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Cardiology in Plain English

Answers to your queries about cardiovascular conditions from Dr P Ruzicka.

Everything you always wanted to know about heart; no question too trivial or embarrassing. Questions and answers about cholesterol, diet and exercise, heart murmurs, pacemakers, cardiac magnetic resonance imaging, heart rate, medication, atrial fibrillation, coronary artery disease, coronary angioplasty and bypass surgery.

Is it possible to reduce cholesterol by exercise and diet?
(A. R., Knutsford)


Yes, it is. The best is aerobic exercise such as brisk walking, running and swimming. People with heart conditions should get advice from their GP or cardiologist before embarking on any regular strenuous exercise. Physical exercise increases the level of 'good' HDL cholesterol. Low-fat diet reduces the level of 'bad' LDL cholesterol. However, unsaturated fat, such as olive oil and omega-3 fatty acids in fatty fish, such as salmon are also beneficial.

How long does a pacemaker last? Can I walk with it through airport security?
(L. S., Macclesfield)


The longevity of pacemaker depends on several factors. Single chamber pacemaker (with one wire) last longer than dual chamber pacemakers (with two wires or leads). Pacemaker setting, electrical parameters and underlying heart rhythm problem all influence how hard the pacemaker works and the amount of energy it needs. Generally, pacemaker last from 5 to 10 years.
Airport security systems will not damage or reset pacemaker but the metalic parts can set the alarm off. You will get a pacemaker identification card which you should show and ask for a manual search or hand held screening device.

I have been told that I had a heart murmur as a child. Is it
(T. J., Hale Barns)


A heart murmur is a sound caused by a turbulent flow of the blood inside the heart. Murmurs can be systolic (occuring when heart contracts) or diastolic (when heart relaxes). Most systolic murmurs in young people are benign and don't require any treatment. Some murmurs are caused by a leaking (regurgitation) or sclerotic (stenosis) valve. Murmurs can be also due to congenital heart problem. I would recommend that you see your GP who - if appropriate - may send you for echocardiogram (ultrasound scan of the heart) or directly to a cardiologist.

Is it OK to have magnetic resonance scan when I had stent
fitted 2 years ago?
(P. T., Cheadle)


Yes, it is. Many clinical trials with magnetic resonance (MR) imaging involved patients with coronary artery stents who went on to have MR scan without any problems. The current concensus is that magentic resonance imaging with magnet strength up to 3 Tesla (most scanners) is safe for stents. The same is true for most artificial heart valves but patients with replaced valves should consult their cardiologist before the scan. Presence of pacemaker or ICD (implantable cardioverter defibrillator) normally means that you must not have MR scan, although there some recent devices which are MR compatible.

My mum's heartbeat increases if waked from sleep after
a bad dream also when hungry; is it normal?
(M. I., Manchester)


A small degree of increase in heartbeat would be expected on waking up or under stress such as being worked up, hungry or uncomfortable. Short episodes of fast heart beat under these conditions are normal response to stress and nothing to be worried about. If the heart rate is irregular or persistently and excessively fast (usually above 100 beats per minute), it would be prudent to get this checked to exclude heart rhythm problems, e.g. atrial fibrillation (see blog) or underlying conditions, such as hyperactive thyroid, low blood count (anaemia) or infection.

Since I have been started on clopidogrel, I get very
easily bruised. I am also having frequent headaches.
Is there any alternative or can I simply stop clopidogrel?
(P. D., Altrincham)


Generally, I would strongly advise against stopping any medication without previous consultation with the doctor who prescribed it and in the case of clopidogrel it is even more critical. The availability of alternative depends on the indication for clopidogrel. Clopidogrel is frequently prescribed in combination with aspirin following insertion of coronary artery stent. The duration of treatment with clopidogrel depends on the type of stent. The most common drug-coated stents normally require 12-month course of clopidogrel. Premature discontinuation in this situation is extremely risky and may lead to massive or even fatal heart attack. Clopidogrel in patient with implanted coronary stent must NEVER be stopped before completing the prescribed course without checking with cardiologist! Headache is not a typical side effect of clopidogrel and is unlikely to be related to its usage.

I have been diagnosed with atrial fibrillation. My
cardiologist started me on warfarin for blood thinning
and beta-blocker to regulate my heart beat. I feel now
fine and my pulse is regular. Can I stop warfarin?
(M. C., Wilmslow)


Atrial fibrillation (AF) indeed increases risk of blood clots being formed within the heart which can get into circulation and end up blocking one of the arteries in the brain and causing stroke. Warfarin as a blood-thinning medication (anticoagulation) reduces risk of blood clot formation and subsequent stroke. The probability of stroke in AF is dependent on several factors summarized in CHA2DS2-VASc acronym. The letters stand for Congestive heart failure, Hypertension, Age over 75, Diabetes, Stroke or TIA (mini-stroke), Vascular disease, Age over 65 and Sex category (female); each risk factor counts as 1 point except for age over 75 and stroke/TIA which count as 2 points. Everybody with atrial fibrillation and CHA2DS2-VASc score 2 or more should be taking warfarin if there is no good reason to the contrary, such as high risk of bleeding or previous brain bleed.

Somewhat counterintuitively, there is a good evidence that the risk of stroke does not depend on whether AF is present all the time or only occasionally (= paroxysmal AF). It is also well known fact that the symptomatic episodes of AF – when the patient is aware of irregular pulse – are only a tip of iceberg and vast majority of the overall atrial fibrillation is silent making the estimation of the overall burden of arrhythmia based on symptoms very unreliable.

Warfarin therefore should not be stopped even if you feel well and your previous problems settled. There may be some exceptions where the AF is due to e.g. hyperactive thyroid gland which if successfully treated would lead to restoration of normal heart rhythm and allow discontinuation of anticoagulation but in most people where there is no obvious reversible cause for AF, warfarin needs to be continued for life.

At any rate, please don’t stop any of your medication without previous discussion with your GP or doctor who prescribed it.

I am due to end the dual anti-platelet therapy after
1 year since I had MI. I have read reports on the web
about clopidogrel rebound effect (i.e. arteries becoming blocked again and people having heart attacks). Should I just stop clopidogel or are people advised to be "weaned off"?
(D. P.)


There are indeed some data suggesting clustering of adverse clinical events following clopidogrel withdrawal after the recommended 12 month course following MI (myocardial infarction, heart attack) or PCI (angioplasty, stenting). The data however largely come from retrospective and/or small trials and are hypothesis-generating rather than definitive evidence. The potential benefit of continuing clopidogrel must be weighed against increased risk of bleeding. Currently cardiology community and ESC (European Society of Cardiology) guidelines in normal circumstances recommend only 12 months of clopidogrel. Increasingly, new drugs such as ticagrelor are being used, and the duration of therapy is also normally 12 months following MI or PCI.

What is better for treatment of coronary artery
disease, angioplasty or bypass surgery?
(C. T., Sale)


It is really impossible to say! Angioplasty (or more accurately PCI, percutaneous coronary intervention, usually with insertion of one or more stents) and surgery (CABG, coronary artery bypass grafting) have both advantages and disadvantages in fact, for most people with coronary artery disease, the best treatment is combination of lifestyle changes and medication only! Intervention – in the form of PCI or CABG – is generally recommended if significant symptoms, such as chest discomfort on physical activity, persist despite optimal medication. The choice between the two methods of revascularization (improvement of blood flow in coronary arteries) depends on many factors including number, location and appearance of the narrowings and/or blockages in coronary arteries (increasing complexity favouring CABG), presence of other diseases, most notably diabetes (again for CABG) but also specific expertise – interventional or surgical – at individual centres and obviously also patient’s preference. In many cases, there is no prognostic difference between PCI and CABG with PCI being less invasive but requiring more re-do procedures and CABG being bigger initial undertaking but with less need for future re-intervention.