Stanley Hazen, MD, PhD
Stanley Hazen, MD, PhD

Tuesday, July 26, 2016 | Noon


Cardiovascular disease is the leading cause of death in the United States, killing over 1 million Americans each year. It is important for you to understand the modifiable and non-modifiable risk factors that are associated with it. Stanley Hazen, MD, PhD, Medical Director of Preventive Cardiology answers your questions about cardiovascular risk factors and how to control them.

More Information

Blood Lipids (cholesterol, LDL, HDL) – Testing and Treatment

candi2525: If my HDL is high - 60; and my LDL is high LDL- 160 - do they still treat the LDL.

Stanley_Hazen,_MD: Yes. While a high HDL is associated with reduced risk, it doesn't overcome the risk of high LDL - and the PRIMARY thing to follow in a lipid panel is the LDL cholesterol.

Frankie52: I was a little disappointed with my test results. I have been walking and watching diet but my doc said my blood sugar is a little high and same with cholesterol. He agreed to let me try being even stricter with diet and exercise and coming back in three months to see if I really need something. Is that enough time to wait to see results - or does it take longer?

Stanley_Hazen,_MD: Yes - three months is sufficient to see if there is improvement; the key is to make sure you return and don't get "lost to follow-up." I always am concerned about folks disappearing. In fact, current recommendations are to often start the medication at the same time as starting the lifestyle efforts, and if significant weight loss and other improvements occur, seeing if some things can be peeled back....the key again - is don't get lost to follow-up and make sure to return and reevaluate the blood sugar and LDLc.

sw4health: How often should one get a full blood lipid profile done? Also, how accurate and reliable are the finger-prick cholesterol screenings often offered at community outreach events/health fairs? Thank you.

Stanley_Hazen,_MD: Recommended Lipid profile frequency depends on age and other items including risk factor prevalence. The finder stick cholesterol measures can give general idea - they are not as accurate as a formal fasting lipid profile.

Other Blood Tests

Nilar: I want to know the causes of elevated CK level, normal CKMB and negative Troponin I. ECG is normal and lipid profile is within normal limit. Is it heart attack or myocardial infarct?

Stanley_Hazen,_MD: CK elevation has many possible causes. First - sex and ethnicity (male and African American) have increased CK levels in general. Second - endocrine issues like hypothyroidism, and parathyroid abnormalities need to be screened. Third - medications can play a role - for example, statins, niacin, and numerous other medications can, as adverse side effect, lead to CK elevations and should be screened for. Lastly, genuine diseases of muscle (myopathies) can lead to CK elevations - sometimes with associated symptoms, and this too should be considered.

Barney33: Are there reliable markers (that can be determined in the blood) or reliable tests (on the body) that can be used to monitor the presence and progression of atherosclerosis, and if so what are they? Thank you.

Stanley_Hazen,_MD: Rather than the progression - there are blood and other tests that predict future risks of cardiovascular disease development and event risk. Examples include what I suspect you know - BP, cholesterol, etc.

sassysheila: Husband has great difficulty taking statins because they caused frequent severe hand cramps which was relieved with CoQ10 at 50mg. He is slowly increasing the dosage of statin to the recommended level. What is your opinion of the also gradually adding the CoQ10 to 100mg?

Stanley_Hazen,_MD: I recommend at least 200 mg daily with food as the dose for CoQ10 supplementation. It is best absorbed with food.

sax64: Thanks! But I have not heard of anyone as Preventive Cardiology specialist in Sweden or Norway. My total cholesterol is around 110 mg. So they reduced the dose. In the beginning I took 40 mg for a year. Should I still take 40mg?

Stanley_Hazen,_MD: LDLc is the major thing we follow - not total cholesterol. We and others use as the low "safety" cutoff for LDLc (in clinical trials) 25mg/dL.

Diagnostic Testing for Cardiovascular Disease

sax64: I am Indian lady (68 yrs.), living in Scandinavia for the last 22 years. I was always healthy practicing Yoga and walking every day. I had normal cholesterol & blood sugar, used to take 2.5mg mg Felodipin for BP. But five yrs. ago, one morning I got jaw pain which lead to a heart attack by the evening. Next day I had angiography, and one stent placed in my RCA. After coming home, the jaw pain persisted. After a month, I got three more stents in the same RCA. Since then I am on Thrombyl 75 mg, Metoprolol, now reduced to 25 mg, Clopidogrel75mg, Felodipin2.5 mg and Atorvastatin10 mg. Since this Feb I am also taking Ramipril2.5mg, by the advice of another doc, while I was sick in India. Doctors here told me that I don’t need to see a cardiologist unless I have further problem. But I live in panic all the time. My blood sugar is normal and cholesterol, etc., are within the range suggested by your clinic. BP below 120/80.I want to ask you which tests should I take and how often, to avoid a sudden heart attack?

Stanley_Hazen,_MD: We don't recommend specific testing beyond what you appear to be doing - but I do recommend seeing a preventive cardiology clinic to make sure that you are optimally doing all that can be done to prevent progression of your disease. For example - the recommended dose of atorvastatin in someone with a history of CAD such as yours is either 40 or 80mg. You should consider addressing this with a preventive cardiology specialist.

mariearc2015: Is having a chemical stress test to test for blockage reliable. Thank you.

Stanley_Hazen,_MD: Pharmacological stress testing is an important tool for cardiovascular risk assessment under specific conditions. You should review this with your doctor or cardiologist.

Risk Factors

sinaihospital: I have high blood pressure, also high cholesterol, type 2 diabetes will this put at risk for heart disease, yes or no doctor? Thank you for help.

Stanley_Hazen,_MD: Yes and yes - both HTN and diabetes increase cardiac risks and are correctable/treatable conditions.

GNT: Does psoriasis increase the risk of heart disease?

Stanley_Hazen,_MD: Yes, especially in subjects requiring a biologic agent. Studies have shown a 2-3 fold increase in cardiovascular risks with psoriatic arthritis subjects requiring systemic interventions (drugs and/or biologic agents).

Debbie: I have a question about the MPO (myeloperoxidase) blood test. Is Cleveland Clinic the only facility that does this test? I live in CA and when I tried to get the test, my lab did a MPOab (antibody) test instead, which I understand from your site is not the same thing. Do I need to have the blood sample sent to your facility? Thank you!

Stanley_Hazen,_MD: No, the MPO test is offered by physicians throughout the country. You can contact Cleveland Heart Lab to find out where you can get this testing near you.

db3096: Is there a link between inflammation due to arthritis and inflammation as it relates to heart disease?

Stanley_Hazen,_MD: Yes, subjects with inflammatory arthritis are at increased cardiovascular risks.

sw4health: What impact, if any, does having kidney stones have on cardiovascular disease risk?

Stanley_Hazen,_MD: Minimal, if any.


Maddie44 : My sugars were high and so the doctor put me on a medication to help with that - he told me I am borderline diabetes. At my next checkup he also noticed my cholesterol is up and now he wants to put me on Crestor. But doesn’t that raise your blood sugar even more? It seems like a circle where I won’t be able to get things in control.

Stanley_Hazen,_MD: One topic that greatly concerns me is the incredible disservice the media have done with the association between statin use and diabetes. While it is true that being on a statin does minimally (but measurably) increase blood sugar and thus in a very small portion of folks accelerate the date of diagnosis of diabetes by three months (that is the magnitude of the effect), it is also true that it is amongst diabetics that the greatest risk reduction in heart attack, stroke and death occur. So all the headlines should read - while statins marginally increase diabetes risk, they markedly reduce mortality rate and cardiovascular disease risks.

Lifestyle Change

heartyhaerhar: My doctor said I should make several changes to both diet and exercise. I know myself and that I won't be able to change everything all at once. Is there something I should focus on more? Make changes to diet first? Exercise first? I want to change, but there's a lot to do and I don't want to fail.

Stanley_Hazen,_MD: I suggest baby steps - choosing small and attainable goals in terms of weight reduction. And ALWAYS - to initiate an exercise program. The single biggest predictor of success in diet and weight reduction is maintaining a routine exercise regimen. A preventive cardiology program can provide guidance and assistance. It is hard to do everything on your own.


Paulc: How often do you really need to exercise - I am sitting at my desk all day but try to do something after work - what type is best, how long, how much?

Stanley_Hazen,_MD: I recommend that folks try and get 10,000 steps in daily. I also recommend a routine exercise regimen consist of at least 30-45 min of sustained activity, 3-5d/week. That can be walking at a brisk pace or anything similar in level of activity - whether it be ballroom dancing, racquetball, jazzercise, treadmill, swimming etc....just find something you enjoy and do it....


mtsdmaxxshop: What is by far the most beneficial food or foods for a healthy heart?

Stanley_Hazen,_MD: I recommend a Mediterranean diet as this has been shown to reduce cardiovascular disease risks by 30-35% on top of medications and exercise.

stacybryant16: Hello, have you ever heard of Table Tasty no potassium chloride salt substitute? I have heart problems and high blood pressure and I was thinking of taking Table Tasty no potassium chloride salt substitute, and it has nutritional yeast extract in it.  I've seen doctors in multiple places saying multiple different things on whether it’s good or bad for you. Can you please tell me if it will be bad on my heart or bad to my body in anyway?

Stanley_Hazen,_MD: I am unfamiliar with this product.

sassysheila: Do you recommend any healthy oils like avocado or olive?

Stanley_Hazen,_MD: I do recommend the Mediterranean diet - so cold pressed EVOO is a definite YES. I am unfamiliar with characterizing other oils as "healthy", but including avocados (technically a fruit - and in moderation) and vegetables in your diet is definitely a healthy food choice.

sassysheila: Do you think cardiovascular atherosclerosis can be reversed using a plant based diet?

Stanley_Hazen,_MD: Data shows that reversal of atherosclerosis is in general a slow process, regardless of the diet. It is associated with significant lowering of LDL, and among those with lower LDL, a higher HDL, and concurrent lower TG level. I think a plant based diet can be a healthy diet (as long as sufficient protein and not too many carbs and problems with diabetes occur) - however, it should be a personal choice - and clinical outcome studies are needed to show a plant based diet reduces heart attack, stroke and death risks - like those that have been shown with the Mediterranean diet.

zippy: Do you recommend fish oil capsules. My doctor said no - but eat fish. I think the good fish to eat is salmon and tuna - but then I read that too much can cause you to have mercury or something bad. What's the recommendation?

Stanley_Hazen,_MD: I recommend eating fish at least twice per week I don’t recommend fish oil per se - I recommend omega 3 fatty acids (DHA + EPA) in the setting of triglyceride elevation.

sassysheila: Just curious why two different cardiologists recommend Magnesium and D3 additions. Would you kindly explain your reasoning? Thank you so much for your time.

Stanley_Hazen,_MD: You would have to ask them. I would only recommend them if they were deficient.

Weight Loss

Trykkergirl: If I can't seem to lose weight (240 lbs,5'5" obese), 71-year-old female what else can I do to keep my heart disease from progressing to heart failure? I am borderline for that too, with one time my echo showing diastolic dysfunction, the next time showing it normal. I have two mildly regurgitating valves as well and am SOB all the time, (worse when exercising). I ride a recumbent tricycle outdoors 15 miles in an hour and half EVERYDAY and eat very heart healthy foods most the time. Sometimes, I eat fast food breakfasts though. I know I will never be able to lose this weight, what else do you suggest beyond eating healthy and not smoking or drinking, and exercising to keep myself alive?

Stanley_Hazen,_MD: I suggest you see a preventive cardiologist for a global evaluation and program. I also do not accept the belief you cannot lose weight. I think if you begin to believe that it would be helpful.


mbakaitis: I never smoked, but my father did quite frequently as I was growing up. Will that increase my risk of heart problems as an adult?

Stanley_Hazen,_MD: Probably not. In general - the effect of smoking on heart disease seems to reverse or stop (in terms of heightening risks) shortly after stopping smoking. That said - family history extends beyond second hand smoke exposure - and if your father or mother (or other first degree relatives) show evidence of premature development of heart disease, that is a risk factor.

TMAO Research

sherman: Dr. Hazen - can you talk about your TMAO research and what is the next step for prevention or treatment recommendations related to TMAO testing?

Stanley_Hazen,_MD: Our most recent studies show a direct link between TMAO and platelet function. A high TMAO is associated with enhanced thrombosis risk, and there is data to indicate that this effect is rapid (i.e. - things that lower TMAO should lower thrombosis risk related to the TMAO). I personally think that TMAO can provide information in the primary prevention patient who might not be on a baby aspirin yet - in terms of identifying those who might be at increased risk and therefore the benefits might outweigh the risks. This is still an area of active investigation - but one I think very clinically relevant.

Cardiovascular Disease

trinialvara: I'm 35-year-old female, I've been getting this discomfort on upper chest, back tension and down my left arm. I went to my doctor three days ago with those symptoms and he did an ECG. It came back abnormal so he send me to ER. They did another ECG came back abnormal too, so they drew blood to check levels, did chest X-ray, which everything came back normal just my magnesium was low. They admitted me to hospital to monitor me 24 hours, did lab work, more ECG, put magnesium IV. After the magnesium, all ECG and lab work came back normal. They did an echo which all was normal function of 50-55%. But why am I still feeling pounding heart beats, chest discomfort and my arm tingling? Please help.

Stanley_Hazen,_MD: You should schedule an appointment for further evaluation with a cardiologist.

[Learn more about symptoms of heart disease]

sassysheila: Husband has three coronary artery stenosis. Two have been stented and a cardiac surgeon says all the vessels are showing by catheterization extensive plaque. Is CABG our only solution? He has moderate COPD and history of severe rib cage injury.

Stanley_Hazen,_MD: We (Cleveland Clinic) can offer you a second opinion. There is no way to determine what you are asking in a web chat format.

[Contact our Resource Nurses if you want to discuss a second opinion]

Heart Valve Disease

gabbyme3: I have a heart murmur, is this considered cardiovascular heart disease? Diffuse thickening of the aortic valve cusps with reduced excursion. Would this cause a heart attack or stroke? Age: 81. Thank you doctor for answering my questions.

Stanley_Hazen,_MD: No – A heart murmur does not increase risk for atherosclerosis, heart attack or stroke.

gabbyme3: Having a heart murmur will that lead to a heart-attack or stroke?

Stanley_Hazen,_MD: No.

[Learn more about heart valve disease]

Arrhythmias (Abnormal Heart Rhythms)

mariearc2015: I am taking Eliquis for a fib I have an ascending aortic aneurysm measuring up to 5.3. Could taking Eliquis cause any change in my aneurysm. Could this blood thinner cause any change to its size. I suffer from shortness of breath, my doctor wants me to have a chemical stress test. Is this a reliable test for blocked arteries. Thank you very much for taking my questions.

Stanley_Hazen,_MD: That blood thinner is not associated with causing worsening of aneurysms.

davidX: I am a male age 88, biological age 50 based on the 2 min. and 400 yard test, and age 70 based on hand grip strength. I wear a sophisticated heart monitor that displays every pulse of arrhythmia real time most of the day. I have made many discoveries that suggest what works best: life style, including food, drink, interval and continuous exercise, resonant breathing, and medication. No symptoms. My question is: How might inflammation be exhibited with PACs, PVCS or in low frequency AF or SSS? My cardiologist wants symptoms.... to be interested. I want prevention. DavidX

Stanley_Hazen,_MD: Your questions belie a misunderstanding. While there is an association between inflammation markers and arrhythmia risks, there will not be a direct visual change in your Fitbit or other monitor readouts directly in the forms you are asking, unless one looked at it on a population basis, and over time.

sbdavisrn: What is your opinion on "lenient" rate control for afib? My cardiologist has adjusted my meds so that my heart rate runs between 70 and 90 at rest and over 100 with some exertion.

Stanley_Hazen,_MD: This is best answered by an EP specialist. Which I am not.

[See Abnormal Heart Rhythms web chat transcripts]

Heart Failure

sbdavisrn: Is it possible to halt chronic heart failure?

Stanley_Hazen,_MD: Yes, there are many therapies for heart failure and improving cardiac function. The causes of heart failure are multifactorial - and in many cases the optimal treatment to halt progression is to get at the original cause. There are some causes of heart failure however that are not readily reversed and in some cases, slowed down. But medical management even on those cases helps with quality of life and functional improvement.

[Heart Failure web chat transcripts]

Reviewed: 07/16

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