Steven Nissen, MD
Steven Nissen, MD

Thursday, November 17, 2016 | Noon


Cleveland Clinic is recognized as the world leader in the diagnosis and treatment of cardiovascular disease and has been ranked No. 1 in the nation for cardiac care by U.S. News & World Report every year since 1995. Learn about the latest newest medical innovations and research presented at The American Heart Association's Scientific Sessions and have your questions answered by Dr. Nissen.

More Information

  • View more information on heart and vascular conditions.
  • If you need more information, contact us or call the Miller Family Heart & Vascular Institute Resource & Information Nurse at 216.445.9288 or toll-free at 866.289.6911. We would be happy to help you.
  • View previous chat transcripts.

Cardiac Exam

Stephen45: Dr. Nissen - I have a family history of heart disease and want to get a good cardiac exam. What should be included? I am a 45-year-old male, dad had a heart attack at 50. Mom's dad died of heart disease in 60s. I exercise, could eat better I think.

Steven_Nissen,_MD: A good general physical exam is fine and should include checking a lipid panel, c-reactive protein, and a careful measurement of your blood pressure. Assuming you do not smoke or have diabetes or are overweight, the major factors affecting development of heart disease are cholesterol and blood pressure.

Diagnostic Tests

pitcher: I had a cardiac calcium heart scan last year. I was 62 at the time. Score was 156. All calcium found was in the LAD which can be widow maker artery I understand. I was told by one cardiologist you can't tell where the location of calcium is in the LAD from the test. Cleveland Clinic has answered the question saying you can tell from the test. I know if it's at the beginning of artery very dangerous. Also my LDL is 92, shouldn't it be more like 70, but I'm an over absorber and didn't tolerate zetia that well. Thx

Steven_Nissen,_MD: Your calcium score is actually very low for your age and does not indicate an increased risk. We strongly discourage obtaining calcium scores because they frighten patients unnecessarily. Your ideal LDL cholesterol can only be determined by knowing your other risk factors but 92 is reasonable.

Mary: Hi. I have a family.history of heart disease. My birthday 11/04/1953, I had coronary calcium with no dye.  Agatston score 14 LAD. Explain. The ascending aorta is ectatic, measuring up to 3.5 cm diameter. The descending thoracic aorta measures 2.5 cm in diameter. Please explain I don't understand. Thank you Mary.

Steven_Nissen,_MD: Your calcium score is low - it does not indicate a major increase in risk. The size of your aorta is not a cause for concern but should be followed every 2 - 3 years for any increases.

Tweets: Had an echocadigram done, said i had some diastolic relaxation otherwise normal what does this mean.

Steven_Nissen,_MD: It means that your heart is a little stiffer than would be considered normal. This tends to occur with aging. If your blood pressure is elevated it should be treated, which may improve the relaxation properties of the heart.

George: I see many things in the paper connected to heart about something called IVUS. What is that? Is it a test I should have? It sounds like it can tell if someone has coronary artery disease narrowing?

Steven_Nissen,_MD: Intravascular ultrasound (IVUS) is a research technique for measuring plaque in the coronary arteries. It should not be used in routine clinical practice.

GNT: I am a 71-year-old male, had a cardiac calcium scan done about 5 years ago that showed small calcium buildup (15%) in 2 areas. I am on a heart healthy diet and exercise 5 days per week. I get blood work done every 3 months, cholesterol 99 LDL 38 HLD 58 with daily 10mg of Lipitor. Do you recommend an updated scan? Are there any new medications on the horizon to reduce CAD plaques? As even with diet and exercise I have CAD.

Steven_Nissen,_MD: You should NOT have a repeat calcium scan. It is strongly recommended that only one calcium scan be done during your lifetime. In fact with statin treatment, plaques will increase in calcification which is actually a good sign since it represents stabilization. Your numbers are terrific. Keep doing what you are doing.

sylviaP: What if one has a coronary CT and it shows significant calcification in the coronary arteries - is angioplasty still an option - or do you have to have surgery.

Steven_Nissen,_MD: We do not perform angioplasty for an elevated calcium score. Angioplasty is reserved for patients with significant symptoms from their coronary disease.

Coronary Artery Disease Treatments

georgiapeach: Was there any new research presented on stem cell therapy for patients who have had damage to their heart from a heart attack?

Steven_Nissen,_MD: So far the evidence for benefits from stem cell therapy is very limited and not ready for prime time. Promising, but not proven.

KenWVA: I have had 4 stents and my arteries blocked up again. I am not sure if I should go back to getting stents or consider bypass surgery? Wonder why my cardiologist has not mentioned bypass surgery but wants to do another stent. Not sure what to do. Is there any research out there that states how many stents someone can have?

Steven_Nissen,_MD: If you are uncomfortable with the choices I strongly recommend getting a second opinion. We see many patients here who needs independent advice and we try to help them understand their choices including the risks or benefits to stenting vs. surgery.

There is no known limit on the number of stents that can be used although we tend to use bypass surgery in patients who require multiple stents without long standing benefits.

Robert2207: I have had many symptoms of coronary artery disease, chest pain, very tired, get shortness of breath more easily. All this with activity only. I had a cath and it showed that my one artery to the left is 65% blocked. I am an active person. I am scared I am going to have a heart attack. My doctor said they don't fix blocked arteries until they are around 80% blocked - so what to do? I want to feel good and get back to my activities. Advice?

Steven_Nissen,_MD: I agree with your doctor about not having a stent for that degree of blockage. You should manage your risk factors including cholesterol, blood pressure, avoidance of tobacco, maintaining a healthy body weight, and you should do fine. I assume you are taking a statin drug.

belinda7759: My dad had heart bypass surgery and came home with a bunch of medications. What medications do you actually need to be on long -term? Are there any that are related to improving longevity long-term?

Steven_Nissen,_MD: The medications that your father needs are entirely dependent on the details of his condition. So - we can’t really offer advice without knowing more about him.

Arthritis and Medications

jojo: I asked my doctor about the news about arthritis pain medications and he said he still does not want me on any of these medications. What medications are safe and what medications are not safe so I can tell him what you said.

Steven_Nissen,_MD: We cannot tell you that any of these medications are safe. Our study compared the RELATIVE safety of three arthritis medications but there was not group that received a placebo so we cannot determine if any of these medications are free from risk. The best advice is to take the smallest amount of these medications for the shortest time possible.

sumbeam88: Dr. Nissen, I know a lot has been in the news about arthritis meds and heart disease - but why are people with arthritis at greater risk for heart disease - I think I read there is a link - but what is it?

Steven_Nissen,_MD: There is a link between one form of arthritis, rheumatoid arthritis and heart disease. We think this is due to the increase in inflammation throughout the body which leads to both the arthritis and increased accumulation of cholesterol in artery walls.

Curtis: I have been on Celebrex for 18 years and at 100 Mg twice daily from the start for the amount of injuries and surgeries that I have had. It has been a blessing considering at the time that I found it, I was up to 3800 Mg of Tylenol, once a day. Thus causing my Barrett’s. I was taken off of it in January this year because of the cost of it, and insurance would no longer pay for it. I am in constant pain now, have tried generic forms of it but they do not work. Thank you Curtis

Steven_Nissen,_MD: Our recent study indicated that Celebrex was just as safe as the other medications. There are now several generic brands and you should try another generic version. FDA rules require generics to achieve the same blood levels as brand name drugs so a generic should work.


buckeye56: I was told by my heart doctor I need to have a pacemaker installed.  I have been researching the new smaller type pacemaker and would like to know if new pacemaker is being installed at Cleveland Clinic or anywhere in Ohio.

Steven_Nissen,_MD: Yes - we do install the latest pacemakers at Cleveland Clinic.

Atrial Fibrillation

rkchuey: I have a 7 year history of afib. I had a good result in 2014 with an ablation at CCF. Thereafter, a biopsy confirmed pulmonary sarcoidosis and I have on methotrexate for 2 years. Last year, the sarcoid spread to the spine (vertebral sarcoidosis). This year I had 2 hospitalizations due to Afib. My local cardiologist believes that the afib is being caused by the methotrexate treatments. What are your recommendations? I suffered a partial syncope this last episode and I am on 240 mg of Cardizem. I have not converted back to sinus rhythm. However, the cardiac MRI came back normal with no sarcoid present in heart.

Steven_Nissen,_MD: Many patients will have a recurrence of atrial fib years after an initial ablation. I recommend you see one of our electrophysiologist here for further recommendations about what can be done for the recurrent atrial fibrillation.

smartini: Are there any new innovations for afib ablations, most importantly to ensure a better success rate?

Steven_Nissen,_MD: There have been some improvements in the technology that has occurred gradually in the past few years.


Caroline66: I really don't want to go on medications for my cholesterol. I do exercise 4 - 5 times a week. I think I follow a good diet - but what else can I do? Are there any good non-medication strategies I can do or at least try my best before I see my doctor next time?

Steven_Nissen,_MD: Depends on how high your cholesterol is however there are limits to the benefits of dietary changes. If your cholesterol is very high you will almost certainly need medications and the medications are very safe.

Rogerthat: Any new medications for lowering cholesterol - I am not able to tolerate any medications - they give me severe muscle pain - I have tried all the statins.

Steven_Nissen,_MD: There are some new medications and at least one old medication. The drug ezetimide (zetia) reduces the absorption of cholesterol in the GI tract. There is also a new injectable cholesterol lowering medication that can dramatically lower the bad cholesterol but it is expensive with a list price of about $1,000 a month.

Valve Surgery

Prairieguy: I'm a 61-year-old male. Dr. Gillinov performed AVR 3 years ago with bovine valve. Standard surgery without complications. Was bicuspid. What are the chances in 10-20 years that valve replacement through groin will be commonplace for non-high risk patients like myself? Also, I'm interested in the new Amgen drug that will "melt away" my plaque in my 3 major vessels which was 30% atherosclerotic at time of surgery. Will that be available or indicated for me assuming I have good insurance coverage?

Steven_Nissen,_MD: First of all, valve replacement through the groin without open heart surgery is becoming more and more common and almost certainly will be available to you if your current valve begins to malfunction in the future.

The Amgen drug is used only for people who have very high cholesterol levels despite statins. We always use statins first in maximum doses because they are the most safe and effective approach.

seamullet2016: What is the latest on transcatheter aortic and mitral valve replacement? Who qualifies?

Steven_Nissen,_MD: It is a complicated evaluation that cannot be simply summarized. If you may be a candidate it is best to undergo a careful evaluation at a center where these procedures are performed.


CAG6623: Dr. Nissen - what do you tell patients about alcohol consumption. I have heard that it is good for you and then it is not good for you. I usually have a glass of wine or cocktail a day at dinner but then may have 2-3 on Saturday - is that bad for me?

Steven_Nissen,_MD: Your level of alcohol consumption does not seem to be a problem. Most studies show that moderate alcohol intake is associated with a slightly reduced risk of heart disease. Moderate means 1 - 2 glasses of wine per day for a man and perhaps a little less for a woman - or the equivalent in spirits.


crackerjack: Was there any research that came out of the American Heart on ecigarettes? Are they ok to use - trying to quit smoking - thought I would switch to those?

Steven_Nissen,_MD: This is a very controversial area. Some prominent authorities believe that e-cigarettes can be a useful approach to helping patients stop smoking. Whereas other experts including me do not want to substitute a new addiction for an old addiction. The best approach is to use products like nicotine patches or gum to stop smoking and then gradually discontinue the patch or chewable form of nicotine.

Second Opinion

Bertie28: Dr. Nissen - what do you do if you get a second opinion - and one person says one thing and the other doctor says something different? Do you get a third opinion? How do you know who is right? I don't think my insurance will pay for another opinion but I am not sure what way to think about the advice I have received.

Steven_Nissen,_MD: It can be very challenging to know who to believe. It's sometimes useful to ask physicians why they are offering the opinion that they provide and try to weigh whether the reasons make good sense.

New Treatments

Nama4: Any new treatments for 1) eliminating a fib, 2) treating ascending arch aneurysms, or 3) replacing aortic valves?

Steven_Nissen,_MD: The treatments that we have now primarily ablation are very effective and there have been small improvements in the technique that makes success more likely. There are no new treatments for ascending arch aneurysms.

More and more aortic valves are being replaced through a catheter in the groin rather than open heart surgery; but this technique is not for everyone and requires careful evaluation.

Other question Is there any reaction while eating during blood transfusion?

Steven_Nissen,_MD: This is not my area of expertise.

[Moderator note: Learn more about blood transfusions]

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.