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Women and Cardiovascular Disease (Dr. Cho 7/19/10)

July 19, 2010

Leslie Cho, MD
Director of the Cleveland Clinic’s Women’s Cardiovascular Center Medical Director of the Section of Preventive Cardiology and Rehabilitation Tomsich Family Department of Cardiovascular Medicine

Description

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, regardless of race or ethnicity. Unfortunately, only 13 percent of women identify heart disease as the greatest health problem facing women today. Dr. Leslie Cho, a Cleveland cardiologist and Director of the Women’s Cardiovascular Center answers your questions about prevention, treatment and what women should know when dealing with heart disease.

More Information

Cleveland_Clinic_Host: Welcome to our online health chat with Leslie Cho MD. Dr. Cho will be answering a variety of questions about Women and Cardiovascular Disease and we are very excited to have her here today.

Dr__Leslie_Cho: Thank you for having me today.


Microvessel Disease

barb: Hi. I am a 53 year old female who has been diagnosed with microvascular heart disease. I did have blockages before with 2 stents 5 years ago. I have high cholesterol and I do not tolerate statins. My doctor told me there is no cure for microvascular disease and there is nothing he can do - can you help me?

Dr__Leslie_Cho: First of all, medications that treat endothelial dysfunction are good for microvessel disease. These are aspirin, ace inhibitor and statins. Also, long acting nitrates and calcium channel blockers can help. Some patients also find relief with Ranexa.

Dr__Leslie_Cho: Lastly, as stated statins are very good for microvessel disease and usually patients even in patients who can't take statins everyday can tolerate taking statins once a week.

diane: I have irregular beats and chest pain but do not have Coronary Artery disease from my cardiac cath. My doctor said I might have microvascular disease. I heard about the women's cardiovascular center and I am hoping you can help me. Can you tell me more about this and what you can do to help diagnose my chest pain?

Dr__Leslie_Cho: Microvessel disease is caused by endothelial dysfunction which means that arteries that are too small to be stented or bypass constrict when they should dilate especially with stress or exercise. Patients with microvessel disease have normal cath (no blockages) but have symptoms of chest pain with exercise or stress. The test we like to do to diagnose microvessel disease is Cardiac MRI. The treatment of choice is to deal with the underlying cause of endothelial dysfunction. Therefore, patients should be on Aspirin, statins (cholesterol lowering medication) and ace inhibitors. Also, long acting nitroglycerin and calcium channel blockers also help. Also, cardiac rehab which is an exercise program also greatly helps these patients.


Symptoms of Cardiovascular Disease

colleen: I have been diagnosed with Prinzmetals Angina, also, Fibromyalgia, CFS, and Peripheral Neuropathy. I get short of breath, have trouble walking up even one flight of stairs and have extreme fatigue. I would like to know if this is caused by my heart or the other issues and should I be concerned? Thank you!!

Dr__Leslie_Cho: You have many problems. Those should certainly explain your symptoms. You should be seen by your primary care doctor.

lauren_uk: I went to the doctor for palpitations and pain in my jaw. My doctor said it was TM. Later a friend of mine said that I should get it checked again because she was worried about me - so I went back to the doctor who reluctantly put me on a treadmill stress test and then all the sudden I am being rushed to the cath lab and now have a stent. Is that common for women to have jaw pain and luckily I had a caring friend who was concerned. What's up with the doctors and women?

Dr__Leslie_Cho: Women have more atypical symptoms as compared to men with coronary artery disease. While women do have chest pressure they can also have shortness of breath, nausea, arm pain, jaw pain or fatigue.

Traditionally coronary artery disease has been thought to be a disease that affects men but now we know that it is the number one disease that affects women. We are raising awareness for both patients and physicians so that women with heart disease can be treated early and aggressively.

sherricraig00: I know I have anxiety but lately I have had rapid heart rate and chest pains. My doctor said it is just a panic attack - but how does he know? I am worried it could be chest pain or a heart disease. Is there a difference in symptoms?

Dr__Leslie_Cho: Usually panic attacks are associated with feelings of gloom and doom. Usually even when cardiac patients are feeling well; they can have chest pressure when they are exerting themselves (during activity). Sometimes it is difficult to sort out the differences between symptoms of heart pain and anxiety attacks - a stress test may be helpful. If you have a normal stress test, studies show that your risk of heart attack is less than 1 percent.

cynthia: I have been having chest pains the past few months - but also notice I am going through menopause (hot flashes). They come and go and sometimes I have irregular beats. Are these symptoms of menopause?

Dr__Leslie_Cho: The number one reason for women of menopause age coming to see a cardiologist is irregular heart beat. They commonly state that they have "fluttering" in their chest, especially at night or at rest. They never get palpitation during exercise. This is very common during menopause and is benign.

We recommend hydration, avoiding caffeine and over the counter decongestants. As for you chest pain, it depends on the exact symptoms. Most women do not complain of chest pain during menopause


Diagnostic Testing

karen: Dr. Cho. I was told I need to have a CTA-. Can you comment on this test for women and also the radiation exposure?

Dr__Leslie_Cho: I am assuming it is a 64 slice CT. If you do gated cardiac CT which means that they lower your heart rate and do a gated CT you can lower your radiation risk. However, if that is not done, the radiation risk is about 700 chest xrays. It really depends on why you are getting that CTA done to determine the benefit of having that type of test.

lulla1: I get intermittent chest pain. Last time I was on the treadmill - I had chest and arm pain. I went to the doctor and he had me do an angiogram which showed I do not have coronary artery disease but showed that I had some problems with my ventricle function. Now they want me to have an echo. Wouldn’t the angiogram show all the disease - why do they want me to have an echo now?

Dr__Leslie_Cho: The angiogram is not a test that is used to look at valvular problems. Echo shows valve dysfunction - stenosis or regurgitation, thus they are complementary and can be used together to determine the cause of your chest pain.

penny: I have been having some chest discomfort and my doctor wants me to get a stress test. I read somewhere that women should have only certain types of tests - can you talk about what tests I should have to help diagnose if I have coronary disease?

Dr__Leslie_Cho: For women, we tend to prefer non-radiation based stress test. Therefore, we recommend Stress echo because it is ultrasound and there are no radiation. Nuclear stress test can have radiation levels that equal 900 chest x-rays.

goldfinch: Is it appropriate to use only resting echo to check for heart issues in someone who has faintness, short of breath, high heart rate, and change in blood pressure (up or down) with exertion? Or should a stress echo be done? Cholesterol and triglycerides are fine and there is no family history of heart disease and no smoking.

Dr__Leslie_Cho: Ideally stress echo is better at diagnosing the effect of exercise on heart muscle and valves. Sometimes a standard ECG stress test is best for diagnosing changes in heart rate and blood pressure associated with exercise.


Risk factors: Assessment

lana: I am 50 year old female non smoker with high blood pressure, high cholesterol both controlled on meds. 3 years ago I had a stress test and it was good. My mom is healthy but my dad had a heart attack at 48 and died when he was 58 from heart disease. How often should I have a heart physical and should this be with a cardiologist. My last physical was with my family doctor.

Dr__Leslie_Cho: You need a cholesterol test once a year according to the AHA. You need to get your blood pressure checked and make sure your weight is within good range. The AHA and ACC do not recommend routine stress testing. They recommend stress testing as guided by symptoms. You can have this testing with your primary care doctor.

lori: I had a heart attack last month - a blockage of 90% in one artery. A stent was put in and I am on a bunch of medications. I am 57 years old - my mom had bypass surgery also but I have no high blood pressure, cholesterol is 200 overall LDL was 130, HDL 35, no diabetes. Are there other risk factors I should look for?

Dr__Leslie_Cho: The main risk factors for coronary artery disease are family history, diabetes, smoking, high blood pressure and high cholesterol. Studies have shown that these established risk factor account for over 90% of the disease in patients. There are other emerging risk markers as well such as lipoprotein a.


Risk factors: Obesity

edrosa15: regarding obesity, what are the risk being obese?

Dr__Leslie_Cho: Over eating is the number one cause of obesity in America. There is a small genetic component of obesity and you want to make sure you do not have hypothyroid - but the number one cause is over-eating. Obesity does cause high blood pressure, high cholesterol and diabetes which all increase the risk of coronary heart disease.


Risk Factors: Lipids

katherineP: I do not have heart disease and do not have it in my family - I have cholesterol of HDL 90 and LDL of 50. I was excited to hear about this but then I read somewhere that it may be bad to have a high HDL and low LDL like that - something about dysfunctional HDL. How do you know and what should I do?

Dr__Leslie_Cho: Dysfunctional HDL is something that is still in research phase. There are medications that can increase your HDL that are not beneficial such as hormone replacement therapy and prednisone. Also, drinking alcohol can increase your HDL as well.


Risk Factors: LP(a)

Mayflower: Dr. Cho, I’m 41. 3 years ago diagnosed with: Pituitary Enlargement/Tumor, Premature Ovarian Failure, Osteoporosis, elevated Rheumatoid Factor, abnormal anti-smooth muscle antibody, lately with mild Heart Valve Regurgitation, Irregular Heart Beat on24-hour Monitor (with many PVCs & PACs), abnormally high LP(a) (102). My Echo, Stress Test , LDL (84), HDL(56), Total Cholesterol (155), Triglycerides (74), CRP (0.5), Homocysteine (9.2) were normal, but I have chest pain/discomfort, tingle/numb in legs/arms, feel clotting moving in artery/vein mostly on legs. easily bruised without knowing causes.

Questions: 1) given my tests & symptoms & family history (mother has Atrial Fibrillation, Heart Valve Leakage and Heart Enlargement), should I be treated or just monitor LP(a)? 2) What cause LP(a) to elevate? How to lower it? 3) What’s my risk with LP(a)=102 but LDL=84? 4) Can Aspirin lower LP(a)? 5) Which is better, Fish Oil or Flaxseed Oil? Please email me answers. Thanks!

Dr__Leslie_Cho: Elevated LPa has been associated with increase risk of thrombosis, heart attack and early heart disease. We usually recommend people with elevated LPa to be on daily aspirin if they can tolerate it and getting LDL levels less than 70.

Fish oil is good but unfortunately increases LDL. Fish oil at high doses can decrease triglycerides but you would need to take about 15 capsules of over the counter fish oil to lower triglyceride. Fish oil does nothing for LPa or HDL.

Flaxseed is actually good for lowering bad cholesterol (LDL) but only lowers it by less than 10%.

mayflower1000: What can lower LP(a)? Aspirin?

Dr__Leslie_Cho: LPa is only lowered by niacin. Prescription Niacin at maximum doses which is 2000 mg can lower LPa by 30 percent. Aspirin does not lower LPa level however we recommend aspirin because it can lower thrombosis which is associated with high LPa. Patients with high LPa have increased risk of heart attack and stroke and their LDL should be less than 70 mg/dl.

mayflower1000: Hi Dr. Cho, Can someone have normal LDL and Triglycerides, but high/increased blood thickness? What's cause blood thickness, LP(a)? What's caused elevated LP(a), Kidney diseases?

Dr__Leslie_Cho: LPa is usually genetically induced. African Americans have high LPa as compared to other groups. Being diabetic can increase platelet activation and aggregation which theoretically increases blood thickness.


Risk factors: HS-CRP

butterfly54: I have a crp of 5 - how bad is that? what do you do for high crp?

Dr__Leslie_Cho: It is important to know whether that is high sensitivity crp or regular crp. CRP is an excellent marker for inflammation and it has been validated in coronary artery disease patients. However it can be elevated when you have an infection, on hormone replacement therapy or birth control - or under any chronic inflammatory condition such as lupus. Obesity can also raise hs-CRP.

If you have elevated crp but no other medical condition and you have normal or mildly elevated bad (LDL)cholesterol, being on cholesterol lowering medication can be beneficial. The cholesterol lowering medication in this case can lower risk of heart attack, stroke and death.


Risk Factor Management

smith: Studies show drinking a glass of wine a day can prevent a heart attack. What else should you do - what are 3 things I should do to prevent a heart attack. My dad had a heart attack this year and I am starting to think about this. I do exercise regularly - I am a good weight. What else?

Dr__Leslie_Cho: You should get your cholesterol checked every year. The American pediatric academy suggest children over the age of 8 get their cholesterol checked firs time. And then anyone over the age of 20, if there is risk factors, every year thereafter. If no risk factors, then every 5 years. This should include a full cholesterol panel including total cholesterol, LDL, HDL and triglycerides. You should also:

  • Get your blood pressure checked.
  • In terms of drinking wine, for women it should be 6 - 8 ounces of red wine per day - not white. Too much alcohol can increase triglycerides which is a bad thing.
  • Hopefully you do not smoke.
  • You should also get a fasting blood sugar once a year.

henrietta: One of my family members had a heart attack recently. Does that mean I'll have one too? I am only 25

Dr__Leslie_Cho: Family history of heart disease is defined as your first degree relative - mom, dad, brother, sister - having heart disease before age 55 if they are a man and age 65 if they are a woman. If you have a family history of premature coronary artery disease, given your young age, we recommend you get your cholesterol checked, blood pressure checked, glucose checked.

To prevent heart disease, maintain a healthy lifestyle which means exercising regularly and eating a heart friendly diet, not smoking, maintaining good weight, and seeing a physician once a year.


Medications, Supplements and Vitamins

Alyce: Should one take coQ10 with a statin?

Dr__Leslie_Cho: No. CoQ10 has been shown to decrease muscle ache in patients who are intolerant to statins. However, the studies were very small. Therefore, unless you have muscle ache on statin you should not take them.

jetblue: I had a stent a couple months ago and I am now on lipitor and plavix - is there anything else I should be on?

Dr__Leslie_Cho: You should definitely be on aspirin. Your bad cholesterol should be less than 70. Good blood pressure control is important. If you have high blood pressure, you should be on beta blockers or ace inhibitors. You should undergo cardiac rehabilitation and if you are smoking you should stop.

Kim: I am a 55 year old woman. I had a heart attack @ 47 and had one stent put in. Have been well, exercise and eat right. I am 5'4" and weight 25 lbs. 5 months ago due I had angioplasty again and another stent placed in the same location as the previous one. This stent was a drug eluding stent. I am on plavix (75 mg) and aspirin (81) once a day-- and I have been on this same medication since my heart attack. (I also take toprol (50mg), altace (5mg), lipitor (75mg) and Zetia (10mg)). My cholesterol runs about LDL 70 HDL 50. My question relates to the plavix and aspirin. It seems to me that I bruise much easier than I did when I initially began taking the plavix and aspirin -- the dosage has never changed. Should I ask about reducing my dosage, or is there a test to see if the blood is too thin? Thanks.

Dr__Leslie_Cho: If you have a drug eluting stent - you absolutely need to be on aspirin and plavix at least for one year. This is due to the increase risk of stent thrombosis which is often times fatal in patients. You seem to be on good dose of aspirin and plavix. There is no lower dose of plavix you can be on. Also your aspirin dose is appropriate.

Sometimes when patients start taking other medications that increase bleeding times such as glucosamine or fish oil they notice increased bruising. There are tests that can check platelet function on plavix. Most of the time, when we check we have to raise the plavix dose - never lower the dose.

lori: Does taking birth control pills increase my risk for heart disease?

Dr__Leslie_Cho: There are conflicting and bad data surrounding birth control pills and heart disease. Women over the age of 35 who smoke have an increased risk for blood clots on birth control pills. Therefore, you should not be smoking on birth control pills.

carriel44: I am taking over the counter no-flush niacin, but my doctor is recommending for me to take a prescription one

Dr__Leslie_Cho: No types of flush niacin contain any free nicotinic acid. It actually has no effect against high cholesterol and should not be used. It is the most expensive brand on the market. Slow release niacin has been associated with increased risk of liver toxicity.

Immediate release niacin is safe however you need to take a lot of that to lower cholesterol and you need to take it 3 times a day - that is why we recommend prescription niacin.

mayflower1000: Dr. Cho, I have Osteoporosis, my doctor wants me to use HRT. Given my elevated LP(a) at 102, is it risky to take Hormone?

Dr__Leslie_Cho: HRT has never been shown to reduce the risk of heart disease and can increase the risk of stroke and heart attack especially early on. Although it is an excellent drug of choice for osteoporosis, given your elevated LPa I would advise you speak to your gynecologist and primary care physician before starting the medication.

diamond1: Is vitamin E good to reduce heart disease?

Dr__Leslie_Cho: Vitamin E has been shown in meta analysis to increase heart failure and death. In randomized control studies it has never shown to be of any benefit for heart disease - therefore - we recommend NOT taking vitamin E.

diamond1: Also, what about red yeast rice?

Dr__Leslie_Cho: Red rice yeast has been around for 1200 years. It contains the same active ingredient as lovastatin. It is effective at lowering cholesterol however in 2007, FDA issued a warning letter against red rice yeast due to patients coming in with liver toxicity. My recommendation is that if you want to be on red rice yeast you may as well be on statin.

mayflower1000: I see Fish Oil contains Cholesterol. Does it contain HDL or LDL?

Dr__Leslie_Cho: It contains cholesterol because it contains oil. If you eat fish - you most likely do not need fish oil. The most important thing to look at the EPA and DHA content of what you are taking. Even though the bottle may say 1200 mg of fish oil it may only contain 300 total of EPA and DHA. That means the rest is just fat or fish fat or blubber. It is important to have DHA or EPA to equal 1000 mg to have any benefit.


Heart Attack

Trace: Hi - I had a heart attack last month and I wonder if there is something other than a blocked artery that can cause a heart attack because my cath showed my arteries are clear?

Dr__Leslie_Cho: Other Causes of heart attack include:

  • Thrombosis - your blood being too thick.
  • Spasm of coronary artery
  • Demand ischemia - your heart needing too much oxygen and not being able to supply it fast enough

Radiation Heart Disease

gh45: I had a lumpectomy and radiation 25 years ago. I spent three days in the hospital recently with atrial fibrillation and found to have coronary disease too - I wonder how common it is to have problems after radiation therapy and what I should do about it

Dr__Leslie_Cho: Early menopause increases the risk of coronary artery disease so if you had chemically induced menopause before the age of 50 the risk of coronary artery disease can increase. Radiation heart disease can increase the risk of having valvular abnormality which can cause afib. However, the most common cause of afib is age and hypertension. The treatment for afib is rate control and decreasing the risk for stroke.


Other questions

Mayflower: My mother (66 old) had a stroke 1.5 years ago due to Atrial Fibrillation (AF). She also has high blood pressure. She is hospitalized in China recently and was told, she now has: 1) Recurring Atrial Fibrillation (AF) 2) Enlarged Left Atrium (54mm), Right Atrium (horizontally measures 42mm & vertically measures 56mm) and Right Ventricle (23mm). Her Left Ventricle measures: 35 mm. 3) Regurgitation in Pulmonary Valve (3.40 CM2 ), Aortic Valve (4.35 CM2) and Tricuspid Valve (9.60 CM2) 4) Ejection Fraction reduced. Questions: a) Is my mother’s heart dangerously enlarged/life threatening? b) is her heart valve regurgitation severe? Does she need heart valve repair or replacement? c) Given her enlarged (left) Atrium, how effective Radio frequency Catheter ablation would be for her AF? d) Any better options you could recommend? e) Is she safe to travel to the US for treatment (18 hours flight)? I can’t join the chat but need answer urgently. Could you email me answer? Thanks!

Dr__Leslie_Cho: Your mother sounds quite ill. We recommend that she be evaluated with a cardiologist. Afib ablation works best in younger patients without valvular disease. Your mother has extensive valvular disease and may not be an optimal candidate for ablation. You can utilize myConsult to obtain a second opinion over the web. eclevelandclinic.org/myConsultHome

juzcureus: If ejection fraction was 30 % and then increased would it still be advisable to have and icd implanted and would MediCal pay for it?

Dr__Leslie_Cho: It depends. There are guidelines for ICD placement and it depends on what type of heart disease you have - whether you have coronary artery disease or not. I would advise that you speak with your cardiologist.


Women’s Cardiovascular Center

Cleveland_Clinic_Host: Dr. Cho, can you please talk a little about the Women's Cardiovascular Center at Cleveland Clinic?

Dr__Leslie_Cho: The Women's Cardiovascular Center has been open since 2006. We see women from all over the country and the world. We see women with problems with heart disease, vascular disease and those with significant family history. We see women with microvessel disease, coronary artery dissection, peripartum cardiomyopathy, and high risk pregnancy. We work in conjunction with endocrinologists, nutritionists, exercise specialists, psychologists to treat the overall patient. We often see patients with statin intolerance or complex genetic cholesterol problems. We also see people with risk factors for coronary artery disease or significant family history of coronary artery disease.

goldfinch: Do you have a program for people without insurance or whose insurance doesn't cover Cleveland Clinic?

Dr__Leslie_Cho: For patients who come to the Cleveland Clinic need to have some type of payment option, either insurance or a payment plan. Patients who do not have the means to pay for services provided at the Cleveland Clinic may request to be considered under the Uncompensated Charity Care Guidelines. If you would like to discuss these options, including any costs involved, please contact our Financial Counselor for Cardiothoracic Surgery at: 216-445-0430 (long distance, call 800-223-2273 ext 5-0430) if you need further financial information. You may view information on the Clinic’s Financial Assistance Program at my.clevelandclinic.org/patients/billing_legal/billing/assistance.aspx.

Cleveland_Clinic_Host: I'm sorry to say that our time with Leslie Cho, MD, is now over. Thank you again Dr. Cho, for taking the time to answer our questions about Women and Cardiovascular Disease.

Dr__Leslie_Cho: Thank you for having me today.

mayflower1000: Thanks a lot, Dr. Cho!

Dr__Leslie_Cho: My pleasure.

Technology for web chats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC).

Reviewed: 07/10


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