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Are Heart and Blood Vessel Diseases Different in Women Than in Men?

For many years, heart and blood vessel diseases were perceived mostly as a “men's disease.” Yet they are also one of the leading causes of death in women. Moreover, in women, the onset, symptoms, risk factors, and some treatment approaches of the disease may differ from those in men.

Why is heart disease different in women?

Women's cardiovascular system is affected by hormones, pregnancy, menopause, and certain biological characteristics. Estrogen in particular has protective effects on blood vessel health before menopause. For this reason, coronary heart disease in women generally appears at an older age than in men. However, as this protective effect diminishes with menopause, the risk of high blood pressure, high cholesterol, hardening of the arteries, and cardiovascular disease rises rapidly. Therefore:

• The idea that “heart disease is less common in women” is wrong; in women, the disease often

appears at a later age.

Symptoms in women may differ from those in men

When people think of a heart attack in men, they usually think of severe chest pain that starts in the middle of the chest and spreads to the arm or jaw. In women, this classic picture may be seen, but different symptoms may also occur:

• Ø Shortness of breath
• Ø Unusual tiredness
• Ø Weakness
• Ø Nausea or vomiting
• Ø Back, shoulder, or jaw pain
• Ø Pressure or discomfort in the chest
• Ø Cold sweats
• Ø Dizziness
• A lack of awareness that these symptoms may come from the heart can delay

diagnosis. However, one important point must be emphasized: In women, a heart attack does not necessarily present with “atypical” symptoms. Chest pain or chest pressure is also one of the most important symptoms in women.

Some risk factors may be more important in women

Smoking, high blood pressure, high cholesterol, diabetes, obesity, and physical inactivity are also important risk factors in women. However, the effect of some risk factors in women is especially striking. Diabetes: Diabetes may increase the risk of cardiovascular disease more in women than in men. Smoking: Smoking is also a strong risk factor for heart attack and vascular disease in women. Hypertension: High blood pressure is very common in women, especially after menopause, and significantly increases the risk of heart failure, stroke, and coronary disease.

Obesity: Excess weight increases the risk of hypertension, diabetes, sleep apnea, and cardiovascular disease. Conditions that arise during pregnancy may indicate future heart risk. Another important issue specific to women is complications that arise during pregnancy. For example:

• Ø Gestational hypertension
• Ø Preeclampsia
• Ø Gestational diabetes
• Ø Preterm birth
• Ø Cardiovascular complications during pregnancy may be signs that the risk of cardiovascular disease

may be higher in later years.

For this reason, it is important that women who had blood pressure or blood sugar problems during pregnancy also have their cardiovascular risks evaluated after pregnancy. In women, the heart arteries may not be completely blocked. There is a very important difference here. In women, heart artery disease does not consist only of the classic atherosclerotic narrowing of the large arteries. In some women:

Microvascular disease, that is, dysfunction of the heart's small blood vessels, may occur. In addition, temporary tightening of the arteries (coronary vasospasm) can also lead to chest pain and heart attack. For this reason, in women with ongoing chest pain, the absence of significant narrowing in the large arteries on coronary angiography does not mean “there is no heart disease.” Conditions such as microvascular disease or vasospasm may be investigated in these patients.

Is there a difference in treatment between women and men?

The basic treatments are the same for women and men. When there is a heart attack, coronary artery disease, hypertension, or heart failure, women should benefit from proven treatments just as men do. For example:

• Statins (cholesterol-lowering medications)
• Antiplatelet medications, Anticoagulants (blood thinners)
• Beta blockers
• ACE inhibitors/ARBs
• Heart failure medications
• Interventional treatments such as coronary stents
• Bypass surgery is also used in women when needed.

However, the treatment approach has some features specific to women.

Why can treatment sometimes be delayed in women?

Viewing cardiovascular disease as a men's disease, interpreting symptoms differently, and the fact that the disease affects the small blood vessels in some women can make the diagnosis and treatment process more difficult in women. In addition, women may be affected differently by some cardiovascular medications in terms of side effects. For example, side effects related to some medications may be more common in women. For this reason, treatment must always be individualized. Should women receive the same heart attack treatment as men? Yes. Being a woman is not a barrier to angiography, stenting, or bypass treatment when needed. However, it is very important not to delay diagnosis, especially when a heart attack is suspected. In women, considering earlier that symptoms may come from the heart and performing the necessary ECG, troponin, and imaging tests on time can be critical to the success of treatment. Stroke risk in women also has different characteristics. In women, cardiovascular disease does not mean only heart attack.Stroke is also a very important health problem in women. In particular:

• Ø Hypertension
• Ø Atrial fibrillation
• Ø Diabetes
• Ø Obesity

Ø Smoking increase the risk of stroke. In women, pregnancy, preeclampsia, and certain hormonal conditions should also be taken into account in lifelong cardiovascular risk assessment. Why is menopause important? Menopause is an important turning point for women's cardiovascular health.After menopause:

Blood pressure may begin to rise. LDL cholesterol may increase. Weight, and especially fat around the abdomen, may increase. Insulin resistance may develop. The risk of hardening of the arteries may increase. For this reason, menopause is an important period not only for gynecological health but also for cardiovascular health. However, it is not recommended to routinely start hormone therapy in every patient and at every age to prevent heart disease. The decision on hormone therapy should be made taking into account menopausal symptoms and the woman's individual risks. How can women protect themselves from heart disease? The most important preventive approach is to control risk factors early. It is especially important for women to:

• Have their blood pressure measured regularly
• Have their cholesterol levels checked

Have their blood sugar monitored

Maintain a healthy weight Exercise regularly Not smoke Eat a healthy diet Get enough sleep Share problems experienced during pregnancy, such as hypertension and diabetes, with their doctor in later years as well.

The most important message for women

Heart disease is not just a men's disease. In women, a heart attack can sometimes present with different symptoms, some risk factors may be stronger, and small vessel diseases may be more common. For this reason, preventing, recognizing early, and treating cardiovascular diseases on time is especially important in women. In particular, chest pressure/pain, new shortness of breath, unexplained extreme tiredness, cold sweats, nausea, or new pain in the jaw, back, or shoulder area may be signs of a heart attack. When these symptoms occur, do not wait, thinking that “heart attacks don't look like this in women.”

References:

• Joynt Maddox KE, Reynolds HR, Adedinsewo D, et al. Forecasting the Burden of
• Cardiovascular Disease and Stroke in Women in the United States Through 2050: A

Scientific Statement From the American Heart Association. Circulation. 2026;153:e1061-e1077.

• Knuuti J, Wijns W, Saraste A, et al. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J. 2024;45:3415-3537. Particularly important with regard to women-specific risk factors and differences in diagnosis and treatment.
• Van Gelder IC, Rienstra M, Bunting KV, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J.

2024;45:3314-3414.

• Virani SS, Newby LK, Arnold SV, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA

Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 2023;148:e9-e119.

• McSweeney JC, Rosenfeld AG, Abel WM, et al. Preventing and Experiencing

Ischemic Heart Disease as a Woman: State of the Science. Circulation. 2016;133:1302-1331.

• Mehta LS, Beckie TM, DeVon HA, et al. Acute Myocardial Infarction in Women: A

Scientific Statement From the American Heart Association. Circulation. 2016;133:916-947.

• Regitz-Zagrosek V, Gebhard C. Gender medicine: effects of sex and gender on cardiovascular disease manifestation and outcomes. Nat Rev Cardiol. 2020;17: ̶?
• Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J.

2018;39:3165-3241.

• Sliwa K, Johnson MR, Zilla P, Roos-Hesselink JW. Management of peripartum cardiomyopathy—Part 1: The ESC position statement on peripartum cardiomyopathy.

Eur J Heart Fail. 2010;12:767-778.

• European Society of Cardiology Working Group on Coronary Pathophysiology and

Microcirculation, et al. Sex and gender differences in coronary pathophysiology and ischaemic heart disease. Eur Heart J. 2026;47:2727-2750.

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How Does Rapid Weight Gain and Loss Affect the Heart?

“I lost weight, then gained it back… I lost it again, and gained it again.” Can this cycle affect your heart? Losing weight can provide important benefits for heart health, especially in people who are overweight or have obesity. Lower blood pressure, improved blood sugar and cholesterol, and a reduced workload on the heart are some of these benefits.

For some people, however, the weight loss process turns into a cycle:

• Rapid weight loss → regaining weight → rapid weight loss again → regaining weight again…
• Known popularly as the “yo-yo diet,” and in the medical literature as “weight cycling” or “body-weight

variability,” this condition may matter not only for appearance but also for cardiovascular health in the long term.

Research shows that large and repeated fluctuations in body weight may be associated with a higher risk of cardiovascular disease. However, more research is needed to say definitively that this association is caused directly by the weight fluctuation itself.

Why can gaining and losing weight affect the heart?

When body weight changes, it is not just the number on the scale that changes. During periods of weight gain and loss, the following may also change:

• blood pressure,
• blood sugar,
• insulin sensitivity,
• cholesterol and triglycerides,
• fat distribution in the body,
• muscle mass,

and physical activity level. In particular, the fact that a large part of the weight regained after rapid weight loss consists of fat tissue may create an unfavorable metabolic picture over time. However, there is an important point here:

Not every period of weight gain and loss is the same. A person who loses 10 kg in a controlled way and then gains 2–3 kg over a few years is not in the same situation as someone who loses 15 kg in a few months and then gains 20 kg.

Does weight cycling increase the risk of heart attack?

Much of the research on this subject shows an association between weight fluctuation and cardiovascular events. In a meta-analysis including twenty-three studies and more than 15 million people in total, people with the highest weight variability were found to have an approximately 27% higher risk of any cardiovascular event, an approximately 29% higher risk of death from cardiovascular disease, and an approximately 32% higher risk of heart attack.

In another previously published meta-analysis, high body-weight fluctuation was also found to be associated with a higher risk of cardiovascular disease, hypertension, and cardiovascular death. But how should these figures be interpreted? Most of these studies are observational studies. That means we cannot conclude that “gaining and losing weight definitely causes heart attacks.” This is because people who frequently gain and lose weight may also have a higher starting weight, diabetes, hypertension, or other health problems. Therefore, the more scientifically accurate statement is: Frequent and marked weight fluctuations are associated with a higher risk of cardiovascular disease; however, it has not been definitively proven that this association is a direct cause-and-effect relationship.

Can heart rhythm also be affected?

Interestingly, an association has also been reported between weight fluctuation and atrial fibrillation (a rhythm disorder). In a large study evaluating more than eight million people, increased variability in body weight was associated with an increased risk of developing new atrial fibrillation. The group with the greatest weight fluctuation had an approximately 14% higher risk of atrial fibrillation than the group with the least fluctuation. This finding is particularly important, because atrial fibrillation can lead not only to palpitations but also, in certain patients, to an increased risk of stroke.

Why might losing weight and gaining it back be more problematic?

During weight loss, muscle loss can occur in addition to the loss of fat tissue. When the person later regains weight, a large part of the weight gained may consist of fat tissue. Therefore, saying “I lost 10 kilos, then gained 10 kilos; in the end I'm at the same weight again” is not always accurate from a metabolic point of view. The body's fat-to-muscle ratio, the distribution of fat in the body, and metabolic health may not be the same as at the start. For this reason, the goal is not just to lose weight on the scale but to be able to keep the weight off.

So is it more important to lose weight or to keep weight stable?

For people who are overweight or have obesity, healthy and sustainable weight loss should definitely be encouraged. The point is not to be afraid of losing weight. The real goal is: Lose weight → stay at a healthy weight → do not fall into the cycle of regaining weight. For example, a person weighing 100 kg who loses 8–10 kg in a controlled way and maintains this weight for a long time is very different from someone who loses 15 kg in a few months, then gains 20 kg, and repeats the same cycle.

“If losing weight is good for the heart, why would gaining it back be harmful?”

Because these are two different situations. Healthy weight loss:

• reduces fat tissue,
• can lower blood pressure,
• can improve blood sugar,
• can increase physical capacity,

and can reduce the workload on the heart. Repeated rapid weight gain and loss:

• may be accompanied by repeated worsening of metabolic control,
• reduced physical activity,
• loss of muscle mass,
• and fluctuations in blood pressure and blood sugar. However, it should also be emphasized that all these effects

do not occur in the same way in every individual.

What should a heart patient do if they want to lose weight?

1. Aim for sustainable, not rapid, weight loss

Instead of the approach “Let me lose as much weight as possible in a month,” aim for a weight that can be maintained in the long term.

2. Avoid short-term crash diets

Diets that are very low in calories, monotonous, or impossible to maintain for long may seem successful in the short term but can set the stage for regaining weight.

3. Try to prevent muscle loss

When losing weight, it is important to lose only fat. Adequate protein, appropriate physical activity, and especially resistance exercises can be added to the program in a way that suits the person's health condition.

4. Look at the trend, not the scale

A daily change of 1–2 kg is usually not a change in fat. Even the amount of water and salt in the body can cause significant differences on the scale. For this reason, it is more meaningful to look at the trend over weeks and months rather than a single measurement.

5. If you have heart disease, plan your weight loss together with your doctor

Especially in people with:

• heart failure,
• coronary artery disease,
• atrial fibrillation or another rhythm disorder,
• diabetes,

or hypertension, medication doses may need to be reevaluated during weight loss. In particular, in people taking diuretics and blood pressure medications, changes in weight and fluid can affect blood pressure.

Medications should not be reduced or stopped on your own decision

just because you have lost weight. Is weight fluctuation always bad? No. There is an important debate on this point in the scientific literature. While some studies have linked weight fluctuation to increased cardiovascular risk, some controlled studies have not shown a clear negative effect of weight cycling alone on classic cardiovascular risk factors. In fact, some research has shown that losing weight and then maintaining that weight is beneficial from a cardiovascular standpoint for people who are overweight. Therefore, thinking “I gained weight once and lost it again; I have damaged my heart” is not correct. The real concern is large and rapid weight fluctuations repeated over many years.

What is the ideal approach to protect your heart?

The healthiest model: Lose weight → preserve your muscles → increase physical activity → eat healthily → maintain the weight you have lost. This approach is healthier than a constant cycle of: “lose weight very quickly → return to normal eating → gain weight quickly → start dieting again.”

In Summary:

• What the heart needs is not just a lower weight but a healthier and more stable

lifestyle. Losing weight is usually a positive step for heart health.

But the goal should be: **not “How can I lose weight the fastest?” but “How can I maintain the weight I have lost while protecting my heart?”** And especially for heart patients, it is more important to avoid the cycle of repeated rapid weight gain and loss than to focus on the weight loss itself.

1. Bangalore S, Fayyad R, DeMicco DA, et al. Body-Weight Fluctuations and Outcomes in

Patients With Coronary Disease. N Engl J Med. 2017 Apr 6;376(14):1332-1340.

2. Zou H, Yin P, Liu L, et al. Body-Weight Fluctuation Was Associated With Increased Risk for

Cardiovascular Disease, All-Cause and Cardiovascular Mortality: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne). 2019 Nov 8;10:728.

3. Sattar N, et al. Weight variability and cardiovascular outcomes: a systematic review and metaanalysis. Cardiovasc Diabetol. 2023 Jan 9;22(1):5.

4. Jeong SM, et al. Association of weight fluctuation with cardiovascular disease risk among

initially obese adults. Sci Rep. 2021 May 12;11(1):10152.

5. Nam GE, et al. Bodyweight fluctuation is associated with increased risk of incident atrial

fibrillation. Heart Rhythm. 2020 Mar;17(3):365-371.

6. Fothergill E, et al. Persistent metabolic adaptation 6 years after "The Biggest Loser"

competition. Obesity (Silver Spring). 2016 Aug;24(8):1612-9.

7. Kris-Etherton PM, et al. A prospective study of effects of weight cycling on cardiovascular risk

factors. Arch Intern Med. 1995 Jul 10;155(13):1416-22.

8. Kajioka T, et al. Weight cycling and cardiovascular risk factors in obesity. nt J Obes Relat

Metab Disord. 2004 Jan;28(1):65-71.

9. Kim MK, et al. Body-Weight Fluctuation and Incident Diabetes Mellitus, Cardiovascular

Disease, and Mortality: A 16-Year Prospective Cohort Study. J Clin Endocrinol Metab. 2019 Mar 1;104(3):639-646.

10. American Heart Association. Obesity and Cardiovascular Disease: A Scientific Statement

From the American Heart Association.: https://professional.heart.org/en/guidelinesstatements/obesity-and-cardiovascular-disease-a-scientific-statement-from-theamericancir0000000000000973?utm_source=chatgpt.com

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What Is Renal Denervation? Will It Lower My Blood Pressure, and Who Is It Recommended For?

Renal denervation (RDN) is a minimally invasive, catheter-based treatment used in some patients whose blood pressure cannot be adequately controlled despite medication. It is sometimes described in everyday language as “burning the kidney nerves.” In fact, the procedure aims to reduce the activity of the sympathetic nerves surrounding the kidney arteries. Controlled randomized studies conducted in recent years have shown that renal denervation

can indeed lower blood pressure. However, there is an important point:

• Renal denervation is not a treatment that can be used by everyone in place of blood pressure
• medication. Rather, in suitable patients, in addition to medication and lifestyle treatment

it is being considered.

How Is Renal Denervation Performed?

The procedure is usually performed by advancing a thin catheter through a blood vessel in the groin or another suitable vascular access point. The catheter is guided to the kidney arteries. Then,

radiofrequency energy or ultrasound energy is applied to the sympathetic nerves located around the kidney arteries, which play a role in regulating blood pressure. The aim:

• Kidney → nervous system → blood vessels → blood pressure
• is to reduce the excessive sympathetic signaling among these.

The procedure is not surgery, and the kidney itself is not removed or cut.

How Do the Kidney Nerves Affect Blood Pressure?

The kidneys are not just organs that produce urine. In the regulation of blood pressure:

• Adjusting the salt and water balance,
• The renin-angiotensin-aldosterone system,
• The sympathetic nervous system play an important role. In some people, excessive activity of the sympathetic nervous system may contribute to blood pressure remaining high. The aim of renal denervation is to reduce this excessive nerve activity.

Does Renal Denervation Really Lower Blood Pressure?

Yes, but the reduction is usually moderate. Randomized, sham-controlled studies using new-generation devices have shown that renal denervation can reduce both office blood pressure and 24-hour blood pressure measurements. For example, in the SPYRAL HTN-OFF MED study, a difference of about 4 mmHg in 24-hour systolic blood pressure and about 6.5 mmHg in office systolic blood pressure was found between renal denervation and a sham procedure. In the RADIANCE-HTN TRIO study, in patients whose blood pressure remained high despite standard triple-drug therapy, ultrasound renal denervation provided an approximately 4.5–5.8 mmHg greater reduction in daytime ambulatory systolic blood pressure compared with a sham procedure. For this reason, you should not assume that blood pressure will necessarily “return to normal” after the procedure.

Can I Stop Taking My Blood Pressure Medications?

For most patients, no.This is a very important point. The aim of renal denervation is usually not to “stop medications completely” but to improve blood pressure control and support the effect of medication therapy. In some patients, it may be possible to reduce the number or dose of medications over time. However, this is not guaranteed. For example, long-term SPYRAL data showed that the reduction in blood pressure continued after renal denervation, but a large proportion of patients continued to use antihypertensive medications. Therefore, thinking "I'll have renal denervation and then I won't need blood pressure medication anymore" is not correct.

Who May Be Recommended Renal Denervation?

The following patients in particular may be considered for evaluation:

1. People with resistant hypertension

If blood pressure does not reach the target despite three or more appropriate blood pressure medications, this may be resistant hypertension.

However, it must first be confirmed that it is truly resistant hypertension.

2. People whose blood pressure is not under control despite medication

In particular:

• If it has been confirmed that the medications are taken regularly,
• If an appropriate combination of medications is being used,
• If lifestyle changes have been made,
• If hypertension persists on 24-hour blood pressure monitoring, renal denervation may be considered.

The ESC/EAPCI consensus document considers RDN as an additional treatment option particularly for uncontrolled resistant hypertension confirmed by ambulatory blood pressure monitoring despite lifestyle and medication therapy.

3. People who cannot tolerate blood pressure medications in the long term

Some patients may not be able to adequately take multiple medications due to reasons such as:

• Side effects,
• Low blood pressure,
• Edema (swelling),
• Cough,
• Electrolyte imbalances. An evaluation of suitability may also be performed in these patients.

Is Renal Denervation Performed on Every Patient with High Blood Pressure?

No. In a newly diagnosed patient whose blood pressure can be controlled with a single medication, renal denervation is usually not the first option. First, the following should be evaluated:

1. Accurate blood pressure measurement,

2. Home blood pressure monitoring,

3. 24-hour ambulatory blood pressure monitoring if needed,

4. Assessing whether medications are being taken correctly and regularly,

5. Reducing excessive salt intake,

6. Weight control,

7. Investigating secondary causes such as sleep apnea,

8. An appropriate combination of medications

. After these, renal denervation may be considered in suitable patients.

What Is Checked Before Renal Denervation?

Before the procedure, whether the patient is truly a suitable candidate is investigated. In particular, the following are evaluated:

• 24-hour blood pressure measurement,
• Kidney function,
• The structure of the kidney arteries,
• Whether there is narrowing in the kidney arteries,
• The medications being used,
• Adherence to medications,
• Secondary causes of hypertension.

The aim is to avoid performing an unnecessary procedure for hypertension that has been misdiagnosed or is uncontrolled for a different reason.

Can the Procedure Harm the Kidneys?

Current clinical studies have not shown a clear signal that renal denervation causes serious kidney damage in suitable patients. However, this does not mean that the procedure is completely risk-free. As with any catheter-based vascular procedure, the following may occur:

• Blood vessel damage,
• Bleeding,
• Narrowing of the kidney artery,
• Problems related to the contrast agent,
• Other procedure-related complications.

For this reason, the procedure should be performed at experienced centers with appropriate patient selection. The American Heart Association's 2024 scientific statement notes that the safety profile in new-generation renal denervation studies is generally good, but that individual responses vary and which patients will benefit most is still being researched.

How Much Does Blood Pressure Fall After the Procedure?

This varies from person to person. On average, sham-controlled studies have shown:- additional reductions of about 4–10 mmHg in 24-hour systolic blood pressure. However, some patients may have a greater reduction and others a smaller one.

Is the Effect Permanent? Current data show that the effect can last for at least several years. However, the evidence on whether it directly reduces clinical outcomes such as heart attack, stroke, and death over much longer periods is still not as strong as the evidence for its blood pressure-lowering effect. For this reason, the procedure is currently used mainly to lower blood pressure.

Renal Denervation or Blood Pressure Medication?

In fact, it is usually not an “either/or” choice. The more accurate approach is:

Lifestyle + blood pressure medications + renal denervation in suitable patients

. Renal denervation should be considered not so much as an alternative to medication therapy but as an option added to treatment in suitable patients.

Does Renal Denervation Prevent Heart Attack and Stroke?

It has now been strongly shown that renal denervation lowers blood pressure. However, there are not yet enough long-term randomized clinical outcome data to say that renal denervation definitively prevents heart attacks and strokes.

We know that lowering blood pressure generally reduces the risk of heart attack and stroke. However, studies directly showing this clinical benefit for renal denervation need to be of longer duration. For this reason, the main expected benefit of the procedure should currently be expressed as “better control of blood pressure.”

In Conclusion:

• Is renal denervation surgery?
• No. It is not surgery. It is a minimally

invasive procedure performed using a catheter through a blood vessel. Will my kidneys be damaged? Modern studies in suitable patients have not shown a significant safety problem in terms of serious kidney damage. However, as with any vascular procedure, there are risks. Can I stop taking my blood pressure medications? Sometimes the need for medication may decrease, but there is no guarantee that you will stop taking medications completely. Medication therapy should not be changed without your doctor's recommendation. Can the procedure be performed on everyone? No. It is considered especially for properly evaluated patients with resistant or uncontrolled hypertension. Is the procedure a definitive solution? No. On average, it lowers blood pressure by a meaningful amount, but it does not have the same effect in everyone. Renal denervation is a catheter-based treatment that has regained importance in recent years in the treatment of hypertension and can lower blood pressure moderately and lastingly. It has become an important treatment option especially for patients with resistant or uncontrolled hypertension whose blood pressure cannot be controlled despite appropriate medication therapy and lifestyle changes.

Current evidence shows that new-generation radiofrequency and ultrasound systems lower blood pressure compared with sham procedures. Nevertheless, renal denervation is not a procedure that should be performed on every patient with hypertension, and it does not automatically replace blood pressure medications. First, accurate blood pressure measurement, 24-hour blood pressure monitoring, medication adherence, lifestyle, and secondary causes of hypertension should be evaluated. In suitable patients, renal denervation can be added to medication therapy to improve blood pressure control. In its 2024 scientific statement, the American Heart Association also emphasizes that the method lowers blood pressure modestly and generally has a good safety profile, but that it has not yet been fully determined which patients will benefit most.

• Bhatt DL, Kandzari DE, O'Neill WW, et al. SYMPLICITY HTN-3 A Controlled Trial of

Renal Denervation for Resistant Hypertension. New England Journal of Medicine. 2014;370:1393–1401.

• Townsend RR, Mahfoud F, Kandzari DE, et al. SPYRAL HTN-OFF MED. Catheterbased renal denervation in patients with uncontrolled hypertension in the absence of antihypertensive medications (SPYRAL HTN-OFF MED): a randomised, shamcontrolled, proof-of-concept trial. The Lancet. 2017;390:2160–2170.
• Böhm M, Kario K, Kandzari DE, et al. SPYRAL HTN-OFF MED Pivotal. Efficacy of catheter-based renal denervation in the absence of antihypertensive medications

(SPYRAL HTN-OFF MED Pivotal): a multicentre, randomised, sham-controlled trial. The Lancet. 2020;395:1444–1451.

• Azizi M, Schmieder RE, Mahfoud F, et al. RADIANCE-HTN SOLO.
• Endovascular Ultrasound Renal Denervation to Treat Hypertension (RADIANCE-HTN

SOLO): a Multicentre, International, Single-Blind, Randomised, Sham-Controlled

Trial. The Lancet. 2018.

• Azizi M, Sanghvi M, Saxena M, et al. RADIANCE-HTN TRIO. Ultrasound renal denervation for hypertension resistant to a triple medication pill (RADIANCE-HTN

TRIO): a randomised, multicentre, single-blind, sham-controlled trial. The Lancet. 2021;397:2476–2486.

• Cluett JL, Blazek O, Brown AL, et al. 2024 American Heart Association Scientific

Statement

• Renal Denervation for the Treatment of Hypertension: A Scientific Statement From the American Heart Association. Hypertension. 2024;81(10):e135–e148.

Barbato E, Azizi M, Schmieder RE, et al. ESC/EAPCI Clinical Consensus Statement

Renal denervation in the management of hypertension in adults. A clinical consensus statement of the ESC Council on Hypertension and the European Association of Percutaneous Cardiovascular Interventions (EAPCI). European Heart Journal. 2023;44:1313–1330. Long-term clinical benefit after radiofrequency renal denervation: pooled 36-month results from the SPYRAL Clinical Program. European Heart Journal. 2026.

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Can a Crease in the Earlobe Be a Warning Sign of Heart Disease?

While looking at yourself in the mirror, you noticed a distinct line running diagonally across your earlobe. You may have come across information, especially on the internet, claiming that this line is a “sign of heart disease.” The medical name for this line is diagonal earlobe crease (DELC), and it is commonly known as an earlobe crease. It is also called Frank's sign.

So, is it really associated with heart disease?

Yes, some studies have shown that this distinct crease in the earlobe may be associated with cardiovascular disease and hardening of the arteries. However, this crease alone does not mean that you have heart disease, and it cannot be used to diagnose heart disease. Today, this finding is regarded more as a simple physical sign suggesting that attention should be paid to the person's cardiovascular risk factors.

What Is an Earlobe Crease?

An earlobe crease is a distinct skin fold running diagonally across the earlobe. It usually starts near the front of the earlobe and extends backward and downward. The crease:

May be on one ear. May be on both ears. May be superficial or deeper. May be short or may run completely across the earlobe. In some studies, a distinct and deep crease present on both ears in particular has shown a stronger association with cardiovascular disease.

Why Is It Called the "Heart Disease Crease"?

This finding was first described in the 1970s by the American physician Sanders T. Frank as a notable physical finding in people with cardiovascular disease. Research in later years showed that this crease in the earlobe may be associated particularly with hardening of the arteries (atherosclerosis) and disease of the arteries that supply the heart. However, there is an important distinction here: The earlobe crease is not a cause of heart disease; it may be a sign that is seen together with cardiovascular disease in some people.

Why Might an Earlobe Crease Be Associated with Heart Disease?

The exact reason is not yet known. Researchers have several different explanations. In heart and blood vessel disease, changes occur in the structure of the blood vessels and in blood flow in the small vessels. Because the earlobe also contains very small blood vessels, it is thought that changes in vessel structure may lead to visible changes in the skin and tissues there. Another view suggests that the earlobe crease may result not directly from vascular disease but from aging and changes in the body's connective tissue. Therefore, as of today, there is no established cause-and-effect relationship of the kind: "A crease forms in the earlobe→ the heart artery becomes blocked."

Does Everyone with an Earlobe Crease Have Heart Disease?

No. This is the most important point. An earlobe crease alone is not a reliable diagnostic method for heart disease. A systematic review published in 2021 examined 13 studies and about 4,000 people and concluded that the accuracy of the earlobe crease in identifying severe narrowing of the heart arteries was not sufficient. In other words: You cannot say "your heart arteries are blocked" by looking at an earlobe crease.

So, Why Does It Matter?

Because some studies have shown that cardiovascular disease is more common in people with an earlobe crease. For example, a 2024 study of 1,050 adults found that the calculated cardiovascular disease risk was higher in people with an earlobe crease. The association with risk indicators was also stronger when the crease was on both sides, deeper, and more distinct. A systematic review and meta-analysis published in 2025 evaluated data from a total of about 5,000 people in 12 studies. It reported that the likelihood of coronary artery disease was higher in people with an earlobe crease. However, these results do not mean that an earlobe crease definitively indicates heart disease.

Is the Risk Higher If the Crease Is Present on Both Ears?

A large share of studies show a stronger association between a bilateral earlobe crease and cardiovascular disease. In an important study conducted in Türkiye in 2004, 415 patients were evaluated, and a bilateral earlobe crease was found to be independently associated with coronary artery disease. Prof. Dr. Mehdi Zoghi was among the authors of this study. The study showed that a bilateral earlobe crease was associated not only with cardiovascular disease but also with cardiovascular risk factors such as: Age High blood pressure Smoking Male sex Family history of heart disease.

Crease Earlobe

On Both Ears

Is the Risk Higher If It Is Present on Both? What Should I Do If I Have an Earlobe Crease? There is no need to panic. However, you can treat this crease as an opportunity to have your cardiovascular health checked. It is a good idea to talk to your doctor, especially if any of the following apply to you:

• You have high blood pressure
• Your cholesterol is high
• You smoke
• You have diabetes
• You are overweight
• There is a history of heart attack at an early age in your family
• You have had chest pain before
• You get short of breath when walking or climbing stairs
• You tire easily

Should I Have a Heart Checkup If I Have an Earlobe Crease?

Yes, especially if you also have other risk factors. However, the aim is not to treat the crease on the earlobe but to assess the cardiovascular risks that the crease may be pointing to. For example, an earlobe crease is more significant in a 55-year-old person who smokes and has high blood pressure and high cholesterol. By contrast, it is not appropriate to perform advanced cardiac tests solely because of an earlobe crease in a young, healthy person with normal blood pressure and cholesterol who does not smoke.

Can an Earlobe Crease Be Related to Aging?

Yes. The frequency of earlobe creases increases with age. For this reason, it is not correct to regard every earlobe crease, especially in older people, as a sign of heart disease.

Does an Earlobe Crease Mean I Will Have a Heart Attack?

Absolutely not. When you see this crease, you should not think, “I am going to have a heart attack soon.” There are far more important factors that determine the risk of a heart attack:

• Smoking
• High LDL cholesterol
• High blood pressure
• Diabetes
• Excess weight
• Physical inactivity
• Age
• Family history
• Existing cardiovascular disease

If you have an earlobe crease, it is more important to have these factors checked. In summary: I have a crease on my earlobe; are my heart arteries blocked? No. An earlobe crease is not a definitive test showing arterial blockage. I have a crease on both ears. Is my risk higher? Some studies have shown that a bilateral crease is more strongly associated with cardiovascular disease. Even so, it does not establish a diagnosis on its own. Can an earlobe crease also occur in young people? It can, but it becomes more common with age. Does it matter if the crease is deep? Some studies suggest that deeper, longer and bilateral creases may be more strongly associated with cardiovascular disease. However, this is not accurate enough to be used on its own for clinical decision-making.

In Conclusion

A diagonal crease on the earlobe, known as Frank’s sign, is an interesting physical finding that may be associated with cardiovascular disease. Many studies show that a prominent crease present on both ears is associated with coronary artery disease. However, the scientific evidence shows that this crease alone is not sufficient to diagnose heart disease. So if you notice such a crease on your earlobe, rather than worrying, think of it as a reminder to assess your heart health. Reviewing your blood pressure, cholesterol, blood sugar, weight and smoking, and assessing your cardiovascular risk with your doctor, especially if there is a family history of early heart disease, is far more important.

An earlobe crease is not proof of heart disease; however, it is a simple physical sign

that can be taken into account when reviewing cardiovascular risks. References:

• •
• •
• •

• • • • • • • • •

Evrengül H, Dursunoğlu D, Kaftan A, Zoghi M, Tanriverdi H, Zungur M, Kılıç M. Bilateral diagonal earlobe crease and coronary artery disease: a significant association. Dermatology. 2004;209(4):271-275. Shmilovich H, Cheng VY, Rajani R, et al. Relation of diagonal ear lobe crease to the presence, extent, and severity of coronary artery disease determined by coronary computed tomography angiography. The American Journal of Cardiology. 2012;109(9):1283-1287. Elliott WJ, Karrison T. Increased all-cause and cardiac morbidity and mortality associated with the diagonal earlobe crease: a prospective cohort study. The American Journal of Medicine. 1991;91(3):247-254. Tranchesi Júnior B, Barbosa V, de Albuquerque CP, et al.Diagonal earlobe crease as a marker of the presence and extent of coronary atherosclerosis. The American Journal of Cardiology. 1992;70(14):1417-1420.

Friedlander AH, López-López J, Velasco-Ortega E. Diagonal ear lobe crease and

atherosclerosis: A review of the medical literature and dental implications. Medicina Oral, Patología Oral y Cirugía Bucal. 2012;17(1):e153-e159. Nardone R, et al. Diagonal earlobe crease (Frank's sign) and increased risk of cerebrovascular diseases: review of the literature and implications for clinical practice. Journal of Clinical Neurology. 2019. Curtis J, Walford S. Why we should be looking for earlobe creases in ENT. A systematic review and meta-analysis of diagonal earlobe crease and coronary artery disease. The Journal of Laryngology & Otology. 2025;139(3):160-167.

Coma F, et al. Diagonal Earlobe Crease (Frank’s Sign) for Diagnosis of Coronary

Artery Disease: A Systematic Review of Diagnostic Test Accuracy Studies. Journal of Clinical Medicine. 2021;10(13):2799. Wang Y, Mao LH, Jia EZ, et al. Relationship between diagonal earlobe creases and coronary artery disease as determined via angiography. BMJ Open. 2016;6(2):e008558.

Llamas-Velasco M, et al. Frank's Sign and Cardiovascular Risk: An Observational

Descriptive Study. The American Journal of Medicine. 2024;137(1):47-54.

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What Is the Most Common Heart Rhythm Disorder? What Causes It? How Is It Treated?

The most common clinically important heart rhythm disorder is atrial fibrillation (AF). Its frequency increases markedly with age. However, AF is not a disease seen only in older people; many factors such as high blood pressure, obesity, diabetes, heart disease, sleep apnea and excessive alcohol consumption can also set the stage for it to develop at younger ages. What is atrial fibrillation? Normally, the upper chambers (atria) and lower chambers (ventricles) of the heart work in a regular rhythm. In atrial fibrillation, the atria begin to work with very fast and irregular electrical impulses. As a result, the heartbeat becomes irregular. Patients sometimes describe this as “my heart is skipping,” “my heart speeds up and then slows down,” or “my heart is beating irregularly.” But there is an important point: AF does not always cause palpitations. Some people may have no symptoms at all, and the rhythm disorder may be noticed during a routine examination, an ECG or a test done for another reason.

Why Is It Important?

The most important problem with atrial fibrillation is not just that the heart beats fast or irregularly. When the atria do not contract regularly, blood can pool and clots can form more easily, especially in the left atrium. If such a clot enters the circulation and travels to the brain, it can cause a stroke. For this reason, one of the doctor’s first assessments in a patient diagnosed with AF is the question, “How high is this patient’s risk of stroke?” In patients at high risk of stroke, the use of appropriate anticoagulant (blood thinner) treatment is one of the most important parts of AF treatment.

Why Does It Occur?

Many factors can play a role in the development of AF. The most important are:

• High blood pressure
• Advancing age
• Coronary artery disease and a previous heart attack
• Heart failure
• Heart valve disease
• Diabetes
• Obesity
• Sleep apnea
• Thyroid disease
• Excessive alcohol consumption
• Smoking
• A sedentary lifestyle
• Some lung diseases
• Structural heart disease
• Sometimes, especially in younger people, AF can also

occur without any significant structural heart disease.

Do Stress and Coffee Cause AF?

Stress, lack of sleep, excessive alcohol consumption and, in some people, heavy caffeine intake can trigger palpitations. However, it is not correct to say that “drinking coffee directly causes AF.” In fact, current data show that moderate coffee consumption generally does not significantly increase the risk of AF. Nevertheless, if a person notices that they consistently experience palpitations or an AF episode after a particular drink, they should share this with their doctor.

What Are the Symptoms?

The symptoms of AF can vary from person to person:

• Palpitations
• Irregular or rapid heartbeat
• Shortness of breath
• Tiring easily
• Weakness
• Dizziness
• Chest discomfort
• Reduced exercise capacity
• Some patients have no symptoms at all. For this reason, especially in older people and in those with hypertension,
• diabetes or other heart diseases, noticing an irregular pulse

should be taken seriously.

How Is AF Detected? How Is It Diagnosed?

The most basic method for diagnosing atrial fibrillation is electrocardiography (ECG). However, if AF occurs in episodes, an ECG lasting a few minutes taken at the hospital may be normal. In such cases:

• Holter ECG

Long-term rhythm recording devices

Rhythm recordings from wearable devices and smartwatches can help with the diagnosis. However, a smartwatch alert alone does not mean a definitive diagnosis of AF. In suspected cases, confirmation with an ECG is required.

What Is the Goal of Treatment?

There is no single goal in AF treatment. In general, there are four objectives:

1. Reducing the risk of stroke

Anticoagulant medications may be used in patients at high risk of stroke. However, not every AF patient is given a blood thinner. The treatment decision is based on the patient’s age, coexisting conditions and individual stroke risk.

2. Preventing the heart from beating too fast

The heart rate can be kept under control with medications such as beta blockers.

3. Trying to keep the heart in normal rhythm

In suitable patients, rhythm-control medications or electrical cardioversion may be used.

4. Trying to eliminate AF itself

Catheter ablation can be performed in suitable patients. In this procedure, catheters advanced to the heart through a vein in the groin are used to target the electrical foci that trigger AF, especially the areas around the pulmonary veins, in an effort to reduce recurrence of the rhythm disorder.

Is It Possible to Prevent AF?

It is not possible to prevent every case of AF. However, there is a lot that can be done to reduce the risk of AF developing or recurring. To protect your heart:

Keep your blood pressure under control. If you are overweight, lose weight in a healthy way. Get regular physical activity. Do not smoke. Avoid excessive alcohol consumption. Keep diabetes and high cholesterol under control. If you have sleep apnea, get it treated. Get enough regular sleep. Keep the risk factors for cardiovascular disease under control. Weight loss, blood pressure control, physical activity and treatment of sleep apnea in particular are becoming increasingly important in the management of AF.

When Should You See a Doctor?

If you feel that your heart is beating irregularly or very fast, especially if this happens repeatedly, you need to be evaluated by a doctor. However, if palpitations are accompanied by chest pain, severe shortness of breath, fainting or feeling faint, urgent medical evaluation is needed. In addition, sudden weakness in the face or arm, difficulty speaking, loss of vision or marked loss of balance may be signs of a stroke and require emergency evaluation.

The Most Important Message: AF Is More Than Just Palpitations

Atrial fibrillation is an important heart rhythm disorder that is becoming increasingly common today. However, it can be brought under control with early diagnosis and proper treatment. The aim here is not only to correct the heart’s rhythm. Preventing stroke, reducing complications such as heart failure, improving the patient’s quality of life and preventing the progression of AF are the core goals of treatment. In short: If you feel that your heart is beating irregularly, do not dismiss it as just “palpitations.” Recurrent irregular pulse in particular may be the first sign of atrial fibrillation.

• Van Gelder IC, Rienstra M, Bunting KV, et al. 2024 ESC Guidelines for the
• management of atrial fibrillation developed in collaboration with the European
• Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024;45(36):3314

3414.

• Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 2024;149:e1-e156.
• Kirchhof P, Camm AJ, Goette A, et al.Early Rhythm-Control Therapy in Patients with

Atrial Fibrillation. N Engl J Med. 2020;383:1305-1316.

• Packer DL, Mark DB, Robb RA, et al. Effect of Catheter Ablation vs Antiarrhythmic

Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial. JAMA. 2019;321(13):12611274.

• • • • • •

Pathak RK, Middeldorp ME, Meredith M, et al. Long-Term Effect of Goal-Directed

Weight Management in an Atrial Fibrillation Cohort: A Long-Term Follow-Up Study

(LEGACY). J Am Coll Cardiol. 2015;65(20):2159-2169. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus Warfarin in Patients with Atrial Fibrillation. N Engl J Med. 2009;361:1139-1151.

Granger CB, Alexander JH, McMurray JJV, et al. Apixaban versus Warfarin in

Patients with Atrial Fibrillation. N Engl J Med. 2011;365:981-992. Healey JS, Connolly SJ, Gold MR, et al. Subclinical Atrial Fibrillation and the Risk of Stroke. N Engl J Med. 2012;366:120-129. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2021;42(5):373-498. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37(38):2893-2962.

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Can Lifestyle Changes Change Our Genetic Inheritance?

“My father had a heart attack; is my fate the same?” “My cholesterol runs in the family; won’t it stay the same no matter what I do?” “If heart disease is genetic, what is the point of living healthily?” The answer to these questions is very important:

• We cannot change our genes; however, we can significantly reduce the cardiovascular disease risk

that our genes create. In other words, genetic inheritance is not destiny.

Do Our Genes Completely Determine Our Fate?

No. Both our genetic makeup and our lifestyle play a role in the development of cardiovascular disease. Some people may be born with a higher risk of cardiovascular disease. For example, the risk may be higher in people with a family history of heart attack at an early age. However, a genetic predisposition does not mean that the disease will inevitably develop. We can think of it this way: genes form the “foundation of risk,” while lifestyle can influence whether, and to what extent, disease develops on that foundation. One of the most striking examples of this is a large study. In this research, which evaluated about 56,000 people, a healthy lifestyle was shown to reduce the risk of cardiovascular events by about 46% in people at high genetic risk of coronary heart disease.

So Does Lifestyle Change Our Genes?

There is an important distinction here. No, lifestyle does not change the letters of our DNA. In other words, we cannot change the genetic code we inherited from our mother and father by exercising, losing weight or eating healthily. However, lifestyle can change how active certain genes are in the body and which biological processes they affect. This field is called epigenetics. Put simply:

• Our genes are like the text in a book; our lifestyle can act like a regulator that makes some pages
• easier or harder to read. For this reason, the phrase “changing genetic
• inheritance” can be used when explaining this to the public; however, the scientifically more accurate

expression would be:

• “reducing the risk that a genetic predisposition turns into disease” or “being able to change the effect

of genes.”

Is Exercise Beneficial If There Is a Genetic Risk?

Absolutely. Regular physical activity helps:

• Ø Lower blood pressure,
• Ø Control blood sugar,
• Ø Control weight,
• Ø Improve the cholesterol profile,
• Ø Preserve blood vessel function,

Ø Reduce the risk of cardiovascular disease. Moreover, these benefits do not apply only to people at low genetic risk. People at high genetic risk also benefit significantly from a healthy lifestyle.

Does Healthy Eating Eliminate Genetic Risk?

It does not eliminate it, but it can reduce it. A diet rich in vegetables, fruit, whole grains, legumes, nuts, fish and healthy fats, and low in excess salt, processed foods, refined sugar and saturated fat, is important for cardiovascular health. In particular, it is not right for a person with a genetic risk of high cholesterol or heart disease to neglect their diet, saying, “It’s genetic anyway.” On the contrary: if your genetic risk is high, you need to pay even more attention to a healthy lifestyle. When it comes to smoking, genetic risk becomes even more important. Smoking is one of the strongest modifiable risk factors for cardio-

vascular disease. Smoking can further increase the risk in a person who is genetically predisposed to heart disease. For this reason, quitting smoking is one of the most important protective steps a person with a genetic predisposition can take. Can losing weight change genetic destiny? It does not change our genes. However, by reducing problems caused by excess weight, such as:

• Ø high blood pressure,
• Ø insulin resistance,
• Ø diabetes,
• Ø high triglycerides,
• Ø sleep apnea,
• Ø vascular dysfunction, it can reduce the risk of cardiovascular

disease.

Therefore, the belief that “there is heart disease in my family, and there is nothing I can do” is not scientifically correct. So what should you do if heart disease runs in your family? A family history is an important warning. In particular, if first-degree relatives such as a mother, father or sibling had a heart attack or coronary heart disease at an early age, the person’s cardiovascular risk assessment may need to be done earlier. Modifiable risk factors such as blood pressure, cholesterol, blood sugar, weight, smoking and physical activity should be assessed regularly. In some families, lifestyle alone may not be enough. For example, in inherited conditions such as familial hypercholesterolemia, medication may be needed. Today, genetic tests are increasingly used in the diagnosis and risk assessment of some inherited cardiovascular diseases.

My Genetic Risk Is High; Should I Be More Careful, Then?

Yes. In fact, knowing your genetic risk should be seen not as “news of your fate” but as an early warning system. For example: High genetic risk + unhealthy lifestyle → the risk rises even further. But:

• High genetic risk + healthy lifestyle + appropriate medication when needed →
• the risk can be significantly reduced. So we cannot choose our genetic predisposition, but we have considerable control over how

we live with it. In Conclusion: Part of our predisposition to heart disease may be inborn; however, whether the disease develops does not depend on our genes alone. Not smoking, eating healthily, moving regularly, maintaining a healthy weight, controlling blood pressure and cholesterol, and taking medication when necessary do not erase our genetic risk; but they can greatly reduce the likelihood of that risk turning into a heart attack and other cardiovascular events. Large-scale data clearly show that a healthy lifestyle is protective even in people at high genetic risk.

In short: We cannot choose our genes, but we can significantly change the “environmental

switches” that act on them.

• Ø Khera AV, Emdin CA, Drake I, et al. Genetic Risk, Adherence to a Healthy Lifestyle,

and Coronary Disease. N Engl J Med. 2016;375:2349-2358. Ø Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Circulation. 2019;140:e596-e646. Ø Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021;42:3227-3337. Ø Musunuru K, Kathiresan S. Genetics of Common, Complex Coronary Artery Disease. Cell. 2019;177:132-145.

Ø Tada H, Kawashiri MA, Nohara A, Sekiya T, Watanabe A, Takamura M. Genetic

Counseling and Genetic Testing for Familial Hypercholesterolemia. Genes (Basel). 2024 Feb 26;15(3):297.

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What You Need to Know About Weight-Loss Injections

In recent years, medications such as semaglutide and tirzepatide have become some of the most talked-about treatments among people who want to lose weight. Commonly known as “weight-loss injections,” these medications have become an important option, especially in the treatment of obesity and health problems related to excess weight. However, it is not correct to see these medications as “miracle weight-loss shots.” They are medical treatments that are effective when used in the right person, at the right dose, under a doctor’s supervision and together with lifestyle changes.

How Do Weight-Loss Injections Work?

Most of these medications mimic the effects of certain gut hormones that occur naturally in our body. By acting on the appetite centers in the brain, they reduce the feeling of hunger,

increase the feeling of fullness and help the person eat less. Some may also slow stomach emptying. Tirzepatide, on the other hand, acts through two different hormone systems. In short, weight-loss injections do not directly “melt” body fat; they reduce appetite so that less food is eaten and, as a result, weight is lost.

Do They Really Cause Weight Loss?

Yes. In suitable patients, significant weight loss can be achieved with these medications. However, not everyone loses the same amount of weight. Starting weight, the medication used, dose, length of treatment, diet, physical activity and the person’s metabolic characteristics all affect the result. For this reason, personal experiences seen on social media, such as “I lost this much weight in 3 months,” do not apply to everyone. Should every overweight person use weight-loss injections? No. These medications are not a suitable option for healthy people who want to lose a few pounds. They are generally used, after evaluation by a doctor, in people with obesity or with health problems accompanying excess weight, such as hypertension, type 2 diabetes or sleep apnea. The decision is based not only on the number on the scale but also on body mass index, waist circumference, coexisting conditions, medications being taken and the person’s overall health. Who should not use weight-loss injections, or should be especially careful? Weight-loss injections are not suitable for everyone. For this reason, the person’s medical history must always be evaluated. These medications should not be used during pregnancy. Whether they can be used while breastfeeding must also be evaluated by a doctor. It is not appropriate for generally healthy people of normal weight who just want to lose a few pounds to use these medications only to look thinner.

People with certain chronic diseases need special evaluation. In particular, a doctor should decide whether people with certain thyroid diseases, pancreatic diseases, serious stomach and bowel diseases, kidney disease, heart failure or certain rhythm disorders can use the medication. There is also an important detail regarding thyroid disease. It is not correct to say that “no one with thyroid disease can use these medications.” However, some GLP-1-based medications should not be used in certain situations, such as a history of medullary thyroid cancer or multiple endocrine neoplasia type 2 (MEN2). In people who take many medications, treatment also needs to be monitored by a doctor because of drug interactions and changes in blood pressure or blood sugar levels that come with weight loss. Are there side effects? Yes. Especially at the start of treatment, nausea, vomiting, diarrhea, constipation, abdominal pain, bloating, indigestion and feeling full quickly may occur. In most people, these complaints may lessen over time. However, in cases such as severe or persistent abdominal pain, continuous vomiting or serious fluid loss, a doctor must be consulted.

Is it true that “the faster I lose weight, the better”? No. The aim is not to lose as much weight as possible in the shortest possible time. With very rapid weight loss, muscle mass may be lost along with fat tissue. So the important question is not only “How much weight did I lose?” but also “How much of that weight came from fat and how much from muscle?” Watch out for muscle loss! One of the important issues for people using weight-loss injections is preserving muscle mass. Muscle can also be lost during weight loss. This is especially important in older people. For this reason, it is important to get enough protein during treatment, to be physically active regularly and, in particular, to include resistance exercises in the program. The goal is not just a lower number on the scale but a healthier body composition.

Will the Weight Come Back If I Stop the Injections?

It may. While the medication is being used, appetite decreases. When the medication is stopped, appetite may increase again and some of the lost weight may be regained. This does not mean the person “lacks willpower.”

Obesity is a chronic disease that affects appetite and the body’s tendency to regain weight after losing it. For this reason, you should not think of a weight-loss injection as “I’ll stop when I reach my target weight and my weight will never go up again.” Some people may need long-term treatment. The doctor should decide how long treatment will last and whether the medication will be stopped. What should be done to avoid regaining weight? First, lasting lifestyle changes should be made. The medication does not eliminate all the mechanisms that cause obesity. For this reason, it is very important to continue the healthy habits gained during treatment after the medication is stopped.

A balanced, healthy diet is one of the core parts of treatment. Using a weight-loss injection does not mean “What I eat no longer matters.” A balanced eating pattern that includes enough protein, vegetables, fruit, whole grains and healthy fats should be established.

Regular movement is also important. Walking and exercises appropriate to the person’s health should be done. Resistance exercises in particular help preserve muscle while losing weight. To preserve muscle mass, enough protein should be eaten and resistance exercises should be done regularly. Preventing muscle loss is even more important in older age. Treatment must always be planned together with a doctor. The medication should not be started, have its dose increased or be stopped on your own. Some people may need long-term treatment. The length of treatment is determined by the person’s weight, health status, response to treatment and risks. Are weight-loss injections good for the heart? Some weight-loss medications have been shown to provide important benefits not only for weight loss but also for cardiovascular health. For example, the SELECT trial with semaglutide showed a reduction in major events such as heart attack, stroke and cardiovascular death in people without diabetes who were overweight or obese and had existing cardiovascular disease. However, this result does not mean that “everyone who uses a weight-loss injection is protected from a heart attack.” Benefits and risks can vary depending on the medication used and the person’s health.

Can Heart Patients Use Them?

Some heart patients may benefit from these medications. However, they are not automatically suitable for everyone with heart disease. Especially if there is heart failure, a rhythm disorder, kidney disease or use of many medications, treatment should be planned by a doctor. Because blood pressure and blood sugar may fall with weight loss, the doses of some medications already being taken may need to be reassessed. Some people may also experience a slight increase in heart rate. For this reason, it is important that people with rhythm problems in particular are monitored by a doctor during treatment.

Beware of Weight-Loss Injections on Social Media!

There are serious risks associated with non-prescription, unknown-source or counterfeit products sold on the internet and social media. Promises such as “stronger,” “works faster” or “no side effects” should not be trusted. It is extremely important that the medication is obtained from a reliable source and not used without a doctor’s recommendation.

A Medication That Works for Someone Else May Not Be Right for You

This is one of the most important messages to know about weight-loss injections. The fact that a friend or relative lost weight very successfully with a particular medication does not mean that the same medication is suitable or safe for you. A person’s age, weight, body build, blood pressure, blood sugar, kidney and liver health, heart conditions, other medications and past illnesses should all be considered together. 5 golden rules when using weight-loss injections

1. Do not see the medication as a solution on its own. Diet and exercise are inseparable

parts of treatment.

2. Do not try to lose weight too quickly. The goal is healthy and sustainable weight loss.

3. Protect your muscles. Enough protein and resistance exercise are important.

4. Do not stop the medication or change its dose on your own. Plan your treatment together

with your doctor.

5. Think about maintaining your weight loss from the very beginning. Remember that when the medication is stopped, appetite and

weight may increase again.

In Summary

Weight-loss injections are an important advance in the treatment of obesity, but they are not a miracle. When used in the right person, at the right dose and under a doctor’s supervision, they can achieve significant weight loss. In some patients, they may also show benefits for cardiovascular health. However, they are not suitable for everyone. They should not be used during pregnancy, and in certain diseases and special circumstances a doctor’s evaluation is essential. Most importantly, do not see the treatment simply as “losing weight with an injection.” The injection can help you lose weight; but the key to keeping the weight off is healthy eating, regular movement, preserving your muscles and a long-term treatment plan created together with your doctor. A weight-loss injection that works for someone else may not be suitable or safe for you.

• • •

Wilding JPH, Batterham RL, Calanna S, et al. Once-Weekly Semaglutide in Adults with Overweight or Obesity. N Engl J Med. 2021;384:989-1002. Jastreboff AM, Aronne LJ, Ahmad NN, et al. Tirzepatide Once Weekly for the Treatment of Obesity. N Engl J Med. 2022;387:205-216. Lincoff AM, Brown-Frandsen K, Colhoun HM, et al. Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes. N Engl J Med. 2023;389:2221-2232. Kosiborod MN, Abildstrøm SZ, Borlaug BA, et al. Semaglutide in Patients with Heart Failure with Preserved Ejection Fraction and Obesity. N Engl J Med. 2023;389:1069-1084. Rubino D, Abrahamsson N, Davies M, et al. Effect of Continued Weekly Subcutaneous Semaglutide vs Placebo on Weight Loss Maintenance in Adults With Overweight or Obesity.

JAMA. 2021;325:1414-1425

Wilding JPH, Batterham RL, Davies M, et al. Weight regain and cardiometabolic effects after withdrawal of semaglutide: The STEP 1 trial extension. Diabetes Obes Metab. 2022;24:15531564. American Gastroenterological Association. AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity. Gastroenterology. 2022;163:1198-1225. Wharton S, Lau DCW, Vallis M, et al. Obesity in adults: a clinical practice guideline. CMAJ. 2020;192:E875-E891. World Health Organization. GLP-1 receptor agonists for the treatment of obesity. WHO Expert Committee on Selection and Use of Essential Medicines, 2025. U.S. Food and Drug Administration. Wegovy (semaglutide) Prescribing Information and Zepbound (tirzepatide) Prescribing Information.

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How and Which Exercises Can Heart Patients with Knee Problems Do?

This question comes up very often, especially in older people who have both cardiovascular disease and knee problems. In fact, the answer is usually “No, do not stop exercising.” That is because, in people with heart disease, regular physical activity is an important part of treatment for protecting cardiovascular health, increasing exercise capacity, controlling blood pressure and weight, and improving quality of life. Current European and American guidelines also recommend regular aerobic and resistance exercise for suitable patients. However, if there is a knee problem, what needs to change is not exercise itself but the way it is done.

Why Do Knee Problems Make Exercise Harder for Heart Patients?

During exercises such as walking, a large part of the body’s weight is transferred to the knee joints. If there is knee osteoarthritis, a meniscus problem, previous knee surgery or another orthopedic problem, the person may feel pain when walking. When movement decreases because of pain, another problem arises: Less movement → more weight gain and muscle loss → lower exercise capacity → more inactivity. This vicious cycle can harm both the knee and the heart. For this reason, the goal is not to keep the patient inactive but to find exercise that the knee can tolerate and that the heart can safely perform.

Which Exercises Can Heart Patients with Knee Problems Do?

1. Walking: Not forbidden, but the amount needs adjusting

Not everyone with a knee problem has to give up walking. If the pain is mild and manageable, you can start with short walks on flat ground. For example, you can increase gradually: 10 minutes → 15 minutes → 20 minutes → 30 minutes. Flat, even surfaces should be preferred; especially at the start, long uphill stretches, many flights of stairs and uneven ground should be avoided. The key here is not the attitude “the more I walk, the better.” The aim is to move regularly without increasing knee pain.

2. Stationary bike: An important alternative for people with knee pain

A stationary bike can be very useful, especially for people who have knee pain when walking. During cycling, less body weight is placed directly on the knee than during walking. At the start:

• low resistance,
• short sessions,

and comfortable pedaling should be preferred. Cycling at high resistance and pushing hard does not mean better exercise for a heart patient. The aim of exercise is not to exhaust the person but to keep them moving regularly and safely.

3. Water exercise: A good option for the knees and the heart

Swimming, and especially walking in water, are important alternatives for people with knee problems. The buoyancy of water reduces the load of body weight on the joints. Studies in knee osteoarthritis show that exercises performed both on land and in water can have positive effects on pain and physical function. The American College of Rheumatology/Arthritis Foundation also strongly recommends walking, strengthening and water exercise among the exercise options for knee and hip osteoarthritis. For this reason, water exercise can be considered especially for heart patients who are overweight, have marked knee pain or have difficulty walking.

4. Elliptical trainer

Some people may tolerate an elliptical trainer better than walking. However, there is an important point here: not all knee problems are the same. If knee pain increases during elliptical exercise, you should not persist with it. The right exercise for a person should be determined according to their knee problem and exercise capacity.

5. Strength exercises: Heart patients need them too

Exercise should not bring only walking to mind. Maintaining muscle strength, especially in older age, is important both for managing heart disease and for controlling knee problems. Strengthening the muscles around the knee, especially the thigh and hip muscles, can help support the knee. Exercise therapy in knee osteoarthritis has been shown to have positive effects on pain and muscle strength. However, strength training does not mean “the heavier I lift, the better.” It should be started with low or moderate resistance, controlled movements and proper technique.

How Much Should a Heart Patient Exercise per Week?

The goal here is, where possible, to do at least 150 minutes of moderate-intensity aerobic activity per week. American cardiovascular guidelines recommend at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic activity per week for suitable patients. In addition, it is recommended that resistance exercises be included in the program. However, this target is not a number that must be reached from day one. Especially for a person who has been inactive for a long time or has a knee problem:

Even 5–10 minutes of exercise is valuable as a start. The duration can then be increased gradually. A large dose-response meta-analysis published in 2023, including more than 30 million people, showed that increases in physical activity were associated with significant reductions in the risk of cardiovascular disease and mortality, especially in inactive people. It also

showed that the benefit does not appear only at very high levels of exercise, and that even small increases in activity can matter. So the idea “if I can’t do 30 minutes, I won’t do any” is not correct.

How Can the 150-Minute Goal Be Achieved If You Have Knee Pain?

For example, if walking for 30 minutes without a break makes a person’s knee hurt:

• 10 minutes on a stationary bike
• o 10 minutes of walking in water

o 10 minutes of short walking: different exercises like these can be combined. Another option:

• is to exercise 10 minutes × 3 times a day. The basic principle here: “Aim not for duration,
• but for sustainability.” Instead of giving up exercise entirely because of knee pain,

switching to a form of exercise that does not increase pain is usually the better approach.

What Are the Benefits of Exercise for the Heart in Heart Patients?

Exercise does more than improve fitness. Regular physical activity can increase exercise capacity, help control blood pressure, make weight control easier, improve blood sugar control, preserve muscle strength and improve quality of life. In people with coronary artery disease in particular, there is strong evidence that exercise-based cardiac rehabilitation reduces the risk of cardiovascular death and hospitalization. The current AHA/AACVPR scientific statement also considers cardiac rehabilitation to be one of the core components of comprehensive treatment for patients with cardiovascular disease.

Must a Heart Patient Keep Their Pulse at a Specific Value

During Exercise? No, there is no single target heart rate for every patient. In people taking beta blockers in particular, heart rate may not rise as much as expected during exercise. For this reason, when assessing exercise intensity, the person’s perceived effort, breathing and, if available, exercise test results should also be taken into account.

In practice: The “talk test” is a useful method. If a person can talk during exercise but their breathing has noticeably quickened, the effort is generally moderate. However, the individual exercise prescription may vary depending on the type and severity of heart disease. The ESC recommends that the exercise program for people with cardiovascular disease be tailored to the disease and the individual’s risk status.

Which Exercises Should Heart Patients with Knee Problems Avoid?

There is no definitive “list of prohibitions” for every patient. However, in people with marked knee pain or joint damage, the following movements can cause problems:

• deep squats,
• jumping,
• high-impact exercises,
• sudden changes of direction,
• high-resistance cycling,
• climbing stairs for long periods,

exercises that markedly increase pain. In particular, the approach “if it hurts, keep going; it will pass with time” is not correct. Mild muscle fatigue can be expected during exercise; however, if there is marked or increasing joint pain, swelling or loss of function, the exercise program should be re-evaluated.

Is it true that “my knee hurts, so I should rest”? Not always. Exercise is one of the core components of treatment for knee osteoarthritis. Studies show that properly performed aerobic and strengthening exercises can be beneficial for pain and physical function. Therefore, rather than Knee pain → inactivity, the approach Knee pain → choosing appropriate exercise is more correct.

When Is a Cardiology Evaluation Needed First?

Especially in a heart patient who has not exercised regularly before, the status of the existing heart disease should be evaluated before starting exercise. In particular, exercise should not be started on your own if any of the following symptoms are present:

• chest pain on exertion,
• new or worsening shortness of breath,
• fainting or feeling faint,
• marked palpitations,
• uncontrolled blood pressure,
• a recent heart attack,
• a recent coronary procedure,

symptoms of heart failure that are not under control. In some patients, an exercise test or cardiopulmonary exercise test may be needed to objectively determine exercise capacity.

Is a Doctor’s Evaluation Also Needed for the Knee?

Yes. If the cause of knee pain is unknown, it should not simply be assumed to be “wear and tear.” Especially if there is:

• marked swelling of the knee,
• locking,
• inability to bear weight on it,
• pain after an injury,
• severe pain even at rest,
• a marked increase in limited movement, an orthopedic or physical medicine and rehabilitation

evaluation would be appropriate. Having a physiotherapist tailor the exercise program to the individual can be beneficial, especially for patients with advanced knee problems.

Sample Weekly Program for a Person with Heart Disease and a Knee Problem

Monday:

• 15–20 minutes on a stationary bike + 10 minutes of light strength exercise

Tuesday:

• 10–20 minutes of walking in water or swimming

Wednesday:

• Rest or a short, easy-paced walk

Thursday:

• 20–30 minutes on a stationary bike + light strength exercise

Friday:

• 15–20 minutes of walking or water exercise

Saturday:

• 20–30 minutes of low-impact aerobic exercise

Sunday:

• Active rest and light movement
• This is only a sample template. Without knowing the type of heart disease, age, exercise capacity and the cause of the knee

problem, it should not be used as a personal exercise prescription.

ü If you have a knee problem, do not deprive your heart of exercise. ü If walking is hard, try a bike. ü If cycling hurts your knee, consider water exercise. ü If you cannot exercise for long periods, start with short sessions. ü If your muscles are weak, add controlled strength exercises to your program. And if you have heart disease, see exercise not just as a “sport” but as part of your treatment. Because the goal is not for everyone to do the same exercise. The goal is to find movement that protects your heart without harming your knees. The benefits of regular physical activity for cardiovascular health have been strongly demonstrated; exercise is also one of the core treatment approaches in knee osteoarthritis. Taking these two facts together, the best approach for heart patients with knee problems is usually not inactivity, but choosing the right exercise for the individual and progressing gradually.

References

1. Pelliccia A, Sharma S, Gati S, et al. 2020 ESC Guidelines on sports cardiology and exercise in

patients with cardiovascular disease.European Heart Journal. 2021;42:17-96.

2. Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC Guidelines on cardiovascular disease

prevention in clinical practice. European Heart Journal. 2021;42:3227-3337.

2. Virani SS, Newby LK, Arnold SV, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the

Management of Patients With Chronic Coronary Disease. Circulation. 2023;148:e9-e119.

3. Brown TM, Pack QR, Aberegg E, et al. Core Components of Cardiac Rehabilitation Programs: 2024 Update: A Scientific Statement From the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2024;150:e328-e347.

4. Anderson L, Thompson DR, Oldridge N, et al. Exercise-based cardiac rehabilitation for coronary

heart disease. Cochrane Database Syst Rev. 2016 Jan 5;2016(1):CD001800.

5. Dibben G, Faulkner J, Oldridge N, et al. Exercise-based cardiac rehabilitation for coronary heart

disease: a meta-analysis. Eur Heart J. 2023 Feb 7;44(6):452-469.

6. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis

Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care & Research. 2020;72:149-162.

7. Holden MA, Metcalf B, Lawford BJ, et al. Recommendations for the delivery of therapeutic

exercise for people with knee and/or hip osteoarthritis. An international consensus study from the OARSI Rehabilitation Discussion Group. Osteoarthritis and Cartilage. 2023;31:386-396.

8. Garcia L, Pearce M, Abbas A, et al. Non-occupational physical activity and risk of cardiovascular

disease, cancer and mortality outcomes: a dose-response meta-analysis of large prospective studies. British Journal of Sports Medicine. 2023;57:979-989.

9. Ferreira RM, Torres RT, Duarte JA, Gonçalves RS. Effects of exercise on knee osteoarthritis: A

systematic review. BMJ Open. 2025 Jul 16;15(7):e093163.

10. Molloy CD, Long L, Mordi IR, et al. Exercise-based cardiac rehabilitation for adults with heart

failure. Cochrane Database Syst Rev. 2024 Mar 7;3(3):CD003331.

11. Fadah K, Payan-Schober F. Physical Activity and Mortality in Patients with Coronary Artery

Disease. Curr Cardiol Rep. 2023 Jul;25(7):663-667.

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What Is a Stroke? How Is It Related to the Heart? What Are the Symptoms and Ways to Prevent It?

A heart attack is a well-known disease that requires emergency treatment. However, another health problem that is at least as important as a heart attack is stroke, commonly known in Turkish as “felç” (paralysis). A stroke develops when the blood flow to part of the brain is disrupted, or when one of the brain’s blood vessels ruptures and bleeds. It can lead to serious consequences such as loss of speech, paralysis of an arm or leg, vision problems and permanent disability.

Stroke is not a disease seen only in older people. High blood pressure, diabetes, high cholesterol, smoking, a sedentary lifestyle and certain heart diseases can increase the risk of stroke. The good news is that a large part of stroke risk can be reduced. Moreover, in some strokes, starting appropriate treatment early enough can limit brain damage. So why does a stroke happen? How can the symptoms be recognized? How can heart disease lead to stroke? What can we do to prevent stroke? A stroke is a neurological disease that occurs when the blood supply to part of the brain is suddenly disrupted. Brain cells constantly need oxygen and energy. When blood flow stops or there is bleeding into brain tissue, the cells begin to be damaged. Strokes fall into two main groups.

An ischemic stroke occurs when a vessel supplying the brain becomes blocked by a clot or for another

reason. It accounts for about 80–85% of stroke cases. A hemorrhagic stroke develops when a blood vessel in the brain ruptures and bleeding occurs into or around the brain tissue. The treatment of these two conditions is different. For this reason, when a stroke is suspected, aspirin or any other blood thinner should not be taken arbitrarily before brain imaging and a doctor’s evaluation.

What Are the Symptoms of a Stroke?

Stroke symptoms usually appear suddenly. Different signs may be seen depending on which part of the brain is affected. Sometimes the symptoms are very obvious; at other times the person only has sudden difficulty speaking, walking or seeing. One of the most important signs of a stroke is sudden facial drooping. If one side of a person’s mouth droops when they smile, or the two sides of their face do not look the same, this can be a warning sign of stroke.

Another important symptom is arm or leg weakness, especially on one side

of the body. The person may be unable to raise one arm, may drop an object they are holding, or may drag one leg while walking. Sudden numbness on one side can also be a sign of stroke. Speech difficulty is another common symptom. The person may be unable to say words properly, their speech may become unintelligible, or they may have difficulty understanding what is said. Sometimes the person knows what they want to say but cannot find the right words. In addition, sudden loss of vision, double vision, marked loss of balance, difficulty walking or loss of coordination can also be signs of a stroke. In particular, an unusually sudden and very severe headache requires emergency evaluation for possible bleeding in the brain.

Even if only one of the symptoms such as sudden facial drooping, one-sided weakness or speech difficulty

appears, call 112 (the emergency number in Türkiye) immediately. It is not right to wait for the symptoms to go away on their own. Other sudden neurological symptoms may also require emergency evaluation. What should you do if you suspect a stroke? The most important step when a stroke is suspected is to get the patient to an appropriate health facility quickly. First, call 112 and describe the symptoms clearly. Note the time the symptoms began or when the person was last seen normal. This information is very important in determining treatment options. Do not give the person food, water or medication by mouth, because a stroke can cause difficulty swallowing. Do not use aspirin or any other blood thinner without a doctor’s recommendation. At first it may not be clear whether the stroke is due to a blocked vessel or bleeding in the brain, and the treatment options are different. Even if the symptoms resolve completely within a few minutes, emergency evaluation is necessary. This may be related to a condition called a transient ischemic attack, which can be a warning sign of an impending stroke. Why does every minute count in a stroke? In ischemic stroke, that is, stroke due to a blocked vessel, suitable patients may receive intravenous treatment aimed at dissolving the clot. This treatment is usually considered within the first 4.5 hours after symptoms begin. In selected patients with a blockage of a large brain vessel, a procedure to remove the clot with a catheter may also be performed. In suitable patients, depending on clinical evaluation and brain imaging results, this procedure can be beneficial up to 6–24 hours after symptom onset. These time windows are not the same for every patient. The treatment decision is made by a specialist team, taking into account the symptoms, brain

imaging, coexisting conditions and other clinical features. Even if you think you are too late for treatment, do not hesitate to seek help. The best approach is to get emergency evaluation as soon as possible. Yes. Some strokes are caused directly by clots that form in the heart. A clot that forms inside the heart can enter the bloodstream and travel to the b

Can Heart Disease Cause a Stroke?

rain, blocking one of its blood vessels. This is called cardioembolism (a clot originating from the heart). This is one of the most important links between heart disease and stroke. Heart diseases that can increase the risk of stroke include the rhythm disorder called atrial fibrillation, certain heart valve diseases, clot formation inside the heart after a heart attack and certain

heart muscle diseases. However, this does not mean that everyone with heart disease will have a

stroke. The risk varies depending on the type of disease, the person’s other risk factors and the preventive treatment being given. Atrial fibrillation is a common rhythm disorder in which the upper chambers of the heart work irregularly. In this rhythm disorder, blood can pool, particularly in part of the left atrium. Atrial fibrillation: a risk extending from the heart to the brain. As a result, a clot may form. If the clot breaks loose and reaches the brain, it can block a vessel and cause a stroke. Atrial fibrillation sometimes causes palpitations, fatigue or shortness of breath. However, in some people it can continue without any symptoms. Especially in older people and those with hypertension or other cardiovascular risk factors, it is important to evaluate heart rhythm when clinically indicated. Should everyone with atrial fibrillation take a blood thinner? No. Stroke risk is assessed by taking into account the person’s age, coexisting conditions and other clinical features. In suitable patients, oral anticoagulant medications can significantly reduce the risk of stroke. However, these medications also carry a risk of bleeding. The decision to start the medication, change the dose or stop it should be made by a doctor. Aspirin does not replace the anticoagulant treatment needed for suitable patients with atrial fibrillation. What factors increase the risk of stroke? A stroke usually develops when several risk factors come together. Some risk factors cannot be changed; however, many of them can be controlled. Older age, a family history of stroke and a previous stroke or transient ischemic attack can increase the risk. The main controllable risk factors are high blood pressure, diabetes, high LDL cholesterol, smoking, atrial fibrillation, excess weight, a sedentary lifestyle and excessive alcohol consumption. Certain sleep disorders and vascular diseases can also contribute to the risk. Among these, high blood pressure is one of the most important modifiable risk factors for stroke. Measuring blood pressure regularly and keeping it within targets appropriate for the individual helps reduce the risk of stroke. Is it possible to prevent stroke? Although the risk of stroke cannot be eliminated completely, it can be significantly reduced with healthy lifestyle habits and appropriate medical treatment. Keep your blood pressure under control. High blood pressure can damage the blood vessels of the brain and increase the risk of bleeding in the brain. Measure your blood pressure regularly and continue your treatment as recommended by your doctor.

Monitor Your Cholesterol and Blood Sugar

High LDL cholesterol contributes to hardening of the arteries. Diabetes can also affect blood vessels and increase the risk of stroke. When necessary, medication can be added to dietary and exercise changes. Quit smoking. Smoking damages the vessel wall and increases the tendency to clot. Quitting smoking is one of the most important steps you can take to reduce the risk of stroke. Get regular physical activity. Walking, cycling or other aerobic activities appropriate to your health can help control blood pressure, weight and blood sugar. If you lead a sedentary life, start at a low level and increase your physical activity over time. Do not neglect your heart rhythm. If you have palpitations, an irregular pulse or an unexplained feeling of faintness, medical evaluation may be needed. Detecting and treating atrial fibrillation in suitable patients provides an opportunity to prevent stroke. Do not change your medications on your own. Do not stop medications prescribed for blood pressure, cholesterol, diabetes or rhythm disorders without consulting your doctor. In people who have had a stroke before, it is especially important to continue treatment aimed at preventing a second stroke without interruption.

What Is a Transient Ischemic Attack?

Sometimes stroke symptoms can resolve within a few minutes. For example, a person may have brief difficulty speaking, weakness in one arm or loss of vision in one eye, and then return to normal. This may be a transient ischemic attack, or TIA. A TIA is an important warning that blood flow to the brain has been temporarily disrupted, and it may be followed by a risk of stroke. The fact that the symptoms have gone away does not mean the danger has passed. Emergency medical evaluation is also necessary when a TIA is suspected. Finding the underlying cause and starting appropriate preventive treatment are important for reducing the risk of a subsequent stroke.

Can a Person Who Has Had a Stroke Recover Completely?

Yes, some people can recover completely or to a large extent. However, recovery depends on the area of the brain affected, the size of the damage, how early treatment was started and rehabilitation. After a stroke, there may be weakness in an arm or leg, speech and swallowing difficulties, vision problems, memory difficulties or limitations in daily activities. Physical therapy, speech and swallowing therapy, rehabilitation programs that build daily living skills, and psychological support are important parts of recovery.

In addition, the cause of the stroke must be identified and a second stroke must be prevented. A personalized treatment plan is prepared by evaluating blood pressure, cholesterol, diabetes, heart rhythm and other possible causes. Should everyone have imaging of the brain’s blood vessels? No. Routinely performing a brain MRI, computed tomography or brain vessel imaging purely for prevention in everyone without any symptoms is not necessary. Instead, the person’s risk factors are assessed and blood pressure, blood sugar and cholesterol are measured. If clinically indicated, heart rhythm is investigated and additional tests are planned according to the individual.

However, the approach is different when sudden neurological symptoms appear. In this case,

emergency evaluation and appropriate brain imaging are needed.

Conclusion:

Stroke Can Be Prevented, and Outcomes Can Be Improved with Early Treatment

Stroke is one of the leading causes of death and permanent disability. However, many adverse outcomes can be prevented by controlling risk factors, properly evaluating heart rhythm disorders and recognizing symptoms early.

When sudden facial drooping, one-sided weakness or speech difficulty

appears, call 112 immediately. Do not wait for the symptoms to resolve on their own, and when a stroke is suspected, do not give aspirin or any other blood thinner without a doctor’s recommendation. High blood pressure, diabetes and cholesterol should be kept under control; smoking should be avoided, and heart rhythm disorders should not be neglected. In people who have previously had a stroke or transient ischemic attack, treatment to prevent recurrence should not be interrupted. Remember: In a stroke, time is brain. Recognizing the symptoms early and acting quickly can change a person’s life and independence. References

1. Prabhakaran S, Gonzalez NR, Zachrison KS, et al. 2026 Guideline for the Early Management

of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2026.

2. Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the Prevention of Stroke in

Patients With Stroke and Transient Ischemic Attack. Stroke. 2021;52–e467.

3. Van Gelder IC, Rienstra M, Bunting KV, et al. 2024 ESC Guidelines for the management of

atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal. 2024;45:3314–3414.

4. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of

Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines. Stroke. 2019;50– e418.

5. Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel

ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. The Lancet. 2016;387:1723–1731.

6. Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 Hours after Stroke

Onset or Last Known Well. New England Journal of Medicine. 2018;378:11–21.

7. Albers GW, Marks MP, Kemp S, et al. Thrombectomy for Stroke at 6 to 16 Hours with

Selection by Perfusion Imaging. New England Journal of Medicine. 2018;378:708–718.

8. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in

patients who have nonvalvular atrial fibrillation. Annals of Internal Medicine. 2007;146:857– 867.

9. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and

management of atrial fibrillation developed in collaboration with the EACTS. European Heart Journal. 2021;42:373–498.

10. O'Donnell MJ, Chin SL, Rangarajan S, et al. Global and regional effects of potentially

modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a casecontrol study. The Lancet. 2016;388:761–775.

11. Amarenco P, Bogousslavsky J, Callahan A III, et al. High-Dose Atorvastatin after Stroke or

Transient Ischemic Attack. New England Journal of Medicine. 2006;355:549–559

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Pulmonary Hypertension:

• Symptoms, Causes, Diagnosis and Treatment
• Increased pressure in the blood vessels of the lungs can, over time, strain the right side of the
• heart. Early diagnosis and proper treatment can significantly

change the course of the disease. When we hear “high blood pressure,” we usually think of the blood pressure measured on the arm. However, blood pressure can rise not only in the body’s general circulation but also in the blood vessels of the lungs. This condition is called pulmonary hypertension, meaning high pressure in the lung’s blood vessels. Pulmonary hypertension is not so much a disease in its own right as a clinical condition that can result from various heart, lung and vascular diseases. When the pressure in the lung’s blood vessels rises, the right side of the heart has to work harder to send blood to the lungs. Over time, this can lead to enlargement of the right heart, heart failure and serious health problems. At first, the disease often does not cause noticeable complaints. The most common complaint is shortness of breath, especially when walking or climbing stairs. For this reason, the symptoms are sometimes attributed to aging, excess weight or lack of fitness and are overlooked. So why does pulmonary hypertension develop? How is it related to the heart and lungs? How is it diagnosed, and what treatment options are there?

What Is Pulmonary Hypertension?

The right ventricle of the heart pumps oxygen-poor blood returning from the body to the lungs. The blood picks up oxygen as it passes through the lung’s blood vessels and then returns to the left side of the heart. The left side of the heart then sends this blood to the rest of the body’s organs.

In pulmonary hypertension, the blood pressure in the lung’s blood vessels rises above normal. As a result, the right ventricle has to exert more force to send blood to the lungs. In some diseases, the normally thin and flexible lung vessels can narrow, stiffen or become blocked, or resistance to blood flow in the vascular bed can increase. In some cases, the problem stems not from the lung vessels but from increased pressure on the left side of the heart. According to the current scientific definition, pulmonary hypertension is a mean pulmonary artery pressure at rest above 20 mmHg, measured by right heart catheterization. However, finding high pressure alone is not enough to determine the type and cause of the disease. Measurements such as cardiac filling pressure and pulmonary vascular resistance are also evaluated. An important distinction must be made: pulmonary hypertension and pulmonary arterial hypertension are not the same thing. Pulmonary arterial hypertension is a specific subgroup of pulmonary hypertension. Not every patient with pulmonary hypertension has this particular disease.

What Causes Pulmonary Hypertension?

Pulmonary hypertension has different causes. Correctly identifying the cause

of the disease is very important, because treatment varies according to the underlying disease. Today, pulmonary hypertension is classified into five main groups.

• Group 1: Pulmonary arterial hypertension o In this group, the problem arises directly in the small vessels of the pulmonary arteries. The vessel walls may thicken, the inside of the vessel may narrow, and it may become harder for blood to move through the lungs. o The cause cannot always be identified. In some patients, it may be related to inherited traits, connective tissue diseases, congenital heart disease or certain medications and substances.

Group 2: Pulmonary hypertension due to diseases of the left side of the

heart o This is one of the most common causes of pulmonary hypertension. When the left side of the heart cannot pump blood well enough, or when there is a problem with the heart valves, the pressure that blood returning from the lungs to the heart encounters can increase. Over time, this pressure is transmitted back to the lung’s blood vessels. The main causes are:

• Heart failure,
• Impaired relaxation of the heart,
• Heart valve diseases, especially mitral and aortic valve diseases,

Certain congenital or acquired heart diseases. Group 3: Pulmonary hypertension due to lung disease and low oxygen levels o In chronic lung diseases, lung tissue and blood vessels can be affected. Long-term low oxygen levels can also contribute to narrowing of the lung vessels and rising pressure. The main causes in this group are:

• COPD,
• Pulmonary fibrosis and other lung tissue diseases,
• Breathing disorders during sleep,

Certain diseases that cause long-term low oxygen levels.

Group 4: Pulmonary hypertension due to chronic blockage of the lung’s blood

vessels o Clots that previously formed in the lung’s blood vessels may not dissolve completely over time. Permanent blockages and narrowing may develop inside the vessels. As a result, chronic thromboembolic pulmonary hypertension can develop. o This disease is particularly important because, in suitable patients, it can be treated with surgical or interventional methods. Group 5: Pulmonary hypertension due to other or multiple causes

o Certain blood disorders, systemic diseases, metabolic disorders and conditions in which several mechanisms act together are included in this group.

What Are the Symptoms of Pulmonary Hypertension?

The symptoms of pulmonary hypertension are usually mild at first and can be confused

with other diseases. As the disease progresses, the complaints may become more noticeable. The most common symptom is shortness of breath on exertion. At first, the person may only get out of breath when walking quickly or climbing stairs. Over time, they may become short of breath when walking shorter distances, and in advanced stages even at rest. Other symptoms include:

• Tiring easily and weakness: Tiring earlier than expected during daily

activities may occur.

• Chest pain or a feeling of pressure: This may occur especially during exertion.
• Palpitations: You may feel your heart beating faster or irregularly.
• Dizziness and fainting: These may develop when blood flow to the brain is insufficient, especially during physical activity.
• Swelling in the legs and ankles: This may occur as a result of strain on the right side of the heart and fluid buildup in the body.
• Abdominal swelling and fullness: In advanced stages, liver enlargement and fluid buildup in the abdomen may be seen.
• Bluish discoloration of the lips or fingertips: This may be related to a drop in the oxygen level in the blood.

None of these symptoms alone is specific to pulmonary hypertension. However,

a medical evaluation is essential, especially if increasing shortness of breath on exertion, fainting or leg swelling occur together.

How Does Pulmonary Hypertension Affect the Heart?

The most important effect of pulmonary hypertension on the heart occurs on the right side

of the heart. The right ventricle normally pumps blood into a low-resistance vascular system, the pulmonary circulation. When pressure and resistance in the lung’s blood vessels increase, the load on the right ventricle also increases. At first, the right ventricle may increase its muscle mass to cope with this load. However, if the high pressure persists for a long time, the right ventricle may enlarge and its pumping strength may decrease. As a result, right heart failure can develop. In right heart failure, swelling in the legs, fluid buildup in the abdomen, prominent neck veins and tiring easily may be seen. As the disease progresses, it may become harder for the heart to pump enough blood to the body. For this reason, pulmonary hypertension is not just a problem of the lungs but also a serious circulatory disease that affects the right side of the heart.

How Is Pulmonary Hypertension Diagnosed?

Early diagnosis of pulmonary hypertension is important. However, to make a diagnosis,

it is not enough to look only at shortness of breath or at a pressure value written in an echocardiography report. During the diagnostic process, the patient’s complaints, examination findings, and heart and lung tests are evaluated together.

• Echocardiography (heart ultrasound) o This is one of the most important first tests when pulmonary hypertension is suspected. It provides estimated information about the size of the heart, the structure and pumping strength of the right ventricle, the heart valves and the pressure in the lung’s blood vessels. o However, echocardiography is not a test that definitively confirms pulmonary hypertension. The measured values help assess the likelihood of the disease and determine whether further investigation is needed.
• Right heart catheterization o This is the key method for a definitive hemodynamic diagnosis of pulmonary hypertension. A thin catheter is usually advanced through a vein in the neck or groin to reach the right side of the heart and the pulmonary artery. o During this procedure, the pressure in the lung’s blood vessels, the filling pressures of the heart and blood flow are measured. In this way, the presence and type of pulmonary hypertension can be determined more accurately.

Other Tests

Additional tests may be needed to investigate the cause of the disease:

• o Electrocardiography (ECG),
• o Chest X-ray,
• o Pulmonary function tests,
• o Assessment of the blood oxygen level,
• o Blood tests and certain immune system tests,
• o Computed tomography of the lungs,
• o Lung ventilation-perfusion scintigraphy,

o Cardiac MRI and exercise tests when necessary. Chronic blockage of the lung’s blood vessels should always be investigated, especially in people who have previously had a pulmonary embolism or who have unexplained shortness of breath. Current guidelines recommend evaluation with echocardiography when pulmonary hypertension is suspected and confirmation of the diagnosis with right heart catheterization in suitable patients.

Is There a Treatment for Pulmonary Hypertension?

Yes. However, treatment is determined according to the cause of the pulmonary

hypertension. It is not appropriate to give every patient the same medications. In pulmonary hypertension due to diseases of the left side of the heart, the underlying problem, such as heart failure or valve disease, is treated first. Blood pressure control, appropriate heart failure medications, maintaining fluid balance and, in patients who need them, valve procedures are important. Indiscriminately giving pulmonary arterial hypertension medications to patients in this group is not recommended. Some medications may provide no benefit and may even worsen the patient’s condition.

In Pulmonary Hypertension Due to Lung Disease

Treating the underlying lung disease is essential. Proper management of diseases such as COPD or pulmonary fibrosis, oxygen therapy in patients who need it, and pulmonary rehabilitation are important. In pulmonary arterial hypertension: In this group, specific medications that target the narrowing of the lung’s blood vessels and the progression of the disease may be used. Treatment options include endothelin receptor antagonists, phosphodiesterase-5 inhibitors, prostacyclin pathway drugs and other targeted therapies. In some patients, more than one medication may be used together. Treatment is chosen at specialist centers according to the severity of the disease, risk status, coexisting conditions and response to treatment. The European Respiratory Society’s treatment guideline update published in 2026 also considers the use of sotatercept in addition to existing therapy in suitable patients. This medication targets a different biological pathway related to the changes in vessel structure caused by the disease. It is not suitable for every patient and requires follow-up at a specialist center. In chronic thromboembolic pulmonary hypertension: In suitable patients with permanent clots and blockages in the lung’s blood vessels, surgical removal of the clot tissue, known as pulmonary endarterectomy, is an important treatment option. In some patients, a catheter method called balloon pulmonary angioplasty may be performed. Medication may also be used in suitable patients. The particular importance of this group is that, in some patients, the disease can be markedly improved with surgical or interventional methods.

What Should Patients with Pulmonary Hypertension Pay Attention to

in Daily Life? People diagnosed with pulmonary hypertension need to adjust their daily lives according to the severity of the disease and their heart and lung function. Physical activity: Regular, controlled movement can be beneficial in suitable patients. However, strenuous exercise, excessive exertion and activities beyond the person’s capacity may be harmful. An exercise program should be planned with a doctor’s evaluation. Taking medications regularly: Treatment medications should be used as recommended by the doctor, and doses should not be changed on the person’s own initiative. Salt and fluid intake: Especially in patients with right heart failure and fluid buildup in the body, salt and fluid intake can be adjusted individually. Not every patient needs the same amount of fluid restriction. Quitting smoking: Smoking damages the lung’s blood vessels and lung tissue. Cigarettes and tobacco products should be avoided. Protection from infections: Respiratory infections can worsen the symptoms of the disease. Preventive measures recommended by the doctor, such as flu and pneumococcal vaccines, should be considered. High altitude and travel: Oxygen levels may be lower at high altitudes. It is important for people with advanced pulmonary hypertension to consult their doctor before traveling to high altitudes or flying.

Pregnancy: Especially in pulmonary arterial hypertension, pregnancy can carry serious risks for the mother. Patients who are planning a pregnancy or suspect they may be pregnant should consult a specialist center without delay.

Can Pulmonary Hypertension Be Prevented?

It is not possible to prevent all types of pulmonary hypertension. In particular,

for pulmonary arterial hypertension of unknown cause or with inherited features, there is no definitive method to prevent the disease entirely. Nevertheless, reducing certain risks and treating underlying diseases early are important. Blood pressure, diabetes and heart diseases should be monitored regularly. Treatment of COPD and other chronic lung diseases should not be interrupted. Do not smoke. People who have had a pulmonary embolism should not neglect their follow-up and treatment. Heart valve diseases and heart failure should be treated properly. Unexplained and increasing shortness of breath should always be investigated. In particular, persistent shortness of breath after a pulmonary embolism requires evaluation for chronic thromboembolic pulmonary hypertension.

Is Pulmonary Hypertension a Serious Disease?

The seriousness of pulmonary hypertension varies according to the underlying cause and the severity

of the disease. Some patients may have a mild increase in pressure, and the condition can be brought under control by treating the underlying

cause. By contrast, some types, such as pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension, can be progressive and serious diseases. The course of the disease depends on many factors, such as the pumping strength of the right heart, exercise capacity, blood oxygen level, blood tests and hemodynamic measurements. Early diagnosis, correct classification and appropriate treatment are very important in controlling the disease. For this reason, it is beneficial for people with suspected pulmonary hypertension to be evaluated at experienced centers.

When Should You Seek Emergency Help?

In patients with pulmonary hypertension, some symptoms require emergency evaluation. Call 112 especially in the following situations:

• Fainting or severe dizziness close to fainting,
• Sudden or markedly worsening shortness of breath,
• New or severe chest pain,
• Marked bluish discoloration of the lips,
• Confusion or severe weakness,

Palpitations accompanied by fainting, chest pain or shortness of breath. These symptoms may indicate that the right side of the heart is under severe strain or that another emergency heart-lung problem is developing.

Conclusion

Do not take shortness of breath lightly. Pulmonary hypertension is an important health problem caused by increased pressure in the lung’s blood vessels, which can strain the right side of the heart over time. The most common symptom of the disease is shortness of breath on exertion. However, this complaint is often attributed to other causes, and diagnosis may be delayed. There are different types of pulmonary hypertension. Heart diseases, chronic lung diseases, clots in the lung’s blood vessels and certain specific vascular diseases can lead to this condition. For this reason, the cause of the disease must be correctly identified before treatment begins. Echocardiography is an important first test in the diagnostic process; when a definitive hemodynamic assessment is needed, right heart catheterization is performed. Depending on the type of disease, treatment may include medication, surgery, interventional methods and control of the underlying disease. Do not ignore these symptoms, especially if you have increasing shortness of breath, unexplained fatigue, fainting during exertion or leg swelling. Early diagnosis, proper treatment and regular follow-up can positively affect quality of life and the course of the disease.

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