Prevention is better than cure!

Cardiovascular disease, commonly known as heart disease, is the leading cause of death worldwide, with one in three deaths in Singapore due to heart diseases and stroke.

While certain types of cardiovascular disease cannot be prevented, such as congenital heart disease, adopting a healthy lifestyle can help reduce the risk of developing heart disease.

In this "Ask the Specialist" forum, Dr Liew Boon Wah, current Chief and Senior cardiologist, and Chief with the Department of CardiologyChangi General Hospital (CGH), and Clinical Assistant Professor Koh Choong Hou, Consultant from the Department of Cardiology, and the Director of SAF Cardiac Fitness Centre at National Heart Centre Singapore (NHCS), answer your questions about heart disease. 

Both CGH and NHCS are members of the SingHealth group.

Don't miss this chance for you to:

  • Find out more about preventing cardiovascular disease, such as managing one’s risk factors to lower the risk of developing heart disease or preventing future heart episodes from happening.

  • Also, enquire about cardiovascular rehabilitation – a programme at NHCS with therapeutic components to help patients get better even after experiencing heart problems.

This 'Ask the Specialist' forum has closed. Thank you for your interest and participation.

1. Question by s***
Dear Dr Liew,
Before I had my baby (4 months ago), I was slim, exercising regularly (pilates, 10K steps a day, jogging) and eating healthfully (siu dai everything, brown rice, lean proteins). But even then, my cholesterol profile was not great (total: 205mg/dL, HDL: 77mg/dL, LDL: 117mg/dL). During pregnancy, I couldn’t exercise (due to threatened abortion) and after the 2nd trimester, drank formula to gain weight (because I lost a lot of weight due to hyperemesis gravidarum). Now I have some belly fat and have not been my healthiest (sleep deprivation, irregular meals when I’m alone with baby, no exercise due to c-section wound). I feel crappy physically, like pregnancy totally messed up my body/sleeping pattern/health. Have I worsened my cholesterol profile during and post pregnancy? Can I reverse the damage through exercise? Also do you think mummy tummy is bad for your heart? I read somewhere that belly fat puts you at higher risk of heart disease.

Answered by Dr Liew:
Dear s***,
It does sound like you have been through a lot lately. But you have also identified the differences in lifestyle pre- and post-natal.
The cholesterol profile will fluctuate according to lifestyle and eating habits. Once you get back to your regular routine and eating habits, the cholesterol panel will be more reflective of your usual health.

What may be more relevant in your situation will be to work out a daily routine during your maternity leave period such that you can get start making healthy changes to your diet. Taking a stroll on a daily basis once you are fit to do so will help you clock some exercises and de-stress at the same time. This will also be a good time to get out of the house and yet bond with your baby.

Yes truncal obesity is associated with cardiac diseases, but do give yourself some time to get your routine back up before you start stressing yourself about the belly fat. 

2. Question by y******
Hi Dr Liew.
I’m a bit concerned about my dad (65y/o). He had stents last year and ever since, he’s been given the all clear, he’s been back to his old eating ways (nasi padang every other day). He’s on high cholesterol and high blood pressure meds so he thinks its ok to eat what he likes. We tried hard and soft approaches to encourage him to eat healthier but he's so stubborn. If we mix white with brown rice, he complain cannot swallow. He won’t eat fruits unless we cut for him. He’s a kind, loving man and I’d like him to live long enough to see my kids grow up. Is it true that he can eat what he likes when he's on medication? His parents died of stroke and heart attack.

Answered by Dr Liew:
Dear y******,
It is heartening to see that you are actively involved in the care of your father’s health.
I presume the all clear given meant he did not require any further procedures for treatment of ischaemic heart disease. However, it has been shown in studies that lifestyle changes (after treatment of ischaemic heart disease) together with good adherence to medications play the most important role in preventing future recurrent cardiac events.

Regular moderate intensity exercise programs and healthy eating are things that the patient can undertake on their part. You can find out regarding the possibility of enrolling your father in a cardiac rehabilitation program in consultation with his cardiologist.

Diets low in saturated fat and trans fat will aid in reducing the LDL-cholesterol (“bad” cholesterol).

Perhaps it will be useful to start small and negotiate baby steps in replacing one meal a day with something healthier that is low in saturated/trans fats and yet high in fibre. Having regular fruit snacks together as a family helps in bonding and encouraging him so he does not feel like he can only eat healthy foods.

3. Question by j****
Dear Dr Liew, I have neighbours who smoke above and below my flat. And I can smell it even when I shut my windows. Will 2nd hand smoke put me at risk of heart disease? In our old flat, the neighbor below us smokes too. My mum who was an athlete and never smoked, had lung cancer 4 years ago. I suspect the 2nd hand smoke was a factor.

Answered by Dr Liew:
Dear j****,
Based on the observational studies that were reported in the medical literature, second hand smoke (or also known as Environmental Tobacco smoke (ETS)) was thought to be associated with a general increased risk of coronary heart disease by about 25%.

However, a large population study done in California, USA had suggested that the effect of ETS on the heart may be smaller than previously thought. All in all, I believe there is some increased risk of CHD with exposure to ETS and hence such exposure should be reduced as far as possible.

4. Question by k****
Hi Doctor, my husband travels 2–3 weeks in a month for work and has been doing so for the past 2 years. Recently, he complains of chest pain, especially at night, or after a jog. He’s younger than me (he’s 34) and has a family history of heart disease (dad has 90% blockage and 3 stents inserted, maternal grandad died of heart attack at 41). Do you think frequent flying and stress puts you more at risk of heart disease? What should I look out for to know if his chest pain is serious? Thanks.

Answered by Dr Liew:
Dear k****,
Lack of rest and high stress levels have been shown in some studies to have a link with increase in heart diseases though it was not a proven cause-effect relationship.

You should encourage him to get an evaluation for his chest symptoms given his family history. This will be important as he is often not within the country and access to medical care may be less consistent. Briefly from your description, I will certainly advise that he gets a formal evaluation by a medical professional.

5. Question by R******
Dear Doctor,
I have Afib and have undergone ablation. Can Afib be completely cured? Must a patient with Afib be put on RivaRoxaban and Bisoprolol for live?

Answered by Dr Liew:
Dear R******,
Afib or atrial fibrillation is a condition where the heart rhythm is irregular. This leads to reduction in blood flow within the heart and can pre-dispose to blood clot forming within the chamber of the heart. Taking Rivaroxaban (a form of anticoagulant or blood thinner) will reduce the chance of such blood clot formation. The studies that have been done showed that appropriate taking of these blood thinning medications/anticoagulants have been very effectively in reducing the risk of stroke.

Patient can develop recurrence of atrial fibrillation even after ablation (recurrence rate varies according to individual patient profile) hence it is advised that patients remain on the anticoagulants to prevent stroke events due to the possibility of silent recurrence of atrial fibrillation.

Bisoprolol belongs to a class of medications known as beta-blockers. The use of Bisoprolol is mainly for heart rate control in the event that one develops atrial fibrillation again as the heart rate tends to be high during atrial fibrillation.

6. Question by F***********
Hi Doctor,
I have not been taking medicine that my doctor prescribed, and I have been watching my diet, eating oats daily, and doing some jogging and I see an improvement in my cholesterol level. But my doctor still ask me to take medicine, but will that cause my body to dependent on the medicine… and let’s say, if I miss a day of my medication, will my body not be able to take it and cause a worst effect? Pls advise.
Is vitamin C crucial to our body? Does our body produces vitamin C. Is it true that animals do not have heart attack. And why is it so? What is lacking in our body system that causes the difference btw humans and animals?
How often should we test our cholesterol?
What is the best food for reducing cholesterol?
Does lowering cholesterol result in better blood flow?
Are having frequent headaches a symptom of high cholesterol? But that normally happens to me after my night shifts. Could they be linked?
All along, our family diet is no oily food, only lean meat and vegetables. But I have a family history of high cholesterol. But with family history, will that be less severe as this is caused by genes.
Can a person with high cholesterol be considered suitable for blood donation?

Answered by Dr Liew:
Dear F***********,
Thank you for your very interesting questions.

The decision whether to start on medications for hypercholesterolaemia will depend on your risk profile and level of your cholesterol. As such, you should engage your doctor for a deeper discussion as to what targets should you be aiming for. This will help you decide when to start back on your medications. Cholesterol lowering medications have good data in the scientific literature for prevention of strokes and heart attacks. They do not cause you to become dependent on them.
Vitamin C deficiency in humans are due to an absent enzyme activity that is necessary for Vitamin C synthesis. AS a result, we need to have vitamin C supplement through our diet. It is necessary for a range of body functions eg repair and growth of tissues. There are fewer reports of heart attacks in animals also because the presentation of heart disease is different compared to humans. It is difficult to ascertain a particular factor why humans and animals behave differently with regards to heart disease as there are many confounding factors eg diet, lifestyle and genetic make-up.
The Singapore guidelines recommend to check your blood cholesterol levels every 3 yearly for those who have cholesterol readings within the targets for your risk profile.
We encourage diet rich in vegetables, fruits, legumes, whole grain, unsaturated fats as well as food low in trans fat.
Lowering your blood cholesterol levels will reduce fatty plaque deposits in the walls of your arteries. Less of such fatty deposits will reduce the narrowing of your arteries and in turn not compromise blood flow.
Symptoms such as headache are often very non-specific and can be caused by multiple factors. If you have persistent recurrent headaches, I will suggest to have your doctor review that. Hypercholesterolaemia itself does not result in such headaches usually as they are often silent.
Familial hypercholesterolaemia due to genetic alterations can result in earlier onset of coronary heart disease as these patients generally start experiencing changes in their arteries at a younger age as well. The risk for heart disease is not lower simply because it is a genetically linked cause.
Patients with hypercholesterolaemia, on medications, are still eligible for blood donation provided there are no cardiovascular complications.

7. Question by A******
Dear Dr Liew, 
I am 59 years old to date.
I had an heart attack in 2014 while doing my run on the treadmill in SAFRA Mt Faber.
The SAFRA instructor used an AED to bring my heart beat back and follow by the Cardio Doctor in Alexander Hospital (under NTFGH) in Aug 2014.

My question to you is, am I allowed to participate in a marathon, eg 10 or 15km run, probably not as fast as before, but at a slower pace. Is there a risk if I start going to the gym to train slowly and get back my form?
Thank you and hope to hear your opinion.

Answered by Dr Liew:
Dear A******,
It is fortunate that you were attended to expediently when you developed the cardiac arrest.
The ability to resume moderate-high intensity exercise depends also on the extent of your heart disease and how much treatment was done for the artery narrowing. The extent of damage to your heart muscle and the current function of your heart pump (usually assessed by an ultrasound of the heart) will also affect how much exercise you can tolerate.

I will suggest discussing with your cardiologist, based on your cardiac history (extent of coronary artery disease as well as residual heart pump function), the safety of resuming your exercises. There are available cardiac rehabilitation programs in all hospitals that cater to patients with cardiac disease who are looking to resume exercising as well.

8. Question by C*********
How do I prevent heart disease when there is no high cholesterol, no high blood pressure nor heart attack?

Answered by Dr Liew:
Dear C*********,
It is heartening to hear you have no abnormality with your blood pressure as well as blood cholesterol levels.
The modifiable risk factors of heart disease include:

High blood pressure
Diabetes mellitus
High blood cholesterol levels
Smoking habit
Sedentary lifestyle
Early detection and treatment of these risk factors by means of regular health screening will reduce the risk of developing a heart attack. Adopting an active lifestyle with regular exercises will also help in controlling the risk factors for heart disease.

9. Question by P*********
Dear Dr. Liew, good morning.
I’m 66 and I think I’m healthy by this age group. My BP is around 130/80, kidneys are healthy, cholesterol level is border line (I think it is in the gene as I could not bring it down even with excessive exercise and disciplined diet), and I’m not taking any medicine.

I walk daily to keep myself healthy. Though feeling healthy, I have always wanted to do an angiogram to confirm that there is no blockage, or potential blockage in my arteries. My late father had a stroke and that worries me. He passed away at 72 in mid 70s.

I have a few questions about angiogram:
Is an angiogram invasive and damaging to the body because of its high radiation?
Can an angiogram confirm 100% at time of scanning about blockages in the arteries?
How much does it cost to do an angiogram? And can part or all of it be deducted from Medisave?

Answered by Dr Liew:
Dear P*********,
It is good to hear that you are currently in the pink of health and that you are taking active steps to stay healthy.

Coronary angiogram is a procedure that we perform in patients whom we suspect has coronary artery disease. It is an invasive procedure which may be performed in the setting of day surgery. However as the procedure requires the use of contrast material injection as well as exposure to radiation, we will advise that the procedure be done based on clinical need. There are other ways to assess your risk for cardiovascular disease which may be less invasive. You can approach your doctor/cardiologist for further discussion regarding your options after a clinical assessment by your doctor.
Coronary angiogram is the gold standard for assessing for any disease involving the major arteries supplying your heart muscle.
The cost of an angiogram depends on the hospital that you are seeing as well as the class of treatment you are under. The cost can be off-set with your Medisave subject to the limits for that class of treatment.

10. Question by O**
Dear Dr Liew,
I recently experienced chest pain (sharp poking on the middle of chest area) and went for a check at A&E. After ECG, Blood Test and X-Ray, I was discharged and given muscle relaxation medication.

My friend told me that he also experienced similar pain, went to A&E and got discharge. But he was found to have 95% blocked on 1 artery after cardiac catheterisation test.
Should I be required to do the similar test? Would the check by A&E be enough to determine that I am not a risk of heart disease? Thank you.

Answered by Dr Liew:
Dear O**,
It was right for you to have gone for further evaluation of your chest pain symptoms. Rightfully, the blood test and ECG will be able to rule out any heart attack.
However, these tests cannot predict if there is any artery narrowing unless the narrowing had resulted in heart attack.

The decision whether further test will be required is dependent on the clinical risk profile of each patient and the presenting symptoms. Hence it will be difficult to extrapolate the results of your friend’s test to your case. If there is any doubt, you may consider getting a review with your doctor/cardiologist.

11. Question by S*********
Dear Dr Liew,
My husband will be having angiogram on Monday, 10 September 2018 at CGH.
Need to know whether can a patient travel to Tokyo for holiday after angiogram?
How long he has to rest before going to overseas for vacation? Thank you.

Answered by Dr Liew:
Dear S*********,
It sounds like your husband will be undergoing the angiogram as an elective planned procedure. The fitness to fly will depend very much also on whether there was any coronary angioplasty (“stenting” procedure) performed on that day.

For patients who undergo elective coronary angioplasty, they can fly after 2 days if needed. However care must be taken to ensure he does not do any heavy lifting using the arm from which the procedure was performed.

I will advise that he goes to the airport early to give himself time to do the pre-flight check in/security screening without having to rush. And always ensure he brings along ample medications for his travel.

12. Question by P******
I'm a 38yr old Indian male, diabetic who has been on insulin for several years now.
Recently, I've been having a lot close friends dying from cardiac arrest and are close to the 40-50 age group. This has really got me worried.
I went for a CT scan earlier this year at NHC on suspicion of a heart attack. The doc gave the all clear though she didnt say anything about heart profile.
My blood pressure has recently been on the high side 160/110 on some occasions but i have been taking meds to reduce it.
I feel symptoms like anxiety and yawning from time to time. I take fish oil on a regular basis and watch my food.
What can I do now? Should I go to A&E and say I've got symptoms of heart attack? What exercise can I start on?

Answered by Dr Liew:
Dear P******,
I presume you had a CT scan of the coronary arteries done this year. As it is a very detailed study, having no significant abnormalities picked up on the scan is certainly reassuring. You do have significant risk factors for developing coronary artery disease and there are certainly things you can do to help reduce your risk.

You should get your doctor to review your blood pressure control. There are a wide variety of medications that one can take to optimize their blood pressure control.

You should embark on a regular moderate intensity exercise regime, aiming to clock about 30 minutes a day for 5 times a week. You should get your doctor to review if you develop any symptoms such as chest tightness or difficulty breathing, The above symptoms you mentioned are not specific to heart disease.

13. Question by Y*
Dear Dr Liew,
I had 2 ECG done, 2 months apart, both were abnormal, shown inverted T wave and long QT. I do not have high BP, high cholesterol and diabetic. Menopause few year ago, underweight, exercise often and eat healthy. No abnormalities found in 3D Echo. Coronary CT scan detected minor coronary ectasia, myocardial bridging in mid LAD, <20% stenosis in some coronary segments, diagonal 1,2 and marginal 2, 3 are twisted. The doctor advises me to show the abnormal ECG if I will do any ECG in future. No medication given.

Is my cardiac status OK?
Will ECG present abnormal every time I take?
Is there anything I can do with abnormal ECG?
What is the main cause to twisted arteries? Could it be congenital?
Can all these cardiac problems cause heart attack and how to prevent it?
Thank you.

Answered by Dr Liew:
Dear Y*,
It sounds like you have a very detailed cardiac evaluation done.
Based on your description, there are no alarming findings so far. It is good that you are physically active and adhere to a healthy diet.
Some of these T wave changes are very non-specific and may be the baseline changes in your case. It will probably be present each time your ECG is done.
There is no specific medication that will change the ECG appearance you have.
The artery course is developmental. There is no apparent cause.
The findings above do not cause heart attack unless there is an acute coronary plaque rupture event. Keeping up with healthy diet and regular exercise with regular health screening for chronic diseases e.g. high blood pressure, diabetes mellitus and hypercholesterolaemia will help reduce your risk of developing a heart attack.

14. Question by E*
My question ,
I'm a mid-30s female who'd like to start taking nutritional supplements to prevent heart disease. As such, what supplements or functional foods would you recommend to add to daily diet for healthy heart maintenance?

Answered by Dr Liew:
Dear E*,
This is a very interesting question you have raised. There are a wide variety of health supplements out in the market. Unfortunately there are no good data in the scientific literature that has shown any supplement to be particularly useful in preventing heart disease.

15. Question by W*****
Dear Doctor,
My hubby just did coronary angioplasty on 9 September 2018 and discharged from CGH on 12 September 2018.
My questions:
Is that normal if his breathing is not very smoothly during sleep in the night.
Any other common effects after his coronary angioplasty
Looking forward to hearing from you soon.

Answered by Dr Liew:
Dear W*****,
Whilst your description of the symptoms is fairly vague, it is not normal to experience difficulty in breathing at night. If the above persists, you should consider getting in touch with the team doctor for a review and discussion. Sometimes the breathing pattern you described may not be related to the cardiac condition.
The wound over the artery puncture site usually heals totally by a week. There should be no particular symptoms that the patient experiences post-coronary angioplasty unless he has other co-existing issues eg low cardiac function due to a heart attack.

16. Question by C*
Dear Dr. Liew,
Cholesterol deposit (plaques) often lead to heart attack or stroke. If we google to find out how to reduce these plaques, many websites give recommendation to take certain diet and / or supplements. Are there any clinical tests to show that it is possible to reduce such plaques (essentially cleaning the blood vessel) through consuming certain food / supplements. Thank you.

Answered by Dr Liew:
Dear C*,
Thank you for raising this important point. With the easy availability of internet access these days, there have been a lot of claims of supplements and therapies that can remove coronary artery plaques.

However, there has been no well proven supplement that can effectively remove coronary artery plaque. Of interest there had been some studies showing treatment with certain high dose statins (cholesterol-lowering medication) led to some reduction in plaque volume. That being said, the statins cannot totally get rid of coronary artery plaques, thus it is important to still stay on the treatment as directed by your doctor.

17. Question by V*******
Hi doctor, 
My questions are - 
Type of exercises which are to be avoided for one having mitral valve prolapse?
How to prevent it from worsening?
Any food to avoid

Answered by Dr Liew:
Dear V*******,
Patients with mitral valve prolapse (MVP) are advised against engaging in competitive sports if they have the following features:

Prior blackout/faints due to abnormal heart rhythm
Severe regurgitation of blood from the mitral valve prolapse
Prior clot related conditions
Poor left heart pump function
Significant abnormal heart rhythms on monitoring
Family history of MVP related sudden death

There is no particular food to avoid. Unfortunately there is no way to really prevent the condition from worsening.

18. Question by S**********
Hi Doctor,
I had heart attack in Jan 2011, had bypass n had 2 stent, it was done SGH. I was discharge from further treatment in early 2012 from National Heart Centre but follow up checkup and treatment for high blood pressure and high cholesterol at Chua Chu Kang polyclinic. My question is, are the 2 stents to be replaced or they are there as long as they do not clog?
I am Female 59 years old and married. Thank you.

Answered by Dr Liew:
Dear S**********,
The coronary stents implanted during the time of the treatment do not require any removal or replacement. Your artery would have healed and the stents would have been covered by the lining of the artery as they healed. The most important component really is secondary prevention through risk factor control and continued medications. The medications that are particularly important in preventing a recurrence of heart attack would be anti-platelets (such as Aspirin) and cholesterol–lowering medications such as statins.

19. Question by L********
Dear Dr Liew Boon Wah,
I did heart stenting to all the tree heart arteries, once at CGH end Nov 2017, and two at NHC early Dec 2017.
I had been on the following medications after discharge:

Aspirin 100mg tab
Perindopril erbumine
Bisoprolol 2mg tab
Rosuvastatin 20mg tab
I had been re-admitted to CGH few times due to pains over the chest and abdomen areas, and the location of pain varies each time when I experience it. Each time the doctor will do a blood test and admits me for observation, but the conclusion was the pain is not heart related. Can the medication causing muscle pains regularly? I am now being directed to gastroenterology department for further investigation.
When I take Bisoprolol, it causes me to feel tired easily, and can't do much normal activities, I try to cut down to half the dosage, and I am feeling better. But doctor advise me try to keep to the recommended dosage of one tab in the morning and night, may I have your opinion please.
Thank you and best regards.

Answered by Dr Liew:
Dear L********,
It is good to hear that your recent symptoms were not due to any heart attack or impaired blood flow to your heart muscles.

The only medication on your list that may cause some muscle pains is Rosuvastatin. However, before you rush to stop Rosuvastatin, you should have a discussion with your cardiologist to determine if your symptoms are related to the musculoskeletal system. They may offer you alternatives such as a reduction in dose if they deem it to be a plausible cause for your symptoms.
Bisoprolol belongs to a class of medicine called the beta-blockers. It is known that beta blockers can result in some degree of fatigue. The decision whether it is recommended to reduce the dose depends on other factors eg the reason why you are placed on the medication. Was it due to an impaired heart pump function or due to significant residual artery blockages. Reducing or stopping Bisoprolol suddenly may have detrimental effects in these cases. I will suggest you check if your doctor can offer any alternative medicine that can replace Bisoprolol. Another alternative to consider is to supplement the reduced dose Bisoprolol with other medicines to achieve the overall aim of heart rate control.

20. Question by V****
Dear Dr Liew,
My husband feels heart pain frequently. May I know, is it useful if he goes to the polyclinic for an ECG? Thanks.

Answered by Dr Liew:
Dear V****,
Please do advise your husband to seek a doctor’s review early if he has recurrent symptoms. A detailed history and risk profile will need to be obtained and an ECG certainly can help in the assessment as well. If needed, he can be referred to the appropriate specialist for further evaluation.

21. Question by J******
Hi Dr Liew,
I am very anxious about old age health issues, significantly heart disease. I have been suffering from rheumatoid arthritis for 30 over years. I am mobile but not completely pain-free. I am also taking simvastatin to keep my cholesterol down. It has been declining steadily. For the arthritis I am on sulphasalasine, diclofenac, tramadol, omerprazole (to protect stomach), calcium and vitamin B. Another problem I face is leg cramps.
Could you advise how I can prevent heart disease, high blood pressure and leg cramps please? Thank you.

Answered by Dr Liew:
Dear J******,
You can do your part in preventing heart disease by choosing wisely the food you eat. Do go for regular health screening to check on your blood pressure, blood sugars as well as blood cholesterol. Engaging in regular moderate intensity exercises 5 times a week for at least 30 minutes is recommended. You may opt for exercises with low impact to reduce the discomfort due to your underlying rheumatoid arthritis. Regular cardiovascular exercise as well as reducing your dietary salt intake has been shown to be effective in reducing blood pressure.
Do ensure you are well hydrated and have proper warm up and cool down before and after exercises to reduce chances of developing leg cramps. Doing stretching exercises prior to sleep may help in reducing nocturnal leg cramps too.

22. Question by A*****
Hi Dr,
I did a transthoracic echocardiogram @ 35yrs old and the result was mildly dilated left atrium LAVI 34ml/m2. I was given High BP medication. May I check is the mildly dilated left atrium a serious condition based on the readings? is it reversible? How long does it take to recover if reversible? What other tests should I undergo to eliminate further risks? I need to consume Visanne on a long term basis.

Answered by Clin Asst Prof Koh:
Thanks for the question. Your left atrium dimension is considered top normal based on the measurement you provided. There are many causes for a dilated left atrium, such as a stiff heart (usually age-related), poorly controlled high blood pressure, mitral valve related conditions, athletic remodelling due to high exercise intensity, or certain abnormal heart rhythms. 

Progesterone containing pills are not known to cause left atrium enlargement. If you have no cardiac symptoms such as unusual palpitations or breathlessness, there is no cause for concerns for this incidental finding at the moment. However, if you are experiencing cardiac symptoms (e.g. persistent palpitations/ breathlessness), it may be best to seek consultation with a cardiac specialist to discuss whether more investigations are necessary.

23. Question by i************
Hi I am a 50 yr old male vegetarian with no smoking or drinking record and a healthy BMI and normal BP. I check my blood cholesterol yearly and have also started doing threadmil stress test last year just as a routine heart health checkup. However I do not exercise at all. How do I ensure that these test are adequate to ensure there is no clogged blood vessels? Can I do an angiogram or any other blood vessel scan test periodically to ensure that there are no clogged blood vessels although I have no symptoms of heart disease? And if I can how often should it be done?

Answered by Clin Asst Prof Koh:
That’s a great question that many people have on their minds. Firstly, exercise has many beneficial effects on overall health and you are encouraged to engage in some form of exercise to reduce long term cardiovascular risk. 

A coronary angiogram is an invasive test to assess for artery blockages in selected individuals. Like in any other tests, angiogram does come with some risks, therefore it is recommended for those with high risk factors or high probability of significant coronary artery disease. 

If you do not have symptoms, and would like to screen for underlying coronary plaques and estimate cardiovascular risk to guide your lifestyle changes, you may consider computerised tomography (CT) coronary calcium score scan. It is a non-invasive procedure and a useful screening tool that provides a good gauge of coronary artery plaque status. Based on the score and the overall risk profile, it also provides recommendations on lifestyle interventions such as initiation or intensification of cholesterol medications. 

24. Question by Anonymous
For Heart problem, does the pain or discomfort always happens at a single location or it can be at different location at different times?

Answered by Clin Asst Prof Koh:
Thanks for the question. The initial occurrence of cardiac conditions varies depending on the type of heart-related disease (e.g. artery blockage, heart rhythm problem, valve issues, etc.), and is affected by the presence of other non-cardiac conditions such as lung, nerve, bone or muscle conditions. It would be useful to check-in with your family physician if you have persistent symptoms to let them perform an initial assessment, and they can advise whether specialist evaluation may be necessary after that.

25. Question by L****
Based on the and some other websites, Omeprazole may increase the risk of having frctures of the hip, wrist, and spine and damage to kidney especially for patients of 50 years of age or older. To reduce the risk is it ok for patients on Omeprazole and Aspirin to take Omeprazole on alternate days or are there alternative medicine for the purpose of protecting the stomach? Thank you.

Answered by Clin Asst Prof Koh:
Thanks for the question. Cardiologists usually combine a blood thinner (such as aspirin) with a stomach lining protecting medication (such as omeprazole), to reduce the risk of stomach bleeding due to the blood thinner. 

Depending on your risk profile (such as previous stomach bleeding episodes or previous healed stomach ulcers), the benefit of maintaining daily omeprazole may outweigh the nominal long term risk of fractures (which is very rare). 

Further discussion with your primary physician will be useful to evaluate your overall bleeding risk to assess suitability to continue long term omeprazole. There is insufficient medical evidence that alternate day dosing provides adequate protection.

26. Question by f**********
Is clopidogrel better than Ticlopidine in preventing heart attack and stroke? If a patient who was on Ticlopidine has a stroke, will changing the blood thinner to Clopidogrel prevent the stroke from worsening?

Answered by Clin Asst Prof Koh:
Thanks for the question. Both clopidogrel and ticlopidine are blood thinning medications that reduce the clotting effect of blood and reduce future events in individuals who had prior stroke/ heart attacks. In recent years, ticlopidine is less used due to its side effects, with clopidogrel (as well as ticagrelor/ prasugrel) replacing it as the preferred blood thinning medication in populations with heart artery blockages. You may want to consult a neurologist to discuss the risk benefits of clopidogrel versus ticlopidine for stroke prevention.

27. Question by c*********
Dear Dr,
I'm 60 yrs old now and I have been trying to keep myself fit by engaging in various sports & exercises regularly and by clocking at least 10000 steps and 30 MVPA every day. What types of health screening do you recommend for people who are 60 & above and who are healthy without any medical conditions. Eg. should they go for treadmill test, colonoscopy, or eye examination on a regular basis, like every 5 yrs? Thank you.

Answered by Clin Asst Prof Koh:
Dear C****, thanks for the great question. Cardiovascular screening is indeed important as we age. Recommended baseline assessments for heart health include:

1.blood pressure assessment, 
2.body mass index measurement (BMI), and 
3.blood tests (such as cholesterol, sugar levels)

If you do not have symptoms, and would like to screen for underlying coronary plaques and estimate cardiovascular risk to guide your lifestyle changes, you may consider computerised tomography (CT) coronary calcium score scan. It is a non-invasive procedure and a useful screening tool that provides a good gauge of coronary artery plaque status. Based on the score and the overall risk profile, it also provides recommendations on lifestyle interventions such as initiation or intensification of cholesterol medications.

28. Question by Anonymous
Dear Dr. Koh,
Just a brief summary of my family's medical history. Both my uncles had a pacemaker implanted for many years due to irregular heart rhythm. I also understand my cousin is also having the same issue of irregular heart rhythm but he did not go for any pacemaker. My late father was also having weak hearts when he was young but he did not consult any specialist.

About myself, I am at age 58 having thalassemia Alpha and fainting spells when seeing blood or being too emotional. I have chest pain on the left side occasionally but goes off after a few seconds and do feel at times my heart beating fast when resting without a reason. I also feel tired easily. I do not have diabetes, high blood pressure or high cholesterol but borderline. 
Should I consult a specialist to do a proper check up for my heart? 

Answered by Clin Asst Prof Koh:
Dear Anonymous, thanks for the question. Fainting spells related to specific triggers such as seeing blood or extreme emotions are usually not due to an underlying cardiac condition. The chest discomfort you are describing is not typical for angina, which is chest pain due to significant heart artery blockages. It may be useful to consult your primary care physician to review your symptoms and perform a standard 12-lead electrocardiogram, who may then refer you for specialist assessment if there are abnormal findings.

29. Question by M****
Hi Dr,
I am Mr Goh, 63 years old. I am interested to do a heart check-up/scan as a private patient. Should I get a letter of referral from my GP or can call direct to make appointment?

Answered by Clin Asst Prof Koh:
Dear M****, thanks for the enquiry. For general screening of the cardiovascular system (heart and lungs), it may be useful to check-in with your family physician first to perform first line screening and basic tests. They can then advise whether specialist review is necessary based on their initial evaluation, and make the referral as required.

30. Question by M*****
Hi Dr,
How does high cholesterol (LDL?) affect one's heart and brain? Should we refrain ourselves from taking animal fat, oily food, etc? 
[By the way, I am in my late sixties and used to visit National Heart Centre regularly to get treatment there. Currently I am living in North America.]

Answered by Clin Asst Prof Koh:
Thanks for the great question. Our diet indeed plays a big role in our overall health, including cardiovascular (heart) and cerebrovascular (brain) health. High levels of LDL is known to increase the risk of heart attacks and strokes, and there are great reliable dietary guidelines and resources provided by our own Health Promotion Board, and American Heart Association, that can be readily accessed online. You can also read our articles on diet and heart health here and here.

31. Question by A*****
Hi Dr,
I am 44+ year old. Lately I've been have chest discomfort. My GP did a NT-ProBNP test which shows a result of 400pg/ml. However all ECG & Heart scans done seems normal. Had a CT Coronary Angiogram done recently & my appointment with the doctor to review the results is only next year. But as there's no calls from the clinic, I would just assume that the results are normal. what are the chances of having a false-positive NT-ProBNP result? Thanks.

Answered by Clin Asst Prof Koh:
Dear A*****, thanks for the question. NT-proBNP, otherwise known as N-terminal pro B-type natriuretic peptide, is a biomarker used to detect cardiac injury or stress, such as in heart failure. However, there are also other non-heart-related factors that can cause the biomarker to be elevated, such as kidney failure, sleep apnoea, high lung pressures, advancing age, etc. It would be best to consult with your doctor to discuss whether any further evaluation is required, as well as to review the CT coronary angiogram result.

About Clin Asst Prof Liew Boon Wah

Dr Liew Boon Wah is the current Chief and Senior cardiologist and Chief with the Department of Cardiology, Changi General Hospital (CGH). He graduated from the National University of Singapore (NUS), School of Medicine in 2003. He completed his basic specialty training in Internal Medicine and obtained his MRCP (United Kingdom) in 2008. He completed his cardiology training in November 2012. He did his interventional cardiology training as a fellow at Kaohsiung Chang Gung Memorial Hospital, Taiwan from 2014 to 2015.

He is currently practising in Changi General Hospital and is involved in the care of general cardiology patients as well as performing interventional procedures for patients with coronary artery disease. His interest lies in the management of acute coronary syndrome patients. 

About Clin Asst Prof Koh Choong Hou

Clinical Assistant Professor Koh Choong Hou, is currently a consultant with the Department of Cardiology, and the Director of SAF Cardiac Fitness Centre at National Heart Centre Singapore (NHCS).

He sub-specialises in Echocardiography, Cardiac Rehabilitation and Sports Cardiology, with a keen interest in Aviation Cardiology, specifically in the evaluation and certification of aircrew with cardiac conditions.

Ref: J22