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Ask the Cardiologist (Dr Barzilai 6 14 12)

Thursday, June 14, 2012 - Noon


Cleveland Clinic is recognized as the world leader in diagnosis and treatment of cardiovascular disease and has been ranked No. 1 in the nation for cardiac care by U.S. News & World Report every year since 1995. Dr. Benico Barzilai from Cleveland Clinic answers your questions about the latest treatments and diagnostic tests for cardiovascular disease.

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MikeN: 61 yr. old male – AMI July 2000. RCAE Sept. 2010. Had all the typical ultrasound vascular tests on extremities, aorta, etc. in 2009. No issues found. Very well controlled lipids and blood pressure. On heart healthy diet. Exercise regularly and have very high age adjusted fitness level. Absolutely no heart related symptoms, even during heavy exercise. I have had echo/treadmill stress tests as recently as 2009 and a treadmill exercise stress test in 2011, with no problems at all. I recently had x-rays taken and one of the comments in the results was “extensive vascular calcification”. Given my history, is there anything else I should be doing? I sometimes feel as though the calcification process has to be progressing in my coronary arteries, and will sneak up on me one day. Can exercise generate sufficient collateral artery growth to offset what seems to be an unstoppable process, and can diet slow or reverse the process?

Dr__Barzilai: I am very aggressive in risk factor management in patients such as you. I would make sure that your:

  • Ldl is less than 70 mg/dl 
  • Blood sugar is controlled 
  • Weight and blood pressure are good

In my experience many people with calcification of vessels also have metabolic syndrome (NHLBI defines this as extra weight around your waist, insulin resistance or elevated blood sugar along with high blood pressure, elevated triglycerides and low HDL- (see ). We have to treat aggressively all the components of metabolic syndrome.


liesel: On 2/2004 I had two bare metal stents back to back in the LAD. In April of 2004 I received intra vascular brachytherapy into the two bare metal stents due to restenosis. At that time I also got a DES in the first marginal. No complications. In December of 2009 heart catheterization showed a 50% blockage in one of the bare metal stents. I was told if and when the blockage gets higher, cardiologist would insert medicated stent inside bare metal blocked stent. My question: Are there any other procedures you might do for removing the blockage inside a bare metal stent: maybe just cleaning it out? Also do you still do the radiation therapy? Or might there be a new procedure out there? I am rather nervous about putting a DES inside a bare metal stent that previously had radiation therapy.

Dr__Barzilai: Brachytherapy is not done any more. We now routinely put DES (drug eluting stents) into bare metal stents that are reblocked (restenosis). Using a procedure to clean out the vessel without a DES often results in restenosis about 30-50% of the time. DES has really been a major advance for the problem of restenosis.

RobV: Have a history of coronary artery disease and had multiple stents placed. Cath was done yesterday as patient was having episodes of angina. Known blockages of 60% are now less than 20%. Is such dramatic regression possible?

Dr__Barzilai: Yes - it has been shown by others that this is possible. Plant based diets with very low fat has been shown to promote regression and high doses of statins such as rosouvastatin 40 mg has been shown to promote regression.

tbsaxena: After having a heart attack last July, I got a DES in my RCA. Next month I got three more DES due to still having intermittent jaw pains. I take Thrombyl 75 mg, Clopidogrel 75 mg, Metoprolol 50 mg, Felodipine 2.5 mg, Ramipril 2.5 mg. No my Total chol is 117.0 mg, LDL 54.6 mg, HDL 39 mg and Trigl 123.71 mg. all blood reports are normal. But after these events my muscles have become very weak. If I lift even 1 kg I get pains spreading from arms, to shoulder to the jaws. I freeze a lot, even at 20 degrees. When I freeze my legs get cold and I get jaw pains. ECG and Echo don’t show anything and Nitro does not help. They say these are not from heart. But my life has become very difficult due to the constant pains. can you please tell me what could be the cause and what should I do? I walk for 30-40 mins everyday and do Yoga for 30 mins. The pains are not related to these activities. I am 64 yr old lady, living in Scandinavia.

Dr__Barzilai: It is difficult to give you an exact cause without evaluating her directly. This is not a typical response after DES. You should be evaluated for both cardiac and noncardiac causes for muscle pain; such as rheumatologic disorders.

Bypass Surgery

gmptg74: Male 61 years old, not overweight, low cholesterol, treadmill stress test of over 15 mets without stress, heart catheterization revealed significant collateral circulation and a 100% LAD artery blockage. Should I risk my life to get bypass surgery?

Dr__Barzilai: This is a hard one to answer. Is this impacting your lifestyle? Do you have symptoms? Are you able to do what you want to? Is your heart starting to enlarge? This is very individualized for each patient. If you are having symptoms, it is very worthwhile to go in for single vessel bypass especially since at this time, there is such low risk (at Cleveland Clinic there is a 1% mortality).

Heart Rhythm– Arrhythmias

SMDTS: Do Cleveland Clinic cardiologists increase tikosyn on an outpatient basis or does an increase require the 3 day hospitalization period required initially for this medication?

Dr__Barzilai: We do not do that as an outpatient. We are very religious about checking the EKG after every dose for 6 doses, which is why the patient is hospitalized.

jtrogus: I was diagnosed with afib in Feb. I am told that the coumadin inr must be in therapeutic level for four weeks before the ablation can be performed. They are having difficulty achieving that because of drug changes. I go into afib about every other day with drastic drop in BP. Is there any way to speed up this process? It is killing me and my wife. We have had 7 trips to the ER. Any help would be appreciated. Thank you.

Dr__Barzilai: It is difficult to tell you without knowing the full situation and medical history to tell you what to do. We would be happy to see you - there may be other options for you.

SMDTS: Is there a relationship between atrial fib and anxiety or increased stress?

Dr__Barzilai: In people who are prone to atrial fibrillation, increased stress and anxiety seem to increase the incidence of these episodes.

hoagie0013: dr. can heart disease cause irregular heart rhythms such as bradycardia

Dr__Barzilai: Absolutely. Coronary artery disease, particularly of the right coronary artery has been related to bradycardia, particularly during an acute heart attack. You should be evaluated if you have bradycardia.

redtaytom: How much should you heart rate fluctuate during the day? How does that correlate with one's resting heart rate? is that true for tachycardia as well

Dr__Barzilai: It is very normal for your heart rate to fluctuate from 50 to 90 beats per minute. Usually lowest when you are asleep and usually highest when you are active. With some tachycardia syndromes, the heart rate does not fluctuate much at all. That is very abnormal and should be investigated.

mmcsherry: I had open heart surgery for mitral valve replacement and on artery bypass in January of 2010, at Cleveland Clinic and an ICD implant in May of 2010. In Oct. of 2011 it was detected that I am in a fib, now controlled by medications. Is this a common occurrence after the type of surgery that I had?

Dr__Barzilai: Atrial Fibrillation is very common immediately after heart surgery and some patients have it afterwards as well. Sometimes there is inflammation of the heart after surgery which seems to promote the afib. If you are tolerating it well, no additional therapy other than to control your heart rate and blood thinning medications to prevent blood clots are needed.

Flames12: My husband 53 yr old healthy male had a catheter ablation to treat his WPW syndrome on May 10, 2012. His heart was perforated-first complication. The second complication is his central pathway in his heart was in ablated causing complete cardiac failure and required a pacemaker. Upon release from the hospital he was completely paced--this week we had a follow-up visit with his EP doctor. The doctor told us that his WPW pathway, which he tried to ablate, has regenerated and his electrical system in his heart is using the WPW pathway to beat. Have you ever heard of something like this happening? How much can you depend on an electrical system using a partially ablated pathway in his heart?

Dr__Barzilai: This is a very unusual manifestation of ablation surgery but certainly not unheard of. We would recommend a second opinion.

liesel: I have moderate MVP and had 8 episodes of extremely high afib within 17 months. It usually lasts from 2 to 6 hours and just goes back to normal. It jumps from around 150 to 200 and then my pulse goes back to 60ish. I usually just take an aspirin, 1 xanax and try to relax. I was hospitalized once and given the usual afib meds which I cannot tolerate. I am now just on my usual generic Toprol XL. I think at my next afib episode I will just take an extra 1 or 1/2 of the Toprol. Would that be advisable???

Dr__Barzilai: You really need to be seen by an electrophysiologist. There are many options for treatment.

rsck: What heart rate is considered tachycardia? Mine is usually between 90 and 105. It will sometimes go down to the mid to high 80s. But at night I often have faster, more intense beating, with AF which can make it difficult to sleep. Why does this happen more often at night?

Dr__Barzilai: It used to be thought that 100 was the upper limits of normal but more recent data suggest that 50 - 90 is the normal range. You should be evaluated if your heart rate is consistently above 90.

SMDTS: When afib is managed by medication, can illness trigger an episode

Dr__Barzilai: Sure - there are many triggers for atrial fibrillation including an illness.

Valve Disease and Valve Surgery

tractorgirl: I also am curious about a more noticeable heartbeat after valve repair. The heart rate is not elevated, it just seems louder. I have heard that sometimes the pericardium is not closed after surgery. In these cases, does the pericardial sac remain empty of fluid? Might this create the thumping sensation? It does seem to be louder when I lie on my left side. Maybe I am just paying more (too much?) attention to my heart now....Thanks.

Dr__Barzilai: Definitely in many cases the pericardium is left open after heart surgery. But in my experience after heart surgery, many people are more aware of their heart and more cognizant of their heart beat. This does not mean there is any problem - unless it is irregular.

tractorgirl: My third question is about Barlow's Disease, which was the underlying cause of my mitral valve disease. I haven't been able to find much information about this disorder other than it's a defect in the connective tissue. I have only found it mentioned in relation to the mitral valve, but if the defect is metabolic it seems it would affect other tissues. For example, if the blood vessel walls are weak and stretchy, what implications does this have for blood pressure? Thanks for your patience with my questions. I really enjoy these webchats and I learn a lot from them.

Dr__Barzilai: Barlow's Disease is a name for a severe form of prolapse. It is named after a cardiologist and does not refer to any specific cause. When I see a patient with severe MVP I look for other manifestations of a systemic disease such as Marfan Syndrome or Ehlers-Danlos syndrome, however the vast majority of patients with MVP have no other conditions in other organ systems.

mitral2011: Dr. B, I underwent mitral valve repair surgery (minimally invasive, port access) on Dec 8, 2011 by Dr. Gillinov. Six months after surgery, my valve has no regurgitation. However, my ejection fraction has been low since the surgery. Ejection fraction was 65% before surgery but has been around 30% after surgery. Dr.Gillinov and my cardiologist suggested that it should improve with time but has not improved after six months. My cardiologist is still hopeful that it will improve with time and we will not have to consider implanting a defibrillator. I am very active and have resumed all my physical activities (jogging, swimming, biking, golf, etc) and am totally satisfied with my quality of life. My question is, after what duration after surgery can I conclude that the ejection fraction will not improve and I should consider implanting defibrillator? Thank You.

Dr__Barzilai: Sometimes with optimization of medications I have seen improvements in the ejection fraction even after 6 months. However, the vast majority of patients see their improvement by the 6 month point.

mmcsherry: My ejection fraction was and continues to be between 15 and 20% Both pre and post mitral valve surgery. I'm told that ef is just a number and that I shouldn't look at it as anything but just a number. Is this true?

Dr__Barzilai: It is kind of true - if you are feeling well and able to do what you want to do - you may not need to do much more than medical management (beta blockers and ace inhibitors).

roullac: Hello Dr, I had severe mitral regurgitation and I had surgery to repair it. I also had mild tricuspid regurgitation and I was told once my mitral valve would get repaired then I will no longer have regurgitation from my tricuspid valve. How does that work could you please clarify? It is almost 3 years since I had my surgery and I still have mild regurgitation from my tricuspid valve. Is there a possibility that over time it may still correct itself? Thank you.

Dr__Barzilai: The blood that backs up into the left atrium from mitral regurgitation is associated with increased pressure in the right side of the heart. This causes the right side of the heart to enlarge and then you get leakage of the tricuspid valve. If the stress on the right side of the heart goes down after MV surgery then one would anticipate that the TV leakage would improve. Mild regurgitation is not a concern at this point.

tractorgirl: Last year I had my severely regurgitating mitral valve repaired. Two pre-op echoes showed an ejection fraction of 60 and 62%. The 3 day post-op echo showed an EF of 52%, and the one year echo showed an EF of 53% but my cardiologist said he would have called it 58% and it was fine. Yet I wonder why all these measurements are lower than when the valve was leaking so badly that more blood was flowing backward than forward. Can you explain? Thanks.

Dr__Barzilai: It is very hard to know the exact strength of the heart muscle before surgery when your valve is leaking since so much of the blood is flowing backwards the EF (ejection fraction) may be falsely elevated. After surgery - the heart no longer has so much blood going backwards so the EF is now a much more true indication of the strength of the heart. Also we must take into account the accuracy of the EF may be plus or minus 5% depending on the proficiency of the technician.

rsck: Can you end up with more energy after valve repair or replacement surgery and does it stop AF?

Dr__Barzilai: Many patients with valvular heart disease have fatigue prior to surgery and feel much better after valve replacement or repair. They may need to do an additional procedure such as maze procedure to stop your atrial fibrillation (AF) during the valve procedure.

Plano1974: I have had endocarditis twice. I had my valve replaced in January and I need a root canal. I have a biologic valve. I should get antibiotics before I have my dental appointment? Should they be IV or can I just take pills?

Dr__Barzilai: Because you are a special high risk category - I would consult with an infectious disease physician for specific recommendations.

rsck: Female 65. After 3 bouts of endocarditis, open heart surgery to repair valve, 3 PVAs, I still have trouble with energy. Had more damage after last bout of endocarditis in 2010. Lifestyle affected. Would surgery to repair or replace valve improve my energy?

Dr__Barzilai: We have had a lot of success with minimally invasive surgery however with your prior medical history and procedures, you may not be a candidate. We would need to evaluate you and look at your medical records.

gkh: is minimally invasive surgery EVER performed after an AVR has already been done?

Dr__Barzilai: Sometimes they can do procedures on the mitral valve - it depends on scar tissue and other indications.

gkh: TAVR/TAVI can't be done on the aortic valve if it has already been replaced?

Dr__Barzilai: yes - only if it is a bioprosthetic valve. This valve in valve procedure is in the investigational stages.

Heart Failure

Kristine: My mom had her BNP checked and it was 395. She has high blood pressure and is taking medications for that. Her doctor did not change any medications or tell her she had to do anything for this number. She seems like she is doing ok but according to the internet, she may have mild heart failure?

Dr__Barzilai: Does she have any evidence of edema (swelling) or fluid in her lungs (shortness of breath)? If she does - she may benefit from a low dose of diuretic.

Risk Factors for Heart Disease Cholesterol

Peppy: The news seems to indicate HDL meds being studies have not showed benefit. Is this the end of the story for HDL treatment? Our target should be LDL alone? I eat Dr. Furhman's diet and add salmon twice a week and my HDL has improved a little but it is a struggle to get it up to healthy levels without eating lots of nuts/calories.

Dr__Barzilai: There are still 2 drugs in clinical trials that raise HDL. Until these trials are completed we really will not know the answer of the effect of drug therapy that raises HDL.

Ashleysheronf: My husband is 35 years old. He has a family history of heart disease. He recently saw a cardiologist and had a coronary calcium score of 104, putting him in the 99% percentile for his age. He does not have any symptoms and his other tests came back normal. We are now following Dr. Esselstyn's diet. In your experience, has this reversed some of the blockages in your patients. Because my husband is young, I feel that we need to be ultra-aggressive for him to have a shot at a long and healthy life. Thank you for your time.

Dr__Barzilai: I would be careful of over-emphasizing the calcium score results. Just because he had that result does not mean he has significant blockage in his arteries. He could have minor blockages. However, I would continue to follow his lipids to confirm the effect of the diet. If you want to be very aggressive we try to get the LDL under 70 mg/dl.

asgalian: At what numbers is blood pressure too low?

Dr__Barzilai: A lot of women have very low blood pressure and are not symptomatic. In general, I try not to get blood pressure below 90/60.


SamH: I had a quadruple bypass many months ago--I met with the hospital dietician and she told me eggs were fine to eat. However, a lot of the diets (such as DASH and the Spectrum heart disease reversal diet) prohibit egg yolks. Is there a consensus?

Dr__Barzilai: We just had a story on the blog, The Beating Edge, on eggs. There many questions and answers about this on our blog. Immediately post op many patients do not eat well and eggs are an excellent source of protein and more may be allowed. However after initial recovery, then we would make recommendations to 3 or less yolks per week but egg whites are fine.


hoagie0013: are there any new meds on the horizon to treat coronary heart disease. and what do you think of the approach of fighting heart disease with vitamins.

Dr__Barzilai: The newest thing on the horizon is HDL raising medications (in clinical trials) which may revolutionize heart care. As far as vitamins - we have been very disappointed over the years. Research has not shown any additional benefit. I would wait until someone shows you the data before accepting this approach.

Aorta Aneurysm

Mymom: Hi my mom was diagnosed with an ascending aortic aneurysm (5.1cm ) and aortic stenosis (AVA 1cm2) . Her cardiologist said she is in the grey zone for surgery.

Dr__Barzilai: We take a very aggressive approach for aortic surgery at our institution. She would be evaluated at Cleveland Clinic for aortic valve and aneurysm surgery. We have a process to send in records. Please contact us if you would like additional information.

Mymom: My 80yo mom diagnosed with ascending aortic aneurysm (5.1cm) last Nov, repeated CTA showed stable size in May. also has aortic stenosis with bicuspid valve (AVA1cm2). EF 71%. Physically able, lives independently, asymptomatic except SOB when walking fast. Cardiologist suggesting cardiac surgeon consult. mild stable dementia. Is surgery recommended and how urgent? Would endovascular therapy be an option for her? Would the use of cardiopulmonary bypass machine compromise cognitive function? Is there any other non surgical intervention to stall the aneurysm? can she do another stress Echo ?

Dr__Barzilai: Unfortunately endovascular therapy has not been used for this indication yet. Further more if she has AS that will progress and will undoubtedly need surgery in the next year or two.

Adult Congenital Heart Disease

Erin: My husband's cousin is 43 years old. She was just diagnosed with a PFO (hole in her heart) and an Atrial Septal Aneurysm. She has had migraine headaches for 20 years and after research, I found that there are many PFO patients who have migraines. She has not had symptoms except some pressure on her chest and a few bad shooting pains in her chest area. If she does not have a procedure to close it what is the risk of having a TIA or stroke? Is the catheter procedure perfected now that once it is closed there is no leakage? Would you recommend that she has the procedure? She has never had a TIA or a stroke, but does get migraine headaches. Would getting Migraine headaches put her more at risk for a TIA or stroke?

Dr__Barzilai: This is extremely controversial area. The FDA has not approved this use of the closure devices (for migraines). We need more data to make an informed decision. We do have some experts at Cleveland Clinic that see a lot of PFO and ASD patients and determine the recommendation on a case by case basis.

Other – Agent Orange

slick49: GW asks: effects of agent orange on your heart, Vietnam veteran.

Dr__Barzilai: I am not sure. Here is an article that may be helpful to you -  

Thank you

gmptg74: Male 63 had bypass surgery, but kept feeling worse. Had mitral valve repair at second hospital, but kept getting worse. I went to Cleveland Clinic for my second mitral valve repair (third heart surgery), and I am getting better. I learned the hard way to go to Cleveland Clinic first. Thanks to everyone at Cleveland Clinic because they helped me survive my third heart surgery in less than three years.

Dr__Barzilai: Thank you for your nice comments. We try very hard to be the best.

Reviewed: 06/12

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.

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