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1 Q and A

Worsening Chest Pains

Forum: The Heart Forum
Topic: Angina

From	To	Post
Jaz 10/12/2000	.	HI there, For several years now I have been experiencing fast/skipped heart beats and occasional pain(every few weeks)which seem to come from the heart, lasting only a few seconds. Three weeks ago I started to feel an aching\burning sensation in the left hand side of my chest. It usually starts in the morning and lasts the whole day, though it does fade a little during the evening. The pain lasts between a few minute to over an hour. It has got a little worse recently. It doesn't seem to get any worse when I walk or run, in fact that and eating seems to help the pain somewhat! I do also get a little light headed sometimes. I have been to seen my doctor and have had a 24 hour EKG doe which has shown nothing, also the hospital were unable to find anything wrong. Q. How quickly can heart probelms manifest themselves?
CCF CARDIO MD - CRC 10/12/2000	Jaz	Dear Jaz, In response to your question about how quickly heart problems can manifest themselves the answer is very rapidly. The onset of an MI or even sudden death can occur without warning. The real question is whether your symptoms are due to your heart or something else. There are many potential causes of chest pain. The one that doctors worry about the most is cardiac because it has the potential to be life-threatening. Once this is ruled out the work-up can proceed at a more leisurely pace. Amongst the cardiac causes of chest pain are: ischemia (due to blockages - including both stable and unstable angina and acute heart attack and coronary artery spasm), pericarditis (inflammation of the sack around the heart), myocarditis (inflammation of the heart), cardiomyopathy (heart failure) and rarer causes such as coronary artery dissection, acute rupture of the heart and valves and infections of the pericardium. Gastrointestinal causes of chest pain include reflux (acid from the stomach washing back into the esophagus), gallstones, esophageal spasm, esophageal rupture, varicose veins of the esophagus, strictures of the esophagus, tumors of the esophagus and other less common GI problems. Pulmonary (lung) causes include pneumonia, pulmonary embolus, pneumothorax, pleuritis and bleb rupture. Other potential causes are aortic dissection, back and spine problems and musculoskeletal (muscle strain, rib fracture, etc.). Psychological causes of chest pain are common and include panic attacks, anxiety, stress and mental duress. As you can see the list of potential causes in long and may take a little bit of time to determine the precise cause. A good Internal Medicine doctor should be able to work through the potential causes of your symptoms. I hope you find this information useful. Information provided in the heart forum is for general purposes only. Only your physician can provide specific diagnoses and therapies.

Heart Health Center

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Alcohol May Lower Heart Attack Risk

Moderate Drinking May Lower Risk for Men With High Blood Pressure

By Daniel J. DeNoon
WebMD Medical News

Reviewed by Louise Chang, MD

Jan. 2, 2007 -- A drink or two a day isn't bad for men with high blood pressure -- and may lower their risk of heart attack, according to new research.

The finding comes from a long-term study of nearly 12,000 male doctors, dentists, and pharmacists with high blood pressure.

Many doctors now warn men with high blood pressure not to drink alcohol, which is known to raise blood pressure.

That recommendation may have to change, say researchers Joline W.J. Beulens, MSc, of the University Medical Center in Utrecht, Netherlands, and colleagues.

Every four years from 1986 to 2002, the men in the Dutch study filled out questionnaires about alcohol use, diet, and health.

Men who drank moderately -- one or two drinks per day -- had a lower risk of heart attack. However, their risk of heart disease and death from any cause was no lower than that of men who did not drink.

"Men with hypertension who drink moderately and safely may not need to change their drinking habits," Beulens and colleagues conclude.

In an editorial accompanying the study, National Cancer Institute researcher Anne C.M. Thiebaut, PhD, and colleagues warn doctors and patients to take the findings with a grain of salt.

Thiebaut and colleagues note that self-report surveys -- particularly those on nutrition -- are notoriously prone to reporting errors. That is, people who actually consume very little of something often overreport their consumption. And those who actually consume a great deal of something often underreport.

This is particularly true of surveys on alcohol use.

"The uncertainties surrounding measurement error should send a strong message to those who formulate recommendations about nutrition," Thiebaut and colleagues suggest. "The discretion of silence may be preferable to the valor of setting recommendations."

The Beulens study and the Thiebaut editorial appear in the January issue of Annals of Internal Medicine.

Heart Health Center

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Blood Test Predicts Heart Attack Risk

Protein Measurement Linked to Risk for Strokes, Heart Attack, and Heart Failure

By Salynn Boyles
WebMD Medical News

Reviewed by Louise Chang, MD

Jan. 9, 2007 -- A simple blood test may help doctors identify heart patients who are at high risk for having heart attacks, strokes, and heart failure.

The test, which measures blood levels of a protein called NT-proBNP, was found to be highly predictive of such cardiovascular events in a study involving almost 1,000 heart patients thought to have stable coronary heart disease.

Patients with the highest levels of the protein in their blood were eight times as likely as patients with the lowest levels to die or suffer a heart attack, stroke, or heart failure during the study. Even taking into account other risk factors such as sex, age, smoking, and cholesterol levels, there was still an increased rate of such problems.

Pinpointing Patients at Risk

NT-proBNP was found to independently predict cardiovascular risk, suggesting it can be a useful addition to tests already used in heart disease, like echocardiograms (a sonogram of the heart), stress tests, and other protein biomarkers.

The study is published in the Jan. 10 issue of The Journal of the American Medical Association.

"We have known that this marker was predictive, but the question has been, 'Does it really tell us anything that these other tests don't tell us?'" researcher Kirsten Bibbins-Domingo, MD, PhD, tells WebMD. "We found that it does, and the hope is that it can be used with these tests to help physicians pinpoint which patients have the highest risks."

The blood test is already used in hospital emergency departments to help ER doctors identify heart failure in patients who have shortness of breath and other symptoms of the disease. Heart failure occurs when the heart's ability to pump blood is weakened, which can result in a backup of fluid in the lungs and other areas.

Protein Levels vs. Heart Risk

It has not been clear if the test has value for predicting risk in asymptomatic heart patients thought to have stable heart disease.

In an effort to address this issue, Bibbins-Domingo and colleagues from the University of California, San Francisco and the San Francisco VA Medical Center assessed the association between plasma NT-proBNP levels and cardiovascular risk in 987 patients followed for an average of 3.7 years.

During this time, roughly a quarter of the patients either died or had a hospitalization from a nonfatal heart attack, stroke, or heart failure event.

The annual event rate among patients with the highest NT-proBNP levels at study entry was 19.6%, compared with just 2.6% among patients with the lowest levels.

There were four times as many heart attack cases reported among patients with the highest levels of the protein compared with those with the lowest, and four times as many strokes.

But the strongest association was seen for heart failure. Eighty cases of heart failure were reported among patients with the highest NT-proBNP levels, compared with just three cases among patients with the lowest levels.

"After adjusting for all other risk factors, it's clear that this marker is picking up something that we are otherwise unable to detect with standard tests such as echocardiography," says study researcher Mary Whooley, MD.

Value Unknown

While there is some suggestion that the test could prove useful for identifying heart risk in the general public, its most immediate use is for patients with established heart disease.

But even among these patients, its role in disease management is not yet clear, cardiologist Robert Bonow, MD, tells WebMD.

Bonow is chief of cardiology at Northwestern University Medical School and a former president of the American Heart Association.

"We aren't sure at this point what to do with this information once we have it," he says. "We can treat these patients [with elevated NT-proBNP] very aggressively, but we should be doing that anyway."

Bonow adds that while NT-proBNP may prove to be a useful test for asymptomatic patients with heart disease, "we don't really know this yet."

In an editorial accompanying the study, Marvin Konstam, MD, of Tufts University School of Medicine agreed that it remains to be seen if NT-proBNP will prove useful for the management of patients with heart disease.

Konstam tells WebMD that more study is needed to determine the value of such testing.

"The real home run will be when we identify a marker and an intervention to go along with it to lower risk," he says. "The best example of this is LDL, or bad, cholesterol. We not only know that LDL cholesterol is a predictor of heart risk, but we know that we can lower that risk with drugs."

Heart Health Center

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Test IDs Risk of Sudden Cardiac Death

Computer Technology Reveals Patients Who Can Benefit From Implanted Heart Defibrillators

By Salynn Boyles
WebMD Medical News

Reviewed by Louise Chang, MD

Jan. 5, 2007 -- As many as one-third of heart patients who get implanted heart defibrillators -- like the one Vice President Dick Cheney has -- might not benefit from them; a simple heart-rhythm test may help identify these patients, new research suggests.

The noninvasive test uses computer technology to gauge a person's risk for sudden cardiac death.

Researchers from the University of Michigan Cardiovascular Center, the VA Ann Arbor Healthcare System, and the Ohio Heart and Vascular Center in Cincinnati found that patients who performed well on the test had the same low risk of death whether they had implanted defibrillators or not.

Saving Health Care Costs

If the findings are confirmed, the test could save hundreds of millions of dollars annually in health care costs in the U.S. alone, researchers say.

But a heart specialist who spoke to WebMD says many important questions remain unanswered.

"Over the last 10 years or so we have evaluated a lot of tests and a lot of tests have failed," says Virginia Commonwealth University professor of cardiology Kenneth Ellenbogen, MD. "[The tests] looked promising in smaller studies, but in larger studies they missed a lot of patients who had cardiac arrest."

Sudden cardiac death due to electrical problems of the heart accounts for roughly 300,000 deaths a year in the U.S. People with certain heart conditions are at greater risk.

Sudden cardiac death is due to electrical problems in the heart; it is not a heart attackheart attack. Such conditions can include cardiomyopathycardiomyopathy (heart muscle disease) due to past heart attack, among other things.

How Implanted Defibrillators Work

Implanted cardioverter defibrillators (ICDs) are often recommended for these high-risk patients as a preventive measure. Like pacemakerspacemakers, ICDs are surgically implanted. But while pacemakers deliver mild, continuous electrical impulses to maintain a suitable heart rate and rhythm, defibrillators can deliver a bigger shock of electricity when they detect an abnormal heart rhythm that can lead to sudden cardiac arrest.

The devices work so well that the U.S. government recently expanded coverage for high-risk patients. It is now estimated that 50,000 MedicareMedicare recipients qualify for them annually, at a lifetime cost of roughly $90,000 per recipient.

The problem has been that the strategies for determining who will benefit from ICDs have been inadequate, University of Michigan researcher Paul S. Chan, MD, tells WebMD.

"There is no doubt that these devices are extremely effective for the right patient, but they are also very expensive and not everyone benefits," he says.

The MTWA Test

In their study involving 768 heart patients considered candidates for ICDs based on conventional testing, Chan and colleagues evaluated the usefulness of a test called microvolt T-wave alternans (MTWA) for predicting who would benefit from the device.

All of the patients had survived heart attacks and had permanent damage to the heart muscle as a result.

Roughly two-thirds had either positive or inconclusive MTWA test results. During up to three years of follow-up, these patients were 70% less likely to die from an abnormal heart rhythm if they had ICDs.

In the remaining one-third of patients with negative MTWA tests, no significant reduction in cardiac arrest-related deaths was seen among patients with the implanted defibrillators.

The study is published in the Jan. 2/9 issue of the Journal of the American College of Cardiology.

Less Impressive Findings

Ellenbogen acknowledges that the latest MTWA findings are impressive. But he points out that in another recent study the test did not perform as well.

In that trial, reported last November at the annual meeting of the American Heart Association (AHA), MTWA testing was compared with a more invasive and expensive screening method.

The best results were obtained when the two tests were used together.

"That study definitely did not show [MTWA] to be as useful as a single measure of risk as this trial did," says Ellenbogen, a spokesman for the AHA

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Lifestyle Vital to New Heart Diet

Learn about the benefits of leading a healthy lifestyle.

By Daniel J. DeNoon
WebMD Medical News

Reviewed by Robert J Bryg, MD

June 19, 2006 --The key to a healthy heart is lifestyle, not a strict diet, according to new guidelines from the American Heart Association.

About every five years the AHA updates its diet advice. This year, for the first time, the guidelines emphasize lifestyle as much as diet.

Tufts University researcher Alice Lichtenstein, DSc, chairs the AHA nutritionnutrition committee that wrote the new recommendations.

"We wanted to present recommendations that would be easily adopted by the general public," Lichtenstein tells WebMD. "There is a de-emphasis on numbers, and more on answering basic questions: What can I do? How do I do it? How do I make changes right now?"

The new guidelines don't lay down the law about how much to eat, what to eat, and when to eat. They instead focus on healthy diet and lifestyle patterns. And they offer practical ways for real people to make lifesaving changes, says WebMD's director of nutrition, Kathleen M. Zelman, MPH, RD.

"Eighty percent of heart diseaseheart disease is preventable with healthy lifestyle: good food, fitness, and normal weight," Zelman says. "Dietary patterns are what it's all about. The AHA says, 'This is the gold standard.' But you don't have to get there overnight. It is not about perfection -- it is about making progress toward the healthier lifestyle. And the payoff is huge."

The guidelines appear in the July 4 issue of the AHA journal Circulation.

In Balance: Food and Activity

Lichtenstein says it's all about balancing the food one takes in with the energy one puts out.

"If you have the best diet, but get no physical activity or if you smoke, it is going to impact your heart health," she says. "When one makes decisions about food choices and activity patterns, it is important to make sure they are balanced."

In a nutshell, the AHA says you can avoid heart diseaseheart disease if you:

Eat a healthy overall diet.
Balance calories consumed with calories burned.
Get at least 30 minutes of physical activity each day.
Eat lots of fruits and vegetables.
Choose whole-grain, high-fiber foods.
Eat fish -- especially oily fish such as salmon -- at least twice a week.
As much as you can, avoid saturated fats and trans fats.
Cut back on cholesterol by choosing lean meats and fat-free or low-fat dairy foods.
Cut back on beverages and foods with added sugars.
Cut back on salt added to food -- especially if you're middle aged or older, African-American, or have high blood pressurehigh blood pressure.
If you drink alcohol, drink in moderation.
Make healthy choices when dining in restaurants.

Don't let this list overwhelm you, Lichtenstein and Zelman say. The idea isn't to burn out after two weeks of strenuous effort, but to gradually adopt healthy habits for the rest of your life.

"We're talking about making small, incremental, permanent changes in your habits," Lichtenstein says. "This is the only way to make enough of a change, for a long enough time, to accrue benefits."

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Eat Your Veggies, Help Your Arteries

Vegetable-Rich Diet Tied to Less Artery-Clogging Plaque

By Miranda Hitti
WebMD Medical News

Reviewed by Louise Chang, MD

June 19, 2006 -- Scientists are serving up yet another reason to put vegetables on your plate: It might discourage plaque from accumulating in your arteries.

So says Michael Adams, DVM. He's a professor in Wake Forest University's pathology/comparative medicine department in Winston-Salem, N.C.

Adams and colleagues recently studied nearly 100 young male mice at high genetic risk for artery-clogging plaque. For four months, the researchers fed half of the mice a vegetable-free diet.

The other mice got the same number of calories, but 30% of those calories came from equal parts of freeze-dried corn, carrots, green beans, broccoli, and peas. Adams' team chose those vegetables because they're five of the most common vegetables in the U.S. diet, not counting potatoes.

Why not include potatoes? Because in the U.S., they're typically served drenched in fat from frying, the scientists note in The Journal of Nutrition's July issue.

Less Plaque

After four months, the scientists checked the mice's arteries. They found 38% less plaque in the arteries of mice that had eaten the vegetable-rich diet, compared with mice that had eaten no vegetables.

Mice fed the vegetable-rich diet also had modestly better cholesterol levels -- including a slight drop in LDL ("bad") cholesterol -- and had gained 7% less weight.

How do vegetables help tame plaque? That's still uncertain, write Adams and colleagues.

Adams' team checked the data to look for clues. They concluded that the differences in weight and cholesterol between the two groups of mice didn't totally account for the plaque gap.

But the researchers found another clue related to inflammation, which is associated with hardening of the arteries (atherosclerosis). Adams and colleagues found lower levels of an inflammatory marker in blood from the mice on the vegetable-rich diet, compared with those lacking vegetables.

The study was funded by the General Mills Company, which supplied the vegetables.

SOURCES: Adams, M. The Journal of Nutrition, July 2006; vol 136: pp 1886-1889. News release, Wake Forest University Baptist Medical Center.

The content below was selected by the WebMD Editorial staff and is solely under WebMD's editorial control.

Diabetes Medications & Diet: Synergistic Success

Reviewed By Brunilda Nazario, MD

By Jeanie Lerche Davis
WebMD Feature

It's a tricky balancing act using diabetes medications to keep blood sugar at just the right level.

You're coasting along, trying to "eat right," when suddenly you're confronted with a crisis -- sharing a very large pizza. It's so difficult turning away from pizza -- yet you face the inevitable blood sugar spike, with your diabetes drugs faltering under the carb load. If you're taking insulin, the mealtime dosage will need lots of attention.

There's also the weight gain issue: Too many calories pack on the pounds, which worsens blood sugar control.

It's serious business, keeping blood sugar and diabetes under control. There are too many health complications at stake to take it lightly. Over time, those blood sugar spikes take a toll on all your major organs and nerves throughout your body. It's nothing to take lightly. But good blood sugar control can prevent the worst complications of diabetes.

In recent years, new drugs that treat diabetes and various types of insulin have helped improve the management of diabetes and greatly improve blood sugar control. Some medication used to treat diabetes help drop weight and reduce blood cholesterol levels. But they can't do the work alone, diabetes experts say.

Lifestyle changes are essential -- a healthy diet, regular exercise, and weight loss -- in letting diabetes medications do their job, says David Nathan, MD, chief of the Diabetes Center at Massachusetts General Hospital and a professor of medicine at Harvard Medical School.

"If you have type 2 diabetes, your pancreas is still trying to release insulin," Nathan explains. "But if you have a rapid rise in blood sugar, it just can't keep up with the demand. With diabetes medicines, it's the same thing. They will work better if you don't challenge the pancreas -- if you don't have spikes in blood sugar."

Bottom line:

You've got to watch your diet.
Exercise regularly and maintain a normal weight.
Test blood sugar often as recommended by your doctor.
Follow your doctor's instructions when taking your diabetes medications.

There's no getting around it, if you want to live a good, long life.

Diabetes Diet Avoids Blood Sugar Spikes

A number of factors influence blood sugar levels after meals, but carbohydrates have the biggest impact, so carb counting is essential. You must learn to make wise food choices that won't cause blood sugar spikes -- yet indulge in an occasional pizza slice.

A dietitian or diabetes educator can help you line up a game plan for meals, says Roberta Anding, RD, a diabetes educator at Texas Children's Hospital in Houston. She is also a spokesperson for the American Dietetic Association.

After all, not all carbs are created equal. "A scoop of white rice is different from a scoop of brown rice," Anding tells WebMD. "The calories may be the same, but they act differently when digested."

Processed "white foods" -- white bread, white rice, cakes and cookies (made with white flour) -- are digested quickly, which causes sharp spikes in blood sugar. Even an apple -- highly nutritious and high in fiber in its natural form -- is done a disservice in processing. When an apple is made into applesauce or apple juice, it loses its fiber content.

"You see remarkable differences in the effect on blood sugar levels," Nathan explains. "The more processed the fruit, the faster the glucose level goes up -- and the higher it goes up. Getting more high-fiber carbohydrates in your diet will naturally slow the absorption rate, and will help the pancreas keep up with the insulin demand."

What are high-fiber carbohydrates? Everything your mother ever advised: vegetables, fruits, whole-grain breads, and cereals. Every colorful fruit and vegetable in your grocery's produce section -- broccoli, spinach, red bell peppers, fruits and berries of all types. Oatmeal is another great source of fiber!

Weight Gain vs. Diabetes Drugs

Weight gain poses its own problems for people with diabetes. The fight against weight gain has always been tough, as many older diabetes drugs may cause weight gain -- which further interferes with blood sugar control.

"The heavier you get, the more you're fighting a losing battle," Nathan tells WebMD. "If you're gaining weight, diabetes medications won't work as well, so you need more of the medicines -- which only makes your weight go up more."

Newer drugs like Byetta and Symlin have made weight control a bit easier. Both drugs stimulate the body's natural insulin-producing capability, plus patients may experience a decrease in appetite leading to weight loss.

Diabetes specialists typically prescribe these newer diabetes medications in combination with older diabetes drugs to get optimal blood sugar control. "It helps minimize the difficulties of dieting. ... People can restrict calories, exercise more, have more positive results in losing weight," says Anne Peters, MD, director of the clinical diabetes programs at the University of Southern California and author of the book Conquering Diabetes.

Lose the Weight, Take Less Diabetes Medication

Lifestyle is key to keeping weight off -- and to controlling diabetes in the long run. "There's no way around it, and it's hard work, but you have to address it. You don't have to get skinny, but you do have to lose weight," says Anding.

In fact, research shows that losing just 10% to 15% of body weight -- dropping 20 or 30 pounds, if you weigh 200 -- can have a marked improvement on diabetes control.

These lifestyle changes help preserve the body's insulin-producing function, explains Hermes Florez, MD, director of the Diabetes Prevention Program at the University of Miami Miller School of Medicine. "With weight loss, patients are able to nearly get off insulin. Some patients are able to come off insulin completely."

An NIH-funded clinical trial, the Diabetes Prevention Program, helped show the positive effects of healthy lifestyle changes. A significant number of patients in the study were able to reduce their diabetes risk with a healthy diet and regular exercise like brisk walking -- about 150 minutes a week.

In the early stages of diabetes, weight loss can also help reduce the dosage of diabetes medications you're taking, Peters tells WebMD. "I can't guarantee you will get completely off pills if you lose weight. But it's likely you will need less medicine. It depends on where you are in the disease process, because diabetes gets worse over the years."

Diabetes Diet and Insulin: Better Mealtime Control

Sticking with your diabetes diet makes it easier to calculate mealtime insulin. With new forms of insulin -- including small "pens" to give injections -- even taking your insulin is hassle-free. If you're out with friends, no one needs to know you're doing it.

Today's rapid-acting insulin can be given with a meal or immediately afterward. "You need to make sure you eat within 10 minutes of taking insulin. These insulins act very quickly, so if you don't eat right away you'll have a low blood sugar reaction. The insulin will start working before food is absorbed," Nathan explains.

Insulin pens are

Worsening Chest Pains

Forum: The Heart Forum Topic: Angina

Heart Health Center

Alcohol May Lower Heart Attack Risk

Heart Health Center

Blood Test Predicts Heart Attack Risk

Pinpointing Patients at Risk

Protein Levels vs. Heart Risk

Value Unknown

Heart Health Center

Test IDs Risk of Sudden Cardiac Death

Saving Health Care Costs

How Implanted Defibrillators Work

The MTWA Test

Less Impressive Findings

Lifestyle Vital to New Heart Diet

In Balance: Food and Activity

Eat Your Veggies, Help Your Arteries

Less Plaque

Diabetes Medications & Diet: Synergistic Success

Forum: The Heart Forum
Topic: Angina