There are a number of reasons why a heart failure patient may return to the hospital shortly after being discharged. Noncompliance with diet (eating too much salt) or medications certainly accounts for a large number of these patients. In some instances a patient’s heart failure is so bad that they frequently return to the hospital for intravenous medications.

Sometimes it is difficult to tell if a discomfort a person is feeling is from the heart or from the stomach or esophagus (heart burn). Typical heart pain is usually described as a heaviness or pressure like sensation in the center of the chest (like someone pushing or standing on your chest). This discomfort can be very mild or quite severe. Sometimes typical heart pain or pressure will radiate up into the neck/jaw and into the left arm. Occasionally typical heart pain will also involve, shortness of breath, nausea, sweating, lightheadedness or feeling faint. Occasionally a person can have atypical symptoms (some type of discomfort other than the above) and it can still be there heart.

Certainly a good batch of Gumbo and watching your favorite Team (the Saints I assume) battle it out in the Superbowl can cause heartburn from too much stomach acid production HOWEVER it is always a good idea to get yourself checked out if you have had any chest discomfort. I urge you to let your doctor know about your symptoms. Your doctor may recommend for you to have an EKG and/or a stress test just to be sure.

Certain heart rhythm problems can be treated and in fact cured by an ablation procedure. In some cases medication can be significantly reduced and even stopped after the ablation. Because each type of heart rhythm problem is very unique and each has different success rtes from ablation I urge you to discuss this with your doctor. The ablation procedure is performed by a highly specialized cardiologist (know as an electrophysiologist) who sub specializes in treating heart rhythm disorders with this type of procedure.

It is always a good idea to discuss the use of any medication (over the counter, supplement, vitamin or prescription) with your doctor. There are a number of benefits to taking low dose aspirin however taking it daily is not completely without risk. This risk mostly coming form the gastrointestinal tract in the form of irritating the lining of the stomach or esophagus, causing heartburn and even slightly increasing the risk of gastrointestinal bleeding.

In my practice, if there is no history of cardiovascular disease I recommend a low dose aspirin as part of a daily regimen if a patient has one or more risk factors for developing cardiovascular disease (high blood pressure, diabetes, high cholesterol, smoking, family history of cardiovascular disease). This low dose aspirin is in addition to whatever medications they may need to address their other risk factors.

If a person has cardiovascular disease then a low dose or regular strength aspirin will likely certainly be a part of their daily regimen.

AS your “referee” I would suggest you discuss this with your doctor so that he/she may advise you and so that it can be placed in your medical record that you are taking aspirin, an important fact that other health care providers might need to now in the future while caring for you.

If someone has normal blood pressure the current recommendations are for an annual screen of blood pressure. If someone has high blood pressure they will likely be evaluated numerous times throughout the year. As long as your blood pressure has always been normal the yearly exam should be sufficient. However, if you are at all concerned and want to know your blood pressure or have other risks for developing cardiovascular disease (smoking, diabetes, high cholesterol or a family history of stroke or heart disease then I would recommend getting an automatic blood pressure machine and checking your blood pressure 3 – 4 times a year. These portable blood pressure machines are affordable (generally less than 100$) and very easy to use.

Based on the results of the JUPITER Trial, which involved 18,000 patients the FDA recently voted to expand the indications for the use of CRESTOR. CRESTOR already has an approved indication to lower cholesterol and triglycerides in combination with diet and exercise in patients with high cholesterol and/or triglycerides, and an indication to slow the progression of atherosclerosis.

The new indications include:
Primary Prevention of Cardiovascular Disease
In individuals without clinically evident coronary heart disease but with an increased risk of cardiovascular disease based on age ≥50 years old in men and ≥60 years old in women, hsCRP ≥ 2 mg/L, and the presence of at least one additional cardiovascular disease risk factor such as hypertension, low HDL-C, smoking, or a family history of premature coronary heart disease, CRESTOR is indicated to:
• reduce the risk of stroke
• reduce the risk of myocardial infarction
• reduce the risk of arterial revascularization procedures

This new indication in no way is meant so that Crestor can replace other medications. The exception to this might be if you are on another statin medication and are questioning whether or not you should switch to Crestor. In this case I would ask your doctor.

I always tell my patients that the best statin drug is the one that works (gets their LDL Cholesterol to goal) and is covered under their insurance. We as physicians who treat high cholesterol have our favorite statin usually, one that we know that most of the time is going to work to lower cholesterol. We may feel that one is stronger than the other or in our experience has been more successful in lowering cholesterol. One of the driving factors in my practice has been cost and which statin is covered under patients insurance. I may have to work with increasing doses or switching to a different statin until I find one that lowers the cholesterol to goal in a given patient.

I will say however, that in my experience, certain name brand statins or combination drugs (statin and another medication combined into one pill) work better than most generics to lower cholesterol.
I would encourage you to make an appointment to discuss this specific issue with your doctor. Let her know that the cost is becoming prohibitive and you wish to switch to another statin.

For the most part it can definitely make a difference if you miss a dose of heart medication. Depending on the medication and the problem being treated (high blood pressure, heart rhythm problems, need for blood thinners) missing one or more doses can lead to problems. Unfortunately doubling up on medications because you missed a dose can also be dangerous. It is always best to consult your physician if you miss a dose or are having trouble remembering certain doses during the day. When discussing this with your physician be certain to ask the question, what do I do if I miss a dose of this medication?

The proposed payment cuts in cardiology will affect health care providers such as cardiologists. The FDA should not take this into consideration as patient safety and effectiveness of therapy are the main concerns of the FDA.

The ICDs used in the MADIT-CRT trial are all market released devices approved for use in patients indicated for ICD therapy. The CRT-D devices used in the MADIT-CRT trial are FDA approved for use in patients who meet the current CRT-D indication, which means they fall into NYHA Class III/IV and therefore have advanced symptoms of heart failure. However, the MADIT-CRT trial looked at patients who have not reached the advanced symptoms of heart failure. Boston Scientific will likely be using the data from this trial to seek an “expanded indication” for all market-approved CRT-D devices to include the MADIT-CRT population.

Even though the MADIT-CRT study results are positive new indications for CRT-Ds in patients in the NYHA Class I/II categories, this type of treatment has not yet been approved by the FDA for heart failure patients in Class I/II. The study will be published and examined by the FDA before a decision is available. In the future, if a person meets the criteria of the MADIT-CRT study then it is likely that those patients will be upgraded to a CRT-D device once FDA approval is received.

CRT-Ds are different than regular ICDs. Specifically, CRT-Ds work with every beat of the heart to create a resynchronized contraction, which may increase exercise capacity AND provide the protection of an ICD. ICDs on the other hand, provide pacemaker support when called upon to do so and also provide protection from sudden cardiac arrest (SCA). Exercise has been shown in general to benefit patients with a variety of heart conditions. However, as every patient is unique, it is important to check with your physician about how much exercise is safe, and what types of exercise are appropriate.

Yes, CRT-D is beneficial for patients with a wide QRS (ECG), reduced heart function (ejection fraction less than 35 percent) and NYHA failure Class III and IV. These results have been demonstrated in a previous trial titled COMPANION and approved CRT-Ds have been approved by the FDA for usage in NYHA Class III/IV patients. The new finding is that preliminary results suggest that high-risk patients with mild heart failure (Class I/II) benefit from early intervention with cardiac resynchronization therapy.

MADIT-CRT preliminary results indicate that CRT-D therapy is associated with a significant reduction in the risk of death or heart failure intervention when compared to ICD therapy. Additional information on the study results will be published in the future. We do know that heart failure is a progressive disease where over time a patient’s clinical status declines. An analysis provided by Dr. Parag Jain in the February 2003 supplement of American Heart Journal discusses the progression of heart failure with each acute event further impacting a patient’s clinical status. Therefore, reducing hospitalizations in heart failure patients greatly impacts patient outcomes.

A major risk factor for any cardiac event is exercising at a level your heart is not accustomed to. The purpose of cardiac rehabilitation is to slowly and deliberately increase the intensity of exercise in a monitored environment. In addition, the goal is to set limits on the intensity to keep you within a safe range. It is clear that having one SCA increases one’s risk of a second and that is why defibrillators are often inserted (a device most like a pacemaker, which has the added capability of identifying, and by means of an internal shock, converting the heart to a normal rhythm).

Margaret, you are never left alone during the entire cardiac rehab program. You will be checked in by rehab staff, making sure it is appropriate and safe for you to exercise that day. Then your heart rhythm and heart rate will be monitored on a screen, by staff while you exercise. Staff will check your blood pressure during exercise and be available to work with you to adjust your settings or answer any questions or concerns.

After your exercise, you will cool down and staff will check your blood pressure and heart rate, clearing you to go. Also during exercise you will have the opportunity, if you choose, to talk with other people who are exercising as well.

The purpose of rehab is to exercise your heart in a monitored safe environment. They will slowly advance your settings while monitoring your vital signs to eventually get you safe and ready to exercise independently. The process is slow and thorough.

For cardiac rehab to be most successful, it requires open communication between staff and patients. Make sure to discuss your concerns, that‘s what they are there for.

After cardiac arrest, developing an exercise program is a powerful part of an individual’s recovery. Since each person has a different set of circumstances related to their cardiac arrest, it is very important to have a personalized exercise prescription written for you. This is designed by your Cardiac Rehab Staff, and approved by your Cardiologist who referred you into Cardiac Rehab.

First I am going to back up and explain aerobic and anaerobic exercise, and how your body uses energy. Aerobic describes a type of metabolism, or how your body breaks down stored fuel to create energy. Your body can create energy aerobically, with direct oxygen, or anaerobically, without direct oxygen. The food you eat is where your energy comes from. This energy is stored in your body as fat, in your muscles and liver. The bloodstream carries oxygen to cells and these cells transform the stored fat into energy, releasing the energy. The higher your demand of energy, the higher the demand of oxygen to release this energy.

The process of using oxygenated blood to release energy is called aerobic metabolism. Aerobic exercise is an activity that involves a steady, continuous motion of the large muscle groups. This places a large continuous energy demand on the heart. These increased demands on the heart, cause it to grow stronger and more efficient. Some examples of aerobic exercise include walking, jogging, swimming, bicycling, and dancing.

Anaerobic metabolism fuels short bursts of activity, such as weight lifting or sudden sprinting, when your body requires energy faster than the cardiovascular system can provide to it aerobically. Anaerobic exercises can build both muscle strength and endurance.

So, weight lifting is an anaerobic exercise. It is an essential part of a total fitness plan; however it does increase your blood pressure and can sometimes be inappropriate depending on your cardiac situation. It would be best to have a consult with your cardiologist about weight lifting and your heart. If you are cleared, then developing a specific program with a Cardiac Rehab Staff and being monitored initially would be the next step.

Aerobic exercise is beneficial after cardiac arrest because with the gradual increase of oxygen demands on the heart muscle, it helps to build a stronger, more efficient circulation. It improves the body’s ability to deliver oxygen rich blood to the rest of the body. This is very important to help your energy level and stamina, which affects your quality of life.

Great question Mark, I hope that was helpful.

Eating a heart healthy diet is one of the most important steps you can take after a cardiac event, when trying to avoid a relapse. What you eat effects many risk factors associated with a healthy heart: your cholesterol levels, your blood pressure, your weight, and your blood sugar level. So learning how to incorporate a heart healthy diet is beneficial to us all.

The “Dietary Guidelines for Americans” offers these recommendations for heart healthy eating.
-Choose a variety of grains daily; half of your daily grains should come from whole grains.
-Choose a variety of fruits and vegetables daily.
-Choose a diet that is low in saturated fat, trans fat, and cholesterol.
-Choose foods and beverages that are low in added sugar.
-If you drink alcoholic beverages, do so in moderation.
-Aim for a healthy weight.
-Be physically active most days.
-Balance the calories you take in with the calories you expend through physical activity.
-Keep foods safe to eat.

These are great basics for heart healthy eating. If you have high blood pressure or high cholesterol, you may need some additional changes in your diet. You may want to work with a registered dietitian to help make these changes. A dietitian can design a specific program for you including calorie intake, choosing foods, help to track your progress and offer encouragement through this process. Ask your doctor about getting a referral, or your Cardiac Rehab Staff. In the meantime here are a few resources, and there are many great heart healthy cookbooks out there. Have fun exploring!
NHLBI Health Information Center: 301-592-8573
NHLBI Heart Health Information Line: 1-800-575-WELL (provides toll free recorded messages)
Heart Healthy Recipes:
www.nhlbi.nih.gov/health/public/heart/other/syah/index.htm
http://www.nhlbi.nih.gov/health/public/heart/other/ktb_recipebk/

Great job Marge! Completing cardiac rehab, and continuing in the maintenance program, is something to be proud of. The feeling you are describing is very common and there are several strategies and tools you can use to help your comfort level in “unsupervised” exercise.


1. Know Your Exercise Prescription Goals-Talk to your rehab staff. Tell them your goal for exercise outside of rehab and review your exercise prescription. Every participant of rehab has their own specific exercise prescription that has been designed for you and been approved by your cardiologist. This prescription has target heart rate, MET level and duration parameters set just for you. You should use those parameters when exercising on the outside. So you need to be comfortable in your method and abilities to measure your target heart rate. You need to determine, with the help of the staff, the MET level of the activity you are interested in doing. And you need to keep in mind the duration goal when planning your outing.

2. Measure your Perceived Exertion –The “Rate of Perceived Exertion (RPE) Scale” is a scale from 6-20 (Borg scale) that measures your perception of difficulty of the activity, your overall body exertion. This is commonly used in rehab as a tool when determining exercise intensity levels. Get a copy of this scale from rehab and use it in your activity. A score of 6 indicates the same exertion as sitting and resting in a chair. A score of 11 is considered light exertion, a score of 15 is hard, and a score of 20 is maximum exertion that you can do no more. An exercise goal on the RPE scale should be between 1-16. If your score is higher than 16, you should decrease the intensity of your exercise.

3. Stay within your Target Heart Rate-Whether you take your pulse or use a heart rate monitor, check your heart rate. You should check your heart rate at rest before you exercise, during peak moments of your exercise and at the end. Stay within your target heart rate range.

4. Monitor yourself for Symptoms-Just like in rehab; if you have symptoms during exercise you stop the activity and rest. If you have been prescribed Nitroglycerine tabs, bring them with you and be confident in how and when to use them. If you develop shortness of breath beyond your norm stop the activity and rest. There are more factors in the outdoor environment then in an indoor exercise room – such as temperature, quality of air, hills, etc. So be smart in choosing the time of the day and check the weather for air quality and humidity.

5. Never Exercise Alone-It’s always safer to exercise with someone or where others are around.

6. Carry a Cell Phone-If you are not in an area that has a phone nearby, it is always safer for you to have a charged phone. Also it is smart to have your doctors’ numbers programmed in, as well as family.

Being prepared with the knowledge and tools on how to keep within your safe range should help give you some confidence to take one baby step at a time. Remember there is nothing wrong with taking it slow, and talk about it with your rehab staff as questions or concerns comes up. Have fun!

Eugene this is a common concern that comes up. And it can be tough. Not knowing the specifics of your heart health, I must say in general exercising alone with a history of heart disease or SCA, is not the safest approach. I believe in safety first and exercising alone has risks.

Most community hospitals host programs such as Mall Walking, where it is a safe environment, not affected by the weather conditions. Joining a gym and going during off hours when it isn’t busy is another idea. It’s best if someone is around in case you ever needed help. You are not the only person in your rehab or area with this concern, so ask your rehab staff for local resources. You are not alone.

Susan, what a great idea! Over the years we have had situations when a spouse wanted to join rehab because they saw how much it helped their loved one. Life style changes are a family affair so it is important to treat and teach the family. The exercise component of cardiac rehab is not covered by insurance for family members, however, several lifestyle counseling components of our program and others are. Spouses are welcome to participate with their loved one during the nutrition counseling, stress management counseling, diabetic teaching, Heart Health educational classes, and cardiac support groups.

I love your idea. Each rehab and hospital has different programs offered. Bring up your interest and need to the rehab staff and community outreach department at your local hospital. Maybe they can start a walking group for spouses or a support group. Everything starts with an idea.