Know Your Heart Numbers with Dr. Haitham Ahmed

Podcast Transcript

Nada Youssef: Hi, thank you for joining us. I'm your host Nada Youssef, and today we have with us Cleveland Clinic preventive cardiologist Dr. Haitham Ahmed, and we're talking about men and their cholesterol. If you have any questions, please leave it in the comments section below. And please, before we begin, remember this is for informational purposes only and it's not intended to replace your own physician's advice.

Thank you so much for being here today.

Haitham Ahmed: Thank you for having me.

Nada Youssef: Sure. If you want to just introduce yourself to our viewers?

Haitham Ahmed: Sure. I'm Haitham Ahmed, I'm one of the preventive cardiologists here at the Cleveland Clinic. Been here for my third year now, I love it. In my clinic, I mainly focus on preventing heart disease. Whether that's primary or secondary prevention, we think about all the risk factors that we need to control to keep the heart healthy.

Nada Youssef: Perfect. Okay, so preventive cardiology. How is that different than just cardiology? When would a patient see you versus a cardiologist?

Haitham Ahmed: Cardiology is such an amazing field. The heart is such a complex and incredible organ. We've learned so much about the heart in the past few decades, and it's become so sub-specialized now. The heart has an electrical system, so the people who specialize in the electrical system are electrophysiologists. It's a muscle itself and it can fail, and the people who specialize in heart failure or cardiomyopathy are heart failure specialists.

And then it has plumbing, it has vessels that supply the muscle, and when that gets blocked, the people who intervene and open those blockages up are called interventional cardiologists. And then there are preventive cardiologists, so people who want to prevent heart disease, prevent heart failure.

We think about all the things that lead to the downstream consequences like high blood pressure, high cholesterol, weight gain, and we really work with our patients to stay healthy.

Nada Youssef: Yeah, very complex. So, speaking of, let's talk about knowing your heart numbers. What that means, which numbers are important to know for our viewers and then the men in our lives.

Haitham Ahmed: There are a few very important numbers that you should keep an eye on throughout your life. One of them is blood pressure. You want your blood pressure, in general, to be less than 130/80, and for younger people it's even nice to see it lower than 120/80. That's because your blood vessels are like pipes. If the pressure goes up in that pipe for a day or a month or a year, nothing bad happens. But over many, many decades, the pipes with the higher pressure just corrode faster. So we want to get that pressure lowered.

We also care about the cholesterol numbers. There are various numbers that you see on a lipid panel. That includes LDL cholesterol, HDL cholesterol, triglycerides, and sometimes that confuses people. LDL is low density lipoprotein, HDL is high density lipoprotein. So L is for lousy, that's the bad cholesterol. Less desirable and lousy cholesterol.

Nada Youssef: And keeping it low.

Haitham Ahmed: You want to keep that number low. Ideally, you want to keep it under 100, because that's the type of cholesterol that causes plaque buildup and causes heart attacks and strokes over the years. And if you've already had a heart attack or stroke or a stent, your doctor may want to keep it even lower, sometimes less than 70 or less than 50.

Your triglycerides are the blood fat, so if we all go out right now and have a pizza, it's the one that shows up in the blood right away. We want that number to be less than 150.

The other numbers that you want to keep an eye on are your weight, and the way that we make the weight uniform across different heights is we use something called the Body Mass Index, or BMI. You can all go online and type in Google, "BMI calculator" and really, the goal is to be under 25. If you're above 25, you're starting to be in the overweight category, and above 30, you are considered obese. So you want to limit your weight gain.

And then waist circumference as well, so you can take out a tape measure and look at your waist, because the way that fat deposits around the body is different in everybody and it can mean different risks. You always hear about the apple versus the pear shape, and people who deposit their fat more in their abdomen can be at higher risk. You want to keep your waist, in men, less than 40, in women, less than 35. Those are good general guidelines. And once you achieve that, then you want to go even lower, and ideally keep it less than 37 in men and less than 32 in women. So those are good numbers that you should know.

Finally, you want to keep an eye on your blood sugar. If your doctor does a fasting blood sugar, normal would be less than 100, and between 100 and 125 is in the pre-diabetes range, and once it's more than 126, that starts to be concerning for diabetes. There is another number called the hemoglobin A1C, which is a longer term average that many patients or your doctors may have ordered, and you want to see that number at 5.6% or lower.

So if you have any confusion about any of these numbers, certainly it's something to talk about with your doctor.

Nada Youssef: At what age do you think we should start getting tested for your heart numbers?

Haitham Ahmed: I think starting at age 20, everyone should probably get a cholesterol check. And if things look good and you're healthy, you probably don't have to do it again for another three or five years, but if things are abnormal, then that's the time to talk to your doctor about an aggressive plan to get that cholesterol controlled.

Nada Youssef: Sure. Very, very good. Okay, well, I was going to ask you about the two main types, but you've covered that. So my next question for you was genetics. Do they play a role in high cholesterol?

Haitham Ahmed: Yes, absolutely. Genetics play an important role, but a lot of things do as well, so it's not just genetics, but diet, your weight, exercise, blood sugar. All of that impacts your cholesterol. We have a lot of data that shows even people who have really unfavorable genetics are able to control their cholesterol, both with lifestyle modifications and medicines, and they're able to reduce their risk of heart disease. So even if you feel like you got the bad side of the genetic lottery, there's still a lot that you can do to reduce your risk.

Nada Youssef: So, I find out I have high cholesterol. What's the first thing I should be doing?

Haitham Ahmed: First thing you do is engage in lifestyle modifications. You really want to interrogate your diet and see how good of a job you're doing. Is there anything that you can change to tweak your lifestyle and help with your weight? Second thing you want to do is exercise. I mean, most Americans do not exercise adequately.

The American Heart Association recommends 150 minutes of moderate aerobic activity per week. So if you break that down, it ends up being half an hour, five days a week, approximately. Those are activities that are enough to get your heart rate up, breaking out in a sweat, breathing hard. That's generally good for your HDL cholesterol, as well as the LDL and the triglycerides.

Nada Youssef: So walking won't just do it?

Haitham Ahmed: Walking is great, I love walking because it's easy, it's low pressure on the joints, particularly fast-paced walking. You can definitely hit that aerobic threshold just from really fast-paced walking. It's a great exercise.

Nada Youssef: Great. I want to kind of jump on and talk a little bit about the common signs of heart disease. I've read that it could differ between a man and a woman. Can we talk a little bit about that?

Haitham Ahmed: Sure. The most common symptoms of heart disease are chest pain or chest pressure, usually it's right here in the middle of your chest or on the left side and it's substernal. It doesn't always have to be a pain. For many people it's a pressure, squeezing, tightness. Everyone can describe it differently. Sometimes it can go up to the jaw, or it can go down the arm. In rare circumstances it can go to the back or some different parts of the body. It's usually accompanied by some breathing difficulty. Those are the most common symptoms.

Some less common symptoms are feeling nauseated, like you want to throw up, fatigued, tired, sweaty, dizzy. Those are some less common symptoms, but can still be suggestive of heart disease.

Nada Youssef: Do men's symptoms differ from women's when it comes to these kind of symptoms?

Haitham Ahmed: Men are more likely to have the common symptoms, the chest pressure, the breathing difficulty. Women are less likely to have those common symptoms, so you may just have to be more attentive. You really have to listen to your body, and if something is concerning you or is different from what you've been experiencing in the past, particularly if it's when you're exerting yourself. So when you're sitting at rest, your heart's getting all the blood flow it needs, the muscle is able to do its job just fine, but once you start exercising, you're walking uphill, you're running up the stairs, and now the heart's pounding and needs more oxygen, and that's when you get the symptoms, that's when you really ought to talk to your doctor.

Nada Youssef: That's when you want to pay attention, okay, great. Now, why do you think symptoms differ between men and women? Is it size, is it what we eat?

Haitham Ahmed: It's a great question. It's really unclear, it's something that we've been looking into in the cardiology community for a long time now. Could it be that the hormones are different, and maybe they have a protective effect in the younger years? For women, before menopause, that's possible. Could it be that the progression of plaque over those decades is different, so that one gender is more at risk for rupture of plaque as opposed to progressive stenosis or blockage? That's a possibility. Could it be different environmental factors? We don't know. So those are all really good questions.

Nada Youssef: Okay, good. Now, how much does dietary cholesterol actually impact cholesterol levels in the body?

Haitham Ahmed: It impacts it some, but it's not the be all or end all. Dietary cholesterol only comprises 15% or so of your blood cholesterol levels. The majority of your cholesterol is actually made by your liver. About 80 or 85% of it is made by your liver, and the remaining 15% is dependent on what you eat. So, certainly improving your diet helps you change your cholesterol numbers, but it's not the only thing that you need to do.

Nada Youssef: Okay. Now, there are so many controversies with diet and heart and fat and saturated fat. I wanted to kind of talk about that a little bit, because there's been a lot of myths out there. There's been some things that maybe we can talk about?

Haitham Ahmed: Certainly.

Nada Youssef: Something like a low fat, high carb diet. Some people think that's an optimal diet, you hear kind of different things about it. What do you think, what's your take on that?

Haitham Ahmed: I think, what you alluded to, Nada, is a very, very important point that I have to make. The more I've studied dietary trials and data and the more I've understood the impact of diet on heart over the years, the more forgiving I have been. The more you learn, the more you realize there are many roads to Rome, and any time I hear someone talk in absolute terms with hyperbole, I tend to think there's less credibility to what they're saying.

Also, you are absolutely right that there's a lot of confusion about what diets are actually healthy and what diets are not, and you don't know what to do because you receive so much conflicting information from the media and from what you're reading, from what you believe to be are credible medical sources. The reason for that is that dietary studies are really hard to do. They're really, really hard to do. People change their diets, no one eats the same thing or follows the same diet for a long enough period of time. There are so many other factors that go into looking at risk other than just diet.

So for example, you mentioned whether saturated fat is harmful or healthy, and there's been a lot of conflicting data, depending on which parts of the world that data is coming from. So, for example, there are certain populations that have high amounts of saturated fat in coconut oil, but they are generally very healthy, and it's because they do a lot of other healthier things than we do here in the US. They are a lot more active, they're exposed to less pollution, they have different genetic data. So it's really hard to make overarching conclusions in a vacuum.

One thing we've seen, there's been a big pendulum swing going from high carb and low fat to high fat and low carb. So maybe 20 years ago, there was exuberance about going low fat everything, low fat everything. And as a result of that, we've seen a lot of unnecessary sugar and carbohydrate intake introduced into our diets, and when you think of the food pyramid back in the '80s, the bottom portion of the food pyramid, the base was cereals and grains and lots of carbohydrate. Over that time period, we as Americans have gained weight, our risk of diabetes has gone up, and so you question whether that was the right approach.

And now, the pendulum seems to be swinging the other way. Maybe in the '90s and early 2000s, there was the Atkins diet and the South Beach diet and all these low carb diets.

Nada Youssef: The keto diet.

Haitham Ahmed: And that went out of favor, and now it's rebranded and renamed as the keto diet, but it's essentially the same thing. It's low carb, high fat. Indeed, that can help you lose weight and can help you reduce your risk of maybe diabetes or higher blood sugar. But if you are replacing your carbohydrate with a lot more saturated fat, that seems to increase your cholesterol. I have so many patients who will do a keto diet and they will lose weight and their blood sugar goes down, but then when they come in to see me, their cholesterol skyrockets.

So the thing you have to be very cognizant of is, if you make a change in your diet, what are you replacing it with? So if you're reducing your carb, are you going to be replacing it with more fat, or are you replacing it with healthy fats and vegetables and whole fruits? And similarly, if you're reducing your fat, are you just replacing it with more carb? A lot of things that are low fat, like skim milk or low fat products, will end up having more carbohydrate. You have to look at the labels and make sure you're not replacing one evil with another.

Nada Youssef: Now, you as a preventive cardiologist, what do you eat? What's your diet like? Put you on the spot.

Haitham Ahmed: I tend to follow the Mediterranean diet, because it's the best studied diet, in my opinion. If you look at large populations-based studies, people who follow the Mediterranean diet tend to live longer, they have lower risk of cardiovascular disease, lower risk of dementia, maybe a lower risk of cancer. It's probably the best studied diet from a trial standpoint.

There was something called the PREDIMED trial, which was published a few years ago and then republished this past year, that showed following a Mediterranean diet, and this was done in Europe, following a Mediterranean diet with extra virgin olive oil and nuts seemed to reduce risk of heart disease compared to a typical low fat Western diet.

So we really focus on things that we all like to eat, like fish and nuts and olive oil and vegetables and whole grains, without really feeling like you're restricting any particular thing in your diet.

Nada Youssef: Right, since we're talking about diet, I'm going to kind of go in there a little bit and talk about, let's say egg yolks. They're high in cholesterol. Are they bad for you?

Haitham Ahmed: I don't think they're bad for you, as long as we do it in moderation. Egg yolks do have saturated fat, it's about one and a half grams of saturated fat. So if you're having two egg yolks, or let's say you're having a breakfast, you're having omelets in the morning, you're having eggs every day, it's two or three eggs. That really tends to pile on the saturated fat content. So depending on what your LDL cholesterol is and what your doctor prescribes ... The American Heart Association says less than 7% or 6% of your daily caloric intake should come from saturated fats. So if you calculate that out, it ends up being 12 grams, 13 grams per day. If you're having a few eggs every morning, and maybe you're having a muffin or something like that, right there and then, that's more than half of your daily saturated fat content.

So one alternative is, instead of having full eggs, you can have one full egg and one egg white only, or just think about egg whites only. You'll still get all of the proteins and many of the benefits that will come with the egg without the saturated fat content. So again, I think anything is fine within moderation. Sometimes we say limit it to one egg a day, on average. Patients who have high cholesterol, who are really keeping an eye on their cholesterol, we say limit it to three eggs a week, maybe.

Aside from cholesterol, our group, my colleague Stanley Hazen has some truly ground-breaking data showing that there's something aside from cholesterol that is important and that leads to cardiovascular risk. That is the gut microbiomes effect on the heart and plaque buildup. It turns out that eggs are more likely to increase a certain gut metabolite called TMAO, trimethylamine oxide, which increases risk of cardiovascular disease as well. People who have a lot more egg yolk increase their TMAO and have more reactive platelets, which increases risk of heart disease. So there may be some harm from overdoing it with eggs anyway. So again, anything within moderation is fine.

Nada Youssef: In moderation. Okay. Coconut oil, it's been trending a few years back or so. What do you think about coconut oil, saturated fats, is that a good thing or a bad thing?

Haitham Ahmed: Yeah, coconut oil indeed has been trending recently. Maybe since 2014 or so, we've seen a huge uptick in the use of coconut oil, and it's been coined a superfood and people are using it in almost everything. The concern that many cardiologists have with coconut oil is the exorbitant amount of saturated fat. About 80 to 90% of coconut oil is saturated fat. The concern there is that that would increase your risk of heart disease.

One tablespoon of coconut oil hits that 12 grams per day mark. Right there and then, you've just met the criteria. The American Heart Association came out with a statement and said, "Because of the high saturated fat content in coconut oil, we are concerned about the risk of heart disease, therefore you should not use it for your routine cooking." And many people on the flip side have criticized that and said, "No, there are a lot of healthy populations like in the Indian subcontinent and Sri Lanka who eat a lot of coconut oil, they have low risk of heart disease," and that's all true. But again, they have a very different lifestyle than Western populations.

Nada Youssef: Different variables, yeah.

Haitham Ahmed: So, I am someone who preaches moderation, and I think coconut oil is delicious, it can add wonderful flavor, it certainly has health benefits. There is some evidence that it increases HDL, although most oils do, most fats do. But I don't think you have to go out of your way to put it in everything thinking that you're going to be getting some heart benefit. I don't think there's any definitive evidence that it does benefit the heart.

Instead, I would focus more on oils that have been shown to be beneficial, that are mostly high in monounsaturated fats, like olive oil. Extra virgin olive oil is probably the best. When you look at oils that at room temperature are actually liquid as opposed to solid, extra virgin olive oil, and without heating it, just drizzling it on your salad. That's the best.

Nada Youssef: Perfect.

So with saturated fat, you mentioned it can increase HDL levels, which is a good thing. But what does it do to LDL levels?

Haitham Ahmed: All oils increase HDL to some extent. But they will increase LDL more. Coconut oil will increase the LDL the most because of the amount of saturated fat content that it has. It has about six times the amount of saturated fat as the same quantity of olive oil. There is some data maybe that olive oil is neutral with regards to the increase in the LDL. So they act differently on the different lipoproteins, basically.

Nada Youssef: Okay, it's very confusing stuff. So I want to kind of jump over to alcohol, because just recently, I mean the past few weeks ago, it was like, one glass of wine is okay daily, but then it's like, no, alcohol's not needed at all. But what about heart health? I've always heard that red wine is okay for heart health, it's actually good for you. What's your take on that?

Haitham Ahmed: It's a good question. There was a big study, maybe two weeks ago, big global study, published in the Lancet, in many, many countries all over the globe. They looked at the benefits versus risks, and they felt there were some benefits from alcohol, but there were mainly a lot of risks related to toxicity to the liver and risk of cancer, and also the fact that it affects the triglycerides. It's actually one of the things that can greatly increase the triglyceride level, one of the lipid markers that we look at.

They concluded that there was no safe level of alcohol, and that was a very controversial study. Historically, the American Heart Association has said, for women, if you do drink, then limit it to one drink per day. For men, if you do drink, limit it to two drinks per day. If you don't drink alcohol, there's no need to go out of your way and start doing so for any particular perceived benefit.

Our recommendations are still in line with that. I would say that if you don't drink, there's no need to start for any perceived health benefit, because the overall net benefit may not outweigh the risk. And if you do drink, try to limit it to one drink per day.

Nada Youssef: Okay, great. Well, we're starting to get a lot of questions, so I'm going to start jumping onto those. I'm going to start with Alice. If the patient is not able to take statins, what are the best recommendations for lowering cholesterol?

Haitham Ahmed: Statins are probably the best studied way to reduce cholesterol, but there are many, both pharmacological and non-pharmacological ways. I'll give you the options that I routinely go through with my patients.

First we want to think about studied medicines that have been shown to actually prevent plaque from building up, prevent heart attack, prevent stroke. Second line medicine would be called ezetimibe or Zetia. It actually prevents absorption of cholesterol in the gut. It's not as powerful as a statin, but it's better than nothing. It has been shown to prevent heart attack and stroke.

A more recent option, which is a novel option, and it's probably the most powerful cholesterol lowering medicine we've ever had, is called a PCSK9 inhibitor. It works completely different from statins. They are very well tolerated. They don't cause increases in liver enzymes, they don't cause the same side effects that statins do. They've now been studied in more than 46,000 patients, so huge clinical trials. The down side is they're new, they've only been around for about four years or so. And because they work so well, they're very, very expensive. You typically have to work with a lipid expert or a cardiologist who is well-versed in using these medications to file for authorization with your insurance.

Those would be the two classes of medicines that have been well studied and shown in large clinical trials to prevent heart attack and stroke and future plaque buildup. We have done clinical trials here with the PCSK9 inhibitors. The two that are out on the market are called Praluent and Repatha, and we have shown with heart catheterization studies and intravascular ultrasound that we can prevent the plaque from progressing when you're on these drugs.

If you can't be on these drugs, then there are other lines that are third line medicines. They do make the numbers look better, but they haven't really been shown to prevent heart attack or stroke in large clinical trials. They include niacin, which is a B vitamin, but when we give it at really high doses, it actually reduces the cholesterol numbers.

Also fibrates, fenofibrate or fibric acid derivatives. They also work. And then there are a lot of dietary things that you can do as well. Plant sterols are able to reduce the cholesterol by about 10% or so. Things like flax seed, oatmeal, things that are high in omega-3. Omega-3 has a particularly potent effect on triglycerides. You'll see people take the fish oil to try to improve their cardiovascular health. Mainly, that reduces triglycerides. We don't know if it improves cardiovascular health. The jury's still out.

Those are some of the natural ways that you can get it down as well.

Nada Youssef: Mike wants to know if statins are effective over the long term.

Haitham Ahmed: Yes. Statins have, now more than 20 years of data show that they reduce heart attack, they reduce stroke, both in primary prevention, people who have never had a heart attack or stroke, if they are at high risk they can reduce their risk. And especially in people who've already had plaque buildup, they've had a heart attack, they've had damage to their brain or their heart. You definitely want to be on a statin, it is actually a class one indication by every cardiology professional society, by the American Heart Association, the American College of Cardiology, the European Society of Cardiology. When you have a lot of experts from all over the world who are all saying the same thing, it's usually for a reason.

Nada Youssef: Right. And then, Heidi wants to know if all men need statins at a particular age.

Haitham Ahmed: Not necessarily. It's not a one size fits all approach. I think what you always should do is have a tailored prescription and tailored care based on your own body's needs. You need to look at all your other risk factors, what your goals are, what your estimated long term survival is. You talk about all of that with your doctor and you decide if the benefits of a medicine outweigh the risks.

Nada Youssef: Sure thing, great. And then Carl. Why do our bodies create LDL cholesterol? What function is it meant to serve?

Haitham Ahmed: LDL is, cholesterol in general is important. It has certain functions it maintains. It's needed to build your cell wall and cell membranes, and it's needed to encase the nerves in your brain and in the rest of your body, so it has important functions. Your body can synthesize most of it, your liver can synthesize most of it. Especially as an adult, there's not much more that you need from diet. You need some saturated fat, that's why the AHA says 5 or 6% or so, but it doesn't need to be 80% of your diet.

Nada Youssef: Sure. And then Mohammad wants to know, how risky is it to have calcium score 185? My elder brother is 50.

Haitham Ahmed: Let me explain to the viewers what a calcium score is.

Nada Youssef: Yeah, thank you.

Haitham Ahmed: We all have calcium in the blood, that's normal. But no one should have calcium in the vessel wall itself, it shouldn't be there. When we start to develop plaque in the vessel, as a normal part of the healing process, the body tries to heal that plaque and it deposits calcium as part of that plaque. Over time, that plaque builds up and you get more and more calcium build up. So sometimes, if we don't know if someone is at risk for heart disease or not, we can do a scan of the heart. It's called the calcium score, and we can see if there's any calcium. If you see calcium, which shouldn't be there, it means you have plaque. It's pathognomonic, that's what it means. It means the horse is out of the barn, and we really need to be more aggressive about treating that plaque.

So the score comes in different variation, it has different cutoffs. The score should be 0. 1 to 100 is considered mild, 100 to 400 is considered moderate. So this would be considered moderate coronary calcium score elevation, and our colleagues who have done significant research on this have shown that once you're above 100, you probably should be on a statin, because you want to prevent that plaque from progressing, and you should probably be on aspirin as well.

Nada Youssef: Okay, great. And then Colette. On my CT scan, it showed evidence of, I'm going to totally butcher this, arter-

Haitham Ahmed: Arteriosclerosis, yeah.

Nada Youssef: Thank you. In arteries and aorta. I'm on cholesterol medicine and I'm 64. What else can I do to stop progression?

Haitham Ahmed: This is one of those examples where you really want to look at all those numbers. You want to see if your LDL is adequately controlled, are you taking just a little bit of statin, like a touch of statin that's not doing anything? Do you need more? Are you taking too much? What is your blood pressure? Do you have diabetes? Is your blood sugar controlled? What is your weight? Are you exercising? Are you following the dietary recommendations that you should be following?

So it's really a comprehensive approach that's needed to prevent further events.

Nada Youssef: Okay, great. And then, Shawn. Does a bundle branch block go away or get worse? And maybe you can explain what that is.

Haitham Ahmed: Sure. That's an electrical problem, so the top part of the heart has to talk to the bottom part of the heart. Your heart has a pacemaker, my heart has a pacemaker, Shawn's heart has a pacemaker. It's a natural pacemaker, and it sends electrical conduction all the way down, so that the top chamber knows when to beat and the bottom chamber knows when to beat. It's like, lub-dub, lub-dub, lub-dub. And the way it sends electricity is through a series of bundles. There's a left bundle and there's a right bundle. Sometimes, if one of the bundles is not working, you have a delay and it's called a bundle branch block, so you only end up having electricity going down one of the sides.

It depends on why you have that block. A common reason people have that block is because of coronary disease, actually. But sometimes you can have fibrosis or scarring around that bundle. It usually doesn't go away. Some people have intermittent bundles that come and go, but if you have a permanent bundle, it usually doesn't go away. It doesn't get worse, you either have it or you don't. It's like driving down the highway, and if the road is closed, if one road is closed, it's closed. You have to take the alternative route.

Nada Youssef: Detour, okay. Great, well said. And then Ken. I have a murmur, and every once in a while I have sharp pains in my chest, then I get a headache and my blood pressure is high. Is this something to have looked at? It has been that way for about a year.

Haitham Ahmed: Yes. I would say that is something to get looked at. There are a number of things that could be causing your symptoms. It could be related to a valve from that murmur. Usually, a murmur is due to turbulent flow. There are valves that open and close. I don't know if you can see this, but the heart has all these valves inside that open and close. If the valve doesn't open as well, it's restricted, then you get lack of blood flow coming out. If it leaks when it's supposed to close, then you get turbulent blood flow going back, and that can cause changes in the blood pressure, in your symptoms, and it can cause many of the symptoms that you're experiencing. So certainly something to talk about with your doctor.

Nada Youssef: Okay, great, thank you. And then Kelly. Is there a test for TMAO, and where can I get it done?

Haitham Ahmed: Yeah, that's a great question, Kelly. That was the gut metabolite that we talked about earlier. It is a blood test and you can get it done at your doctor's office. If they don't do it, they can send it out. We certainly do it here at the Cleveland Clinic.

Nada Youssef: Okay, great. I'm going to give you one more question, before we go.

Haitham Ahmed: Sure.

Nada Youssef: Robin. Do you recommend Q10 supplements?

Haitham Ahmed: Yeah, I think Robin is talking about coenzyme Q10, CoQ10, and the thought here is that you are able to increase your energy levels and reduce your risk of statin intolerance with CoQ10. There's certain pathways with statin therapy that may reduce your CoQ10, which is needed for muscle energy. The thought was, if we give you CoQ10 back, it's going to make your symptoms go away. It's a fabulous idea in theory, but in clinical trials it hasn't been shown to be more beneficial than placebo.

If you're on it and you feel it's working, go at it, but if you're not, I don't recommend that you go out of your way to buy it.

Nada Youssef: Okay, great. And then for last words, you want to give your word of advice of keeping HDL high and LDL low for their cholesterol?

Haitham Ahmed: Yes. Maintain a healthy diet, a well-balanced diet. Low in saturated fat, higher in monounsaturated fat, healthy types of fats, more vegetables. And then exercise regularly. It really is a key to maintaining lower body weight, lower blood pressure, lower triglycerides, lower LDL, and lower blood sugar. That truly is one of the keys to long term health.

Nada Youssef: And it's all about balance, right?

Haitham Ahmed: It's all about balance.

Nada Youssef: Great. Thank you so much.

To learn about your heart numbers, treatment options, or help you choose the right heart doctor, our Cleveland Clinic Heart and Vascular Institute nurses are available as a resource for you before you've made an appointment to discuss your condition. To speak, chat, or e-mail with a heart nurse, please visit clevelandclinic.org/heartnurse.

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