February 2006

Chris asks:
I have an enlarged heart due to a congenital ASD that was not closed until I was in my 30's. I believe my eject fracture is 20-23%. I function very well, but from time to time I have a lot of palpitations. One thing that causes them is caffeine. I gave that up, except for chocolate. I did even cut out chocolate, for the most part, but every once in a while I still eat it. Sometimes being over tired and just eating a large meal will give them to me. My question is: Is there some drug that can keep me from getting these palpitations? I am on Lasix, Lanoxin and coumadin.

Dr. Matthai responds:
You really need to know exactly what is causing the palpitations in order to treat them. If they are due to brief periods of atrial fibrillation, treatment is quite different than if they are due to ventricular arrhythmias. You should be monitored, either for 24-48 hours with a Holter monitor, or, if your symptoms are more infrequent, an implanted loop monitor.

Mary asks:
I have a long history of PVC's. I may go for weeks without any then I will begin to have them. I also have a lot of fluttering on those days as well. They might last for 4-24 hrs. During this time I do not feel well at all and I have pain in my neck and jaw. I have worn a monitor many times and only once was this fluttering documented. At that time I was put on Cartia XL 300mg daily. I have been taking Toprol XL 100 mg daily as well. Could this be a-fib or a more serious problem with the ventricle?

Dr. Matthai responds:
In the absence of structural heart disease (heart attack, weakened heart muscle, heart artery disease, etc), it is unusual for there to be problems with the ventricle that cause palpitations. Fainting (syncope) or near syncope are symptoms that prompt more vigorous evaluation. Otherwise, the treatment for occasional extra heart beats is often worse than the initial problem. If you have not had an evaluation for structural heart disease, possibly and Echocardiogram (ultrasound of the heart) or stress test, these might be indicated. It also might be worth insuring that you are not taking any medication or supplement - like coffee, tea, cola - that might precipitate palpitations. If your monitor demonstrated afib, it should be treated to prevent the afib or reduce the chance of a stroke.

Jane asks:
A couple of weeks ago, I was hospitalized with a-fib. It took about 7 hours to convert with IV meds. I was put on cardizem, which I reacted to, and then was switched to a beta blocker. I have always had good BP (in the 120/60 range), but now my blood pressure hovers around 150 over 65 to 90. I have had a history of what I always referred to as "flutters." I had an echocardiogram several years ago that showed my heart as beautiful. The recent echo showed my septum?(heart divider) out of sink with the heart rhythm. When I see the cardiologist, what should I be asking?

Dr. Matthai responds:
The natural history of blood pressure is to rise as we age. If non-medical therapy (diet, weight loss, exercise) do not improve your blood pressure, you may need more aggressive treatment of your blood pressure, probably a medication in addition to the beta blocker. I am not sure what you mean by your ECHO results. Be sure the cardiologist explains them to you in detail.

Blazer3003 asks:
Can you walk around with only 30% of your heart usage?

Dr. Matthai responds:
Yes. While this is significantly limited, many people will have a reasonable quality of life with severe heart disease with appropriate medical and sometimes surgical management. This might involve involvement of a heart failure specialist. There are new medical and surgical treatments for heart failure such a specialist might provide that cannot be provided by a general cardiologist.

Young asks:
At times, I feel faint and I have chest pains. When those symptoms ocurr, I have shortness of breath. I went to the ER three times and was sent home with non-cardiac discharge papers. What should I do?

Dr. Matthai responds:
If your symptoms are interfering with your lifestyle, it might be worth a more thorough evaluation, if for no other reason than to give you peace of mind. You should see your primary care physician (and not the ER) to arrange this evaluation.

Gary asks:
I had a 3-way bypass one year ago, my second in 23 years. The dye they have given me over the past few years for blockages in legs and kidneys has now, after this past surgery, resulted with me on dialysis for a few months. My kidneys are still not where they should be, but I am off dyalsis. When I walk for a 1/4 of a mile, I get tightning in my chest. My doctor says he thinks one of the by passes my have failed. I cannot have the dye any more as it will destroy what is left of my kidneys. Is there any way I can have my arteries checked without using the dye?

Dr. Matthai responds:
While there are non-invasive tests which may provide some information, any further intervention would need to be based on cardiac catheterization with contrast dye. Unfortunately, if your kidney function is as bad as you suggest, you will likely have to go back on to dialysis in the not-too-distant future. You should work with your physicians to optimize your time off dialysis, but consider repeat catheteriztion once a final decision for dialysis has been made.

Ced asks:
Does the 64 slice CT scanner evaluate heart murmurs and mitral valve prolapse?

Dr. Matthai responds:
No. Cardiac CT scans have very limited application at the current time and have no role in the evaluation of valvular heart disease.

Barbara asks:
Can the medical establishment determine if your arteries are 75% or 80% clogged before you have a heart attack and without invasive procedures? How? If your HDL is 39, LDL is 100, Triglycerides 197 and Total col. is 178, should you have this procedure done?

Dr. Matthai responds:
A problem we face as cardiologists is that we cannot accurately predict which stenosis (blockage) will go on from 75% to 100% and cause a heart attack. If an artery is over 90% blocked, that stenosis is more likely to go on to occlusion, but if this is an important artery, the person is likely to have symptoms. In reality, for each 75% stenosis, there are many, many more 30% stenoses, and since there are so many more of these mild stenoses, statistically, one of the mild stenoses is more likely to suddenly tear open, form a blood clot, totally occlude the artery, and cause a heart attack.

Our goal, therefore, is to stabilize these partial occlusions to minimize the chance that one will proceed to total occlusion, and this is where cardiac risk reduction comes in - don't smoke, control your blood pressure, maintain a good weight, exercise regularly, know your cholesterol and have it treated if appropriate, and maintain good blood sugar control. Identification of the so-called "vulnerable plaque" which might suddenly proceed to total occlusion is a target of significant research.

Non-invasive studies such as a stress tests may help identify important lesions, but these tests are not indicated for widespread screening. Electron beam CT scans, which provide a coronary calcium score, help determine risk, and can be used to identify a person who is at increased risk and should practice particularly aggressive risk factor modification. Coronary CT angiography exposes a patient to significant radiation and contrast dye, but it may provide similar risk information.

Learn more about Penn Cardiac Care's services by visiting us online. If you have any questions or would like to make an appointment with a Penn doctor, please contact 1-800-789-PENN (7366) or request an appointment online.

John asks:
At age 58, I have been quite active - biking, jogging, working out with dead weights and a bowflex machine, hiking on the Appalachian Trail, playing soccer, etc. I was taking Lipitor 10 mg, aspirin 81 mg, and various supplements (eg. 1000 mg fish oil, CQ-10 50 mg) and planning to "carry on" well into my 60's. My only "issues" have been gradually increasing BP (high 130's to low 140's), and finding about 1 1/2 years ago that I had to really stop and suck for air if I "sprinted" more than 20 yards during a soccer game.

Last March, after playing (very little) in my college alumni vs. varsity soccer game, I developed A-Fib and was hosptialized for 24 hours. After 2 days and meds, my pulse returned to normal. Over the spring and summer, I gradually resumed my former exercise habits and felt I was returning to normal. In September of 2005, I went out for a 3+ mile jog (took 35 minutes), then went to dinner a few hours later where I consumed several strong alcoholic drinks. At 4 a.m. the following morning, I awoke in A-fib which continued for 2 1/2 days until I had a negative TEE and cardioconversion.

Since then, I remain on Coumadin 7.5 mg, Diovan 160 mg, Cartia XL 240 mg, Lipitor 20 mg and the aspirin. My exercise is now reduced to long walks and the occasional 9 mile bike ride. I worked out vigorously one day over the holidays and felt winded. My pulse rate went to the high 80's and would not come back down to "normal" for several hours.

Three questions:
1) Do you have any idea what is triggering the A-fib?

2) Is there anything I can do that will allow me to return to my former relatively vigorous exercise levels?

3) Am I being over-treated/medicated? I feel like I have gone from being a vigorous 58 year old to an "old" 58 year old. I am concerned that the medications may be causing my sense of exertion, very hard breathing, and prolonged elevated heart rate after any attempt at vigorous exercise. I'm not ready for this; I still have some miles on my treads (I hope.)

Dr. Matthai responds:
1) While there are some identified triggers for a-fib (high thyroid, structural heart disease), these have probably been evaluated already. In most cases, the specific trigger for afib is not identified. A-fib will occasionally follow binge drinking ("holiday heart"), and the recommended maximum of 2 drinks daily for men or 1 for women (if you choose to drink alcohol) should be followed.

2) There is no obvious reason that you should be unable to return to an active lifestyle with few limitations. After a period of little or no exercise, a gradually aggressive exercise program should be followed. Sometimes, it is helpful to initiate exercise in a supervised setting like cardiac rehab.

3) You should have a frank discussion with your physician about your medications. If you do not have a history of high blood pressure, you may not need the Cartia. It is possible that it is being used to control your heart rate should you go into atrial fibrillation. If you go into a-fib rarely, you might not need it. One other thing to consider....if you are in a-fib more often than you recognize, the arrhythmia might be playing a role in your lack of energy. Many people have no symptoms whatsoever from a-fib, but if you are having a lot of unrecognized a-fib and your symptom is lethargy, maintenance of normal sinus rhythm should be your goal.

Mary asks:
I'm taking Vytorin for high cholesterol. My doctor says my overall numbers are down, but my triglyceride numbers are higher - over 200. She says to keep up the Vytorin and cut back on fruit and chocolate. I can understand the chocolate, but why fruit? What else can I do? I'm in WeightWatchers, lost 10 lbs. and am working on at least 30 more. Will that help and how quickly?

Dr. Matthai responds:
Triglyceride levels are affected by fatty foods which should be avoided, or, at least, limited. Triglyceride levels also respond to weight loss and activity. While fruit is, in general, healthy, some fruits are not low in calories. Too much fruit may result in too many calories and weight gain (or less weight lost). Attainment and maintenance of an ideal body weight must be a top priority.

Ver asks:
I am 53 years old. Since my mid-teens, doctors have been sending me for EKG tests as they said they heard a heart murmur. Everytime - the last time just three years ago - tests were negative. My cholesterol is normal and my blood pressure is normal. I am worried to death that I will have a heart problem. There have been no heart problems in my family history on both sides. I eat healthy. The bulk of my diet is vegetables and fruits. I drink lots of water and I exercise. What else can I do?

Dr. Matthai responds:
It sounds like you are living a good, heart-healthy lifestyle, assuming you don't smoke. You don't have a family history of heart disease, don't have high cholesterol, don't have high blood pressure, don't have diabetes, and you exercise regularly. Statistically, the likelihood of heart artery disease is low. EKGs do not evaluate heart murmurs. ECHOcardiograms (ultrasounds of the heart) do this. If you are concerned about your risks or your heart murmur, you should have a frank discussion with your physician and be sure all of your questions are answered. Ask exactly what the tests mean and what the results mean. Keep up the heart-healthy lifestyle.

Cindy asks:
My cholesterol is 171. I have a family history of heart disease (heart attack/hypertension) and stroke. I'm a 36 year old, 135 lb, 5'7" active female who eats out frequently. What can I do to lower my cholesterol?

Dr. Matthai responds:
Exercise regularly, maintain a good weight, and eat sensibly (see americanheart.org for references). If you drink alcohol, drink 1 drink or less a day (2 per day for men). Don't ignore other cardiovascular risk factors - don't smoke, have your blood pressure checked annually, and, if you have diabetes, be sure your sugars are well-controlled.

Bart asks:
Is a blood pressure of 123/90 considered to be risky? I've lowered it from 145/90+ in the last two months.

Dr. Matthai responds:
A disatolic blood pressure (the lower number) of 90 is considered "borderline hypertension". It does not need treatment, but continued lifestyle and dietary modifications are recommended. The exception to this statement is that in diabetic patients, a diastolic BP of 90 is considered high and would merit drug therapy if not controlled with non-drug therapy.

Anthony asks:
Can you tell me if the 64 slice cat scanner will check the lungs for disease without using contrast dye?

Dr. Matthai responds:
Thank you for your question. We are currently only answering questions related to heart disease. You will need to ask a radiologist about the utility of this CT scanner for lung exams.

If you have any questions or would like to make an appointment with a Penn doctor, please contact 1-800-789-PENN (7366) or request an appointment online.

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