What is a Silent Heart Attack?

A study of approximately 9,500 middle-age adults found that nearly half of the heart attacks that occurred during the study period were “silent”. TheDr Haghighat patients were not aware they had a heart attack and did not seek medical attention however, their electrocardiogram (ECG) screening during a regular follow-up appointment showed that a heart attack had occurred.

The study, Atherosclerosis Risk in Communities (ARIC), analyzed the causes and outcomes of atherosclerosis – hardening of the arteries. Over an average of nine years after the start of the study, 317 participants had silent heart attacks while 386 had heart attacks with clinical symptoms.

Amir Haghighat, M.D., interventional cardiologist at the Cardiovascular Institute in Panama City, clarifies that “Silent does not necessarily mean a total lack of symptoms. More likely, it’s that the symptoms were subtle or not recognized as a heart problem.”   Frequently, television and movies depict a heart attack as a dramatic event with crushing chest pain. “Chest pain is a common symptom, however everyone experiences heart symptoms differently.” says Dr. Haghighat. “For some, it may be shortness of breath, pain in their left arm, in their neck or jaw, or even in the shoulder blades, and it may not be as dramatic as you think.”

“The outcome of a silent heart attack is as bad as a heart attack that is recognized while it is happening,” said Elsayed Z. Soliman, M.D., MSc., M.S., study senior author and director of the epidemiological cardiology research center at Wake Forest Baptist Medical Center, Winston-Salem, North Carolina. “And because patients don’t know they have had a silent heart attack, they may not receive the treatment they need to prevent another one.”

Dr. Haghighat stresses that these study results are further proof that patients should see their primary care providers regularly and discuss any unusual symptoms they may be experiencing. “We all know when we’re feeling something different in our bodies and it’s important to discuss it with a healthcare provider,” says Dr. Haghighat. “Take note of when your symptoms occur, do they happen with exertion or at rest? Don’t ignore symptoms just because they come and go. Your primary doctor may be able to identify the issue with basic screenings and prescribe preventative measures. Or in the case of a “silent” heart attack, coordinate treatment with a cardiologist that can lower your risk of having additional heart attacks.”

After following participants in the ARIC study for 20 years, researchers found that having a silent heart attack increased the chances of dying from heart disease by three times. As a result, silent heart attacks should be treated just as aggressively, once discovered, as a heart attack with recognizable symptoms. “For both kinds of heart attacks,” says Dr. Haghighat, “the risk factors and the treatment are the same. Even though a patient may not have experienced a scary heart event in an ER, they still need to be proactive and make lifestyle changes to reduce their risk such as quitting smoking, losing excess weight, eating healthy and getting regular exercise.”

What To Expect at Your Stress Test

A Q & A with Cathy Rodes, MSN, ARNP with the Cardiovascular Institute of Northwest FloCathy Rodesrida

Under what circumstances would a patient need a stress test?

Patients may be scheduled for stress tests to evaluate symptoms of chest pain, for an exercise prescription, to evaluate for exercise induced arrhythmia or for surveillance of known coronary artery disease.

Do all stress tests require physical exercise?

Graded exercise tolerance tests (GXT), whether with or without imaging require exercise on a treadmill to achieve the patient’s target heart rate, which is determined by patient’s age. Pharmaceutical Nuclear stress tests do not require exercise.

When is a nuclear stress test needed versus an exercise stress test?

Pharmaceutical Nuclear stress tests are utilized when patients are unable to exercise, in cases of certain ECG (electrocardiogram) abnormality, when the patient is unable to reach the target heart rate with exercise due to medications, or when a patient has certain brady arrhythmias (slow heart rates requiring pacemaker). Nuclear stress tests, where treadmill exercise is used along with nuclear images, are generally ordered versus a standard GXT when the baseline ECG is abnormal, when imaging is desired because of the patient’s coronary anatomy or a previous standard GXT was not quite normal.

With an exercise stress test, what sort of physical activity should I expect?using a treadmill for a stress test

GXT or Stress Nuclear test requires walking on the treadmill long enough to raise the heart rate to target as well as long enough to be physically stressed (tired, short of breath, etc.). The treadmill gradually speeds up and elevates incline every three minutes. Most patients exercise for 7-9 minutes, depending on functional capacity. Be sure to dress comfortably with appropriate shoes for exercise.

With a nuclear or medication-induced stress test, what should I expect?

With a pharmaceutical nuclear study, the patient does not exercise. Lexiscan Nuclear dilates the patient’s arteries as if they have exercised. They may experience shortness of breath with the medication. Also, patients are encouraged to eat 2 hours prior to the test to reduce any GI effects. Patients must avoid all caffeine products for 24 hours prior to Nuclear stress tests.

How long does the test take?

Patients are usually here for about 30 minutes for a GXT secondary to paperwork, setup and recovery. We ask patients to anticipate being here for 2 hours for a Nuclear stress test to allow for imaging. There is a second day of testing required for Nuclear stress tests, however patients are usually only here for approximately one hour for injection and imaging.

What can be revealed about your heart health during these types of tests?

All stress tests are screening tests and cannot exclude the presence of Coronary Artery Disease (CAD) or progression of CAD, but exercise stress tests give a good idea of functional capacity and prognosis if the patient does have CAD. Also, nuclear imaging gives a good idea of coronary perfusion which helps the cardiologist determine if further testing is needed.

If I “fail” my test, what’s the next step?

If a GXT is abnormal, your provider may recommend a Nuclear stress test or a cardiac catheterization. Every situation is different and other health history comes into play for this decision. Nuclear stress tests that are abnormal may indicate older heart damage or narrowing / blockages in the arteries. Therefore the provider would recommend catheterization vs. medical management based on the particular situation. Next steps are usually discussed at a follow up appointment after all testing is completed.

Is leg pain a sign of vascular disease?

In our latest “Ask a Cardiologist” video, interventional cardiologist Dr. Amir Haghighat addresses the signs and symptoms of vascular disease in the legs and how a diagnosis is made.  Common symptoms include cramping when walking that goes away with rest, swelling of the ankles and feet, and discoloration, however Dr. Haghighat explains the types of leg pain and other symptoms in greater detail in our video.  Vascular ultrasound can identify blockages and reflux.  The Cardiovascular Institute in Panama City, Florida offers a nationally accredited vascular lab and minimally invasive treatments for the most common issues.


What is a Heart Murmur?

Cardiovascular Institute cardiologist Dr. Michael Morrow explains the most common causes of heart murmur and how cardiologists make a diagnosis using ultrasound technology for echocardiograms. While many heart murmurs are benign, some are a symptom of valve disease such as aortic stenosis. The Cardiovascular Institute has a nationally accredited echocardiography lab in our main office in Panama City, Florida to make getting a diagnosis quick and easy for our patients.

Heart Disease Patient Benefits from World’s Smallest Heart Pump

Nellie Smith was suffering from severe abdominal cramping and was convinced she needed to have her gallbladder removed. The problem with havingNellie_Smith this routine surgery however was Nellie’s heart. Nellie had survived a heart attack seven years ago and was told that her heart disease was severe. Multiple vessels around her heart were narrowed. She had previously been very active, but following her heart attack found that she tired very easily, was frequently short of breath and experienced chronic chest pain. She hoped to avoid further heart procedures by taking medications.

Eventually, Nellie’s abdominal pain became so severe she found herself at Bay Medical. Her cardiologist Dr. Michael Stokes was called to assess her heart health and delivered dire news. The blockages around her heart had left her with only one main vessel supplying blood flow to her heart and her ejection fraction (a measure of how well the heart is pumping blood) was only 15%. In this condition, it was far too risky to have surgery on her gallbladder and it was very high risk to perform a standard cardiac catheterization to open her heart blockages as well.

Fortunately, Bay Medical is the only hospital in the region with a unique technology designed to support heart function during high-risk cases. Dr. Stokes contacted his partner Dr. Amir Haghighat, one of three local cardiologists trained to use the Impella, the World’s Smallest Heart Pump, to help with Nellie’s case.

The Impella is roughly the size of a small writing pen and, using guide wires, can be inserted through a small incision in the groin area and navigated through the major blood vessels into the heart. The device can continuously keep blood pumping while the dangerous work of opening multiple blockages takes place.


Unlike an open surgery, a cardiac cath requires only mild sedation and patients are awake and able to interact with their physician. Nellie was able to see the images on screen of her blood vessels during the procedure and noted that “as he opened each blockage, it was like a road map suddenly began to appear on screen.” The previously blocked vessels filled with blood to feed the heart muscle. “I felt a difference immediately, right there on the table,” said Nellie.

The next day in the hospital, Nellie was up and walking around the cardiac nursing floor. “I feel really good,” she says. “I’m looking forward to going home, cleaning my house and cooking a meal. I know that doesn’t sound like much, but it was too tiring and too difficult to do those things before.” To her surprise, Nellie noted that she was no longer experiencing abdominal pain. She excitedly put her grandchildren on notice to expect “a NEW Granny” when she returned home.

Prior to the availability of Impella technology, patients like Nellie would not be able to have a cardiac procedure to open narrowed vessels due to the high risk involved. In many cases, bypass surgery would be too risky as well, leaving these patients with little hope of recovery. CVI cardiologists Dr. Samir Patel, Dr. Amir Haghighat and Dr. Thompson Maner have used the Impella technology to give many of these patients deemed too high-risk a second chance. “This is why we’re always learning and working to bring the latest technology to Bay Medical,” says Dr. Haghighat. “To have a great save like this one and to give those grandkids ‘a NEW Granny’ is why we do what we do.”


How are cardiologists involved in treating stroke?

Our latest Ask a Cardiologist video featuring Dr. Samir N. Patel covers why a stroke, or a brain attack, is definitely something you should see your cardiologist about.  A common underlying cause of stroke is vascular disease. An ischemic stroke occurs when a piece of thrombus or plaque that has been dislodged travels into the arteries in the brain causing a blockage. Plaque build-up in the carotid artery is often a culprit as is atrial fibrillation.  Fortunately, cardiologists at Cardiovascular Institute also offer interventional treatment for stroke prevention such as a stent placement procedure to open up a clogged carotid artery.

CVI to Participate in Two New Clinical Studies

The Research Department at the Cardiovascular Institute will participate in two new national studies which will provide valuable information to validate or improve current treatment protocols.

The CHAMP-HF observational study will examine treatment of heart failure and will help physicians and researchers better understand how different medications affect patients with this condition. This study will enroll up to 5,000 patients across the U.S. who have been diagnosed with heart failure and have a reduced ejection fraction (LVEF < 40% within the last 12 months). Ejection fraction is a measurement physicians use to determine how well the heart is pumping out blood. Patients who qualify and agree to participate will be asked to fill out questionnaires during their usual health care provider visits that occur during the study period (up to two years). Participants will receive payment for their study related expenses and can change their mind to opt out of the study at any time.

The Affordability and Real-world Antiplatelet Treatment Effectiveness After Myocardial Infarction Study (ARTEMIS) will assess the impact of copayment reduction by equalizing copayments for clopidogrel (Plavix) and tricagrelor (Brilinta). With financial factors removed from the equation, the ARTEMIS study will follow prescribing patterns, patient medication adherence and clinical outcomes for up to one year. This study is designed for patients 18 or older who have been hospitalized for heart attack (STEMI or NSTEMI) and treated with antiplatelet medications (P2Y12 receptor inhibitors). To qualify, patients must also carry US-based health coverage with prescription benefit. At enrollment, patients will receive a prescription voucher card to offset copayments for Plavix or Brilinta. The ARTEMIS study is a multicenter cluster-randomized trial, which means that that each participating site will be randomized as a control site or an interventional site. Sites in the interventional arm of the study will have the opportunity to offer enrolled patients the previously described voucher card to cover costs for the medications included in the study for 12 months following their discharge from the hospital for heart attack. Sites in the control arm will provide the usual standard of care.

Cardiologist Dr. Michael Morrow is the principal investigator at CVI for both of these studies however all CVI cardiologists can enroll patients. “We are grateful to have the opportunity to participate in this research,” says Dr. Morrow. “This gives us access to recent data collected from across the nation that can help us refine our treatment protocols and offer our patients the best, proven therapies currently available.”


New Technique Opens Hardened Coronary Arteries

The rotating Diamondback 360 device sands a tunnel through the calcified plaque lesion to restore blood flow.

Plaque build-up in the arteries, or atherosclerosis, is the cause of heart attack. This plaque is usually soft and pliable and a cardiologist uses a procedure called balloon angioplasty to push open the plaque build-up in narrowed arteries to restore blood flow. However, in up to 40 percent of patients who need this procedure, this plaque that has been building for a long time can become calcified or hardened where a standard balloon procedure is not effective. Fortunately, the FDA has approved a new technology to remove this hardened plaque called the Diamondback 360.

The Diamondback 360 is essentially an orbital sander literally coated with diamonds for an extra-fine grit to open hardened plaque build-up. Interventional cardiologist, Dr. Samir Patel, who was first to use the technology in the coronary arteries in our area says ” This technique has been successful for several years in treating the long, relatively straight blood vessels in the legs when calcified lesions are present, however this is the first device approved for use in the arteries around the heart.”

The tiny round device uses centrifugal force to sand away the calcification while the flexible, healthy tissue flexes away. As with any sanding process, particulates are produced, however these are far smaller than the blood cells and do not create any further blockages. Once the hardened plaque is removed, a stent can be placed to hold open the artery.

“Clinical trials of this device prior to FDA approval have shown it be highly safe and effective in treating patients with these very difficult coronary lesions,” says Dr. Patel. “At medical centers without advanced technology and techniques such as this for blocked and calcified arteries, these patients might not receive treatment other than medications. The blockage would remain and so would the symptoms that come with it such as chest pain and shortness of breath and leave the patient at increased risk of heart attack.”

Dr. Patel used the new coronary device for the first time in April at Bay Medical Sacred Heart, the only facility in our area offering this technology.