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Ask the Heart Doctor (Drs Nissen & Stephens 02 03 14)

Monday, February 3, 2014 - Noon


Cleveland Clinic is recognized as the world leader in the 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. Learn more about the latest treatments and diagnostic tests for cardiovascular disease and have your questions answered by Dr. Nissen and Dr. Stephens.

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Hari A: I am 21 years old and I have more pain in my chest every day. Sometime at the time of walking and sleeping. I am not able to breathe. I take the air but it cannot work. And also suddenly sometime i feel week and thirsty. My blood pressure is also high. What are the signs of those things. I want free from all of those things. What do I have to do?

Steven_Nissen,_MD_: It is difficult to give you advice without seeing you and performing an examination. There are many causes of chest pain, not all of which are heart-related. The most common cause of shortness of breath in young people, is asthma. High blood pressure in a 21 year old needs to be investigated and I would strongly urge you to see a doctor for further evaluation.

JonR23: Hello, I am a 20 year old male with tight chest pain that travels throughout my chest and back as well as leaving my arms sort of weak. Should I be worried?

Steven_Nissen,_MD_: Coronary heart disease is rare in people your age, but there are other causes of chest pain. You should see a physician for evaluation.

misfroe: I am a female, 47 years old, was very active and healthy and enjoyed life. It came on gradually feeling tired and out of breath. it came to the point where I was so breathless and exhausted after simple activities like taking a quick shower I had to sit down and rest before I could go on. And even eating was wearing me out so that I had to rest in between to catch my breath. Started to notice chest discomfort like tight squeezing kind of like spasm in center of chest that radiates up my throat and shoulders, and my heart was racing and felt light headed as if I was about to faint. Went to doctor they diagnosed me with Atrial Tachycardia and put me on 75 mg. Beta Blocker which has helped tremendously with my tachycardia. But still feeling exhausted and fatigued, shortness of breath, feeling compressed by heavy weight. Had an angiogram done to check for any blockages and it came back negative. My question is, why am I still feeling like this or what else going on? I can't go on like this.

John_C._Stephens,_MD: My first concern for these symptoms would be blockages in the heart arteries. The best test for this is a heart catheterization. Assuming your angiogram was obtained by way of heart catheterization, then this is less likely to be a concern. However, the issue of diastolic heart dysfunction remains and an evaluation by a specialist in the heart failure area would probably be your best next step.

Abnormal Heart Rhythms

jimz: I have AFlutter and had an ablation done six months ago. It did not correct my condition. My heart rate is irregular now and tends to be in the upper 70's and 80's. What is my best course of action.....meds or procedures? Thank you.

John_C._Stephens,_MD: The first and most important thing is to make sure you are on anticoagulation - warfarin or one of the new blood thinner type of medications. The rationale for this is that afib or aflutter can increase your risk of stroke, whether it is there all the time or comes and goes.

Steven_Nissen,_MD_: Sometimes after a failed ablation a second procedure can be successful. This can be discussed with one of our electrophysiologists - doctors who treat rhythm problems.

Masooma: Dr., I am patient of arrhythmia from 2006.. now increasing day by day. Sometimes when i deep sleep then feel a jerk to my body and wake up, after that, heart beat becomes too fast and lose my energy of whole body. Especially my nerves and brain disfunctional and also shivering in body. It also happened when I’m doing routine work at day time. Sometimes i feel pressure on temporal. Please help me and advise me. My age is 31.

John_C._Stephens,_MD: There are multiple heart rhythm problems that can affect people, therefore it can be somewhat difficult to know what is affecting you by your description alone. Frequent symptoms that you are describing do warrant further evaluation by a heart rhythm specialist.

Hmoud: Hello, my name Hmoud and my age 25. I have WPW, Wolff-Parkinson-White. My heart rate cost 200 and its happening like every six-seven months. Every time I go to hospital they give me cordarone shot, are cordarone damage the body?

Steven_Nissen,_MD_: Wolff-Parkinson-White syndrome or WPW is almost always treated with an ablation procedure which can frequently cure the disorder. After an ablation, most people do not require medications and do not have recurrent episodes.

BooDreaux: I have atrial fibrillation and currently take 80mg sotalol two times per day and a 25mg xarelto daily. Is there any amount of alcohol that is acceptable? I haven't had anything alcoholic for over six months for fear that my heart rate would increase to the 140-160 range for an extended period. I am asymptomatic, don't ever feel it, nor is it a hindrance to my lifestyle. I only noticed it while at the gym checking heart rate. I work out two times daily, weight training and cardio in morning (45-60 minutes of elliptical/treadmill) Cardio(same as morning) and core in evenings. I'm 59 and had a MI in 1996, quad CABG in 2007 and have type 2 diabetes. Heading to Napa and Sonoma in a few months and would like to feel comfortable enjoying some wine tastings.

John_C._Stephens,_MD: The combination of xarelto and sotalol are a dangerous combination of medications to be taking with the use of alcohol as well. In general, I typically do not recommend people to consume alcohol while taking blood thinners. A small amount of alcohol is probably ok.

Verla: Binge drinking prior to Atrial Fibrillation converted by electroshock six months ago - No re-occurrence -Stress test and EKG normal. How long are the following medications required? - Amiodarone, metoprolol, Xarelto.

Steven_Nissen,_MD_: You appear to have had what we call "Holiday heart syndrome" -- if there is only a single episode of atrial fibrillation we would not, ordinarily treat you with Amiodarone. If a holter monitor shows no episode of atrial fibrillation it may be safe to stop the Xarelto, but it is always good to talk to you doctor.

Grampjet: My resting heart rate changed from 55 to 110 about a month following catheter ablation for AFIB. The change occurred about the same time as the AFIB episodes stopped. It has not changed since. Even with160mg two times a day of Sotalol. I am in sinus rhythm but the rate doesn't seem to be dropping below 110 at rest. What is the usual cause of this change? Is it common following Ablation? Is another ablation the only way to solve this? Can a Cardioversion solve this? What are the long term effects of a high HR with normal rhythm? Regards, Rod.

John_C._Stephens,_MD: High heart rate after ablation is not normal and needs careful evaluation with your electrophysiologist. You may not have normal sinus rhythm.

Coronary Artery Disease

zenrunner53: After a successful CABG, I experienced three years of being totally symptom free. During this time, I remained very physically active, took a statin which lowered my LDL to the low 40's, watched my diet and blood pressure, and generally addressed all risk factors which could be addressed. I recently began experiencing angina again, and cardiac cath showed progression of a single distal lesion (grafts are intact). I have been advised to proceed with medical management (beta blocker, NTG, etc). Is there anything else at this time to prevent further progression of disease, which I understand will occur in 40% of maximally treated patients? Thanks.

John_C._Stephens,_MD: At this time - the optimal way of treating recurrent symptomatic CAD is to address risk factors as you are - keep your blood pressure in control, exercise, and treat your cholesterol.

Steven_Nissen,_MD_: There are some investigational new drugs to raise HDL cholesterol but they are not available yet and the jury is still out as to whether they will help. Seven years ago a high "calcium score" led to a catheterization and two stents, when I had never had high blood pressure or any A Fib and slightly increased blood pressure and started 50 mg atenolol. Eight months ago, my atenolol stopped working and atrial fib resumed along with a mildly elevated heart rate, resulting in another cath and stent. All was good until a month ago when the intermittent atrial fib resumed. Now have increased to 100 mg atenolol, and A Fib continues. I have never had a heart attack or angina. Should I undergo another cath and potential stent, or should I await a heart attack, or angina, etc.??? Some say I should not have gotten the earlier stents, without heart "symptoms". It just made sense, at the time, since the cath was done and they did see sufficient narrowing to justify a stent.

Steven_Nissen,_MD_: We almost never place stents in patients without symptoms and we do not recommend a heart cath for patients merely because of a high calcium score. To be very frank, I would urge you to seek a second opinion at a large hospital center to determine what procedures should be performed. Atenolol is considered an obsolete drug and is not used for treating HTN or afib anymore.

rguy2012: What do you think of EECP Therapy?

John_C._Stephens,_MD: It is not used widely, but there is some evidence that supports its potential benefit. Particularly for people who have exhausted all treatment options.

Steven_Nissen,_MD_: In some people it may reduce the frequency of angina. At Cleveland Clinic we offer this service.

nailivic: At what percentage of the blockage of a LAD in the heart is stenting generally done? If there is some blockage how often should one have a nuclear stress test to assess the blood flow?

John_C._Stephens,_MD: In general, stenting of coronary arteries is performed when patients have symptoms of blocked heart arteries, such as chest pain or difficulty breathing with exertion. There is no specific percentage of blockage that always requires stenting, however blockages ranging from 70 - 80% or greater may be responsible for symptoms. Stress testing is usually not performed in the absence of symptoms.

Diagnostic Testing

jezzabell: My cardiologist has done test and suspects a valve blockage. Not 100% sure of it and wants to do a heard cath. I have heard of the CT scan (ccta) that shows how much and what kind, you see walls and arteries and what kind of plaque, a better pic. Isn't this a better choice? I also have other major health issues and don't feel a cath scan is safe or for me. i have very severe anxiety issues and panic attacks that come on suddenly.

John_C._Stephens,_MD: From what you are describing, it sounds like your cardiologists are concerned about artery blockages rather than valve problems. Our best means of determining the severity of blockages are by doing a procedure called heart catheterization. CT scans of the heart are not a reliable substitute.

Charles L: A recent nuclear stress test showed a problem in the infero-apical wall; what would this imply?

John_C._Stephens,_MD: The utility of doing a stress test is based upon the symptoms of a person and as such we do not routinely make recommendations based on stress test findings alone. If your stress test is accurate, it may suggest reduced blood flow in that area of the heart from a blockage in a heart artery. But only this determination can be made by your physician.

Cardiac Risk Factors

GeorgeBMac: I am concerned about the new AHA standards... For most people they rely on the new calculator as a basis for prescribing a statin. This concerns me for two reasons: this new calculator estimates my risk as being much higher than the traditional calculators. But, more importantly, it uses age and blood pressure as a basis for determining if the person should take a cholesterol lowering medication. That makes NO sense to me. For myself, it shows my risk being 7.5% -- even though all of my numbers are "optimal" (as shown by the calculator) and my diet and lifestyle are both very good. But, in six months I will turn 64 and the calculator will show my risk increasing to 8.1% and the guidelines will say I should start taking a high dose statin. I would have a hard time taking a statin based on age alone. Can you explain the logic behind incorporating age and blood pressure as criteria for prescribing a cholesterol lowering medication?

Steven_Nissen,_MD_: Your criticism of the new guidelines is valid and I agree with it. The decision on whether to take a statin or not should be made with you and your physician after careful consideration of all your medical history - not simply one calculator.

sinaihospital: I have high blood cholesterol, high blood pressure, hypertensive heart disease, heart valve stenosis, left ventricular hypertrophy, type 2 diabetes, plus I am overweight. My dad died at the age of 48 from a heart attack in the hospital. Will this put me at risk for a heart attack? I am only 48 years old. How often must I get an ekg, a stress test, a stress echo, and cardiac blood tests from my cardiologist? Thank you.

Steven_Nissen,_MD_: You have many risk factors and you need close follow-up and treatment to prevent the development of heart disease. Routine stress tests are NOT recommended unless you have symptoms. You should have your cholesterol and blood pressure carefully managed. With treatment of these risk factors, you can do very well for many years.

sax64: My son (42 yrs), lives in NJ, has a stressful job in the finance sector with lots of traveling. Recently done, his blood reports are far from normal. Total cholesterol 238 mg, LDL 178 mg, HDL 36mg, Non HDL 202 mg, Tri Gly 118 mg, CardioCRP 1.1. But his Calcium Score (0. B.P.) is normal. In our family, I, myself has had 4 stents after a heart attack (had borderline high cholesterol only), my sister has one stent, my brother has undergone five bypass surgery after a massive attack. For this reason I told my son to have a checkup. Now I am very much worried. Is it possible to have a 0 Calcium score With such high LDL cholesterol? Should he start with cholesterol lowering treatments? What other measures or tests should he take?

Steven_Nissen,_MD_: You can have a 0 calcium score and still have a heart attack. The level of LDL cholesterol is high enough for someone with a family history that we would almost always recommend taking a statin drug. The recent guidelines indicate the need to treat everyone with an LDL above 180, but at 178 with a family history taking a statin now is a no-brainer.

Micro Vessel Disease I have MVD and would like to know what the possibilities of being able to clean out the plaque in the small vessels that are not accessible for a balloon or stent solution. For example, are any drug companies trying to produce a drug (pill) that will dissolve the plaque?

Steven_Nissen,_MD_: For patients with multi-vessel disease, there is no "liquid drano" for the coronaries but we do know that achieving a low level of bad cholesterol (LDL), exercise, diet, and blood pressure control can slow the progression of plaque build-up and in some cases reverse it.

Aorta Disease

dph: I am a 58 year old male with a bicuspid aortic valve, moderate aortic stenosis (1.1 cm sq aortic valve) and dilated ascending aorta (4.5) based on my last echo in June 2013. I am due for another echo in June 2014. My left and right ventricle findings were normal. I am 5 feet 9 inches and weigh 165 pounds. What concerns me now is that the aorta went from 4.1 to 4.5 cm during an eight-month period (October 2012 to June 2013). I know the echo is not the ultimate test, but if the 4.5 reading is accurate, do you think it is wise to wait another six months for my next echo? Given the bicuspid valve, under what circumstances should I be considering surgery, and what is the probability for a dissection/rupture with a 4.5 cm ascending aorta? Thanks for your time.

John_C._Stephens,_MD: Your concerns regarding the rapid expansion of the aorta are valid. Yes it is ok to wait six months. We found the optimal way of following patients such as you are CT scanning - We have an aorta center here that sees patients like you and would be happy to provide an evaluation.

tangodude: In June, 2013, I was diagnosed with a thoracic aortic aneurysm which measured 4.5 cm. This was discovered during an echocardiogram and confirmed by a thoracic MRA. Six months later, in December another echocardiogram and CT angiogram measured the size of the aneurysm again at 4.5cm.I have been told that things get worrisome when the aneurysm reaches 5 cm and that surgery is definitely recommend at 5.5 cm. In addition, my father died of a burst aortic aneurysm (I don't know if it was thoracic or abdominal). My question: Is there anything I can do to retard the growth of this aneurysm?

Steven_Nissen,_MD_: In patients with thoracic aneurysms we recommend careful control of blood pressure as a means to prevent progression. Given your family history you should be followed closely and your aneurysm size measured periodically. The information you provided about when surgery is indicated is generally correct, but we always make a customized decision for each individual patient.

Aortic Valve

paulwk: I am a 44 year old 5'10, 175lbs. male who has had two prior OHS. First was porcine valve to replace aortic valve, second one, ten years later to replace that one with a mechanical valve. I was given a .19mm valve due to small aortic root. I've been diagnosed with PPM, and experiencing moderate LVH. I am being told I need a new operation at some point for a larger valve. What are my options if the root is too small? How will they be able to fit a larger valve in there, and won't a third OHS be too dangerous due to scarring?

Steven_Nissen,_MD_: For patients who have had multiple surgeries to replace heart valves, decision making is very complex and involves many factors. To adequately advise you, we would need to see you in our valve center. We do sometimes 3rd or at times 4th heart surgeries when it is necessary -- particularly in younger patients like yourself.

dph: I am a 58 year old male, with aortic stenosis. I have been seeing a cardiologist for about two years, once every six months. My aortic valve on echos has varied between 1.1 and 0.8, and I am not symptomatic. LVEF is 60 to 65% and mild symmetric left ventricular hypertrophy. For my last echo, the aortic valve peak velocity increased to 4.9 m/sec (from 3.7 m/sec eight months earlier). Is this increase a reason for alarm/surgery? Thanks.

John_C._Stephens,_MD: Your reason for concern is valid because the aortic peak velocities you quoted are indeed high. We sometimes will operate on severe AS before the patient develops severe symptoms if the valve is that diseased. On a final note, we often find that patients may not fully appreciate the presence of symptoms at this stage. But instead, have actually adapted to the valve stenosis by slowing down or limiting activities.

dkmgray: Has valve replacement by going in through the groin been approved for everyone yet, or is it still only for people who cannot withstand open-heart surgery, etc.? Hoping I can have it done this way (aortic stenosis) instead of through the chest. My TEE indicated I can wait a while. Having echos done every three mos. About how much longer do you think it might be before everyone can have the valve replaced in this manner? Saw where I have mitral valve regurgitation, too. Can mitral valves be replaced at same time as aortic valves? Not sure how bad the mitral valve is. No MD has mentioned it to me; saw it on a report.

John_C._Stephens,_MD: The procedure (transcatheter or TAVR) is only approved for some patients - not most patients - you are correct it is only for patients who have high risk for traditional open heart surgery. Never the less, this is an area for rapid development and indications for lower risk patients are expanding perhaps in the near future. Treatment for mitral valve disease is not being done at the same time as TAVR - however if both valves need surgery they can be repaired using minimally invasive surgery techniques at the same time.

Tonyheart55: I have moderate aortic valve murmur. It has been nearly two years but I can now start to feel it in my chest. My aorta is 5.1 and considering a second opinion for surgery. I have no other symptoms but would rather not wait until they develop. I run marathons and trying decide if I should stop running. What would you suggest as the next course of action? The surgeon here in Louisville and my cardiologist are still trying to decide if I should get surgery now or wait and see. I am 58 male in great shape and trying to decide to go pig or mechanical. I realize it will be open heart since the aorta will also need to be repaired.

Steven_Nissen,_MD_: These are difficult decisions and should be made by physicians with considerable experience in treating diseases of the aortic valve and aorta. We would be pleased to see you for a second opinion at Cleveland Clinic, where more surgery of this type is performed than anywhere in the world. There is no reason not to exercise but a second opinion is definitely a good idea.

kahuna8: SUBJECT - Adjusting urgency for Aortic Valve replacement based on body weight/mass. I am 77, male, 5'7'' and 215lb, same weight as 35 years ago, no symptoms, echo readings 0.9 valve area, 54 mean gradient, eject fraction 74%. Health overall excellent. My Cardiologist states " the above data places me in a "critical status" vs "severe." Thank you for your comment.

Steven_Nissen,_MD_: Based on the information provided, your aortic valve is on the borderline for critical aortic stenosis. We would strongly urge you to seek an opinion regarding the need for surgery at a large center where a large number of patients like this are routinely seen.

gwbjr1: Dr Stephens, I am 68 years old and have aortic valve stenosis. My AV area is 0.8 cm. My mean gradient is 21 mm. My max gradient is 43 mm. I had an open heart double mammary bypass in 2000. The heart doctors at the Center for Advanced Cardiovascular Care at The Heart Hospital, Baylor, Plano, TX are recommending that the best treatment for me is to enter the registry for the Edwards Sapien 3 TAVR trial that is upcoming even though I would have to wait until May 7 to get approved because I had a mild stroke on 11/07/2013. They say the Sapien 3 is designed to reduce regurgitation and is better than the previous models because it will provide more AV area. But, there is no guarantee that I will be picked for the registry. They say there is 0.4 percent chance of me dying from my aortic valve problem in the next four months. My question: Should I wait and try to get into the Sapien 3 registry, or should I go ahead and schedule traditional AVR? Or, do you have another recommendation? Sincerely, George.

John_C._Stephens,_MD: In general, surgical aortic valve replacement remains the recommended form of treatment for people with symptomatic aortic stenosis. Your findings from the echocardiogram alone are not sufficient for determining timing of surgery; your physicians will base the decision on several clinical factors, the most important is your presence of symptoms. If you are deemed to have very high risk for complications from aortic valve surgery, then entry into the trial would be an option.

Ejection Fraction

DocktorDick: I'm requesting that a spectrum of Degraded Ejection Fraction numbers, (65, 60, 55, 50, 24, 40, 35) be Identified against the Symptoms, e.g. (Zero Symptoms, Ankle Selling, Congestion in the Lungs, Fatigue with some Quantifiers, At Rest, While Walking, Jogging, A 60 Mile Bike Ride, During Sexual Activities, and or Fatigue Following the aforementioned Exercises). Also, at what point would some combination of the above suggested symptoms be presenting Heart Failure? And, what are some of the suspected contributors to Degraded Ejection Fraction? And, what therapy and or what success is achievable to correct Degraded Ejection Fraction, (Severity of EJ probably plays a factor here)? How often do Echo Cardiograms present false positives, (Degraded E/J)?

Steven_Nissen,_MD_: There is NOT a close link between ejection fraction (EF) and symptoms for many patients. We see patients with a normal EF who have moderately severe symptoms and we see patients with a low EF who have very few symptoms. However, a worsening EF is definitely a sign of worsening heart failure. It is important that you take the right medications designed to protect the heart against worsening. If you are uncertain of your medications, you should see a cardiologist who specializes in heart failure who can adjust your medication as needed.

Heart Failure

sgwilson1951: What's the latest on efforts to repair damaged/dead heart muscle following a heart attack? Any new promising developments with stem cells or other tissue-growing/repair techniques, or even new artificial hearts for transplants?

John_C._Stephens,_MD: Your question is related to one of the most actively investigated and challenging areas of medical research.

Steven_Nissen,_MD_: To-date none of the stem-cell therapy have showed clear-cut evidence, but research is continuing. The total artificial heart is still not ready for wide-spread use.

chrisriley7: Diastolic Dysfunction In Women: Is this condition an inherited heart condition? Does this mean by definition-diastolic heart failure? At what age can this type of condition cause more serious problems if it goes untreated for several years? What are the basic symptoms to be aware of? Should I see a Intervention Cardiologist or EP Cardio doc ?Is this linked to causing Blood Clot problems -PE's or DVT 's? (I apologize for these direct questions. My heart conditions were diagnosed in 2006; told they were mild and that those conditions can be treated with BP meds. And directed to ignore and go on with my life).

Steven_Nissen,_MD_: Diastolic dysfunction remains one of the great mysteries in medicine. We are uncertain what causes it and how best to treat it. In general, we direct treatment at symptoms which often involve shortness of breath. Diuretics are commonly used. The prognosis is highly variable. No two patients are exactly the same.

John_C._Stephens,_MD: Cardiologists who typically treat patients with diastolic dysfunction are specialists in heart failure.

Radiation Heart Disease

JAD: I am a 75 yr. old female, and was diagnosed with constrictive heart disease (pericarditis) and restrictive lung disease one year ago. I received radiation to my chest 50 yrs. ago. Doctors thought I had a malignancy but when I did not show improvement from the radiation, surgery was performed and I had a teratoma tumor located in the mediastium. The surgery injured my phrenic nerve on the left side and since it does not function I am short of breath. I am currently on Hydrochlorothiazide 25mg ,Kor-con M20,and low sodium diet. Is there any other medications that would be helpful, and what is your opinion of surgery?

John_C._Stephens,_MD: This combination of heart and pulmonary disease due to radiation is very complicated and best evaluated by specialists that focus in this specific area, such as those at our Pericardial center and Cardio-Oncology center. Patients such as yourself typically benefit from the comprehensive center that can offer multiple specialists that deal with this condition.

Reviewed: 02/14

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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