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Ask the Heart Doctor (Dr Barzilai 10 28 13)

Wednesday, October 30, 2013 - Noon


Cardiovascular disease is the leading cause of death in the United States and Cleveland Clinic is recognized as the world leader in the diagnosis and treatment of cardiovascular disease. Cleveland Clinic has been ranked No. 1 in the nation for cardiac care by U.S. News & World Report every year since 1995. Cleveland Clinic cardiologist Benico Barzilai, MD answers your questions about your heart.

More Information

Moderator: Welcome to our "Ask the Heart Doctor” online health chat with Benico Barzilai, MD. We are very excited to have him here today! Let's begin with the questions.


Zen: Is severe nausea a symptom of heart disease or a heart attack?

Benico_Barzilai,_MD: It can be - particularly in a woman. You would need to be evaluated for associated symptoms such as shortness of breath, chest tightness, and sweating. Not everyone with heart disease has classic chest pain. On the other hand, severe nausea could be a symptom of other things as well.

Jamie Tuttle: Sometimes when I stand up from sitting I get a rush of pressure in my neck and head, occasionally it is so much that I can hear my heart beat in my ears or the sound goes in and out until the pressure goes away. Others times when I lay on my stomach to play with the kids or watch TV, the same thing happens, the rush of pressure to my neck and head, then after a few minutes it goes away. What could be causing this to happen?

Benico_Barzilai,_MD: It may be helpful to check your blood pressure from sitting to standing to see if there are drops when you stand. This condition is called orthostatic hypotension. It is also possible that you are having abnormal heart rhythms and you would need an ambulatory monitor to see what is occurring during these times.

Xomue: If a person in the 70's feels a little chest pain or tightness when walking up hills (sometimes, but not always), is that cause of further testing? Or is that something that is to be expected at this age? My relative experiencing this has no other sign of heart problem and his blood work is within normal limits (although his total cholesterol is at the high end of normal).

Benico_Barzilai,_MD: Yes - that should be evaluated. You may need a stress test or echocardiogram.

okie694: I had to get a heart monitor three years ago because I was experiencing difficulty breathing and racing of the heart. The tests came back and said that nothing was wrong. For the past six or seven months, I have been having pains in my chest and I am having difficulty breathing when I am not doing anything out of the ordinary, but especially when I walk up two flights of stairs at work. When I walk up the stairs, it takes about a minute at least to calm my heart. Also I am feeling like my heart is skipping a beat at random times and my chest will get very tight. I have googled these symptoms, but I am getting a lot of different answers so I am wondering what I need to do about this?

Benico_Barzilai,_MD: It sounds like you may need a more complete evaluation. You may need a stress test to look at your heart more closely. You may also need an echocardiogram, and also more prolonged monitoring, such as an event monitor to pick up if you are having intermittent irregular beats.

Cathappy: Recently had a echogram completed. It showed that I had fluid on the bottom of my heart. Also, at night and even many times during the day I can feel my heart beating fairly quick. Especially when I get tired, it seems like it is beating crazy. Flutter type sensation. At times I find I have to catch my breath when I lie down and feel this. As well my ankles are swelling when I am on my feet to much, which I am. Never had this before. Concerns me, doctor is doing nothing as of now, and felt maybe I needed a second opinion. Heart problems are strong in the family, Should I get another opinion?

Benico_Barzilai,_MD: You seem to have significant pericardial disease possibly with fluid in the pericardial sac around the heart. You should be evaluated by a cardiologist specializing in pericardial conditions.

Harley1949: I had quadruple bypass in 2001. Around 2008 I started getting angina-like chest pains. Since then I have had several stress tests, two heart caths and at least 25 trips to the emergency room. In every case I have always checked out good. Exercise and stress do not make the pain worse. I have tried nitro and it does not change the pain. My question is, can people that have had open heart surgery develop scar tissue or nerve problems that can cause this type of pain years after surgery? I can tell you that this pain is very scary. I have always wondered if there is any possibility that one type of imaging over another might show any problems. I just do not seem to be getting pointed in the right direction when I talk to my cardio. doctor about this. I know this is a hard question to answer without seeing me in person but please tell me about your experience with your patients.

Benico_Barzilai,_MD: You are absolutely right - we would need to see you and review your angiograms. In patients I see, I look very closely at their catheterizations to look for large and small vessel disease to rule out any coronary artery disease as a cause of your pain. Sometimes I like to do assessment of coronary blood flow with tests such as PET scans or even stress MRI to really rule out any causing your disease. If these tests come out normal, then we would look for other causes - non-cardiac.

stuti: I am a girl of 16...I often suffer from a pain at the mid left of my chest accompanied by a back ache right behind the area of chest pain...its even harder to breath at that time especially while exhaling...but it doesn't really last for much becomes normal after I take rest...but then I suffer from shortness of breath for sometime.....I doubt that it is because of low level of haemoglobin because I even suffer from nausea at times....I just want to know. if it is really very serious??

Benico_Barzilai,_MD: Your symptoms suggest that you definitely should be evaluated by your family doctor who may elect to send you to a cardiologist.

Teenamd034: I'm deteriorating by the day with 37 disorders including a rapid worsening of my Dysautonomia! Now comas and seizures! So complicated that doctors can't help me and my life is on the line! I have a lifelong mystery condition a two untreated infectious diseases that caused two of my conditions! If I don't get help soon, this will be fatal! I've tried every foundation possible! Dr.john Fergeson at NIH went over my full history and his thoughts are genetic/immune and infectious diseases are playing a role! Help me please! I don't want to die!

Benico_Barzilai,_MD: You need a second opinion consultation - your options are MyConsult second opinion online or coming here for a visit with multiple specialists - in either option, you would need to have all your medical records and testing available for review.

issa01: Hello, my question is: I have my cousin he is 18 years old, he's athletic, does not smoke or drink, and he always has low blood pressure of 80/40 and sometimes he suffers from shortness of breath and cold extremities and dizziness. What is the cause?

Benico_Barzilai,_MD: It is possible that he has autonomic dysfunction (a condition where your sympathetic nervous system that controls your blood pressure and blood vessels is not functioning normally). He should be evaluated by his doctor.

miamickey: Female 59, total cholesterol 500, had open heart surgery four years ago (Davinci messed up) repaired a major ASD that was found, Maze procedure and one bypass of main coronary. I have had flu for a week and though I've had some leg pain, mostly in one leg for the past couple years... I now have severe leg pain in both legs when I lie down. I have pain when I exert too, but not as painful. Has flu compromised my circulation even more? What else should I be watching out for. I don't have any swelling. I am seeing doctor tomorrow, though not my cardiologist.

Benico_Barzilai,_MD: It is difficult to say, but it sounds like you need an examination of your legs to make sure of the circulation of the legs.

Diagnostic Testing

QuintBy: This is a question about nuclear stress scan testing. Is it true that nuclear cardiologists who read and compare imagery generated during these tests have much difficulty distinguishing between the images of a test subject who is genuinely negative for CAD (coronary artery disease) and a test subject who has three-vessel disease?

Benico_Barzilai,_MD: Nuclear stress testing is very accurate. It is possible that if someone has reduced flow in all three territories of the heart, it can come up as a false negative. This is very rare in my experience. I still use nuclear stress testing very often in my practice.

alexjohn: What is CA 125?

Benico_Barzilai,_MD: That is a blood test for ovarian cancer. I have no experience of this being used for heart disease.

Tigerette: I had a silent heart attack when I was 23 yrs old, my problem is every time I see my heart doctor they always take an EKG, are these accurate enough to tell you anything? I do not believe in them , I don't feel comfortable with the results. Is there anything better that I can ask my doctor to do?

Benico_Barzilai,_MD: An EKG will only show evidence of an old heart attack. It is not sensitive for a heart blockage that has not caused damage. One would have to do other testing such as a stress test to look for blockages.

Coronary Artery Disease

circusman: On a recent cardiac nuclear profusion scan, my post exercise left v ejection fraction is 68 percent; my left v end diastolic volume is 78 ml and the left ventricular end systolic volume is 25 ml. I am 73 and had a heart attack in 2011 when a stent was put in my Dis RCA. Am I doing all right?

Benico_Barzilai,_MD: Based on the information you provided - your heart is doing very well. You should be happy with your results. Keep the good work - maintain a healthy lifestyle.

hookem: My husband has six stents on one artery (full metal jacket). He has changed diet and lost weight but still needed the last two stents so clogging appears to be hereditary. Would he still be a candidate for bypass surgery if something else happened?

Benico_Barzilai,_MD: We would need to review his angiogram to make sure there is a place to insert the bypass. However, in many cases it is feasible for bypass surgery in patients who have had multiple stents.

kahuna8: I am interested in information RE: operative risk assessment (Society of Thoracic Surgeons [STS] score). My source is "Indications for and Outcomes of valve replacement for asymptomatic aortic valve stenosis." By KUNKALA M. & SCHAFF H. Can you direct me to a website that has details as to how this "score" is compiled, components of score. Thank you. HWH.

Benico_Barzilai,_MD: It is a proprietary scoring. You need to go contact the STS for more information on how this score is compiled. But if you want to calculate a score on a particular patient, just search for Society of Thoracic Surgery Risk Calculation and utilize the program.

XYZ: My husband had three stents in Jan. In July, one stent clogged and failed, it was "unclogged" he developed pericarditis three days later, 10 days later he had pneumonia and afib. Now in October, that same stent is failing. Another procedure is scheduled for Mon. Nov. 4 to either unclog the stent or replace it. Is this common? His cardiologist says it is not common. Would appreciate your advice on this. He still has the afib.

Benico_Barzilai,_MD: This is very unusual in this age of drug eluting stents. If you would like, we can offer you a second opinion either online or through a visit - we would need to review his medical history and angiograms. The afib is another problem that may need further treatment - either with medications or ablation to control.

Prevention and Lifestyle

fairgo: I am a female 60 years old and have a 60% blockage in LAD and a 20% blockage in the RCA, I have had these for nine+ years and treated with statins 10mg, as my arteries are too slender for stents. Are there any suggestions of how I can continue to remain stable or even reduce the blockages? I also have A/F and Atrial Tachycardia for the same amount of time. I’m not sure if one caused the other to occur. What do you think is the most likely, although three ablations have failed to cure this it also limits the kind of drugs I can take. Would a fourth ablation help or hinder the blockages and would taking supplements help in any way to lessen them, for example capsicum and ginger capsules, I've heard can help unblock arteries. Is this true or just a marketing ploy, any advice would be welcome. Thank you for your time.

Benico_Barzilai,_MD: You should keep your LDL under 70 - usually requires statins, eat a healthy diet and manage other risk factors optimally. For your arrhythmias, you need to be evaluated by an electro physiologist to see what exactly occurred during your last ablations - as it is possible that a fourth one would work. I doubt there is a relationship between the atrial arrhythmias and the coronary artery disease in your case. We have no data on supplements and their impact to decrease heart disease progression.

martinsd: My cholesterol levels have been normal to excellent my entire life. I developed blocked left main arteries and required bypass surgery which failed within a year and a half. I was told family history/genetics trump just about everything else. I follow a vegan diet with extremely little fat and take all my meds (10 mg Crestor, Plavix, baby aspirin and 3.125 mg Coreg). Cardiologist will not let me exercise longer than three-five minutes on the recumbent bike at this point and sees me every eight weeks. How does one beat genetics?

Benico_Barzilai,_MD: You seem to be doing everything right - you should be congratulated. Keep up the good work and try to keep your LDL under 70.

stosh: What is the recommendation for a 58 year old male, six months post-op for bypass surgery and an endarterectomy to continue with a statin regimen? I'm on a 10 mg daily dose. Currently exercising daily with four-five miles of walking and some calisthenics. 6' 1", 213 lbs. Generally good health. All blood levels are excellent. No family history of diabetes. Mostly vegetarian, eat no processed foods. Working full-time in sales.

Benico_Barzilai,_MD: As mentioned before, we are very aggressive with LDL management at Cleveland Clinic - see note above earlier in chat. If you can achieve the goals (below 70 mg/dl) without statins - that is great.

Xomue: Do you think that a "particle size LDL" blood test should be routinely ordered for people in their 70's. I have read on the web that many cardiologist think it should be part of the standard annual testing now. What is your opinion?

Benico_Barzilai,_MD: Dr. Hazen in a recent web chat states that LDL particle size does add a minor amount of information to risk stratification. The ultimate goal should be based on national guidelines of LDL. (see recent web chat transcript with Dr. Hazen for a more lengthy response)

tabialex: My cardiologist suggests that I take a low dose statin. The averages of my lipid panel since 3/2/10 (same lab) are as follows: Total cholesterol 213, HDL 78, LDL 122, Triglycerides 67, hsCRP 0.91 in 2011, and Pattern A large buoyant LDL in 2009. CAD runs in my family - father died at age 77 from complications of open heart surgery, brother former heavy smoker doing fairly well even though some or all of four vessels re-occluded after surgery. I am an active, normal weight and blood pressure, non-diabetic female age 71 who watches what I eat but does not exercise. Are statins effective in elderly women?

Benico_Barzilai,_MD: It is controversial - some authorities suggest you should be treated since you have a family history. Many prominent cardiologists would question the use of statins in patients such as you since so many patients would have to be treated before you would save one life. Yes, statins are effective in elderly women, particularly in high risk subgroups.

jimjo: My question is that after 10 years on Lipitor I suddenly started itching and then developed a rash. A dermatologist did a biopsy and said it was a drug eruption. Since Lipitor was the only drug I was taking it was easy to figure out the cause. I tried Crestor and had the same result. Even fenofibrate gave me a reaction, though milder (my allergist thought the fenofibrate reaction was related to latent reaction to the statins). I would like to add that the initial reaction was during the six month transition to generic Lipitor. I've looked at all the inactive ingredients among the three and only found a cellulose in common. Since my cholesterol is 275 and have a lot of dementia in my family, I think I need to get it down someway. Are there any options to statins available? Even in testing. I jog two miles at least five-six times a week, but my hdl is still in the 30's. I'm curious about products with red yeast rice. Or do you think I should still try other Statins since I had such good results.

Benico_Barzilai,_MD: This is a difficult case as we do not know what caused your reaction - in cases like yours, it is best to try trial and error. You may have success with pravastatin, another medication. We are also testing new drugs in our Preventive Cardiology Clinic that may be beneficial.

mgaax: Hello. I had triple by pass 09/01. Based on current studies and information, is it true that 50% of patients need a re-do after 15 years? My chol numbers are excellent, I eat well and exercise regularly on the treadmill. Thank you.

Benico_Barzilai,_MD: Even though many patients need repeat procedures - we find that patient such as yourself, who are mindful of healthy lifestyle such as regular exercise and keeping their cholesterol at very low levels, as well as other risk factors in check, can actually prevent progression of their disease.

stosh: 58 year male quintuple bypass and endarterectomy of LAD 4-9-13 6' 1" 213 lbs. Walking four-five miles every day. Currently on 6.25 mg Coreg and 10 mg Lipitor. Do you think Lipitor is needed to reduce inflammation? Eat very healthy, mostly plant-based diet, lots of fruits, veggies, beans, etc. No soda, very infrequent processed foods, no food with HFCS. My blood test results are looking good.

Benico_Barzilai,_MD: We are very aggressive at lowering LDL at Cleveland Clinic - Lipitor would be appropriate to get the LDL under 70 mg/dl. We find that this type of aggressive approach retards the progression of disease.

Xomue: I had emergency thoracic surgery a year ago to repair an esophageal fistula (caused by a medical mistake). The fistula had opened my heart area (pericardium) to bacteria. I was told that my heart had to be "scraped" clean of the bacterial/infection during the life-saving surgery. Would the "action" on my heart and other measures that had to be taken around it cause any long-term problems? Or make me more vulnerable to other heart problems?

Benico_Barzilai,_MD: It is difficult to know for sure since we do not know what was done. However, I suspect that the cardiac procedure should have little impact on your long term cardiac health. You should ask your doctor.

Xomue: Exercise is difficult for me (with foot problems, I am only able to ride a recumbent bike). To ensure I get enough exercise to keep the heart muscle in shape, what is the minimum daily or weekly amount (time and intensity) I can do (or "get away with")? I am 73 year old, female. What do you think of the new exercise theory/research that you need to exercise at maximum intensity only seven minutes a day to keep in shape? Of course, those seven minutes have to leave you breathless in order to see any benefit. Is this dangerous in any way? Or effective?

Benico_Barzilai,_MD: As a cardiologist, we have to make sure our heart is strong enough to tolerate very high levels of exercise. Usually in patients such as you, I recommend a stress test to see the effects of high heart rate on your heart before allowing a patient to do high intensity exercise. Dr. Blackburn, head of our Cardiac Rehab program will be leading a web chat next month - this is a great question for him. Hope you can join the chat.

Xomue: Diet and supplement questions: Do you recommend any supplements such as fish oil for heart health? And what about dietary guidelines? There have been a lot of recent articles on the web from highly respected research centers that suggest that saturated fats may not be as big a threat to heart health as once thought. What is your opinion?

Benico_Barzilai,_MD: I don't recommend any supplements. We recommend the Mediterranean diet for heart health.

jimjo: How common is sudden intolerance to statins long use (10 years)?

Benico_Barzilai,_MD: I don't think it is very common but I have seen it in practice. It is very difficult to explain this happening after such a long period of time, however I have had patients that have said they can no longer tolerate a statin - and I usually switch to another one.

Irish: I am a 35 yr. old male with strong family history (Dad died of heart attack at 50). I have attended the Clinic's Card Prevention Unit and vitals were good, only blemish is NMR score around 1100. I read of many males in similar situations as myself with good vitals, BMI, who have heart attack in 40s which leads me to question. It seems like the cardiology field only encourages the numerous available tests or drugs in those with high chol/BP 2nd prevention not primary. In early heart attacks such as these, I have read where these early tests could have signaled the problem. Are these types of early heart attacks unavoidable. Can a statin or aspirin regimen help prevent this. I was on a 5mg zocor for about six months and it took my LDL from 99 to 57 and raised my hdl to from 47 to 61, but my cardiologist advised me to get off of it because all my other vitals were good. I know the standard answer is "studies show no strong correlation between statin use and prim prevention" but isn't the chance it could be enough to consider use?

Benico_Barzilai,_MD: Even though it is difficult to find studies that show a benefit of "primary prevention" I personally have used very low dose statins in patients with such a strong family history such as yourself. I do not believe the studies that you mention address patients like you.

martinsd: I had a double bypass (left main) in August 2011. Started having shortness of breath in May and Angiogram discovered that one was 90% blocked and the other 50%. My blood chemistry is excellent (total cholesterol 107, LDL 23%) and triglycerides well below normal range. I am taking Plavix and one baby aspirin, 3.125 mg Coreg. I had been exercising prior to the recurrence of my symptoms but my cardiologist has now limited vigorous exercise. Currently I am trying to prevent any further progression by following Dr. Caldwell Esselstyn's diet. Is exercise dangerous for me? What else can I do? Should I consider stents prior to another surgery?

Benico_Barzilai,_MD: What I do in patients like you is do an exercise stress test to guide the exercise prescription. If you show no evidence of any problems on the stress test at maximal exercise then I do not think exercise is dangerous.

alanpr: What questions should I be asking my cardiologist about taking vitamin and other nutritional supplements after receiving two stents following a heart attack? I had been taking Nu Skin "life pak" and "age loc" prior to my heart attack.

Benico_Barzilai,_MD: You have to ask your cardiologist to look up the supplements to make sure there is nothing that would interact with the medications you are taking. For example, some supplements include caffeine like substances which is probably not a good idea.

alanpr: What are the common negative impacts from nutritional supplements after receiving stents following a heart attack?

Benico_Barzilai,_MD: It all depends what is in the supplements - see answer above.

Valve Disease

mimi02: My mother had bypass surgery and aortic valve replaced. It was approximately two and a half years ago. She now has 40% stenosis; her overall health is ok. My concern is cracking her chest. Do you all have a less invasive procedure? Thanks.

Benico_Barzilai,_MD: Your mother would need heart surgery in the future, there are less invasive techniques such as percutaneous valve replacement for aortic valve and angioplasty/stent for coronary artery disease.

jhshores: I am a 45 y/o woman, living in HI, recently diagnosed with MVP with moderate regurgitation. Doc put me on low dose of Losartan--so far no relief from symptoms. I'm being told that the leakage needs to be severe before surgery is indicated? Is that correct? My symptoms are shortness of breath, chest pain, fatigue, and most troubling, inability to exercise at even a moderate level without SOB and pulse jumping to 160-180. At my age, do I have increased risk of this becoming more severe? Does CC consider surgery for moderate regurgitation for a person my age?

Benico_Barzilai,_MD: No - we usually do not consider an operation for moderate MR - however, sometimes it is very useful to do a stress echo as it would show what occurs with the valve leak during exercise - as it may become more severe with exercise.

jhshores: Thank you for your answer to my earlier question--I am the 45/yo female with moderate MVR. Does the stress echo involve the test with all the colors? I have other health issues, such as severe sleep disorder and depression--taking meds and inability to exercise complicates these illnesses already. Even though my condition is still considered moderate, would those extenuating circumstances make a difference.

Benico_Barzilai,_MD: Yes - the stress echo with color doppler needs to specifically be done to evaluate whether the mitral valve regurgitation gets worse with exercise.

jhshores: Thank you--I had a stress test with great results, and they did the echo with doppler about 15 minutes after the stress test, so I guess that is considered resting not with exercise.

Benico_Barzilai,_MD: That is true. We like to do it a peak exercise and resting.

sinaihospital: I have high blood cholesterol, high blood pressure, hypertensive heart disease, left ventricular hypertrophy, aortic valve stenosis, plus I am overweight. I am only 48 years old and I am @ risk for a heart attack. How often must I have a stress echo, a stress test, an ekg, and a cardiac blood test for my age? By my cardiologist, I must get an ok from my cardiologist before I have surgery or a major test.

Benico_Barzilai,_MD: Depending on the degree of aortic stenosis, I would repeat echocardiogram every 12 months at least. You need to also control your risk factors of high cholesterol and high blood pressure. You are probably going to need surgery in the future and it would be best if you could optimize your risk factors and particularly your weight which would impact the risk of surgery.

kmarsch1: I'm 82 years old and had a aortic valve (porcine) replaced in Aug. 2008. How long will this valve last and if I need a "redo", will I be eligible for TAVR procedural surgery? I know right now the guidelines for this procedure are limited to high risk patients. But as time passes do you think these stringent rules will be relaxed??

Benico_Barzilai,_MD: We are presently performing TAVR in patients with a previous aortic valve replacement. At the present time, it is restricted to very high risk patients but I anticipate that over the next five years these restrictions will be eased somewhat.

clara: If the tricuspid valve is severe, how long does one wait to have it fixed? I have had open heart surgery - aortic valve and grafts. Since surgery, eight stents. Does one have to have open heart surgery for the tricuspid valve?

Benico_Barzilai,_MD: In patients with severe tricuspid regurgitation, I do not send the patients to surgery unless they have severe edema (swelling) or evidence of a very low cardiac output due to the tricuspid problem. There is some early work with percutaneous treatment of tricuspid regurgitation but I suspect it will be years before it is ready for general cardiology use.

Heart Rate and Rhythm

Winter24: I am having a fluctuating pulse rate. My pulse reading goes from 40 to 70 in a matter of minutes when I take my blood pressure reading. My recent blood pressure readings are: 156/65 Pulse 41 - 133/63 Pulse 50 - 145/64 pulse 49 and 134/65 Pulse 75. Is this something I should see a Cardiologist about?

Benico_Barzilai,_MD: We would suggest you be seen by a cardiologist if you are having symptoms. This may be a sign of an abnormal heart rhythm.

JudyfromNJ: My question concerns my daughter who is 41 years old. About two years ago, she had a cardiac ablation because she had been having episodes of SVT's. Sometimes her heart rate was over 200 and her doc recommended the ablation. Since then, she has been having episodes of chest pains, dyspnea, overwhelming fatigue to the point that she is unable to do at least 50% of the physical things that she used to. She has had numerous testing including echocardiograms, nuclear stress tests, MRI of the heart, right-sided heart cath. to rule out pulmonary hypertension, cardio-pulm. stress test, and they have all been negative, except she did have an elevated lactic acid level and her PFT's did show some abnormality. One doc thought that she had mitochondrial disorder and she had a muscle biopsy which was also negative. My question is: could the ablation have caused some damage to her body, maybe the diaphragm that would cause these awful symptoms that she is having?

Benico_Barzilai,_MD: This case is very complicated, without reviewing your daughter's records, it is difficult to comment. I would suggest a second opinion consultation either online (MyConsult) or a visit to a cardiologist.

Jsweetie: My pulse rate runs approx. 95 at rest. If I just walk around the house it can increase up to 120 or 135 range. I do not feel short of breath, I have low blood pressure. Last year I was diagnosed with pulmonary fibrosis and underwent many tests -- all of which were negative. I had a stress test and an echo and they were fine also. Should I see a cardiologist? Is there any other testing that should be done based on my only symptom of high heart rate? I am not on oxygen and am considered mild with my IPF at this point. Thank you.

Benico_Barzilai,_MD: If you truly have been ruled as mild pulmonary fibrosis, then yes, I would suggest an evaluation with a cardiologist.

Warner: I have atrial fibrillation and have for the past approx. 12 years, I have a low resting heart rate approx. 55 and I am unable to exercise. Is there an easy solution?

Benico_Barzilai,_MD: It sounds like you have atrial fibrillation which is complicated by a very low resting heart rate. It may be worth seeing a cardiologist to see whether a procedure such as ablation or a pacemaker may be beneficial.

Warner: I have had atrial fibrillation for several years, is there a current solution to curing this?

Benico_Barzilai,_MD: Sometimes medicines are effective (anti-arrhythmics); however, if anti-arrhythmics do not work, then ablation is becoming commonly used for this condition. Our electrophysiologists do many procedures a month to try and "cure" atrial fibrillation with ablation.

Tamar: Female, Age 79, AF Diagnosed in 2010. On warfarin. No other medication. Asymptomatic bradycardia. 40's- 50's. In AF heart rate 65-85. AF symptoms, I can live with, irregular HB, fatigue, dehydration. Duration of episodes 8-24 hrs. Not debilitating. Needing a pacemaker indicated in the future. Under what conditions would a pacemaker be necessary?

Benico_Barzilai,_MD: If we can prove that your symptoms are related to the bradycardia, then we would recommend a pacemaker.

Herzlich: Hello, I am very new to this topic and am not familiar with many terms used in this chat. I had an ablation done mid July this year because of chronic fast heartbeat. Shortly after that I noticed I was short of breath at the end of a long sentence. This has progressed to where now I have a hard time breathing under moderate exertion, like walking up several flight of stairs. I am in the hospital right now and have had several tests done. Stress EKG planned for tomorrow. The doctor told me so far that with the symptoms described it can be heart failure, but could not give me a life expectancy prognosis. I am now feeling very unsure and concerned. What are my best actions right now. The doctor was also talking about catheter examination.

Benico_Barzilai,_MD: It is very difficult to comment on your case without knowing more information. The important things to ask your doctor are: what is the heart function (ejection fraction) and; are the blood vessels in my heart ok? If you have normal heart function and your blood vessels are normal, your prognosis would be excellent.


Joeleen: I have been recently diagnosed with hypertrophic cardiomyopathy. I have seen a cardiologist referred by my primary physician. Do I need to see a cardiologist that specializes in this form of heart disease? Thank-you.

Benico_Barzilai,_MD: Yes. We would recommend that you see a cardiologist with a specialty in HCM. We have a whole group here dedicated to the treatment of this condition.

CMX: I'm 34 yrs. old, female, 5'9" / 165lbs. I'm active with strenuous exercise three-four times per week and have been active for years regularly. I had thorough investigations for PVCs, which flared up a few months ago during exercise recovery, then slowly progressed to present at any time of the day, but typically when moderately active, i.e. walking, exercise recovery, bending, doing chores, etc. However, heavy exercise makes them disappear and exercise itself feels very good. No dizziness, nausea, trouble breathing or any other symptoms. I had u/s, 24h holter (231 PVCs, total heartbeats 79,900. Ave. HBPM 56, at its lowest 35), stress test, ecg and finally an MRI done. All other tests were fine, but the MRI showed mild to moderate dilation of both ventricles (right more than left). EF on LV was 67% and 56% on RV. Everything else was fine, i.e., no thinning or anything else abnormal. What is the likelihood of this being early DCM? I am incredibly worried of the prospect of that.

Benico_Barzilai,_MD: It is very unlikely that you have cardiomyopathy at this time since you have had such extensive testing. The fact that your PVCs go away with exercise is very reassuring. If the PVCs are very bothersome, sometimes it is helpful to try a medication such as a beta blocker. Many times PVCs are not treated if you have a structurally normal heart.

CMX: Dear doctor, thank you for your response you my question about possibility of early dilated cardiomyopathy (34 yrs old, active, female). In my MRI report they have suggested I could have early dilated cardiomyopathy given the mild to moderate dilation (although EF normal). Do you normally consider the MRI measurements of cardiac dimensions to be the gold standard? I am still worried I might be manifesting signs of early cardiomyopathy that is developing....

Benico_Barzilai,_MD: Depending on the experience of the operators - we do expect the MRI to be the gold standard. But we also have to mention that athletes have enlarged chambers and that is entirely normal. You have to look at the whole picture.

Blood Pressure

pei2: I am currently taking amiodarone, metoprolol, aspirin, avapro, and furosemide, daily. My blood pressure is still extremely high. Are there any meds to help bring my blood pressure down? These meds are currently not doing its job. (I had heart valve replacement surgery at Cleveland Clinic, Dec. 2010).

Benico_Barzilai,_MD: Yes - there are other medications that could be beneficial to you For example, amlodipine (a CA channel blocker) or an alpha blocker such as doxazosin or clonidine. You may also need to be evaluation of your renal arteries to make sure there is no blockage which would cause an increase in BP.

Congenital Heart Disease

jig: Sir my daughter had successfully operated from TOF before six years ago. Now heart surgeon told me by showing an x-ray in regular follow up, her heart size mildly enlarge due to valve leakage. Can it be cured without surgery?

Benico_Barzilai,_MD: It is very common in patients with repaired TOF to have leakage of one of the valves, usually the pulmonic valve. These patients need to be followed very closely to make sure there is no enlargement of the right side of the heart. We would recommend very close follow up with a specialist.

General comments

futuresurgeon: Hello I am a student in high school and I have to do an interview for my school project. These are some questions that I would like to ask:

  • What influenced you into choosing this career?
  • What are some common struggles that you face everyday?
  • In an operation, do you ever get nervous and stressed out? Why?
  • How many years of experience do you have?
  • What are some everyday things that you do as a cardiothoracic surgeon?
  • Are you on-call or set work hours and if so is it stressful or annoying being on-call?
  • What are some of the basic procedures or operations that you do?

Benico_Barzilai,_MD: I am a cardiologist - not a surgeon. I became extremely interested in cardiac physiology when I was in college - I was actually an engineering student at the time and found the anatomy and physiology of the heart fascinating. I have over 30 years experience. The biggest struggle is tremendous demands on your time and I am pulled in many directions.

martinsd: Just wanted to say thank you for this chat. Very informative and I learned so much! Thank you for offering such a helpful tool! Please tell Dr. Barzilai thank you for his valuable help. :)

Benico_Barzilai,_MD: You are welcome!

Reviewed: 11/13

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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