Heart disease is the No. 2 killer in Singapore. With 1 in 3 deaths due to heart disease, it is important to know your risk factors and what you can do to minimize them.

Dr Tan Ju Le, Senior Consultant and Dr Peter Ting, Visiting Consultant from the Department of Cardiology at National Heart Centre Singapore, give detailed answers to your questions.

Question by catkoh14

I was diagnosed with palpitation during the medical check-up early this year and I am on medication (Sotalol) to control the heart beat PVC since then. Am I on higher risk of getting heart complication later or older? Other than relying on medication, is there any other ways to reduce the PVC? What is the risk of skipping the medication? Should I go for 2nd opinion for my condition?

Answered by Dr Tan Ju Le, Senior Consultant, Department of Cardiology, National Heart Centre Singapore

Palpitation is a symptom, which can mean different things to different people (i.e. strong beats, extra beats, skip beats, fast beats). PVC means premature ventricular complexes, which may or may not need treatment depending on the type, frequency and whether it occurs in isolation or in series of beats.

There are many reasons for PVC but occasional isolated PVCs with no other heart problem can also be benign and need not lead to heart complication later on in life.

To reduce PVCs, you can cut down on the consumption of caffeine (eg coffee, tea, coke) which is a heart stimulant. You should also check and make sure that your thyroid hormone levels (blood test) are normal.

Whether you need to be on sotalol or whether it can be stopped really depends on the reason for your PVCs, how symptomatic you are with your palpitations and whether there are other associated types of heart rhythm abnormalities.

Question by Wonderland

Dear Specialist,

My dad has been taking simvastatin for more than 5 years. He will go for cholesterol test annually as well as liver test. I read from article that simvastatin will affect liver function. Is that why he has to take the liver test annually to ensure that the liver is still fine? Please elaborate.

Also, if LDL is > normal and HDL is > normal resulting in high total cholesterol but the ration is about 3 plus. Does it mean that the person is ok and does not need to take statin? Please elaborate.

Please advise.

Thanks & regards,
Wonderland

Answered by Dr Tan Ju Le, Senior Consultant, Department of Cardiology, National Heart Centre Singapore

Simvastatin helps to lower the level of cholesterol in the blood by increasing the elimination of the LDL from the liver. Hence, it is an acceptable practice to monitor his liver function whilst your father is on the medication.

High level of HDL is cardio-protective but we also need to look at absolute LDL level, rather than the ratio alone. For example if the patient’s HDL is 1.5 but LDL is 4.5 and the patient has heart disease, the patient would still need to get the LDL to less than 2.6 (for heart patient with blocked coronary arteries) and hence will still need to be on statin.

Question by catkoh14

Dear Specialist I have heard people discussing about palpitation/PVC and try to get more information on this topic through internet, magazines or even newspapers but are mostly concern of heart disease that is due to cholesterol, high blood pressure, etc.

I would like to get more information as follows:

1. What is palpitation, PVC and Bigeminal beats?
2. What causes palpitation, PVC or bigeminal beats?
3. How do people know that they are having PVC/palpitation if they are not aware of the symptoms?
4. If PVC or bigeminal beats are not treated, what are the long term consequences?
5. Is PVC categorise as heart disease and can it be cure?
6. From the online information, it seems that most people will get PVC or palpitation, what is the min. no. of PVC (in 24 hours) is considered serious?
7. If a healthy person below 40 (no high blood pressure, cholesterol, etc) has 22k of PVC and 15k of bigeminal beats in 24 hours consider serious?
8. What are the various medications that will help to control the PVC and what is the side effect of the medications?
9. Does exercise or taking supplement like magnesium, fish oil, etc help to improve PVC/palpitation?

Hope you can provide the necessary information on this matter.

Regards
Pony

Answered by Dr Tan Ju Le, Senior Consultant, Department of Cardiology, National Heart Centre Singapore

1. Palpitation is a symptom, which can mean different things to different people (ie strong beats, extra beats, skip beats, fast beats). PVC means premature ventricular complexes. Bigeminy happens when the heartbeat alternates between a normal beat and a premature complex. Bigeminy can be ‘atrial; or ‘ventricular’ depending on where the beat comes from (i.e. the upper chamber ‘atria’ or the lower chamber ‘ventricle’).
2. There are many causes for palpitations, PVC and bigeminy such as hormones, stress, some medications, heart disease, electrolyte abnormalities in the blood, etc.
3. Usually if the PVCs are very frequent, people are usually aware of these symptoms.
4. If PVCs or bigeminy are infrequent and there is no structural heart disease, there is very little evidence of serious long term consequences.
5. PVC is just a description of an extra beat, in this case a premature ventricular complex and not a type of heart disease.
6. Yes, it is very common to get PVCs on holter but usually these are infrequent <5% of the total beats. Certainly if the number of PVCs or bigeminy is very frequent, then other cardiac tests such as exercise test/echocardiogram are usually requested to assess if the PVCs can be suppressed with exercise and also to assess the pumping function of the heart.
7. There are different types of medication that may help and the side effect profile is different for each type. The patient’s full medical history, the cause of the PVCs, results of various investigations must be taken into account before deciding on the type of medication to be used.
8. Some PVCs can be suppressed with exercise but this should be formally assessed (i.e. in an exercise treadmill test).

Question by cnsh1962

I'm in my late forties and in good health. I've 2 congential heart condition - Mitral Valve Prolapse & Atrial Septre Aneurysm. I'm not on any medication or treatment, just yearly review. I wish to know

1. Are these considered as heart disease? Whenever I need to fill up any medical form asking for heart disease, I'm not sure whether to indicate these conditions.
2. I heard that ASA patients has the risk of getting a stroke. Is this true? What can I do to reduce my risk?

Thanks.

Answered by Dr Tan Ju Le, Senior Consultant, Department of Cardiology, National Heart Centre Singapore

1. Yes, you should mention the mitral valve prolapse when you fill in the medical form.
2. Atrial septum is name of the wall separating the right and the left atrium (atrium = upper heart chamber). In atrial septal aneurysm, the wall is redundant and floppy.

S​ome patients with atria septal aneurysm (ASA) have an associated small hole in the form of either a small atrial septal defect (ASD) or a patent foramen ovale (PFO) through which small clots on the right side of the heart can cross over to the left side which can then go to the brain giving rise to stroke.

If there is no ASD or PFO, the risk of stroke from ASA alone is very low. To decrease the risk is to decrease the chance of clots in the right side of the heart usually from say small clots in the leg (i.e. dehydration and prolonged inactivity such as during a long flight).

Question by yapfookwing

I am 58 male and use to jog for 5 to 7 KM once a week at the rate of 4.8 min/KM. My blood pressure reads at 126/65 mmHg and heart rate at 45 pulses/min. What do these figures tell in term of my heart condition.

Answered by Dr Tan Ju Le, Senior Consultant, Department of Cardiology, National Heart Centre Singapore

A: Your blood pressure of 126/65 mmHg is within normal range. Your resting heart rate is slow at only 45 bpm (sinus bradycardia). The question is whether the slow heart rate is physiological or pathological. If you feel well and have no symptoms, most likely your slow heart rate is physiological.

One easy way is to check your pulse during and after your 7km jog and see what is your maximum rate during and post exercise.

1. Physiological - Good level of fitness from physical training such that with each heartbeat, the volume of blood ejected per beat at 45 beats per minute is adequate to supply all organ system.
2. Pathological – Due to heart rhythm disorder such as heart block, sick sinus syndrome, thyroid dysfunction, etc.

If you develop any symptoms of dizziness or breathlessness with the slow heart rate, you may want to see a cardiologist for some tests such as ECG, exercise test (assess if your heart rate increases appropriately with exercise) or Holter (assess your heart rhythm over 24 hours for heart block, pauses, rhythm disorders).

Question by avkamali

my husband is 41,he is overweight and in high cholestral.he is not doing any exercise because of his thight schedule but he go walking(normal)in weekly 4 times for halk an hour its not woking what can i do to prevent him from any disease

Answered by Dr Peter Ting, Consultant, Department of Cardiology, National Heart Centre Singapore

People who are overweight, particularly if they have fat accumulation around the waist are at higher risk of developing coronary artery disease and its complications.

Being overweight predisposes to other risk factors for heart disease such as hypertension, high cholesterol and even diabetes.

In order to reduce your husband’s risk and prevent heart disease,he should have his blood pressure checked and treated if it is high. He should also observe good healthy eating habits, in particular, avoid excessive portions, taking less fatty, fried or processed foods (unfortunately many Singaporeans love to eat, and tend to overeat). Exercising regularly in addition to helping to lose weight also has health benefits of its own.

He should continue his 4x/week exercise (at least 30min each), and increase this to 5 or more times / week. The intensity should also be increased; brisk walking or walking on a slight slope to increase the heart rate and the breathing should be the goal. Leisurely or casual walking alone may not provide as much benefit.

Try exercising together to encourage each other, and gain the benefits of exercise yourself too!

Question by thl22

My brother-in-law recently discovered that he has a high reading on his lower blood pressure. His doctor would only says that it is pretty high. Does this means that he has high blood pressure or at risk? What can he do if he is concerned?

Answered by Dr Peter Ting, Consultant, Department of Cardiology, National Heart Centre Singapore

Blood pressure is reported as a higher reading (systolic blood pressure) over a lower reading (diastolic blood pressure). If only the diastolic pressure is high, it is known as isolated diastolic hypertension (IDH) and is a form of high blood pressure.

Although some studies tend to suggest that IDH tends to be less harmful as compared to isolated systolic hypertension (ISH) or combined systolic and diastolic hypertension (SDH), it is not totally harmless either.

People with IDH tend to be more likely to develop systolic hypertension as well, and other studies also do show that IDH increases risk of cardiovascular disease although less compared to the other 2 forms of hypertension mentioned.

He should still look out and correct any risk factors that might predispose him to hypertension such as being overweight or lack of physical activity. Reducing alcohol intake and quitting smoking will also improve the blood pressure. He should also have his blood pressure monitored regularly in case systolic hypertension develops as well, in which, more aggressive treatment may include medication.

Question by lee

A friend of mine, only 38 years old, recently was feeling chest pain and numb in his hands. He started sweating, so got worried and he went to the hospital A&E where the docs put him on test and 4 hour observation. His blood test was okay, and ECG was also ok. They asked him to do an angiography, but he was scared, so he said no.

He was thinking/hoping that it was just 'stress' since his test results were okay.

What do you think? When is it time to worry, or not? Should he go further tests to verify? What kind of test would that be?

Answered by Dr Peter Ting, Consultant, Department of Cardiology, National Heart Centre Singapore

Heart disease, in particular coronary artery disease, while less common in the younger population, can still occur, and may even be increasing recently due to the influences of a modern lifestyle and practices.

Any chest pain lasting more than a few minutes should be taken seriously, even more so if there is a family history of heart disease or if there are other risk factors for coronary artery disease such as hypertension, diabetes, smoking, high cholesterol or even advanced age.

Your friend may need further consultation to evaluate if he has coronary artery disease as blood tests and ECG’s done after the pain has resolved may be normal and miss this.

A consultation with a cardiologist would be a good first step, and depending on the findings he may or may not need further testing. There are a whole range tests that can be employed, each with pros and cons.

An angiogram is very accurate, but is invasive and can be intimidating. However depending on the situation, other less invasive tests can be done instead,such as treadmill stress test, nuclear perfusion or stress echocardiography or cardiac coronary CT scan. The cardiologist can best advise which would be the most suitable.

Question by john

My cousin is 55 years old and wants to do a heart health check. He recently has been feeling some occasional pain in his chest, and has high cholesterol.

What's the difference and benefit / pros and cons of the various tests? Treadmill, echo cardiogram, CT scans and angiogram. How should he know which he should go for?

He doesn't want to go for anything unnecessary, but at the same time, does not want to have to go for one after the other and be told that results are 'not conclusive'...

Seek your trusted advise here please.

Answered by Dr Peter Ting, Consultant, Department of Cardiology, National Heart Centre Singapore

Your cousin has a few risk factors for developing coronary heart disease: he has high cholesterol, he is 55 and he is male.

If he has a family history, smokes or has hypertension, his risk may be even higher. He also sounds like he has some chest symptoms as well.

My advice would be for him to be evaluated by a cardiologist who then can best decide whether further testing is necessary.

With regards to the different tests, an angiogram is currently considered the gold standard for evaluating coronary artery disease or narrowing, but is invasive and has a very small risk of serious complications.

Coronary CT scan is quite new and is also very accurate for detecting coronary narrowing although it may be less precise in estimating the degree of narrowing. Both these involve some degree of radiation exposure and use of intravenous contrast which may hurt the kidneys in certain cases.

Stress tests on the treadmill may be done with or without echocardiography or nuclear scanning, these can also provide “functional” information on how physically fit a person is. While they are also accurate in detecting significant coronary narrowing, they are less accurate compared to CT or angiography. You should have a better idea after reading the brochure.

Question by David

Dear Drs, I had one of my right hand side blood vessel inserted with 2 stents last year June in SGH & I am on medication & doing fine now.

1. Why is my morning blood pressure is always high. Average at 150/85 & sometime 160/90. After taking medicine for nearly an hour or two it is back to <130/<85. In the evening before medicine it is oaky till going to sleep at night.
2. Why is my heart beat's is most of time <70 & sometime lower than 60 too. But I feel okay & normal nevertheless. I do normal morning qi-gong breathing in & breathing out exercise & brisk walk too.
3. I had my left hand side heart blood vessel blockage average around <50%. Is it dangerous or like to have another angioplasty?
4. I always check my blood pressure readings & I can obviously feel the pulses functioning cum stopping too on the BP equipment. What is blood pressure reading meant to a patient's blood vessel?
5. • I mean what is the upper reading as per blood flow in the vessel as well as the lower reading on blood flow in the vessel.
   • You can explain or illustrate by meant of a tube or pipe flow rate as example if you like possibly with diagram if applicable or neccesary.

Thank you with best regards!

Yours sincerely,
David

Answered by Dr Peter Ting, Consultant, Department of Cardiology, National Heart Centre Singapore

1. Blood pressure usually varies throughout the day, and it is not uncommon to have a surge in pressure in the early morning or waking period. However it is best to avoid these morning surges in pressure.

2. Speak to your regular doctor regarding this, as you may need some adjustments in your type of medication or the time of dosing of medication to ensure a smoother control of blood pressure throughout the day.

3. You have coronary artery disease and 2 stents inserted before. Generally you should be on a class of medication called a beta blocker (can have different names). This medicine is designed to reduce the heart rate, which is desirable for coronary heart disease patients.

4. As long as you feel well and have no side effects from the low heart rate, there is no need to worry or adjust the medicine. Some patients may feel dizzy or lethargic with the medicine and may need adjustments to dosing or type.

5. Stable narrowing or blockage <50-70% in general are unlikely to significantly reduce the blood flow down the artery, and usually do not cause any chest pain. Hence they usually do not benefit much from stenting procedures, which are designed mainly to reduce symptoms.

6. However any degree of narrowing or what we call atherosclerosis puts the patient at higher risk of future heart attack, the treatment is to maintain healthy habits and practices that will keep the heart muscle and blood vessel healthy, and the blood less sticky and flowing well.

   These include lowering cholesterol, maintaining normal blood pressure, no smoking, reducing mental stress, controlling or preventing diabetes and maintaining optimal weight. These are achieved through a combination of lifestyle practices and medications, which will reduce the chances of heart attack but never quite eradicate it totally.

7. The top larger number is the systolic pressure which measures the pressure generated when the heart pumps. It reflects the pressure of the blood against the artery walls. The bottom smaller number is the diastolic pressure and is the pressure in the arteries while the heart is filling and resting between pumping. A persistently high pressure in either reading can damage vital organs or the blood vessels in the long term.

Question by rachel

My father, now in his 70s, previously had a heart attack 10 years ago. He continues on medication, but his last heart check was more than 4 years ago, and he doesn't want to go anymroe saying he 'feels fine and so,... is fine'!

Since he is taking his medication regulary, and goes for a walk almost everyday, is that as best as he can do, and can get? I guess he thinks there is not much point going for more tests as he is already doing what is right, so doesn't want any more worry, or bad news, or restrictions in his lifestyle.

He also read somewhere that eggs are actually okay ( its got cholesterol but the 'good' cholesterol, he claims) and that nuts are good for the heart. I have read about almonds and walnuts, but does that apply equally to the general groundnuts that are available easily and locally? He says that its not mentioned because the western countries do not grow it, so they don't publicise it as well as the almonds, etc.

Can you please help verfiy/clarify.

Thank you very much

Answered by Dr Peter Ting, Consultant, Department of Cardiology, National Heart Centre Singapore

Regular heart checks are good but not entirely necessary. The main thing is to ensure that all the risk factors for coronary artery disease are well controlled if not corrected.

This can be achieved through lifestyle changes and medications, and is the best thing that one can do to prevent another heart attack. Regular heart checks with a doctor can help by detecting any subtle changes in a patient’s condition or any new symptoms. They also serve to help the doctor ensure that the risk factors are in fact optimally controlled and implement the appropriate measures if they are not. You are right, many times patients are so comfortable with their current lifestyles that they do not wish to see to doctor and get told of more “restrictions”!

Eggs are actually a good source of protein and nutrition. More recent studies have shown that a moderate consumption of eggs (up to one a day) does not seem to increase the heart disease risk in healthy individuals, however it should still be taken in moderation. Try removing or having less of the yolk, which contains most of the fat and cholesterol. More important than dietary cholesterol, is the type and amount of dietary fats in the diet. Saturated and trans fats are the “bad” fats found in animal fat, fatty meats, dairy products, cakes, certain oils like coconut or palm oil, fried snacks etc. These fats are more likely to raise the total and “bad” cholesterol or LDL. Conversely healthier fats like mono or polyunsaturated fats can reduce the total or LDL cholesterol.

Most nuts appear to be healthy, but some are probably better. Nuts usually contain the healthier fats mentioned above. Walnuts, almonds, macadamias, hazelnuts and pecans all seem to be heart healthy, and even perhaps peanuts. Some nuts also contain omega-3 fatty acids or beneficial vitamins. Nuts make a healthier snack substitute for other less healthy snacks such as chips, French fries or cookies. However all things in moderation, nuts are very calorie rich, and if taken in large amounts can lead to weight gain and even obesity which has its own health risks.

Ref: V10