Steve Nissen, MD
Steve Nissen, MD

Chadi Ayoub, MD
Chadi Ayoub, MD

Wednesday, February 7, 2018 | 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 Chadi Ayoub, MD answer your questions about cardiovascular disease.

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BigPicture: Do you recommend chewing and swallowing a 325 mg non-enteric coated aspirin after calling 911if a heart attack is suspected? And what symptoms most frequently indicate heart attack?

Steven Nissen, MD: Yes!!!! Chest pain is the most common symptom - in center of chest and sometimes radiation to both arms or jaw and may be associated with nausea, sweating or shortness of breath.

KOLKATA1: Sir, I have a pain on the left side of my chest and I am very sick. I did the ECG. But normal. Sugar, normal ; Press, normal ;Head around HB12.9. What is my heart condition?

Chadi Ayoub, MD: Chest pain can be caused by serious heart conditions. It is important to be evaluated further by a cardiologist for any underlying heart disease or process that may be causing the chest pain.

sheilad: My husband has been getting more winded with activity. Not having chest pain but worried about him and wonder if he is having heart symptoms . What type of doctor should he see? He doesn't look right to me.

Chadi Ayoub, MD: It would be reasonable to see a cardiologist or general internal medicine doctor to evaluate causes of shortness of breath.

jtorres: Due to x-ray results, I was referred for a CT of the chest with contrast that showed cardiomegaly, sclerotic mitral valve leaflets with moderate mitral regurgitation. My hypertension has been very difficult to control with my doctor adjusting meds 4xs in the last two months. Now it feels like there is swelling at my chest and neck and i can feel and see the vein distended in my neck. (I have peripheral venous insufficiency in both legs and the swelling feels like that). Two ER trips in these two months because my BP was at stroke level w chest pain but EKG showed normal. Strong familial history with mother dying at 53 and brother at 46. My sister is a RN and suggested it is carotid blockage due to symptoms. I have metabolic syndrome as well. My doc doesn't seem concerned and has not referred me to a cardiologist. Should I push for a referral?

Chadi Ayoub, MD: A cardiologist review would be very helpful in this situation, and tests starting with an echocardiogram would help give a better understanding of this condition.

Arrhythmia (Abnormal Heart Rhythm and/or Rate)

SoloAct: I have bradycardia, and my heart rate keeps getting lower when I'm sitting -- at the computer for instance. It's often down on the low 40s. While sleeping, it's often 38-42 range (based on Fitbit Charge HR, which is within 1 or 2 beats of measurements in the local clinic or even when I was hospitalized overnight for possible TIA). I'll be 73 in April. Also have SVT and diastolic dysfunction, Grade II. At what point is the low heart rate a concern for fainting or even cardiac arrest. My cardiologist's nurse responded merely that "everyone's heart slows when they sleep." Sure, but this is happening when I'm awake! When I'm moving around, it gets into the 50s, sometimes up into normal range even. I've had ZIO tests twice and been evaluated for a pacemaker. They said I'd need one eventually but maybe five years. That was two years ago. THANKS for telling me what –number or range– is a concern or when I should push the doctor to pay more attention or be more concerned. Or not.

Steven Nissen, MD: The lower limit of acceptable heart rate is highly variable. In general, in the absence of symptoms or evidence of unstable conduction, we are reluctant to put a pacemaker in patients because of a specific number. You will need follow up and certainly if you develop symptoms consideration for a pacemaker would be warranted.

SoloAct: Addendum to my question submitted last night re: bradycardia. What heart rate is too low: Also have severe sleep apnea, use CPAP machine.

Chadi Ayoub, MD: The lower acceptable heart rate may vary and depends on activities performed and whether awake or asleep. The more important question is are there any symptoms associated with this and any associated cardiac conduction disease that may be a cause of your bradycardia. This may require further evaluation if warranted.

Pepitone62: Dear Doctor: I had a 24-hour Holter test recently. From the Holter test report: “The patient’s underlying rhythm is NSR with an average heart rate was 63 BPM. Heart rates greater than 120 BPM were noted less than 1% of the time. Heart rates less than 50 BPM were noted 33% of the time. RHYTHM STRIPS DEMONSTRATE SHORT PR INTERVAL WITH EPISODES OF SVT. CONCERN OVER WPW WITH SVT 112 ventricular ectopics, which represented less than 1% of the total beat count, were noted."   What does this mean?  Please advise. Thank you.

Steven Nissen, MD: WPW or Wolfe Parkinson white syndrome is a relatively uncommon disorder but requires careful evaluation by a specialist in electrophysiology. We encourage you to seek advice from an electrophysiologist at a medical center.

Jeffore: I am 64 years old. I ride a bike for an hour at a time at a fairly fast pace. My muscles feel weak from the Amiodarone and the blood thinner. I take a very low dose of Amiodarone. I would prefer to not take the medication if I could, so I could return to my normal muscle strength on my workouts.

Chadi Ayoub, MD: If you are referring to Amiodarone, this can be associated with a number of side effects long term including thyroid, lung and liver disease. It may be worthwhile to discuss with your care provider regarding the need for this medication and any potential alternatives. If your care provider feels that this medication is needed for you, then ongoing monitoring is recommended.

JJAltoona: Hello. I have a question concerning the protocol for receiving an ICD. Is it determined strictly by the LVEF number, or are there other circumstances which would allow a patient to qualify for an ICD? I have had three MIs and have nine stents. The MIs were all in the LAD, OM and CX region and as a result, I have a fair amount of muscle death in that area as well as problems with arrhythmias, mostly PVCs. My LVEF is ~ 40% so I don't qualify to receive an ICD even though an EP specialist has determined that an ICD is warranted, but not possible due to the LVEF being above the 35% cutoff. Thank you.

Steven Nissen, MD: The presence of arrhythmias can be an important determinant of whether a person with a particular ejection fraction (EF) should require an ICD. These rules should be interpreted on an individual patient basis rather than a general guideline.

Arrhythmia: Atrial Fibrillation

Heart1: I have AFIB.I think due to stress. I have given so many meds. The doctors don't look at the cause they just throw another pill at me. I have been given so many different things and have reactions to all of them. I quit taking anything but vitamins. I am not having it now without the meds. What is your recommendation? Thanks, Nancy

Chadi Ayoub, MD: With atrial fibrillation, prevention of stroke and controlling heart rate would be important aspects. Sometimes atrial fibrillation may be related to other cardiac conditions and it would be important to be evaluated in the context of your overall heart health.

Blood Pressure

earl359: A few weeks ago I took my mother’s blood pressure and it was 70/40, she was feeling dizzy so I decided to take her into the ER to see if anything was wrong. The problem is that the doctor quickly told me that she actually had high BP. The ER doc wrote the script for the Norvasc, based on his BP finding that she was slightly outside of the new normal blood pressure guidelines. I brought my mother in because she had a BP of 70/40, almost ready to fall and pass out, and we were quickly handed a prescription for Norvasc to LOWER her BP.

So my questions are, what is your opinion on white coat syndrome and prescribing blood pressure medications to elderly women who have low blood pressure like my mother?

Are there medications that can increase BP for the elderly like my mother's who regularly falls as low as 70/40? Is it ok to give her a little sea salt to raise her BP when it falls like this, maybe a little in some tomato juice? Do all hospitals treat low BP the same? Her BP avg. is 100/70.

Steven Nissen, MD: The best way to treat high blood pressure (BP) is to get a good quality home BP machine and take your BP several times during the day. Bring this chart to your doctor to guide BP control. It is not okay to take sea salt for blood pressure without discussing with your doctor.

BigPicture: I'm a woman in her late 70's who takes 80 mg/day Pravastatin, 5 mg/day Amlodipine and 2.5 mg/day Lisinopril. Over the last four days I've had several low home BP readings (taken with an Omron monitor), including 94/44, 99/50, 104/49 and 107/42. I haven't experienced any symptoms such as dizziness or fainting. My average BP over the last six months has been 124/64, while the average of 10 BP readings over the last four days is 110/54. Lisinopril was added last year when my average BP increased to 145/76 over several months from my average of 133/69 over the course of the prior 12 months. Are BP values as low as the ones I noted over the past four days normal? If not, what are the possible underlying causes and under what circumstances and at what point should I follow up with my cardiologist (e.g., if low BP readings continue over the course of several weeks, etc.)? Thank you.

Steven Nissen, MD: in the absence of symptoms, blood pressure in this range is not a cause for concern.

Carotid Artery Disease

Eunnie: Nell: I’m taking simvastatin only twice a week (1. Tablet -10mg) by mouth. Do you think this will eventually clear my blockage in my left neck artery?

Steven Nissen, MD: High doses of statins have been shown in several studies we have performed to reduce the burden of plaque - but we have not done studies on the effect on plaque in the neck arteries.

Chadi Ayoub, MD: This is a relatively low dose of statin. A more standard dose, if tolerated, would be more helpful for treatment targets.

Coronary Artery Disease: Cholesterol, Stents, Plaque, Post Procedure Care

PennsylvaniaTeacher: How long do you recommend taking blood thinners after placement of a stent which was prompted by a mild heart attack? Would the decision depend on which blood thinner? I am on Effient. On meds, cholesterol is 104, LDL is 34, but Lp (a) is 80. I have no stroke issues (yet) but both parents died of stroke in their mid 80s. Does that impact decision?

Steven Nissen, MD: To some extent it depends on type of stent but determining a contemporary decision, most authorities recommend three months of treatment with drugs like Effient, and critically important, aspirin for life.

charles: I have had stents placed because of plaque buildup in the coronary arteries and angina during strenuous exercise. My cardiologist put me on metoprolol to ensure that my peak heart rate would be reduced because at high BP and HR. Since the stent placements I have been put on statin, aspirin and better lifestyle control. Currently my heart rate is starting to go up again. Is this a sign of heart disease, resistance to metoprolol, or other reasons?

Steven Nissen, MD: Metoprolol always needs to be adjusted for individual patients since there is an approx five fold variability in response to the Metoprolol.

thomasl: I had a stent due to a blockage in the widowmaker. How often should I get rechecked and what testing should I get to make sure I am not getting reblocked.

Steven Nissen, MD: We generally recommend effective preventive measures for CAD but we do not recommend routine testing such as exercise testing or CTA for patients with known CAD unless they have a change in symptoms.

xdwl: Hi, I am 60-year-old female with HCM (post-surgery, NYHA II). Today my question is about cardiovascular calcification. I was found aortic arch calcification in my early 50th, and then found calcification in coronary artery. My recent echo shows calcification in my mitral valve annulus with mild MR and AR. My BMI 24, blood pressure and blood lipids are normal (my LDL is even lower than normal 1.56mmol/L). I would appreciate your advice on how could I prevent or slow down the calcification process. Since I got back pain, I am on calcium pill 600mg/day extracted from plants, Vit D and Vit K2. Should I stop calcium supplement? Thank you very much in advance!

Chadi Ayoub, MD: Calcification in coronary arteries and major arteries in the body is a marker for atherosclerosis plaque and disease. There is no evidence at this stage for a specific tablet to reduce calcification progression in general. Modifications of risk factors that lead to heart disease would be advised. Sometimes treatment with a cholesterol tablet of the statin family helps to stabilize coronary plaque and reduce risk of heart attack, but this treatment may be associated with a numeric rise in calcium quantification.

PennsylvaniaTeacher: What are your recommendations for someone with Lp(a) of 80 but Cholesterol of 104 and LDL 34 (on meds)? Can Lp(a) be lowered?

Steven Nissen, MD: There is no therapy that is proven to be effective at reducing heart disease risk from Lp (a) - but stay tuned there are several companies working with new therapies that are very promising.

Diastolic Dysfunction

bobob: Is left diastolic dysfunction a concern? Any medications for this?

Chadi Ayoub, MD: Diastolic dysfunction can be an important cause of shortness of breath. It is important to evaluate the degree of diastolic dysfunction, and the effect it has on a given individual. The mainstay of treatment for this condition is to treat the underlying cause, often this is due to hypertension, and if necessary to treat any excess fluid that may accumulate as a result of this with a water pill.

Heart Failure

Wick: My 69-year-old wife has end-stage kidney disease and has been on PD for 22 years. She had been in extraordinary good health until about two years ago when she began to exhibit symptoms of CHF. She has been hospitalized three times and most recently was discharged “dry” but at one point had an ejection fraction of only15 percent. To control her fluid load, she is on a rigorous low salt diet and her dialysis regimen is regulated to keep her weight between 123 and 125 pounds. Despite these steps, not surprisingly, her energy level is very low and she feels “weak” (her description), which is to say lousy, most of the time. It’s no way to live. I understand that CHF is a progressive condition not amenable to treatment. Nevertheless, with the controls mentioned, plus a gradual planned increase in her physical activity, can an increase in my darling wife’s EF - and improved wellbeing - reasonably be anticipated? What else, if anything, might support these goals?

Steven Nissen, MD: There are important new treatments for congestive heart failure that your wife may be a candidate for - this is best evaluated by a heart failure specialist rather than a general internist or cardiologist. Yes - ejection fraction can increase with good medical therapy in some patients.

xdwl: Hello doctor, to improving survival for HF with preserved EF (HFpEF), would Carvedilol is also more benefit than Metoprolol succinate? Thank you!

Steven Nissen, MD: There really has not yet been developed therapies that have been proven to improve life with HFpEF - we often treat with meds to improve the symptoms but do not have proof that any of these meds improve survival.


Shazbeastie: Ten days ago I woke with the worst pain ever. Codeine didn’t help so asked go for stronger painkillers. I was tachycardic so ambulance to an A & E . Morphine didn’t help. A CT Scan, ultrasound and x-ray confirmed pericarditis again. They started steroids after five days as they were trying to avoid them. After nine days of being on a cardiac ward, they reluctantly let me go home with 20mg Prednisolone, 60mg Codeine and 1000mg Colchicine. I was still in pain and the consultant apologized they hadn’t managed my pain. I was low with feeling poorly and confined and really wanted to go home. I will be on the steroid for 14 days and the anti-inflammatories for three months. Is this going to cure this forever? Will I get flare-ups in future? Do I need to see a Rheumatologist? What else can I do to manage this? How soon can I get back to my usual bubbly self? What can I do to prevent reoccurrence? Thank you and sorry for the long message.

Chadi Ayoub, MD: Often an initial approach to pericarditis is with NSAID, such as Celecoxib, and Colchicine. Pericarditis occasionally can be a difficult condition to treat, and a full evaluation for potential causes is advisable, preferably with someone who is an expert in the treatment of pericarditis. We have a center for the treatment of pericarditis at Cleveland Clinic.

Pulmonary Hypertension

eugeno: Hello. I have PVH Pulmonary Venous Hypertension. I am doing what my doctor told me, control blood pressure, exercise, etc. Are there any treatments on the horizon? Thank you.

Chadi Ayoub, MD: Pulmonary venous HTN is often related to cardiac problems in the left side of the heart and the thorough evaluation regarding how to address these is best to approach this. While there are directed treatments toward PAH they are not specifically helpful at this time for PVH.


EJER: How soon prior to heart surgery should I stop taking aspirin? I presently take one 81mg aspirin per day.

Steven Nissen, MD: We generally do not recommend stopping aspirin before coronary surgery but you should check with your heart surgeon.

adourian: Had surgery at the Clinic four months ago (new bio aortic valve, modified maze, LAA removal). A prior coronary cath had shown only mild arteriosclerosis. Post-surgery echo was good but EKG did show that I had developed a mild LBBB. Currently dealing with high resting heart rate (100) and low BP (95/70). Recent blood tests have shown Troponin, WBC and all other blood tests normal but high ESR (50+) and CRP (8). No symptoms of any autoimmune/arthritic problem or no other symptoms of anything other than phlegm in lungs when waking, and of course, the high resting heart rate. Recent CT Chest PE negative and Chest X-ray in unremarkable. What am I missing that escapes being detected by all these tests thus far, but could be a virus that could affect my new valve or my heart in general? Next steps?

Steven Nissen, MD: We think you should check back with the surgical team and perhaps make an appointment with one of our heart valve specialists. The most common cause of a fast heart rate after heart surgery is a low blood count. In modern practice we allow patients to go home with low blood counts to avoid the risks of blood transfusions. Eventually their blood count will go up and their heart rate will come down.

Valve Disease: Aortic Valve Disease

LLD186: Can a-fib subside with weight loss? I also have aortic stenosis. How much exercise can I engage in with both conditions? In evaluating the degree of stenosis, would the precision of the echo technician make a difference the AVA?

Chadi Ayoub, MD: There has been some recent research to show that weight loss is helpful to reducing recurrence of atrial fibrillation (afib), and is generally favorable to overall health and the risk factors that lead to afib. The question about AS and exercise would be related to how severe the AS is, and this would need to be evaluated by a cardiologist.   But if the AS is not severe, exercise would be recommended to help with overall health.

Steven Nissen, MD: Precision of echo measurements have a big impact on the AVA and gradient measurement.

DGiessen68: Are there any clinical trials or research that I as someone with BAVD can participate in that are offered at CC? I have researched the national list of clinical trials periodically and sometimes find myself missing opportunities to help out.

Chadi Ayoub, MD: Not to our knowledge in terms of research. We see many patients with this condition at Cleveland Clinic, and have experience with following this condition and intervening when necessary.

Diet, Vitamins, Supplements

earl359: About a month ago I started taking L-Citrulline 750mg 3X, along with an array of other important supplements that my doctor does not recommend, including coenzyme q10, fish oil, and vitamin D. I successfully lowered my BP to completely normal levels thereby avoiding going on the blood pressure medications. I was wondering if you could explain how the L-Citrulline worked so efficiently in lowering my blood pressure? My limited understanding is that it somehow increases nitric oxide or something like that in the arteries, are there any blood pressure medications that work in the same way that the L-Citrulline does, because for me it works very well, and if there is a medication similar to it I wouldn't mind going on it. Thank you Sir for your time here in taking my questions.

Steven Nissen, MD: There is no evidence that any of your dietary supplements have a positive effect on BP. I recommend that you have your blood pressure checked carefully using a home blood pressure cuff. We do not recommend dietary supplements for this condition. There is a diet that has been helpful for patients with hypertension known as DASH diet - you can read about this on the internet and that is a reasonable course of action however most patients with hypertension will need some type of medication.

Chadi Ayoub, MD: Other lifestyle strategies, such as exercise, are very helpful for hypertension.

Mcollado14: Hello! I️ would like to know what is good to take as in vitamins for iron deficiency.

Steven Nissen, MD: We do not recommend vitamins routinely for any typical cardiovascular conditions. The best approach for iron deficiency is to find the cause and address it.

seagypsy: Is it true that a Vegan diet, devoid of any animal fat, is best for someone who already has stents and heart damage? How about sugar?

Steven Nissen, MD: Vegan diet is one of several healthy choices but it is not necessarily the diet that most authorities prefer. The best evidence is for a Mediterranean diet which is rich in fruits and vegetables, low in sugar but does allow some limited meat and fish.


markrj: What types of exercise are considered strenuous vs. moderate types? Please list examples.

Steven Nissen, MD: The type of exercise is less important than the intensity - you can get high intensity exercise from cycling, running, skiing, and many other activities. The typical approach is to ask people to grade their effort on a 10 point scale. The higher the number the greater the intensity.

Sleep Apnea

jltk95: How is sleep apnea related to the heart? My brother wears cpap and has sleep apnea, but also has allergies and still has trouble breathing. Worried about future heart problems as our father died at age 60 from a heart attack.

Chadi Ayoub, MD: Sleep apnea can be associated with increased risk for heart disease including electrical abnormalities such as atrial fibrillation, and risk factors for narrowing in the coronary arteries.

Diagnostic Testing

benlomondeast: I’m 36 years from XRT for Hodgkin’s (total nodal 8200 cGy - mediastinal tumor dose 4600 cGy). I’m symptomatic, paced for third degree heart block, echo results reveal mod - severe valvular disease, diastolic dysfunction and restrictive pattern. Next step is cardiac cath, but I’ve been hesitant to do anything invasive. Is the risk higher in my case than the potential benefit? Thank you.

Chadi Ayoub, MD: Radiation, although lifesaving for lymphoma, can have serious effects on the heart many years later. Including some of the things you described. Cardiac cath is safe in patients with radiation heart disease and may be necessary to determine the best treatment.

xam1955: I have a family history of heart disease, pretty strong. I watch my diet, exercise and have been thinking of getting a calcium score test. I know that this is controversial - some docs say yes and some say no. But worried if a heart attack will be my first sign of coronary disease.

Steven Nissen, MD: It is controversial.  we tend to not recommend calcium scanning because the information is not actionable - good preventive measures are always a good idea regardless of your calcium score.

Genetic Testing

brucefromVA: Drs. What do you think of genetic testing that will help target the right medications for the patient? I like that idea. I have hard to regulate high blood pressure and also some heart failure, EF 45%. Wondering if there is targeted personalized medicine that would help me.

Steven Nissen, MD: There has not yet been developed any uniformly useful genetic test for determining optimal cardiac medications. Perhaps someday.

General Questions

maryjanew: Dr. Nissen, I have Heart 411 and really liked that book. I am wondering if there is anything new you would add to that book that we should know about heart health.

Steven Nissen, MD: We are thinking about a new edition - the fundamental principles that we discussed in the book have not changed much but there are new therapies that have been developed since we wrote the book.

Reviewed: 02/18

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