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Women's Cardiovascular Health (Dr Cho 2 5 09)

February 5, 2009
Leslie Cho, M.D.

Leslie Cho, M.D.
Director of the Cleveland Clinic’s Women’s Cardiovascular Center
Medical Director of the Section of Preventive Cardiology and Rehabilitation
Tomsich Family Department of Cardiovascular Medicine

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Cleveland_Clinic_Host:Thank you for joining us! Today's chat with Dr. Cho will begin shortly. Please submit your questions by typing them below and then clicking 'Ask'. We'll get to as many questions as we can. Welcome Dr. Cho and thank you for being with us today. Let's begin!

Speaker_-_Dr__Cho: Thank you for having me.

helpshawna: I would like to know more about small artery blockages.

Speaker_-_Dr__Leslie_Cho: I assume you are talking about Microvessel disease.

Microvessels are tiny blood vessels in the heart that can’t be seen with the naked eye. In microvessel disease, these vessels constrict (or narrow) when they should dilate (or widen). This starves the heart muscle of oxygen and causes chest pain – which can range from mild discomfort to severe pain that limits activity and negatively impacts quality of life. More women than men are affected by microvessel disease. Men are more likely to develop macrovessel disease, or blockages in larger blood vessels. Diagnosing microvessel disease can be difficult.

Microvessel disease is simply one, of many, ways that cardiovascular disease differs in men and women. While this disease is under diagnosed and under treated, help is available. Because these blood vessels in microvessel disease are so small, stents and surgeries are not an option. But there are many good medications that can help ease your pain. Aspirin, platelet inhibitors, cholesterol lowering drugs are options that commonly provide relief. We also help women keep their weight and diabetes under control, which also improves their symptoms. Together, these therapies and lifestyle changes provide very effective relief.

diane43: Hi, I have heart and valve disease. I had a DES stent in 6/08 in my LAD and I'm on Plavix. I have PACs and SVTs. I had a 6 mo myoview stress test that show icsemis and that my right side of my heart wasn't getting enough of oxygenated blood. The dr. sent me angiogram and it came back clear. They tell me nothing wrong with my heart and the test was not accurate. I'm still having angina. I feel there is something wrong here. Can you help?

Speaker_-_Dr__Leslie_Cho: If you are still having angina - you could have microvessel disease. Angiograms are often normal in these patients. Patients with microvessel disease often get relief with medication and exercise. Seek a second opinion.

clara: I hope it is all right to ask to separate questions. I had bypass surgery 3 years ago. They did a cath July 07 and the grafts had filled up 60%. They also told me the LAD had diffuse blockage 50% with 80% places (not sure I am correct about places). The circumflex is now 70%. There are 3 laterals that can't be stented because my vessels are too small. I have basically been told that nothing else can be done. What happens when the blockages increase if they can't do anymore? I also had a recent echo and the tricuspid valve is moderate/severe regurgitation and the mitral valve is moderate/severe. Is this something that I should be concerned about? I have increased angina symptoms plus short of breath at times. Can you give me a direction?

Speaker_-_Dr__Leslie_Cho: It seems like you have a very complex problem. A cardiologist would need to evaluate your medical records and test results including the films from your tests to provide you with options for care. I would recommend that you have a second opinion. We would be happy to see you at the Cleveland Clinic women's cardiovascular Center for second opinion.

catnan: Please explain "Small Blood Vessel Disease," causes, treatments, prognosis. Thank You.

Speaker_-_Dr__Leslie_Cho: Are you referring to microvessel disease? Patients with diabetes sometimes have small vessel disease which means that the arteries are diffusely diseased/narrowed. The arteries are diffusely narrowed and small, bypass surgery or angioplasty with balloon or stent may not be an option. The only other option if patients are having symptoms is medical therapy. Often being on right medication exercising and losing weight can help patients with small vessel disease.

Prevention and Women

cricks: I am a woman who recently had a stress test that showed some problems, my father had early heart disease and I am worried about what to do. I recently started menopause and wondering how to tackle all these problems at once.

Speaker_-_Dr__Leslie_Cho: If you have a positive stress test - it would depend on what that showed to tell how to move forward with care. So the first step would be to find out what your stress test showed and see a cardiologist.

cricks: Besides your doctor what are good resources for women in the prevention and intervention of heart disease?

Speaker_-_Dr__Leslie_Cho: Our website is a good resource - we have many articles specific to women with cardiovascular disease. The American Heart Association website is a great resource. This month in particular will have a lot of great information for women as it is Go Red For Women month - geared to the prevention of heart disease.

Cleveland_Clinic_Host: If someone has been told they have metabolic syndrome, what is that? what are the risks? what can be done?

Speaker_-_Dr__Leslie_Cho: Metabolic syndrome is low HDL, high triglyceride, obesity and hypertension. These patients are at risk for developing heart disease, stroke, and diabetes. It is curable by losing weight most of the time.

junebug: My mom died of a heart attack when she was 65. I have high cholesterol – LDL 170, HDL 45. I wonder about what I should do about medications and what other tests I should check - what about the C reactive protein and homocysteine tests?

Speaker_-_Dr__Leslie_Cho: Ideally your LDL should be less than 100. Statins are a good choice. C reactive protein, which is a marker for inflammation is a good test because we can quantify your risk. High levels of ultra sensitive CRP increases your risk for having a major adverse cardiac event. As for homocysteine, it is a risk factor but lowering that with folic acid has not been shown to be of benefit.

janeawilson: If you live far away from Cleveland Clinic but you are able to see a doctor there at least once, what can of follow-up/checking in afterwards can be done long distance?

Speaker_-_Dr__Leslie_Cho: We have patients from all over the world who communicate with us via the telephone or internet. For a more close supervision, sometimes they go through our secure online services - . But - we definitely would be happy to see you for a visit.

cricks: I know that you have a women’s heart center at Cleveland Clinic; do you have a satellite center for women too?

Speaker_-_Dr__Leslie_Cho: We have women's cardiovascular center at the Cleveland Clinic main campus but we do not have any satellite centers at this time.

Cleveland_Clinic_Host: Dr. Cho, can you talk a bit for our audience about the risk factors for heart disease in women?

Speaker_-_Dr__Leslie_Cho: High blood pressure, high cholesterol, diabetes, smoking, family history, and early menopause are risk factors for developing heart disease in women.

Ideally your blood pressure should be less than 140/90 - or if you are diabetic or have other risk factors - it should be less than 130/80.

Ideal cholesterol level is bad cholesterol (LDL) less than 100 if you do not have heart disease. Good cholesterol (HDL) greater than 45 for a man and 55 for a woman. And triglyceride less than 150.

If you have heart disease, your bad cholesterol should be less than 70 and your good cholesterol should be greater than 45 for a man and 55 for a woman. Your triglycerides should be less than 150.

Ideal waist circumference should be less than 40 inches for a man and 35 for a woman. If you are Asian, it should be less than 35 for a man and less than 32 for a woman. The most important is waist to hip ratio less than 0.8.

Symptoms and Women

hopeful: I survived a heart attack of the LAD while being in the hospital for observation overnight. The only symptom was bad GERD, the initial echocardiogram was normal and my blood enzyme levels were borderline. When I was kept overnight, the GERD got worse and I started vomiting and had a heart attack of the LAD with the only symptoms initially of GERD. After 2 stents were put in I have about 45% capacity and am doing well. My question is, how do you tell the difference from a heart attack and GERD if your only symptom is GERD, no chest pain, nothing else? I had a recent episode thinking it was a possible heart attack and thank God it wasn't but it's frightening. I take lots of TUMS now along with Nexium 40 mg twice daily. There is a history of heart disease in my family and I also have fibromuscular dysplasia which did not cause the heart attack. Thank you.

Speaker_-_Dr__Leslie_Cho: Women often have atypical symptoms of heart attack than men. Women will often complain of GERD like symptoms which is actually heart symptoms. Sometimes it is very difficult to distinguish the difference between GERD and heart attack symptoms. That is why it is important to let a professional distinguish it rather than relying on your judgment. If you have symptoms of angina (which for you may be GERD symptoms), take sublingual nitroglycerin as prescribed by your doctor. If this relieves your symptoms this was not GERD.

hopeful: Hi Dr. Cho: This is hopeful again and I was only given nitroglycerin in the hospital and it didn't do a thing.

Speaker_-_Dr__Leslie_Cho: You should speak to your doctor about your symptoms and treatment. If you continue to have chest pain or GERD like symptoms that do not go away - you should go to the emergency room.

conniew: Hello, i have been getting a heart pain. It happens usually randomly through out the day. I feel out of breathe, and it has been worrying me lately as it is so often.

Speaker_-_Dr__Leslie_Cho: Usually heart pain occurs during exertion - whether it is physical or emotional. However, women can have atypical symptoms, therefore we ask that you seek a professional evaluation.

win2k: Can you have a normal stress test and still have a blockage. I have symptoms of chest discomfort buy my stress test was normal. Someone told me I should get an echo. Would that help?

Speaker_-_Dr__Leslie_Cho: Stress test determines whether you have a significant blockage that is causing decreased blood flow to your heart. It is a great test, however it can be wrong 15 percent of the time. If you had a normal stress test but continue to have symptoms, you may need further diagnostic testing such as an angiogram or 64 slice CT.

Cholesterol and Women

janeawil: What is latest recommended treatment for women with very elevated lipoprotein A?

Speaker_-_Dr__Leslie_Cho: The latest recommendation is if you have very elevated lipoprotein A - your LDL should be less than 80 mg/dl. Lipoprotein A is another type of cholesterol in our body and it increases your risk of having heart attack and stroke. You do not have to lower the lipoprotein A level if your LDL is less than 80.

janeawilson: My lipoprotein a is 160. I just started 10 mg of Lipitor along with taking 2 aspirin daily. Is this all that I can do at this juncture?

Speaker_-_Dr__Leslie_Cho: Your LDL should be less than 80 and taking 1 aspirin which is 81 mg is recommended. The other things you can do are healthy lifestyle: low fat diet, exercise, don't smoke, maintain healthy body weight.

janeawilson: My mother tried taking a statin to lower her cholesterol and it made her very hyper and unable to sleep at night. Could this have been the type of statin? Is there an alternative?

Speaker_-_Dr__Leslie_Cho: That is not a side effect described for statins. There are numerous other medications to lower cholesterol such as niacin, or cholesterol absorption inhibitors or fibrates. However, your mother's symptoms does not seem like it was caused by statin therapy.

vjs1226: How much exercise should i get to lower my cholesterol?

Speaker_-_Dr__Leslie_Cho: If you are ideal body weight - you should exercise 30 - 45 minutes most days of the week. If you are overweight - then 60 minutes on most days of the week.

There are some people who have dramatic results with their cholesterol numbers with regular exercise and diet - particularly if they are losing weight. However some people even with significant exercise, do not lower their cholesterol because they have genetically high cholesterol levels.

Joy: I was diag. with CVD in November although I have been compliant with my HBP meds for 13 years. I have been watching my diet closely and increased my exercise to 45 minutes every day. How soon should I get my blood drawn to see if I have improvements?

Speaker_-_Dr__Leslie_Cho: after we evaluate a patient and put them on treatment, we generally follow them every three months - however it is individualized.

Vitamins, Supplements and Women

rgsmith25: Are there any supplements that women should take to help with heart disease? I have seen special women’s vitamins in the store – should I take them?

Speaker_-_Dr__Leslie_Cho: Vitamin E at 400 iu should not be taken. It may increase your risk of heart failure and death. Vitamin C has never been shown to be helpful. Folic acid has not been shown to be helpful.

Probably the best thing out there is fish oil especially if you do not eat fish - however it does not lower cholesterol. I don't take any vitamins. I believe eating well and exercising is the best preventive measure. Take time to learn about healthy diet. We have a lot of information on our website that can help you.

Coronary Artery Disease and Women

skiimania: I am young, 45, and have a 90 percent blockage in my stent. I have had a heart attack and heart failure. My doctor said my stent area cannot be bypassed. Are there other things that can be done?

Speaker_-_Dr__Leslie_Cho: It depends on what type of symptoms you are having. There are medications that can help you. On the frontier there are stem cell therapies that are being researched. At the Cleveland Clinic, sometimes we are able to treat areas or blockages that people are told are not treatable. We would be happy to provide you with a second opinion.

bj: Had MI at 41, 2 stents, previous heart attacks discovered. Am turning 53 and found I am able to swim laps ...up to 2000 meters x6 days/wk. However, cannot stand or walk upright without hitting wall, feeling overwhelming need to sit and lie down w legs up. Any ideas on how to get past this vertical 'wall' and out of 'horizontal' world more?

Speaker_-_Dr__Leslie_Cho: Have you been checked for positional vertigo? You could be evaluated by your ENT or primary care doctor.

Abnormal Heart Beats and Women

carol1961: Is it true that everyone experiences arrhythmias?

Speaker_-_Dr__Leslie_Cho: Yes - everyone has extra heart beats - some people feel it more than others. But it is normal. Other arrhythmias such as atrial fibrillation, is not normal and should be treated.

smbaker79: I just had some major fluttering and skipping around in my chest. made me feel a little dizzy. Not sure if I should be concerned. I take a medication that is known to cause problems for people with heart valve disease. Dostinex for a pituitary tumor. I also have high blood pressure.

Speaker_-_Dr__Leslie_Cho: Palpitations is the most common things that cause women to see a cardiologist. Often these are benign - but given your history - you should speak to your physician about these symptoms.

carol1961: Hello Dr. Cho. I am a 47 year old female and have heart skips. I have been through a complete heart check and they say nothing is wrong with my heart. They did catch a short run of v-tach ( 6 beats) years ago and told me that since I have a normal heart that I need not worry. I maybe get around 50 times a day where I feel my heart skip or flutter. It is a lot worse when I am stressed and I can feel it beating completely irregular. The cardio has told me that everyone gets these things and not to worry since I have a normal heart. What would your opinion be on this?

Speaker_-_Dr__Leslie_Cho: it is very common for within to have extra heartbeats called PVC (premature ventricular contraction) or PAC (premature atrial contraction). These are normal and benign. Women often get this during menopause, post menopause, or after delivering children. This may have to do with hormonal variations. We usually do not treat this unless patient feels like their life if limited by these. Reassurance and avoiding things that can exacerbate this such as caffeine, over the counter cold medication is best. As for you specific case, it sounds like you had NSVT nonsustained ventricular tachycardia. However, it is unclear in what setting this occurred. Therefore I would need to know more prior to giving any further advice.

knit: I read somewhere that hyperthyroid can cause irregular heart beats. Is that true?

Speaker_-_Dr__Leslie_Cho: Yes. High levels of thyroid hormone can make your heart go fast - that is why hyperthyroid needs to be treated.

Pregnancy and Heart disease

kjfowkes: I am pregnant. I have been having very strong pains in my chest and it feels like I have some chest discomfort at times. What types of tests will I need?

Speaker_-_Dr__Leslie_Cho: It is very common for women who are pregnant to have extra heart beats. It is important to tell your OBGYN and you may be referred to a cardiologist. Most of the time, these extra heart beats are benign and do not need to be treated. However, people with congenital heart disease need to see a cardiologist during their pregnancy.

hasock: I am a Type 1 diabetic with high cholesterol. I hope to start a family soon, so i know i can not take medication for my cholesterol; anything else I could do?

Speaker_-_Dr__Leslie_Cho: Diet and exercise is the cornerstone of therapy for high cholesterol. Patients who are diabetic have an increased risk for heart disease and their bad cholesterol needs to be less than 100. During child bearing age, statins are contraindicated because they can cause birth defects.

Valve Disease and Women

wondering: I have been told I have a leaky valve, is this going to be a problem if I want to have a baby?

Speaker_-_Dr__Leslie_Cho: It depends on what valve is leaking and how much it is leaking. You should see a cardiologist before you get pregnant, or if you are already pregnant - definitely see a cardiologist.

Peripheral Vessel Disease and Women

wrtmlb: I'm 44 with a family history of hypertension. I was recently diagnosed with high blood pressure and was placed on a RX water pill. At my appointment several weeks ago my doctor as well as two nurses got a low reading on one arm and a higher one on the other. Today I went for a follow up and the readings were: left arm at 80/60 and right arm at 138/78. My doctor now wants to send me to see a cardiologist since there is such a difference between the blood pressure in each arm. My doctor mentioned something about the arteries. Is this common? What could it be? What causes this and what tests are done to figure out what it is?

Speaker_-_Dr__Leslie_Cho: If you have differing blood pressure in each arm, you may have blockage of the artery to your arm. The most likely artery affected will be the right innominate or left subclavian artery. there is a simple noninvasive test to diagnose this problem. Also, angiogram, CT scan, or MRA can diagnose this problem. If there is significant blockage that is lifestyle limiting, then revascularization with stents are an option.

Enlarged Heart and Women

sabb: What does an enlarged heart mean? Is that bad? Do you take medications to help that? What do you do to treat it?

Speaker_-_Dr__Leslie_Cho: We need to find the underlying cause of your enlarged heart. Sometimes it can be due to coronary artery disease, it could be due to a virus or medications you have taken in the past. We need to find the underlying cause first. It can often be treated by ace inhibitors or beta blockers and people do well and have a good quality of life.

High Blood Pressure and Women

barblk: I have high blood pressure. Should women take certain high blood pressure medications? Do any in particular help with menopausal symptoms?

Speaker_-_Dr__Leslie_Cho: Unfortunately not one of them help with menopausal symptoms. First line medication should be a diuretic or an ace inhibitor. Beta blockers have fallen out of favor as a first line agent for hypertension due weight gain and fatigue and hair loss in some patients. If you have heart disease or heart failure, beta blockers are still first choice.

smbaker79: I take Nifedipine XR for high blood pressure since I'd like to consider having a baby soon. I was taking an ace inhibitor linsipril; it worked very well but Nifedipine XR doesn’t seem to be doing much for me. Is there something else I could consider?

Speaker_-_Dr__Leslie_Cho: You are right - ace inhibitor is contraindicated during pregnancy because it can cause birth defects. The treatment of choice for high blood pressure during pregnancy is a beta blocker.


karlina_2: How strong is my heart? I work-out 5 to 6 days a wk doing cardio for an hr and a half , 3 of those days are w/weights.

Speaker_-_Dr__Leslie_Cho: it sounds like you are exercising vigorously every day. This is a good way to prevent heart disease. However, the only way to assess the heart pumping function is to do a cardiac test such as an echocardiogram.

Joy: Do you get similar health benefits of replacing some or all of your moderate activity with vigorous activity in half the time?

Speaker_-_Dr__Leslie_Cho: For weight loss benefit - it is actually not the vigorousness - it is the length of time - we actually ask patients to work longer at lower intensity. Unfortunately there is no short cut to exercise.

It’s Heart Month!

Speaker_-_Dr__Leslie_Cho: In honor of heart month - I would suggest you become more proactive. Participating in this heart chat is a great first step. Have your cholesterol checked, get your blood pressure checked, make sure you are not diabetic by checking your fasting glucose, do not smoke, exercise and eat healthy. The goal is to lead a healthy long high quality life.

Cleveland_Clinic_Host: I am sorry to say our time with Dr. Cho is up. Thank you Dr. Cho, this was great information.

Speaker_-_Dr__Leslie_Cho: Thanks for having me.

Technology for web chats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC).

Reviewed: 02/09

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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