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Holy Cross Cardiovascular Blog

How do we Determine whether a Person's Chest Discomfort is Angina?

  • Posted Oct 05, 2011
  • Charles D. Russo, MD, FACC

In addition to the risk profiling, which we have talked about previously, we can do provocative testing to see if we can bring out the patient's symptoms or objective findings of a lack of blood flow to the heart. This is traditionally done by what is called stress testing. There are several different types of stress tests available to us depending on the clinical situation and the patient's risk profile.

A regular stress test consists of hooking a patient up to a standard EKG and watching them carefully while we monitor their blood pressure, EKG and symptoms as they walk on a treadmill attempting what is called a standard Bruce protocol. This is invaluable because this type of stress test has been done hundreds of millions of times in the past, and we can make predictions based on it. However, there are certain situations where a regular stress test cannot be performed. This may be in patients with EKG's that are not normal, if they have high blood pressure or if they are on any medications that may affect the EKG during exercise.

However, stress tests are not infallible. In addition, a plaque has to block more than 75% of the artery in order to limit blood flow! Therefore, even if the patient has a negative stress test, it does not mean he does not have any blockages, it just means he has no significant blockages yet.

The error rate of a standard stress test can be as high as 25 or 30% and may be even higher in women. But if the test is of very good quality and negative, it may be reliable. Because of these problems with the standard stress test, we often combine it with other ways to look at the heart, or the circulation of the heart, to make it more accurate.

One of these ways is to do what is called a stress echocardiogram which combines a simple ultrasound picture of the heart before and after exercise, looking at how the walls of the heart are beating and to make sure that after exercise, they are beating more vigorously. When the EKG is not normal or when a person has high blood pressure or is on medications that can affect the EKG, this is another way of making the test more reliable. However, the error rate with this test is still approximately 15 to 20%.

A third way to do the stress testing is to combine the EKG and exercise portion with the injection of nuclear tracers before and after exercise and to take pictures of the circulation of the heart. This not only gives us information about prior heart attacks and the extent of damage to the heart but also if there is a lack of circulation and by how much. However, this test has its own pitfalls and has an error rate that is better than the other two types of stress testing, but it is still at 10 to 15%.

In addition, there are chemical stress tests that can be done for patients who cannot exercise or that have what is called left bundle branch block or have a pacemaker. One type of chemical stress test combines a medicine that stimulates the heart, called dobutamine, while doing an echocardiogram during the test to look at heart wall motion.

Another type involves injecting a medication to make the arteries of the heart open up widely. This type of stress test uses the injection of the radioactive tracers before and after the chemical to open the arteries up is given and pictures are taken. The thought behind this test is that in areas where there are significant blockages, the arteries cannot open up as wide as in other areas, and they do not light up as well on the pictures.

These chemical stress tests have the same error rates and limitations as the regular stress tests do. As you can see, the type of stress test that is best for you depends on many factors which your doctor must weigh carefully when deciding how to proceed.
When a stress test is negative, it may be very reassuring, but we always tell patients if their symptoms persist or change to come back for a reevaluation since none of these tests are 100%. Likewise, depending on whether the test is mildly, moderately or very positive, your doctor may decide whether you can be treated medically or need to have a different kind of test called a cardiac catheterization to clarify the situation. Because the stress tests have error rates, they can not only occasionally miss disease, but they can make your doctor think that you have the disease when you really don't. That is why almost 20% of patients sent for catheterizations after having positive stress tests are not found to have significant disease. However, it is considered good medicine to prove that they don't have significant disease rather than go on treating them for years with medicines they may not need.


Why Do We Get Angina?

  • Posted Sep 28, 2011
  • Charles D. Russo, MD, FACC

Angina is a chest discomfort that generally arises because of a relative lack of blood supply to an area of the heart. Since the heart needs to work 24 hours a day, seven days a week, it requires a tremendous amount of energy. Any interruption in the supply of oxygen, which is used to burn the fuel, may result in angina. It should be noted that the oxygen demand to the heart can be increased by supply or demand or both.

What I mean by this is that the heart is dependent on oxygen, which is attached to hemoglobin carried in the blood. Therefore, if a person is severely anemic, this will limit the oxygen-carrying capacity of blood and may result in angina without a limitation in blood flow. But, the most common cause of angina is from a decrease in the amount of blood that can get to an area of the heart that is working. This is caused by blocked arteries. Also, if the heart muscle is thicker than normal because of, let's say, high blood pressure or other disease processes, that thickened muscle requires more oxygen to get its work done and if the blood flow is not adequate to that area, it may result in angina. This angina has both a supply and demand component.

This limitation in blood flow to the heart muscle occurs most commonly because of a fatty buildup on the inside of the arteries which we call atherosclerosis. This fatty buildup or plaque takes place over years or decades and when it becomes significant enough it can limit the vital flow of blood and oxygen to working heart muscle.

When this happens the most common manifestation is angina. Again, classically, this occurs during times of stress or exertion when, generally, the heart rate will go up and increases the oxygen demand which cannot be met because of the limited flow down the artery due to a significant blockage.


Angina: What is the Scope of this Problem?

  • Posted Sep 21, 2011
  • Charles D. Russo, MD, FACC

Approximately 10 million Americans are estimated to experience angina every year. There are more than 500,000 new cases of angina per year. As of 2009, it was estimated that 785,000 Americans will suffer their first heart attack, and another 470,000 Americans will have a recurrent heart attack per year. It is also estimated that about every 25 seconds an American will have a coronary event, and each minute someone will die from such an event.

One out of every five deaths in the United States each year is caused by coronary artery disease. This is the number one killer of Americans, and it does not discriminate with approximately 53% being men and 47% being women. Yes, coronary artery disease is the number one killer of women in this country not breast cancer.

In addition, the rates of angina increase with age with approximately 8.5 cases per 1,000 in the age group 45 to 54 and 13.7 per thousand in the age group 65 to 74. Also, Black men and Black women have a higher incidence of angina in the younger age groups 45 to 54, but by 65 years old Caucasian, Latin and Asian men and women surpassed Blacks.

Another problem is that, with this high prevalence of atherosclerotic heart disease in both our male and female population, only a very small percentage of people will have the warning signs of a heart attack before the event. This has been estimated at only 18%! This means that the majority of Americans will not have warning symptoms before an event. By this I mean symptoms for several days or several weeks before an actual event. In terms of men and women, women do tend to have the warning signs of a heart attack almost twice as often as men.

This is what makes routine evaluation and screening invaluable. Depending on a patient's risk profile, it can be determined what their annual and 10 year risk of a cardiac event is, and then, they can be placed in low, medium or high risk categories which can help guide your doctor to the proper screening procedures and treatments.


Atrial Fibrillation and Electrophysiology: Dr. Rishi Anand, Clinical Cardiac Electrophysiologist

  • Posted Sep 14, 2011
  • By Holy Cross Administrator

Atrial fibrillation is an abnormal rhythm of the heart. The heart's electrical system normally sends regularly spaced, predictable signals, telling the heart muscle to contract, or beat (Holy Cross Online Health Library).  In the following video, Rishi Anand, MD (Clinical Cardiac Electrophysiologist with the Holy Cross Medical Group and Medical Director of the Holy Cross Electrophysiology Studies Lab) explains atrial fibrillation, ablation and the field of electrophysiology. Learn about a procedure that can benefit patients who suffer from atrial fibrillation: http://youtu.be/_D-PXK2NvCM To learn more about Dr. Anand, click here to visit his physician profile: Rishi Anand, MD.


What is Angina?

  • Posted Sep 07, 2011
  • Charles D. Russo, MD, FACC

Classically, angina is described as a chest pressure or tightness. It may spread to the back, the arms or the lower jaw and may be accompanied by other symptoms such as nausea or cold sweating. Unfortunately, your body does not read the book, and therefore, what one person feels as angina may be quite different from what another person feels. What I mean by this is that some people describe an ache, a hollow feeling or even fullness in the chest. Sharp pains, in general, are not angina pains. To make the situation even more complicated, there are certain stomach and gastrointestinal symptoms which can mimic angina and vice versa. In other words, certain sensations such as a discomfort in the lower chest or upper belly area associated with belching and cold sweating with nausea can be an indication of a stomach problem or an angina. Just to add another level to this whole situation, women tend to have even less typical symptoms compared to men which makes the diagnosis of angina even more difficult. This is why women tend to come to the diagnosis of angina and heart disease at more advanced stages than men. Typically, however, angina will be the same in an individual time and time again. By this, what I mean is that although one patient may have a left arm discomfort and another may have jaw pain, while still another has classic chest pressure. When the angina comes back in these individuals, it will usually come back in the same way. In that particular person, their angina pattern is set and can be well known to them. It is not common for the feeling of angina in a particular person to change over time. This is very helpful to the doctor and the patient. So, if angina can be many different things in many different people when someone complains of particular sensations that they have in their chest, arms or jaw, how can we distinguish whether these symptoms are truly angina? One way to do this is to look at it in the context of the patient's risk profile. What do I mean by that? Well, if the patient is middle-aged and has a history of high blood pressure, high cholesterol, diabetes, smoking or a family history of heart disease at young ages, then they are at a much higher risk to have blocked arteries then a person without those risk factors and therefore, angina. Another way to look at this situation is the pattern of the discomfort. In other words, what brings it on and what relieves it. If a person consistently has the discomfort during some form of activity or stress, and it is relieved by rest or relaxation, then it has a much higher likelihood of being angina regardless of what it feels like to the patient.


Transesophageal Echocardiogram: Dr. Vicente Font, Cardiologist

  • Posted Aug 31, 2011
  • By Holy Cross Administrator

Echocardiography uses sound waves (ultrasound) to make images of the heart. Transesophageal echocardiography (TEE) passes the ultrasound probe down the throat in the esophagus, or food pipe. The esophagus is close to the heart, and this TEE allows for clearer images of the heart than other methods. Below is a video of Dr. Vicente Font explaining this method as he performs the procedure on one of his patients: http://youtu.be/9Us9mXXILSk To learn more about Dr. Font, visit his physician profile: Vicente Font, MD, FACP, FCCP, FACC.

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Choosing Your Salmon

  • Posted Aug 24, 2011
  • Vicente Font, MD, FACP, FCCP, FACC

In other blogs, we have discussed the benefits of fish, particularly oily species for the high amount of omega 3 fatty acids they contain and their relationship with a healthier heart. The question that we get asked frequently is what’s the best salmon to buy? Farmed or wild?

Salmon is the common name for several species of fish in the family Salmonidae. Salmon live along the coasts of both the North Atlantic and Pacific Oceans and have also been introduced into the Great Lakes of North America. In addition, salmon are intensively produced in aquaculture in many parts of the world. Salmon aquaculture is the major economic contributor to the world production of farmed fish, representing over $1 billion annually. Other commonly cultured fish species include: tilapia (one of my favorites), catfish, sea bass (my favorite), carp, bream and trout. Salmon farming is significant in Chile, Norway, Scotland, Canada and the Faroe Islands. It is also the source for most salmon consumed in America and Europe. Atlantic salmon are also, in very small volumes, farmed in Russia and the island of Tasmania, Australia.

Typically, salmon are anadromous, meaning that they are born in fresh water, migrate to the ocean, then return to fresh water to reproduce. Interestingly, studies that track the fish have revealed that salmon tends to return to the exact spot where they were born to spawn, a phenomenon that has been attributed to olfactory memory.

Most people like salmon, but sometimes you may feel that you need some type of marine biology degree to figure out which one to choose, Atlantic, Alaskan, farm-raised? Well, here are a few consumer tips on this delicious and healthy food.

U.S. Atlantic salmon
Other names: U.S. farmed salmon
Should you buy it? Yes
Farmed is nutritionally as good as wild salmon. Farmed Atlantic salmon frequently contain similar amount of omega-3s as wild salmon.

Imported Atlantic salmon
Other names:
Farmed salmon
Should you buy it? Depends
Most non-US Atlantic salmon come from farms in Chile, Norway and Canada. Chilean farms have been scrutinized because fish are raised with antibiotics and pollute the waters.

Alaskan or wild salmon
Other names:
Chum, keta, king, pink, red, sockeye, sake
Should you buy it? Yes
Wild salmon are caught off the coast of Alaska or the Pacific Northwest, the former population is not as depleted. Wild salmon is less firm, less fatty and may be a slightly gamier-tasting fish.

Coho salmon
Other names:
Silver salmon
Should you buy it? Yes
Coho are smaller and eat less than other salmon. Let me interject and discuss the issue about toxins in salmon. A study of more than two metric tons of North American, South American and European salmon has shown that PCBs (polychlorinated biphenyls) and other environmental toxins are present at higher levels in farm-raised salmon than in their wild counterparts. These PCBs have been associated with cancer and may pose health risks to people.

Back to Coho. Some people will say that their smaller body and eating characteristics may result in less PCBs and therefore, may be a safer option.

By the way, mercury should not be a concern in either wild or farmed salmon. Over the years, there have been health concerns because high levels of methylmercury have been found in long-lived fish species nearer to the top of the food chain - such as tuna and salmon. High mercury levels have been associated with an increase in the risk of cancer, and this has led many people to avoid consuming certain fishes. Studies like one published a couple of years ago in Environmental Toxicology and Chemistry have found  that mercury levels in both wild and farmed salmon are substantially below human health consumption guidelines (the levels found in wild salmon were three times higher than in farmed salmon).

Canned salmon
Brand names:
Bumble Bee, Wildcatch, Chicken of the Sea
Should you buy it? Yes
Canned salmon is a good way to get wild salmon cheaper and year-round (most brands use wild Alaskan salmon), along with all the same nutritional benefits of salmon. But you might have to taste-test a few brands to find the flavor and texture you like best.
Remember that there are other fish that should be considered. If oily fish is what you are looking for, consider arctic char (good substitute with a flavor and omega-3 content similar to salmon, farm-raised) as well as small, oily fish like sardines, Atlantic mackerel, and herring; they are caught wild from an ocean full of them, and they're just as healthy as salmon.


Exercise and Physical Activity for Older Adults: Part 8 - Conclusion

  • Posted Aug 17, 2011
  • Vicente Font, MD, FACP, FCCP, FACC

How to Stay Active - Plan for Breaks
Sometimes ordinary events, like vacations to see grandchildren or getting a cold, can temporarily interrupt your exercise schedule and make it hard to stick with your activities. At other times, unexpected events like family illness, caregiving responsibilities or the death of a loved one can permanently change your life and interrupt your physical activity routines. Regardless of the reason, there are ways you can get back on track with your exercise activity. During these times, it's important to remember the reasons you started exercising and the goals you created for yourself. You may want to ask family and friends to help you get back on track or talk with your trainer or doctor to get the boost you need to start again. You might consider trying something easier or an activity you haven't done recently. You might even want to try something you've never done before. Mastering something simple or new may give you the confidence you need to resume a regular exercise program. The sooner you resume some sort of activity, the better you'll feel and the easier it will be to get back into your routine. Feel confident that even if your activity is interrupted, you can start again and be successful. If you haven't exercised for several weeks or longer, make sure you start back at a comfortable level, and then gradually build back up. With a little time, you'll be back on track.

Here are tips to help you stay active during temporary breaks or start again if you've had to stop:
•    If your grandchildren come to visit, arrange to take them with you for a walk or reschedule your exercise during their nap time.
•    If you go on vacation, check out the facilities where you'll be staying and bring along your exercise clothes and equipment (resistance band, bathing suit, or walking shoes).
•    If you can't go outdoors because of bad weather, try an exercise video, jog in place, dance around the house or walk up and down the stairs a few extra times.

Here are tips to help you stay active, or start up again, when there has been a permanent change in your life:
•    If your usual exercise buddy moves away, ask another friend to go with you on your daily walk or ask other older adults where they go for walks.
•    If you move to a new community, check out the fitness centers, parks and recreation associations in your new neighborhood. Look for activities that match your interests and abilities.
•    If you are recovering from hip or back surgery, talk with your doctor about specific exercises you can do safely once you feel better. Start slowly and gradually build up your activities as you become stronger.
•    If a spouse you are caring for has a long-term illness, ask family members to come over so you can go for a walk or work out to an exercise video when your spouse is napping.

Final Words
According to the U.S. Surgeon General's Report on Physical Activity and Health, inactive people are nearly twice as likely to develop heart disease as those who are more active. Lack of physical activity also can lead to more visits to the doctor, more hospitalizations and more use of medicines for a variety of illnesses. Staying physically active and exercising regularly can produce long-term health benefits and even improve health for some older people who already have diseases and disabilities. I hope that this information helped in guiding you towards a healthier lifestyle.


Exercise and Physical Activity for Older Adults: Part 7

  • Posted Aug 10, 2011
  • Vicente Font, MD, FACP, FCCP, FACC

How to Stay Active - Check Your Progress
You are more likely to stick with regular exercise and physical activity when you can see the benefits, so it can be very motivating to measure your progress. Also, measuring progress is a good way to let you know if you are continuing to make progress and if you need to update your goals. As you become more active, you'll probably notice signs that you're getting more fit.

•    You have more energy.
•    Your overall mood and outlook on life have improved.
•    It's easier to do your usual daily activities.
•    Climbing a couple of flights of stairs is easier.
•    It's easier to get in and out of the car.
•    You can get down on the floor and play a game with your grandchildren, and get back up again more easily when the game is over.
•    You're sleeping better at night.
•    You have less pain when you move around.
•    Symptoms of an ongoing health condition may improve.

How to Stay Active - Build on the Benefits
Once you start exercising and becoming more physically active, you'll begin to see results in just a few weeks. You'll feel stronger and more energetic, and you'll notice that you can do things easier, faster or for longer than before. This tells you that your body is getting used to a higher level of activity. Now is the time to build on those benefits by adjusting your routine and doing more. When you adjust your level of activity, remember to keep your starting point in mind and to review your goals, too. For some people, switching from 1- to 2-pound weights is a big step forward. For others, building up to walking briskly, or even running, is a reasonable goal.

Ways to build on the benefits include
•    doing your current activities more often
•    doing your current activities longer, farther, or harder
•    adding new activities Do the activities more often.
•    Spend time in your garden more often.
•    Head over to the gym three times a week instead of two.
•    Walk every day. Do the activities longer, farther, or harder.
•    If you walk 30 minutes at lunch time every day, make it 40 minutes. If you only have 30 minutes for lunch, pick up the pace so you're walking faster and farther in the same amount of time.
•    Try using a pedometer, or step counter, to track your progress. Seeing the number of steps add up can be great motivation.
•    If you usually swim half a mile, build up to three-quarters of a mile.
•    Use a harder resistance band or heavier weights when you do strength exercises. Add new physical activities. Be creative. Try some new activities to keep your interest alive.
•    Sign up for dance lessons.
•    Talk to your friends about bowling together once a week.
•    Join a water aerobics class.
•    Check out an exercise video from the library, or check out several and do different ones on different days.
•    Save gas by walking to your nearby grocery store.
•    Can you trade in any of your electric appliances for muscle-powered versions: How about your electric can opener? Your electric lawn mower? Your electric leaf blower? Next blog will be the last part of this series.


Exercise and Physical Activity for Older Adults: Part 6

  • Posted Aug 03, 2011
  • Vicente Font, MD, FACP, FCCP, FACC

How to Stay Active
Once you've started exercising, it's important to keep going because physical activity needs to be done on a regular basis to produce maximum benefits. If you sometimes find it hard to keep doing your activities or you stop exercising for some reason, don't give up. There are lots of things you can do to keep going or start up again if you've stopped.

How to Stay Active - Make Exercise a Habit One of the best ways to stay physically active is to make it a life-long habit. Set yourself up to succeed right from the start by seeking to make exercise a regular part of your day. When it becomes a normal part of your everyday routine, like brushing your teeth, then you'll be less likely to stop and will find it easier to start up again if you're interrupted for some reason. If you can stick with an exercise routine or physical activity for at least 6 months, it's a good sign that you're on your way to making physical activity a regular habit. Here are a few ways to help you make exercise a regular part of your daily life.

•    Make it a priority.
•    Make it easy.
•    Make it safe.
•    Make it social.
•    Make it interesting and fun.
•    Make it an active decision.

Make it a priority.
Many of us lead busy lives, and it's easy to put physical activity at the bottom of the "to do" list. Remember, though, being active is one of the most important things you can do each day to maintain and improve your health. Make it a point to include physical activities throughout your day. Try being active first thing in the morning before you get busy. Think of your time to exercise as a special appointment, and mark it on your calendar.

Make it easy
If it's difficult, costs too much or is too inconvenient, you probably won't be active. You are more likely to exercise if it's easy to do. Put your 2-pound weights next to your easy chair so you can do some lifting while you watch TV. Walk up and down the soccer field during your grandchild's game. Do more of the activities you already like and know how to do. Walk the entire mall or every aisle of the grocery store when you go shopping. When you go out to get the mail, walk around the block. Join a gym or fitness center that's close to home. You can be active all at once, or break it up into smaller amounts throughout the day.

Make it safe
Exercise and moderate physical activity, such as brisk walking, are safe for almost all older adults. Even so, avoiding injury is an important thing to keep in mind, especially if you're just starting a new activity or you haven't been active for a long time. Talk to your doctor if you have an ongoing health condition, certain other health problems or if you haven't seen your doctor for a while. Ask how physical activity can help you, whether you should avoid certain activities and how to modify exercises to fit your situation. You may feel some minor discomfort or muscle soreness when you start to exercise. This should go away as you get used to the activities. However, if you feel sick to your stomach or have strong pain, you've done too much. Go easier and then gradually build up.

Make it social
Enlist a friend or family member. Many people agree that having an "exercise buddy" keeps them going. Take a yoga class with a neighbor. If you don't already have an exercise partner, find one by joining a walking club at your local mall or an exercise class at a nearby senior center. Take a walk during lunch with a co-worker.

Make it interesting and fun
Do things you enjoy and pick up the pace a bit. If you love the outdoors, try biking, fishing, jogging or hiking. Listen to music or a book on CD while walking, gardening or raking. Plan a hiking trip at a nearby park. Most people tend to focus on one activity or type of exercise and think they're doing enough. The goal is to be creative and choose exercises from each of the four categories -- endurance, strength, balance and flexibility. Mixing it up will help you reap the benefits of each type of exercise, as well as reduce boredom and risk of injury.

Make it an active decision
Seize opportunities. Choose to be active in many places and many ways. Multi-task the active way.

•    When you unload the groceries, strengthen your arms by lifting the milk carton or a 1-pound can a few times before you put it away. When you go shopping, build your endurance by parking the car at the far end of the parking lot and walking briskly to the store. Or, get off the bus one or two stops earlier than usual.
•    Instead of calling or e-mailing a colleague at work, go in person -- and take the stairs.
•    Take a few extra trips up and down the steps at home to strengthen your legs and build endurance.
•    Try to do some of your errands on foot rather than in the car.
•    While you're waiting in line, practice your balancing skills by standing on one foot for a few seconds, then the other. Gradually build up your time.
•    While you're talking on the phone, stand up and do a few leg raises or toe stands to strengthen your legs.

Take advantage of small bits of "down time" to do an exercise or two. For example, while you're waiting for the coffee to brew or for your spouse to get ready to go out, do a few wall push-ups or calf stretches.

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This blog was archived on June 14, 2016. New blogs are being posted to The Medical Insider Blog


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The Jim Moran Heart and Vascular Center at Holy Cross offers the latest in high-tech cardiac care. Holy Cross was the first in Broward County to offer Induced Hypothermia, which has shown to increase the odds of surviving cardiac arrest, and has been shown to improve neurological outcomes after such an event. We were also the first in Florida to use the Prime ECG Vest which, in select patients, may give physicians additional data beyond a traditional electrocardiogram. Our outstanding cardiovascular team, utilizing cutting-edge technology, can treat any heart and vascular situation especially in an emergency.

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