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Ask the Cardiologist (Dr. Rimmerman 11/7/11)

November 7, 2011


Heart disease is the No. 1 killer in United States. It is therefore important for you to stay informed about heart health and what you can do to prevent or treat the disease. There are many types of heart disease, each having their own diagnosis and treatment options. Some forms can be prevented by making lifestyle changes including diet and exercise. Dr. Curtis Rimmerman, Cleveland Clinic cardiologist answers your questions.

More Information

Cleveland_Clinic_Host: Thank you for joining us, let's begin with the questions.

Dr__Rimmerman: Let's get started.

Valve Disease

BruceG: I’m 55 years old with aortic stenosis and insufficiency diagnosed in 12/06. (a symptomatic except for shortness of breath with extensive exercise) Based on the progression my doctor estimates valve replacement in 1 to 1-1/2 years from now. My understanding is a mechanical valve is recommended for my age group. I lead an active life style and concerned with taking Coumadin. My question is if I go with a biological valve and it needs to be replaced can I change to a mechanical. I know biological valves only last est. 7-15 years and that re operations are more difficult but I’m willing to take the risk if it will give me the life style I enjoy now and then when I’m older and not as active be on the Coumadin. I’m also told that there are new and better blood thinning drugs coming out. Can you comment on this? Thanks

Dr__Rimmerman: A biologic valve followed by a mechanical valve is entirely possible and makes sense if you live an active lifestyle and want to remain off Coumadin. Blood thinning drugs have either been approved or are emerging as options to warfarin. So far they are indicated for afib and not for valves - but stay tuned.

Brealm12: What are chances of 74 yr. old who had pneumonectomy 10 yrs. ago with severe aortic stenosis(valve .7-.9, EF 60-65%,gradient 50mmHg) with mediastinum shifted to enter a percutaneous or Core Valve trial? How long does it take to learn if you qualify for a trial?

Dr__Rimmerman: Every situation is a case by case basis - if you are truly interested in this procedure, I would suggest a visit to the Cleveland Clinic for this procedure - or we have a method to send in records for review. Please see  to contact us regarding an evaluation.

piyush1175: is there a robotic replacement for aortic valve in near future?

Dr__Rimmerman: There is catheter based replacement of the aortic valve which was recently approved by the FDA. Robotic replacement appears not to be imminent.

BruceG: I’m 55 years old with aortic stenosis and insufficiency diagnosed in 12/06. (a symptomatic except for shortness of breath with extensive exercise), on 2/11 my valve area was 1.0, Max. Velocity 3.9, Mean Pressure 28 and injection fraction 61-65%. With no symptoms at what point do you consider replacement.

Dr__Rimmerman: With no symptoms, aortic valve replacement is not indicated. Replacement in asymptomatic patients could be considered as you approach an aortic valve area of 0.6 - 0.7 cm sq. Check out and look at the valvular heart disease treatment document. We also have a tool on our website that is based on the ACC guidelines that you may be interested in.

Irregular Heart Rhythm

dgatti1: Dr Rimmerman, I am scheduled for my 5th ablation in later this year. I have had sic sinus syndrome, atrial flutter, and now chronic afib. I had a pacemaker after my first ablation in 1994 so my ventricles are not the issue. I did enjoy 22 months of sinus rhythm after my last ablation. in 2009. My question is if I continue having ablations does there come a time when I have had too many and my will heart will not function normally I am 62 years old and have remained active all my adult life. (I still run 10 -15 miles a week. Thank you

Dr__Rimmerman: One might consider given your preserved functional capacity after so many ablations that you accept your abnormal heart rhythm at the present time given your heart rate is well controlled. Studies have demonstrated no great superiority of rhythm vs. rate control. Please be mindful of additional radiation exposure with future procedures.

dliving41: I am a 70 year male who exercises 6-7 days a week. When doing aerobic exercises, my heart rate exceeds 140. When playing tennis, it can exceed 150 (I wear a heart rate monitor). I had a successful ablation in April, 2010. However, a cat scan performed after the ablation showed a fair amount of calcification in the proximal portions of the left coronary system, left main, LAD and Cx. I take Crestor (40 mg) and an 81 mg aspirin. My total cholesterol in September was 167 with a HDL of 86. When atrial fib was common, at times I would have a heart pause when I returned to Sinus rhythm. Should I reduce the intensity of my exercise? I had my ablation at the Clinic

Dr__Rimmerman: It would be important to distinguish if your heart rhythm is recurrent afib or normal sinus rhythm. If it is an underlying normal rhythm it is of less concern. If you have not had a stress test to assess your coronary calcification with exercise, please discuss this with your doctor.

DRJ110145: 66 year old. had pulmonary vein ablation about 2 yrs ago. Am sensitive to feeling my heart rate. This generates some anxiety, the HR goes up and some PACs. Am taking a low does of Paxil daily and in last annual appt. with EP, he is suggesting a very low dose of a beta blocker. While that should reduce my HR, any issues with combining with Paxil?

Dr__Rimmerman: No concerns regarding the proposed medication combination.

dliving41: You mentioned radiation concerns with frequent ablations. Any plans at the Clinic for utilizing the MRI for ablations?

Dr__Rimmerman: I am not aware of using MRI and I apologize that I do not specifically work in that area.

Coronary Artery Disease

JMG9620: Is it possible to have a myocardial infarction with normal coronary arteries without blockage of any kind?

Dr__Rimmerman: Yes. Especially as it pertains to coronary artery spasm. Also patients with minimal obstruction can still rupture a plaque which can cause a heart attack. Sometimes the obstruction is not visible to the naked eye even at the time of heart catheterization. We have learned this via intravascular ultrasound studies (IVUS)

JMG9620: Can heart attacks be silent without the classic symptoms? Do heart attacks occur without symptoms in individuals with perfectly normal coronary arteries and who lack a family history of such events?

Dr__Rimmerman: Approximately 30 % of patients have no symptoms or have extremely atypical symptoms when experiencing a heart attack. One key is to focus on your exertional capabilities. If for unexplained reasons, they diminish please consult with your physician.

hig: 61 yr & runner 30yrs. Now speed walk to save knees. Walk 3 mi. 3-4 days/wk. 2 yr ago noticed burning pressure middle of chest when walking after about ¼-1/2 mi. Would last 1 to1-1/4 mi then go away. Went to Dr. for EKG& exercise stress test-both normal, had chest pain during test. Dr. said it was fine. 1yr later at physical, told Dr. still get chest pain walking. Also rarely dancing or basketball. Also found that when walking after pain stopped, I tried to run & pain came back. Dr. sent me for EKG which was fine,& echo stress test. Got pains, but results very good. Dr. sent me to cardiologist for cardiac cath. It turned out good. Next annual went Dr., told him still had chest pain, sent me to cardiologist who looked at file & said, no further testing; not heart related. Sent me to pulmonary testing. Pulmonary did PFT-normal. Then exercise PFT, with Ibuterol- also ok. Dr. said pain must be muscular. How could this be if exertion triggers it?

Dr__Rimmerman: It sounds like you have been evaluated extremely thoroughly and life threatening conditions have been excluded. Certainly musculoskeletal discomfort with exercise merits consideration however, I agree it is perplexing that it has only occurred recently over a lifetime of exercise. If musculoskeletal causes are considered to be a possibility you may want to consider a rheumatology evaluation.

rojas9198: I have been having some kind of heartburn for the last two weeks and a small pain on my the right side of my chest as well as some pressure on the center of my chest. I went to Urgent care last week and an ECG showed normal. Also blood work eliminated a heart attack at the moment. Am I suffering from Angina?

Dr__Rimmerman: This could still represent angina and should be evaluated. Please discuss with your doctor in the near future and if concern remains, you may be a candidate for an exercise stress test.

srbrsn11: 60 years old. Had quadruple bypass 14 years ago. Very active walking/hiking/stationary bike/light weights. Last year I lost my right coronary artery bypass. RT coronary artery is 90% blocked and cannot by surgically fixed. I go through cycles of strength, where I can hike 20 miles a day, then without warning I lose my stamina and have difficulty walking short distances. Have discussed with my cardiologist. He has found nothing, EKG and stress tests are normal. Can this be silent heart attacks?

Dr__Rimmerman: If in fact you are hiking 20 miles a day it strongly suggests your heart is in excellent shape and your symptoms reflect fatigue due to exercise and not due to your heart. Especially - since your testing results have been satisfactory. If you would like a second opinion on your test results, we are happy help.

tirreno: I am 53 years old and had a triple by pass eleven years ago. I had a stent put in two years ago because one of my grafts collapsed. Since the stent I have felt the better than the previous nine years. This collapsed graft could have happened immediately after surgery. Why else could I have been feeling much better after the stent?

Dr__Rimmerman: I think you hit the nail on the head - I do not have another explanation.

agr583: I am a 28 year old male who has been experiencing chest pain for the last 2 and a half years. I have a thorough cardiac work up: multiple ekg's, echocardiogram, stress test, 48 hr halter monitor, and event monitor which show nothing. I'm wondering what this could be In addition, the pain normally comes along with exertion. I have normal blood pressure 129/83 and received my cholesterol today

Dr__Rimmerman: : It sounds as though you have had a comprehensive evaluation. In your age group, with your lipids the likelihood of obstructive CAD is very low. It would be highly unusual to perform a heart cath. You may consider an evaluation for exercise induced respiratory difficulties such as asthma, which can be manifested as chest discomfort – or consider a rheumatology evaluation. Please go to this page on our website -  to learn about cardiac and non-cardiac causes for chest discomfort.

SKBURMAN: Can you please discus the first symptoms of heart attack? What are early alert signals?

Dr__Rimmerman: You can find this information on our website at

Coronary Artery Disease: Risk Factors and Prevention

UpstateNy: I am 81. I have had 2 CABG operations plus 22 angiograms; radical prostatectomy; stomach surgery for a hiatal hernia, etc. I am an insulin dependent diabetic. I exercise 3 times a week and walk 2 times. I have been going to the Clinic annually, but I am wondering "why”. Obviously I have survived quite well , but at some point isn't it realistic to stop looking for more?

Dr__Rimmerman: I appreciate your perspective. I concur with your view point. You might consider a Preventive Cardiology specialist or following the Esselstyn diet - check out

PhylAndes: I have been on a totally nonfat, vegan diet for 7 weeks. I began the diet in an effort to stop taking Lipitor for my very high cholesterol. I have lost 16 lbs. and I'm delighted but is it too soon to check my cholesterol again - it was done two months ago? Also, can ones cholesterol get too low?

Dr__Rimmerman: Great news, your lifestyle modification efforts will certainly be beneficial I would suggest rechecking your blood work 3 months after changing your diet and would include an usCRP. If your cholesterol panel is truly within normal limits as well as your usCRP, please re-discuss the Lipitor with your physician.

clara: I had open heart surgery 5 years ago - aortic valve and bypass 2 arteries. 2009, I had 1 stent / 2010 I had 3 stents / 2011 2 stents. I have been told that I have an aggressive disease that is not connected to cholesterol. The stents are all different arteries. The bypasses have filled up to around 60% but were left alone. The last 2 stents were the L main and the left anterior descending artery. I am somewhat concerned that if I keep blocking up it may lead to open heart surgery again. Isn't it unusual for a person to have that many stents in such a short time? I am thin, workout, do not have high blood pressure. It is hard to know exactly how to treat this disease.

Dr__Rimmerman: It sounds like you may have a genetic predisposition to cholesterol deposits and atherosclerosis. You can't modify your genetics and your other risk factors seem to be under excellent control. Make sure your cholesterol is in good control. If you have not done so already, please consult with an expert preventive cardiology nutritionist and consider a vegan diet or something similar.

thomasR: I read in the news a link between insomnia and heart disease - if I have insomnia - should I actually see someone to treat it? I have just lived with it. I am on Crestor for high cholesterol.

Dr__Rimmerman: My bigger concern would be the possibility of undiagnosed sleep apnea which is clearly under diagnosed and under reported. There is an established relationship between sleep apnea and heart disease including heart rhythm abnormalities and sudden cardiac death. Please discuss with your physician.

lmgaiso: Do you believe that there is a benefit to lowering LDL below 70? If so, do you believe, the lower, the better?

Dr__Rimmerman: We believe the lower the LDL the better provided your nutritional status is optimal and you are not chronically malnourished.

lmgaiso: The lower the LDL, the better. Got it. What if lowering LDL also lowers HDL? HDL of 40 is considered a cut off for men. Would you continue to lower LDL at the expense of going below 40 on the HDL?

Dr__Rimmerman: When you lower LDL< HDL does typically follow. We believe the most important parameter is LDL.

lmgaiso: It seems that your answer did not come across completely. You wrote "When you lower LDL" I was asking - What if lowering LDL also lowers HDL below 40. 40 is considered a cut off for men for HDL. Would you continue to lower LDL at the expense of going below 40 on the HDL?

Dr__Rimmerman: I understand that when you lower LDL, lowering of HDL will also occur. I worry less about a low HDL than I do about a high LDL.

piyush1175: I am 36 years male and I have aortic valve stenosis with echo it was 1.5 and with TEE dr said it is normal not to worry about it and put me on zocor 20mg. My recent physical was high in triglycerides 207 and LDL 132 total chol was 212. My stress echo was 6min dr said when I walk my rate goes high but BP stay same. My LFTS was high in July so dr stopped the zocor and since then I am not taking any medicine. What should I consider as medicine for my cholesterol and what kind of exercise I should do based on my stress test.

Dr__Rimmerman: It sounds like it is safe to perform regular aerobic exercise and I am concerned your heart rate response may reflect deconditioning. Please consult with a nutritionist regarding a low fat and low cholesterol diet; reduce your calories if indicated and consider an alternative to zocor starting very low dose perhaps once weekly and gradually increasing as your liver function tests permit.

Left Axis Deviation

Msin: What is left axis deviation? Is isolated left axis deviation with sinus tachycardia is serious?

Dr__Rimmerman: Left axis deviation is often related to cardiac position within the chest and not necessarily indicative of heart disease. It can also be seen in patients with thickened heart muscle such as LV hypertrophy, which does cause a leftward shift of the heart position.

Hypertension – High Blood Pressure

Frank_B: Is Labile Hypertension a recognized subcategory of hypertension? Is it rare? When I say labile hypertension I mean blood pressure which spikes not only in a doctor's office but also in response to major and minor stimuli of everyday life and living. Is labile hypertension treated with antihypertensive medication? Can untreated labile hypertension cause Mild Diastolic LV Dysfunction and Concentric LV Remodeling with normal LV mass as seen in a regular echocardiogram? Can the stress of a person suffering from striking labile hypertension during the echocardiogram procedure result in mildly erroneous readings like indication of mild diastolic LV dysfunction or concentric LV remodeling when it is not present

Dr__Rimmerman: We all have fluctuating blood pressure. Although it sounds like yours is greater than average. Please discuss with your physician the placement of a 24 hour blood pressure monitor. This is an ambulatory monitor, which will provide an average blood pressure reading throughout the day and night. This will be much more important data than minute to minute readings.

Frank_B: Could the fasting blood glucose readings of those not suffering from diabetes but suffering from striking labile hypertension give higher readings than would be expected from their HbA1C readings?

Dr__Rimmerman: I am not familiar with a relationship between labile blood pressure and blood glucose readings.

Eric_C: What is the risk-benefit of hypertension drugs compared to the increased risk for heart attack and heart failure? In other words, what is the risk/benefit analysis of when to take meds vs. no meds to prevent heart failure/MI in someone with hypertension?

Dr__Rimmerman: If you have established hypertension, it is exceedingly important to take medications to normalize your blood pressure should lifestyle modification efforts not succeed. Normalizing your blood pressure with medication will actually reduce the incidence of heart attack and heart failure. Goal blood pressure should be 120/80 or less.

Francois: With regard to your recommendation for 24-hour ambulatory blood pressure monitoring to diagnose labile hypertension, my results were inconclusive with night time readings normal and day time readings indicating hypertension. As in my case the first reading is higher than the second or third even on the home monitor, would the ambulatory 24 hour monitoring not be of only limited use to me.

Dr__Rimmerman: I appreciate your follow up question. I would suggest you focus on your average blood pressure for 24 hours, the so called blood pressure load. Frequent blood pressure recordings are known to contribute to heightened anxiety and falsely elevated readings.

Diagnostic Tests

Constance: risks/side effects of angiogram done through the wrist?

Dr__Rimmerman: Bleeding, bruising and blood vessel damage not dissimilar to the traditional femoral artery/groin approach. Bleeding more controllable via the wrist given the superficial location of the radial artery.

DonD: In May of 2011, I had a cardiolite stress test with my cardiologist. The report from that test stated I had an ejection fraction of 62%. In November of this year, after having pneumonia, a Echocardiogram showed an ejection fraction of 40to 45%, and a Multi-gated Analysis showed a reading of 44%. Neither report indicated what could have happened between May and November. My question is -- Could the fluid build-up from the pneumonia influence the ejection fraction reading? Also, what further action would you recommend to determine the possible causes behind this change?

Dr__Rimmerman: You are comparing two technologies - one ultrasound and one nuclear based. Therefore it is difficult to ascertain with certainty if the pneumonia can be implicated as the cause of your reduced heart function. I would go with the echo result as that is the current gold standard for assessing heart function in multi directional views.

ruthanne: How serious is a severe left atrial enlargement?

Dr__Rimmerman: tough question as it depends on the cause. In the absence of significant valvular heart disease, no heart rhythm abnormalities and normal blood pressure, it is significance is minimized.

SKBURMAN: I am 49 yrs was diagnosed with Hypertrophic Cardiomyopathy. My echocardiogram shows the report with conclusion: "Mild LVH with normal chamber size and systolic function, EF > 55%". What does this mean and how serious is this. I am on Blood pressure medication: AMLODIPINE/BENAZ 5-10 MG LUPI

Dr__Rimmerman: That actually is a favorable echo result in your clinical situation with the most important clinical parameter being optimal blood pressure control, aiming for 120/80 or less.

SKBURMAN: What is the easiest way to check plaque in heart arteries? What is coronary calcium scan and at what age do you recommend this?

Dr__Rimmerman: A calcium scan can assess for asymptomatic coronary atherosclerosis - it is not a blanket recommendation as it often leads to unnecessary testing including heart catheterizations. Additionally, calcium scans can create shadows and over-estimate the degree of atherosclerosis. At Cleveland Clinic, we prefer exercise stress testing prior to proceeding with heart catheterization. Calcium scans are utilized at Cleveland Clinic but much less frequently.


Snakeskin77: Hi! I'm a 34 year old male, 155 lbs., 22% BMI. I'd really like to lose some fat weight and replace it with muscle; HOWEVER, I also have a bicuspid aortic valve, had coarctation repair surgery when I was 4 (the narrowing has since returned slightly, putting me on Corgard since '99), and due to the re-narrowing, I've had an aortic aneurysm (4.5 cm, stable now with little/no growth) that has popped up in the past few years. Is there ANY way to be able to lose the weight AND be able to weight lift enough to gain muscle without completely risking an aneurysm rupture/dissection, or am I out of luck until the eventual aneurysm repair surgery/valve replacement (which won't happen until my cardiologist determines it has grown enough to require the surgery)?

Dr__Rimmerman: We see many patients such as your self and it is important if you are lifting weights to focus on lower weight and higher repetitions. Your 4.5 cm aorta is not aneurysmal as an aneurysm is 5.0 cm or greater. I would not recommend lifting heavy weights with the idea of bulking up significantly given your aorta condition. Aerobic activities are highly recommended without restriction.

Medications and/or Supplements

WilliamD: Do you have any reports about the Bp medication called losartan causing problems with the urinary system ? I have been taking losartan 50 mg and it seems I am not relieving myself as often as I was. Also I had a bladder infection and now I have a really bad prostate infection. I am now on Cipro . I feel that losartan has caused this problem . My family Doctor disagrees with me . What do you think ? Thank you , William D

Dr__Rimmerman: Thank you for your question outlining your concerns. I am not aware of losartan being a cause of reduced urinary output or aggravating prostate function/the urinary tract.

Linda_J: Does the 1,200mg calcium supplement I take each day to avoid bone loss have any connection to the 75% calcium build-up in my coronary arteries? Can the calcium in my plaque be reduced if I stop the supplement? I'm allergic to dairy and eat little meat.

Dr__Rimmerman: I am not aware of a prescribed calcium supplement relationship with obstructive coronary artery disease and coronary artery calcification

Tahir_H: I recently had a stent implant in my left coronary. I have no history of heart attack or strokes. I am taking Plavix 75 mg and aspirin 325 mg. Should I be taking such a high dosage of aspirin? Or just take 81 mg. Also I saw a Cleveland clinic study indicating that Plavix did not have any more benefit than taking Aspirin alone. Is this correct?

Dr__Rimmerman: Please consult with your prescribing physician. I am not sure if your stent is bare metal or coated. In either case Plavix is indicated. The aspirin dose is controversial and often we prescribe 325 mg daily for 30 days after stent placement reducing to 82 mg daily thereafter. I am not aware of this study as we are regularly prescribing Plavix in a patient such as yourself.

HH_Fla: I had a heart attack in 2002 and had a defibrillator inserted. Under Dr. Rimmerman's orders I was tested at the Cleveland Clinic about 8 years ago for aspirin resistance, told that I had aspirin resistance, and as a consequence was told to take 2 baby aspirins per day, instead of one. Is this still valid, what Is the current thought about aspirin resistance?

Dr__Rimmerman: Difficult question with many possible answers. It is still relevant to be tested for aspirin resistance at the higher dose. You may want to discuss this with your current cardiologist. This is still an evolving topic with a variety of opinions.

Interested123: In flying from the east coast to the west coast, necessitating 3 flight changes, I made sure to walk the isles in the plane every 20 minutes because I was on warfarin after one episode of afib. The second day I was on my feet all day shopping. The third day my legs were both completely black and blue. A cardiologist who saw me in Cal said, in layman's terms, that I was a bleeder and that with only one afib episode he would suggest substituting warfarin with a full aspirin each day. Would you comment on this? (I have had 3 afib incidents in 3 years.)

Dr__Rimmerman: Interested123: The indication for warfarin in your situation based on the information you have provided is unclear. I recommend referring to the CHADS2 score which can be found on the internet and see what your score adds up to. If 0 or 1; aspirin daily is likely ok . If 2 or greater consider warfarin.

tirreno: I've had a stent put in two years ago - is it OK to go off Plavix? My cardiologist said OK but I'm concerned of the consequences. I'm also on 325mg of aspirin daily. I have cut back on my metoprolol to 25mg a day because my HB per minute was at 52 - it is now averaging 64 and I feel much better. Sometimes I feel that I can manage my medication regime better than physicians because I watch it everyday.

Dr__Rimmerman: Regarding your stent and plavix, this is an individualized decision best made between you and your cardiologist. At Cleveland Clinic, if you are having no side effects from the plavix, it is frequently continued.

SKBURMAN: My primary physician recommended taking a baby aspirin (80mg) daily? Do you agree?

Dr__Rimmerman: It depends on your age and your associated risk factors. There is actually a Framingham heart attack risk score which you can find on the internet, which can help you in this regard. If you are young with minimal risk factors, most times the risk of bleeding outweighs the cardiac benefit.

Heart Failure and Cardiomyopathy

Cynthia: Could you please tell me how a person can be diagnosed with dilated cardiomyopathy thru a heart catheterization and 2 echoes only to be told 10 months later that its restrictive cardiomyopathy due to was diagnosed by a second Doctor thru an echo how can a person be diagnosed as restrictive cardiomyopathy only to find out 10 months later its amyloidosis

Dr__Rimmerman: Amyloidosis affecting the heart can be a difficult diagnosis to immediately ascertain, best arrived at through a myocardial biopsy. Since a patient such as the one you describe had weakened heart muscle initially possible causes are many and amyloidosis remains one of many.

Heart Surgery

Lisa_L: What are the statistics on life expectancy for heart surgery on female at age 41? Surgery included: mechanical valve, artificial ascending aorta, coronary reconstruction into artificial ascending aorta, and Coumadin level remains constant at 3.0?

Dr__Rimmerman: Provided your surgery is successful, your life expectancy should be quite favorable. Please recognize it is always difficult to predict for one particular patient but we routinely see patients such as yourself living three to four decades after the surgery.


Dr__Rimmerman: I do believe you have established a new baseline for your heart rate since it has been greater than 3 months since your surgery. Regarding pacemaker wires, these are of no concern and do not need to be removed.

Cleveland_Clinic_Host: Thank you again for taking the time to answer our questions about heart disease. As we end the chat, Dr. Rimmerman, you recently wrote a book "You and Your Cardiologist", what are the best recommendations for a patient when seeing their cardiologist.

Dr__Rimmerman: My best recommendation is to do the most advanced preparation as available by obtaining and collating your medical records - and any testing; particularly testing which would be available by CD rom to bring with you to your appointment.

Reviewed: 11/11

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.

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