Dear Dr. Gott: I'm a 54-year-old female who had a heart attack at age 47. They think it was a coronary spasm.

I've begun to work out recently with a personal trainer because I am about 80 pounds overweight. He is concerned that I have difficulty getting my heart rate up. After 20 to 30 minutes of cardio (three miles per hour at a two percent incline on the treadmill), my heart rate is still around 98 to 105. Should I be working harder or could it be a result of taking Toprol XL even though I do not have high blood pressure, nor have I ever had it? My cardiologist thinks taking one-half of a 100-milligram tablet daily is a good idea to prevent future attacks.

I also take simvastatin, tizanidine and an 81-milligram aspirin each day. My triglyceride result just came back at 223, but the rest of my cholesterol was normal. My total was 180, and my heart rate while standing still is about 68. And I smoke cigars daily. Need I worry? My trainer is.

Reply: For the benefit of those readers who may not know what a coronary spasm is, I will explain briefly. It is a contraction of the muscles in the wall of the artery. Because of the narrowing, blood flowing to the heart muscle could have been reduced or stopped briefly, resulting in chest pain and possible heart attack. Coronary spasms typically occur in people with an increased risk of heart disease, such as those who smoke, have a history of hypertension and/or hypercholesterolemia. Already, you are three for three.

Treatment involves smoking cessation, consuming a healthful low-fat, low-sodium diet, lowering blood pressure, exercising and taking medications to prevent recurrence. While I don't know your complete medical history, I have some concerns and wonder whether more than one physician is involved in prescribing for you. For example, Toprol XL slows down the heart rate. Simvastatin can cause angina in three percent of treated patients. I am not in any way implying you have been incorrectly prescribed. I would simply feel more comfortable knowing all physicians involved have a complete game plan when it comes to your health.

While on simvastatin, your triglycerides remain high. Does your diet need revision? Are you reading labels, staying away from cold cuts, hot dogs, kielbasa, sausage, sweets or baked goods containing tropical oils, ice cream and cheeses? Have you substituted fresh fruits and vegetables and broiled fish? A modification in diet, if appropriate, might go a long way toward bringing down your blood pressure, cholesterol levels, weight and your risk of a repeat cardiac event. Beyond that, I suggest you give up the cigars.

Make an appointment with both your primary-care physician and cardiologist, and go over the issues you have presented to me.