Every year, over 17 million lives are claimed by the global burden of cardiovascular diseases. But this can be largely prevented through simple lifestyle changes.

As we mark World Heart Day on 29 September 2011, do take this opportunity to check the risk factors for heart disease for yourself and your loved ones.

​​​Dr Chin Chee Tang​ and ​Dr Tang Hak Chiaw, Senior Consultants​ from the Department of Cardiology at Singapore General Hospital, give detailed answers to your questions.

Question by Tina



I lately had an extra heart beat confirmed by a GP. I had been exercising regularly except lately more frequent.

During the che​ck it heart beat rate is normal but additional beat. At that point I can feel the discomfort. No pain though. This happens most at rest and its continuous for more than 20 mins.

Understand that this is known as Arrythmia and its no cause for alarm.

In that case, can I still continue with my gym workout?

Please advice.



Answered by Dr. Tang Hak Chiaw, Consultant, Department of Cardiology, National Heart Centre Singapore

Arrhythmia is a general term for 'abnormal heart rhythm'.

The 'additional beat' that you mentioned is called ectopic beats. It is generally a benign condition. Most of the time, there is no explanation for its occurrence. For some people, however, ectopic beats can be due to strong coffee, tea or certain type of medications.

You can still continue with your exercise. In fact, you may have notice that the ectopic beats actually are less frequent when you are exercising. This is the nature of benign ectopic beats.

Question by klim

My mum (age 64) had gone to a specialist for cough as she had been having frequent intermittent coughs. At the same time, there is kinda 'pain in her left chest' once every 2-3 months. Both her legs gets 'like water retention' about 3-4 times over the last 2-3 years. We thought it better we seek some consultation on this.

During the consultation, it seems her heart had some sounds, of which he suggest for us to consult a heart doctor. He had suspect the valve is weakening. We henceforth went to see a private heart specialist, of which it seems the specialist had confirmed that there is nothing wrong with her heart. The heart specailist recommend us to see a 'chest & lung doctor'. Both are private practise. The lung doctor did a scan and blood test. The blood test did not result in any high blood pressure or chloresterol etc. From the scan, it seems the gut could be pushing onto the diaphragm, causing irritation on the lungs (call Hernia) but it was later confirmed by radialogist that there is nothing wrong there. So she was given some medicine which would ease her cough as he suspect her oesophagus could be sensitive.

However, this does not solve our concern on her legs swelling and I am unsure if the advsie given is appropriate. I would like to seek your advise on this.

Thank you very much.


Answered by Dr Tang Hak Chiaw, Consultant, Department of Cardiology, National Heart Centre Singapore

From your description, it is difficult for me to ascertain whether the three main symptoms that you mom has i.e. cough, chest pain and leg swellings are related or separate issues. There are many causes for each of the symptoms that your mom presents. For example, causes of leg swelling can be just simply due to varicose veins. On the other hand, congestive heart failure can give rise to complaints like cough, breathlessness and leg swelling as well.

If you have any concern, I would suggest you talk to your heart specialist and seek further advice.

Question by beneo1948

Dear Docs, I had sternotomy carried out about 4 weeks ago. This was to remove a benign cyst in my chest which compressed by tracea.

I still encounter pain at the sternum area. This is especially so during coughing. Is pain after 4 weeks normal? How long will my pain last after sternotomy?

I also lost my voice due to tube inserted into my airway during operation. I can only whisper now. I understand that stretching of my vocal chord and difficult intubation is the reason. Will I ever get back my voice? I am worried.

Answered by Dr Chin Chee Tang, Consultant, Department of Cardiology, National Heart Centre, Singapore

Pain after sternotomy is quite common. It can be from a variety of causes but the most common include discomfort as the bone heals, or from nerves that have been stretched or disturbed when the skin was cut. The duration of discomfort after sternotomy varies from person to person, and may commonly last for weeks. If the pain is not improving significantly, or if it is getting worse, it would be a good idea to consult your surgeon and seek his/her advice.

Similarly, having a sore throat or a change in the voice character or quality is a known, albeit not very common, consequence of intubation. This usually does recover, but once again, you may wish to speak to your surgeon to see if there were any special circumstances related to your case.

Question by jamescalee

Dear Doctor,

I am wearing a mechanical mitral valve.

I am taking Warfarin.

Now, I have a toothache. Perhaps, I may need to extract the tooth.

Can I stop taking the Warfarin a few days before the tooth extraction?

Thank You very much.

Answered by Dr Chin Chee Tang, Consultant, Department of Cardiology, National Heart Centre Singapore

Because mechanical heart valves have metal parts that are exposed to blood, there is a possibility that a blood clot may form on the metal parts. This may lead to damage to the valve or may cause complications such as strokes.

As such, all patients with mechanical heart valves are strongly advised to take warfarin to thin the blood and thus reduce the risk of these complications. Therefore if you stop taking warfarin before the tooth extraction, there would be an increased risk of these problems.

To avoid this, we normally advise patients to have another form of blood thinning during the period when they have stopped taking warfarin - this is usually a medication that is delivered directly into the blood stream via the vein and therefore requires hospital admission. I would advise that you discuss this with your cardiologist or cardiac surgeon further and not stop warfarin on your own.

Question by Pokkadot

Dear Dr Lee

My mom, who has just been diagnosed with high blood pressure, has a few questions

  1. How many types of medicines for hypertension are available now? And what are they? What are their differences?
  2. If she starts taking the hypertension medicine regularly, what kind of test for her heart must she go for?

Thanks a lot!

Answered by Dr Tang Hak Chiaw, Consultant, Department of Cardiology, National Heart Centre Singapore

There are many types of medication available to treat high blood pressure. They act on different systems and biochemical pathways of our body to affect lower blood pressure.

If you mother has no symptoms, it is generally not necessary for her to undergo any heart test.

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 Chin Chee Tang, Consultant, Department of Cardiology, National Heart Centre Singapore

It is known that the risk of having a heart attack increases as we get older, and that someone who has had a previous heart attack is more likely to have another one as compared to a person who has never had a heart attack.

However, it is still very difficult to predict with certainty when a heart attack will occur, even by having regular tests or clinic visits. Therefore the approach that your father has adopted is perfectly reasonable - by taking his medications regularly, exercising regularly, keeping an eye on his diet, and monitoring himself for symptoms he is doing everything that a cardiologist would normally advise.

In addition however, I would still suggest that he check his blood pressure and cholesterol levels regularly (as well as his diabetic control if he is diabetic) and that he asks a doctor to adjust his medication if the control was not optimal. Of course if he were to develop any symptoms, it would be prudent for him to consult a doctor early rather than wait and see if they will resolve on their own. The doctor can evaluate and decide if tests would be useful at that point to decide what to do next.

In terms of diet, the general rule for the heart is that no one food is completely prohibited but rather, one should have a varied diet which should also contain a generous amount of food and vegetables.

Question by chantosa76

Dr Lee

I am 60 year old. My blood pressure reading high between 142-158hg low between 90-100. I do not take medication but use to take sea cucumber jelly. Am I at risk? Best regards.

Answered by​ Dr Tang Hak Chiaw, Consultant, Department of Cardiology, National Heart Centre Singapore

I'm not sure if the blood pressure readings provided were obtained at home or in a healthcare facility. If they were home blood pressure readings, then your blood pressure would be categorised as stage 2 hypertension. Generally you are advised to start medication for this stage. Treatment with medication is even more important if there is evidence of damage done by the high blood pressure to your body e.g. protein in your urine. Consult your family doctor for tests to assess for possible damage done by high blood pressure, if these have not been done.

The risk of high blood pressure includes higher likelihood of a stroke, kidney, heart and eye conditions. You would be at risk when your blood pressure is above the recommended range i.e. more than 140/90 mmHg for office blood pressure and more than 135/85 mmHg for home blood pressure.

Question by eccles

Dear Dr Chin & Dr Tang

My diabetic mum had s/p CABG x 4 done on 19 Aug in NHC and currently warded in 53 for CT scan of aorta.

Her CTS surgeon's on leave till 25 Sep.

May I know if know if Dabigatran is suitable for Atrial Fibrillation (AF). Currently she's on Plavix 75mg and Asprin 100mg. We do not think wafarin therapy is suitable for mum has she is prone to falls, had a spiral fracture in Jan '07 and thigh contusion when she fell again in Jan '10.

I understand Dabigatran side effects are heartburn, nausea & vomitting.

Thank you

Mrs Tan

Answered by Dr Chin Chee Tang, Consultant, Department of Cardiology, National Heart Centre Singapore

Atrial fibrillation (AF) increases the risk of a patient developing blood clots in the heart and if these blood clots were to leave in the blood stream, there is a risk of strokes and other complications. Medications such as aspirin, Plavix (generic name is clopidogrel), warfarin, and dabigatran are all 'blood thinners' and thus reduce the risk of these problems. However, because they thin the blood, if a patient was to develop a bleed (for instance, be it from a cut from a fall, or a spontaneous bleed from the stomach) it would be more difficult to stop the bleeding. In certain cases, such as bleeding in the brain, this may be very dangerous and even potentially life threatening.

The degree to which these previously mentioned medications thin the blood varies - typically warfarin (when taken correctly) is regarded as the most effective blood thinner, while aspirin and clopidogrel thin the blood to a lesser extent. Dabigatran is a new blood thinning medicine, and has been shown in clinical trials involving patients all around the world (including Singapore) to reduce the risk of strokes and other similar events in patients with AF. It thins the blood more than aspirin or clopidogrel, and depending on the dose taken, the degree of blood thinning is probably similar or even greater than warfarin.

Because of this, I would think that if warfarin was not suitable for your mother because she is prone to falls and hence has a greater risk of injury and bleeding, the risk of bleeding if she were to take dabigatran may not be much less. I would advise you to consult your cardiologist on this.

Question by healthblur

There are so many kinds of heart tests out there - how do I know which one is suitable for me?

My husband is 55 years old and wants to do a heart check. A friend recommended an echo cardio stress test, but another said just go straight for the cardiac CT scan once and for all, to be sure.

What should he do?

He doesn't want to go for multiple tests, but then, doesn't want to get unnecessary radiation either.

Is there a decision tree matrix that one can refer to as a general guide?

Answered by Dr. Tang Hak Chiaw, Consultant, Department of Cardiology, National Heart Centre Singapore

For patients who have no symptoms, a ‘heart check’ should always start with a global risk assessment i.e. the likelihood of one suffering from heart attack or cardiac death. There are several tools available internationally. The Framingham Risk Score adapted to Singapore population is the ideal tool to start. This score includes risk factors such as smoking status, blood pressure, cholesterol level and others.

If it has not been done yet, I would suggest your husband to check his blood pressure and cholesterol level. If he belongs to the low risk group, further testing for coronary artery disease is not recommended. Even if he is in intermediate or high-risk group, cardiac testing is only recommen​ded for certain type of patients. You husband’s focus should be directed to interventions that have been proven to reduce chance of cardiac events i.e. maintaining healthy body weight and healthy diet, regular exercise, targeting cholesterol and blood pressure to ideal level.

Ref: U11