A heart attack, characterised by severe chest pain that radiates up the neck or down the left arm, is a condition that everyone fears.

How do you prevent a heart attack? What can you do if a loved one has a heart attack? Are the symptoms of a heart attack the same for both women and men?

Take the chance to ask Assistant Professor Ho Kay Woon, Senior Consultant with the Department of Cardiology at National Heart Centre Singapore (NHCS), a member of the SingHealth group, all about heart attacks.


Question by catbear (reposted by Forum Admin)

Dear Asst Prof Ho, I'm a fairly slim woman in my mid 30s. I try to get 10K steps per day and eat fairly healthy. But my latest cholesterol level was not so good (213 mg/dL). My HDL is 80 mg/dL and the LDL is 122 mg/dL. I read somewhere that bad cholesterol can be lowered through diet. Is this true? What can I eat to improve my heart health and prevent a heart attack later in life?

I'm a bit concerned because my paternal grandma and maternal grandad both passed on due to heart attack. On top of that, my dad has high cholesterol + high blood pressure and is on medication for both.

Answered by Assistant Professor Ho Kay Woon, Senior Consultant with the Department of Cardiology at National Heart Centre Singapore.

Dear Catbear,

First of all, please keep up the good work in keeping fit and leading a healthy lifestyle. Your cholesterol profile is excellent. The total cholesterol comprises of a few components including low density lipoprotein (LDL) or “bad” cholesterol and high density lipoprotein (HDL) or “good” cholesterol. To prevent future heart attack, we look to reduce LDL through lifestyle changes, diet control or medication if needed. We aim for a high HDL level mainly through exercising. Looking at the total cholesterol result may be misleading as in this case, the good HDL cholesterol elevates it, whereas of the breakdown of HDL and LDL may be more informative. For your age and health condition, LDL of 122mg/dL is optimal even considering the family history of heart attack. HDL of less than 40mg/dl is considered low whereas more than 60mg/dl is considered a protective factor. Your HDL is in the healthy range. 

In general, diet plays an important role in controlling LDL cholesterol, where lowering calorie intake, a high fibre or complex carbohydrate diet, moderating consumption of fried food items will be helpful. More information can be obtained for the health promotion website on health living and diet (https://www.hpb.gov.sg/healthy-living/food-beverage).

Hope this clarifies and please continue with your healthy living that you are currently maintaining.


Question by dawnie (reposted by Forum Admin)

Dear Doctor Ho, Thank you so much for allowing me the opportunity to ask for your medical advice. I am asking on behalf of my father. He is generally in good health, had a stent placed 2 months ago, and have been experiencing chest pains at night that keeps him awake throughout the night. Is this normal?How long will this last? Any exercise tips can help him for his situation?

Thank you for your advice.

Answered by Assistant Professor Ho Kay Woon, Senior Consultant with the Department of Cardiology at National Heart Centre Singapore.

Dear Dawnie,

Thank you for the post. Having chest pain at night after coronary artery stenting 2 months earlier is not normal especially so if this keeps him awake throughout the night. Kindly inform your doctor early with regards to this so that the symptoms can be evaluated and treated appropriately.


Question by Sonia09 (reposted by Forum Admin)

Dear Doctor,

My mother has angina in her 40s and now I am in my late 30s and im starting to worry that it is hereditary condition. If I keep to a healthy diet, exercise regularly, maintain low cholesterol and blood pressure, will I get angina? What are some things that I can do in order to reduce my risk?

Thank you for your time.

Answered by Assistant Professor Ho Kay Woon, Senior Consultant with the Department of Cardiology at National Heart Centre Singapore.

Dear Sonia,

Thank you for you post. Major risk factors that predispose one to coronary artery disease which will lead to angina include old age, male gender, diabetes mellitus, cigarette smoking, sedentary lifestyle/obesity, hypertension and high cholesterol levels. The more uncontrolled risk factors present increases the risk of developing earlier coronary artery disease. It will be important to maintain a healthy lifestyle like you are currently doing by having a healthy diet, exercising regularly, quit smoking (if you are a current smoker) and maintaining a healthy weight / BMI (less than 23).

In spite of a healthy lifestyle, certain risk factors tend to be inherited, for example, diabetes mellitus, high cholesterol or high blood pressure. These conditions may not exhibit any symptoms until serious problems are caused such as angina or stroke. As such, it would be important to screen for such risks on a regular basis and take corrective measures if these risk factors are not optimally controlled. Once optimised, the risk of coronary artery disease at an earlier age would be markedly reduced. Hope this helps towards your journey to an even healthier lifestyle.


Question by healthblur (reposted by Forum Admin)

Does statin really work to cut a heart attack risk? How effective is it ? I have a friend who is 60 years old and was diagnosed with high cholesterol. He was prescribed statin. His cholesterol dropped significantly and now he has taken to ‘enjoy’ eating generously again. Does this really protect him from a heart attack despite his diet?

Answered by Assistant Professor Ho Kay Woon, Senior Consultant with the Department of Cardiology at National Heart Centre Singapore.

Dear healthblur,

Statins have been established to reduce the risk of heart attack and stroke in patients with high cholesterol both in situations when patients have had previous events like heart attack (secondary prevention) or if they did not have an event (primary prevention). Nevertheless, medication works in concert with a healthy diet, compliance to medication intake and healthy lifestyle. In addition to high cholesterol, excessive dietary intake can also lead to health problems such as obesity, diabetes mellitus and hypertension. It is essential to maintain a healthy diet and lifestyle, in addition to medications.


Question by amostoh (reposted by Forum Admin)

I'm 50 and do weekly exercise like jogging and is generally in good health.  Recently, I felt slight tingling feel on my left chest sporadically for about a month.  This happen usually when I'm not doing any exertion. After consulting a GP last sunday, he recommended that I go to A&E for a quick check-up.  ECG, x-ray & blood test was done and nothing show up.  I was then referred to do a treadmill test yesterday.  The doctor in attendance shared that there's abnormaility and the cardiologist on duty recommended that I start on Aspirin and Cholestrol med immediately and appointment with cardiologist was brought forward. My questions are as follows:

  1. Between now and the next appointment, what do I need to watch out for?
  2. I do feel that the tingling feeling has slightly worsen with higher frequency and I can occasionaly feel tingling feeling on my left arms as well.  Is there justification for me to seek immediate medical attention? Otherwise, I do feel fit enough to do normal office work.
  3. If there's narrowing of heart artery, is it possible to treat it without the need to be on long term medication as I undertand that there will defintiely be side effects with such medidicine like gastric ulcers, increased risk of strokes due to internal bleeding etc.
  4. What will be my chances to a full recovery so that I can go back to my usual exercise routine, in the event that I need to insert a stent in my heart?

Answered by Assistant Professor Ho Kay Woon, Senior Consultant with the Department of Cardiology at National Heart Centre Singapore.

Dear Amos,

The discomfort that you have described does not fit a typical description of angina which is classically brought on by exertion. However, the abnormal treadmill stress ECG suggest perhaps underlying coronary artery disease and hence the additional medications. Symptoms to watch out for will be prolonged severe chest tightness lasting more than 5 min, usually associated with profuse sweating and nausea that may represent a heart attack. You should seek immediate medical evaluation if such severe symptoms occur.

The need for medication depends on whether there are any underlying coronary artery narrowing. The next evaluation could be an angiogram to determine if there are any significant narrowing. Most medication can be stopped if no blockage is found. However, medication will be needed long term if narrowing of the coronary arteries are found. The medication serves to reduce the risk of future heart attack, and reduce the progression of narrowing. These medications generally will be needed long term. Each medication has its own side effects but the benefits generally outweigh the risk. Hence, it is typically recommended to continue long term medication to reduce cardiac events, such as heart attack, once the diagnosis of coronary artery narrowing is established.


Question by bernardlow (reposted by Forum Admin)

Hi Prof Ho, further to my earlier question, I'd also like to find out what supplements you would recommend for a patient like with coronary heart disease.

Answered by Assistant Professor Ho Kay Woon, Senior Consultant with the Department of Cardiology at National Heart Centre Singapore.

Dear Bernard,

Supplements have not conclusively found to reduce the risk of future heart events and are not essential for the maintenance of heart health. Hence, I will not recommend any supplements beyond the medications that you have already been prescribed.


Question by googleoauth2 (reposted by Forum Admin)

I have been taking Asprin + Statin for years to control my cholesterol level and my Stress Echocardiography result taken on 10/10/2017 was "Normal". How else may I prevent / detect heart attack / stock related diseases, given 3 of my friends about my age had heart bypasses recently? Thanks!

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Dear googleoauth2,

It is reassuring that the stress echocardiogram was normal. The result suggests that there is no significant coronary artery blockage that cause a reduction of oxygen supply to the heart. Despite this result, it is important to control risk factors such as cholesterol levels, diabetes and hypertension. Leading a healthy lifestyle by regular exercising and having a healthy diet also helps. In the appropriate clinical situation, a CT calcium score can be done to assess the degree of calcium deposit in the heart artery. The higher the calcium score the higher the risk of future heart events. If the score is high, risk factors can be more aggressively controlled. You may approach your doctor to discuss further testing that is required.


Question by Sunshine (reposted by Forum Admin)

I am 52 years old female with no high blood pressure or cholestrol issues. I have type 2 diabetic but under control through diet with no medication. I have been experiencing heart palpitation for the past 10 years. But for the last 3 years, it has progress to squeeziness of the heart that leads to breathlessness. I have gone to National Heart centre for a few check up inclusive echo test but the heart always never palpitate or become breathless during those time when check were conducted. 1 cardiologist even thought i was paranoid. The palpitation always starts when i am lying on my bed which affect my sleep or when i am sitting. But I feel better when I walk which is very strange. Some days the heart behaves very well but some days the palpitation can go on for weeks especially when i am lying down. And i do get tired more easily than before. Btw, I am not ovetweight. I am actually under weight since young. Please advise. Thank you.

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Dear Sunshine,

There are many causes of palpitation ranging from harder and faster heart beating from physical and emotional stress (normal but faster heart beat) or abnormal fast heart rhythm. To establish the diagnosis will require a recording of the heart rhythm at the time of having symptoms. This can be established by a few ways. If you have such symptoms and there is a nearby medical facility e.g. polyclinic or GP clinic, request for an ECG to be done to document the heart rhythm at the time of symptoms.

Hear monitoring devices available in NHCS include holter and transtelephonic ECG. Holter monitoring is a continuous ECG monitoring for a relatively short duration of 1-2 days (for more frequent symptoms). Transtelephonic ECG can be performed when the symptoms are less frequent and involve putting out the recording device when symptoms occur and the ECG is recorded and transmitted to NHCS for analysis. Hence, we establish the symptoms of palpitation with underlying heart rhythm. At time, we may use treadmill stress ECG to evaluate if there are any abnormal rhythm that is precipitated by exercise.

Tightness of chest may be a sign of heart artery narrowing and evaluation should be performed to identify if there are any coronary artery disease with the appropriate test e.g treadmill stress ECG. Hope this clarifies.


Question by Seok Gek (reposted by Forum Admin)

My husband is in his 61 years old. His hypocount always reads between 6.2 to 6.8. 

He also has hypertension (controlled 120/70) and high cholesterol (on Simvastatin 10mg). 

I would like to know, if his condition stays controlled, usually how long can such patient lead a normal life before his condition deteriorates? 

What kind of exercise and food can help him?

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Dear Seok Geok,

Major risk factors that predispose one to coronary artery disease which will lead to angina include old age, male gender, diabetes mellitus, cigarette smoking, sedentary lifestyle/obesity, hypertension and high cholesterol levels. The more uncontrolled risk factors present increases the risk of developing earlier coronary artery disease.

It is heartening that you are very involved in your husband's health and taking good care of his medical condition. With good control of blood pressure, blood sugar and cholesterol, we reduce the risk dramatically for coronary artery disease, stroke and peripheral vascular disease.

Lifestyle measures are important to healthy living. Exercises help maintain our well-being and maintain our ideal weight.  On the other hand, a healthy diet with reduction calorie intake; a high fibre or complex carbohydrate diet, moderating consumption of fried food items will be helpful to reduce the risk of high cholesterol, blood pressure, obesity and diabetes. More information can be obtained for the health promotion website on health living exercise and diet (https://www.hpb.gov.sg).


Question by Audrey (reposted by Forum Admin)

Hi Doc,  

My Husband age 49 is working as Bus driver driving on the road most of time.  

When he is panick or rushing for time, his heart have a feeling like riding on roller coaster. Is this a likely symptom of a heart Attack or blockage?  

How can he conduct check whether he has any heart problem? We ever visited the Polyclinic n was refer to NHS. We waited for months for the appointment in NHS, the doc in NHS just diagnosed less than 5 mins n sent him off. We have very bad experience with NHS doc.

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Dear Audrey,

Thank you for your post. It is expected that our heart rate increases in rate and strength when we are under stress either emotionally or physically. Some may feel more intense symptoms than others, although, faster heart rate with stress is generally not a disease state.  Danger signs when there are accompanying symptoms like chest pain, fainting, sudden onset of fast heart beat when not under stress. When having symptoms of palpitation or racing heart beat especially if not under stress, it is important to seek medical evaluation and better still have an Electrocardiogram (ECG) to document the heart rate and rhythm that caused the symptoms of palpitation. Perhaps it may be helpful to advise your husband to approach the nearest medical faculty, such as a GP clinic or polyclinic the next time he has such racing heart symptoms to diagnose objectively with an ECG, to find out if his palpitation is due to a normal heart rhythm that is going faster with stress or an abnormal condition.  If his condition is persistent and difficult to detect, recording devices such as continuous ECG ambulatory monitoring (holter) are available in NHCS to correlate palpitation to the underlying heart rhythm.

(Note from NHCS: Hi Audrey, thank you for your feedback and we are sorry for your experience. If you wish for us to get in touch with you, please send your contact details to nhcs@nhcs.com.sg and our feedback team will follow up with you.)


Question by SK Cheong (reposted by Forum Admin)

Dear Sir, 

May I know how to determine a heart attack? Does it comes with chest pain, radiate to neck or arm, breathless and leg swollen? Do they come together or as long as one or two of such symptoms? What is the best time to send for Emergency after giving GTN? What if GTN is given wrongly as patient is unable to differentiate from GERD. What is the difference or how can a 3rd party know is GERD or Heart attack?  

Is there such a symptom of the heart or chest being feeling cold? What does it mean to a heart patient with no sweating? Cold sweat means feeling cold but is sweating? 

How do we determine PVD from swollen legs and why frequent leg cramps? 

Thank you very much for your enlightenment as I am a caregiver for my mother who has IHD.

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Dear SK,

Heart attack occurs when blood supply to the heart muscles is suddenly reduced, usually because of cholesterol plaque rupture within the heart (coronary) artery with clot formation. With the reduction of blood supply to the heart muscles there will classically be a crushing central chest pain lasting more than 30 minutes associated with profuse perspiration, nausea. The pain may also spread to the neck or left arm. GTN may be tried with the onset of chest tightness but one should seek medical evaluation if the pain is persistent despite GTN beyond 5-10 minutes.

Gastroesophageal reflex is due to acid entering the oesophagus and causing pain as it irritates the oesophagus. It classically is worse with lying down and may be associated with the taste of acid in the mouth. GTN may relief chest pain due to angina and oesophageal muscle spasm and may not be reliable to distinguish between the two conditions. There are many overlap between GERD and angina and it's best to leave it to your health professionals to make a distinction.

Classically, angina is not described as the sensation of the chest being cold although there may be atypical presentation of angina and heart attack especially for patients with diabetes.

Peripheral vascular disease involves the narrowing of the limb arteries supplying the extremities. It classically does not cause swelling and generally presents with calf aches with walking, and becomes better with rest.

Hope the above clarifies your queries.


Question by Francis (reposted by Forum Admin)

Hi Dr, 

Recently I keep feeling my heart is being poke by needles, a first is feel like a few needles, now it’s feels getting more needles poking. 

May I know what could be the problem? Thanks.

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Dear Francis,

From your description, it does not sound typical of pain due to a heart attack or narrowed heart artery. Typical pain from narrowed heart artery is worse with exertion and better with rest. It presents usually with a heaviness of the chest that may spread to the neck or left arm. It would last for minutes rather than seconds. If the discomfort is persistent or worsens it may be prudent to seek medical evaluation and diagnose the underlying cause of the chest discomfort.


Question by iris (reposted by Forum Admin)

Hi Prof Ho,  

My Mother, now in her late 80s, has been diagnosed with AS recently. She is on beta blocker.  

Over the past 1 month, she has been experiencing right leg pain every now and then. She described the pain as ‘nerve pain’ at the back of her right leg, below the knee cap area.  

She is also wheelchair bound. Would like to check if her leg pain could be related to her heart condition. Tks.

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Dear Iris,

Thank you for your post. Classical symptoms for aortic stenosis are chest pain, fainting and breathlessness on walking.

The pain that goes from the back of the leg to the knee cap may be due other causes, such as nerve compression around the spine area. Seeking medical evaluation can help clarify the cause and further investigations can help confirm the diagnosis and determine the appropriate treatment for her leg pains.


Question by john (reposted by Forum Admin)

Hi. Thanks for this forum!

My elder brother in his late sixties is on statins as his cholesterol was borderline high and he is just so scared of getting  a heart attack as two of his close friends have suffered one.

My question is : is there a difference between the ‘branded’ statins and the generics?

How much difference ? 

How long must one be on statins for to ‘protect’ the heart? Is it lifelong? 

Lastly, since he went on the medication, his cholesterol dropped so he is really enjoying his fried food now. Is it safe?

Otherwise,  he’s actually very active, slim and exercises a lot! 

Look forward to your answers. Thanks again.

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Dear John,

The active components of branded or generic statins are the same and generally the effectiveness of both medication should be similar. In rare circumstances, patients may experience side effects of generic medication and not with branded medicine and can only tolerate taking branded medication. This may be related to differences in the manufacturing process difference components to the medicine other that the active compound.

In general the risk of heart disease is related to:

  1. How high the low density lipoprotein is (higher LDL levels means higher risk of heart disease)
  2. How long the exposure to high cholesterol is (a young patient exposed to high cholesterol for a long period of time will have a higher chance of heart conditions vs an older patient with similar cholesterol level exposed to a shorter duration
  3. Are there other risk factors other than cholesterol present e.g diabetes/hypertension (the more the risk factors especially if they are uncontrolled will represent higher risk for heart conditions in the future)

The initial treatment for high cholesterol is the change of lifestyle with maintaining of a healthy diet. If these changes are not able to control the cholesterol levels adequately, medication will be needed.

Conversely, if medication is started and dramatic lifestyle changes have been made, the cholesterol levels can be reduced to such an extent that medication can be reduced or stopped. Nevertheless, it will be necessary to regular check the cholesterol levels to ensure they continue to be adequately controlled.

Maintaining a healthy diet is important beyond cholesterol control e.g. reducing salt levels to reduce the risk of blood pressure, reduce calorie intake to maintain a healthy weight and reduce the risk of diabetes. Medication should also be taken in concert with a healthy diet to reap the maximal effects. Hence, do continue to eat healthily even though there are encouraging signs on blood tests on cholesterol control with medication.


Question by mlewsk (reposted by Forum Admin)

Dear prof Ho, I had 4 cardiac stents implants since Aug 2016. Since then have been on 5 medications: aspirin, plavix, bisoprolol, lipitor, and famotidine. Can I stop aspirin or plavix and reduce the statin from 40 to 20mg if my bloodwork shows a LDL of less than 2.0 mmol/l? I dont snack, eat whole, unprocessed foods, dont drink alcohol, coffee or tea, dont take supplemrnts, have no diabetes, non smoker, brisk walk 30 mins everyday, height 170cm, weight 57kg and also have switched to a predominantly vegan diet since the operation. Thanks.

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Dear mlewsk,

With regards to the medications that you have been placed on since the stenting procedure:

  1. Aspirin and clopidogrel (Plavix )- they are antiplatelet agents or weak blood thinners. They reduce the risk of blood clot forming within the stents and reduce the risk of a heart attack. Both may be taken for up to one year after stent implantion before one of the two medications is stopped and one continued long term to reduce the risk of heart attack (usually aspirin). The antiplatelet medication should not be stopped unless for a short duration e.g. operation or tooth extraction when bleeding is expected.
  2. Lipitor or atorvastatin reduce the low density lipoprotein of the blood cholesterol and reduces the rate of atherosclerosis or cholesterol build up in the heart arteries. Depending on why the stents were implanted in the first place (heart attack vs a stable chronic angina situation) the LDL target might even be lower than 2.0mmol/L. Hence, the dosage of Lipitor should not be reduced.

Congratulations on changing to your lifestyle to a healthy one with healthy diet and frequent exercising. This will indeed help to reduce the risk of cardiovascular disease in the future. Nevertheless, there are risk factors that may be inheritable or genetic e.g. high blood pressure, high cholesterol or diabetes that might not be adequately controlled with a change to healthier lifestyle and may still require medication for control if blood tests and physical examination showed suboptimal control of these risk factors. Please check with your health care professional regarding the control before any changes to the dosages.


Question by Wei Peng (reposted by Forum Admin)

What is Ischaemic Heart Disease?

Is this different from Heart attached?

Thanks for the reply.

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Dear Wei Peng,

Ischaemic Heart Disease, also known as Coronary Artery Disease, is the narrowing or blockage of the artery or arteries supplying blood to the heart muscle. This narrowing is caused by plaques, which are cholesterol deposits on the vessel wall.
The cholesterol plaque causing the blockage can sometimes rupture suddenly, causing a blood clot to form. This blood clot will cut off blood supply and cause damage to the heart muscle, which leads to a heart attack.  


Question by Michelle (reposted by Forum Admin)

Hello,

Just want to check ,my brother heart weak but we planning to travel on this coming June,can advise to me is he suitable to take a plane?

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Dear Michelle,

Patients with weak heart can have changes in their status. He should be ok to travel by air if there is no fluid overload and if he continues to have his medication during his travels. However, it is best to have his condition evaluated by his doctor-in-charge just prior to the trip, to assess his fitness for travels.


Question by Katherine Quek on behalf of Angie (reposted by Forum Admin)

Dear Asst Prof Ho

I am in my mid 50s with BMI 16.9. The total, LDL and HDL are in the normal range. I exercise regularly and have healthy diet. I measure my BP every morning and before bed and is between 110 – 120/70 – 80. My BP monitor is function fine. I have elevated BP in clinic setting as I tense up easily when visit doctor. I did a 24-hr BP but was unsuccessful as I felt irritating and unable to sleep for the whole night. ECG indicates LVH, prolong QT interval and anterior T-wave inversion. 3D Echo: Mildly abnormal – Aortic valve sclerosis and mitral annular calcification. Carotid Ultrasound: 20% stenosis on the right side. Coronary CTA: Mild ectasia in LMCA and proximal LAD. Minor irregularities (<20% diameter stenosis) in some coronary segments. Tortuous at D1, D2, OM2 and OM3. Myocardial bridging in mid LAD.

  1. What is the cause of inverted T-Wave on ECG? Is the ECG abnormal OK? If that is the case, how to tell whether the heart is OK if I have to do new ECG in future?
  2. Understand that BP will dip at night, is that a concern if BP does not dip at night (lower than day time) but it is still within the normal range, ie below 120/80.
  3. What is the main cause to arteries inflammation and how is this lead to blood clot.
  4. Can one ignore prolong QT interval when aged?
  5. How often should patient go for Carotid US, Echo and CTA?
  6. Any exercise should I avoid? I do jogging and yoga.
  7. How should I take care my heart?

Thank you for your time and advice.

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Dear Katherine/Angie,

With regards to your queries:

  1. The cause of inverted T waves and left ventricular hypertrophy is still most likely hypertension and thickening of the heart muscles. Did the echocardiogram report any left ventricular hypertrophy or thickening? This may indicate hypertension that may have not be diagnosed in the past. The reassuring finding is that of normal BP measurements taken at home. It would be important to ascertain that the BP machine used at home is accurate and have enough readings throughout the day to be accurate.
  2. We expect the blood pressure to be lower when we sleep at night by about 20%. This is much less of a concern if blood pressure is in the normal range. No treatment is needed this.
  3. Traditional risk of artery inflammation leading to early cholesterol build up in the heart artery and increasing the risk of heart attack includes: smoking, diabetes, hypertension and high cholesterol. With more uncontrolled risk factors present, the more likely the inflammation and to a higher extent. In the heart artery, cholesterol build up within the wall to the artery in structures called cholesterol plaques. The cholesterol material is separated from blood cells within the blood vessel by a thin wall. When there is a lot of inflammation of the blood vessel, this weakens the thin wall and can cause the plaque to burst or rupture during periods of stress that exposes the cholesterol to blood cells. When this happens, the exposed cholesterol forms blood clots with the blood cells and this can lead to complete blockage of the blood vessel with blood clot leading to a heart attack.
  4. QT interval is considered prolonged when QTC is greater than 460 milliseconds. The longer the interval, the higher the risk of abnormal heart rhythm. The significance of the prolonged QT interval will be assessed by your healthcare professional. Age itself does not mitigate the prolonged QT interval.
  5. In general, unless there is a good indication or clinical reason to suspect disease state, there is no reason for regular screening with the investigations that you have stated.
  6. There is no exercise to avoid. Please live life as usual.
  7. In general, maintaining a healthy diet and lifestyle by exercising regularly, avoid smoking and controlling any cardiac risk factors like high blood pressure, diabetes, high cholesterol will help maintain good heart health.

Question by Chow May Chia (reposted by Forum Admin)

What should first responder do when faced with a heart attack patient?

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Dear May Chia,

Thank you for being so civic-minded. What to do when faced with a heart attack patient depends on:

  1. Condition of the patient: alert having chest pain or in a collapsed state
  2. Whether the first responder is trained in cardiopulmonary resuscitation.

The principle of management is to alert the emergency medical response (e.g. ambulance and paramedics) as soon as possible by calling 995.

If the patient is in a collapse state and someone who is trained in CPR is available, CPR should be initiated immediately if necessary. Furthermore, many places in Singapore are equipped with Automated External Defibrillator (AED). If available, an AED should be connected to the collapsed patient and the AED would advise if any shocks are required. CPR should be continued till the arrival of the paramedics or ambulance.

If the patient is still alert and conscious and have symptoms suggestive of a heart attack (severe crushing chest pain with cold sweat), he should be brought to the nearest medical facility available for assessment and stabilisation. If there are no available medical facilities nearby, please alert the medical emergency medical response for assessment, stabilisation and evaluation to hospital if needed.


Question by Willis (reposted by Forum Admin)

How do we differentiate heart attack from muscle pain of heart intestine.  Both seem to have similar symptom of short breath, sweat & pain? Calmness & slow breathing seem to help reduce the latter & reduce intestine twist.

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Dear Wills,

Angina pain due to heart artery narrowing typically cause chest tightness that is brought on with exertion (e.g. chest tightness when climbing stairs and gets better with resting.

Chest pain that are of short duration (few seconds), not associated with exertion and affecting a localised spot is not typical of angina pain due to chest artery narrowing. This may suggest chest wall or muscular pain is especially if the same pain is reproduced with pressure on the chest wall or increased with coughing.

When in doubt, your doctor may order a stress test e.g. treadmill ECG to evaluate for ECG changes that would suggest progression of narrow that may account for increasing chest pain.

Intestinal pain is intermittent and is localised to the abdomen. The discomfort again will not be increased by exertion. The discomfort may be relieved with bowel opening or passage of gas.


Question by Willis (reposted by Forum Admin)

How do we differentiate heart attack from muscle pain of heart intestine.  Both seem to have similar symptom of short breath, sweat & pain? Calmness & slow breathing seem to help reduce the latter & reduce intestine twist.

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Dear Wills,

Angina pain due to heart artery narrowing typically cause chest tightness that is brought on with exertion (e.g. chest tightness when climbing stairs and gets better with resting.

Chest pain that are of short duration (few seconds), not associated with exertion and affecting a localised spot is not typical of angina pain due to chest artery narrowing. This may suggest chest wall or muscular pain is especially if the same pain is reproduced with pressure on the chest wall or increased with coughing.

When in doubt, your doctor may order a stress test e.g. treadmill ECG to evaluate for ECG changes that would suggest progression of narrow that may account for increasing chest pain.

Intestinal pain is intermittent and is localised to the abdomen. The discomfort again will not be increased by exertion. The discomfort may be relieved with bowel opening or passage of gas.


Question by KarenL (reposted by Forum Admin)

Occassionally I do wake up from sleep due to palpitation.  It is so strong I thought my heart will explode and suddenly stop. Can palpitation be caused by narrowing arteries?

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Karen,Palpitation can mean different things to different persons. Some would consider palpitation as stronger heartbeat, others faster or extra beat. Many a times we may be made aware of our heart beating at night when there are no other distractions and this may be normal. In general, a sensation of feeling a stronger heart beat that is neither fast or slow is not indicative of any underlying heart condition or narrowing. Rather our heart contracts harder during times of physical or emotional stress and this reaction from the body is to be expected during times of stress or anxiety.


Question by KarenL (reposted by Forum Admin)

I am 60 years old.  In May 2017, tests showed I have mild blockage to 2 of my heart arteries.  My doctor is satisfied that tests also showed I do not need invasive angiogram and has since put me on aspirin, lipitor and Concor.  I am due for review in August 2018.  Occassionally, I feel mild tightness (as in like muscle tightening) or mild throbbing pain near or over my left breast.  Sometimes, tingling of my left arm.  I also have occassional strong palpitations during my sleep, which woke me.

Although I read about the severe symptoms of heart attack, I do not know if they do come in milder form as a pre-warning / alert.  Since my diagnosis, I get stressed by any "possible" look-a-like symptoms.  I cannot tell if it is really my heart having these symptoms, or I am just getting perhaps a muscle pull or strained muscles that's near my left chest.  How do I sift out the noise?

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Dear Karen,
I would assume that the mild blockages were picked up by CT angiogram and if so such narrowing will be less than 40% narrow. In general, for the narrowing to be severe and cause symptoms, the degree of narrow would be greater than 70%. Rest assured that the medication advised are appropriate to reduce the risk of heart attack (aspirin) as well as controlling risk factors of high cholesterol and hypertension (with Lipitor and concor) to retard the progression of the narrowing.

While mild narrowing would not cause symptoms, severe narrowing typically cause chest tightness that is brought on with exertion (e.g. chest tightness when climbing stairs and gets better with resting. Chest pain that are of short duration (few seconds), not associated with exertion and affecting a localised spot is not typical of angina pain due to chest artery narrowing. When in doubt, your doctor may order a stress test e.g. treadmill ECG to evaluate for ECG changes that would suggest progression of narrow that may account for increasing chest pain. Hope this clarifies.


Question by bernardlow (reposted by Forum Admin)

Dear Prof. Ho,

Thank you for your kind reply. Can you advise what tests should be done to determine the severity of coronary stenosis?​

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Several tests are available for determining the presence of significant narrowing.

  1. Stress test: treadmill ECG or stress echocardiogram or myocardial perfusion scan are performed when the heart under stress either with exercise or medication to increase heart contraction. We then look for evidence of narrowing during times of stress either from symptoms, ECG changes or scan suggestion of lack of blood supply to the heart. If this test is positive for abnormalities, a more invasive coronary angiogram will be performed to confirm the presence of coronary artery stenosis
  2. Invasive coronary angiogram: done when the stress test above area positive or symptoms highly suspicious of underlying coronary artery narrowing.
  3. CT coronary angiogram: contrast is injected from a vein of the arm and a CT scan is performed to evaluate if there are any narrowing. This is noninvasive but this test may be difficult to interpret the significance of borderline narrowing or if the coronary artery if heavily calcified (especially in the elderly) or if previous stenting has been performed (creates artifacts). In general, should not be done as a first line for evaluating coronary artery disease.

Question by Melric (reposted by Forum Admin)

Hi Dr

My wife has nightmare with heart palpitation. Does heart palpitation cause nightmare or vice versa?

She exercise quite regularly and on strict diet with occasion of IBS symdrone. She was once on statin prescribe by polyclinic. With chloresterol under control, she stop taking statin and continue medical follow up at polyclinic.
Please advise palpitation frequency that warrant concern. Is there a difference in heart palpitation and abnormal heart beats cause by events like nightmare or exercise?
Thank you.

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Dear Melric

Palpitation can mean different things to different persons. Some would consider palpitation as stronger heartbeat, others faster or extra beat. Many a times we may be made aware of our heart beating at night when there are no other distractions and this may be normal. In general, a sensation of feeling a stronger heart beat that is neither fast or slow is not indicative of any underlying heart condition or narrowing. Rather our heart contracts harder during times of physical or emotional stress and this reaction from the body is to be expected during times of stress or anxiety (when brought on by nightmares).

If her palpitation is clearly brought on by nightmares or stress then it is to be expected and no further evaluation needed. However, if the palpitation especially fast heart beat occurs without any stressors then further evaluation may need to be carried out.


Question by Chan Weng Sun (reposted by Forum Admin)

I am 67 after CABG.

What estimated life span for patient after cabg? I know there are other factors. So you can make some assumptions in your reply.

Answered by Asst Prof Ho Kay Woon, Senior Consultant from the Department of Cardiology, National Heart Centre Singapore

Dear Mr Chan Weng Sun,

There are difference types of grafts that a surgeon can use during coronary artery bypass operation /grafting (CABG) . The most important and long-lasting graft is the left internal mammary artery (LIMA) graft that is used to graft the left anterior descending artery which is the most important artery of the heart. This graft last well beyond 10-15 years without issues in general. However, there is only one LIMA available for use in CABG and the rest of the vessels are usually grafted with vein graft harvested from the legs. These vein grafts have a 50% chance of lasting 10 years.

Controlling risk factors like cholesterol, high blood pressure and diabetes as well as cessation of smoking with a healthy lifestyle will extend the lifespan of the grafts. When the grafts fail there may be a recurrence of chest pain on exertion and if the grafts are found to be indeed narrowed, coronary angioplasty or stenting can still be done to restore flow of the narrowed grafts. In extreme cases when the graft have all failed, we may even consider doing a redo CABG to restore adequate blood supply to the heart.


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Ref: N18