Women&Cardiovascular Disease&Treatment (Dr Cho 09 17 13)
Tuesday, September 17, 2013 - Noon
Cardiovascular disease is the Number One killer of women over age 25 in the United States. It claims the lives of more women than all forms of cancer combined. At the Women’s Cardiovascular Center at Cleveland Clinic, women can get comprehensive heart care, designed to meet their unique needs. Dr. Cho, Director of the Women’s Cardiovascular Program, answers your questions.
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Prevention of Coronary Artery Disease
pilatesgirl: What ways might one do to prevent cardiac disease in women? What dietary, exercise, and supplement or medication recommendations might you share? And do you think that statin meds are appropriate for women? I have read experts who say they are only appropriate statistically for men with prior heart attacks. What do you think about that understanding based on incident statistics? Thanks so much.
Leslie_Cho,_MD: There is good data that good diet - Mediterranean - and exercise can decrease cardiac events. The diet that has the best data is the Mediterranean diet. There are some extreme diets but they do not have randomized control studies behind them. Obviously controlling blood pressure, diabetes, not smoking and controlling cholesterol has all been shown to decrease heart disease. The primary prevention data on statins and women is very strong. Women do benefit particularly women with risk factors and elevated HS-CRP.
Jerry: Isn’t the heart a muscle? Why would you want to take a drug that weakens it? If statins weaken muscles why would they not affect all muscles, including the heart? I don't quite understand that. Are there independent studies that confirm that only some muscles are affected? I don't read the Pharma-sponsored studies as I believe they may be biased.
Leslie_Cho,_MD: Statins do not affect heart muscles - there are some statins that go to all muscles but there are some statins that do not go to muscles. But overall, in all major studies looking at patients with heart disease, statins consistently lowered heart attack, death, and adverse cardiac events.
mooreke126: Great topic. I am a 55 yo woman with extensive family history of heart disease. Have been doing what I can for the last 10 years with exercise, vegan diet. Been on 20mg simvistatin and BP meds for 10 years. All controlled. TC 165, LDL 69 HDL 55, BP 110/60. Had a ct scan 3.5 years ago with calcium score of 22 and a < 50% calcified plaque in my LAD. cardiologist says I am doing great but that plaque seems like a ticking clock to me. What do you suggest?
Leslie_Cho,_MD: It is not a ticking clock. You are doing everything right. By exercising and taking medications you have changed the characteristics of your plaque. Most plaque that lead to heart attack have thin fibrous cap. With medicines such as statins, you change the plaque to a thick cap which has less tendency to rupture and cause heart attacks.
sax64: Hi Doctor! I am an Indian lady living in Sweden. After a heart attack (no high cholesterol or sugar, BP little high) two years ago, I am taking 50 mg Metoprolol, 75mg Thrombyl and 2.5mg Felodipin. For the last 2 yrs. BP was at average 110/65 and pulse rate 65-68. So last month doctor told me to take 25 mg Metoprolol. Now, as of today it is 115/78.3, Pulse 70.6 (average of 3 readings). Is that OK for me? I have four stents in my rt. coronary artery of which three are DES. I take also vytorin 10/10. Total Cholesterol 117mg/DL, LDL 54.6mg/DL, HDL39mg/DL taken on 10.07.13. After reducing metoprolol I feel less cold, muscles have become relaxed, which were always tight and painful. I felt jaw pain whenever I felt cold in my feet, even at 20 degrees. Now that is gone, after about a month of reduction. Now I want to know from you that is that OK for me to remain at these levels of BP and Pulse? Last wk one morning after disturbed sleep, BP was 152/101. It was 130/82 by the evening. Please advise. TX.
Leslie_Cho,_MD: When we do blood pressure, we make patients measure BP few times over a week or two to get an average. We don't base it on one reading. You may have had high blood pressure due to eating salty food or were excited or stressed. Overall it looks like your blood pressure is well controlled.
email@example.com: I need to know if there are natural remedies for treating high blood pressure. I have been using a store bought blood pressure monitor and take my BP in the morning. The first BP is the highest running from 159/75 HR 56 to 226/99 HR 53* (this morning-..the highest reading to date and the meter showed errors three times with the last two reading being 16581 HR 51 and 154/76 HR 51 which falls within the reading I have recorded this month. (This AM from 7:52 - 8:08 AM (213/90 HR 53, 204/94 HR 53, 189/90 HR 55, 226/95 HR 53, 190/90 HR 51 and the last reading at 8:08 was 154/76 HR 51). Most of the reading over the last month average (taking them four-five times within 15 minutes) 151/79 HR 53 to 162/78 HR 78. I am now taking DANDELION Drops, Garlic, 900-1800 Mg, eating bananas (two per day) Vitamin C and Cinnamon. I am concerned because of the aortic valve stenosis which is being followed. I would also like to know what kind of testing CC has for monitoring heart valves. I currently get yearly echoes.
Leslie_Cho,_MD: You have very high blood pressure which increases your risk of stroke. BP in 200s exponentially increases your risk for stroke and is very bad for your aortic valve. When your blood pressure is this high, it needs to be lowered with prescription medicine. Unfortunately there are no herbal supplements to take to lower blood pressure when it is this high. Echos are the best test for monitoring heart valves.
sax64: BP average of three readings is about 120/75. I am afraid that by reducing metoprolol I may get another attack soon. I am(66) a vegetarian, except fish. Walk for 45 min. everyday, do yoga for 45 min., don’t drink or smoke.
Leslie_Cho,_MD: Your blood pressure appears to be fine - continue what you are doing and monitor your blood pressure and heart rate and see how you do.
bc4494: I think the reason women die from this disease more than men is because we have different symptoms after the diagnosis. I was still having chest pain and other symptoms after my stent but two doctors could not explain what they were or why I was still having them. I think that the continuing symptoms wreak more havoc on our hearts and therefore make the chances of having another attack more imminent. Do you agree and if so is there anything that we can do to help ourselves?
Leslie_Cho,_MD: Women often die more often than men when diagnosed with heart disease because they are often older and have more co-morbidities. It is true that they do have different symptoms and their diagnosis is made later. They tend to have more complications after receiving certain treatments. The best thing to do is to be active in your care, take your medications, watch your diet, and be your own advocate.
lexi77: Quest #1: Will Stress Echocardiograms (sens,76 and spec 88) become obsolete in view of better Cardiac CT Scanners (sens 94-95, spec 82) in determining the patency of coronary vessels? If the stress test requires 65% narrowing before the amount of blood flow thru the artery cannot inc. enough to meet the demand of the heart muscle and a portion begins to become ischemic, and if most heart attacks happen in arteries with less than 40% narrowing (too little of a blockage to cause the reduction in maximal coronary blood flow that is required for detection by stress testing, why isn't Coronary CT Angiograph (CTA) preferred? If a CTA test DIRECTLY examines the lumen of the vessels thereby detecting calcium deposits which are excellent indicators of heart risk, it seems this would be a better test than the stress echo which INDIRECTLY assesses the patency of the coronary vessels. Also, I understand that the stress test is likely to be normal right up until sudden death or a heart attack.
Leslie_Cho,_MD: Stress test looks at the functional significance of the lesions and Cardiac CT does not assess functional significance. Cardiac CT looks at the vessel patency. They are two different tests. You have to assess both function as well as patency. They are complementary. There are numerous studies that show that CT scan overestimates blockage in coronary arteries. Also, there are numerous studies that show that there is no benefit in treating lesions unless it is functionally significant (in regards to reduction of death, MI). CT scan does not show functional significance. The reason why people have heart attack in moderate lesions is due to thin fibrous cap and acute plaque rupture. Thus, it is crucial to get your cholesterol, diabetes and blood pressure under control.
antideluvian: One day at the age of 36, in the night I felt pain in my left side of chest almost two inches below to my left nipple. That pain increased and disturbed me whole night. In that pain feeling was like somebody is scratching my chest with nails from inside. But than after few hours I slept. In morning when I visited a doctor who was (MD), told me that it was nothing but a muscular pain. Now that I am age 41, I almost feel myself very tired, sometime I feel troubled my self in breathing. My BP is normal, all my checkups are normal. In Echocardiography report, doctor said that you have previously suffered one heart attack. I shocked. He asked me to go for angiography. As per his report 2-D IMAGING (SMALL AREA OF APICOLATERAL LV HYPOKINESIA), REST OF LV CONTRACT IS WELL, LVEF=- 60%, ALL VALVE NORMAL, NO TR/ NO PAH. I went to another doctor and as per his report DOPPLE STUDFIES (A/E OF 1.1 ON MITRAL DPPLER SPECTRAL TRACE, MILDLY REDUCED LV COMPLIANCE). Kindly suggest me is it serious matter?
Leslie_Cho,_MD: Without looking at all your data, it is difficult to say. There seems to be a conflicting opinion between the two doctors regarding regional wall motion abnormality on your echo. Given that, we recommend you get another echo to see if you really have changes. If you do have regional wall motion abnormality - then we do recommend a cardiac catheterization. Trivial mitral regurgitation is nothing. Sounds like you need another echo to figure this out.
healthquery: When a computer interpretation comes up with, "may have been a prior infarct, undetermined age”, or something similar, should one go to a doctor as soon as possible, or can the issue reasonably wait?
Leslie_Cho,_MD: Sometimes EKGs tend to over read and call something an old infarct when there are no significant problems. That is why it is important to have a doctor read the EKG and compare it to a previous EKG if you have one. Also - your symptoms and your history are important in determining if there is significance.
sax64: I understand one day reading is not so serious. I am measuring regularly. Now my pulse rate is coming about 74-75 after reducing metoprolol to 25 mg per day. is it OK? Or should I take 50 mg again? I am told that none of my heart muscles are damaged.
Leslie_Cho,_MD: It is good. 74 - 75 is good heart rate but it depends on the blood pressure also.
amber: What if any progress has been made in testing, diagnosing and treatment of microvessel disease.
Leslie_Cho,_MD: Cardiac perfusion MRI appears to be a reasonable alternative to the invasive coronary flow reserve (CFR) to diagnose patients with microvessel disease.
gatorfrog: Hello Dr. Cho, I have been diagnosed with microvascular disease and mild pulmonary hypertension. As to the microvascular disease, my question is: How will that relate to other areas of health in my body and am I at more risk for a heart attack or a stroke? I am currently doing ok on my medication which is Verapamil but I do worry about it and worry that I am more at risk. Thank you for any comments.
Leslie_Cho,_MD: Patients with microvessel disease have endothelial dysfunction which increases their risk of heart attack compared to patients who do not. However, their life expectancy appears to be same. Therefore, we tend to treat our patients with aspirin, statins and other medication that improve not only endothelial dysfunction but reduce major adverse cardiac events.
miamickey: How does doctor diagnosis angina as a result of microvascular blockage in female? My angina can be described as sharp pains relieved by nitro. Also have numbness and left arm and shoulder pain along with dyspnea and cough. (Previous surgery three years ago included ASD closure, one main coronary bypass and MAZE procedure). I am 59 yr. old female. Thanks
Leslie_Cho,_MD: Microvessel disease traditionally has been diagnosed in the past with an invasive procedure called coronary flow reserve - CFR. Currently, they can be diagnosed with cardiac perfusion MRI at good centers. Not all chest pain is from the heart or coronary artery disease. Therefore we recommend patients get specific testing appropriate to their diagnosis.
Angioplasty and Stents
lexi77: Quest #2: Stents. I understand that stents do not prolong life or prevent future cardiac events. However, stents do save lives in emergency situations. Is coronary artery bypass grafting (CABG) preferable, especially in the case of diabetics, since it has a better long range prognosis. What criteria do you use in determining whether a person should have a stent or opt for CABG in non-emergency situations?
Leslie_Cho,_MD: Coronary artery bypass surgery or CABG is better for patients with diabetes, poor heart pumping function and in patients who have multi-vessel disease. However, stents and CABG are equivalent in regards to death and MI (heart attack) outcome. It is only in reduction of further revascularization where CABG is clearly superior. Whether someone has CABG or not really depends on their bypass conduits, their overall comorbidities (some people with severe lung disease cannot undergo CABG due to high risk etc).
Peppy: I had a DES placed seven years ago in the diagonal artery. They said I had a non-STEMI. Every stress test and ekg show no heart attack damage or sign of a heart attack. What am I to think? Did I or didn't I? Thank you.
Leslie_Cho,_MD: Yes - you did - you were lucky enough not to sustain heart damage. You should take aspirin every day; and control your blood pressure; don't smoke, eat a healthy diet; exercise.
nimra: Sir, there is a heart problem with my uncle his age is 74 or 75. In Pakistan, doctor's diagnoses that he has only one valve open and his heart is working 25%. Sir, I want to ask that is there is any treatment for this problem or any surgery or heart transplant?
Leslie_Cho,_MD: Well it depends on what valve we are talking about. Most likely it is the aortic valve due to your uncle's age. There are a lot of options for patients with low pumping function and aortic valve disease but heart transplant is not one of them given the age of the patient.
Carotid Artery Disease
alplaus130: I have had surgery for blocked carotid artery and also have had treatment for PAD in both legs. What can I do to protect heart and other arteries? Martha.
Leslie_Cho,_MD: Patients with PAD and carotid artery disease should have a test to make sure they do not have coronary artery disease. The risk factors for carotid and PAD are the same as for CAD - you should minimize your risk factors - do not smoke, control BP, cholesterol and diabetes, maintain good diet and exercise.
swimmersyl: I have a thoracic aneurysm which currently measures 4.5. I've been advised that when it reaches 5, repair will be necessary. My question is, since I do NOT wish to have my chest opened, what the alternatives? (From the side, through the groin?) . What is the success rate and what are the risks? I am 84 years old, and keep fit with regular exercise 6 days a week.
Leslie_Cho,_MD: It depends on where it is - sometimes we can put in an endovascular stent - most thoracic requires an open repair. However, it depends on where it is or if there are any branches coming off the aorta near there. It is best to be evaluated by an aorta surgeon to determine your options.
Grannyscott: I am 85 years old, have moderately high blood pressure, controlled with medication; have high CRP for which I am taking a statin; have had stress test which did not indicate any problems; have had several occasions when I thought I might be having a heart attack because of pain in left side and dizziness, but trip to ER negative; think I am too aware of stories of heart attacks in women that did not have typical symptoms, and at my age am somewhat nervous! Would a carotid artery screening and an abdominal aortic aneurysm screening be something I should consider?
Leslie_Cho,_MD: AAA (abdominal aortic aneurysm) screening should be done only if you were a smoker and carotid artery screening if there are indications of Peripheral Vascular Disease. Otherwise, you do not need these tests routinely.
Cormorant: I am a 62 year old female, 5 foot 2.5 inches, 120 pounds, that is physically active, eats very carefully, taken statins to control probably hereditary high cholesterol, never smoked, don't drink and I have an aorta abdominal (thoracic) aneurysm that is almost 5 cms. Is there anything I can do - or should not do - to avoid probably needing open surgery which I do not want to have?
Leslie_Cho,_MD: If you have any type of aneurysm- the most important goal is tight control of blood pressure. Control high blood pressure is the most important along with controlling cholesterol, healthy diet, not smoking and overall risk factor modification.
AAA: I have a suprarenal AAA which is being monitored but it is near the 5cm diameter. I am a very physically active 62 year old (backpacks, kayaks, hiking, health club classes, etc.), weigh 122 pounds and am 5' 2.5", who eats a healthy diet, takes statins and has no known family history of AAAs. What else should I do or not do to prevent surgery, and if I have to have surgery, will it be open body? Will surgery change my lifestyle? What is the chance of death, paralysis, kidney problems or other complications from surgery?
Leslie_Cho,_MD: It sounds like you are taking good care of yourself. We recommend tight blood pressure control. Whether you get an open surgery or stent really depends on the vessels that come off near the area of AAA. The technology in surgery is such now that most patients go back to their normal lifestyle after either procedure. Paralysis risk depends on what other vessels are coming off there.
AAA: I have a relative who is a doctor and warns me to not take statins. (I am female, 62 years, have an AAA and my doctor put me on statins). My relative says cholesterol may be good, patching the weak points of the aorta. He gave me a website that has pages of anti-statin information, listing all the negative consequences of the drug. Should I continue to take statins?
Leslie_Cho,_MD: Yes - you should take statins. Patients with AAA actually have less heart attacks during their procedure if they are on statin therapy.
ssuzowsky: I have been diagnosed with a thoracic aneurysm, currently measuring 4.5mm. I do NOT want to have open-chest surgery, but would opt for endoscopic surgery. I am 84 yrs. old, in excellent health. I work out six days a week, swimming, biking and lifting weights. At what point would you recommend surgery: what would be the risks vs. the benefits?
Leslie_Cho,_MD: At 4.5 cm you definitely do not need surgery - however you do need monitoring. Controlling your blood pressure is the best way to prevent it from growing. It seems as though you are doing everything right but I would be cautious about lifting weights. I would not lift very heavy weights. If you want to do lifting, I would use very light weights with more repetition.
Debradaniell: What are PVC's? When are they considered "normal" and what does that really mean? What risks are there with PVCs? What treatments, lifestyle changes, etc., should be made if you have PVCs? What does chest pressure feel like? When should we be concerned when we feel something? What can we monitor and track from home to proactively detect heart problems?
Leslie_Cho,_MD: PVCs are extra ventricular beats and usually normal in 99% of the people. When abnormal, it is over 10% of your total heart rate is PVCs - most PVCs are completely benign and should not be treated. Many women during hormonal changes, after delivery, during lactation, menopause, have PVCs which is self limiting and benign. We recommend avoiding caffeine, alcohol, dehydration and over the counter cold medications. Usually when most people feel pressure associated with heart disease it feels like tightness, or pressure and may be associated with shortness of breath, it may travel down the left arm, they may feel nauseous. The best thing to do is track blood pressure, check for symptoms, decreasing tolerance to activity. Get regular check ups with your doctor and reduce your risk factors.
misslottie: Is atrial fibrillation (afib) considered a cardiovascular disease? I seem to get that when my father was dying in hospice in 2009. All my heart tests done at cardiologist’s office over the summer show I am in good shape pretty much. He just said I have an electrical problem. Maybe three times in past few years I had to go to ER for it racing off the track, and one time I had to get the electro shock to get it back. I don't drink coffee or alcohol or do drugs. I am 61. My BP is usually 120/60 and HR is like 50 normally. I chew 4 baby aspirins a day and sometimes more when I have pain for arthritis. So I refused the warfarin. But what is normal since I take this medicine? Is there any chance that will cure itself? I take 180 Cardizem once a day dose and occasional Atenolol maybe half of a 25mg when my heart seems to race up a little. A recent Holter showed top speed was 96 bpm. I wonder can I just stop taking all this medicine and get back to square one and see what my heart is really doing?
Leslie_Cho,_MD: Technically, it is a cardiac disease because it is from the heart but it is due to arrhythmia. Typically CVD refers to coronary artery disease. Most patients who have afib have either Coumadin or Aspirin for stroke reduction based on their risk factors. Whether you need Coumadin or not will depend on your risk score.
Pelicans: Is Atrial Fibrillation considered a Heart Disease? I take 325 mg aspirin daily. I do not want to take prescription drugs such as Pradaxa, Xarelto or Coumadin. My A-Fib is paroxysmal. In 2011 & 2012, I had episodes every month, sometimes lasting 30 minutes to an hour---one time 2 hours. I have not had an episode since October 2012. I am just confused about this condition. I know it has not gone away, but why have my episodes have ceased? Thank you very much for addressing my questions about this mysterious condition.
Leslie_Cho,_MD: Technically, it is cardiac disease because it is from the heart but it is due to arrhythmia. Either you may have silent episodes or your PAF was due to something that has since been taken care of (sometimes it is decrease caffeine, controlling thyroid, etc.) or it can be quiet until later in life when it comes back and is more permanent.
ABC32: I am 32 years old and constantly have heart palpitations. They can happen when I workout or if I'm lying on the couch. I drink one to two cups of coffee a day and I sometimes have iced tea in the evenings. Do you think the palpitations are occurring because of the caffeine or do I need to get this checked out? I wore a heart monitor four years ago for the same problem and the Dr. advised that the palpitations were from stress. What are your thoughts?
Leslie_Cho,_MD: The number one cause of your palpitations are likely caffeine intake. This is a benign palpitations - most people with benign palpitations are having them while at rest and not with exertion and usually this occurs in women. We recommend that you avoid caffeine including coffee, tea, chocolate; dehydration; alcohol; and over the counter decongestants.
Peppy: I am reading more and more that migraines are not as benign as thought previously. Some are linked to heart disease. Why?
Leslie_Cho,_MD: It is true that patients with migraine with aura are at increased risk for heart disease. It has to do with endothelial dysfunction which is something that patients with cardiovascular disease also have. So - the treatment for migraine has also been geared toward reducing risk factors as part of the treatment plan.
deband: I am on Synthroid for hypothyroidism and sometimes I get heart flutters/palpitations. I read that Synthroid can cause them. Why, and is there anything to do for them? I am 57 and have been on Synthroid 75mcg for five months and on synthroid for two years.
Leslie_Cho,_MD: Synthroid does not cause this unless your thyroid level is off. Palpitations are normal in women your age. If it is because of your Synthroid then your TSH would be abnormal.
Vitamins and Supplements
pilatesgirl: Do you think calcium intake without proper vitamin D levels and K2 creates heart risks? I am concerned about the interrelationship of these supplements, and the amounts of calcium without mention of D and K that some doctors recommend to me. Thanks!
Leslie_Cho,_MD: Calcium supplementation has been shown to increase risk of heart attack, however, the data is still unclear on what is the right thing to do. Most of the time we recommend dietary supplementation for calcium intake. Vitamin D data is also quite unclear. There is association of very low vitamin D level - less than 15 - with some increase in cardiovascular risk however good randomized control studies have not been done.
sax64: Thank you so much! I benefited from the whole chat.
Leslie_Cho,_MD: We had a lot of great questions today. Thank you everyone for participating!
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