When you are at rest in a warm bed, arteries dilate and blood pressure tends to be low. When you stand up, your body elevates blood pressure to be sure your brain is perfused so you don’t black out. Getting out of bed in a cold room could cause an increase in pressure. How high does it get when you stand up? Does it then return to normal? Is your blood pressure cuff accurate? Discuss these questions with your doctor.

High BP in A.M. The Saturday Evening Post

Both of your doctors could be right. It depends on where the calcium is, how much is there, and whether it is buried in the heart muscle or mobile, like in a valve leaflet. If it is immobile, it may not be necessary to remove because it is anchored in place and may not be causing any problems.

If it is moving, it may be susceptible to breaking off into the bloodstream, and its removal might be a priority. Be bold and ask both doctors to explain their positions. Having a significant leak in your valve could be a reason for operating to try to fix it.

Two Views on Calcium Deposits in Heart The Saturday Evening Post

A: Skeletal muscles in your arms and legs need oxygen and can produce pain if they do not get enough of it. However, pain in the arm, neck, jaw, shoulder, and back because of coronary artery obstructions (which I assume led to your open-heart surgery and stents) is thought to be “referred” from the heart itself because of the lack of oxygen to the heart muscle. I agree that your next step is to have a stress test to determine if you have remaining coronary artery obstructions.

Burning Pain in Arms The Saturday Evening Post

A: What you describe is not common, though it unquestionably happens. Unfortunately, atrial fibrillation generally recurs unless the factors that first produced it are no longer present — for example, a narrowed heart valve is replaced by a prosthetic one, or hypertension that made the heart work harder is now under control. Another factor to consider is that having AF actually changes or “remodels” the atrial heart muscle into tissue more conducive to having AF. However, the reverse is true also.

Having a normal rhythm can help reverse the remodeling and deter future AF recurrences. You are most fortunate, and I hope the normal rhythm continues. Do let me know what happens.

Atrial Fibrillation Stops on Its Own The Saturday Evening Post

A: I am not aware of the information you cite. In fact, the body tightly regulates its pH (a measure of the acid-base balance) between 7.35 and 7.45. For example, if your blood becomes too acidic, a condition called metabolic acidosis, the body compensates by breathing more rapidly to exhale carbon dioxide and return the pH to normal limits. I am also not aware of a way to achieve an alkaline system that the body will not attempt to rebalance to normal. Nor am I aware that such an alkaline system would be better for the body’s organs.

Acid Versus Alkaline The Saturday Evening Post

My heart sometimes pounds while I am relaxing or when I stop walking around. Wearing a 24-hour heart monitor showed nothing. The pounding is getting more frequent as time goes on. Any advice?

-P
via e-mail

More Heart Testing May Help The Saturday Evening Post

A: Sinus bradycardia with rates as low as you describe can be a completely normal finding. I exercise a lot, and my heart rates are just about like yours. Well-conditioned athletes have resting heart rates in the 30s. Generally, we only treat sinus bradycardia (usually with a pacemaker implantation) if the individual is symptomatic from the slow rates. Since you say you are doing fine, I would recommend not doing anything except for following up with visits to your cardiologist maybe once or twice a year for a checkup. Should you experience dizziness, a lightheaded spell, or loss of consciousness, tell your doctor immediately because a pacemaker may be indicated at that time.

Slow Pulse The Saturday Evening Post

A: There are many causes of atrial fibrillation, including a hereditary form, coronary disease, hypertension, overactive thyroid, and the list goes on. Warfarin (Coumadin) is important to reduce the risk of stroke and should not bother your sleeping. Some forms of atrial fibrillation can be cured by catheter ablation or surgery. Success rates depend on the kind of atrial fibrillation you have. If you are interested, contact a heart rhythm expert at the Heart Rhythm Society
(hrsonline.org or 202-464-3400) for an evaluation.

Atrial Fibrillation The Saturday Evening Post

A: The heart has a conduction system that is like a major wiring system along which the electrical impulses travel from the top right side (sinus node in the right atrium) where they are formed, to the bottom chambers (ventricles) to coordinate the contraction of each heartbeat (see picture). Slowing or blocking of the impulse produces changes that can be recorded in the ECG. A person may or may not experience symptoms from such alterations in conduction. When the impulse slows or blocks in the right ventricle, it is called right bundle branch block, and in the left ventricle, left bundle branch block. The changes may or may not be important and need to be correlated with your clinical condition by your cardiologist. In general, left bundle branch blocks carry more significance than right bundle branch blocks, but this needs to be determined by your doctor.

Left Branch Block The Saturday Evening Post

A: Sinus bradycardia with rates as low as you describe can be a completely normal finding. I exercise a lot, and my heart rates are just about like yours. Well-conditioned athletes have resting heart rates in the 30s. Generally, we only treat sinus bradycardia (usually with a pacemaker implantation) if the individual is symptomatic from the slow rates. Since you say you are doing fine, I would recommend not doing anything except for following up with visits to your cardiologist maybe once or twice a year for a checkup. Should you experience dizziness, a lightheaded spell, or loss of consciousness, tell your doctor immediately because a pacemaker may be indicated at that time.

Slow Pulse The Saturday Evening Post

A: These medications are commonly used together, and their combination should not present a problem for you.

Drug Safety The Saturday Evening Post

Pacemakers ramp up heart rates that drop too low. ICDs detect deadly heart rhythms and shock quivering hearts back into action. Both deliver electricity via thin wires called leads that connect to the inside of the heart and are gradually surrounded by scar tissue.

Over time, however, cardiac leads may wear out or interfere with blood flow. In some cases, an older wire may be in the way of a new one that is needed.

Heart doctors may use a tube-like sheath attached to a laser to remove scar tissue around a cardiac lead and gently pull it from the body.

How to detect—and address—potential problems with cardiac leads is an active focus of discussion and research. The Heart Rhythm Society (HRS) recently issued the industry’s first comprehensive guidelines for cardiac lead removal at their annual meeting in Boston.

“Removing leads that have been in place for some time can be a difficult procedure, requiring specialized skills and equipment,” Dr. Zipes explains to the Post. “A Heart Rhythm Society Task Force has just published (in the June issue of HeartRhythm) information about lead performance and follow-up while the new HRS guidelines on cardiac lead removal help the clinician decide who should have a lead removed and how it is best done.”

New study details presented at the HRS annual meeting suggest that the Spectranetics Excimer Laser System may allow heart physicians to break down scar tissue and extract problematic leads in a controlled fashion.

The SLS II from Spectranetics Corporation utilizes a ring of laser energy to break down tissue that is binding cardiac leads to the vein or heart.

The four-year LExICon (Lead Extraction in Contemporary Settings) study demonstrated a clinical success rate of 97.7 percent utilizing the Spectranetics Laser Sheath (SLS II®). The system emits pulses of low temperature ultraviolet light from a circle of fibers to break down tissue that binds the lead to the vein or heart, permitting removal.

“As increasing numbers of patients receive implanted cardiac devices, understanding lead management options is critical,” said Dr. Bruce Wilkoff, principal investigator of the study and Director of Cardiac Pacing and Tachyarrhythmia Devices at Cleveland Clinic. “Patients are living longer, but leads don’t last forever.”

Keep the Beat The Saturday Evening Post

Dear Dr. Zipes: I have calcium deposits on the aortic valve that keep it from opening and closing all the way. If my family doctor had not told me, I would not know I have the problem. I am 82, have no symptoms and am very physically active. Is there anything I can do to keep the problem from worsening? Would avoiding high calcium foods help?

Dear Reader: It sounds like you have aortic stenosis (narrowing of the aortic valve) and aortic insufficiency/regurgitation (leaking) due, in part, to the calcium deposits you describe. These changes can be caused by simple wear and tear effects from aging, due to a bicuspid (two valve leaflets instead of the normal three) valve from birth, or due to rheumatic valve disease (not likely). Given your age and that you are physically active without symptoms, I would opt for the first explanation. Assuming the blockage and leak are both mild and have not affected the major pumping chamber, the left ventricle (easily determined by a cardiac echo), I would do nothing except have annual evaluations to be sure nothing has changed. Avoiding high calcium foods will have (and have had) no effect on these changes.

Calcium Deposits and Valve Function The Saturday Evening Post

Dear Reader: It is clear you have significant coronary artery disease and are a prime candidate for taking statins to reduce your risk of another heart attack. Unfortunately, you are also one of the relatively few individuals who develop muscle pain from the statin. Statins can produce varying degrees of myositis, which is inflammation of the skeletal muscles. This can just be muscle aching, which usually disappears several weeks after stopping the drug. Sometimes it is more severe, with some muscle weakness and pain. A muscle enzyme called CPK can be elevated in the blood. Finally, statins can cause severe muscle inflammation producing damage, weakness, and CPK elevation so great that the proteins released from the inflamed muscle cells can damage the kidneys, leading to kidney failure. There is no reliable therapy to counter these effects in a susceptible patient except for stopping the statin. Suggested treatment is to try different statins, since they all don’t produce the same response, take the lowest effective dose, eliminate other drugs that may enhance this side effect, and consider taking drugs other than statins to improve the lipid levels.

Muscle Soreness and Statins The Saturday Evening Post

Dear Dr. Zipes: I have an implanted defibrillator for hypertrophic cardiomyopathy. My blood pressure is under control. In November, 2007 I had a stroke. After the stroke I had fluid in my legs and chest, but that has gone away. Now I seem to have fluid around my waist. I take three Lasix pills a day. I gain two pounds one day and lose two pounds three days later. A recent BUN (blood urea nitrogen) count was 48. What might cause the fluid build up? Can my high BUN be a result of too many Lasix?

Dear Reader: You have a complicated medical history, and I will not be able to answer all your questions satisfactorily. The best advice I can give is to find a good cardiologist. That said, let me attempt to answer some of your questions. The implantable cardioverter defibrillator (ICD) you have is similar to the device Vice President Cheney had implanted years ago to monitor his heart beat and treat both fast and slow heart beats if they occurred. Your device will do the same and can effectively prevent sudden death in patients with hypertrophic cardiomyopathy. If you are interested, there are a number of patient support groups for patients with HCM, such as the Hypertrophic Cardiomyopathy Association (www.4hcm.org). It sounds like you developed heart failure after your stroke, which was treated with Lasix (furosemide, a strong diuretic). Weight fluctuations you describe are not that unusual. You need to watch your diet and avoid a lot of salt. You should also guard against a steady weight gain because that could signal fluid retention and worsening of your heart failure. The elevated BUN indicates kidney problems that could be related to kidney damage, heart failure, excessive Lasix, or all of the above. You are basically walking a tight rope between taking enough Lasix to prevent the heart failure and not too much to worsen kidney function. So, as I said in the beginning, find a cardiologist expert in heart failure problems and do as he/she recommends.

It’s a Balancing Act The Saturday Evening Post