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Women's Cardiovascular Health (Dr Cho 5 13 08)

May 13, 2008

Leslie Cho, MD
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: Welcome Dr. Cho and thank you for being with us today. Let's begin!

Speaker_-_Dr__Cho: Thank you for having me.


Heart Attack

volvianacer: Two years ago I had a heart attack and 3 metallic stents were implanted in 2 coronaries. since that date I was taking ASAC, clopidogrel and pravastantina however 4 months later I had an angina and 3 by-pass were implanted. Now I only take enalapril and ASA, what is the risk to suffer another attack. I walk 1 hour /day.

Speaker_-_Dr__Cho: To prevent future heart attacks it is important to modify risk factors. We advise our patients to not smoke, keep blood pressure less than 130/80, keep their bad cholesterol less than 70 and their good cholesterol greater than 40, keep their weight in the healthy range and if they are diabetic then keep their HgA1c less than 6.5.


Stent

satin312: I am 54 years old. I 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__Cho: I wonder why it cannot be bypassed - a second opinion would be good. There are emerging therapies such as stem cell therapy that might be helpful to you. You need to be optimally medically treated - which means - aspirin, beta blockers, ace inhibitors, and long acting nitrates, and statin therapy based on your history.

dgschmidt: Is there any new information on the length of time to take Plavix after a medicated stent? I've heard, from various doctors, 6 months, 1 year, forever ... ???

Speaker_-_Dr__Cho: In the past, cypher required 3 months of plavix and taxus required 6 months of plavix. Now we know longer therapy is better at preventing stent thrombosis. At the Cleveland Clinic, we put our patients of at least 18 months of plavix therapy and if they have stents at a very critical location, we put them on lifelong therapy.

dgschmidt: Because of bleeding issues while taking Plavix and aspirin, is there a problem with dental work like cleanings and other procedures such as procto. exams? My GP told me to hold off on a procto. till I'm off Plavix.

Speaker_-_Dr__Cho: Yes it is true that being on plavix and aspirin increase their risk of bleeding.

Patients that have stent thrombosis, are usually the ones that have been taken off of both therapies. We do not recommend that you come off both antiplatelet agents.

We usually have our patients do their dental work on both agents.

Other procedures depends on the bleeding risk of that particular procedure they are having done.


Bypass Surgery

nanajan: I need to have bypass surgery. I am a 68 year old woman in fairly good shape. I am diabetic but I just take a pill every day and watch my diet. I do not take insulin. Is there anything I should worry about with this surgery?

Speaker_-_Dr__Cho: All procedures in medicine has risks. However, your doctor probably feels that the benefit of the procedure outweighs the risk.

Women are known to have more bleeding and higher transfusion rates during bypass than men. Thus it is important to seek a center where they have a large female patient population experience.


Microvascular Disease

kazoolaw: I've recently been diagnosed (by process of elimination) with Microvascular Agina & treated with a beta blocker; How do you diagnose Microvascular Agina and how is it treated?

Speaker_-_Dr__Cho: Microvessel disease usually is a diagnosis of exclusion.

Coronary angiogram must be normal in a patient with chest pain typical for angina. A positive stress test may or may not be present. The standard treatment for microvessel disease are beta blockers, calcium channel blockers, statins, ace inhibitors and exercise training. Some patients benefit from nitrates and others do not.

lkay54: Can you explain "diagnosis of exclusion?"

Speaker_-_Dr__Cho: You need to make sure that you have a coronary artery disease by catheterization. You need to rule out other causes of chest pain besides heart - such as esophageal disorder reflux disease.

In addition - there is large vessel and small vessel disease - a catheterization needs to be completed before you determine if it is microvessel disease.

maryjane72: Can you speak to microvascular disease in women? What is the best way to diagnosis this? MRI ? Cat Scan? How do you best treat this?

Speaker_-_Dr__Cho: This question is very similar to the last question regarding microvessel disease. Other tests may be used to look at the coronary arteries - such as cardiac MRI - however the cardiac catheterization is the definitive test to determine if it is microvessel disease or not.


Symptoms

martzj: 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__Cho: I would recommend a stress test to rule out cardiac causes for your symptoms. There are both lung and cardiac components to your symptoms. The first thing to do is to rule out cardiac causes. Usually could be diminished exercise capacity - just because you can do one exercise - may not be able to do all exercise. Discuss your symptoms with your doctor.

lkay54: I had an spasm of some sort in January that led to an MI, as confirmed by my blood enzymes. I have no blockages, as confirmed by angiogram. All heart tests are now relatively normal - ECG, EKG, and CAT scans. However, I continue to have chest pressure/pain and arm pain on a daily basis. Can you speak some on the diagnostic tools available to look for signs of microvascular angina or other diagnosis I should ask my cardiologist to consider?

Speaker_-_Dr__Cho: If you have coronary vasospasm, you should not be on beta blockers - you should be on calcium channel blockers and long acting nitrates. Beta blockers can worsen vasospasm. You should take sublingual nitroglycerin as prescribed by your doctor if you have symptoms - See your doctor for your symptoms.

zoomNet: Are women's heart symptoms different than men?

Speaker_-_Dr__Cho: Yes. Women can have chest pressure like someone sitting on their chest or radiating to their jaw or left arm. But - they also have more atypical symptoms such as shortness of breath, nausea, fatigue, and sometimes stomach pain.

kjf52: If you have a history of panic or anxiety attacks - does that increase your risk for heart attack. I have racing heart beat with pain in my chest and my doctor said it is anxiety attacks. I am 38 years old. My mom had a heart attack when I was young. How will I know if it is a heart attack or anxiety?

Speaker_-_Dr__Cho: First you should be treated for anxiety. Because your mom had a heart attack, you should have a thorough cardiac work-up. Sometimes it is difficult to tell the difference if it is anxiety or a heart attack. You should go to the doctor to figure that out.

baker: 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__Cho: Enlarged heart on a chest x-ray can mean many things - you need to have a thorough exam by your physician with an echo, EKG and perhaps a stress test. A chest xray is not specific about the cause of the enlarged heart. I would want to figure out if you really have that and the cause before determining treatment.

szujanek: I have had every possible test 2 chk 4 blood clots-I'm using plavix+aspirin. My symptoms when the TIA is happening-deafness, difficulty swallowing, coordination, and difficulty walking. Obesity is an issue-Recently-(within 6 wks-the wt gain was 40#. I went 2 the ER at a local hospital-they couldn't discover any particular cause because testing results were normal. I'm on 15+ medications. There is a family history of heart problems. Thank you for your advice and the Clinic for offering this service!

Speaker_-_Dr__Cho: It sounds like you need a second opinion. This seems very complicated and a doctor would need to review your medical history, test results and examine you to determine a plan of care.

Having a 40 pound weight gain in 6 weeks could be water weight - therefore you should have this evaluated.


Medications

dgschmidt: Are there beta-blockers that don't make one tired? Are ace-inhibitors "easier" to take?

Speaker_-_Dr__Cho: In general beta blockers do make people feel tired. Used to be the first agent for hypertension. But they are good to treat some conditions, such as heart failure, coronary artery disease.

With just essential hypertension, Ace inhibitors would be better - easier to take but may still have side effects - dry cough and problems with kidney - should have that checked if you are on Ace inhibitors.

Cleveland_Clinic_Host: Thank you for your questions! Please be patient, as Dr. Cho has to answer a page.


Diagnostic Tests

enewman: RE: If a Doppler ultrasound study is performed, you may actually hear pulse-like sounds that change in pitch as the blood flow is monitored and measured. - Question: do you hear the same sounds on each side or is one side going to sound different?

Speaker_-_Dr__Cho: Are you talking about your carotid arteries?

mmcdonald6692: My Echo report shows the following: Ejection Fraction is about 45% with global hypokinesis of the left ventricle. There is mild tricuspid regurgitation and Aortic Sclerosis. On a previous echo there is both dystolic and systolic dysfunction and a trace of mitral valve regurgitation. My blood work shows a NT-pro-BNP level of 321 and my HDL is 41. My recent MRI shows "A few scattered foci of white matter hyperintensity/injury both frontal and the right occipital lobes perhaps related to ischemic microangiopathy and migraine headaches. Can you tell me how all this is related? From my research it seems to indicate Congestive Heart Failure and Vascular Disease (small vessel is what I was told) I also have swelling in my legs.

Speaker_-_Dr__Cho: You need to see a physician to evaluate your test. Congestive heart failure is actually a diagnosis by exam not echo. Nt-pro-bnp is different than BNP. It is more sensitive and is a predictor of future cardiovascular event.

Your symptoms would help guide your diagnosis.


Risk Factors

Overall Risk Factors

alliemet: My grandfather died of a heart attack, and my father has had two heart attacks and my mom has high blood pressure. Sometimes my blood pressure is a little high, and with the family history of heart problems, it just worries me. Are there signs that i should look for? I weigh 160 but I am 140 pounds. I can't seem to lose the weight. But I work out almost every day and try to watch what I eat. Should I go to a cardiologist?

Speaker_-_Dr__Cho: You do have family history of heart disease so it is important to control your risk factors aggressively. This means LDL less than 100, not smoking, exercise, blood pressure less than 130/80 and if you have diabetes, A1c less than 6.5.

You also need to monitor your blood pressure - there are free Blood Pressure checks and cuffs around - so it should be more easy for you to check this.

If you want to see a cardiologist, you can - you need a good risk assessment either by a cardiologist or a good internist - someone who would address your risk factors.

Cholesterol, HDL, LDL

suzanne24: I know that raising HDL is important. What is the research in this area? I heard about a class of medications being looked at- Cept inhibitors?

Speaker_-_Dr__Cho: Unfortunately, CETP inhibitors has been disappointing so far. The first CETP inhibitor to be test called Torcetripib caused increased heart attack and death rates for patients who took CETP inhibitor.

High Blood Pressure

frankem: I keep having high blood pressure - 160's and then low blood pressure - 90 or 91 top number. I am not sure what to do. I am on a beta blocker but I think it is because my doctor didn't know what to do with me. I am not feeling well. Should I see a cardiologist or what type of doctor?

Speaker_-_Dr__Cho: Blood pressure 160 is high and you should seek treatment. A good internist should be able to help you control your blood pressure. Beta blockers are not the first line of treatment for essential hypertension - a diuretic and/or ace inhibitor would be good. If you have other disease such as coronary artery disease or congestive heart failure than beta blockers are excellent.

As for a doctor - a good internist or a cardiologist - or even a nephrologist would be good.

In a national study, 70 percent of patients were aware that they had a blood pressure problem but only 29 percent were treated optimally. Having high blood pressure leads to stroke, heart attack and early dementia.

So - good control is important.

judikay: I suffered a heart attack about a year ago. My blood pressure had always been on the low side 90/50. The doctor put me on high blood pressure meds. He said it is for heart function. Is that necessary?

Speaker_-_Dr__Cho: Yes. We sometimes put patients on blood pressure medication even if the blood pressure is good to help the heart remodel favorably after a heart attack. Blood pressure medications such as ace inhibitors help people live longer after a heart attack.

Activity

gtrichards6: At what point should a person consider not working? I had a heart attack 2 months ago. My EF was 35% as measured during the cath. I am a 42y/o Charge Nurse on a busy L&D unit. It is very physically and mentally stressful. Will that more than likely cause further strain on my heart? I still get SOB and fatigued. I also have asthma. I want to do what is best to improve my chances of preventing this from happening again. Tina

Speaker_-_Dr__Cho: People who stay active do better. However, having high stress isn't so good. Therefore, you should exercise and try to reduce your stress level. We encourage patients to work, because being active and having exercise capacity is the best predictor of reduced cardiovascular event. You should be on a good heart failure regimen which includes ACE inhibitors, beta blockers, and diuretics.

Also - being an optimal body weight can help. Talk to your doctor about an exercise program that would be appropriate for you.


Alternative Medicine

Nitric Oxide

marybeth: I have heard more about Nitric Oxide being important in prevention of heart disease? Deep breathing helps or so I have heard. Are there supplements that can be used? Can you explain this concept?

Speaker_-_Dr__Cho: Nitric oxide is an important compound that is involved mainly in dilating arteries.

Things that improve endothelial function which is the function of the vessel lining helps. These are improving blood pressure, cholesterol, diabetes, not smoking, exercising etc. Arginine supplements may increase Nitric oxide but it has not been shown in studies to improve outcome.

vjsmith: Have you heard of nitrous oxide used to treat blocked arteries?

Speaker_-_Dr__Cho: Nitric oxide is a vasodilator released by the blood vessel lining. It is decreased in hypertension, diabetes, high cholesterol, when you smoke. So controlling those things actually helps with endothelial dysfunction, thus indirectly improving vasodilation.

Hormone Replacement Therapy (HRT)

kathleen52: I am 52. Had early menopause and have been on hormone replacement for about 7 years. I had some symptoms and recently had a cath that showed moderate disease but not enough to treat yet. Can I stay on HRT?

Speaker_-_Dr__Cho: There are good studies that show that HRT does not prevent heart disease.

Since you have moderate disease already, it is important for you to control known risk factor for heart disease with medication that have shown concrete proven benefit.

L-arginine

vjsmith: What does l-arginine do for you? Does it improve your health if you have heart disease?

Speaker_-_Dr__Cho: L-arginine has never been shown to reduce risk for heart disease. Theoretically it is thought to increase nitric oxide which is a vasodilator - but that has not been translated into favorable outcomes.

ADHD

mmcdonald6692: I have adult ADHD and migraines. I have been told due to heart issues such as low ef and hypokinesis I can not take meds for either of these which is having a severe impact on my ability to function daily. What can be done as an alternative?

Speaker_-_Dr__Cho: I am not sure about treatments to ADHD and migraines - you should seek a specialist in those areas.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Cho is over. Thank you again for taking the time to answer our questions today.

Speaker_-_Dr__Cho: Thank you 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: 07/08

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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