
Vitamins for heart and women’s health
saunders: Are there certain vitamins a woman should take for heart health and women’s health?
Speaker_-_Dr__Huang: Many of the studies looking at supplements and vitamins showed no benefit in regards to cardiovascular health. In particular, folate and vitamin E were associated with no improvement or worse outcomes. I normally recommend a multiple vitamin and vitamin D if there is evidence of deficiency.
Thyroid and Heart Health
jem: What do thyroid and the heart have to do with each other?
Speaker_-_Dr__Huang: The thyroid gland produces thyroid hormone which affects all the organs of the body. When the thyroid is overactive, it can lead to palpitations, fast heart rhythms, and cardiomyopathy (enlarged or weakened heart muscle). Underactive thyroid is also associated with cardiomyopathy as well as fluid around the heart.
Underactive thyroid can also affect lipid levels. Hypothyroidism is a fairly common diagnosis and we always screen for thyroid disease in patients with high cholesterol.
Omega 3 Fatty Acids
WKally: What are the benefits of omega 3s to the heart and the best way to get them?
Speaker_-_Dr__Huang: Omega 3 fatty acids have been shown to decrease the risk of sudden death from arrhythmia and are thought to have anti-inflammatory effects, which are involved in the formation of atherosclerosis. Most American diets do not contain enough omega 3.
You should try to eat at least 2 servings a week of fatty fish such as salmon to have enough omega 3 in your diet. Another question came in about salmon and tuna - the omega 3 content of tuna is much lower than that of salmon. We have a page on our website about this content Here is the link - http://my.clevelandclinic.org/heart/prevention/nutrition/omega3.aspx
Women’s Cardiovascular Center
kitr: I have heart disease – I see a cardiologist. I was thinking of going to the women’s cardiovascular center – that sounds kind of appealing – but what does it offer that my cardiologist wouldn’t offer – is it worth the trip? And then do I follow up still with my regular cardiologist? How does that all work?
Speaker_-_Dr__Huang: Our Women's Cardiovascular Center is staffed exclusively by women cardiologists, which may be an advantage for you in terms of your comfort level discussing symptoms or concerns that you have. We also have nutrition, exercise, smoking cessation, and mental health services as part of our program. Many patients like this unified approach to their medical issues. It would be up to you whether you would want to follow with your regular cardiologist or follow regularly in the Women's Cardiovascular Center. That decision may be dictated by the severity of your illness and your preference. We would be happy to see you for consultation.
Cleveland_Clinic_Host: I am sorry to say our time with Dr. Huang is up. Thank you Dr. Huang, this was great information.
Speaker_-_Dr__Huang: Thank you for having me today.
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