heart attack symptoms

>> we are joined tonightby dr. jane lombard. she's a very well regardedcardiologist and also debra. debra is a woman muchlike many of you. she is active in manyareas of her life. she is going to describe herstory to you and we would

heart attack symptoms, like to just thank you somuch for being willing to come and talk to us tonightand tell your story. so if you don't mind, wejust like to get started and i would love to know justcould you tell the group a

little bit about yourselfand why you are here tonight? >> sure. i was 53 years oldwhen my heart symptoms started. i'm 55 now and i have 2 twins. one set of twins, a boyand a girl 14 years old which i swear is the cause ofmy heart problem, teenagers. this is my daughter righthere and i taught aerobics. i still sub. some of you might have seenme at the y across the street. and i have done thatfor about 26 years.

so-- >> what kind of heart issuesdid you have and tell us when they started and likewhat you first noticed? >> what i first noticed wasfatigue, extreme fatigue and one day i was walking up to the 3rd floor i was takingthe stairs to my boss' office, it is exercise and inoticed this weird feeling on my left arm. it was like i was wearinga blood pressure cuff.

and then it just kind of flowed down after a while [inaudible]shake it a little bit but then i would call intowork and i would say well, i'll be in after lunch becausei just couldn't get out of bed. i couldn't get the airanymore to get out of bed. >> how is it? >> can you not hear me? >> no. we are not hearing you. >> okay. how's that?

okay. >> fine. >> i just i couldn't getthe air to get out of bed. so i would say i willbe in at 12 o'clock, i will be in at 1 o'clockor i won't be in at all. and eventually i just usedup all of my sick time because i was so fatigued. if i did go to work ihave to go and lay down. i have to tell somebodyto make sure and wake me

up because i didn'twant to be there when the groups would come in. and-- >> how long did that go on? >> a good 6 months. >> a good 6 months andfatigue could be from lots of different symptoms,right dr. lombard? >> that is correct but youknow, when she tells us that she has a symptom in herarm and every time she goes

up the stair she gets worse. you got to reallythink it is your heart but she didn't know that then. >> that is why she is here. >> and i went to my pcp. >> your primary care provider. >> roll over my name list andthey thought it was muscular because i worked out so muchand was going to send me to physiatry and iknew that wasn't right

so i went back 2 weeks later because my symptomswere worsening. and i got the nurse practitionerwho said the doctor is going to be mad but i amsending you to cardiology. and i got sent to dr. lombardwho said, "let us do a stress or non-stress testand echocardiogram." >> a stress echo. >> we did just the echo first. >> we did just the echo just

to make sure your heartfunction was normal. >> and it showed nothing. >> correct. >> so she said, let's doa stress echo which is where they take the echowhen you are laying down and then you run like heckon this machine and you have to go back all dizzyand lay down and then they takeyour heart rate again. and i saw this, i could see it

and everything else was goingboom, boom, boom and this one in front i could see itwas going umph, umph, and i said to the doctors,that doesn't look good. and he said it is not. so we scheduled about 2 weeks. i ended up in the er,i couldn't breathe so we scheduled the nextweek and i woke up and i have to tell you, i feltdifferently like when i woke up. >> so we did an angiogram andshe had a blockage in the ostium

or the very origin of one of thelargest arteries to her heart, it is called the left anteriordescending and we put a stent in debra and she isnot seeing me now and she is back aerobicisingagain. so i just want to, you know,go over a few points that debra so kindly illustrated for us. one, is that her symptomswere very unusual. fatigue, you know most peoplethink oh yes because i stay up too late or whatever,but hers were as you know,

particularly exertional fatigueassociated with the arm pain. and as she, you know,you are smart, you insisted there wassomething wrong with me and you have always exercisedand so you know that wasn't like you were out ofshape or whatever. you know there is somethingwrong so you insisted that you, you know, continueto work up and-- >> and you had shortnessof breath also is that what brought you to the er?

>> not really. no. >> no shortness of breath. >> i just i couldn'tget a satisfying breath if that makes sense buti could breathe to walk or i even taughtaerobics during this year. >> i think you got really tired. >> yeah, i got really tired. >> oh my goodness.

so and you had a stentput in, is that right? so after the stent you saidyou felt completely different. so what are you able to do now? can you describe your life now? >> i can walk up 3flights of stairs to my boss' officealthough a lot of times i don't really want to. i can walk. i can walk the dog.

i can walk with my kids. i am not fatigued anymore. >> what would you tell, whatwould you tell other women? can you guys hear? what would you tellother women, debra, who may be havingsimilar symptoms or things that they are worried about but really they don'thave a definition for why this is happening?

>> pay attention to your body. think of the things thatmay be you don't feel right that are new. if you don't feel that yourhealth care provider is doing what you think is theproblem, keep at it. don't just settlebecause i was guaranteed if i went another month iwould have had a heart attack. and i have got young kids so obviously i can'tleave them yet.

>> and this is a hard questionfor me to ask dr. lombard because you are here andyour daughter is here. dr. lombard, what could havehappened had deb ignored those symptoms even for another month? >> well because the blockageis in the artery that was, you know, that provides probably50 percent of the blood flow to her heart, if thatartery would have shut off, she probably would havehad a massive heart attack with risk of death.

and that would not be goodfor the ymca because nobody-- that oh my god that is whathappens when you exercise >> everyone is dying. >> yeah. >> now did you-- do youhave high cholesterol? >> not really? >> never have. >> never have and what about anyfamily history of heart disease? >> oh my god.

everybody on my mother's sideof the family either died young of a heart condition orcirrhotic liver or both. >> so there is heartdisease in the family. maybe a little bit of theelevation of cholesterol or not much and did youhave high blood pressure? >> no. so a lot that describesa lot of us in this room, right? a lot of us do not have a lot of high blood pressure,high cholesterol. is there a question?

>> did her problemshow up on an ecg? >> did her problem showup on an ekg or ecg, no. >> the ekg will onlypick up a heart attack. so if you don't havea heart attack but you are pre heart attack,the ekg will be normal, okay? the reason the treadmill test,she got a stress echo was because her symptomsare very atypical. she was more exertionalfatigue and as barb said, a lot of things cancause fatigue

so we want not just the ekg and actually i reviewedyour treadmill test, the ekg on the treadmillwasn't even that abnormal. but what happens is when youdon't have enough blood flow to your heart, when youstress the heart and such as we made debra run orjog on the treadmill. if the heart doesn'tget enough-- a normal heart pumpslike this, okay? so but if a heartdoesn't get enough blood

when it is being stressed,so the normal part will pump like this and the front partof her heart was stationary. and then immediately weknew that was the artery to the front part ofher heart and we need to get her in right away. >> so you are sayingif i am correct, you can have normal testing, you can be told you havenormal testing but you need to dig deeper and you needto be your own best advocate.

>> yes. you need-- if you arehaving exertional symptoms that is a sort of a,you know red flag, if you have any exertionalchest pain, arm pain, shortness of breath--you don't have pain. >> i was wearing ablood pressure cuff. >> right. people say tightness. i ask a lot of patientsdo you have pain? they will say, i don'thave any pain even when they are havinga heart attack.

they have tightness. >> i have a question? >> so is that thesame thing hardening of the arteries is ittotally different conditions? >> that is hardeningof the arteries, we will get to that later and we will see why call ithardening of the arteries. >> so i think if you are okaywe are going to just thank you so much for comingto talk with us.

you are welcome tostay and if you would like because we aregoing to have question and answer at the end. but now dr. lombardand i are going to give you some moreinformation about women and cardiovascular disease. so i want to thank youso much, thank you. >> thank you so much for coming. before the [inaudible]debra [inaudible].

you know, one thingyou have done for yourself all thistime is you exercise. if you had never exercised,you wouldn't have known. and see that is anotherkey thing. that is why i always tell mypatients to exercise, you know, because if they if people sayhow often should i get a screen? well, you screen once a year,once in every 5, whatever but it happens onthe wrong time. it doesn't happen on the day youwant to go to see your doctor

for a screening test youare not going to catch it. but she is actually puttingherself out there exercising so she noted a difference. she noted the difference. she could always do this but suddenly one dayit was really hard. so you know, i think that knowyour body, always exercise and when things don't fit,you know, keep pushing until you get the answer.

i really appreciate you comingto, you know, hear the story because i think itis really different from when we tell the story versus people hear itdirectly form the patient. >> and now debra [inaudible]here for herself and she watches and knows all the symptoms, there is obviousdifference [inaudible] >> she's going to be thenext aerobics instructor. thank you so much let's give a--

>> thank you very muchwe really appreciate. [ applause ] >> okay. we'd loveit, let us see what-- all right so i think deb youwere very generous of your time to come and sit with usi think i'll move over. >> i'm also a nursepractitioner. i like to be closerto dr. lombard. she is one of my favoritedoctors and i refer a lot of patients to hermostly because she listens

and she is the kind of physicianwho leaves no stone unturned. so when i say, here is aproblem, she will say, "yeah, i believe you andwe will keep digging until we find out what it is." so dr. lombard, i thinkdebra's story is really, really important and it reallytells us that women can be, not always but can bedifferent from men. you know, most of usassociate a heart attack with that crushingchest pain or pain

in the shoulder orpain down the arm. but when it comesto heart attack, we are not always the same. can you describe what womenshould really watch out for? >> yes. let me see. i have some slides so yeahpracticing my yoga right now, turn around. so number one, thereis a misperception that women don't get heartdisease but we do, you know.

we just get it later. we are protected beforemenopause and then it is because of this misconception,a lot of times people are not like debra and they don'tlisten to their body and they ignore their symptoms. the symptoms arevery different not-- are very differentbut a large number of women do have atypicalsymptoms like debra and only 30 percent, 1 out of 3women have classical symptoms,

the crushing chestpain, et cetera, whereas 2 out of 3 menwill have the chest pain, substernal chest tightness, even when people arehaving a heart attack, the chest pain is very atypicaland women have more shortness of breath, nausea,vomiting, indigestion, fatigue that debramentioned, sweating. i had women say, oh mygod, every time i go up the stairs i just break outin a sweat and i get nauseated.

a lot of them will give us,you know, other symptoms such as arm pain and a thirdof heart attacks in women are "silent" because they didn'trecognize that these symptoms. they thought theyhad indigestion. maybe that is why wecall it, you know, some of us call it heartburn. and a lot of times women withsort of the crushing chest pain, you know, is notnecessarily their heart. so-- but always think thatif you do have chest pain

that is particularly exertionalor any kind of symptoms that are exertional, you needto do what debra did which is to follow through and makesure it is not your heart. if it is not your heartthen you don't have to worry about it, okay. so here is the statistics. these are data that arecollected over 10 years ago but things haven'tchanged very much which is that the perception and thereality of the incidence

of heart disease doesn't fit. so people a lot ofwomen still think that breast cancer is the numberone cause of death in women and actually, you know, heartdisease causes more deaths than all the cancers added. and most women are not cognizantof the kind of symptoms that might be relatedto having a heart attack or coronary insufficiency, okay. and here is the statistics,as you see the incidence

of heart disease goesup us we get older. like i said if you dothis slide in blue, you just shift everythingover a little bit but actually we havemade tremendous progress in heart disease in men. we have actually managedto educate, you know, the public to take better careof themselves be more aggressive about getting cholesteroldown, et cetera. we are still workinghard on women.

the statistics wereobtained 10 years ago and so there is a huge campaignto educate women and the public about taking better careof themselves and getting to the doctor when theyhave these symptoms. but in 2010, the statistichaven't changed that much so we are still trying. so here is the scopeof the problem. more women die of cardiovasculardisease than all cancers and about 2 and a half womenare hospitalized every year

for cardiovascular illness and half a million womenwould die every year from cardiovascular disease. and the sad thingis the mortality where women just don'tdo as well even though when you adjust them all forthe risk for diabetes, age, et cetera, we still don't doas well as the men in blue. so you now, this is themortality rate so you want to be or death rate, so you wantto be as low as possible.

and we are a littlehigher than men. and so people say well maybeit is because, you know, we don't get treated as often, we don't come tothe doctor sooner. i think it is multifactorial ie there is a lot of causes why we don'tdo as well as men. but a big part of it thisdisease is very aggressive in women. >> could you explain what arethe initials stand for chd, ami?

>> oh thank you. okay, so yeah. this is all fromcardiology study so, okay. chd is coronary heart disease and then ami is acutemyocardial infarction. now i'm like where am i? but i don't think-- >> here you go. >> okay. post ami is acutemyocardial infarction.

so, after you have a heartattack, women don't-- the death rate is still higher. does that make sense? it doesn't but i mean that isthe reality, unfortunately. so the key thing right now iswe don't want to even get there. we want to preventheart disease. >> and i think we have togo back over this again. one of the most importantpoint that you are going to take away tonight is

that women's symptoms areoften different than men's. so, a third of women aregoing to have chest pain. but that means that two thirdsare not and i want to ask you. i am going to ask youto raise your hand. is shortness of breath a symptom of possible heartdisease in women? >> yes. >> what about fatigue? >> right. what about what aresome of the other-- nausea?

>> sweating. how about you exerciseand typically you are fine but sometime after you exercise,you feel that shortness of breath or maybea pain in your arm. could that be a symptom? >>great. could all those thingsbe symptoms of something else? >> sure. >> yeah. but, the key is togo out and get it evaluated. dr. lombard, you know i have hadpatients and i have sent them

to you who have chest painon exertion or we call that with exercise andi have suspected that. and so, i have sent them toyou or other cardiologists. so, what do you advisewomen who suspect that they may havecoronary artery disease? what is the first stepthat they should take? >> if they have symptoms, they should immediatelysee a physician. and, you know, likedebra illustrated,

usually they willget an ekg just to make sure there isno acute heart attack or acute processand that is normal. the doctor will usually followup with some other studies. we do the echocardiogramand echocardiogram is like the ultrasound, verysimilar to the ultrasound that we all know about babies. so-- but it is a different probeand you get to see your heart on tv and that would tell ushow well the heart is moving.

actually, we get aton of information. we can also tell ifyour lungs work well because we can get apressure from that, et cetera. but, like in debra's case,everything was normal. so i said, "okay, your heartis strong, it is working. why are you so tired? it must be something else." and the key trigger was she hasthis horrible family history. you can't do anythingabout that.

but you have to read allthe tests, all the symptoms and the context of thepatient's family history and the other risk factors. so that is where i will start. and we have, you know, manydifferent ways of evaluating for coronary disease butthat is certainly a start. >> can we keep going andtalk a little bit more about the differencesin men and women? i think you have somecool slides here.

yeah. >> okay. so-- here we go. oh, thank you. we needed some of them. so here is, you know, one thingabout women is that, you know, women, we are different,thank goodness. it makes the world moreinteresting, but we also have-- there have been many studies. women have a differentresponse to pain, okay?

and our response to pain mayeven vary depending on hormones. so they have done a study onwomen and various, you know, phases of the menstrual cycle and they can feeldifferent pains depending on their hormones. but the other difference is that we deposit atherosclerosisdifferently than men. so here is an-- this iscoined by dr. noel bairey merz who is a very wellrespected advocate

for women in heart disease. she is at cedars-sinai at ucla. and she called it theyentl syndrome, okay? everybody seen barbara streisandin the yentl, she has to pretend to be a man, to be let intonot to [inaudible] school but you know, to become a rabbi. so she had to pretendto be a man because they would notallow girls to go in. and she called itthe yentl syndrome

because dr. bairey merzthinks that women all have to have the classical symptoms of the men beforepeople recognize that they are having a problem. well, you know, two thirds of us are not goingto have chest pain. we are going to presentlike debra with you know other symptoms. so, you know, so she startedthis huge campaign while

in conjunction with actuallythe american heart association and the americancollege of cardiology to educate the public. so it is called the yentlsyndrome and part of it is so these are [inaudible]to work. so here is a nucleusstudy, okay? so you see so whatis a nucleus study? a nucleus study is whenwe exercise the patient and we inject an isotope intothe veins and it goes everywhere

where the blood flows. so you see like afull donut, okay? like a full donut, sothis taking a heart and like a cucumber and slicingit down so we you have this-- you fill the round donuts. and here this patient hasa blockage in an artery and you see thatdonut is thin now. it is like somebody tooka bite out of that donut. and that is because that patientis not having any blood flow

going down that-- that artery. and the angiogram,this is an angiogram. okay, so these are the arteriesand you want to see this nice, the whiteness is the contrast soyou want this to be really big. but let me just goahead and this isn't-- these are all the differenttests we can do but i don't know if this does show you hereis a post mortem study and here you see this-- westart laying cholesterol in the artery.

so you want thislumen to be very big. but what women do is that wejust sort of diffusely pack fat around the arteries, okay? so and then what happens iswhen these arteries rupture like this, that causesa heart attack. so it actually bleedsinside the artery and you have theblood clot closing up that artery givingyou a heart attack. so women, we pack thefat all the way around.

so dr. merz has this sayingthat women we get fat all over, men they just get a beer belly. so this is what happens. in men, they get thislike little constriction. so the doctor will say, oh you got a narrowingin that artery, okay? women's would pack itall over, it just look like oh you got reallysmall arteries. the big arteries are not small.

they only look thatway because the whole, the whole lumen is packedwith atherosclerosis. and later, i will show yousome slides but we are talking about hardening of the arteries? when you have all these packingwith this cholesterol stuff up here, cholesterol,lipids attract calcium. okay so then we havethis cholesterol and then you havecalcium on top of it and that is what causeshardening of the artery.

so that is sort of anold fashioned term, hardening of the artery isbasically atherosclerosis. okay, so that is thedifference how we respond to atherosclerosis. we pack it all over and men sortof pack it in a focused spot. it is easier to identify andactually it is easier to stent because you think, okay, we could just pop a stenthere whereas with this vessel, where do you put the stent?

okay, so you basically haveto get like to drain it all down to get rid ofall the stuff. >> so will you always have anelevated cholesterol level? >> not necessarily, there areother factors and you think about all these risk factors asbeing compounded like interest. okay so it is like your-- you have a 2-fold riskand you have high-- you know high blood pressureand other 2 fold risk. two times 2, blah blahblah, so it just adds up

and then you smoke, man thatshoots your risk way up. so people may havethe same cholesterol but not necessarilythe same risk. >> so i am sure a lot of youcook maybe you make rigatoni, right, nice, big,round rigatoni. so you want this nice,big, round rigatoni. you don't want it to belike capellini or spaghetti. and that's what happensto the rigatoni. it gets filled with thatfat all the way around,

so that the amount of blood flowis not going through something as big as rigatoni, it is goingthrough something as narrow as spaghetti or capellini,right? and in here, for women, itis like we line our vessels. we line our vesselswith fat, right? and it goes all the way around. for men, they may bemaking a bulge in an area so there is a narrowingin that area. but for women, it can beall the way down that artery

and that is why, youknow women and men are-- that is another waythat we are different. but it means that we wantto ask for specific testing because some of thetesting that is done for men and women is the same, but we should all bedoing that testing. but women may have totake those extra steps and we are goingto talk about that. so let us start with what shouldwomen start with, dr. lombard?

you know if they are thinkingthat there is an issue or they want to be screened, letus say you have a family history of heart disease, maybe you havegot a little moderately elevated cholesterol, whatshould you start with? >> well, i thinkyou know, again, you should work withyour physician. always get your bloodpressure checked. you can't do anything aboutyour family history, right? you are what you are butyou can decrease your risks

by changing your lifestyle. okay so if you havehigh cholesterol which is also geneticallyrelated, just not fair, some people can eat all theeggs and bacon they want and their cholesterolstill is okay. but you know, if youdo have propensity to have high cholesterol,you should really watch out on your diet and youshould exercise a lot. you know and you can makea big difference just

with your lifestyle. so, you know, measuring things, one is so we alwayscheck your blood pressure and check the cholesterol because those things wecan fairly easily treat. and then depending on whatyour cholesterol shows, the doctor may choose to doother tests to you know figure out how much risk yourcholesterol profile actually confers on your cardiac status.

>> well let's talk aboutcholesterol because i think that even though it is outthere and we hear a lot about cholesterol, canyou walk us through? i think you havesome good slides also about total cholesterol and some of the fractionsthere, in there. >> okay, so this is--these are some numbers. does everybody here knowwhat their cholesterol is? good, who does not?

oh-- sure you are very youngso you are still growing, so. but you should, everybody shouldknow what their baseline is. if yours is normal, thenyou don't have to worry about it you know for-- butthey're recommending that you at least have a baselinecheck when you go you know in your middle years justto see where it is, okay? and so here is what happens whenyour cholesterol is elevated. and here is, this twotheoretical patients and neither one of them smoke.

their blood pressure isnormal, okay, 120, 120. here is a cholesterol thatis 220 and here is one that is less than 160. 160 is pretty low, okay? and the hdl here unfortunatelyin that here, hdl is low and here is a personwhere the hdl is high. and neither one arelike diabetic. so you have mildly elevatedcholesterol and a low hdl and this individualhas a 5 fold risk

of having a coronary eventcompared to this person who has a differentkind of profile. this again, just lookingat the general public and you know there are other-- we don't know anything abouttheir family or anything else but this is justbased on one feeding. so i think everybody shouldget their cholesterol checked as to you know whatit is and you want to know all the differentsub types.

okay, this is-- they are comingout with new recommendations, but this is based onagain, population studies. so we want people tohave cholesterols-- the ldl which is the badcholesterol less than a 160. actually, we like prefer themto be, if you have any risk to be less than 130, and if youhave several risk to be less than a 100, and wewant the triglyceride, those with triglyceride. oh, i don't haveit on this slide.

okay. so, but thoseare the numbers. we want it to be-- you want-- itis like money except in inverse, you want the lowestof cholesterol that you can have, okay? and so what is all thischolesterol business? how does cholesterol work? well, believe it or not,cholesterol, yeah, it all starts in your gut, whatever you eat. so here is in your intestine,

okay so everything you eatincluding fats, carbohydrates, sugars, anything, sopeople don't realize this. this is not just the fatwe eat it is everything because whatever youdon't metabolize, it gets convertedinto fat, right? if you are going to eatlarge amount of food and you don't work it off,you are going to get fatter. well, same as cholesterol,if you don't work out the extra sugarsor carbs, then it gets,

it is getting transferredinto call it microns, it is just like littlebubbles of fat. so that if you like cream,okay so you actually, if you eat ice cream andthen we draw your blood, your blood will sometimes have like little bubblesof fat in them. that's called the microns. they transport them tothe liver and that is where the cholesterolis manufactured.

and all those statins that youhear about on tv, they all work in the liver trying toprevent the metabolism of this little fat, you knowparticles into cholesterol. but okay so if you're not takingthe statins, it goes in here and it gets manufacturedinto initially vldl which is very lowdensity lipoprotein into the intermediate density. so they get sortof like formatted and then they get biggerand bigger into the ldl.

okay, that's thebad cholesterol. >> that's the cholesterol thatdeposits in the arteries, right? >> correct, and thenit get shifted out into the extrahepatic organs into everywhere elseincluding your arteries. so this ldl is shipped out,okay and it goes everywhere. so there is too much ofit then it gets stuck in your arteries just likethe previous pictures. so what about thegood cholesterol, hdl?

so what is hdl? it is high density lipoprotein. it is high density because ithas got extra proteins in it. and what it does, theextra proteins are like the garbage collectors. they are like little pac-man. they go into thearteries and say hey, we have got too muchgarbage here. and so they gobble itup and they take it back

to the dump which is the liver. the liver is the source of allthis cholesterol metabolism and they get rid of it. and that's why whenyou have a high ldl, you need a high hdlto balance it out. and dean [inaudible] thisreally cutely he said, do you have a lot of garbage, you need a lot ofgarbage trucks. and that's basically it.

but if you have a low[inaudible] people come to me and say, oh, my ldl is60 but i'm so worried because my hdl is only 35. well, you don't havea lot of garbage. you don't need a lotof garbage trucks. you are okay. most of these people are on cholesterol medicinesalready, okay? so here is a thingabout triglycerides.

triglycerides arethe smallest fat. it is like the earliest form offat before it gets metabolized into the ldl as in allthe other dls, okay? we used to thinktriglycerides are fairly benign, and triglycerides oncan go up in a thousand. some people have familialhypertriglyceridemia. and but now we know that triglyceridescan increase your risk of having heart disease.

so i think nowadays, we'lllook at the whole structure of what your totalcholesterol, your ldl and your triglyceridesand your hdl. okay, and >> so, i think we aregoing to go pass this. we are going to skipthis and we are going to go to the baby with a-- >> that is goingto be-- here we go. >> so when i see this--this is basically,

this is dr. lombard'squote, "you are what you eat and french friesare great example of something that's ahigh carbohydrate food. and you know when we eat a lotof carbs, carbs get converted into sugar and you willnotice triglycerides, "glycer" sounds alot like glucose. so carbohydrates getconverted to triglycerides. triglycerides are thebuilding block for ldl. so i want you to walk usthrough a couple more slides

about high triglyceridesand hdl, if you don't mind. >> okay so, you know thereis a lot of you know, lot of people asking questionsabout, do i really need to be on a statin and there are somuch bad press about statins and they keep you know,i have a lot of patients who have very highdoses of statins but they have hadbypasses or stents before, and the reason we putthem on high doses is because we don't wantthem see them back again.

and actually, it had the statinshave made a huge difference in our practice. we used to do a lot moreangiograms and put in stents and bypasses, now unfortunatelyfor surgeons are going out of business, they are doingvalves and we don't do stents as often as anymorebecause of this-- because of the drugs, yeah. but statins do have side effectsand my motto has always been, if you can manage your,you know conditions

through lifestyle changes,it is a much preferable way of taking care of yourself. and yes, you are what you eatand people either they hear and they don't get it buthere is some surprising facts about you know cholesterols. okay, so i gave this talk to thenutritionists and they wanted to know how do we manage highcholesterol, high triglycerides. and you know for people withvery, very high triglycerides and this is usually inpatients who have diabetes

as anybody you know, know that people have diabetescan have high triglycerides? >> yeah, and youknow why is that? because with the sugars that youcan't metabolize gets converted into triglyceride which islike a very small fat, okay. the problem withhigh triglycerides is that they could leadto pancreatitis and that is a really nastything, very, very painful. so for people who are veryill [inaudible] triglycerides

regardless of cause,we want to lower down, so you don't get pancreatitis. so you-- they put themon very low fat diets, okay and occasionally we haveto do drugs including fibrates which are special drugs tolower their triglycerides. and occasionally, we have to use while we lower thetriglycerides before we add another drug to lowerthe total cholesterol. okay, so here it is so you know,you can lower your cholesterol

by diet but mostpeople did not realize that you can increase yourhdl by diet and exercise. did anybody know that? >> good then you guys havebeen to my other classes or-- >> i have a question thoughon your triglycerides. is it, it should be overthe 500 milligrams-- >> no it should be lessthat's it, that's it. >> no, i mean to causethe pancreatitis. >> the pancreatitis, thereis-- usually it is very high

but i have seen patients--yeah, but i have seen patients who have-- it is not thathigh and so again it depends on what other contextis in there, you know-- other than that, a lotof fatty liver is lost. so causes of lower hdl, whileyour triglycerides are high, sometimes that couldcause your hdl to be low. being overweight causesyour hdl to be low. if you are inactive, you don'tmake the good you know proteins that make hdl.

diabetes, cigarette smoking, it is amazing how many peoplewe see who smoke cigarettes and their hdl is like halfnormal and once they quit, the hdl comes back up. people who eat a lotof carbohydrates, the carbohydrates then causesthe elevated triglycerides and their obesity, well,that makes your hdl go down, and then certain drugs,hopefully you know, most of the people herewon't be on those except

for beta-blockers oranabolic steroids and proges-- you know these areusually prescribed for very specific conditions. but you know a lot of thesethings you could do things about to quit smoking, loseweight, change your diet, low carb diet, exercise. okay, so we are strong advocatesof you know lifestyle changes. cut your dietary fat, loseweight, even losing 10 to 20 pounds not a lot isgoing to make a big difference,

make a big difference inyour cholesterol metabolism. exercise, just think about it. from millions of years, we arerunning away to preserve life because that tiger orwhatever is going to eat us if we don't, youknow if we stop. and all of a sudden a hundredyears ago we become sedentary. we have machines, in the last20 years you know the average persons spends like 8 hoursa day in front of a screen. it is a computer, itis your cellphone,

it is your tv whatever. i mean we were notmade for this. we were made to run, to goto aerobics class, okay? so what other things can you do? well, you know if you do,if you have done all these, and your cholesterolis still high, then you can use plant stanols. those are like benecol,those you know, there are things you can get

over the counter inthe grocery store. and soluble fiber,you can just get it from patients tell me itis cheapest in costco. i just saw a young man today,my goodness, peter is not even over 50 and he had2 stents put in. and he has a horriblefamily history as well. and i put him on maximumdoses of the lipitor. his cholesterol is still like,you know ldl is still over 100. and we have put him on you knowtablespoon of soluble fiber

and it dropped downby 30 points. >> wow. >> yeah. so i mean there arelots of things you can do, okay. and then of course very, verylow fat diet is the ornish diet but that is really hard formost citizens to follow. >> okay, what is theexample of soluble fiber? i don't know, i havenever heard that. >> soluble [inaudible]or you could just go and they actually sellthem in the stores--

>> they are justcalled soluble fiber? >> yeah soluble fiber. >> or you can lookfor bread that is like high protein breadthat has a lot fiber. so you read the labels tomake sure you know there is when you look for the numberof carbs, maybe you are looking for something that hasless than 15 grams of carbs and maybe 11 gramsof soluble fiber. so you are really going to lookfor more fiber in your cereals,

you know the brands those kinds of things will help yourbody clear cholesterol. >> what do you think of thesouth beach diet, dr. lombard? >> well i think it'san excellent diet. the south beach diet isbasically lots of fresh fruits and vegetables and lowcarbohydrates and i think that you know very few preservedfoods, and it's a great diet. >> and when you are eating alot of fruits and vegetables, what else are you getting?

>> you are getting fiber. >> you are getting tons of fiberand your plate is full of fruits and vegetables, there islesser room for those carbs-- there is less roomfor high fat protein. >> alright, no french fries. >> and you know, one frenchfry a year, that's it. so, a lot of patients that isee coming in and they say well, i just have a high-- youknow i have a family history, my cholesterol ishigh, i am screwed.

there is nothing i can do. what do you say tothat dr. lombard? >> there are lots of things, i just gave you a wholelist of things you can do. >> so you can be incontrol of this situation? >> you can do a lot of things. the point is not to give up,not to say okay i am 30, 40, 50 or 100 pounds overweight. the key is, even if you havea lot of weight to loose,

think about losing themin 5 pound increment. even small changes in yourweight will change your body mass index and it will help youlose, help you decrease the rest so can you tell us about that. anyway so, we just go backwards. this is the definition,although i think that you know, we may have to bepolitically correct and not call peopleobese these days. but the data is you know,there is no advantage

to be lower than 22 or so. and actually, theyfound that even people who are mildly overweightwould be fine, okay? but what happens here is that you can see it islike-- so here is 22 to 25. okay, so what is a 22 to25 person looking like? so i am around here, okay? and as we see, i don't getany benefit and probably when you start gettingreally skinny,

your immune system starts youknow deteriorating, et cetera. so we don't people to be,it is what we call j curve and it starts your risks of something elsehappens goes out here. but you can see that youknow this is over 35. so these are people whoare really overweight. but you know youjust lose 10 pounds, and then you drop down by a lot. and so you lose another 10pounds and you drop down here.

and then here, this is 27 to 30,and so these people are so kind of over weight but lookat the big difference between here and here. so my point is that evenlosing 10, 20 pounds is going to make a big difference. and you know again, likebarb says, you know it is like running a marathon. you know you can'tlook at it like, oh my gosh, i can't do all this.

it is like, make one mile thenmake the next mile and you find out that you have more andmore energy and you have when you lose weight,it gets easier. so any way, everylittle bit counts. >> and tell us about exercisebecause i think some people feel like well i am kind ofoverweight, i don't want to get out there and exercise,couldn't i have a heart attack? what do you advice? >> good point.

you know, people whoexercise very vigorously, like they sprint or whatever,you can increase their risk of having a heart attack becausevigorous exercise causes your blood to very sticky. just think, you know, forlike again, millions of years, while you are running becausei say there are two tigers are going to kill you. well, if he gets a chunk of you, you want to make sure yourblood clots really well.

so your body is gearedwhen you are under physical stressto clot, okay? and clotting we knowcauses heart attacks. so i actually tell my patientsafter they have a new stent, i don't want them to be youknow running like racing. they can jog slowlybut the benefits of exercise are immense,just that moderate exercise. so walking, okay,brisk walking-- >> even walking your dog.

>> walking your dog also-- >> how about when you check themail, walking around the block-- >> absolutely. >> looking at theneighbors gardens. >yes, and all that wellif you do 30 minutes of moderate exercise everyday,it will reduce your risk of having a heart attack by about you know50 percent, by half. it is really great.

and you know and i don't knowif you guys know this but people who have dogs also live longerand have fewer incidence than people who have a cat. oh, because a dog makes himout go out and exercise. >> so walking the cat? >> does anybody done that? i have. it's not easy. >> so speaking of weight loss,there is a book here called "the alpha plan" by a localdoctor, dr. mariam manoukian.

and this book is gearedto her college students and it helps them decrease theirincidence of metabolic syndrome and for them having longterms issues of heart disease. you can also go to my blog. nursebarb.com, ihave all section and they are calledweight loss 101. so i have a couple of questions for you before we takequestions from the audience. dr. lombard tells us a littlebit about whether people,

women especially shouldbe on baby aspirin. what's your thought on that? >> well if you have-- ifyou had an event, okay. so if you had a heartattack or stent or bypass, you should be on baby aspirin. for prophylaxis, the studiesare not so, so convincing but we also know thataspirin is good for stroke. so if you are, you know, inyour 60s or whatever, older, and you are concerned about therisk of heart attack and stroke,

definitely go, you cantake a baby aspirin. there are certain[inaudible] down side you know with the baby aspirin. >> how about fish oil--what is you thought on that? >> so fish oil, we were all likereally gung ho on the fish oil. so people know about thebackground of the fish oil. so you know for a long time, cardiologist werepuzzled about eskimos. eskimos eat almostno vegetables.

try to find vegetablesin northern alaska. there aren't any. they eat-- they're almostcompletely carnivorous but they don't havecoronary disease. they have other things you knowthey get depressed isn't it? you know and they got frozen but they don't getcoronary artery disease. and so they noticed that and it was probably they thoughtit was related to their diet.

well they eat tons of fish offish related products, right? even the seals andwhatever, the seals eat fish so they have a lot ofomega-3 fatty acids. so for a long time we thoughtwell maybe fish oils will be protective but they just cameout with a huge study and showed that fish oils do not seem toeven though fish oils seems to raise the hdland lower the ldl and the triglyceride make ournumbers all look much prettier. it didn't seem to make an impacton mortality and event rate.

so we are not recommendingit for prevention anymore. but, it still seen to behelpful in prevention of stroke but that is the background whythe whole fish oil thing came through is because lookingat studies of the eskimos. so right now, i will say,you know it hasn't shown to be harmful like thevitamin e study that came out about 10 years ago. so if you take fish oil, you cancontinue taking it and it seems to be helpful forprevention of stroke.

>> okay, so now i am goingto switch gears a little bit. i want to talk to you about-- wewill get to that in just a sec. i want to talk toyou a little bit about coronary arterycalcium scores or coronary calcium scoresbecause i think for women, after you get yourcholesterol level checked and you know whatyour triglycerides are and you are having a healthydiet and you are exercising and you are doingeverything right,

but you are still wondering,i have a normal ekg, could there still be somethingwrong how do we diagnose that in women. >> so let me just reframe,that's a great question. and this applies to the guys and by the way guys,thanks for coming. you can take bettercare of yourself and your significant other. so, this appliesto both genders.

so here is a situation thati encounter frequently. a patient comes in and theircholesterol is mildly elevated but they said you know mybrother got a stent put in when he was 40. what should i do? should i go on drugs and youknow i don't have any symptoms. my ekg is normal. and you know becausei don't want to put a stent inthem in any year.

so coronary ct is a great way ofrisk stratifying to let us know in advance is that patientalready depositing cholesterol in their arteries? so let me just showyou some pictures. so here is a cardiac ct andi forgot somebody mentioned about hardening of the arteries. so well calcium is white andis also very radio opaque. so x-rays don't go throughit so it looks white, right? just like bone.

>> what is a ct? >> computerized tomography. so it is like x-raysby a lot of x-rays and the computer slices it up, so it presents you knowbasically it is like x-rays and the computerregenerates these pictures. >> it use nuclear-- >> no it is not nuclear. this is no nuclear,it is radiation.

it is just like gettinga bunch of x-rays and the computer rebuilds it into two dimensional,three dimensional. >> some people usedto call it a cat scan. >> oh yeah, good. cat scan. except thereare no cats involved. >> right. >> you can't hurt them. okay so here is an artery

and you can see this person hashere is your artery here, okay? so, when they have and it isnot deposited, just spotty. so that's a high-- thisperson has calcium. when young people, okay,so a calcium score of zero. we are born with acalcium score of zero and you should have no calcium in your arteriesuntil you get older. and as you see the red bars,this has a high calcium score, the red and the purple bars.

so as you get older, that'sthe aging process, okay? you start depositingcalcium in all the places. you get it in your eyes andcall it cataracts, right? you get in your valves andyou have aortic stenosis or valvular problems. you get it in your arteriesand you have hardening of the arteries, okay? >> and this is not from takingyour calcium supplements for your bones--

>> thank you. >> okay? >> this is not from that. >> you can take nocalcium, and you still end up in all those weird places. you know people who don't takecalcium still get cataracts, right? okay. so but what happens if, ifyou have early atherosclerosis, you will end up, you know,you can be 30 years old

and you can have a calciumscore of a hundred, okay? and then when we seethat-- that's bad. this person, we need todo something about it. we need to get theircholesterol lower than normal because we want it toleach out of the arteries. so the calcium score, oh,i think i include that. what happened with the slide? >> so, you want tokeep advancing it, it might put your--if you go forward, no?

it might give us the phases. so you don't want to have a lotof calcium in your arteries. >> and this slide, i don't knowwhy it didn't show up like this. i guess sometimes it reformatsand then it does not show up. but anyway there, it shows thatthe graphs are very similar. but the higher yourcalcium score, the greater the riskyou are going to die from a heart attack. so, my point is that if you--

if a patient is sort of thatintermediate risk group, a calcium score can bereally helpful in determining if that patient isactually high risk, and we should intervene early and treat them veryaggressively particularly with respect to theircholesterol. >> how do you getthat calcium score? >> how do you getthe calcium score? so unfortunately, the sideeffect is a really great task,

medicare won't pay forit which means none of the insurance will-- occasionally theywill pay for it, okay? so, basically, it's just likea cat, a cat scan or x-ray. yeah. and-- it's not a blood,it's not a blood calcium. it's an x-ray. >> what is this called? >> why did you say it's notcovered by the insurance? >> why is it-- i thinkeventually it will, because

but at right now it is not. and you know medicareis very, very slow and they cover some--it depends. it depends on whereyou get it done. but usually, i think weare charging at 400 dollars and i am trying to talkto radiology to this to get it cut down even more. >> so you are saying it isonly indicated for people who are young andyou are suspecting?

>> no, for intermediate--intermediate risk and you want to decide whether, because youknow, if you already have a-- had a heart attack, i don'tcare what your calcium score is. you already declaredyourself as high risk, right? so it is-- we want tocheck it and like a patient who maybe a particulargroup of a people who have strong familyhistories, because we want to know, should we interveneearly in these people to prevent them fromhaving an event.

>> so, go ahead. >> how did we-- isthe crp-- crp? >> crp? crp, so, that's acompletely different test. that is a c-reactive protein. that is what crp stands for andthat's a very good question. c-reactive protein isan inflammatory protein that your body makes wheneveryou get an inflammation. and atherosclerosis isvery inflammatory, okay? this shows a lotof other things.

you get a cold and yourinflammation index goes up. you get pneumonia, it goes up. so, it is helpful butit's not very specific. so, crp is helpful but--calcium, that's a blood test. >> okay. >> that is a blood test. >> and so, if someone has ahigh crp, we want to look at it in context with high blood. if they have highblood pressure,

their total cholesterol,their triglycerides, so it is something tobe looked at in addition to a lot of other tests. you don't want to justtake any test in by itself. what other questions doyou have in the back? >> she talked about the calciumin relation to cross over the-- when you talk aboutcalcium, that's too or over the cholesterol,that calcium go on the one in our artery and the veins.

do vitamin helps you that weintake, what's those different-- difference in between dose? >> there is actuallyno molecular difference but it is just howit is metabolized. so the calcium in your blooddoes not necessarily mean it is going to go into the arteries. if you have clean arteries, you won't get any calciumdeposits no matter how high your calcium is.

but if your arteries arechockfull of cholesterol, it will stick right there. like a sticky fat. >> so those peopleshouldn't take calcium? >> no, no, no. the calcium-- no. the calcium-- if you havenormal arteries, okay? and yo have no atherosclerosis,you can take-- you can-- the calcium will notgo to your arteries.

it is irrelevant. if you don't take any calciumand your arteries are full of atherosclerosis, yourbody will still manage because your bones areconstantly being built and rebuilt, right? so the calcium from the boneswill end up in the arteries. so it doesn't matterwhat you eat. it is basically how thatthe cholesterol kind of sucks up the calcium.

the calcium, remember,is not the cause of the problem, itis an indicator. you have an atheroscleroticproblem. >> so we want to be very clearyou should take your calcium for your bones butwhether you take calcium or you don't take calcium doesnot influence whether it is going to be depositedin your arteries. so it is very different. do you have a question?

>> there was a-- therewas an article though about calcium and heart disease. maybe she's relatingfor that kind-- >> i didn't see that article. where was that? >> it was in thebritish medical journal. >> it's always been yeahtalked about the, you know, too much calciummake-- that [inaudible]. >> well, too much calcium,it's pretty unusual

to take unless you havelike kidney issues. most of us don'ttake calcium too. yeah. but even-- causeyour supplements. >> there was a study fromthe british medical journal and it was published last year. and basically, they said don'texceed 1500 milligrams a day. so-- they say, be sure youget it from dietary sources. and if you are getting it fromdietary sources you don't need to take 2 or 3 supplements.

you have a question. >> i have a questionfor dr. lombard. where do you come downon drinking a glass of wine for a day? >> so, alcohol. that's a very good questionbecause there's a lot of study showing that alcoholmaybe beneficial for your heart. and alcohol changes how yourliver metabolizes cholesterol. so then, that may be the impact.

and on, you know, initially,it was like red alcohol but it seems like the studyshow doesn't really matter what it is. but i need to tell for men,no more than 2 glasses, okay? and in this country likea lot of other countries, they have a lot of problemwith the alcoholism. so i certainly don'ttell people you have to drink alcohol to benefit. because they are,you know, even that--

it is a very smallbenefit unlike exercise and losing weight. so i much rather them do thatand drinking and then yeah, if you drink a lot of alcohol,you end up getting fat, right? but for women, it is probablycloser to one glass a day because our bodymass is smaller. so, if you enjoy drinking, thendrink one if you are a woman and you can have twoif you are a guy. >> okay. and back there?

[ inaudible audience question ] >> no. so-- okay. the calcium is just indicative of whether you have anycoronary disease or not. it doesn't tell us if thereis a significant blockage. remember the picture ishowed you with the waste? okay. so, you may have like,you know, very mild blockage and it still wouldn't-- you still could havevery high calcium score.

the times you put a stent in arefor people who have symptoms. so if you have any symptoms? you know they'll make thepatient feel any better, right? so we don't usually putin or do bypass or put in a stent unlessthere are some, we can make the patientlive longer or feel better. >> so once again thecardiac ct would be a good-- test to find out just-- >> what your risks are.

>> what your riskare if you pass-- >> so here's a perfect case. you know i have a patient whois probably, when did i meet him about 10 years ago maybe,and he is into his 40s, you know he is a [inaudible], he is very well traveledand everything. and exercises, runs youknow half marathons, he just came back from everest. and his cholesterolis kind of borderline

and his uncle had aheart attack in his 50s, no other risk factors. and he says, "youknow what should i do? i mean it is just my familyis riddled with this disease." so he did his calciumscore in hand and his calcium score was 150, not real high buthe is 40, right? so i don't want him to havea heart attack when he is 50, particularly if his upeverest, there is nobody

up everest to take care of it. so any way, we did start him onstatins and we debated this back and fourth, back and fourth. and after his calcium score was200 which is like really high for somebody who is 40. so and the thingabout the calcium, it doesn't go away eventhough you get rid off the arthrosclerosis. it just stays there, butat least i don't want to go

from 200 to 400 and it basicallystayed right there about 200. >> we only have a coupleof minutes and we'll stay, won't go outside but ilike to take a question from over here in the back. >> about estrogen? does estrogen help? >> estrogen we used to thinkit helps but there are lots of data showing that it maynot necessarily be helpful. in fact, the hertz study thatcame out 5 years ago or so show

that you know may increase theincidence of heart attacks. and may be related to the fact that estrogen makes your bloodthicker too as in you clot. >> after 15 yearsof estrogen and now that if i have a high crp test,if crp and all for the estrogen. >> another questionfrom the back? >> what is the average fora 50 to 60 year-old woman who have calcium score,what would be the ideal? >> zero. yeah and you know ithink i have my graph back there

but its-- so, 50,so you know it's a-- yeah so for 57 year old person,less than a hundred for sure. >> so estro-- i will take that. if women start estrogen-- this is by urinalysis from northamerican menopause society. if woman start estrogen earlyin their late 40's, early 50's, there seems to be a slightbenefit for the heart, however, there is an increasedrisk of stroke. so but it is not a goodidea, if a woman has been

without a period andno estrogen for 5 or more years not to start it. the risks are too high forboth heart attack and stroke. but younger women, thereseems to be a little benefit of the heart but nobenefit in terms of stroke. >> but it is not strong enough that we are recommendingpeople to go on estrogen-- >> yeah, we do notrecommend estrogen for heart-- for prevention of heart disease.

so i have time for onequestion, one more. >> there's an ebt-- >> ebt-- >> screening. what is ebt? >> electron beam tomography,so it's like cat scan. >> we got to get onemore good question-- i mean that was a good questionbut anything related to-- >> yeah i won't showthat slide because--

>> i want to let you know thatthere is something called "day of dance" and i'mgoing to be there, it's february 25and we can do zumba. so we can start exercising yeah. [inaudible] it's warmer there. i will use some exercise,work out some calories. i also want you to know thatthere is health perx and many of you are alreadymembers of health perx. we have a wonderfulrepresentative

from the health library here. health perx, if you're notalready a member, please join. and if you join andyou use nurse barb as the promotioncode, it is free. now normally this is 25 dollars. they are going to beoffering, this is a secret, like free life line screening, a lot of cardiovascularscreening coming up in the next few weeksthrough health perx.

you also get a free consultation with the nutritionist,free, free, free. and for those of us inthe sandwich generation, dealing with elderly parentsa free elder care consultation plus lots and lots of discounts. also there is a coupleof whole apps. there is the familymedical officer app. if you have smart phone, iwould use this seriously. one of my friend's parentswas going into septic shock

on christmas eve, i opened upthis family medical officer app and found out thewait time in the er that night was 46 minutesso guess what i did? 911. so we got here right away. >> why i did not know that? >> i was here on christmas eve. >> i knew that. i knew that out. >> so i just wantto say dr. lombard,

it has been a pleasuretalking with you. you have given us all somuch information thank you. we need to [inaudible] buti'm pretty sure because she is so committed to help andcardiovascular help will be out in the hallwayanswering questions. thank you. [inaudible discussions]