Heart Health

06 April 2011

The Cardiologist: heart questions

Heart disease is the number one killer in South Africa. Do you know enough about what causes heart disease, and how to prevent it?

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Heart disease is the number one killer in South Africa. The current statistics show that 1 in 3 men and 1 in 4 women will have a heart condition before the age of 60.  Do you know enough about what causes heart disease?  Besides hereditary factors, there are also lifestyle factors such as lack of exercise, stress, smoking and an unhealthy diet which can contribute to heart disease and heart attacks. Here are some of the questions sent to the Cardiologist.

Q:  Sudden pain

For the last few days I get a sudden, sharp thumping-type pain in the centre of my chest. It occurs every few minutes for a few hours, and then nothing for a few hours. There is no specific pattern to it - like after meals or early morning.

It feels like that heart-dropping feeling when you get a fright, but no heart palpitations or increased pulse. I have had constant heart burn for the last few months which has now eased since I have lost quite a significant amount of weight (intentional). I don't have any shortness of breath and am exercising (spinning) as normal. Can you give me some sort of idea what it might be or do I really, really need to see a doctor?

A:  You don't mention your age or medical background eg. whether  you smoke, are diabetic, etc.  However, you sound young and are exercising without difficulty. Your chest pain does not sound at all like cardiac pain, which tends to have a clear pattern and is not sharp or sudden or thumping like yours is. Your other chest discomfort, which you call "heartburn", sounds like what is called reflux.  It's caused by reflux of stomach acid into the oesophagus. It often gets better - as in your case - when people lose weight, but sometimes requires treatment with drugs called PPI's (proton pump inhibitors) or with laparoscopic ("keyhole") surgery.

From the evidence we have we can be confident your chest pain is not from the heart. However it is less easy to know where it is coming from. The most likely is that it is part of what is called a "chest wall syndrome" - ie it comes from the bones or cartilages or muscles that make up the structures of the chest wall. This is a common condition, which often causes anxiety about the heart, but usually disappears spontaneously with time. If you are generally healthy and well and not at high risk for heart disease my advice would be to give it time - the probability is high that it will just disappear on its own without her having to see a doctor.

Q:  Medication for leaking heart valve

I'm a 43 year old male with a leaking mitral heart valve. My heart is also enlarged. I used to be on Coversyl Plus, but I'm using Ziak and Unat at the moment.

Which of the medication is the better one for my condition? I feel that the Coversyl has worked better before.  I'm getting some pains in my chest lately with dizziness, and my feet are swollen a lot. Thanks for reply.

A:  You say you have a leaking mitral valve and an enlarged heart. Enlargement of the heart in the context of a leaking mitral valve usually means that the valve is leaking quite badly, but the usual symptom caused by this combination would be shortness of breath, not chest pain or dizziness.

The best drugs for a leaking mitral valve and enlarged heart - of the three which you mention - would usually be the combination of Coversyl (perindopril) and a diuretic like Unat (torasemide), rather then Ziak (a beta blocker plus very low dose diuretic). However there may be better ways of managing the problem. My advice would be to see a cardiologist for an opinion about the best treatment for your leaking valve and the cause of your chest pain and dizziness.

You don't mention your age or medical background eg. whether  you smoke, are diabetic, etc.  However, you sound young and are exercising without difficulty. Your chest pain does not sound at all like cardiac pain, which tends to have a clear pattern and is not sharp or sudden or thumping like yours is. Your other chest discomfort, which you call "heartburn", sounds like what is called reflux, due to reflux of stomach acid into the oesophagus. It often gets better - as in your case - when people lose weight, but sometimes requires treatment with drugs called PPI's (proton pump inhibitors) or with laparoscopic ("keyhole") surgery.

From the evidence we have we can be confident your chest pain is not from the heart. However it is less easy to know where it is coming from. The most likely is that it is part of what is called a "chest wall syndrome" - ie it comes from the bones or cartilages or muscles that make up the structures of the chest wall. This is a common condition, which often causes anxiety about the heart, but usually disappears spontaneously with time. If you are generally healthy and well and not at high risk for heart disease my advice would be to give it time - the probability is high that it will just disappear on its own without her having to see a doctor.

Q:  Low pulse rate

I have had a low pulse rate as long as I can remember - 62 (I exercise once - twice a week, lately even less because I feel fatigued every day). 3 years ago I a had blood clot in my lungs after a minor operation. Since then my health is not what it used to be. My pulse rate dropped to 47 and I feel fatigued most of the day. My lung function test also reduced to 88% - some say the birth-control pill I use also has an impact. Please can you assist? If I need to see specialists, what type of specialist do I need to see?
ps. I am 34 years and my sugar level  is normal and my blood pressure 125/80

A:Usually a low resting heart rate is a sign of a healthy heart, and people with low heart rates on average live longer than those with high rates. It is unlikely that your low heart rate is in any way responsible for your tiredness.

Of more concern is your history of clots in the lung after a minor operation, and your mildly reduced lung function. Young women who have had clots in the lung should not be using oral contraception, and if you are a smoker it would be very important to stop that as well. You should also have a blood test to see whether your blood has any abnormal tendency to clot.

My advice would be to see a pulmonologist (respiratory physician) for an opinion about your tiredness, your lungs and your clotting function, plus you should see your gynae or GP for advice about alternative forms of contraception.

Q:  Is this a side effect from heart medication?

I am a 67-year-old female.  On my front right lower leg, shin height, I have a slight blue round circular patch, it has burning sensation & is sensitive.  It's been there for 2 days now.  I have very high cholestrol (9), and I started taking Crestor (20 mg) 17 days ago.  Is this patch related, and what can I do?  Thank you.

A:It is unlikely but not impossible that this blue patch on your shin is due to the Crestor you began three weeks eralier.

As you are post-menopausal and have a very high cholesterol I would agree with the decision to start you on a drug to bring it down. However, although lowering your cholesterol is very important, it is not an emergency. Also, there are other drugs avalable. Crestor is the most potent of the drugs available to reduce cholesterol, but the others are also very effective.

I would give the blue patch another few days. If it hasn't disappeared in a week, then stop Crestor and wait another week. If the blue patch is still present and is showing no sign of disappearing, it becomes very unlikely it is due to Crestor in which case you could re-start Crestor - or an alternative - but see your GP or a dermatologist about the patch.

Q:  Family history of heart disease

We do have heart problems in the family. My father died of a heart attack at 53 – it was his first and last heart attack. My mother had a heart attack a year ago. In her side of the family there is a lot of heart disease.

My question: Is it good for me (35) to start drinking a disprin or some kind of medication to keep my blood thin etc? There is another pill that is coated instead of the disprin. Can a disprin cause harm to my stomach if used daily?

A:  A good question! The simple answer is no, the statistical risk of a side-effect of Disprin (or any form of aspirin) in your situation is higher than any small benefit you might derive from taking it.

Let me explain. Because of your family history, your relative risk of developing heart disease is higher than average - in other words your risk is theoretically higher than other young women of your age. However your actual risk of getting heart trouble - such as a heart attack - in the next 10 -15 years is very low - because young premenopausal woman like you are generally at very low risk. (Provided they are not diabetic and don't smoke.) In addition to that, the benefit of taking aspirin in women who have never had heart trouble is very uncertain - and even if there is a benefit it is small.

So - if your risk is already low, it makes no sense to take a drug which has a doubtful or small theoretical benefit. At best, it might make a low risk slightly lower. At worst, it carries the risk of side effects eg stomach bleeding as you mention.

Having said all that, it is important to reduce your long term risk with a healthy lifestyle - ie maintain healthy weight, don't smoke, take regular exercise. And its important to exclude diabetes and to check your cholesterol and blood pressure, especially after menopause when women's risk starts to increase.

Q:  Am I at risk of a heart attack?

I am 60 years old. I have just started taking a betablocker owing to the fact that my BP has been around 140/98 for over a year and rarely differs. I have been on an HRT patch for 4 and a half years. I have weighed around 55 kgs for 30 years and take good care of my health. Am I at risk of having a heart attack?

A:  Most women age 60 are at some risk of heart attack, but of course the risk varies widely and depends on a number of risk factors - so-called "global risk"  - and not just on blood pressure. Risk factors include family history, smoking, cholesterol, blood pressure, presence of diabetes, sedentary lifestyle, psychosocial stress, lack of regular exercise, and a diet deficient in fruit and vegetables.

So without some more information its difficult to give you a good idea of your risk, but it doesn'd sound as if you are "high risk". To get a better idea, I suggest contact your GP and ask him to help you calculate risk.

A healthy lifestyle can go a long way towards reducing risk and yours sounds healthy. Sometimes medication is necessary to try to reduce risk, eg by reducing blood pressure. Beta blockers are less popular as first line medication for high blood pressure these days but are very suitable for some patients. At one time we believed that HRT reduced risk of heart attack but know now that is not the case.

Q:  My husband survived "sudden death", how do we prevent this happening again?

My husband survived "sudden death" and has been diagnosed with hypertropic Cardiomyopathy. He is an athlete and loves exercise. May he still exercise and what type? How do you live with this condition? He is on a beta blocker (for life). I believe this medication is tiring him out more, is there any other type of medication that could be prescribed for this condition? Thank you.

A:  I'm delighted to hear your husband survived sudden cardiac death but sorry to hear he has hypertrophic cardiomyopathy. This is a condition which is very variable in its severity but unfortunately is sometimes the cause of sudden death during exercise, which it does by causing dangerous heart rhythms. Unfortunately this means that athletes who survive "sudden cardiac death" due to hypertrophic cardiomyopathy should no longer do strenuous exercise, even if they take a beta blocker. Equally unfortunately, beta blockers often cause tiredness, as in your husband's case, and may also have other undesirable side-effects.

There are some other drugs which are occasionally used in patients wih HCM but your husband should be guided by his cardiologist. There are also surgical treatments available for patients who have the obstructive form of hypertrophic cardiomyopathy. Your husband should ask his cardiologist about this, and also about the possibility of implanting a cardioverter defibrillator, a device like a pacemaker  that can detect and terminate abnormal heart rhythms.

Many patients with HCM live very comfortably with the condition, depending on severity, but as mentioned strenuous exercise should be discouraged in patients with HCM who have survived sudden death.

Q:  Relief from angina pain

I have high blood pressure and also a small leak in the heartvalve. I sometimes get these chest cramps that move to my left arm (angina?), and find that it happens more often when I am stressed. I am on medication for bp and a beta blocker. Is there anything else I can get for the cramps?

A:You do not mention your age, or which valve is leaking, but I assume from what you say that you are no longer "in the first flush of youth"!

Small leaks in heart valves usually never give trouble. "Cramps" involving your left arm at times of stress are probably nothing to do with the heart, ie. not angina, but for peace of mind it is probably better to see your doctor for reassurance. There is no good way of preventing "cramps" that I know of, but treatment would depend on the cause. For example, pain down the arm is often due to wear and tear in the vertebrae of the neck ("cervical spondylosis") which is a very common problem as people get older. X-rays of your neck may be very helpful, which your doctor could arrange for you.

More information:

Visit the Heart Centre

Send your questions to the Cardiologist
 

(Joanne Hart, Health24, April 2011)

 

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