a) How is heart failure diagnosed? Does having ischemic heart disease and low ejection fraction mean a patient has heart failure?
b) Can the CT calcium scoring test show the severity of blockages in the coronary arteries?
Thank you for your assistance.
Heart failure is diagnosed from a combination of symptoms, signs and also tests like echocardiography. Having a low ejection fraction indicates the person has weak heart function, which is the underlying issue in heart failure.
CT (computed tomography) calcium scoring does not show the severity of blockages in the arteries. However, it can be used to estimate the risk of heart attack in combination with other clinical risk factors such as cholesterol and blood pressure levels.
Dear Asst Prof Huang,
I have few questions concerning about vessel blockages which I hope it is related to the heart topic.
a) I am at my late 50’s, how can I know the condition of my blood vessel to prevent a stroke or heart attack?
b) I feel tired easily, does it mean that my blood flow is poor?
c) I am not a coffee or alcohol drinker and I started to have double heartbeat in my earlies 50’s. It happens a few times a year and lasted about 12 hours before the heart rate goes back to normal. During the double heartbeat, my blood pressure will drop to quite low in which I will feel restless and giddiness. What can be the possible cause and any precaution needed?
d) With regards to condition of blood vessels, is there an check-up programme available which is subsidised by MOH?
Thanks in advance for answering my questions.
Answer by Asst Prof Huang Zijuan
Dear Mr Lim,
a) While there are various investigations to find out the current state of your blood vessels, what is important is to reduce your risk of having a heart attack. The key to reduce the risk of heart attack in most cases is to control risk factors. Many of us, to some extent, could have deposits of cholesterol in our arteries, depending on how well we have controlled various risk factors in the past. Whether these deposits in the arteries will rupture and suddenly cause a heart attack would depend on several factors such as bad cholesterol levels, smoking status, sugar levels, type and amount of regular exercise done, diet, and etc.
If you are experiencing symptoms of concern such as a new decrease in exercise tolerance, chest discomfort (especially on exertion), you should seek medical attention so the appropriate investigation can be done to assess your condition. However, if you did not have symptoms of concern, and do not have adequate medical reason, it may not be necessary for you to go for certain tests. Certain scans may involve radiation exposure, or may involve risks of stroke, heart attack and abnormal rhythms when undertaking the test. Therefore, it would be best to focus on getting your risk factors controlled with advice from your doctor, which will be beneficial to your vessel health, and reducing risk of heart attack and stroke.
b) Tiredness does not necessarily mean your blood flow is poor. Being tired can be due to multiple factors, such as simply not having enough rest.
c) These sound like irregular heartbeats. It is best to seek immediate medical attention if you feel dizzy, breathlessness, chest discomfort or even faint during episodes of these palpitations. Certain irregular heart rhythms can pose a significant risk, and in severe cases, they have the potential to result in cardiac arrest, where the heart ceases to function.
d) To my best knowledge, there is currently no specific programme with subsidies for overall cost on testing for vessel blockages. If you are Singapore citizen or permanent resident, and are referred by approved Community Health Assist Scheme (CHAS) clinics or polyclinics, you will be eligible for subsidies for medical tests which are clinically indicated as subsidised services.
You can schedule a consultation with a primary care physician to discuss your concerns. Following the consultation, the doctor can decide whether to recommend relevant tests or make a referral if necessary.
12. Question by How Sheng
Hi Dr,
I have been doing Calcium Score test a few times on average once every 3 or 4 years. It's been zero.
I am told that Calcium score detects only hard blockage and not soft plague build up. So should I do CT scan for soft plague blockage? Does it replace the Calcium score or should I do both? Thanks.
Answer by Asst Prof Huang Zijuan
Dear How Sheng,
I would assume that you are doing regular calcium score test to either mitigate or manage the risk of heart attack.
If so, I would like to share that what reduces the risk of heart attack is actually the control of risk factors. Like many us, it is possible that we have accumulated cholesterol deposits in our arteries to varying degrees, depending on how effectively we have managed different risk factors in the past.
Whether these deposits in the arteries will rupture and suddenly cause a heart attack would depend on several factors such as bad cholesterol levels, smoking status, sugar levels, type and amount of regular exercise done, diet, and etc.
If you do not have any symptoms, it will be more meaningful to start managing your risk factors by addressing these issues instead of doing a CT coronary angiogram. However, if you do already have symptoms of concern, like new decrease in exercise tolerance, chest discomfort (especially on exertion), you should seek medical attention so the appropriate investigations can be done to assess your condition.
If you did not have symptoms of concern, certain tests can be inappropriate, such as CT coronary angiogram which involves contrast administration and radiation exposure. CT calcium score has lower radiation than CT coronary angiogram and hence can be used even in individuals without symptoms. However, if you did not have adequate reason to proceed for such tests, it would be best to instead focus on getting your risk factors controlled with proper advice from your doctor, which will be more beneficial for vessel health.
13. Question by Soon Heng
Hi Dr,
I am always low on HDL since young. Was told by doctor that the way to increase it is to exercise. I have always been an exercise fanatic, running marathons and now at 73 years old, doing brisk walk for 10 to 12 km daily, yet my HDL remains low.
Understand that this has to be higher to reduce my lipid ratio which is an indicator of heart attack.
My Question: Other than exercise, what other means can I increase my HDL? What kind of food can help? Thank you for your advice.
Answer by Asst Prof Huang Zijuan
Dear Soon Heng,
Focusing on increasing HDL has not been shown to be effective in reducing the risk of heart attack. In fact, a clinical trial involving a medication aimed at increasing HDL levels revealed an increased the risk of heart attack when HDL levels became excessively high.
What has been proven helpful in predicting the risk of heart attack among the commonly conducted tests in Singapore are LDL (often referred to as bad cholesterol) and the non-HDL level (calculated by subtracting HDL from total cholesterol). If these levels fall within the most ideal range for you, there is no need to be overly concerned.
Higher HDL levels are also associated with a healthy lifestyle, which includes factors such as your diet and exercise habits. Do not forget that these lifestyle factors also play a significant role in lowering your risk. You can read more about the heart healthy diet here: https://www.nhcs.com.sg/news/stories-from-the-heart/blog-article-for-patients-diet-for-cardiovascular-disease-risk-reduction. We will also be adding a Mediterranean diet article soon, stay tuned to our NHCS website for that!
14. Question by CS Chew
Hi Dr,
What is the most comprehensive/effective cardiology check on the health of my heart? I have seen some friends who gone on health checks including heart but still had cardiac arrest and block in arteries gone undetected. Thanks.
Answer by Asst Prof Huang Zijuan
Dear CS Chew,
This is a common concern from some of my patients too. Let me break it down for you.
Firstly, it is important to note that all tests have their limitations and to assess the benefits versus risks (also known as risk-benefit ratio). There are different tests which may be more suitable for different patients to achieve the best risk-benefit ratio. Tests used to check for coronary artery disease are not without associated risks, for example there are risks of radiation in some scans, hence we would want to be judicious and choose it for those who do have good indications for it. There are other tests which might involve risks of heart attack, stroke, abnormal rhythms etc. Hence, there is no single best test for the various patient profiles.
Next, let's consider a scenario where you had a test done for valid reasons. For instance, if you underwent a CT coronary angiogram and it revealed a plaque deposit (a fatty blockage primarily composed of cholesterol deposits and occasional calcium and fibrous deposits) in one of your coronary arteries, which was only causing mild blockage. This would not warrant any invasive treatment, such as coronary stenting or bypass surgery which have their own risks.
In fact, many of us to certain extent, have some deposits in our arteries depending on what risk factors we have. It was found that as young as 3 year olds, could start having fatty streaks in their arteries. Therefore the question is whether it will get worse and lead to a heart attack.
While a scan may reveal minor coronary artery deposits, it does not guarantee that a heart attack will not occur too, as the original plaque can change and there is also risk of new plaque in new areas. Hence whether there are changes in a positive or negative direction, it is dependent on how well the risk factors are managed. Poor control of risk factors such as smoking, high bad cholesterol levels, sedentary lifestyle, and unhealthy diet (high sugar, excessive processed foods and meats, saturated fat and minimal greens) can lead to higher risk of getting heart attack.
Therefore, the best protection for everyone is to achieve our cardiovascular risk factor targets. An acceptable result now does not guarantee that a heart attack will not occur in future.
What are the targets to take care of? For a start, work on managing your cholesterol, blood sugar and blood pressure levels, and setting an exercise regime (type, duration and frequency) and watching your diet. Importantly, quit or no smoking. Please consult your doctor for specific details on how to better manage your risks and know your health targets according to the other risk factors that you might have.
You may use the heart risk calculator in the Health Buddy app to calculate your current risk based on your risk factors and learn how to make modifications accordingly (for example, if your risk falls in the orange or red range, a risk modification button will appear, to lead you to more health resources/information).
15. Question by Anthony
Dear Asst Prof Huang,
I’ve heart palpitations for the last 2 years. I’m 63 years of age and male. My questions are:
a) My palpitations normally comes in the night when I’m asleep. I will be woken by the heart thumping and disrupt my sleep for few hours. Why does it happen at night?
b) I will need to go to urine frequently, about 5 minutes intervals for several time once the palpitations start. Is the heart and kidney/bladder related?
c) I regularly do long distance running - once or twice a week for 45 mins. Has the running exerted the heart causing the palpitations?
d) Lastly, what should I do to stop this palpitation?
Thank you for taking the time to look into my questions.
Answer by Asst Prof Huang Zijuan
Dear Anthony,
a) The palpitations may be better felt at night when it is quiet or it may be that they tend to happen more when you are resting. Certain types of abnormal rhythms may exhibit this behaviour. It is best to consult a doctor so the appropriate assessment and testing can be done. If you have palpitations causing giddiness, chest pain, breathlessness or even fainting spells, please seek emergency medical attention.
b) This does not sound related to the heart, but rather more urological system related, for example, due to bladder or prostate issues.
c) It is advisable and safer for you to avoid vigorous exercise like long distance running, until your palpitation issue has been fully investigated.
d) Seeking medical attention is advisable, and if appropriate for your condition, medications may be prescribed.
16. Question by Mr Sim
Hi Asst Prof Huang,
I had a long stent placed at the heart junction in 2012 but since 2017 I have been experiencing breathlessness and upper Jaw pain again.
I can pinpoint my pain to a nerve in my tooth (no cavity) that is giving me excruciating pain for about 1 minute simultaneously with the breathlessness.
My question is, do I need a neurologist consultant as my heart breathlessness is not a troubling concern, at least it is easily manageable but not the "Toothache-like" pain. What would your advice be?
Answer by Asst Prof Huang Zijuan
Dear Mr Sim,
Blockages in your heart arteries can present as jaw pain, especially when coupled with breathlessness, like in your case. It is advisable for you to seek early medical attention, and you may be scheduled to see a cardiologist.
17. Question by Viv
Hi Dr,
Recently I felt my heart was beating very fast all-of-a-sudden. I don't feel any pain nor any shortness of breath, but it lasted for about more than an hour continuously non-stop.
This sudden fast heartbeat happened before but usually it last for only a few seconds. But this time round, it's more than 1 hour.
Is this a symptom? Should I go and see a heart specialist about this? Thank you for your advice.
Answer by Asst Prof Huang Zijuan
Dear Viv,
This sounds like an abnormal heart rhythm issue. You should visit a polyclinic or a GP clinic for an initial assessment, after which you can be referred to see a cardiologist if needed.
If palpitations become associated with dizziness, fainting, breathlessness, or chest pain, do not wait for your appointment; instead, call 995 for an ambulance and go to the emergency department.
18. Question by Al Mlsa
Dear Dr,
I have done a couple of annual check-ups including treadmill and scan. I do this because sometimes I do have chest pains but test results confirm that its only my chest muscle.
How do I know when this is beyond my chest muscle? What are the symptoms and indicators? I do have a family history of heart disease with my late father, who has gone through bypass surgery.
My cholesterol is currently under control with statins and my BP with Cozaar. Thank you for your advice.
Answer by Asst Prof Huang Zijuan
Dear Al Mlsa,
Cardiac-origin chest pain is typically more persistent, lasting for at least 5 to 10 minutes, and it does not usually manifest as a brief, seconds-long stabbing pain (which is more likely to be musculoskeletal in nature). Additionally, cardiac chest pain tends to occur during physical exertion.
There are several factors to manage to have effective control of your heart artery disease risk.
For a start, work on managing your cholesterol, blood sugar and blood pressure levels, and setting an exercise regime (type, duration, and frequency) and watching your diet. Importantly, quit or no smoking. Please consult your doctor for specific details on how to better manage your risks and know your health targets according to the other risk factors that you might have.
You may use the heart risk calculator available on the SingHealth Health Buddy app to calculate your current risk based on your risk factors and learn how to make modifications accordingly.
19. Question by Catherine
Dear Asst Prof Huang,
I recently had 2 stents done at NHCS. It is supposedly titanium stents.
Can I travel and what precautions should I take on board? Would titanium stents be safe to go thru the immigration check without triggering beeps?
My hubby and I are in our 60s. He keeps fit by running and swimming. How to check if his heart is not at risk?
Also, is there a difference between having a heart attack and a chest pain that needs intervention because of blockage?
Thank you for your advice.
Answer by Asst Prof Huang Zijuan
Please be rest assured that titanium stents will not trigger metal detector alerts. Unless you are advised by doctor on specific instructions, travelling with coronary stents generally does not require any specific guidelines. Nonetheless it is good to be always prepared before travelling, for example, remember to pack and continue to take the prescribed medications.
Do schedule a consultation with a doctor if your husband has any symptoms of concern. The doctor will advise on appropriate steps to take if any concerning symptoms are identified and provide guidance on his cardiovascular risk based on his risk factors, if any.
To find out about his cardiovascular risk, he could also use the ‘Heart Risk Calculator’ which we have recently included in the Health Buddy app. Upon entering his health-related details such as medications, blood pressure, cholesterol levels, the calculator would indicate the risk of heart attack within the next ten years. If results displayed is green, it means that he is at a relatively lower risk as compared to persons of the same age. If results showed orange or red, it suggests a higher level of risk, and there will be guide and resources provided on how to reduce these risks effectively.
20. Question by Joan
Hello Dr Huang,
I recently underwent a CT-Scan on my heart. Everything seemed to have went well. However, I started to feel lethargic and breathless over the following days.
Basically, I need to pause to take deep breaths when I talk and eat. So I began to converse less, mostly by texting and take short intervals when I eat. Simple daily activities like brushing my teeth and washing my teeth are now done in a slow manner to avoid experiencing breathlessness.
I am not sure if this is a side effect post CT-scan. It has been a week and I am concerned. Kindly advise me of your thoughts. Appreciate your kind response. Thank you.
Answer by Asst Prof Huang Zijuan
Dear Joan,
This could potentially be a new medical concern, and its development may or may not have been triggered by medications or substances administered during the CT scan. It is strongly recommended that you consult a primary care doctor, such as a GP or doctor at a polyclinic, for an early evaluation.
21. Question by James
Dear Dr,
Sometimes my BP exceeds 185/105. I am 38 and not on medication. May I enquire would your recommendation be as my next step?
Appreciate your advice.
Answer by Asst Prof Huang Zijuan
Dear James,
For the most effective evaluation, it is advisable to bring your home blood pressure (BP) records along when you visit a GP or polyclinic doctor. Based on the information you have provided, it’s possible that you may require medications to manage your blood pressure. Ensuring optimal BP control is vital for the prevention of heart disease and stroke. By having access to your daily BP records, the doctor can make the most informed and beneficial decision for your health.
22. Question by Sam
Dear Doctor Huang,
I have been having my heart hitting (pounding) very hard until I wake up every night and also I am feeling very tired. Not sure what's is wrong? I have gone to A & E 3 times and the doctors there told me I am fine and no issue with my heart.
I use an Apple watch and each time when I feel my heart pounding, I will use the ECG apps on my watch to take the reading...and it shows Sinus Rhythm (50 or less BPM).
Appreciate your kind advice. Thank you.
Answer by Asst Prof Huang Zijuan
Dear Sam,
The Apple Watch ECG captures a snapshot of your heart rhythm during the moment you record it. Therefore, it is possible that it might not detect an abnormal heart rhythm if it doesn’t occur when you take the ECG. You may wish to consider consulting a GP doctor for a comprehensive ECG assessment, it is also advisable to share the ECG recordings with the doctor to evaluate whether your heart rhythm appears normal. If necessary, based on the overall assessment, your GP may recommend a referral to a cardiologist for further assessment.
23. Question by Mabel
Dear Doctor,
I am a 62-year-old female with no known heart conditions, diabetes or hypertension. I have a resting heart rate of between 65 to 70per minute.
I notice there is a tendency for my heartbeat to increase to more than 100 for 1 to 2 minutes, usually in the morning, shortly after waking up, when I am not active.
My heart rate also easily increases to more than 100 when I walk around the neighbourhood (not brisk walking). After a minute of jogging on the same spot, it rises to about 115.
I did a treadmill stress test last year and the results were normal. May I know if my quick heartbeat is of any concern? Thank you.
Answer by Asst Prof Huang Zijuan
Dear Mabel,
It is advisable to schedule an appointment with a general practitioner for a thorough assessment to determine the nature of your concerns. Based on the information you've shared, there may be several potential factors including the possibility of abnormality or variations due to normal physiological responses, as well as occasional inaccuracies from the device you're using.
Following the assessment, should the doctor identify any potential indicators of concern, you may be referred to see a cardiologist for a more comprehensive assessment.
24. Question by Susan
Dear Prof Huang,
I’ve been taking “Atorvastatin” 10mg 1 tab every morning for nearly 2 years.
Though my cholesterol level dropped remarkably by 50%, kindly advise whether to check on liver function ..enzymes?
Lately I experienced “reflux”, burping and gas. My blood glucose reading is optimal - “below 7” on an average.
Am an active senior exercise brisk walking as and when. BP 109/74/96 on 11 Sep (note pulse 96 at best). In 2022 pulse reading 100 range.
Thank you for your kind attention.
Answer by Asst Prof Huang Zijuan
Dear Susan,
Based on current medical evidence, it is not recommended to have re-checks of liver enzymes at every medical follow-up. However, if you have concerns regarding potential liver function impairment, it is advisable to have your liver enzymes checked.
It is also important to note that liver dysfunction as a side effect of statins is uncommon. For further information about statins, you can refer to these articles authored by NHCS doctors:
Reflux and gassiness can have various causes, which may or may not be related to your medications, especially if these symptoms are new despite long-term medication use. It is advisable to consult your regular healthcare provider to assess whether there is any cause for concern and if specific medications could help alleviate your symptoms.
25. Question by Fitim
Dear Dr,
My question is:
How is a patient correctly diagnosed with atherosclerosis?
I am asking this question because I went to different doctors (cardiologists) within 30 days when one Cardiologist says that I have atherosclerosis and suggested to drink Roswera 10 mg per day, whereas the second Cardiologist says that I do not have atherosclerosis and do not need to take Roswera 10 mg but only to drink water because your blood vessels need water.
Appreciate your insight into this. Thanks in advance for answering my question.
Answer by Asst Prof Huang Zijuan
Dear Fitim,
Atherosclerosis can be seen through a range of diagnostic scans. The presence of fatty deposits in your arteries may likely lead to the diagnosis of atherosclerosis based on the imaging results.
Ref: I23
