Diagnostic Tests, Treatments and Procedures

I have been experiencing mild chest pain after exercise for the past six months. My EKG was normal. Do I need further testing?

An electrocardiogram (EKG, ECG) may show evidence of heart enlargement, signs of insufficient blood flow to the heart, signs of a new or previous heart attack, heart rhythm problems, changes in the electrical activity of the heart caused by an electrolyte imbalance and signs of inflammation of the sac around the heart (pericarditis). However, a normal electrocardiogram does not necessarily mean that your chest pain is not cardiac in origin. An electrocardiogram cannot predict whether you are at a risk of having a heart attack.You may need further evaluation of your symptoms and stress testing to determine the cause of your chest pain.

What is a thallium or nuclear stress test?

A thallium scan is a test used to estimate the amount of blood reaching the heart muscle during rest and exercise. It is typically done for people with unexplained chest pain or to determine the location and amount of injured heart muscle after a heart attack. For this test, a radioactive substance (tracer) is injected into a vein and a special camera is used to view the amount of tracer that reaches the heart at rest and when stressed (through exercise or medication). As the tracer moves through the heart muscle, areas that have good blood flow absorb the tracer. If an area of heart muscle does not adequately absorb the tracer, it means either that the blood flow is severely reduced or there has been a previous heart attack. An abnormal thallium stress test may be consistent with a blocked artery and you may be at risk for a heart attack. In many exercise laboratories, they use a newer radioactive substance called “sestamibi” that is comparable to thallium.

I recently had an abnormal stress test. My doctor recommended coronary angiography. How will this test help?

Angiogram, or cardiac catheterization, is an appropriate follow-up test to see what is happening on the inside of your arteries. A special dye is injected into the coronary arteries to trace the movement of blood through the arteries. The purpose of this test is to pinpoint the size and location of plaque that may have built up in your coronary arteries due to atherosclerosis.

What is angioplasty? Is it different from stenting?

Angioplasty is a procedure to reopen narrowed coronary arteries. During the angioplasty procedure, a thin, flexible tube (catheter) is inserted through an artery in the groin or arm and carefully guided into the artery that is narrowed. Once the tube reaches the narrowed artery, a small balloon at the end of the tube is inflated. The pressure from the inflated balloon presses fat and calcium deposits (plaque) against the wall of the artery to improve blood flow. If necessary, a small, expandable wire tube called a stent is inserted into the artery to hold it open. Stents may be medicated to decrease scar formation on the stent, which increases the likelihood of the artery remaining open over a longer time. Reclosure (restenosis) of the artery is less likely to occur after angioplasty followed by stenting than after angioplasty alone.

My father has CAD that has been worsening despite medical management. What treatment options are available?

There are several treatment options available. Angioplasty (with or without stent placement) and atherectomy (shaving the plaque from the inside of the coronary arteries) are nonsurgical procedures to reopen narrowed coronary arteries. Coronary artery bypass surgery involves bypassing the blocked artery with a graft fashioned from a leg vein or chest or arm artery (mammary or radial artery).The choice between angioplasty with or without stent placement and bypass surgery depends on a number of factors including the artery blocked, the number of vessels blocked, the location and severity of blockage and other heart problems.

Medications

I've heard that these cholesterol drugs cause bad side effects that can kill people. I'm concerned since I recently started Lipitor.

The most widely used cholesterol-lowering drugs are called statins. They are effective in lowering cholesterol and along with it the risk of dying from heart disease and/or having recurrent heart attacks. In general, statins have very few side effects. In a few cases there may be some liver abnormalities along with muscle tenderness and weakness. From time to time your doctor may order liver function tests if you take statins. The incidence of serious muscle injury and progression to life-threatening rhabdomyolysis (muscle breakdown) is very rare, but it’s essential to report any muscle pain, weakness and/or tenderness to your doctor. I have chronic stable angina for which I take a long-acting nitrate and atenolol.

How do these medications work?

Nitrates are a first-line therapy for the treatment of acute anginal symptoms. Nitrates open (dilate) the arteries to the heart. This action increases blood flow to the heart, relieving chest pain (angina). Nitrates also dilate veins throughout the body so that they can hold more blood.This action reduces the amount of blood going back to the heart, reducing the heart’s workload. Beta blockers reduce the workload on the heart by slowing the heart rate and reducing the blood pressure, which allows the heart to pump more efficiently. As a result, beta blockers can help relieve or prevent chest pain (angina).

I do not like to take a nitroglycerin tablet because it gives me a headache.

Nitroglycerin and other nitrates relax the arteries (vasodilatation) and improve the blood flow to the heart. The major side effects associated with nitrate use are headache, lightheadedness and flushing, which are due to the vasodilatation and tell you that the medication works.These symptoms tend to improve with time. Since the nitroglycerin evaporates from the pills once the bottle is opened, you need a new prescription every six months.

I am taking aspirin, atenolol, lisinopril and simvastatin for medical management of CAD. What are their benefits?

Platelets are responsible for forming blood clots. Aspirin reduces platelet function and the risk of having a heart attack or stroke from a blood clot forming in the arteries of the heart or brain. Beta blockers (atenolol) reduce the heart rate and blood pressure and therefore decrease the workload on the heart. ACE inhibitors (lisinopril) decrease the blood pressure and reduce the workload on the heart by preventing the formation of the hormone angiotensin, which narrows arteries. Statins (simvastatin) block an enzyme that the body needs to form cholesterol. All these medications have been shown to decrease the chance of another heart attack and lengthen life in patients with CAD.

I was started on an ACE inhibitor after I suffered a heart attack. For the past few weeks, I’ve had a cough that I was told could be related to the medicine. Should I continue the medicine?

ACE inhibitors are recommended immediately after a heart attack to reduce the risk of death associated with a heart attack and prevent the development of heart failure. Cough occurs in 20% of patients on ACE inhibitors. If coughing is a severe problem, consult your doctor, as other medications such as ARBs (angiotensin receptor blockers) can be tried.

Primary Prevention

What is Primary Prevention?

Primary prevention is early identification of cardiovascular risk factors and taking action to reduce these risks before cardiovascular disease develops. Primary prevention strategies are aimed at helping people make lifestyle changes, such as quitting smoking or losing weight, before they are diagnosed with a heart attack or stroke.

My most recent cholesterol test numbers are: 208 total cholesterol; HDL 67; triglycerides 96; LDL 126. Because I have rheumatoid arthritis it is difficult for me to do strenuous exercise… I do practice Tai Chi. What suggestions do you have for lowering my LDL?

Ways in which a person could help reduce a high cholesterol level are to start and maintain a low-saturated-fat, low-cholesterol diet and lose weight if overweight. Meat, cheese and dairy products are the major sources of saturated fat. Increase your intake of fiber, which can lower cholesterol. Fiber is found in legumes (beans), whole-grain breads and cereals and fresh vegetables. Exercise and being physically active plays an important role in helping reduce cholesterol – in doing Tai Chi, you are doing a good job in helping yourself be active. One should aim for 20 to 30 minutes of moderate exercise (walking, gardening, easy bicycling) at least 5 days a week. Exercise can help control cholesterol, blood pressure and blood sugar (important if you have diabetes or a family history of diabetes). It would be wise to discuss these levels, along with any other risk factors you may have, with your physician to set your target cholesterol goals and create the best plan of care to reach them.

My recent lipid profile was abnormal and my doctor wants me to work on improving it in part through more exercise and in part through diet. The American Heart Association (and others) recommends a low-saturated-fat, low-cholesterol diet. My doctor says not to worry about eggs or shrimp, and instead to eliminate sugar, alcohol and refined wheat flour from my diet as much as possible. How and where can I find some credible discussion of this conflicting advice?

One good resource for you to get this information is from your doctor since he suggested the dietary changes.The Therapeutic Lifestyle Changes (TLC) diet is recommended by the National Cholesterol Education Program of the National Institutes of Health.You may want to work with a registered dietitian or nutritionist to help you follow the TLC eating plan, which is low in saturated fat and cholesterol. According to this eating plan, less than 7% of your daily calories will come from saturated fat, and cholesterol should be limited to 200 milligrams (mg) per day.Also, the TLC plan recommends increasing soluble fiber and adding plant stanols and sterols to your diet. Plant sterols and stanols are found in small quantities in many fruits, vegetables, nuts, seeds, cereals, legumes and other plant sources.Vegetable oils, for example, contain both plant sterols and stanols. Plant stanols and sterols are available in salad dressings and margarines, such as Benecol and Take Control.

How can I increase my good cholesterol?

The “good” cholesterol is known as HDL (high density lipoprotein) cholesterol.You can increase your good cholesterol in several ways. First, increase your exercise activity to 30-60 minutes a day on most days of the week.Also, losing weight and not smoking will increase HDL levels. A level of HDL less than 40 mg/dL is considered a risk factor for heart disease, whereas a level of 60 mg/dL is considered protective against heart disease. Medications such as fibrates and niacin also raise HDL levels.

My total cholesterol is 230. My internist says that it’s okay for me but I am concerned. What should I do?

In order to determine whether this level of cholesterol is appropriate for you, you need to determine your LDL and HDL levels and whether other coronary artery disease risk factors are present.Your number of risk factors and your 10-year risk of having a heart attack will determine whether your treatment begins with lifestyle changes alone or whether it includes cholesterol-lowering medications. Generally, unless you have CAD or are at high risk for CAD, therapeutic lifestyle changes will be tried first, for at least three months.

You will need to be assertive about your health and not accept a borderline total cholesterol as okay without further assessment of LDL and HDL cholesterol.

For the past six months, I have been trying to manage my high cholesterol by dietary modification and exercise. My recent LDL cholesterol was 180 and HDL was 30. My internist does not believe me and he wants me to try losing more weight before considering medication.

If your LDL cholesterol is still 180 after six months of strict adherence to a trial of therapeutic lifestyle changes and you have mentioned that you have at least one coronary risk factor (low HDL), you will need medication to lower your LDL cholesterol. You need to be evaluated for the major risk factors that modify LDL goals – cigarette smoking, high blood pressure, low HDL cholesterol, family history of premature CAD and age (men > 45 years; women > 55 years). Your LDL goal will be based on the risk category you fall in: <160 mg/dl – Zero to one risk factor <130 mg/dl – Multiple (2+) risk factors <100 mg/dl – CAD or CAD equivalent (Diabetes, other forms of atherosclerotic disease such as peripheral artery disease, symptomatic carotid artery disease and abdominal aortic aneurysms.) If your internist is not willing to make a treatment plan that includes a dietitian consult, an exercise regimen and medications, then consider getting a second opinion.

How often should I exercise? What are the benefits of physical activity?

It is important to try to incorporate physical activity for 30 minutes on most, if not all, days. Physical activity gives you strength and energy; helps you handle stress, sleep better, look good, feel positive; helps control weight and blood pressure and strengthens your heart, lungs, bones and muscles. Regular moderate physical activity lowers the risk of heart disease, stroke, diabetes, high blood pressure, obesity, high total cholesterol and low HDL cholesterol.

What kind of exercises should I do?

Moderate activities such as pleasure walking, gardening, yard work, dancing, home exercise and moderate to heavy housework can reduce your risk of heart disease if done on most or all days. More vigorous exercises such as brisk walking, jogging, stair climbing, hiking, swimming, rowing, bicycling, aerobic dancing and cross-country skiing can improve the fitness of your heart and lungs. If you haven’t been active and want to start exercising, you should discuss with your doctor an exercise program that is right for you.You can also add more activity to your daily routine such as taking stairs instead of elevators/escalators and taking a walk during the lunch break.

What is the ideal body weight to reduce the risk of heart disease?

A body mass index (BMI) between 18.5 and 24.9 Kg/m2 is considered ideal (calculated as weight/height2). BMI 25 corresponds to 110 percent of desirable body weight. People with a BMI of 25-29.9 are considered overweight, while people with a BMI of 30 or greater are considered obese.When a person’s BMI is 25 kg/m2 or higher, the waist measurement goal is 40 inches or less for men, 35 inches or less for women. General recommendations are to achieve and maintain the ideal weight by restricting calories in diet and increasing the caloric expenditure by exercising. Overweight or obese persons should reduce 10 percent of their body weight in the first year of therapy.

I know I should quit smoking – it’s bad for my heart and my lungs – but I’ve tried everything and nothing works. Any suggestions?

The more attempts you make to quit smoking the greater your chances are of succeeding. Counseling also increases your chances of quitting for good. Yale-New Haven Hospital runs a 7-week program called “Freedom from Smoking” that provides education, counseling and group support for people who want to quit. Another resource for smoking cessation programs is the American Lung Association at www.lungusa.org. Nicotine replacement therapy, in the form of nicotine transdermal patches and nicotine gum, are more effective in helping you quit smoking when used as part of a more comprehensive smoking cessation program. There is also a medication, bupropion, which may help you. Consider talking with your doctor about the best option for you.

How can I avoid gaining weight after I quit smoking?

You do not automatically gain weight after you quit smoking. People usually gain weight because they start eating more once they quit smoking. If you watch what you eat and stay physically active, you may not gain any weight.The benefits of quitting smoking on your cardiovascular health outweigh the risk of gaining a few pounds, which can be controlled if you are cautious with diet and exercise.

I continue to read about red wine’s benefits… the latest in a December issue of “Bottom Line Health,” where it suggests 3 glasses a week. Is this proven? I really don’t care for regular red wine, nor do I drink daily; however, I’m interested in everything that helps heart health.

The jury is still out and more research regarding red wine consumption and possible cardiovascular benefits needs to be conducted. Some studies have indicated possible cardioprotective effects of red wine due to the flavonoids present in the red grape seeds and skin.These flavonoids are identified as antioxidants, which may possibly reduce the risk of heart disease. However, according to a recent American Heart Association science advisory, drinking red wine or any other alcoholic beverage cannot replace effective conventional measures of reducing a person’s risk for heart disease. Conventional measures include controlling weight, lowering cholesterol and lowering blood pressure.

Recently my sister and I were diagnosed with hypertension. I was started on medications, whereas she has only been advised lifestyle changes. I would like to avoid medications as well.

Your treatment will depend upon how high your blood pressure is, whether you have other medical conditions, such as diabetes, and whether any organs have already been damaged.Your risk of developing other diseases, especially heart disease, will be another important factor your doctor will consider. If you fall into the prehypertension range (120-139/80-89 mm Hg), your doctor will likely recommend lifestyle modifications, including losing excess weight, exercising, limiting alcohol, cutting back on salt, quitting smoking and following the Dietary Approaches to Stop Hypertension (DASH) diet. Drug therapy is not recommended for prehypertension patients with the exception of patients with diabetes who have blood pressure readings over 130/80 mm Hg. Combination drug therapy in addition to aggressive lifestyle changes is usually necessary for those with hypertension, defined as either stage I (140 -159/90-99 mm Hg) or stage II (>160 / >100 mm Hg).

How can I reduce high blood pressure?

You can reduce your blood pressure by making some changes in your lifestyle and taking proper treatment. Lose weight if you’re overweight. Eat a healthy diet low in saturated fat, cholesterol and salt. Be more physically active. Limit alcohol to no more than one drink per day for women or two drinks a day for men.Take medicine the way your doctor tells you and know what your blood pressure should be and work to keep it at that level.

What is a DASH diet?

The DASH eating plan is a low-sodium, low-fat, and low-saturated fat diet that emphasizes eating more fruits, vegetables, whole grains and low-fat dairy foods. For more information visit this National Institutes of Health page.

I have diabetes and am on Metformin. What can I do to prevent the complications of diabetes?

Diabetes is a disease that can be controlled. Careful monitoring of diet, daily blood sugars and a blood test called hemoglobin A1c will all help to reduce complications. The hemoglobin A1c measures average blood sugar over the course of 3 months and your physician can order this test for you. Ideal hemoglobin A1c for people with diabetes is <7%. Studies have demonstrated that tight control over diabetes reduces the risk for subsequent heart attack and stroke. You should aim to achieve near-normal fasting plasma glucose (blood sugar) of less than 110 mg/dL and near-normal hemoglobin A1c of less than 7%. Other cardiac risk factors associated with diabetes need to be treated more aggressively. For example, change your blood pressure goal to less than 130/80 mm Hg and your LDL cholesterol goal to less than 70 mg/dL.

My doctor recommended that I start aspirin as I am at high risk for coronary artery disease. I thought aspirin is for people who have angina or who have had a heart attack.

Aspirin is definitely recommended for patients who have had a myocardial infarction (heart attack), unstable angina, ischemic stroke (caused by blood clot) or transient ischemic attacks (TIAs or “little strokes”), in the absence of contraindications. This recommendation is based on sound evidence from clinical trials showing that aspirin helps prevent the recurrence of such events as heart attack, hospitalization for recurrent angina, second strokes, etc. (secondary prevention). Studies show aspirin also helps prevent these events from occurring in people at high risk (primary prevention). The American Heart Association recommends low-dose aspirin in high-risk people.

Secondary Prevention

What is secondary prevention?

Secondary prevention is aimed at identifying and treating people with established disease and those at very high risk of developing cardiovascular disease. It also includes treating and rehabilitating patients who have had a heart attack or stroke to prevent another similar event.

I had a heart attack two months ago. I am on aspirin, metoprolol, pravachol and lisinopril. How long will I need to be on these medications?

Aspirin, beta blocker (metoprolol),ACE inhibitors (lisinopril, accupril or monopril) and statins such as Lipitor, Zocore or Crestor have been shown to reduce the risk of future heart attack in people with known CAD.The American Heart Association recommends to continue aspirin, beta blockers and ACE inhibitors indefinitely for patients who have had a heart attack, unless contraindicated.

I am overweight and I have diabetes, high blood pressure and high cholesterol for which I am taking medications. I have also had a heart attack and a mini-stroke one year ago. What can I do to reduce my risk of having another heart attack or stroke?

Aggressive lifestyle changes in addition to medications will lower your risk for a future heart attack or stroke. Complete cessation of smoking, weight control, 30 minutes of physical activity on most days, alcohol moderation, moderate sodium restriction and emphasis on fruits, vegetables and low-fat dairy products are some of the changes you need to consider.Your blood pressure should be less than 130/80, LDL cholesterol should be less than 100 (less than 70 being the optimal) and hemoglobin A1c should be less than seven.You will benefit from working with a dietitian or nutritionist to help you achieve your dietary goals. Ask your doctor to help you make a plan of care that includes a dietitian and an exercise program, in addition to medications.You may also want to discuss whether you are a candidate for cardiac rehabilitation.

I am a 50-year-old woman who recently underwent bypass surgery. Will a cardiac rehabilitation program benefit me?

Cardiac rehabilitation is a medically supervised program that includes exercise, lifestyle changes, education and emotional support for people who have had a heart attack, bypass surgery or have other heart problems. It is individually designed to enhance your quality of life by improving your physical and emotional health. It can stabilize or reverse CAD. Benefits include enhanced exercise tolerance, less depression and anxiety, controlled CAD symptoms and most importantly, lower risk for future cardiac events. Attending a cardiac rehabilitation in your community is strongly recommended by the American Heart Association.