April 17, 2008
The New York Times

Answers to Questions About Heart Disease

By DR. ELIZABETH NABEL

Dr. Elizabeth Nabel, a practicing cardiologist and researcher studying the genesis of plaque in coronary arteries, became director of the National Heart, Lung and Blood Institute on Feb. 1, 2005. Her answers to readers’ questions about heart disease appear below.

Editor's Note: New answers were added on April 26, 2007

Q. What questions should I ask of my hospital emergency facility about their capacity to provide full service to a person undergoing a heart attack? - Paul Taxey

Here are some suggested questions to ask:

a. What treatments are available for heart attack at your facility (e.g., "clot busting" drugs, coronary or balloon angioplasty, coronary bypass surgery if needed)? (It is ideal to have all of these available.)

b. If coronary angioplasty is available, for how many hours is the catheterization lab staffed by an interventional cardiologist who is a hospital staff member and for what days of the week? (Ideally it would be available 24/7 or at least have someone on-call 24/7)

c. What percentage of patients treated with a clot-busting drug are treated within 30 minutes or less? What percentage of coronary or balloon angioplasty patients are treated within 90 minutes or less?

d. If angioplasty or coronary bypass surgery is not available, are transfer agreements in place along with a transport system to ensure timely treatment elsewhere? Where is the patient transported and who determines that?

e. What diagnostic tests are available to check for a heart attack or acute coronary syndrome in the emergency department?

f. How many patients with chest pain and how many with heart attack are treated at your facility each year?

g. How many diagnostic catheterizations (angiography), angioplasties, emergency angioplasties for heart attack, and coronary bypass operations are done at your facility each year?

Q. Thanks for taking our questions. I occasionally have symptoms of heartburn and/or one or another type of reflux, which seem to mimic those ascribed to heart attacks. (Once, while on vacation, I did go to the local ER, resulting primarily in nearly a year’s worth of insurance hassles.) These symptoms don't seem to occur frequently enough to warrant daily medication. Knowing how symptoms can vary and that a good diagnosis may be as much great art as great science, do you have a suggestion for those of us who have learned that what would appear to be an MI is almost certainly not? - C. Ferullo

Thank you for your question. A pain or burning sensation in the chest could be indicative of a heart attack, or less life-threatening conditions such as heartburn. Anytime you experience new or unusual pains or other feelings in your chest, it's important to seek medical attention. You obviously did the right thing to go see a doctor when you experienced problems.

The symptoms associated with a heart attack and heartburn have some differences, although often it is difficult to distinguish them.

Typically, a heart attack feels like your chest is being squeezed or crushed. Some people describe the feeling as an elephant sitting on their chest. The pain often extends to the shoulder, back, throat, jaw, and arms. Most patients experience lightheadedness and have trouble catching their breath; some also have cold sweats and nausea. Exertion, exercise, or other activity usually makes the pain worse in contrast to heartburn, a condition in which rest makes the symptoms worse. Not all heart attacks have a sudden onset. In fact, most people diagnosed with a heart attack have had symptoms for a while, beginning with mild pain or discomfort. In some cases, the discomfort comes and goes for a while.

If you have severe, crushing chest pain that lasts for more than a few minutes, or other symptoms of a heart attack, call 911 and get immediate medical help. Do not be alone or isolate yourself from other people and do not drive yourself to the hospital.

Heartburn does not actually involve your heart. The condition gets its name because the symptoms associated with it typically are located in the chest. Heartburn is caused by small amounts of digestive acid escaping from the stomach and moving toward the throat. This acid irritates the esophagus, and produces the common “burning” feeling described by people who experience it. Other symptoms include a feeling that small amounts of food or liquid are coming back up. This is often accompanied by a bitter or acidy taste in the mouth.

For most people, heartburn typically occurs after eating a meal. Large meals, and certain foods, are more likely to trigger the burning sensation. Although the foods that cause heartburn are different for different people, generally foods that are high in fat, spicy or highly acidic (such as orange juice) are identified as being the culprits. Drinking alcohol or caffeine-rich beverages (coffee, soda, tea) and using tobacco products also can cause heartburn for many people. Laying down makes the pain worse for most people.

The use of a liquid or tablet antacid relieves the symptoms of heartburn for many people. If your heartburn persists, gets worse over time, does not fully go away after taking medicines, causes vomiting, appetite loss, or tarry, black stools, see a physician.

Heart disease is the leading killer in this country. If you have high blood pressure, high blood cholesterol level, or high blood sugar level, be sure to treat and control them. If you are a smoker, quit it. Be physically active and fit. Your doctor can help you manage these conditions that could lead to a heart attack, but you are the one who should put your own health as a top priority.

Recognize the symptoms

The list below shows some basic differences between symptoms of a heart attack and heartburn. It is not intended to take the place of a visit to, or discussion with, a qualified health professional. Furthermore, not all heart attacks occur with the same symptoms, and not all of the symptoms below have to be present.

Heart Attack

Chest discomfort. Most heart attacks involve discomfort in the center of the chest that lasts for more than a few minutes, or goes away and comes back. The discomfort can feel like uncomfortable pressure, squeezing, fullness, or pain.

Discomfort in other areas of the upper body. Can include pain or discomfort in one or both arms, the back, neck, jaw, or stomach.
Shortness of breath. Often comes along with chest discomfort. But it also can occur before chest discomfort.
Other symptoms. May include breaking out in a cold sweat, nausea, or light-headedness.

Heartburn

Burning, irritation below breastbone
Pain usually does not move to back, shoulders, neck, arms, and jaw
Usually occurs after meals
Gets worse when lying down
Antacids will often make pain go away
Rarely causes shortness of breath, lightheadedness, dizziness, or cold sweats

Q. Today's article was great and answered many of my questions. I am on blood pressure meds and have mild cardiomyopathy. My question is this: please describe what happens when I call an ambulance thinking I am having a heart attack and I’m mistaken. Do I pay for the ambulance? Will I get unnecessary procedures? What tests are done to determine my status? - D. Skibo

It is advisable to review your health insurance plan and ask questions to clarify ambulance coverage before you need it. If you are a Medicare beneficiary, Medicare will cover medically necessary transportation by ambulance when other means of transportation are contraindicated and you are transported to the nearest appropriate facility to receive care.

Hopefully, you will only get those procedures that the physician feels will help clarify what is wrong. The specific tests done depend on many factors, such as the nature of the symptoms, a patient's age, prior medical problems/history, other "risk factors" (e.g., high cholesterol, high blood pressure, smoking, family history, diabetes). Usually an electrocardiogram (ECG) will be done. Cardiac "marker" blood tests may be done once, and often will be checked "serially" over a period of 8-12 hours to see if the levels are rising. At some institutions, other screening tests are available from the emergency department, including cardiac nuclear imaging, coronary CT angiogram, cardiac MRI, and a significant number of hospitals have a chest pain/observation service with specific protocols to evaluate and treat patients with chest pain. If the results are suspicious, or indicate that a heart attack is occurring, you may be sent directly to the catheterization lab for a heart catheterization.

Q. I understand about half of all heart attacks happen in folks with "normal" cholesterol. Is there a way to assess overall risk — the probability of having a heart attack — based on one’s score on each of the risk factors? - C. Robertson

A cholesterol level that is "normal" in the US can still be high enough to contribute to hardening of the arteries and lead to a heart attack. This is because average cholesterol levels in this country are quite high. Although a cholesterol level of less than 200 mg/dL is called "desirable" in the US because more than half the population has a cholesterol above this level, the optimal cholesterol level is considerably below 150 mg/dL. Where average cholesterol levels are truly low, such as some of the countries in Asia, heart disease is relatively rare. In addition, your cholesterol level is one of a constellation of risk factors that promotes risk for heart attack. For these reasons, some people with “normal” cholesterol levels (less than 200 mg/dL) can suffer a heart attack. For example, at age 50 and with a cholesterol level that is below 200 mg/dL, the 40-year risk for developing a heart attack is about 40% for a man and about 20 percent for a woman. For people with cholesterol levels that are high (240 mg/dL or above), the long-term risk of a heart attack jumps to about 60 percent in men and 40% in women.

Tools for assessing 10 year risk of a major coronary event (heart attack or death from heart disease) have been developed as part of the National Cholesterol Education Program’s Adult Treatment Panel III (ATP III) guidelines. Those risk assessment tools, which take into account the risk not only from cholesterol but also from other risk factors such as age, smoking, and high blood pressure, are easy to use, both for physicians and the lay public, and can be accessed at:
http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm

Q. Having gotten atherosclerosis, does it ever get better in any way or is the disease merely one to be treated? What is the prognosis with this disease? Will the treatment merely delay the end result awhile, and if so, how long? - John Cook

Atherosclerosis affects the arterial wall and, once present, will not disappear. The most important question is not whether atherosclerosis is present but how it behaves. Some people have heart attacks and die with very little atherosclerosis, while others have widespread disease that never even causes symptoms. The key is treatment that prevents heart attacks and damage to the pumping function of the heart. Damage occurs most often when the lining covering places in the artery where there is atherosclerosis (plaques) breaks down. The blood is exposed to what is inside the plaque and forms clots, blocking the blood supply to a portion of the heart, which results in the death of heart muscle cells. These cells do not grow back and, if the patient survives, are replaced by scar tissue. This sort of event can also cause a bad heart rhythm that can result in sudden death.

Fortunately, there are treatments that reduce the risk of heart muscle damage and fatal bad heart rhythms in individuals with atherosclerosis. These include drugs, like aspirin, that make it harder for the blood to clot, drugs that lower cholesterol, and families of drugs, beta-blockers and ACE inhibitors, that work by a variety of mechanisms to help the heart live with blockages without incurring additional damage. The best results are obtained when patients work with their doctor to achieve a medication regimen and practice a healthy lifestyle that controls blood pressure, maintains low blood cholesterol and appropriate blood sugar levels, and avoids smoking. Eating nutritiously, getting regular physical activity, and maintaining a healthy weight are also key heart-healthy habits.

What happens to a patient with atherosclerosis depends on the behavior of the disease, not just its presence. With proper treatment, including attention to risk factors – cholesterol level, blood pressure, diabetes, not smoking, not being overweight or obese, and physical inactivity - many patients with atherosclerosis will never have heart attacks, fatal heart rhythms, or weak pumping function.

Q. Current heart imaging detects calcium in the heart. Exactly what is the relationship between calcium and heart disease? - Elliot Herskowitz

Specks of calcium are often deposited in the walls of the coronary artery where atherosclerosis or “hardening of the arteries” has developed. Because calcium shows up easily on X-rays, and particularly on CT scans, it can be seen on certain types of CT scans of the chest. The amount of calcium seen correlates with the amount of atherosclerosis in the coronary arteries and is related to the likelihood of developing a heart attack in the future. However, it does not necessarily correlate with stenosis, or narrowing of the heart arteries, which indicates specific areas of the heart that might be involved in a heart attack. These scans are not used in people who have already had a heart attack.

It is important to understand that calcium intake does not influence calcium build-up in arteries, so people should not limit their intake of calcium because of this concern. It is also important for people to know that the benefit of screening using CT scans to detect calcium in the coronary arteries is not known. Heart scans may be offered in some mall screenings. However, getting tested in a medical setting also allows your doctor to interpret the results for you and evaluate your need for further testing. Regardless of whether a person has calcium deposits in their coronary arteries or not, the same basic messages about preventing heart disease apply.

Q. What dietary changes can you make to help lower your cholesterol? Please be specific. For example, how many eggs can you eat a day? - Tracy Wallace

To lower your cholesterol through dietary changes, limit the amount of saturated fat, trans fat, and cholesterol that you consume. More specifically, try making the following changes to your diet:

- Select lean meats, remove skin from poultry before cooking, and eat nonfat or low-fat dairy products.

- Increase consumption of fish, fruits, vegetables, beans, and whole grains.

- When possible use liquid vegetables oils that are high in unsaturated fats, like canola, corn, and olive oils. Choose soft tub margarines that are low in both saturated and trans fats.

- Choose low fat preparations such as baking, steaming, roasting, stewing, or boiling instead of frying.

- Aim for no more than four egg yolks per week, including egg yolks in baked goods and processed foods.

More detailed tips on eating a heart-healthy diet are available online here: http://nhlbisupport.com/chd1/Tipsheets/resourceroom.htm

Q. Asking about prevention, what’s the role of physical exercise? Is there a better one to decrease the risk of a heart attack (walking everyday, workout, running, etc.) - Mario Nobrega (Brazil)

Regular physical exercise is very important for good health. Thirty minutes daily of moderate-intensity physical activity will improve overall health, help prevent heart attacks, and improve heart health after a heart attack. Moderate-intensity activity includes brisk walking - like walking when you’re in a hurry to catch a bus or if you’re late for an appointment. But the activity doesn’t need to be walking - it can be gardening, mowing the lawn, dancing, biking, swimming - any physical activity that you enjoy or need to do. It can be different each day and whatever can be fit into one’s lifestyle will work. The 30 minutes doesn’t have to be done all at once; it can be done 10-minutes at a time. Some experts say “the best exercise is the one that you will do.” Most people can begin or increase their physical activity without consulting a doctor. However, some people should get medical advice before starting or significantly increasing physical activity, including those who currently have a heart condition, have developed chest pain within the last month, or have had a heart attack; feel extremely breathless after mild exertion; or tend to easily lose their balance or become dizzy.

Q. There is much in the literature about the longer-term risks of taking aspirin, the highest of which appear to be gastrointestinal bleeding and hemorrhagic strokes. How do you square that against your recommendation to take a daily aspirin? - Ron

Current treatment guidelines stress the importance of controlling risk factors in patients at higher risk for heart attack and death related to coronary heart disease.. Aspirin is an antiplatelet medicine that can help to keep arteries open and the drug has an established role in preventing blood clots in those who have heart disease and lowering the risk of a heart attack or stroke for those who have already had one. Administration of low-dose aspirin for the prevention of heart attack in patients with heart disease is now considered routine practice. Aspirin is also given to people who arrive at the hospital with a suspected heart attack or stroke. Use of aspirin in those who have never had a heart attack or stroke should be weighed in light of a person’s cardiovascular risk profile, the side effects of the drug, and its potential benefit in reducing risk of a first heart attack. Aspirin is a powerful drug with many side effects, and can mix dangerously with other drugs. Taking a daily aspirin to prevent heart attack should be done only with your doctor’s specific advice and guidance. As with any other therapeutic approaches, both the physician and patient need to consider the evidence, benefits, and risks including ultimately patient preferences. If your doctor advises you to take aspirin, it should be an adjunct, not an alternative, to managing other cardiovascular risk factors – smoking, high blood pressure, high blood cholesterol, overweight, physical inactivity, and diabetes.

Q. Given the high probability [25 percent] of the risk of heart attack among women ages 40 and older, why do you think women have greater fear of breast cancer with its lower age-specific risk rates than heart disease? What public health education programs would you suggest to alert women to the comparative higher risk of heart disease than breast cancer without increasing more anxiety? Given the latest studies preventive measures such as exercise, weight control and healthy diet are important for overall health maintenance. - Ruby T Senie

Many women think that heart disease is "a man’s disease." Focus group research conducted by the National Heart, Lung and Blood Institute showed that most women know the risk factors for heart disease. However, women don’t take their risk for heart disease personally—they don’t think heart disease is something that could happen to them. Women often think that heart disease can be cured with surgery or medications and they don’t understand the devastating consequences of the disease: death, disability, and impaired quality of life. There is no yearly equivalent to a mammogram that checks women’s hearts. This makes it hard for women to have heart disease on their radar screens. In addition, studies have shown that health care providers generally don’t talk to women about their risk for heart disease. Heart disease risk factor assessment is not often a part of a woman’s routine health care. Finally, breast cancer advocates have been raising awareness about early detection for the disease for 25 years. We are still in the infancy of raising awareness about women’s heart disease.

I encourage all women to become familiar with The Heart Truth, the National Heart, Lung, and Blood Institute’s national campaign for women about heart disease. Launched in 2002, the campaign targets women ages 40 to 60, the time when a woman’s risk of heart disease begins to increase. However, it’s never too early—or too late—to take action to prevent and control risk factors since heart disease develops over time and can start at a young age—even in the teen years. The campaign message is paired with an arresting visual—the Red Dress—designed to warn women that heart disease is their #1 killer. The Heart Truth created and introduced the Red Dress as the national symbol for women and heart disease awareness in 2002 to deliver an urgent wake-up call to American women. The Red Dress reminds women of the need to protect their heart health, and inspires them to take action.

The Heart Truth urges women to talk with their doctor about their personal risk for heart disease and take steps to lower their risk. The campaign has many materials that are easy to use for setting and reaching your own heart health goals as well as for spreading the word about heart disease in a wide variety of settings, such as health care facilities, businesses, non-profit organizations, government agencies, or community groups. These materials include The Heart Truth Web pages, The Healthy Heart Handbook for Women, a speaker’s kit, a variety of fact sheets and brochures, and the Red Dress Pin. In addition, the National Heart, Lung, and Blood Institute has many other resources to help both women and men lower their risk for heart disease including Keep the Beat Heart Healthy Recipes, and the Institute’s new Your Guide to Better Health publications, science-based consumer education booklets that include step-by-step action plans for establishing and maintaining heart and sleep health.

Q. What are the best current ways to detect clogged arteries before a heart attack happens? - Jack Gibson

There are many ways to detect clogged arteries before a heart attack happens. Medically, the best ways to detect clogged arteries involve either stress tests or directly taking pictures of the coronary arteries.

A stress test involves either exercise or medications that challenge the heart. If there are clogged arteries, the stress causes brief imbalances in the heart muscle that can be detected during the test. Doctors use either the electrocardiogram (ECG) or imaging tests to detect these imbalances. Echocardiograms (ultrasound) and nuclear medicine tests are most commonly used. Magnetic resonance imaging (MRI) and positron emission tomography (PET) scans can also take high-quality pictures capable of detecting abnormalities in the heart due to clogged arteries before a heart attack has occurred.

Taking pictures of the coronary arteries usually involves an invasive coronary angiogram (also called cardiac catheterization) performed as a minor surgical procedure. This is called invasive angiography because it is accomplished by introducing thin plastic tubes called catheters through the blood vessels close to the heart. By injecting small amounts of X-ray contrast medicines into the coronary arteries, doctors can take the most detailed pictures of partially or completely blocked arteries. Recent developments in X-ray computer assisted tomography (CAT scan or CT scan) can now take pictures of the coronary arteries noninvasively. The CT scan only requires medicines to slow the heart rate and a simple injection of X-ray contrast medicines in a vein.

The best way to detect blockages in the coronary arteries depends on many factors that apply to individual patients. There are other general considerations including availability, local experience, and cost that need to be considered. In general, the imaging tests are more sensitive than the ECG but more costly. For research conducted at the National Heart, Lung and Blood Institute, we use a large number of nuclear medicine stress tests and MRI stress tests to detect blocked arteries.

Most doctors do not use invasive angiography unless the likelihood of coronary artery blockages is extremely high or if one of the stress tests is abnormal. The CT scan is changing the balance in how coronary blockages are detected and is now considered a reasonable alternative to stress tests in some patients.

The obese patient provides additional challenges to all medical tests used to detect narrowing of the coronary arteries. Many obese patients cannot exercise sufficiently for the ECG to be useful and all of the imaging tests provide lower quality pictures in very large patients. A sestamibi nuclear stress test is probably the best test that is widely available. At the National Heart, Lung, and Blood Institute, we are studying patients with an MRI scanner capable of imaging patients up to 440 pounds with promising results.