9/2/14

Why Can Imminent Heart Attack Cause Shoulder Pain?

Cause of shoulder pain may be impending heart attack.
Ever wonder how an impending or in-progress heart attack can cause, of all things, shoulder pain? There are cases of people (my mother being one) who experienced recurring bouts of shoulder pain, thinking it was a rotator cuff problem or arthritis or even bursitis.

But some of these cases are not caused by a problem in the shoulder joint; they are caused by a problem with the heart: a warning that a heart attack is right around the corner. I consulted with cardiologist Dr. Ronald Scheib, MD, Medical Director at Pritikin Longevity Center & Spa in Miami.

Dr. Scheib explains, "Most commonly, pain of a heart attack occurs in the center of the chest, but may radiate down the left arm into the shoulders, into the throat or jaw, and at times only occur across the shoulders or the upper back. Referred pain is the description of pains caused by internal organs, which are felt at some area distal on the surface. That area can be, in the case of heart attacks, jaw, shoulders, chest, upper abdomen, and occasionally in very unusual places, possibly related to an individual's prior illnesses."

Does this mean that if you suddenly start developing shoulder pain, that you should rush to the ER to get your heart evaluated? Pain in this joint is extremely common. As a certified personal trainer, I know this for a fact.

A person must review the entire picture, however, when it comes to shoulder pain. Do you recall straining the joint recently? Is the pain just like the pain you had when you first strained the shoulder lifting something above your head?

What are your risk factors for heart attack? A lean person who exercises, doesn't smoke, sleeps well, limits processed food, has low blood pressure and a normal lipid profile, need not fear an impending heart attack as much as, say, a woman over the age of 50 with excess abdominal fat, who never exercises and has very high triglycerides. This described my mother.

I was alarmed at her triglyceride levels and actually said to her, "You could be dead from a heart attack in six months!" She went to bed that night worried sick over my comment, but made no changes in her diet after that point, and still refused to exercise.

Recurring episodes of shoulder pain were a common complaint from her, and I never made the connection between these "pain attacks" in her shoulder and the condition of her heart, especially since she had had a total of three surgeries on her rotator cuff.

As a fitness expert, it's never surprising to me that a senior-aged person, who has never exercised her shoulders, eventually develops problems in this versatile but vulnerable joint.

About four months after I made my comment, I took my mother to the ER for chest pains. The day after that she underwent quintuple bypass surgery. The surgeon had told me that a "massive" heart attack was imminent, possibly within a week, without the surgery.

Once my mother was recovered from the surgery, she reported that the bouts of shoulder pain had disappeared. This sounds like more than a coincidence. It has always been the same kind of pain, same general location of the joint. Dr. Scheib explains, "On occasion, the location may vary based on the specific coronary artery, but in general it tends to be repetitive in the same location."

Why Can Imminent Heart Attack Cause Nausea & Vomiting

Vomiting and nausea can be a sign that a heart attack is imminent. I'm not talking about an actual heart attack in progress, but vomiting and nausea as a warning sign that a heart attack is in the very near future.
I consulted with Dr. Michael Fiocco, Chief of Open Heart Surgery at Union Memorial Hospital in Baltimore, Maryland, one of the nation's top 50 heart hospitals.

Dr. Fiocco explains, "Nausea and vomiting are very complex interactions between the brain and the stomach. The scientific thinking behind myocardial ischemia or infarction associated with nausea relates to the vagus nerve."

Myocardial ischemia simply means depletion of oxygen to heart muscle. Infarction means tissue death. The vagus nerve "arises from the brain and travels through the neck, along the esophagus, and gives off nerve fibers to the heart before continuing into the abdomen where it supplies nerves to the stomach," continues Dr. Fiocco.

"So there is the stomach-heart-brain connection. Why people get nausea prior to a heart attack may be similar to why people get arm, neck or jaw pain rather than chest pain. A lot of overlapping circuits may cause the brain to misread the signals, leading to nausea or left arm pain rather than chest pain."

Of course, being overcome with nausea, as a result of conditions ripe for a heart attack, can then lead to vomiting. Vomiting was a tip-off to me that my mother might be having a heart attack, or that a heart attack was looming around the corner for her.

She awakened one morning reporting difficulty breathing. I brushed it off as a panic attack, since trouble breathing is one of a panic attack's classic symptoms. She had a history of panic attacks, along with "labored breathing."

That particular morning seemed like just another panic episode, especially since I knew that about five or six weeks prior, she had quit taking Effexor altogether. Effexor helps suppress panic and anxiety attacks.

I was staying with my parents because my father, just days prior, had back surgery. About a half hour later I heard my mother call out to my father, "Quick, bring it over here!" Intuition told me she was referring to a waste can and that she was about to vomit.

I raced upstairs to their bedroom and saw my mother upchucking into a small waste can. Much of it was dry-heaving, actually, but yellow gunk definitely was coming out.

The bells went off because my mother had never vomited during a panic attack or after one subsided. Since when did she vomit? I knew that an imminent heart attack can cause vomiting. She just had a bout of breathing difficulty bad enough to make her weep. Something told me to get her to the emergency room for a cardiac evaluation.

Two evenings later she was undergoing quintuple bypass surgery - just in time, said the cardiothoracic surgeon; though my mother had not suffered a heart attack, he said that a massive heart attack could have occurred any moment due to severe coronary artery blockage.

In my mother's case, the vomiting was a sign that something was wrong with her heart, I believe. Nothing she ate the day prior could explain the upchucking. She had not been in any pain, either (pain can cause nausea). So in hindsight, it's logical to conclude that my mother's pending heart attack caused the vomiting (and difficulty breathing).

Does this mean that next time you feel nauseous or vomit, you should fear imminent heart attack? Of course not. But take notice of any other symptoms like shortness of breath, trouble breathing, chest pain or tightness, sweating, and pain in the jaw, arm, neck or back that can't be explained by other benign factors ... and take into consideration if you have risk factors for a heart attack like smoking, excess weight, lack of exercise, diabetes and a junk food diet.

Low Blood Pressure Symptoms, Causes, Dangers, How to Raise

Too low blood pressure can be serious or harmless; hypotension can cause mild to serious problems. Low blood pressure has many causes including heart conditions, nutritional deficiencies and medications. The cut-off for normal BP readings and high readings is 140 over 90. 
So when does blood pressure get too low?

"The first question to address is if the blood pressure is really too low," says Teresa Caulin-Glaser, MD, Executive Director at McConnell Heart Health Center/Riverside Methodist Hospital in Columbus, Ohio, and Clinical Associate Professor in the Department of Internal Medicine/Division of Cardiology at Ohio State University.

"In general, if patients are asymptomatic and the systolic ("top number") blood pressure is approximately 90mmHg or better, you do not need to treat. However, if the person is developing symptoms such as dizziness, fatigue, and/or passing out, there needs to be a full history and medical evaluation."

If you believe your blood pressure is too low, review any medications you've been taking. Explains Dr. Caulin-Glaser: "If the evaluation determines there are no medical problems and/or medications such as diuretics, ace-inhibitors, beta blockers, calcium channel blockers causing low blood pressure and symptoms, then there are non-pharmacologic treatments that can be implemented."

Other symptoms of low blood pressure: lack of concentration, blurred vision, fatigue, nausea, thirst, cold and clammy skin, and rapid shallow breathing. A big danger of low blood pressure is organ damage due to insufficient blood supply to them. 

As you can see, low blood pressure can present with an assortment of symptoms, while high BP (also known as hypertension), which is a major risk factor for stroke, offers up no symptoms, which is why hypertension is nicknamed "the silent killer."

So how do you raise low blood pressure that's creating symptoms? Dr. Caulin-Glaser says, "Some simple options for treatment are drinking fluids to decrease the risk of dehydration, increasing the amount of sodium in the diet, and decreasing alcohol intake. There are medications such as fludrocortisone that can be considered in the treatment of symptomatic low blood pressure, but this would be under the direction of a physician after a full medical evaluation."

Other causes of low blood pressure: vitamin B12 deficiency causing anemia (result of a vegan diet, since this vitamin is found in animal-derived foods); pregnancy; low blood sugar; severe infection. The low blood pressure that's caused by infections of the urinary tract, lungs or abdomen, can be fatal. (High BP can be life-threatening, but there are natural ways to bring high BP down to normal levels.)

Typically whenever one sees a doctor for any reason, a BP reading is taken. It's perfectly okay to request that your BP be taken at the conclusion of the doctor visit, because by then, much of your anxiety will be diminished. Otherwise, your readings may be uncharacteristically high if taken at the beginning of the visit, due to anxiety; this is known as white-coat syndrome.

Low blood pressure has many causes, but if there are no accompanying symptoms, then you need not worry about having BP that is below normal.

Life Expectancy in Elderly After Coronary Bypass Surgery

The life expectancy (long-term survival) of elderly people after coronary bypass surgery is receiving increasing attention, since the population of advanced age people is ever-growing. This means more and more elderly people, including octogenarians, are having coronary bypass surgery (a.k.a. CABG).
I consulted with Dr. Michael Fiocco, Chief of Open Heart Surgery at Union Memorial Hospital, one of the nation's top 50 heart hospitals. "Life expectancy after CABG is difficult to determine because so many factors are involved," he explains, and this applies to the elderly population. "Mortality within 30 days of CABG is less than 2 percent, and that is including some very sick patients undergoing CABG."

When an elderly person has coronary bypass surgery, other factors still remain an important part of the life-expectancy equation: In other words, the CABG and post-op may have gone without a hitch, but an elderly individual inherently is at risk for other serious conditions such as cancer, Alzheimer's disease and dying in a car accident that otherwise would result in only moderate injuries for someone much younger.

Thus, the question of "What is the life expectancy for the very old patient after coronary bypass surgery" almost doesn't seem to make a lot of sense -- again, this is about life expectancy, rather than a more immediate survival rate.

Once the elderly patient is out of the woods in terms of possible post-op complications (e.g., internal bleeding, pneumonia, infection, stroke), the life expectancy is extremely variable, but of course, it's within the confines of how much longer any 80-year-old (CABG or not) is expected to live.

For elective coronary bypass surgery (meaning, it's not performed on an emergency basis), the mortality rate falls below 1 percent 30 days post-op.

Dr. Fiocco explains, "Life expectancy beyond that is determined by so many factors it is hard to quantify. Was the patient 50 years old when the surgery was performed or 80? Did the patient stop smoking? change their diet? exercise regularly? control blood sugar levels after CABG or did they continue in the ways that led them to surgery in the first place?"

Though the patient's new "plumbing" consists of cleaner veins harvested from either the leg or arm, to replace the clogged, plaque-caked coronary arteries, don't assume that the elderly patient can get away with bad health habits, with the idea that it will take another 20 years for the grafted blood vessels to develop severe blockage, so why bother being health-conscious if the patient would have to live to 100 or older by the time another bypass surgery is needed?

Well, here's the deal: The grafted vessels are veins from the legs and arms; they were not designed by nature to endure the blood pressure forces that coronary arteries are! They aren't as durable, and if the patient takes excellent care of his body, the replacement vessels should last 10-15 years. So imagine the potential disaster if the elderly CABG patient fails to quit smoking or lose weight, and/or won't stick to an exercise program and eat healthfully!

The plaque-buildup rate in the grafted veins that came from the leg or arm is much faster than the plaque-buildup rate in coronary arteries.

Dr. Fiocco adds, "A large study did show average life expectancy after CABG was approximately 17 years, but this was from the 1980s and it is likely even higher now. Again, what determines anyone's life expectancy after CABG is what got you there and what you change going forward."

Some elderly coronary artery bypass patients will continue living on a food pyramid whose bottom tier is comprised of foods that damage the heart, and who will continue to avoid exercise and maintain other habits hazardous to the heart.

And likewise, other elderly coronary bypass patients will completely overhaul their lifestyle habits: quit smoking, lose weight, avoid trans fats and saturated fats, take up aerobic and strength exercise, practice better stress management and be compliant with appropriate medications. It's intuitive who will have the much longer life expectancy.

How Long Does it Takes for A Diet to Lower Bad Cholesterol?

To find out how long it would take a heart-healthy diet to lower LDL or bad cholesterol, I interviewed Dr. Richard Kelley, MD, a bariatric physician, author of "The Fitness Response" and "The Three-Hour Appetite." A bariatric physician specializes in obesity treatment and fat loss.

"Any blood work that is obtained on an individual can be viewed as a snapshot in time," says Dr. Kelley. "Consequently, specific lab values, regardless of what they are, can often vary from hour to hour and day to day.

Though lipid and cholesterol testing is usually done at intervals of several weeks between panels, depending on what a given practitioner is interested in looking at, I have had the opportunity on many occasions to observe repeated studies of LDL and other components of the lipid panel, within days of a patient changing to a cleaner form of diet, and have been able to observe improvement in LDL within a matter of days."

LDL, the "bad cholesterol," stands for low density lipoprotein, and you don't want this number getting above 150. It's possible to have a very low triglyceride number (the lower, the better) at the same time that the LDL is on the high side. Don't underestimate the power of a better diet in lowering bad cholesterol, regardless of your age.

Dr. Kelley continues, "We know, without a doubt, that in patients who have no predisposition to elevated triglyceride or LDL cholesterol, these values can be elevated or show improvement, sometimes within a matter of two to three days, to varying degree, with simple changes which improve one's diet."

As one loses weight from an improved diet, it's not surprising for medical professionals to observe marked improvements in cholesterol and lipid values, even normalization of these values, adds Dr. Kelley.

If you're worried about an LDL value that's increased or is already over 150, the best diet to lower bad cholesterol is one that severely restricts processed foods.

Avoiding buying food in the center of the supermarket right off the bat will go a long way at lowering bad cholesterol; foods that are in the centers of grocery stores tend to be the most processed (with the exception of the bakery department which is typically in the perimeter).

To lower LDL bad cholesterol through diet, avoid the store's bakery department, increase consumption of raw vegetables, eat more fruit, eliminate beef from grain fed sources (eat only wild game or grass fed beef), eat salmon/tuna/scallops/halibut several times a week, eliminate fast food products, and eat nuts and seeds.

High Calcium Score but Normal Stress: Test Should You Worry?

So your calcium scan score is high, but your stress test was negative and showed no diminished blood flow through your coronary arteries. Are you off the hook?

I consulted with Dr. Larry Santora, MD, cardiologist, medical director of cardiac CT, and medical director of the Vascular and Wellness Center, Saint Joseph Hospital, Orange, CA., and author of the book, "OC Cure for Heart Disease." I wondered about the implications of a high coronary calcium score and a normal-result stress test (either chemical or exercise) in the same patient.

After all, a stress test measures blood flow through the coronary arteries. A stress test does not show plaque buildup, including the "soft" type of plaque, which is the type that has the potential to rupture and cause a heart attack.

For such a patient with both findings (high calcium score but normal stress test), Dr. Santora explains: "Never assume all is well. Look it as a great opportunity to change your life and make things better. 

You cannot ignore the calcium or plaque, but now that you have identified it and you know what your heart is like, there is no longer any question that you have coronary disease. You can take charge; you can now control it."

There is a third variable, besides the high calcium score and the normal stress test: absence of symptoms (e.g., chest pain, difficulty breathing). Suppose a patient has a really high calcium score, but the stress test is normal, and he or she is not experiencing any symptoms and even "feels fine." Dr. Santora says that such a patient does "not need an invasive angiogram or stent or bypass surgery."

In fact, the general consensus is that if the stress test is normal, the patient has no symptoms, but the calcium score is high, it is not warranted to have an elective bypass surgery or even stent procedure.

But does this come to terms with the phenomenon that sometimes, the first symptom of severe heart disease is a heart attack? Is it smarter to wait to see what might happen? Should this patient undergo the invasive catheter angiogram which carries the risk of heart attack and stroke? After all, a high calcium score means something is wrong.

Perhaps a CT angiogram is in order, to get a clearer picture of the arteries and see how much soft plaque (the dangerous plaque) there is. Only problem is that if the calcium score is high enough, this will contraindicate a CT angiogram; the presence of all that calcium will obscure the imaging.

So what should the patient do? Dr. Santora says, "You need to make lifestyle changes and be on a combination of cholesterol medications (even if cholesterol is normal) to prevent the plaque from progressing, or worse, suddenly rupturing and causing a heart attack. The calcium score (think of it as a plaque score) tells us: how low to get your cholesterol and the types of cholesterol medications, and how frequently to get a stress test; for instance, if you have zero calcium you do not even need a stress test if you have no symptoms."

Just when you thought the plan sounds simple, keep in mind that taking a cholesterol-lowering drug to prevent plaque progression doesn't guarantee this result. For example, a person has a calcium score of 450, which is considered high risk for heart attack, or severe heart disease.

He or she goes on a statin drug to help prevent plaque progression. Over the next 10 years, the patient doesn't bother with follow-up calcium scans, but finally has a second calcium scan 10 years later: The score is nearly 1200. Yet all this time he'd been on the cholesterol-lowering drug.

What happened? These drugs do not guarantee prevention of further plaque buildup, especially if the patient has a junk food diet.

The coronary calcium score is the "total amount of plaque in all the arteries and gives a very good prediction of heart attack risk over 10 yrs. (that is, long-term risk), and chance of short-term risk, that is, what is the chance of having an abnormal stress test due to the artery being significantly narrowed," says Dr. Santora.

And then there is the coronary calcium percentile, which "reflects how aggressive your atherosclerosis is. If you have a percentile of 75%, that means you have more plaque than 75% of others of similar sex and the same age. You need aggressive treatment."

Aggressive treatment starts with setting goals. Dr. Santora says that the HDL cholesterol should be greater than 50; and the LDL cholesterol should be less than 70. The LDL in this case should be less than 70 "if you have a high score ( >300 or percentile >70%)," adds Dr. Santora. "However, if the score is zero, then an LDL cholesterol <160, near 130, is fine. A big difference in your cholesterol based on calcium score."

Diet should consist of a moderate amount of carbohydrate (about half of total calories), and slow-absorbing carbs at that; 25% protein and 25% "healthy fats" like olive oil and safflower oil.

The patient is prescribed a statin. Dr. Santora adds, "If the percentile is >75%, we order an advanced lipid panel to look for LDL size, HDL subtypes, and Lp(a); these abnormalities respond to niacin which, when added to a statin, provides the best chance in preventing plaque progression."

Does Normal Blood Pressure Mean You Don't Have Heart Disease?

Can you have heart disease yet still have normal blood pressure?
Yes, yes, yes. In fact, you can have life-threatening heart disease - extensive coronary artery blockage -- and still have consistently normal blood pressure readings.

I consulted with Dr. Michael Fiocco, Chief of Open Heart Surgery at Union Memorial Hospital in Baltimore, Maryland, one of the nation's top 50 heart hospitals. "High blood pressure (Htn) causes the occlusions (blockages), but occluded arteries do not cause Htn," says Dr. Fiocco. "Blood pressure can be normal even in patients with severe coronary artery disease because they still may have diabetes, elevated cholesterol, genetic abnormalities, and/or a smoking history, all of which can cause coronary artery disease. Htn is a common cause, and often a contributing factor amongst these others, but sometimes the blood pressure is normal."

In fact, you can have 97 percent blockage in your coronary arteries - an emergency situation - yet have perfectly normal blood pressure. This was the case with my mother. She faithfully took her blood pressure almost daily with a home device, and the always-normal blood pressure readings gave her peace of mind when it came to her heart health.

However, little did she know that her coronary arteries were becoming dangerously blocked. In fact, the catheter angiogram report said "sub-optimal occlusion." The heart surgeon told me this meant about 97 percent blockage. He took one look at the angiogram and decided that my mother needed quintuple bypass surgery ASAP; about two hours later she was wheeled into the operating room.

Yet right up to that point, her blood pressure was in the normal range. So if you have good blood pressure readings, don't be fooled and think you can't possibly have heart disease.

Though high blood pressure (hypertension) is one of many risk factors for heart disease, the absence of hypertension does not in any way get you off the hook from America's #1 killer of both men and women.

Other factors can cause heart disease even if you have normal blood pressure: 
1) Lack of structured exercise, 2) Poor diet such as high sodium, 3) Smoking, 4) Overweight/BMI greater than 25, 5) Chronic emotional stress, 6) Insomnia/sleep deprivation/sleep apnea, 7) Sleep exceeding 9 hours/day including naps, 8) Family history, 9) Diabetes/prediabetes, 10) Poor cholesterol profile. Do you have any of these risk factors for heart disease?

So don't be deceived by normal or low blood pressure readings. The risks of heart disease are numerous, and the absence of one of these risk factors in no way means you can't possibly have dangerous blockage in your coronary arteries.

Coronary Bypass Surgery Post-op Complications that Seem Scary

If a loved-one has coronary bypass surgery, you as the visitor may become aware of a lot of interesting things that occur post-op. Some of these will be considered "complications," and they may seem very alarming, when in fact, they're not as bad as they seem.

The first complication that my mother had, while in the ICU after coronary bypass surgery, was "A-fib." This is atrial fibrillation. You, as the visitor, will become aware of this when the heart rate monitor starts giving off a warning beep. The monitor should be silent otherwise, so the sudden beeping will get your attention and be scary.

Staff will rush into the room and may awaken the patient if the patient is asleep during this event. The first time my mother went A-fib, staff cleared her gown from her chest and attached monitors. This indeed looks frightening to the onlooking family member.

You may hear a nurse contacting a doctor by phone, describing the event and asking for directives.
You may see an EKG report being churned out of a computer and staff examining it.

And you will see, on the heart rate monitor, the heart rate continuously bouncing all over the place in the high range. You will hear the word "A-fib" more than once being spoken. You may also remember that the heart surgeon told you, pre-op, that one possible complication of coronary bypass surgery is atrial fibrillation.

And you will remember, as I did, that the surgeon said it could easily be controlled, and that the more serious complication is ventricular fibrillation (V-fib).

Nevertheless, witnessing my mother's first A-fib was nerve racking. So was the second one. But each subsequent one was less alarming; you will notice that staff reacts casually, and that no doctors are present: a good sign. You'll learn that drugs control the situation, and that sometimes, the patient will spontaneously "pop out" of A-fib and the heart rate will return to normal.

If you witness several A-fibs, you'll become very sensitized to the heart rate monitor's distinctive beeping. So that when you hear the monitors of other patients start beeping, you may have a conditioned response of anxiety and your own racing heart. Over time you'll become desensitized to the beeping.

Coronary bypass surgery may affect kidney function. A kidney doctor was called in to see my mother and explained she had mild kidney failure, and that they'd be just "watching it for now."

Coronary bypass surgery causes the kidneys to be shorted of blood, and hence, they may "fail." The "failure" may only be mild, and is measured by a daily creatinine test. The doctor will be on top of this to see if the number gets above a certain value.

In the meantime, treatment will include fluid restriction. The worst case scenario impression that I got was that if the kidneys didn't "bounce back," my mother would need dialysis. No mention of possible kidney transplant was ever made.

The coronary bypass patient (or other type of surgery) may be delirious or confused even several days out from surgery; a definite alteration in normal mental status. My mother thought I was her other daughter, for instance. Assume that off-the-wall comments, oddball questions and bizarre observations are the results of lingering anesthesia and/or the effects of powerful painkillers.

The coronary bypass patient may complain of agonizing pain, particularly in the chest. Don't assume the patient is having a heart attack. Instead, remind yourself that the patient was very recently cut open in the chest. Complaints of severe pain may also center around the belly - where tubes had been inserted.

The coronary bypass patient will have significant visible swelling and bruising, especially in the legs if veins were harvested from the legs for the coronary artery grafting. This isn't pretty, but it's normal.

The coronary bypass patient will have fluid in the lungs; this is normal and is called pulmonary edema. Fluid in the lining of the lungs, called pleural effusion, is also normal. Drugs called diuretics treat this post-op condition.

Coronary bypass surgery is very frightening, but extremely lifesaving. Enough visits to the coronary bypass patient and you'll become acquainted with different kinds of beeping sounds that hospital equipment makes. You may then develop a conditioned response of anxiety every time you hear things in daily life beeping, like your car when the seatbelt isn't put on.

9/1/14

Can Stress Test Miss Severely Blocked Coronary Arteries?

If your stress test was normal, does this mean you can't possibly have severely blocked coronary arteries? I consulted with Dr. Larry Santora, MD, cardiologist, medical director of cardiac CT, and medical director of the Vascular and Wellness Center, Saint Joseph Hospital, Orange, CA, and author of "OC Cure for Heart Disease."
"A stress echocardiogram or a nuclear stress test are each about 90 percent accurate in correctly identifying a severe coronary blockage ( i.e., at least one of the coronary arteries has a narrowing greater than 70 percent). However about 10 percent of the time it will miss the blockage, and the stress test will be 'falsely negative'," explains Dr. Santora.

"These false negative stress tests are more common in women . It is more common to have a false negative if the blockage is in the circumflex artery which, on the back side of the heart, is more likely to be missed since it tends to be a smaller artery, and rarely, even if all three arteries are equally blocked (called ‘balanced ischemia')."

This got me wondering, then, about someone with a high coronary calcium score who has a normal stress test. He may worry he might be in that 10 percent in which the test results are not accurate.

Dr. Santora explains, "There is no test in medicine that is 100 percent accurate; not a mammogram or colonoscopy, etc. If you have a high coronary calcium score and you are asymptomatic (no chest pain), and your stress test is normal, the probability of a severe blockage (meaning a narrowing more than 70 percent in one of the major coronaries) at that time is very, very low.

"If the patient had symptoms, even if the stress test is normal, then the chance of a severe blockage is perhaps 25 percent, and another test is needed, maybe a CT angiogram."

The CTA will reveal amount of soft plaque versus hard (stabilized) plaque. Soft plaque can rupture and block an artery. "Anyway, it is the CAC that tells you if you need an aggressive approach to lower cholesterol and other risk factors," says Dr. Santora.

So if you had a high coronary calcium score and normal stress test, this does not excuse you from taking aggressive measures to improve the state of your coronary arteries. " The high coronary calcium score tells you that you must take aggressive risk reduction measures," continues Dr. Santora.

"You cannot put full faith in a stress test. But some 90 percent blockages in the more distal ends (towards the end of the artery) can be treated without surgery or a stent, with risk modification. In these there can be plaque stabilization or some reversal, and the development of collaterals; that is, new arteries grow from a normal coronary over to the artery that is blocked. This can be promoted by exercise and external counterpulsation."

If one's coronary calcium score is deemed too high to allow a CTA image to be read (usually over 800), then Dr. Santora says, "You can still feel comfortable if you have no symptoms and a normal stress test, with vigorous risk modification."

Modification would mean exercise, change in diet (e.g., severe restriction of refined carbohydrates and sugars, saturated and trans fats ), supplements and perhaps a pharmaceutical agent. If the stress test is not clear, and you have a very high CAC, "then do an invasive cardiac catheterization and coronary angiogram ," says Dr. Santora.

Can Coronary Soft Plaque Buildup Be Reversed with Diet?

Can diet reverse soft plaque buildup in the coronary arteries? I took this question to Dr. Larry Santora, MD, cardiologist, medical director of cardiac CT, and medical director of the Vascular and Wellness Center, Saint Joseph Hospital, Orange, CA, and author of "OC Cure for Heart Disease."

As a certified personal trainer and nutrition/weight loss expert, I'm always acutely aware of how much impact that diet has on human health. Dr. Santora explains, "Soft plaque can certainly be reversed, and so can some of the smaller areas of calcium."

There are two kinds of plaque buildup in coronary arteries: soft and hard. The soft plaque is the dangerous kind that can rupture and cause a heart attack (a fragment of this soft plaque breaks away from its base and travels through the coronary artery, blocking blood flow)

When someone has harmful levels of soft plaque, the goal is to stabilize this soft plaque. Dr. Santora explains, "This means the plaque becomes more adherent to the inner vessel wall, and the cap on the plaque becomes stable and less likely to rupture. This occurs as soon as diet and medications are instituted, even before the cholesterol levels change."

The diet for reversing coronary soft plaque is not a temporary diet; it is a permanent diet. Dr. Santora says, " If you eat well 90 percent of the time, that is a reasonable way to go. So as a rule of thumb, all high glycemic foods like white bread, white rice, can be eaten, but only 10 percent of the time."

The glycemic value of a food is a numerical measurement of how quickly its carbohydrates (sugars) are absorbed into the bloodstream after being eaten. White sugars and simple, processed carbohydrates like white flour impose a terrible burden on the coronary arteries if eaten too often.

This means the occasional Boston cream pie is permissible, but knock out the white rice if you eat rice often; eat wild, basmati or brown rice instead. Do you eat cereal every morning or most mornings? It should be whole grain with no sugars added, and this includes high fructose corn syrup.

White flour is a ubiquitous food ingredient. Read ingredients lists. "Sugar" also shows up everywhere, including salad dressings and soups. Every "little bit" adds up. What about whole eggs? Will whole eggs disrupt one's dietary plan of reversing soft plaque?

"As far as eggs go, they are now considered health foods; eating one or two per day, if not fried, are healthy since the cholesterol in eggs is not converted to cholesterol in the bloodstream," says Dr. Santora.

What about going by the USDA Food Pyramid? The food pyramid is ambiguous in that it names only food groups. At the bottom of the food pyramid are breads, for instance. This does not mean make a staple out of a highly processed bread product like Wonder bread, bagels, English muffins or pancakes.

In fact, just about all commercial breads are full of synthetic chemicals; many contain high glycemic carbohydrates like molasses, corn syrup and even sugar. Even breads at so-called health food stores may contain these heart-unhealthy items. Read ingredients lists.

The food pyramid doesn't differentiate between carbohydrate sources and does not show information on "bad" fats. A pancake mix labeled as "whole wheat" may still contain partially hydrogenated oil, which is a very bad fat: a trans fat.

So as far as the food pyramid, Dr. Santora explains, "The food pyramid is fine as long as the carbs are the good low glycemic type, and the fats are the good fats like monosaturated fats, and no trans fats. Simply avoid cookies, crackers and chips."

In order for diet to halt soft plaque progression, or even reverse soft plaque levels, you must not adopt an "a little bit won't hurt" mindset. A "little bit" (of a bad thing) can indeed hurt, because "a little bit" often morphs over time to a lot of "little bits." Remember the 90 percent rule.

Can Coronary Calcium Score Be Lowered?

You may have been led to believe that coronary calcium score cannot be lowered; that the coronary calcium score progression can only be slowed down, or at best, halted. But according to a cardiologist whom I consulted with for this article, you can, indeed, lower your calcium score.

I consulted with Dr. Larry Santora, MD, cardiologist, medical director of cardiac CT, and medical director of the Vascular and Wellness Center, Saint Joseph Hospital, Orange, CA, and author of "OC Cure for Heart Disease."

Dr. Santora says, "Yes you can reverse the plaque." If this is to be done, it is through commitment to a "clean" diet, exercising daily, a statin drug, and certain supplements. Sounds simple, right? Well, it's not as straightforward as you may think.

The statin part of lowering calcium score is as simple as taking it as prescribed. Same with the supplements that are known to lower calcium score and benefit heart health.

The confusion is with the diet and exercise part. I'm a certified personal trainer, and nutrition expert. I can't begin to tell you how many people I've encountered who truly believed they had a "healthy diet," but just the opposite was true.

A perfect example of this is my mother. She was floored upon being told she needed emergency quintuple bypass surgery. "How could this have happened to me?" She kept asking. "I've always ate a health diet '" I've been on the Mediterranean diet! I've always been active!"

My mother did not have a coronary calcium score test; she had a catheter angiogram. I can assume that had she had a calcium score test, the result would have been a very high number.

Are you one who thinks you're on the Mediterranean diet because you cook your white rice with olive oil, or because you dip potato chips in yogurt, or because you eat a daily salad with dressing that contains sugar? Is your idea of cardiorespiratory exercise doing housework and walking about at Walmart?

The calcium score can be lowered, but not without pinpointed changes in diet and exercise habits. Think whole foods. Not foods that come in a box, can or bag. Exceptions are all-natural whole grain foods, or the actual grains, that are sold in plastic bags.

Go very light on red meat and eat only grass-fed beef; grain-fed beef contains a lot of "bad" fats. Replace chicken from frozen dinners with whole chicken. Eat a lot of wild-caught fish. Don't even look at processed meats. Try to eliminate foods with white flour, high fructose corn syrup and sugar.

Avoid partially hydrogenated vegetable oils. Eat as many raw vegetables as possible, and have fruit every few hours. You can indulge in pizza, waffles, white bread, donuts and candy '" but only occasionally.

Daily exercise means using weight machines, dumbbells, tension tubing and cardio equipment, or attending fitness classes, hiking, jogging, or swimming laps. A lengthy visit to Costco does not replace your exercise session for that day.

Supplements that will help lower calcium score (in combination with the other lifestyle changes just mentioned) are niacin (vitamin B3) and vitamin D3, along with magnesium citrate, turmeric, green tea, garlic, fish oil, and plant sterols. Though there is some controversy over whether or not some of these supplements actually aid in lowering calcium score, there are plenty of studies showing that all of these supplements are very beneficial to heart health.

Dr. Santora says, "I had my first heart scan in 1999, and then every two years since, and have had a reversal of some plaque. But remember, you do not have to reverse the plaque; you just need to stabilize the plaque so that it does not rupture. Studies show that if the plaque does not progress more than >10 percent per year; the chance of a heart attack is low."

Can a Blood Test Tell If You Had Heart Attack

A simple blood test will tell if you had a heart attack.

The blood test is for an enzymatic protein called troponin. The troponin blood test for heart attack is highly sensitive and is considered the gold standard for determining damage to cardiac muscle.

If you go into an emergency room complaining of current or recent chest pain, the doctor will order a blood draw to check your troponin levels. Damaged cardiac tissue (the heart is a muscle) will leak this protein into the bloodstream.

This very sensitive test is used to determine if a patient had a heart attack, as well as determine extent of cardiac tissue damage. However, an elevated troponin level alone should not be used to outright diagnose heart attack, according to labtestsonline.org.

An issue of Circulation (2002;106:2871-2872) states: "... the American Heart Association/American College of Cardiology(AHA/ACC) Guidelines and the European Society of Cardiology (ESC) Task Force Report on acute coronary syndromes without ST elevation have attributed troponin measurements a central role in the diagnostic work-up and therapeutic decision making."

The marvel of this blood test is that it can detect a heart attack that occurred more than a day previous, since troponin levels remain elevated in the blood for that long. For just how long does troponin remain elevated following a heart attack? For one to two weeks.

If you present with chest pain or a complaint of recent chest pain, a nurse in the ER will promptly take your blood sample, and the results may be back within an hour or sometimes two hours, depending on the hospital and patient load. Some hospitals can have the lab results back in 30 minutes.

However, two or three of these blood tests are typically taken, to see if there is any trend towards elevation of the levels. Troponin takes a while to elevate if you've had a heart attack, so the second blood draw will be taken six hours later, and then another six hours after that, depending on the results of the first two blood tests. If the first two results were normal, there won't be a third blood draw.

Interestingly, a person who's just had a heart attack can actually have a normal troponin concentration. Nevertheless, the troponin blood test is still considered the gold standard for determining the presence of heart attack, even though this protein can leak into the bloodstream as a result of non-heart attack related issues, such as cardiac procedures, cardiac inflammation, renal failure, pulmonary embolism (blood clot in lung) and septic shock.

Sources:
http://www.labtestsonline.org/understanding/analytes/troponin/test.html

Angiogram vs. CT Angiography for Diagnosing Heart Disease

Is it best to have an angiogram or a ct angiography (cat scan) of your heart's arteries?
You've heard of the angiogram (which is invasive), but are you aware of a less-invasive procedure called CT angiography to obtain images of blocked arteries in your heart?

The CT angiography also goes by the name computed tomography angiography (CTA), and it's not as expensive as the invasive angiogram, the latter requiring catheterization (tubes) inserted into your body beginning at the groin and threaded through the blood vessels leading into your heart.

Angiography carries the same risks as major surgery, including blood clots, cardiac arrest and infection. A CT angiograph, however, does not pose these risks, and according to a study done at Thomas Jefferson University, the CT angiography is a good alternative for people who had a stress test indicating coronary artery disease, but also have below a 50 percent chance of having significant blockage.

"Patients with positive stress test results but no heart-related symptoms, as well as patients with a positive stress test with atypical chest pain often receive referrals for cardiac catheterization for the evaluation of CAD," says Ethan J. Halpern, MD, professor, Dept. of Radiology at Jefferson Medical College, and lead author of the study. 

But for these particular patients, says Dr. Halpern, who is the director for Cardiac CT at TJU Hospital, the CTA is an "alternative, non-invasive diagnostic imaging test that can be used to effectively triage these patients."

But does the CAT scan have any risks? Yes. The radiation exposure from any CAT scan will slightly increase the patient's risk of cancer.

The amount of radiation received from one CAT exam is the equivalent of about the same amount of "background" radiation a person receives over a time period of eight months to three years. Background radiation comes from naturally occurring radioactive materials. CAT scans are not recommended for pregnant women.

Though a life-threatening allergic reaction to the contrast dye is rare, less serious complications can occur, such as nausea, flushing, and itching. Kidney damage can also result. People with the following conditions may not qualify for a CT angiography: kidney problems, diabetes, a pre-existing allergy to contrast dye, and a weight of over 300 pounds (some X-ray tables do not support this load).

This all sounds scary, but here are possible complications of the angiogram (cardiac catheterization), but note that they are rare: heart attack, stroke, injury to the catheterized artery, injury to the heart, excessive bleeding, blood clots, kidney damage, and allergic reaction to the dye. X-ray exposure should also be considered.

The biggest risk of all, however, is having extensive blockage in your arteries (coronary artery disease), and delaying getting an accurate diagnosis; a fatal heart attack may occur during the delay. The TJU study report is in American Journal of Roentgenology (May 2010).

Sources:
http://www.radiologyinfo.org/en/info.cfm?pg=bodyct#part_nine

Two Supplements May Reverse Plaque in Coronary Arteries

Two supplements may actually reverse buildup of plaque in coronary arteries. This news comes from The Los Angeles Biomedical Research Institute. There is controversy over whether or not natural supplements can reverse coronary plaque buildup (a disease called atherosclerosis), which is strongly correlated to heart attack risk.

So the researchers studied a group of people who, when compared to the general population, have a two- to four-fold greater risk of heart attack. This group was firefighters, and for the study, they took daily supplements of coenzyme Q10 (coQ10) and aged garlic extract (AGE).

Another group of firefighters did not take these supplements, so that a comparison could be made. An important feature of this study was that these two supplements were investigated in combination.

Nobody in the study was on statins. At the beginning of the study, all subjects had their calcium score taken (a numerical value of measurable plaque buildup). The supplement group took 120 mg and 1,200 mg a day of coQ10 and AGE, respectively. The control group took a sugar pill, but nobody knew which group they were in, and neither did the researchers.

The calcium scores of both groups, at the beginning, did not differ that much. At the end of one year (during which the supplement group took their daily doses), another calcium score test was given. The supplement group had about half the rate of coronary arterial plaque progression as did the placebo group, and this includes an adjustment for typical risk factors for plaque buildup.

So why did the researchers choose the AGE-coQ10 duo? Many studies have already demonstrated garlic's effectiveness at slowing plaque progression. However, garlic may deplete the body's natural levels of coQ10. This potent antioxidant needs to be replenished, and hence, the duo.

The researchers stress that the earlier in the game that you take supplements to fight coronary plaque buildup, the better the result. This means that the supplements are most effective during early atherosclerosis, as opposed to advanced.

"For at-risk populations, taking this very cost-effective, easy step may slow down the progress or even prevent many serious complications of atherosclerotic heart disease further down the line," says Vahid Nabavi Larijani, M.D., research fellow at LABRI, and the study's co-investigator. Because garlic is a blood thinner, people at moderate risk for coronary artery disease should consult with their physician should they decide to take this herb; it can negatively interact with pharmaceutical blood thinners.

Lengthen Life Span After TIA (Mini Stroke) with Easy Steps

A TIA (transient ischemic attack) is linked to shorter life span, but specific steps will increase one’s life span.

New research says that a mini stroke (aka TIA or transient ischemic attack) can shorten a person's life span - by up to 20 percent over a nine-year period.

A TIA in and of itself does not shorten life span. Rather, it is an indicator or marker of things about the patient that can shorten life span.

"People experiencing a TIA won't die from it, but they will have a high risk of early stroke and also an increased risk of future problems that may reduce life expectancy," states Melina Gattellari, Ph.D. She is senior lecturer at the School of Public Health and Community Medicine, The University of New South Wales, Sydney and Ingham Institute, Liverpool, Australia.

Dr. Gattellari recommends that doctors very closely help TIA patients manage their lifestyle for many years after the mini stroke. She urges mini stroke patients to quit smoking, manage their weight, exercise daily and eat healthy.

And therein lies the problem, because only one of these recommendations is straightforward and not open to misinterpretation: that of quitting smoking.

But just what does "exercise daily" mean? I'm a certified personal trainer. Many people, including those who have suffered a transient ischemic attack, believe they "exercise daily" or get "plenty of exercise."

My mother has never been diagnosed with a TIA, but she did undergo quintuple bypass surgery. She told her doctors she had always gotten plenty of exercise.

If you've had a TIA (heart disease is a huge risk factor), ask yourself if the many shopping trips you do should count as structured cardio and weight-bearing exercise; or if mere housework counts as bone-building, muscle-strengthening, coronary plaque-fighting exercise.

A transient ischemic attack can result from a plaque fragment breaking off and traveling to the brain.

"Regular exercise" is that which does not include housework or "all the walking" you did at the store or on the job. "All the walking" my mother does at the store is a very slow walk, frequently interrupted by pausing to examine merchandise. This hardly compares to a nonstop, brisk, arm-pumping walk for 30 minutes.

High blood pressure is a risk factor for mini stroke. Strength training and aerobic exercise lower blood pressure. The TIA patient needs to work out hard enough to produce a training effect. Going through the motions is not enough.

My father has had what I believe were two transient ischemic attacks. The first TIA was never diagnosed, but what else could have caused his sudden dizziness and the feeling that one side of his body was "heavy" and "wants to pull to the right"?

The second suspected mini stroke consisted of sudden onset double vision. In the belated visit to the doctor, the doctor said he believed it was a TIA; an MRI more than two weeks later was negative, but a delayed MRI can't always detect a mini stroke!

My father has been weight training for years - but - I recently discovered he hasn't been doing much more than going through the motions! This really makes a difference!

"Regular exercise" means making the effort very challenging. At the end of a weight set, you should feel as though you worked hard. Not necessarily a beaten-up-and-battered hard, but at a minimum, a very challenging kind of hard.

If you've had a mini stroke and believe you eat healthy, read the ingredients of your foods. Avoid anything that says "hydrogenated" in the ingredients, regardless of what the front of the package says!

The FDA allows food companies to get away with labeling the front package with "Zero Trans Fats," even though the product contains trans fats (disguised by the term "hydrogenated").

Learn the names of synthetic food additives, then stop eating products containing them, along with foods containing artificial flavors, dyes and added sugars. It's difficult to avoid added sugars (they are ubiquitous), but it's easier than you think to avoid foods with synthetic chemicals and trans fats. Healthy eating means focusing mostly on plant-derived foods with minimal processing.

At the conclusion (nine-year mark) of Dr. Gattellari's study, the survival rate of TIA patients came to 20 percent lower than expected. She says that "certainly, the risks faced by TIA patients go well beyond their early stroke risk."
As for maintaining a "healthy weight," a transient ischemic attack patient should have his body composition measured by a personal trainer, as this reveals percentage of body fat.

Is it Safe to Exercise After a TIA (Transient Ischemic Attack)?

It's hazardous to exercise after an untreated transient ischemic attack...

If you've had a TIA, you may be wondering if it's safe to exercise.

I'm a certified personal trainer, but consulted with a cardiologist to find out just how dangerous it is to exercise after a TIA. I've known that a TIA (transient ischemic attack) is actually a "mini stroke," or to put it another way, a temporary stroke, and that high blood pressure is a major risk factor for stroke.

And of course, I've known that exercise raises blood pressure. Simply adding two plus two spells potential catastrophe if a person who just had a TIA ("just" could mean weeks ago) goes out and exercises.

"I would say exercise (aerobic or strength training) is unsafe for anyone who has experienced symptoms consistent with a TIA before formal evaluation by a health care professional," says John M. Kennedy, M.D., medical director of preventative cardiology and wellness at Marina del Rey Hospital, and author of the new book, "THE 15-MINUTE HEART CURE: The Natural Way to Release Stress And Heal Your Heart In Just Minutes A Day."

Though a TIA, in and of itself, doesn't cause permanent damage, it is a very serious issue because it signals a possible impending stroke. A TIA involves a blood clot in the brain that temporarily prevents oxygenated blood from nourishing the part of the brain that the blocked vessel supplies.

Having a transient ischemic attack means that the blood vessels in your brain have a propensity to develop blood clots. The next blood clot could end up staying there (a stroke) rather than dissolving (a TIA). It is a health hazard to exercise after having a TIA.

If you believe you've had a TIA, do not exercise, as this will raise blood pressure. Instead, get a full medical evaluation to find out if you had a transient ischemic attack. Symptoms of a transient ischemic attack are identical to those of a stroke and come on suddenly:

- Tingling, weakness, numbness or heaviness on one side of the body
- Visual impairment: blurriness or darkness; sudden loss of vision in one eye
- Slurred speech or difficulty speaking
- Paralysis on one side of the body
- Alarming headache
- Cognitive impairment; confusion
- Dizziness, loss of balance, difficulty walking
- Suddenly falling with no warning

Symptoms may resolve within minutes to up to 24 hours. You may feel perfectly fine after symptoms of a transient ischemic attack resolve. DO NOT LET THIS FOOL YOU ! By definition, a TIA is transient, so of course you'll feel fine afterwards! 

But the next blood clot could be a stroke, which can kill you or leave you permanently crippled.

If you believe you had a TIA, don't exercise before you find out if you indeed had a transient ischemic attack. Dr. Kennedy explains: "TIAs are signs of a threatening 'full blown' stroke. Two possible causes include hypertension (high blood pressure) and certain arrhythmias such as atrial fibrillation (AF), both of which can be triggered by or exacerbated by exercise. After a stroke, data suggests in order to achieve the best quality of life, and greatest functional capacity, walking is the best type of exercise."

If you suspect you had TIA, don't delay; head straight to the ER for tests, and do not exercise or perform any challenging physical activity like carrying out heavy garbage before heading out to the ER.