Ask the Cardiologist (Drs Nissen&Hubbard 9 24 12)
Monday, September 24, 2012 - Noon
Heart disease is the leading cause of death in the United States. It can take shape in any of a number of specific diseases that affect the heart itself and/or the blood vessel system, especially the veins and arteries leading to and from the heart. 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. Steven Nissen and Dr. Carlos Hubbard answer your questions about the latest treatments and diagnostic tests for cardiovascular disease.
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Ebvann: I had TOF surgery in 1960 at Mayo Clinic, pronounced complete correction. I am a 55 year old woman. No problems till recently now have been passing out. Echo was great in Jan; 24 hour heart monitor this past Tues/Wed revealed no issues. Earliest appt I could get at CC is Dec 19th. Are there any precautions I could take... anything I can do? The second episode was worse than first. Anything I can do till Dec 19th when I see the TOF expert there. After a week of trying to see my cardiologist I am going to a new one next Monday. My internist doesn’t have a clue what to do.
Dr__Hubbard: The evaluation for syncope can be complex and a congenital heart expert is helpful but also seeing an electrophysiologist who specializes in heart rhythm abnormalities may be beneficial. Testing such as tilt table testing; loop recorders or ambulatory monitors over a long period of time may be helpful.
Patients with congenital heart disease may have increased risk for heart rhythm abnormalities and that is why an electrophysiology appointment may be appropriate while waiting for your congenital heart disease appointment. Please contact our nurses to schedule an additional appt with our electrophysiologists - www.clevelandclinic.org/heartnurse or call 800-223-2273, extension 46697.
Heart Valve Disease
sinaihospital: I have heart valve stenosis also my ankle swells is caused by my aortic valve stenosis yes or no is there a link with people who aortic valve stenosis and migraine headaches yes or no
Dr__Nissen: It is possible for aortic valve stenosis to cause ankle swelling. But there are many other causes of ankle swelling so a careful evaluation by a cardiologist would be necessary to determine if the aortic stenosis is actually the cause. I am unaware of a link to migraine headaches.
fowens: Is there any correlation between alcohol consumption and the development of stenosis such as aortic stenosis?
Dr__Hubbard: No - there is no correlation. However significant alcohol consumption can lead to weakening of the heart muscle or cardiomyopathy.
fowens: If one has mild stenosis that does not yet require surgery what life style thing can be done to prevent it from getting worse
Dr__Hubbard: At this point, there are no known interventions to prevent worsening.
dennisr: I have a bad mitral valve which was damaged during a bout with rheumatic fever about 50 years ago. I am 64. I have afib, regurgitation, and stenosis as a result according to my cardiologist. My valve number is 1.2 which is short of severe as I understand. My symptoms are not debilitating. A couple of times a month I have a little shortness of breath, I have no swelling of my ankles, and my heart rate is pretty well controlled with Diltiazem (120 mg every third day), and I take Jantoven 5 mg every day basically. My INI holds between 2 and 3 quite well. My concern is when do you recommend either repair or replace the mitral valve? It seems to me the longer I wait the larger my heart becomes potentially causing problems in the future. And if robotic surgery has such a fantastic success rate now would be the time, rather than when symptoms multiply. Thank you.Dennis
Dr__Nissen: We do not recommend prophylactic repair or replacement of a valve. When the valve is sufficiently abnormal to cause increasing symptoms, surgery is often the next step. In a few patients, when the valve leakage is very severe, we may recommend valve repair or replacement before significant symptoms have occurred.
Peppy: I understand there is a new cholesterol medicine that seems to have no side effects that may be available in a couple years. Does it reduce inflammation and have a long term mortality benefit?
Dr__Nissen: There is a new class of cholesterol lowering medication that can be taken as infrequently as once a month by injection (PCSK9 inhibitors). The therapy has not yet been shown to reduce long term morbidity or mortality but many experts believe that it will.
Peppy: Are the PCSK9 inhibitors available now or still being studied?
Dr__Nissen: They are still being studied but may reach the market place within the next 2 to 3 years. There are trials - check www.clinicaltrials.gov for information on studies.
zenrunner53: Does lowering LDL below 40-50 cause regression of existing CAD more than an LDL 0f 60-70?
Dr__Nissen: There is some evidence that suggests the lower the LDL the better with respect to regression however this has not been proven beyond shadow of doubt and is the subject of ongoing studies.
mlg944: I have been taking Lipitor for 8 years; are there adverse health effects for taking statins for this period of time, are there alternatives?
Dr__Nissen: The longer you take a statin the greater the benefits. There are no alternatives at this time.
Stentman: are there "natural" ways to improve your "good" cholesterol?
Dr__Nissen: Yes; vigorous exercise has been shown to improve good cholesterol (HDL). There is also some evidence that a moderate intake of alcohol can improve good cholesterol levels in some patients.
jayshree: I heard Statins causes muscle weakness
Dr__Nissen: Statins do sometimes cause muscle weakness - if you have this symptom you should discuss this with your doctor.
RayMC: I am a 65 yr old male with asymptomatic heart disease. Non-smoke/drink and take 81mg aspirin + 40mg simvastatin daily, being hypercholesterolemic. Blood pressure is normal. In 12/2010, I experienced a Branch Retinal Artery Occlusion. 2012; follow-up: Carotid Doppler showed thickening of Lt IMT and unchanged multiple calcified atheromatous plaques Cholesterol 175, HDL 46, LDL 85256 Slice CTA both Carotid Arteries: mild atherosclerosis with no significant stenosis CTA of Coronary Artery: CAC = 2020.78At peak of exercise 11:01 min, 13.40 METS, 88% PMHR revealed increase in wall motion and wall thickness with hypokinesia in apical septum, apical to basal lateral, posterior with ST depression in II, III, aVF, V4-6, and frequent PVCs, triplet PVCs w/o angina or discomfort. I declined an angiogram. My sense is to continue the meds, manage my diet and have another lipid panel/carotid doppler around Jan. What does the historical data suggest my life expectancy to be? Do you agree with my game plan?
Dr__Hubbard: We agree with your current plan because you are not having symptoms and you are addressing your risk factors. In the absence of symptoms, angiography is not recommended. If you do not have a greater than 50% narrowing of your carotid artery we do not recommend a follow up scan so soon. With your excellent exercise ability your overall life expectancy is good.
Peppy: I am reading more and more about atherosclerosis possibly starting in the "gut". Could this be?
Dr__Nissen: There is some emerging evidence that the bacterial flora in the gut may be related to development of atherosclerosis but this is in early studies.
mlg944: I have plaque in both of my carotid arteries, about 40 % blocked with complex formation in left carotid - Is there a way for me to help clear out the plaque without surgery??
Dr__Hubbard: No. But, aggressive cholesterol lowering and blood pressure control will help to decrease your risk of complications or stroke with carotid artery disease.
Abruner2001: I am a 34 year old female, who has heart disease on both sides of my family. My mother had her first heart attack at 45 and another at 48, she is 59 today with 3 stents, my father had open heart surgery at 67, he is 76 now. I use to be on high blood pressure at 21, but recently was taken off after they put me on celexa for anxiety...my blood pressure has been 96/60. What can I do to lower my risk factors?
Dr__Hubbard: The number one thing you can do is regular exercise - at least 30 minutes of activity daily. You should know what your cholesterol is and also cholesterol lowering with a statin medication if appropriate.
Irregular Heart Rate or Rhythm
Francois: Is symptomless bradycardia (heartbeat between 50 and 60) probably caused by Risperdal Consta and present for several years harmless? Heartbeat increases somewhat when I am not resting. My bradycardia is not indicated by my EKG because I suffer from white coat hypertension which also increases my heart rate in a medical environment. It is shown by my automatic blood pressure monitor; which also gives heart rate. I am a fairly healthy 74 year old male.
Dr__Hubbard: Asymptomatic bradycardia in otherwise healthy individuals, such as in people who have heart rates in their 50s, is typically not of concern. There may be interactions that result in bradycardia, but as long as the patients remain asymptomatic with no decrease in quality of life, and if the medications have significant benefit - they should be continued. In regards to the Risperdal, there are some cardiac rhythm affects in some patients but bradycardia would not be a common reaction to the medication.
roger: hi, I went to the cardiologist because it seemed like my heart was pounding. when I went he said I have a slow pulse, around 50... gave ekg, echo, said everything looks normal, I still don’t feel good, headaches, fatigue, indigestion, anxiety. My question is what else would cause my slow heart rate (I don’t exercise), and are these symptoms of a slow heart rate? thank -you...........
Dr__Nissen: It would be important to make certain that your thyroid studies are normal since hypothyroidism can cause a slow heart rate and some of the other symptoms you are describing
garchinh: I am a 62 year old male and have been treated for high blood pressure since I was in my 20s; it is reasonably well controlled and generally 125/70. In 2009, I had a single bypass to deal with an 80% blockage (widow maker). I exercise regularly, swimming mostly. When I exercise, I often notice that my heart beat becomes irregular, skipping beats. Also, after I exercise my pulse rate often stays between 85 and 95 for the rest of the day. When this happens, I find that it is difficult to relax. I am on Lotrel 10/40, simvistatin and 81 mg aspirin. My cardiologist is not concerned about the heart rate but it does bother me. Would there be any reason to change meds? Also, is there any reason to be concerned that my heart rate doesn't return to normal after exercise?
Dr__Hubbard: It is important to see what the irregularity is. Wearing an ambulatory monitor while exercising will help to determine whether the rhythm requires change in therapy or further testing.
Stentman: I had a stent put in 6 weeks ago; now I am told I have an irregular heartbeat; are these 2 events related? how quickly, if ever should I have my irregular heartbeat fixed? thanks
Dr__Nissen: It is unlikely that these two events are related. Your irregular heart beat should be completely evaluated.
Stentman: would an ablation procedure be more risky for a patient who also has myasthenia gravis?
Dr__Nissen: An ablation procedure would be more risky in a patient with myasthenia gravis due to the risk of anesthesia in a patient with myasthenia gravis.
FibroJoe: Pacemaker installed. No symptoms at all. 6 yrs. earlier, stent implant; Found 11 blockages per two cardiac CT's. 15 months ago, due to low pulse, pacemaker implanted. As adult, resting pulse has been 55-60, normal for me. According to the heart Docs, needed the pacemaker immediately due to an intermittent pulse drop below 30. Pacemaker at 70. For last 15 months, experienced almost continuous palpitations/poundings attributed to premature atrial/ventricular contractions. These are bothersome and become more so when at rest, worsening sleep. Recent check of device by St Jude revealed a ventricular abnormality showing up in all past reports, but just discovered by the surgeon's staff. Use bedside Merlin monitor. What can I do about these bothersome palpitations/poundings? How can I determine the optimal setting for pacemaker since this seems to be an area of disagreement between current Docs? Who would be best choice for cardiac evaluation at CC per my experience and frustration?
Dr__Nissen: You will need to see one of our cardiac electrophysiologists. We are happy to see you and do offer same day appointments. 800.223.2273 ; ext. 46697.
Peppy: I heard a woman cardiologist in the Maryland/Washington area speak on a heart panel. She had looked at stents placed in the heart arteries and has seen some pretty bad inflammation. She said the stents increased atherosclerosis after placement. Something that didn't show up in early studies and was not expected. She is strongly against getting a stent at all. Do you agree?
Dr__Hubbard: There is always some injury and inflammation after stent placement however the trials that have studied the efficacy of stents in appropriate patients clearly show the benefits in appropriate patients.
Dr__Nissen: But a stent is not right for everyone and the decision should be taken after careful discussion with your physician. In certain cases, like a heart attack, stents are placed urgently and have been shown to have a life saving benefit.
Peppy: I was told five years ago by my cardiologist that Metropolol Tratrate prevented many repeat heart attacks in many studies. But I've read lately that it is a drug used as a second choice and actually can shorten ones' life. What is the story on this medicine? How long should you take it after the first heart event? Does it affect lipids adversely especially triglycerides? Does it cause weight gain?
Dr__Nissen: Metoprolol reduces the risk of death after a heart attack; but is not the best choice for hypertension. We generally recommend metoprolol for 2 years after a heart attack.
Dr__Hubbard: If there is significant heart damage after a heart attack; metoprolol succinate is preferable to short acting metoprolol.
Dr__Nissen: There may be a slight adverse affect on triglycerides.
sm: Father's Brief Med History: 88yr age with renal transplant in '00, Angioplasty in '00; Angiography in Nov '11 & all clean. Recently had spinal fusion. DM2 and HTN and lipids. Typical BP around 125 - 135 systolic and 55-65 diastolic with pulse 43 to 55. Walks 1.5 to 2 km a day. 1. Is aspirin 100 mg of benefit at this Age or would daily clopidogrel be better if cost is not an issue. He is not clopidogrel resistant but has some aspirin resistance per Mayo tests. 3. Could Vit-K2 help? 4. How much EPA omega3. Read that EPA is more beneficial than DHA. Currently takes 130mg * 2 EPA per day. Would you recommend more EPA.
Dr__Nissen: Aspirin is indicated in patients with known coronary heart disease; there is no clear evidence for a benefit with long term clopidogrel. There is no indication for vitamin K. There is no evidence for a benefit from omega 3; regardless of whether it is EPA or DHA.
clara823844: I am gaining tons of weight. Could the meds I'm taking be the cause of my weight gain (amiodarone, metoprolol, avapro, and furosemide)? I'm exercising and cutting my calories.
Dr__Hubbard: One thing to consider would be hyopthyroidism as a result of amiodarone. It can happen with this therapy. Your doctor should your thyroid function and also to determine if the weight gain is fluid vs. fat.
adourian: Once one has had an afib episode and even if it was classified a lone paroxysmal episode does it make a future episode more likely?
Dr__Hubbard: Yes. A further episode is likely. We generally recommend consideration of anticoagulation in patients with atrial fibrillation.
adourian: I had an afib episode recently and the only triggers seemed to be dehydration from coffee consumption and exercise and lower than normal potassium levels. Could a mild form of hypokalemia have caused the condition? Can better hydration and higher consumption of foods high in potassium avoid future episodes?
Dr__Hubbard: Caffeine consumption and potassium loss have seemed to be triggers for afib for some patients. But a high potassium diet should be discussed with your doctor before starting one in case there are other considerations such as kidney dysfunction which would be a contraindication to this type of diet. Other activities particularly exercise should not be avoided with no clear indication that they are particular triggers for afib.
octubre: afib and stroke, is the chance of a stroke only during the afib episode and 24-48 hours after or is it consistent after a diagnosis of AFIB? That is to say, does the risk remain constant once you are diagnosed? Thank You
Dr__Hubbard: The risk remains constant and for patients who are deemed to be high risk for stroke may need to be placed on blood thinners other than aspirin.
rugbydog9: Are there any other options besides a CTA or a cardiac cath to determine whether I am at risk for a heart attack. I already had a negative echo stress test. Is there another non-invasive, low radiation option for further diagnosis beyond the echo stress test?
Dr__Nissen: We do not recommend CTA to screen for risk of heart attack and we do not recommend stress testing in patients without symptoms. The best defense is a healthy lifestyle and cholesterol and blood pressure medication if needed.
cheryl: My Cardiologist has ordered a CAT for my heart . LY had a positive Stress test. Heart Cath proved clear. I still have SOB and Chest Pain on exertion, walking on incline. Min Exertion. Heart monitor shows I still have Rapid irregular heart rate and taking meds. Why would he order the procedure? What are the expectations to find? Thanks
Dr__Nissen: It is difficult to make a recommendation without knowing more about your case but in general a heart cat scan is not useful when the catheterization is normal.
clara: I had open heart surgery 2006 (aortic valve / 2 grafts) - 2009 - 2012 I have had 7 grafts in all the major arteries. None have been restented. I had the last stent May 3, 2012 & was told I would need surgery, because the tricuspid valve is now severe. The mitral valve has gone from mild to moderate in a short time. I don't know if that matters. I was told that they would have to wait until I can go off Plavix. My concern is the last 6 weeks I have developed symptoms ( chest pressure upper chest or hard to breathe. It is hard to describe. Also lightheaded at times with it. This past week I am unable to do anything without symptoms that are concerning. Nitro helps somewhat. Is this valve or arteries. I know that it is progressing. Thank you so much for answering questions for all of us.
Dr__Nissen: We share your concern about these symptoms and recommend that you see your cardiologist promptly for re-evaluation.
gatorfrog: I have been diagnosed with Prinzmetal's Angina/Microvascular Disease. I am currently on Verapmail, Lasix, Potassium and Digoxin. I am wondering how often do I have to be tested to see if there are any changes in my condition. I am having a terrible time walking up a flight of stairs w/o getting winded and if I take a walk on level ground, my legs are killing me afterwards, they hurt so much. I don't know if this is cardiac related and that is why I am asking the question about being tested. Thank you so much!
Dr__Nissen: Your symptoms may be cardiac related and also peripheral arterial disease is possible. You will need to be evaluated by a cardiologist.
susma: My 6 year old son has Aortic Stenosis, bicuspid aortic valve and dilated ascending aorta. His recent measurement of the dilation was 5.5cms. His cardiologist warned us about a rare possibility of aortic dissection. We learn from many sources that an adult with a 5.5 or 6 cms of dilation needs to undergo surgery as soon as possible. We would like to know if that's the case for children also. Also, my son comes back home from school some days, complaining of his back hurting. Is this something to worry about? Thank you for your answers. - Susma
Dr__Hubbard: Your son needs to be evaluated promptly by a pediatric cardiologist at a major medical center; particularly with his history and symptoms. We are happy to see him at Cleveland Clinic.
sharig153: I just got diagnosed with enlarged heart, for which I'm taking Toprol and Altace. Do we know what causes enlarged heart? And is there anything lifestyle-wise I can do to help? I'm already a vegan and exercise regularly. Is lack of rest a factor (I don't always get a full 8 hours of sleep)? I also have mitral valve prolapse. Are the two related?
Dr__Hubbard: The causes of heart enlargement are numerous and medical therapy can be an effective way to treat and sometimes improve this problem. But, an evaluation with a heart failure specialist is vitally important for long term success. Mitral valve prolapse is likely unrelated but mitral regurgitation can be seen with heart enlargement and may need further investigation.
Poor Ejection Fraction
mikeK: my wife has an EF of 35-37 for the last 5 months and after an echogram still remains at the same number, she had an episode in march of a racing heart which eventually was shocked back into arrhythmia, and now they want to put a defib unit in her, she has never had any previous problems, she is 60 years old. She is on 2 meds right now, but we are hesitant with this procedure, and are wondering if diet and exercise can move her numbers up, she is 5ft 5in, 150 lbs, slightly overweight, no history of heart problems on her dad’s side or ma's side. You are 180 miles away were in buffalo, and have heard great things of your clinic, I am looking for some guidance...PLEASE. .... Thank you in advance for your troubles.. Mike
Dr__Hubbard: The best treatment can only be recommended if we know more about the cause of the low EF. Does she have CAD, cardiomyopathy? Some people may improve with optimal medical therapy; but others do not; so having that background information is important when recommending advanced therapies.
nancyh: 82 year old man with defibrillator ,biventricular pacing ,,echo below 30 with ITP and Wandrenstroms -some sob and fatigue course of rituxaban, on promacta at what point do you transfuse with blood products for anemia. Platelets stable in 40's.
Dr__Hubbard: This is a difficult question because it involves both cardiology and hematology issues. In general, we recommend transfusion when patients develop symptoms from their anemia but otherwise not routinely.
jayshree: Father's Brief Med History: 88yr age with renal transplant in '00, Angioplasty in '00; Angiography in Nov '11 & all clean. Recently had spinal fusion. DM2 and HTN and lipids. Typical BP around 125 - 135 systolic and 55-65 diastolic with pulse 43 to 55. Walks 1.5 to 2 km a day. With higher fluids we start developing PH (from left heart) and left atrial dilation. Current is ~2.5 liters brought down from ~3.5. Less fluid is leading to High uric acid. More leads to PH and LA dilation. How much fluid do U recommend at this age?
Dr__Hubbard: In general; for patients with heart failure, we usually recommend 2 liters of fluid daily with allowances for more or less depending on other conditions.
Elis: Have an EF of about 25 percent. Unable to take drugs (ace inhibitors, beta blockers, even aspirin is difficult. Have, what has been called, stage 4 congestive heart failure. Two major heart attacks a year apart. First one blocked the major artery on the right side. Second one on the left (widow maker.). Do you know of anyone successful in using natural foods or herbs, etc, vitamins on those with a lot of heart muscle scaring. I eat only simple natural foods now weighing 210 lbs at 6 feet tall.
Dr__Hubbard: Good diet and exercise are important but at this point you should be considered for advanced therapies if you are very symptomatic such as LVAD or even transplant if appropriate at a large medical center.
Jenny: My 58 yr old son who sustained a traumatic brain injury at age 19 in 1973 is experiencing low blood pressure. I want to know something about this problem and if it can be harmful to him, especially with his TBI. He has been dizzy a couple of times, fallen at least once and his thinking capacity appears to be diminishing. Mark is an early TBI survivor, before early 70's 90% of TBI injured people simply died, now they survive, but no one really knows what to expect from or for this population. Can you give me some info. He is living in a TBI residential facility -- Belden House here in Santa Rosa, CA and they have him on several medications, including Inderal, which I understand can cause low blood pressure. I want to do what I can to help my son stay as alert and viable as possible, and I'm getting scared. So any low blood pressure info you can give me would be appreciated. Thank you.
Dr__Hubbard: The cause of the low blood pressure needs to be investigated. You are correct that inderal may be a problem here. Your doctor may want to look at other drug options if other causes of low blood pressure are investigated and ruled out.
JJAltoona: Hello, I am a 56 year old male with a history of 2 MI's (3 & 6 Yrs ago). I have an MRI measured LVEF of 41% and a partial LBBB. I am taking Lisinopril 1 per day (2.5mg) & Carvedilol twice per day (12.5mg) with a normal BP of ~95/60. I still go bicycling (20-40 miles) but have noticed that my blood pressure plummets (65-75 over 40-45) after my ride if I have taken my meds before I ride. I feel better and my blood pressure remains closer to normal if I wait until after my ride to take the meds but am wondering if this is a normal reaction and if it's safe to wait until after my ride to take my meds. Thank You.
Dr__Hubbard: We typically recommend that patients continue medications as scheduled as long as they are asymptomatic with their low blood pressure.
scottie: I have arterial fibromuscular dysplasia in my cervical arteries and renal arteries. Occasionally I am woken with squeezing chest discomfort which subsides after about half an hour. The possibility of Prinzmetal angina is being explored. What tests would you advise, given that an angio may not be as safe due to the stenotic and dissected vessels, and a stress test is not possible for me due to physical limitations? Recent findings seem to be linking FMD and SCAD. Is this something you have been finding in your patients also? Thank you.
Dr__Nissen: You should be evaluated by one of our FMD specialists and can recommend appropriate therapy and testing. Ask for Dr. Heather Gornik or one of her colleagues - 800-223-2273 , extension 46697.
Peppy: Thank you so very much to both doctors for taking their time to answer our questions/concerns.
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