*Q: Why does angina come and go?
Think of heart function as an economic system where oxygen is the main currency. Angina is related to the supply and demand of oxygen to the heart. With adequate blood flow in the arteries, oxygen delivery is balanced (inadequate blood flow usually occurs when the artery is blocked due to a fixed obstruction like plaque or a spasm of the artery wall). Anginal symptoms occur when the oxygen supply no longer meets the heart’s demands during increased physical exertion or psychological stress, thereby starving the heart muscle of oxygen.
Angina can also be triggered by air pollution, high altitude, cold air, excessively low or high heart rates, extremely high blood pressure, perceived stress, anxiety, withheld anger, grief or heartbreak. So always avoid exercise when any of these additional triggers are present if you have been diagnosed with angina.
Intermittent spasms in the walls of arteries may also account for angina’s sporadic occurrences. Blood vessels may narrow or expand depending on the balance of minerals, hormones and various substances that cross the cell membranes and determine the constriction or relaxation of blood vessel walls. On a daily basis, however, blockage in the arteries does not change, unless a new clot is formed.
*Q: I have just been diagnosed with heart disease. What should I do?
Unquestionably, it is a terrifying and unsettling moment when a patient learns that he or she has heart disease. Initially, you will be scared and anxious. But after a few weeks, you’ll come to accept your illness, and that’s when you’ll be ready to adopt a more hopeful and positive outlook. Believe me, you’ll recover faster if you strive to maintain a positive attitude. This is the most important aspect of healing.
The first thing you should do is accept your feelings and reach out to others, particularly loved ones, for support and guidance. It’s important to let your feelings come out by talking quietly and occasionally, using your voice to release your anger and even tears. Venting in this way will allow you to begin the important work of healing and freeing up the energy you need to modify your lifestyle.
Once you’ve had a chance to deal with the emotional impact of learning that you have heart disease, you should get on my safe, effective and inexpensive program.
Here’s a synopsis of my program:
- Get on the modified Mediterranean diet, which offers a combination of healthy fat, moderate protein and fewer carbohydrates, all of which are optimal for heart health.
- Raise your fitness level through an exercise program such as daily walking. The best exercise is the one you will stick with. Depending on the degree to which you have heart disease, you may want to enter a supervised basic core cardiac rehab program for awhile. At the very least, request that your MD write you a personal exercise prescription based on a stress test.
- Take targeted nutritional supplements that include a multivitamin/mineral formula.
- Take coenzyme Q10, fish or squid oil, L-carnitine, magnesium and D-ribose or the “Awesome Foursome”. To learn more about metabolic cardiology, click here.
*Q: My neighbor told me that sometimes the symptoms of a heart attack and those of an angina attack are very similar. I have angina, and I’m worried that I won’t know when it’s necessary to call 911 because I’m actually having a heart attack. What are your guidelines for getting help?
This is an excellent question. Angina and heart attacks result from ischemia, a lack of sufficient oxygen to the heart muscle. In the midst of either attack, you might experience identical symptoms, which may include: chest pain or discomfort, shortness of breath, tingling in the arms/jaw/hands, indigestion, upper back discomfort and sweating.
Even cardiologists like myself cannot tell the difference between angina (a temporary lack of oxygen to the heart) or a heart attack (a prolonged lack of oxygen resulting in damage to the heart) without the benefit of an electrocardiogram or blood tests.
What’s most important to pay attention to, should either ischemic attack happen to you, is an awareness of a PATTERN of the symptoms. I tell my patients with angina (who have been prescribed nitroglycerin to alleviate their symptoms) to do the following:
- If you suspect you are having an anginal episode, take one nitroglycerine (NTG) under the tongue. You should get relief in three to five minutes.
- If the symptoms have partially decreased, yet are still present, take another NTG and wait five minutes.
- If your symptoms intensify, fail to subside or return when the NTG wears off, you need immediate attention. Call 911 and let the paramedics give you oxygen and take you to a hospital for assessment-it can save your life. NEVER drive yourself!
*Q: When and how do you suggest using nitroglycerin? Are there any known side effects?
Nitroglycerine (NTG) is usually prescribed for patients who have been diagnosed with angina in order to treat episodes of inadequate blood flow to the heart muscle. It makes good sense to always carry NTG with you if your doctor has prescribed it for angina.
NTG can be taken to reduce the symptoms of angina, such as chest discomfort (which may be in the form of pain, tightness, heaviness or a burning sensation), indigestion or shortness of breath. Other symptoms might include tightness in the throat, a painful or aching jaw, arm/hand ache or numbness and back pain. If sitting quietly for 60 seconds does not eliminate your anginal symptoms, then it is a good idea to reach for your NTG.
I tell my patients to consider the symptoms of angina a warning to immediately cease physical exertion or to try to eliminate the emotional stress that is placing a strain on their heart.
Nitroglycerin has been the preferred treatment for angina for 100 years because it quickly dilates coronary arteries and increases blood flow to blocked segments of the heart muscle. Its dilation effects impact your entire cardiovascular system, however, so blood pooling in the arms, legs and the head may occur, which can lower blood pressure to the degree of extreme lightheadedness or fainting. For this reason, always sit down when you take NTG to avoid injury from falling. NTG will work in 3 – 5 minutes if not faster. You can arise slowly about 10 minutes after your last dose.
I recommend to my patients that they take up to three NTG tablets every five minutes for relief of angina. I tell them to start off by placing one tablet under the tongue. If your symptoms fail to subside, or only partially abate after five minutes, take a second NTG and wait another five minutes. If your symptoms persist after resting and taking three NTG at five-minute intervals, then you need immediate medical attention and evaluation.
For my patients with “stable angina” (the same oxygen demand creates a predictable angina symptom at a predictable level of exertion), I often recommend they use nitroglycerin up to 15 minutes prior to activities that have consistently precipitated angina for them, despite maximum medical therapy. This may include exercise, sexual relations or an event that they anticipate to be stressful, like the first hole of golf. Remember, if your symptoms increase in frequency, intensity of duration, or you find yourself upping your usage of nitroglycerin for relief, your angina has become “unstable,” and you must consult your physician immediately.
NTG is a safe and nonhabit-forming medication. The major side effect is a headache. Also, check the expiration date on your bottle to ensure that your NTG is “fresh”.
*Q: I’ve just discovered that I have atrial fibrillation. My doctor doesn’t seem worried, but I am. Can you please explain the symptoms and the impact of this condition on my heart?
Atrial fibrillation (AF) is the most typical arrhythmia I see in my practice. Some of my patients complain of either a fast or slow, irregular pulse. Some patients say they feel no symptoms at all. Others feel like they have the flu or report feeling “strange,” “weak” or “out of sorts.” The most common symptoms are shortness of breath, fatigue, chest discomfort, sweating, lightheadedness or dizziness.
AF can be dangerous if an episode lasts longer than 24 hours, if your heart rate is either extremely high or extremely low or if you are very lightheaded from low blood pressure. Such conditions place a strain on your heart. In rare cases, they can lead to congestive heart failure or heart attack. Also, the risk increases for blood clots to form in the quivering upper chambers of the heart (fibrillating atria), which might lead to a stroke.
Most patients with chronic AF must take Coumadin (or other anticoagulants such as aspirin) to prevent clots from forming. If your heart rate is rapid, you may need anti-arrhythmic drugs to bring your heart rate back to normal. If you are hospitalized for uncontrolled AF, your doctor may try to reestablish your normal rhythm by administering an electrical charge to override the AF.
Please refer to the next question to see if your situation meets my criteria for starting a treatment program. If you would like to try my plan, I recommend that you work closely with your physician to get your heart rhythm normalized.
*Q: I’ve had arrhythmia-like atrial fibrillation for some time, but lately I’ve noticed that my heart seems to speed up when I’m a little anxious or if I have coffee or even a cocktail or two. Is there something really wrong with my heart, or might this be due to just nerves or some other condition?
I’m often asked this question. The majority of patients who I treat for rapid heartbeat have atrial fibrillation (AF), a common type of arrhythmia. And often with this condition there is an interplay between emotions and physical symptoms that supports the concept that our minds and bodies are immeasurably interconnected. So, when you feel “a little anxious” about something, an increase in stress hormones (like adrenalin) may be causing the faster heart rate that you described. The reverse is also true of cardiac arrhythmias – when your heart is out of rhythm, you may feel increased anxiety.
Any cardiac arrhythmia can be frightening because it is a change in the timing or rhythm of the heartbeat. Let me explain what happens. During episodes of AF, the upper cardiac chambers (atria) are bombarded with electrical conduction discharges and actually quiver or “fibrillate,” instead of fully contracting. AF may occur in a healthy heart and is usually not a problem. But when it’s associated with heart disease, it can be problematic and precipitate bouts of congestive heart failure if the rate is not adequately controlled. I have treated this condition in both young and old alike, but older patients are more often affected. 2% to 4% of individuals over age 60 experience symptomatic AF.
AF may also be the result of any of the following:
- The heart’s electrical conduction system ages, becomes fibrotic or misfires;
- The atria become enlarged or lose their ability to contract;
- There is a long history of high blood pressure;
- You have valvular disease;
- The heart’s conduction system is over stimulated by metabolic states such as hyperthyroidism;
- The heart is manipulated during open heart surgery;
AF may also occur if the heart’s electrical system has been overstimulated by drugs, nicotine, caffeine or stress. So, if you are vulnerable to episodes of AF, you should abstain from alcohol, excessive sugar, chocolate and other foods that contain caffeine; avoid exposure to the toxins in cigarettes, exhaust fumes and heavy air pollution; and don’t use over-the-counter cold remedies that contain stimulating chemicals like ephedrine.
*Q: During my annual physical, my GP informed me (almost like an afterthought) that I have mitral valve prolapse. He said there’s nothing to worry about. Is my doctor correct?
Your question is not unique. Although it sounds ominous, mitral valve prolapsed (MVP) is relatively common, yet benign, condition that affects about 4% of the population. Physicians most often pick it up as a click, a murmur or regurgitation when listening to the heart. 99% of those diagnosed with MVP are asymptomatic or have only mild symptoms and require no medical treatment.
More severe symptoms of MVP like chest pain or shortness of breath can be brought on by excessive fear, anxiety, stress or overuse of caffeine or alcohol. And it can last a lifetime, or it can be gone tomorrow.
I was fortunate to train with Dr. Robert Jerasaty, an authority on the subject of MVP. His book, Mitral Valve Prolapse, covers hundreds of cases and is considered a major contribution in cardiac circles. Because of Dr. Jerasaty’s mentoring, I’m confident that the majority of people I’ve diagnosed with MVP (who are asymptomatic) over the last 20 years, needed only reassurance, not medical intervention.
If you’re feeling anxious about your diagnosis, get an echocardiogram to confirm your doctor’s finding. This procedure displays a moving picture of your heart’s valve structures and will show whether the mitral valve in fact prolapses into the left atrium when your heart contracts, and if so, the degree to which it prolapses.
*Q: I know that family history is a risk factor for the heart, so what must I do to take myself out of the line for cardiovascular disease?
First of all, follow the best preventive plan you can. I believe that my core program of seven paths outlined in my report, Healing the Secret Causes of Heart Disease, covers the essential steps to keep you physically and emotionally well.
Secondly, I would encourage you to “reframe” your family history in a different way – think of it as an opportunity to reduce your controllable risk factors such as stress, obesity, smoking, unhealthy diet and lack of exercise. Prevention is something everyone should focus on, regardless of genetics, due to the fact that a heart attack is often the first symptom of heart disease.
I believe that some of the coping skills learned in our families pose a greater threat to our hearts than our gene pools, especially if you mirror self-destructive parental actions, behaviors or habits. The term “psychological genetics” is becoming more and more popular among cardiologists. For example, if you watched a parent constantly overeating or stuffing food to cover up uncomfortable feelings, and you avoid your painful feelings by using food in the same way, you will be vulnerable to chronic problems with weight, self-esteem and self-expression.
The psychological risk factors can be just as lethal as the physical risk factors. Heart health depends on paying attention to the profound physical effects that emotions have upon the body. As we mature, we unconsciously pattern expressions of love, anger and fear after our role models. If your family tends to deny or suppress these emotions, and you find that you are emotionally bottled up or cool and isolated from people, you should consider looking more deeply into your emotional self in order to protect your heart.
Also, I encourage you to feel thankful for your family “messengers” – reach out to them in their suffering, and risk opening your heart a little further. And keep taking risks with your feelings, as you have done by reaching out to me with your concerns.
*Q: Since my husband’s heart attack, he hasn’t been interested in physical intimacy. I don’t want to complain, but is there anything I can do?
My patients and their spouses often tell me about their difficulties resuming sexual closeness after a heart attack or surgery. For starters, I recommend they consider the following factors that may contribute to lack of interest in intimacy:
- For some individuals, certain cardiac drugs – particularly beta-blockers such as Lopressor and Inderal, which are commonly prescribed to reduce mortality after a heart attack – have a direct effect on the part of the nervous system responsible for sexual arousal as well as physical performance.
- Abnormal fatigue may be present for up to three to six months after a heart attack or surgery.
- Some patients become preoccupied with their health and “forget” the importance of reconnecting with a loved one.
- Depression, after any cardiac event, can decrease libido.
- Fear of failing in sexual performance or of placing a strain on the heart may create an obstacle to sexual expression.
I would encourage you to bring up this subject by reaching out in a loving manner to your husband. When you speak with him, please don’t see yourself as complaining, but as communicating, with the hope of exploring one another’s viewpoints. Look at this approach as an important opportunity in the healing and recovery process for both of you. Your husband, most likely, will appreciate the chance to relate his feelings so that you can understand him better.
Sometimes all that’s needed is a gradual return to intimacy, starting with cuddling, bathing together or the comforting touch of massage. Set aside time for intimacy when you are both rested, relaxed and free of distractions from work or family.
Also, if it’s been longer than three months since you and your husband have been sexually intimate, you may want to talk to his physician to explore the factors I discussed earlier. It may be a good idea to evaluate the possibility that he is depressed or emotionally unsettled. I know that talking about your sexual relationship can be a difficult subject to bring up with your doctor, but be assured, you’re not in a unique situation.
*Q: My father died of a stroke, and I’ve just read that it is the third-largest cause of death in the United States. My husband and I are presently in excellent health but want to make sure that we do everything we can to avoid having a stroke. Can you give us some guidance?
First of all you get high marks for your proactive attitude. Your overriding concern should be to keep your blood pressure within normal levels (below 140/80, which is the upper range of “normal” blood pressure established by insurance companies) because elevated blood pressure is a leading cause of strokes, as well as a major risk factor for heart disease.
To keep your blood pressure within normal ranges, I recommend you do the following:
- Exercise daily and keep your weight at an optimal level (even a reduction of 10% of total body weight will lower blood pressure).
- Take a daily multivitamin/mineral formula.
- Take at least the equivalent of 180 mg of coenzyme Q10 daily.
- Follow my high-fiber modified Mediterranean diet, making sure you eat five to nine servings of fresh fruits and vegetables daily. This diet provides foods with a healthy balance of magnesium, potassium and calcium, all of which help to keep blood pressure low. Be sure to include foods containing omega-3 essential fatty acids such as cold-water fish, tofu, oatmeal and nuts. Eat plenty of garlic which, in addition to its blood pressure-lowering properties, helps to prevent the formation of blood clots that can block arteries. Eat sardines, wakame seaweed and onions, which also help to lower blood pressure.
- Don’t smoke. And if you must drink alcohol, I recommend red wine in moderation – one to two glasses every other day. Avoid hard alcohol.
- Avoid antihistamines and over-the-counter cold remedies, which can raise blood pressure. Use ibuprofen preparations like Motrin, Advil and Nuprin sparingly. Chronic use may impair kidney function, which can, in turn, lead to high blood pressure.
A word of caution. Even if you follow these lifestyle guidelines to the letter, “hidden risk factors’ such as repressed anger, hostility and fear are frequently responsible for soaring blood pressure. I recommend developing a strong emotional support system with people you care about and who care about you. Such loving connections will reduce any tendencies to hold on to anger and hostility.
*Q: I was shocked to learn recently that six times as many women die from heart disease as from breast cancer (which I thought was my greatest health risk). What amazed me even more was the statistic that one-half of the women who die after the age of 50 are being lost to heart disease. Isn’t this a new phenomenon? Why is this happening?
Yes, it’s true. In the 21st century, the incidence of heart disease in women is rising at an alarming rate. In fact, in 1994, the American Heart Association reported the astounding statistic that women were surpassing men in deaths due to heart disease.
Often, when I inform some of my female patients that their symptoms are due to heart disease, they’re simply stunned because they always grew up with the common assumption that is men who have heart problems.
Although there are several factors responsible for this gender turnaround, one of the main reasons is that women are finding themselves locked into what I call “an unholy trinity” – they are expected to be feminine, yet act like a man at work and work like a dog at home. These multiple roles may be very stressful for some women. Of course, the impact of stress will vary, depending on the social and emotional support system available to the woman.
Luckily, a shift in medicine is occurring in recognition of the growing numbers of women at risk. We now recognize that the diagnosis criteria and treatment guidelines for heart disease in women are different than they are for men.
Much of the research on symptom recognition, disease course, treatment options and outcomes, has been based on large groups of men, and we’ve found that what is true for men is not necessarily the norm for women.
I’m so concerned about the recent developments regarding heart disease and women that I wrote a book on it entitled Heart Sense for Women where you can find an expanded discussion.
*Q: Several times in the last few months I’ve had a “spell” where my breathing went funny and my heart felt like it was going to jump right out of my chest. I’ve been told this is a panic attack. Will this hurt my heart?
Panic disorder can mimic cardiac symptoms. I’ve noticed that it’s common for individuals in excellent physical health to see me for an evaluation, in response to sudden episodes of chest pain, shortness of breath, palpitations and a rapidly beating heart. It often turns out after a full history and complete cardiac evaluation that these patients are suffering from anxiety, not a cardiac disorder.
Nothing is wrong with their hearts. But they often find it hard to believe. This reaction often goes hand in hand with anxiety, for a very apprehensive person often finds it difficult to be reassured. It is common for people with high levels of anxiety to “doctor shop” in the hopes of finding a doctor who will eliminate or “fix” their uncomfortable symptoms.
A word of caution, however. Women may be mistakenly told they “just have anxiety,” when there really is a problem with their heart. Symptoms of heart disease for women are vague and more generalized than symptoms experienced by men. Some common symptoms for women might be dull and continuous chest pain (lasting longer than an hour) with discomfort that radiates into the neck or jaw, or chest discomfort coupled with extreme fatigue. Also, studies have shown that fewer women than men are referred for appropriate diagnostic tests.
My advice is to have a full cardiological evaluation by a specialist. Then, if anxiety or panic are found to be causing your symptoms, you’ll need to address and treat your anxiety. Talking to a psychologist or psychotherapist is a good place to start, and anxiety support groups often meet at local hospitals.
*Q: Are elevated iron levels a risk factor in heart disease?
It is true that an elevated iron level is a critical parameter in heart disease for some people. An elevated iron level combined with a high LDL cholesterol may be a prescription for plaque development. One of the problems with iron is that many of us unknowingly take excessive amounts when we don’t need to. Men over 18 and postmenopausal women do not need iron unless prescribed by their physician. Too much iron can oxidize LDL and cause inflammation lending to heart disease.
Sometimes, hematologists treat some deficient patients with injectable iron, particularly if they are severely anemic or if their bone marrow is severely depleted in iron. For this population, supplemental injectible iron is appropriate. Although the body regulates the absorption of iron, remember that oral iron is absorbed to some degree in everyone. If you are not losing iron and are constantly taking it in, this could be a problem.
**Q: I would like some information on testing for heart disease. If a person has no other symptoms of heart disease other than mildly high cholesterol, should he or she consent to a stress thallium scan intead of a cardiac scoring or regular stress test?
Most likely not. If the person does not have a history of hypertension, a regular stress test (which involves the use of an electrocardiogram, or EKG, to monitor the heart’s electrical activity while the patient exercises) is fine.
Both the stress thalium scan and cardiac scoring expose patients to ionizing radiation, especially cardiac scoring, which involves a CT scan. As ionizing radiation is carcinogenic, doctors and patients should together assess whether the potential harm of not conducting these tests outweighs the risk of radiation exposure.
**Q: My ferritin levels are slightly elevated and my carotid arteries are approximately 75 percent blocked, yet my doctors don’t seem concerned. Any suggestions?
Your body requires ferritin (iron) to make hemoglobin, the red blood cell pigment that carries oxygen to the cells. The normal range of ferritin for men is typically 12-300 ng/mL. Research suggests that elevated ferritin can contribute to cardiovascular disease (CVD). Too much ferritin can promote inflammation, especially because it can oxidize LDL cholesterol and result in unstable plaques. When plaques rupture, blood clots form and break off into the bloodstream and increase a person’s risk of having a cardiac event. According to a 1992 Finnish study, if your LDL cholesterol level is high (above 193), ferritin levels above 200 can significantly increase risk of heart attack.
Decreasing cardiac risk, then, is threefold: it involves decreasing arterial inflammation, small particle LDL cholesterol and ferritin levels. For more information about preventing cardiovascular disease, check out the articles in this (Cardiovascular System) section, specifically Cardiovascular Disease Awareness and Let’s Clear Up the Cholesterol Confusion Once and For All. As for ferritin, once you know why your levels are elevated, you can start taking measures to lower them. You may want to ask your doctors to run a total iron, TIBC (total iron binding capacity), ALT/AST (to assess liver function), and ultrasound of the liver to determine the causes and to assess organ function.
While women naturally lose iron through menstruation, men and post-menopausal women lack this natural iron-reducing mechanism; for the latter, donating blood can serve the same protective purpose. Other ways to decrease iron levels include avoiding red meat, iron-fortified foods,supplements containing iron, and using iron cookware. You may also want to test your water to see if it is high in iron and use a water filter.
Since vitamin C promotes iron absorption, taking no more than 500 mg per day can also help prevent excess ferritin.This is especially important if you have hemachromatosis, an acquired or hereditary defect of iron metabolism in which excess iron is deposited in tissues and not available for oxygen transport. It’s estimated that 10 percent of Americans carry the gene for hereditary hemochomatosis.
**Q: I have a mild regional wall motion abnormalities consistent with CAD (coronary artery disease). I have normal valvular structures and no significant valvular abnormalities. I do not have diabetes or high cholesterol, and I do not smoke. How can I help reverse this condition?
In Reverse Heart Disease Now (Wiley & Sons, 2007), you can find detailed information about plaque stabilization as well as plaque reversal – we encourage you to read this book as it puts together a strategic plan to optimize your cardiovascular health.
In the meantime, here are some basic lifestyle tips that can help you as you continue to work with your cardiologist or general practitioner:
- Diet is probably one of the most important changes you can make to reduce complications associated with CAD. We suggest eating a pan-Asian modified Mediterranean-type diet that consists primarily of whole foods… This means eating a “rainbow” assortment of vegetables and fruits with every meal, as well as raw and/or cooked grains (try quinoa, buckwheat, brown rice, etc.) and legumes (lentils, beans). Be sure to choose healthy fats (like omega-3s, coconut oil and olive oil), and have small servings of organically raised grass fed meats. Try to eat 1-2 servings of wild-caught fish per week. Make sure to consume very little sugar because it causes inflammation, so be mindful of what foods contain sugar in them (juices, pastries, sodas, processed foods). Try grinding up 1-2 Tbsp of flax seeds every morning and consuming with rice milk or on top of your cereal or oatmeal. Doing so will help you get essential fatty acids and the extra fiber you need to help support your gastrointestinal tract and liver.
- Get moving! Try walking every day to increase circulation. Being outside in the sun will also support your condition, as Vitamin D is good for heart health.
- Relax… Find a meditation practice or stress reduction technique that feels right for you.
- Nutritional supplementation. For CAD, taking coenzyme Q10, magnesium, L-carnitine, and D-ribose is suggested because these four supplements support ATP production. With CAD, the heart works very hard and needs energy (ATP) support. For more information about dosing, you may want to read The Sinatra Solution: Metabolic Cardiology(Basic Health, 2011). You may also want to consider a good fish oil (minimum 3 g/day), an antioxidant multivitamin and/or a resveratrol product. Try drinking 4 oz of pomegranate juice a day (diluted in 4 oz of water). Hawthorne extract has also shown great results with CAD.
- Do something FUN everyday. Engage in something that makes you laugh or smile, or brings peace into your heart.
**Q: Is it ok to take fish oil and aspirin together?
Yes it is ok to take them together. Fish oil dose should remain in the 1,000-2,000mg range and aspirin should be a low-dose.
Do you have a question about a heart condition that you’d like answered on our site? E-mail us at [email protected] we’ll do our best to post an answer in this article or elsewhere on the site.
*Indicates that Q&A has been reprinted or adapted from Candid Advice About Your Heart, a Heart, Health & Nutrition supplement, with permission from Healthy Directions, LLC.
**Indicates that Q&A has been posted in response to emails or comments submitted to Heart MD Institute. © 2012 HeartMD Institute. All rights reserved.
Please note that Dr. Sinatra does not provide medical advice through Heart MD Institute; any and all information found on this site is intended solely as an informational tool, and it should never replace a visit to your physician, nor be considered medical advice upon which you rely when making health-related decisions.