Dr. Kulick received his undergraduate and medical degrees from the University of Southern California, School of Medicine. He performed his residency in internal medicine at the Harbor-University of California Los Angeles Medical Center and a fellowship in the section of cardiology at the Los Angeles County-University of Southern California Medical Center. He is board certified in Internal Medicine and Cardiology.
Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
Thrombolytic (fibrinolytic or clot dissolving) therapy has been shown to reduce
death from heart attacks similarly in men and women; however, the complication
of strokes from the thrombolytic therapy may be slightly higher in women than in
men.
Emergency percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting for acute
heart attack is as effective in women as in men; however women may have a
slightly higher rate of procedure-related complications in their blood vessels
(such as bleeding or clotting at the point of insertion of
the PTCA catheter in the groin) and death. This higher rate of complications has
been attributed to women's older age, smaller artery size, and greater severity
of angina. The long-term outcome of angioplasty or stenting however, is similar
in men and women, and should not be withheld due to gender.
The immediate mortality from coronary artery bypass graft
surgery (CABG) in
women is higher than that for men. The higher immediate mortality rate has been attributed
to women's older age, smaller artery size, and greater severity of angina (the
same as for PTCA). Long term survival, rate of recurrent heart
attack and/or need for reoperation, however, are similar in men and women after
CABG.
What about hormone therapy and heart attack in women?
After menopause, the production of estrogen by the ovaries gradually diminishes
over several years. Along with this reduction, there is an increase in LDL
("bad" cholesterol) and a small decrease in HDL ("good" cholesterol). These
changes in lipid levels are believed to be one of the reasons for the increased
risks of developing CAD after menopause. Women who have had their ovaries
surgically removed (oophorectomy) or experience an early menopause, also have an
accelerated risk of CAD.
Since treatment with estrogen hormone results in higher
HDL and lower LDL cholesterol levels, doctors thought for many years that
estrogen would protect women against CAD (as well protect against
dementia and stroke). Many studies
have found that postmenopausal
women who take estrogen have lower CAD rates than women who do not.
Unfortunately many of the studies were observational studies (studies in which
women are followed over time but decide on their own whether or not they wish to
take estrogen). Observational studies have serious shortcomings because they are
subject to selection bias; for example, women who
choose to take estrogen hormones may be healthier and have a lower risk of heart
attacks than those who do not. In other words, something else in the daily
habits of women who take estrogen (such as exercise or healthier diet) may make
them less likely to develop heart attacks. Therefore, only a randomized trial (a
study in which women agree to be assigned to estrogen or a placebo or sugar pill at random but
are not told which pills they took until the end of the study) can establish the
whether hormone therapy after menopause can prevent CAD.
HERS trial results
The Heart and Estrogen/progestin Replacement Study (HERS), was a randomized
placebo-controlled trial of the effect of the daily use of estrogens plus
medroxyprogesterone (progestin) on the rate of heart attacks in postmenopausal
women who already had CAD. The HERS trial did not find a reduction in heart
attacks in women who took hormone therapy. This lack of benefit in preventing
heart attacks occurred despite an 11% lower LDL and a 10% higher HDL cholesterol
level in the women treated with hormones. The study also found that more women
in the hormone-treated group experienced blood clots in the veins and
gallbladder disease than women in the placebo-treated group. (Blood clots in the
veins are dangerous because these clots can travel to the lungs and cause
pulmonary embolism, a condition
with chest pain, shortness of breath, and even shock and death.) However, the increase in gallbladder disease and blood clots
among healthy users of estrogen who do not have heart disease is very small.
Based on the results of this study, researchers concluded that estrogen is
not effective in preventing coronary artery disease and heart attacks in
postmenopausal women who already have CAD. It should be noted, however, that the
results of the HERS trial only apply to women who have known CAD prior to
starting hormone therapy and not to women without known coronary artery disease.
WHI trial results
The Women's Health Initiative (WHI) was
the first randomized controlled trial designed to determine the long-term
benefits and risks of treatment with estrogens plus medroxyprogesterone
(progestin) in healthy menopausal women (women without CAD). The results were
reported in a series of articles in 2002, 2003, and 2004. The estrogen +
progestin portion of the WHI study had to be stopped earlier than planned, after
just 5.2 years, because the increase in coronary heart disease, stroke, and
pulmonary embolism among women who use
estrogen + progesterone outweighed the benefits of reduced bone fractures and
colon cancer. The estrogen-alone portion of the WHI was stopped because women
who took estrogen alone had no reduction in heart attack risk, yet there was a
significant increase in stroke risk.
The increase in breast cancer became apparent after three to five years, but the
increase in heart disease and pulmonary emboli occurred early on, in the first
year.
Recommendations for the use of estrogens plus medroxyprogesterone (progestin)
in women
Medicinenet Medical Editors believe that:
Decision regarding use of hormone therapy has to be
individualized, and all women should discuss with their physicians what is
best for her.
Estrogens plus medroxyprogesterone (progestin) is still the best therapy
for hot flashes. Despite the WHI study, many women remain good candidates
for estrogens plus medroxyprogesterone (progestin) therapy (or estrogen
alone if they have had hysterectomy). This is especially
true if hormone therapy is limited to the shortest duration, optimally less
than five years.
Estrogens with or without medroxyprogesterone (progestin) should not be
used to prevent or treat either Alzheimer's disease, heart
disease, or stroke.
While estrogens plus medroxyprogesterone (progestin) are effective in
preventing osteoporosis and related bone fractures, women concerned about
the risk of hormone therapy should discuss with their doctors, the use of
other non-hormonal alternatives to prevent and treat osteoporosis.
Heart attack - Symptoms at Onset of DiseaseQuestion: The symptoms of heart attack can vary greatly from patient to patient. What were your symptoms at the onset of your disease?
Low blood pressure, also referred to as hypotension, is blood pressure that is so low that it causes symptoms or signs due to the low flow of blood through the arteries and veins. Some of the symptoms of low blood pressure include light-headedness, dizziness, or even fainting if not enough blood is getting to the brain. Diseases and medications can also cause low blood pressure. When the flow of blood is too low to deliver enough oxygen and nutrients to vital organs such as the brain, heart, and kidneys; the organs do not function normally and may be permanently damaged.
Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to meet the body's needs. A poor blood supply resulting from congestive heart failure may cause the body's organ systems to fail, leading to a weakened heart muscle and fluid accumulation in the lungs and body tissue. There are many diseases that can impair pumping efficiency and symptoms of congestive heart failure including fatigue, diminished exercise capacity, shortness of breath, and swelling. Treatments include lifestyle modifications, medications, heart transplant, and therapy.
High blood pressure, also known as hypertension, is a repeatedly
elevated blood pressure exceeding 140 over 90 mmHg -- a systolic pressure above
140 with a diastolic pressure above 90. There are two causes of high blood pressure, primary and secondary. Primary high blood pressure is much more common that secondary and its basic causes or underlying defects are not always known. It is known that a diet high in salt increases the risk for high blood pressure, as well as high cholesterol. Genetic factors are also a primary cause. Secondary high blood pressure is generally caused by another condition such as renal hypertension, tumors, and other conditions. Treatment for high blood pressure is generally lifestyle changes and if necessary, diet.
Blood clots can occur in the venous and arterial vascular system. Blood clots can form in the heart, legs, arteries, veins, bladder, urinary tract and uterus. Risk factors for blood clots include high blood pressure and cholesterol, diabetes, smoking, and family history. Symptoms of a blood clot depend on the location of the clot. Some blood clots are a medical emergency. Blood clots are treated depending upon the cause of the clot. Blood clots can be prevented by lowering the risk factors for developing blood clots.
Panic attacks are sudden feelings of terror that strike without warning. These episodes can occur at any time, even during sleep. A person experiencing a panic attack may believe that he or she is having a heart attack or that death is imminent. The fear and terror that a person experiences during a panic attack are not in proportion to the true situation and may be unrelated to what is happening around them. Most people with panic attacks experience several of the following symptoms: racing heartbeat, faintness, dizzyness, numbness or tingling in the hands and fingers, chills, chest pains, difficulty breathing, and a feeling of loss or control. There are several treatments for panic attacks.
Diabetes mellitus is a chronic condition characterized by high levels of sugar (glucose) in the blood. The two types of diabetes are referred to as type 1 (insulin dependent) and type 2 (non-insulin dependent). Symptoms of diabetes include increased urine output, thirst, hunger, and fatigue. Treatment of diabetes depends on the type.
An arrhythmia is an abnormal heart rhythm. With an arrhythmia, the heartbeats may be irregular or too slow (bradycardia), to rapid (tachycardia), or too early. When a single heartbeat occurs earlier than normal, it is called a prmature contraction.
A stroke results from impaired oxygen delivery to brain cells via the bloodstream. A stroke is also referred to as a CVA, or cerebrovascular incident. Symptoms of stroke include: sudden numbness or weakness of the face, arm or leg. Sudden confusion, trouble speaking or understanding. Sudden trouble seeing in one or both eyes, sudden trouble walking, dizziness, or loss of balance, and/or sudden severe headache with no known cause. A TIA, or transient ischemic attack is a short-lived temporary impairment of the brain caused by loss of blood supply. Stroke is a medical emergency.
Angina is chest pain that is due to an inadequate supply of oxygen to the heart muscle.
Angina can be caused by coronary artery disease or spasm of the coronary
arteries. EKG, exercise treadmill, stress echocardiography, stress thallium, and cardiac
catheterization are important tests used in the diagnosis of angina.
Palpitations are unpleasant sensations of irregular and/or forceful beating of the heart. Palpitations can be relieved in many patients by stress reduction, stopping cigarettes, and reduction of caffeine and alcohol.
Cholesterol is naturally produced by the body, and is a building block for cell membranes and hormones. Low-density lipoprotein (LDL) cholesterol is the "bad" cholesterol, conversely, high-density lipoprotein (HDL) cholesterol is the "good" cholesterol. High cholesterol treatment includes lifestyle changes (diet and exercise), and medications such as statins, bile acid resins, and fibric acid derivatives.
Dementia is a significant loss of intellectual abilities such as memory capacity, severe enough to interfere with social or occupational functioning. There are different criteria classification schemes for dementias such as cortical, subcortical, progressive, primary, and secondary dementias. Other conditions and medication reactions can also cause dementia. Dementia is diagnosed based on a certain set of criteria. Treatment for dementia is generally focused on the symptoms of the disease.
Fainting, also referred to as blacking out, syncope, or temporary loss of consciousness has many causes. Often a person will have signs or symptoms prior to the fainting episode. Diagnosis and treatment depends upon the cause of the fainting or syncope episode.
Depression is an illness that involves the body, mood, and thoughts and affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. The principal types of depression are major depression, dysthymia, and bipolar disease (also called manic-depressive disease).
Chest pain is a common complaint by a patient in the ER. Causes of chest pain include broken or bruised ribs, pleurisy, pneumothorax, shingles, pneumonia, pulmonary embolism, angina, heart attack, costochondritis, pericarditis, aorta or aortic dissection, and reflux esophagitis. Diagnosis and treatment of chest pain depends upon the cause and clinical presentation of the patient's chest pain.
Toothache usually refers to pain around the teeth or jaws. In most instances, toothaches are caused by tooth or jaw problems, such as a dental cavity, a cracked tooth, an exposed tooth root, gum disease, disease of the jaw joint (TMJ), or spasms of the muscles used for chewing. A toothache can also be caused by a problem that does not originate from a tooth or the jaw, like diseases of the heart (angina or heart attack), ear infections, and sinus infections. A thorough oral examination, which includes dental X-rays, can help determine the cause.
Polycythemia (elevated red blood cell count) causes are either primary (aquired or genetic mutations) or secondary (diseases, conditions, high altitude). Treatment of polycythemia depends on the cause.
Epilepsy is a brain disorder in which the person has seizures. There are two kinds of seizures, focal and generalized. There are many causes of epilepsy. Treatment of epilepsy (seizures) depends upon the cause and type of seizures experienced.
Premature ventricular contractions (PVCs) are premature heartbeats originating from the ventricles of the heart. PVCs are premature because they occur before the regular heartbeat. There are many causes of premature ventricular contractions to include: heart attack, high blood pressure, congestive heart failure, mitral valve prolapse, hypokalemia, hypoxia, medications, excess caffeine, drug abuse, and myocarditis.
Heart rhythm disorders vary from minor palpitations, premature atrial contractions (PACs), premature ventricular contractions (PVCs), sinus tachycardia, and sinus brachycardia, to abnormal heart rhythms such as tachycardia, ventricular fibrillation, ventricular flutter, atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia (PSVT), Wolf-White-Parkinson syndrome, brachycardia, or heart blocks. Treatment is dependant upon the type of heart rhythm disorder.
Heart disease (coronary artery disease) is caused by a buildup of cholesterol deposits in the coronary arteries. Risk factors for heart disease include smoking, high blood pressure, heredity, diabetes, peripheral artery disease, and obesity. Symptoms include chest pain and shortness of breath. There are a variety of tests used to diagnose coronary artery disease. Treatment includes life-style changes, medications, procedures, or surgery.
Myofascial pain syndrome is muscle pain in the body's soft tissues due to injury or strain. Symptoms include muscle pain with tender points and fatigue. Treatment usually involves physical therapy, massage therapy, or trigger point injection.
Obesity is the state of being well above one's normal weight. A person has traditionally been
considered to be obese if they are more than 20 percent over their ideal weight.
That ideal weight must take into account the person's height, age, sex, and
build.
High blood pressure (hypertension) means high pressure (tension) in the arteries. Treatment for high blood pressure include lifestyle modifications (alcohol, smoking, coffee, salt, diet, exercise), drugs and medications such as ACE inhibitors, angiotensin receptor blockers, beta blockers, diuretics, calcium channel blockers (CCBs), alpha blockers, clonidine, minoxidil, and Exforge.
Pericarditis is the inflammation of the pericardial sac that surrounds the heart. The causes of pericarditis include injury from heart attack, heart surgery, trauma; viral or fungal infection, HIV, tumors, mixed connective tissue disease, metabolic disease, medication reactions, or idiopathic. Treatment for pericarditis is generally medication, however, sometimes surgery is necessary.
Smoking is an addiction. More than 430,000 deaths occur each year in the U.S. from smoking related illnesses. Secondhand smoke or "passive smoke" also harm family members, coworkers, and others around smokers. There are a number of techniques available to assist people who want to quit smoking.
A heart murmur is the sound generated when blood flow within the heart is not smooth. Causes of heart murmurs can be functional, congenital, or caused heart valve conditions. Symptoms of a heart murmur may be none, or may include chest pain, shortness of breath, and arm, leg, and ankle swelling. Treatment of a heart murmur depends on the cause.
Coma is the inability to waken or react to the surrounding environment. The Glasgow Coma Scale is frequently used to measure the depth of coma. Causes of coma include trauma, bleeding, edema, lack of oxygen, poisoning, or hypoglycemia. Prognosis for a patient in a coma depends on the cause of the coma.
When a portion of the brain loses blood supply, through a blood clot or embolus, a transient ischemic attack (TIA, mini-stroke) may occur. If the symptoms do not resolve, a stroke most likely has occurred. Symptoms of TIA include: confusion, weakness, lethargy, and loss of function to one side of the body. Risk factors for TIA include vascular disease, smoking, high blood pressure, high cholesterol, and diabetes. Treatment depends upon the severity of the TIA, and whether it resolves.
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