Steve Nissen, MD
Steve Nissen, MD

Mouin Abdallah, MD
Mouin Abdallah, MD

Wednesday, November 20, 2017 | 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. Steve Nissen MD and Mouin Abdallah, MD answer your questions about cardiovascular disease.

More Information

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  • View previous chat transcripts.

Symptoms of Heart Disease

concern: I am a 36-year-old female and over the past few months developed symptoms of shortness of breath, chest pains and passing out once. I have been diagnosed with a bicuspid valve and regurgitation. However, my cardiologist doesn't seem to think there is any reason to worry and that my symptoms are not related to my heart. Is that true?

Mouin Abdallah, MD: Bicuspid aortic valve by itself does not cause heart symptoms, however it might be associated with valve dysfunction like regurgitation or stenosis. Valve dysfunction usually does not cause symptoms unless severe. Though your symptoms might not be directly related to your valve disease, they do warrant investigation and we recommend following up with your cardiologist or one of the cardiologists here at CC.

Cardiotaff: Hi, I am 63-year-old male, always active running/hiking etc., good stats/diet, low alcohol. Three years ago I started experiencing a mild sensation over my heart area six minutes into my run that typically resolved a further six minutes later. This has been the pattern since, but with varying onset/resolving times and increasing intensity of sensation, though still mild; up until a few weeks ago. I had a nuclear perfusion stress test a year ago that was normal. While feeling the onset of my symptom on a recent run I also remembered I had left a cooking pot heating on the stove and my dog was locked in the kitchen. I turned, and, immediately the pain over my heart increased six fold. Walking/jogging it resolved in three minutes. Two weeks ago I felt the sensation in the last 150 yds of my run and used sublingual GTN spray. Instead of easing, the pain was increasing each stride. On finishing I thought I may need medical help, but it resolved after 5/6 minutes. Your views would be appreciated. Brian

Steven Nissen, MD: Your symptoms are not typical of a coronary blockage but a coronary blockage cannot be excluded. It would be reasonable to see your physician for an electrocardiogram and possibly stress test since the test previously was a year ago.

Diagnostic Testing

nailivic: There have been a number of articles in NY times and AARP magazine recommending that folks avoid the nuclear stress test if possible because of exposure to radiation by the injection of radioactive dyes and its possible cancer producing effects. I would be interested in your opinion on this. Does it yield more information on the heart function than the echo ultra-sonic imaging?

Steven Nissen, MD: You are correct that the radiation exposure from nuclear stress testing is relatively high. You are also correct that there has been a decline in utilization in nuclear procedures in recent years. However, there are some circumstances where it is the best test. And should be performed. We would advise you to discuss the radiation burden with your physician when a nuclear stress test is advised and determine whether the benefits exceed the risks.

ForPatient: Hi, I am requesting information for another person. The patient has high blood pressure, a family history of heart disease and is currently on high blood pressure medication. The patient is a 60+-year-old, obese male with has a history of stress. I am asking to be pointed in the right direction for possible tests that can be done to determine if he has partially blocked, hardened arteries and what are the least invasive and clinically proven methods for determining arteriosclerosis. I have tried in vain to find specifics on testing and what tests are offered at various facilities in the area. He is due for an appointment with a specialist to go over heart tests, but I want to make sure the right questions are being asked and the right procedure options discussed. Please let me know as soon as possible. This is very important to me. Any information you can offer would be helpful. Thanks!

Mouin Abdallah, MD: There are several types of heart stress testing. Treadmill echo or treadmill nuclear stress tests usually suffice for most patients who have symptoms concerning for heart disease.

Abnormal Heart Rhythm (Arrhythmias)

J@CC: I had five defibrillator shocks and was put on Amiodarone. It really lowered my pulse rate to below 40. Had some issues with tachycardia and Mayo Pace Clinic raised it to 50. Still had lots of PVCs and non-sustained tachycardia. So they raised it to 60 then to 70. Still lots of PVCs so did ablation surgery. Improved PVCs somewhat but still at 13,000 in the 24 hour holter monitor. When I had the defibrillator shocks I was put on an additional 6.25 of carvedilol (was on 25 mg two times a day) since HR went down they took me off 6.25. For ablation surgery I was taken off Amiodarone. Which on it I could barely get another 10-20 beats higher than what pacemaker was pacing at. But slowly as the amiodarone was flushed out of system my pulse rate began getting higher and higher. Question: Should I now question the pacemaker still set at 70 bpm? Should I go back on the 6.25 mg of carvedilol as HR now is getting higher and gets in the 90s and 100s almost all the time now with exercise? RC

Mouin Abdallah, MD: Dear RC, considering the complexity of your case, it is difficult to make a definite recommendation without thorough review of your chart. However I think both your suggestions are good and probably your cardiologist would recommend which one to try first, adding the Coreg or changing the pacemaker programming.

CherylK: I have been diagnosed with PVC's. Sometimes several a day. I have counted up to 72 "skipped beats" in a three hour period and they continued all day long but were not counted. I have had an event monitor done and a Stress Echo. They happen mostly while sitting or lying down and especially when I am trying to go to sleep. It seems like they are nonstop. They are very hard to ignore. This has been happening for the last 6 months. It was suggested that I try Cardizem but I got mixed reviews on that. Two EP's telling me it wouldn't do a thing for me but I could try it if I wanted to. I have tried Beta Blockers before and they caused bradycardia but that was about 30 years ago or more. I believe I was having some tachycardia then. What is the impact on the heart for people who have daily multiple PVC's? I heard that it can eventually cause changes in the heart. Are these changes concerning? Thank you for your input.

Mouin Abdallah, MD: It depends on the frequency and the PVC burden. Usually if it is less than 20 percent it will not have much impact. We can consider ablation if it is affecting your lifestyle or your heart function.

Steven Nissen, MD: In most people, frequent PVCs do not indicate the presence of serious heart disease.

Anxious5: Hello I was wondering I have been experiencing a fast heart rate lately. Well actually it started three years ago. Right after I had my daughter like two days. Every time I stood up immediately within me standing my heart rate was 130. Cardiologists at Fairview could not understand why. I also had SVT so that wasn't why. A month later I had cardiac ablation. This fast rhythm comes and goes. Anyways my iron was low but is better because I take medication I have low vitamin d and also low vitamin b12. I keep having doctors tell me its anxiety related. Maybe. Here is my symptoms: cold hands and feet, body chills that come and go, insomnia (which us terrible) I can’t fall asleep stay asleep and wake up early. Never had I had this problem. I have sleep apnea. Pulsatile tinnitus in right ear. I was thinking maybe thyroid related but my PCP didn't do a full thyroid panel. Only did TSH free T4 and total T3. Please help also blood pressure 142/78.

Mouin Abdallah, MD: It does appear that you might have more than one thing going on, sleep apnea as you mentioned and that needs to be treated, heart rhythm problem that was ablated, If you have an additional problem however you need everything else treated and optimized prior to evaluation for other problems. Consider coming to the Syncope clinic at main campus for additional testing.

clevehal: I have had two recorded and probably one or more other AFIB episodes. Cardiologists want me to take blood thinners. I have agreed to take low dose aspirin, which started in 4/17. Before taking any blood thinners, including aspirin, would it not be advisable to have a test for my blood coagulation propensity. My platelet count runs consistently in the 130's. I bruise rather easily in my garden combat with the bougainvillea. I want to discontinue the aspirin, but new evidence suggests risks: I take no other medication, am 85 years old with parents who died at 103 and 97. Blood pressure and pulse generally run 115/65/ 55-60; exercise daily; good diet; no tobacco; only alcohol is wine, now at minimum levels due to AFIB research and more recently consistent headaches resulting from wine consumption. Would appreciate your thoughts on: need for coagulation test; advisability of discontinuing aspirin.

Steven Nissen, MD: In most people with atrial fib - they should be taking an anticoagulant. Aspirin does not produce sufficient reduction in risk of stroke compared with full anticoagulation. Usually the risk of stroke with afib does go up in women and blood pressure and age and other medical conditions. You do not need to get a blood test prior to starting anticoagulation. There are newer anticoagulants that are easier to take and safer.

govols123: Had tricuspid heart valve repaired in 2014 at CCF. Had an ablation for atrial flutter in 1/15 and had to end up getting a dual chamber PM with coronary sinus lead in 4/15 for complete heart block. Have developed significant number of PVC's (30%) in the last few months and a trial of Multaq didn't help (I'm on 25 mg of Metoprolol). How long is it typically safe to go with this number of PVC's before developing cardiomyopathy? Is PVC induced cardiomyopathy typically reversible if PVC's ablated?

Mouin Abdallah, MD: Yes, typically PVC induced cardiomyopathy is reversible.

dricke: I have afib that cannot be addressed successfully by the usual surgeries. So I take 5 mg warfarin daily, self-test weekly, and never stray from the 2.0 to 3.0 goal. The complication for alternatives usual excludes other options because of I have a bad mitral valve from rheumatic fever as a child. I'm wondering if the "Watchman" surgery would be a viable and economical alternative for me. I'm concerned if I would ever be in an accident that my blood would not coagulate fast enough to save my life. Thank you. I'm 69 years old with afib, damaged heart valve, but not symptomatic in any other meaningful way. My cardiologist feels I'm years away from valve replacement or repair given my test results.

Mouin Abdallah, MD: It is difficult to comment on the economic aspect since every insurance plan is different from a patient perspective. WATCHMAN is an alternative for anticoagulation therapy for certain patients with A fib. We have been pioneers in the device and perform more than 200 each year.

Usually we ask patients to run on the treadmill to definitively evaluate their symptoms to clarify whether they are really asymptomatic. In your case, the decision depends on which valve and how bad the problem is. Sometimes in the setting of Afib, we need to be more careful in evaluating severity of valve disease.

Pka: I recently had a stenotic aortic valve replaced with a bioprosthesis and had LAA removed along with modified Maze to address a paroxysmal afib condition. Two weeks after surgery I experienced a-flutter (a first time diagnosis vs. past AFibs) that converted after 18 hours of medications. Assessment was that surgery could have been the trigger and temporarily put on 200mg amiodarone and warfarin. My question is how long does it typically take for the heart to fully accept the new valve, for all surgical inflammation to go away and for the lesions to become fully scarred so that I can get off amiodarone and begin to find out if the maze has been successful?

Mouin Abdallah, MD: Usually takes inflammation six months to heal up, to confirm whether maze worked or not. Sometimes we wait up to a year, usually we use amiodarone for few months after surgery and then we stop it.

Farmlover: Dear Doctors, thank you so very much for your valuable time for answering questions of patients! I began experiencing PVC's about one year ago. (My heart is structurally healthy, healthy weight, fit, NO stimulants of any kind). However, the PVC's increased profoundly during the last three months. (Living in the "fast Lane", and a bit of anxiety, more or less in "remission"). At times it appears that I have two consecutive PVC's. When do consecutive PVC's become dangerous/worrisome? Did you ever see patients who reduced their PVC's or eliminated them, after managing stress more sufficiently? Also, are PVC's somewhat a precursor for higher risk of cardiac arrest at middle or higher age, despite healthy heart?

Mouin Abdallah, MD: Stress is one of the issues that increase PVCs in patients. Managing stress is preferred over medical treatment and minimizing stimulants. PVCs, even two in a row in the absence of heart disease, is not overly concerning.

outlyarr: I have ventricular tachycardia/ CHF. White male 64-year-old, BMI 28, EF 41... ICD and meds Coreg CR 80 QD, Entresto 24/26 BID, Pravastatin 40 QD, PPI (for stomach ). I was on amiodarone for two years with good results but pulmonary function began to diminish. DC amiodarone in October had an eight second interval of v-tach (LVAD paced me out of it). My EP has me scheduled to go into the hospital to titrate Tikosyn for the antiarrhythmic effect....What has been your experience with Tikosyn in v tach and do you have any other thoughts? Thank you in advance.

Steven Nissen, MD: Tikosyn is not generally used in treatment of ventricular tachycardia. You may want to get a second opinion by another electrophysiologist.

Hamlin: I am a "young" 80-year-old male. Had stent LAD 2001 no MI. Lipids HDL 62 LDL 58 Trig. 87 total 137. BP in upper 130's. HR in upper 50's. Meds Metoprolol 25 mg twice daily Zocor 10mg aspirin 81mg. "no acute issues" per MD. Echo 9/2017 okay. Holter report 8/2017 Ventricular Ectopics 11% Super. Ectopics 10%. How do I prevent having AFIB in the future or is it possible? Thank you for answering our questions.

Mouin Abdallah, MD: Your best option is controlling risk factors. Keep your blood pressure in good control and sleep apnea if present. Per the new guidelines, the optimal blood pressure is probably less than 130.

Nodinoff: I have had a cardioversion for Afib that was not successful. The current heart doctor in my location said that was all he could do. He stated that there were some “electrical doctors" at the clinic that might have other ideas. Your take on that statement?

Mouin Abdallah, MD: Yes of course we have specialists that specialize in and can treat your atrial fib - your options include cardioversion while on medications or an ablation.

johnnnita: I would like a better understanding from the speakers about the concept of "Heart Block". In 2007 I had mitral valve repair surgery performed at Cleveland Clinic by Marc Gillinov. After the recommended post-surgery therapy, exercise, etc., I have had no issues with my mitral valve or any other issues. I have continued having regular/annual cardiology follow ups with my local cardiologist. Then, last year, after running a routine ECG, I was told I have "heart block". Well, I had never heard of this before and actually thought it was some sort of artery blockage. Fortunately, I learned that was not the case and it had to do with (pardon the simplification) the electric pulses in the heart. The determination initially was based on the reading of the ECG. After this, with further testing, it was determined I had a type of intermittent Heart block (Two) that wasn't as serious. Then, about a month ago during my last follow up, running the same test, there was no sign of this. Thoughts?

Mouin Abdallah, MD: It is common to have different types of heart block after heart surgery, especially mitral valve surgery. If you are not having symptoms, you probably do not need treatment at this time.

jeffrey: I am a 70-year-old male with constant Afib for 30 years now. Take warfarin and amlodipine: blood pressure normal, resting heart rate 50. Heart is enlarged apparently due to the Afib. Overweight but regular exercise. I guess it is too late for ablation. Anything else that can or should be done?

Steven Nissen, MD: No - it sounds like you are doing well.

Foot: I have been diagnosed with tachycardia and a mild valve leakage. Is this A Fib?

Mouin Abdallah, MD: Not all tachycardia is atrial fib - however you would need to have your ECG evaluated by a cardiologist to see what type of tachycardia you have. It may also be useful to have a holter monitor which records your heart rhythm over 24 or 48 hours.

hoagie0013: Good afternoon, I have had four ablations for a-fib; started 13 yrs. ago; .I am much better than when I was first diagnosed but continue to have episodes of mainly Tachycardia seems to come and go out of nowhere. I see that doctor from France that has stated that these types of tachycardia are one of the main drawbacks after ablations and must be mapped and ablated by very skilled electrophysiologist. My question to you is shall I try one more ablation to stop the tachycardia or just let it go. Thanks.

Mouin Abdallah, MD: Considering your case, it would be helpful to see an expert here to see if ablation would be helpful in your case.

Aortic Aneurysm

rum1212: I am a 67-year-old female. Was diagnosed in 2008 with an ascending aortic aneurysm measuring 4.2 cm in diameter. I am 5'4", weigh 168. Am having yearly CT scans. Recent scan indicated aneurysm is 4.7 cm in diameter. Last CT scan in Dec. 2016 was 4.5 cm. BP is mostly under control. My cardiologist indicated that surgery would be warranted at 5.0 cm. Is that still the case or is surgery for my size warranted earlier? What are my dangers of waiting? I have been having periodic dizzy spells lately. Could this be related to the aneurysm in any way?

Mouin Abdallah, MD: It is extremely unlikely that dizziness is related to the aneurysm. Usually we operate on aneurysm size 5.5 or 5.0 under certain conditions depending on the location and look of aneurysm and rate of growth.

DGiessen68: I’m a 49-year-old male, overweight, bicuspid valve with a 4.6cm aneurysm and BP in the mid-130s/mid 80s. I’m doing my best to try and lose weight (which has been near impossible). I’m trying to do daily cardio workouts through rowing and cycling, my pulse can run from 110-125 during those workouts. What can my heart (and aneurysm) take as far as workload during my workouts? Am I risking anything by getting pulse up any higher than 130? What else can I do to lose weight (tried Mediterranean diet, Mayo diet, etc. with little benefit)?

Mouin Abdallah, MD: It is important to control BP tightly in your case in the setting of BAV and aneurysm. It is also important for you to continue aggressive aerobic exercise without weight lifting, which may help also with weight loss. A dedicated exercise program combined with diet will help him with weight, BP and also when it is time for surgery with the result of surgery. We generally recommend avoiding weight loss medications or products.

rum1212: I was diagnosed in 2008 with a thoracic ascending aortic aneurysm at 4.2 CM. Latest CT shows 4.7 CM. Since May of 2016 it was 4.3 cm, then Dec. 2016 4.5 cm and Oct. 2017 4.7. I am 5'4 and 168 lbs. What are the risks of rupture/dissection? When would you recommend surgery? This is the most movement in size in nine years over the past 18 months. I read that for my height, new recommendations are for further evaluation for surgery @ 4.7 CM. Is that true, or should it just be monitored again in six months. Currently BP is around 130/80 with medication.

Steven Nissen, MD: You should be evaluated by an expert in aortic disease. We would be happy to see you here.

Coronary Artery Disease

bergem: I am 90 with CABG in 1982, 11 angioplasties since 1997 for Dyspnea, follow heart healthy diet, exercise daily 35 minutes walking 1.5 miles , Ht 5'7" wt 155 lbs. taking Coreg, Clonidine, Micardis daily for HTN, Furosemide + Aldactone twice a week for ankle edema. Question: Is there a limit how many angioplasties I may have in the future?

Mouin Abdallah, MD: Dear Bergem, first of all congratulations on making it to the 90’s. There is no real limit on the number of angioplasties that people can have, however at some time we reach a point where angioplasties don’t help anymore.

earl359: What are your thoughts on EECP therapy where they put the wraps on your arms and legs and inflate and deflate it in a rhythm that is synced to the heart and patients heart rate in order to reverse heart problems? Is it true that it is an alternative to bypass? Some say that this is a natural alternative to bypass surgery and that many hospitals offer it for those types of patients. I just recently learned of this and was wondering what your thoughts are on it as I have seen that it is not discussed very much by doctors. Thank you.

Steven Nissen, MD: EECP is not an alternative to bypass surgery. It can be useful in patients who are not candidates for bypass surgery and may in some cases relieve angina and chest pain. It does not reverse heart disease.

Omarkhan: Left Kidney Cyst 32mm in middle, 3 heart arteries 99 %blocked; Hypertension; Diabetes.
1) During surgery how many of complications.
2) How many chances that operation may cause other organism's damage.

Mouin Abdallah, MD: First of all, you need to figure out how urgent the surgery is and does it need to be done before your heart status is optimized. You need a careful discussion between your cardiologist and surgeon to determine best course of action.

Juanita: Can you please tell me how common it is for a patient who just had a heart attack, and had a stent placed in upon arriving at the ER, then to have that stent to close up within 20 minutes causing another heart attack and having to go back to surgery to have the stent cleared? Sorry for the run on sentence. In my research I not been able to find anything mentioning this happening, but it happened to me.

Mouin Abdallah, MD: Usually less than 1% of patients have stent problems that early after deployment. This is not unheard off. Consider having another cardiologist review the cath films if you have concerns.

Dodger1: Dear Doctors, I am a 69-year-old male who had two stents in 1999 that occluded, double bypass in 2000 and a DES in 2005. My original symptom was some right bicep pain on exertion which I have had all along and still have but is quite mild and doesn't affect my lifestyle. I take Plavix, a statin, an ace inhibitor, beta blocker, calcium channel blocker and low dose aspirin. I'm a non-smoker, non-drinker, exercise regularly and feel good. I have a LBBB. I recently moved to a new state and will seek new doctors including a cardiologist. My question is whether I can monitor my cardiac health by my symptoms and any change in them or whether you would recommend some testing on a periodic basis and what kind of testing that would be (in light of a LBBB) and how often would you recommend testing. Thank you for offering these chats.

Mouin Abdallah, MD: Your main driver is your symptoms. If you are feeling good I would recommend the same medications. We would not recommend routine testing without symptoms, especially a stress test. You do need to follow up annually with your cardiologist and continue with your exercise program, lifestyle and medications.

Dodger1: Dear doctors, what is the current thinking on long term use of Plavix. When is it appropriate to be on Plavix for life? Thank you for what you do for patients.

Steven Nissen, MD: Plavix is generally recommended for 3 - 6 mos. for placement of stent. There is less certain evidence of benefits beyond the initial treatment period. Some physicians may choose to treat long term but it is controversial. In addition some people with disease in the carotid arteries are treated longer term.

Kittens: I recently had a card cath and a 20% blockage was found in one artery. I was put on a Statin and baby aspirin. How will I know if the blockage doesn't get worse? How can I prevent plaque from breaking away and causing stroke, etc.?

Mouin Abdallah, MD: It is important to control risk factors including cholesterol BP smoking (if you smoke) and healthy lifestyle. Routine follow up stress testing is not recommended.

Risk Factors for Coronary Artery Disease and Prevention

SnakeOil: Did a Calcium test a year ago. Who a moderate risk score of 70, I was prescribed a different statin - atorvastatin. Is there anything one can do to reduce risk/reduce calcium? I'm a non-smoker, exercise daily, ok diet, looking to reduce risk and improve condition if possible. Thank you.

Steven Nissen, MD: A calcium score of 70 depending on your age may actually be quite low. One surprising fact is successful treatment with a statin drug generally results in an increase in the calcium score. Therefore the calcium score should not be repeated at any time in the future. It would be best to have a low LDL cholesterol. I assume that your LDL is low while taking the atorvastatin. Healthy lifestyle is always recommended.

kmworld: Could a sky-high blood pressure incident (220 for a while, not this patient's usual level) CAUSE a minor heart attack, or would it have been just one of the results/symptoms
of the heart attack?

Mouin Abdallah, MD: Yes - very high blood pressure can cause a heart attack as it makes the heart work harder than normal. It is also reflective of uncontrolled hypertension which needs to be treated and controlled.

Kittens: I was just diagnosed with 20% blockage in mid-RCA. I'm now on statin and baby aspirin. I've never smoked hardly drink alcohol and exercise regularly.
I've read that I can still have heart attack if plaque breaks off and clot forms. Is there anything I can do to prevent this from happening?

Mouin Abdallah, MD: Healthy life style includes medication, diet, exercise, good sleep, relaxation techniques, and BP control

chickbull: My wife age 82+ has high blood pressure, somewhat irregular, and it was suggested she take Trinogen which is a Nitric Oxide formula. She does take blood thinner for A-Fib but has not been aware of any episodes in about seven years. Also follows a healthy diet and exercise. Any suggestions would be appreciated.

Steven Nissen, MD: The nitric oxide formula has no scientific basis and should be avoided.

EinsteinGC: What is your opinion about coconut oil for heart health? Saturated but not a trans-fat.

Steven Nissen, MD: Historically, many authorities discouraged use of coconut oil as it is a saturated fat. However, recent evidence has challenged the assumption that naturally occurring saturated fat is harmful. More research is needed to determine which oils are healthy but one thing is certain, hydrogenated vegetable oil also known as trans-fat is harmful. There is no evidence whatsoever that coconut oil is particularly helpful or protective.

Diastolic Dysfunction

PROF16: Does Spironolactone constitute an appropriate medication to treat Grade II/pseudonormal LV Diastolic dysfunction indicated on Echocardiogram? Echo indicates normal LV systolic function, mild LVH,EF 60-65%, Mild LA enlargement, trace AI, no AS, mild MR, mild/moderate TR. Sestamibi stress test (done 1 and 1/2 years earlier) showed no evidence of reversible ischemia. Other conditions: CAD: significant disease in small branch of bifurcating dual LAD system—treated medicine. Sleep Apnea- CPAP treated. Lipids: TC 174,LDL63,HDL 87, Trig 116, CPK 75. Meds:aspirin,Pravachol, Altace, and Lovaza. Vitals:mid 70’s male,BP 140/84,normal HR 55-65 and BMI 31. Exercise: walk 4 to 5 miles per day on four days per week.

Steven Nissen, MD: Spironolactone has not been shown to improve outcome in patients with diastolic dysfunction but it is a med that is used to treat high blood pressure and your blood pressure is higher than what is recommended as normal. Altace is one of the least effective BP meds and you may do better with other drugs. The best treatment for your diastolic dysfunction is to lower your BP below 130/80 with meds and/or lifestyle.

Claramarleen: I am 68 and have advanced diastolic heart failure. Is there any treatment? What is the average life expectancy? Will I become disabled? Also have two valves leaking. Thank you.

Mouin Abdallah, MD: Research suggests diastolic heart failure may be as concerning as systolic heart failure - please follow up with your cardiologist to control risk factors such as hypertension. The need for treatment of our valve disease would depend on your severity - it would be best to discuss with your provider.

PROF16: Are there any other important treatments for left ventricular dysfunction in addition to BP control?

Mouin Abdallah, MD: Yes we have several medications to treat lv dysfunction even though there are more than one type of lv dysfunction. I recommend you seek care with a doctor who specializes in lv dysfunction. Usually it does improve with medications. More importantly you need to find the cause of the lv dysfunction and treat the cause not just the symptoms.

Heart Failure

Bbird: I am being treated for heart failure due to idiopathic dilated cardiomyopathy. I am taking Bisoprolol, Spironolactone, and Bumex to medically treat it, and follow a low salt diet, and do moderate aerobic exercise. I was taking Lisinopril but my blood work showed it was adverse to my kidney function. My last echo showed EF at 25-30% and my heart failure is not currently symptomatic. My doctors are recommending a biventricular pacemaker with an ICD which I am reluctant to have. Will my heart weaken without this device? Are there any other options to improve the heart function?

Steven Nissen, MD: It may be useful to try again to take a drug like lisinopril perhaps in a lower dosage since it has shown to improve survival in patients with hf. In some patients kidney function gets worse temporarily but then gets better. A biventricular pacemaker can significantly improve heart function in patients carefully selected.

cpk2001: What are some additional steps that can be taken for someone with heart failure. Ejection fraction has improved some, ICD implanted, taking medications. Diet is modified to be gluten free, low fat, etc. Some supplements such as CoQ10. Any other natural steps that can be taken or suggestions? Thank you.

Mouin Abdallah, MD: Exercise, weight at goal, evaluate and treat sleep apnea, relaxation techniques of your choice and compliance with the medications and diet.

sbdavisrn: I have chronic heart failure and pulmonary hypertension plus A-fib for 20 plus years. Two years ago my bnp was in the 1300's. It decreased to 720 last year. Last week it was 93. Is a lower bnp ALWAYS good news? I still have sob on mild exertion.

Mouin Abdallah, MD: Yes a lower bnp is preferred over a higher bnp. Which suggests your heart function is probably better. The shortness of breath may be related to the pulmonary HTN which may also affect your bnp.

cpk2001: With patients with cardio disease and heart failure and an improved ejection fraction, are there any other tests or indicators of improvements? I have found mixed reports of whether HF patient’s heart damage can actually improve.

Mouin Abdallah, MD: Yes, heart function does improve after treatment of CHF and cad. We usually check the echo at six months to check the improvement in heart function.

Hypertrophic Cardiomyopathy

kelly3927: I am a 40-year-old female that has experienced pain in my left shoulder, should blade, down my left arm and in my chest several times in the last few years. I have had an EKG and ultrasound, cardiologist says my heart looks fine. I take a baby aspirin as precaution. My last episode was transported in EMS, given nitro and pain stopped. My father passed away at age 47 from a heart attack. I recently found out that my father’s cousins, daughters both tested positive for HCM. One had a heart transplant at age 20. Should I have genetic testing? Should I have my children tested? What other options should I be looking at?

Mouin Abdallah, MD: Dear Kelly, if you are concerned about HCM, then an echocardiogram should be able to show if you have that problem or not. Also it appears that you need a stress test at some time to evaluate your symptoms. If your cousins are positive genetically for HCM, and your are positive yourself, then your children will need to be screened.

gd1822: What factors would make ablation preferable to myectomy for HCM?

Mouin Abdallah, MD: In patients who are not good surgical candidates we would use alcohol ablation however the best preferred treatment is myectomy. You should also go to a center where they perform a large number of myectomies as the outcomes are much better, such as Cleveland Clinic.

gd1822: I am taking metoprolol, generic Ranexa, and losartan for HCM and hypertension. I have had little relief of symptoms (pain in chest, shortness of breath, crushing pain down left arm) and am considering myectomy. Is there any other non-surgical approach to be considered?

Steven Nissen, MD: Treatment of HOCM is complex and can be best administered at a center where large numbers of patients with this disorder are seen. We have several specialists at the CC that treat HOCM patients - several of them who exclusively treat HCM patients.

Valve Disease

jack@: I am an 80-year-old male diagnosed with severe aortic stenosis (AVA=0.86cm²). I would prefer the TARV procedure to open heart surgery but I’m told that Medicare won’t approve me. I would like to know what criteria Medicare uses. Can you help me obtain the criteria? There may be a catheter access issue since I have an endograft from just below my renal arteries through my left and right iliac arteries. Thanks, Jack

Mouin Abdallah, MD: TAVR is approved in the US for patients that are high or intermediate surgical risk. Surgical risk is determined based on a national standard calculator called the STS calculator. If you are interested in TAVR and you are really in the low surgical risk category (which appears your doctors think so), we have an option to be enrolled in a trial where you have a 50/50% chance of having TAVR.

Larry G: Two months ago, mitral valve repair and LAA reduction. Still very, very tired. Also, pulse now averaging around 80 bps. In first few days after surgery, pulse in low 60s. Dizzy as all get-out when try to go 4.6 mph on treadmill; prior to surgery, no problem averaging 7.5 mph for at least a mile. Turned 71 years old day after surgery. Your thoughts (including random speculation if you are so inclined) greatly appreciated. My amateur speculation includes growth of scar tissue inhibiting electrical pathways; is this at all possible? Thanks.

Mouin Abdallah, MD: Usually healing process takes up to six months to one year even in certain cases. A treadmill test might help you and your doctor evaluate your heart rate response to exercise and usually cardiac rehab sessions will train your heart to recover from surgery. Make sure you complete cardiac rehabilitation after your surgery.

adourian: Guidelines seem to say antiplatelet therapy with aspirin for three months is suggested over VKA antithrombotic therapy after an aortic valve replacement with a bioprosthesis. However, I also had a maze/LAA ligation along with the valve replacement to address paroxysmal afib. As long as the maze keeps me in sinus does the fact that I had these additional procedures suggest antithrombotic therapy for some temporary period of time after surgery and if so, for how long?

Mouin Abdallah, MD: Usually we recommend antithrombotic therapy, such as aspirin for life after any bioprosthetic valve procedure. Additionally anticoagulation with vitamin k antagonists is recommended in some cases for a month and in the setting of atrial fibrillation even longer (for a few months).

jerry56: I have a bicuspid aortic valve, with combined regurgitation and stenosis (both moderate ones). I will be very grateful if you answer 2 questions.
(1) Is there is anything in lifestyle (besides the control of conventional risk factors of heart disease) that can postpone the aortic valve replacement?
(2) From your experience, what percent of patients with BAV are lucky to avoid having the aortic valve replacement during their lifetime?
Thank you very much for sharing your knowledge.

Steven Nissen, MD: 1) There is no known treatment that can delay the progression of aortic valve disease.
2) Since you already have moderate disease, it is likely that it will progress although the rate of progression is variable.

momofboys: Diagnosed w/ Bicuspid Aor. Valve two years ago. I'm a 40-year-old female, smoker, 122 lbs, high cholesterol in past hasn't been checked for years, upper end BP last couple years 145/95-100. The past few months my BP has now been low, 90's-80's/50's -70's, I can tell when it's low as I get dizzy. I've also had some episodes when walking for long periods and finishing up hills or when I try to jog a short distance. I get pain/pressure in my mid chest, short of breath, skipped beats, dizziness and slight nausea once with numbness of fingers. This doesn't last long, anywhere from a minute to under 10 minutes. I've only had five of these episodes since Aug., and they only happen when I have walked quite a bit and finish with a hill or exert myself rather suddenly with a fast, short jog. I recently had a stress echo done, cardiologist said looked good come back in one year. He wants me on Toprol XL, for few PVC's, is that wise with low BP already? Any help w/ all of this is appreciated!

Mouin Abdallah, MD: Considering her bicuspid valve, it is important to maintain a normal BP range. Preferably less than 130/80. Adding more meds if you are already having low blood pressure it may not be a good idea. You need to keep track of blood pressure and valve function long-term. We really do not know the full picture - we would be happy to see you for more evaluation.

General Questions

tim: Could you please comment on the quality and "speed “of care given at the Cleveland Clinic compared to surrounding area hospitals in northeast Ohio when it comes to heart related things like heart attacks and stroke. Recently a friend of mine who is 70 years old passed out and was rushed to our local hospital and almost died from having a severe heart blockage, but it took them over a week to complete tests to determine the extent of his heart problem before any treatment options were given, and they even had to transport him to another area hospital, back and forth, because they didn't have the technology to do all of their testing in one building, and now it will be the weekend, going into week two while getting weaker all the more with no clear course of action. I'm just wondering if at Cleveland Clinic, if things go quicker when it comes to emergency care when it comes to receiving emergency heart care, or if it is about the same everywhere in northeast Ohio, and if it is normal to wait such a long time for testing to be done.

Mouin Abdallah, MD: Dear Tim, we are one of the best centers for cardiac care in the US and pride ourselves in the quality of our care, and delivering fast care during heart problems is critically important for us. Please understand that we cannot comment on the details of the unfortunate events and what happened with your late friend.

Foot: Should I change doctors? My doctor doesn't really tell me anything. I am 71 years old and when I purchased long-term health care, I found out more on the forms from them than him. It says I have Valvular Heart Disease Mitral found in APS Irregular. I am taking diltiazem 120mg. I take 5mg lisinopril for BP and 20mg LipitorĀ®. Lately I can feel the irregular heartbeats and get out of breath when exercising.

Steven Nissen, MD: If you're not comfortable with the communications you are receiving from your doctor it is entirely appropriate to seek another physician with whom you feel more comfortable.

EinsteinGC: Electrolytes such as K, NA, Mg, Ca - too high or too low: Are they a cause or result of heart problems? Both cause and result?

Steven Nissen, MD: these blood chemistries can change with heart disease but we would need much greater details about your condition to tell you what is causing these changes.

Reviewed: 11/17

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.