 The second Q&A event. I hope you're enjoying these scorching heat out there, especially if you're in Houston. This is Dr. Brianna Costello, Texas super doctor, rising star, Brianna Costello. I'm Alexander Postalian. We're both cardiologists, interventional cardiologists. Rising superstar. OK, so we are going to answer some questions. Once they start to come in, we'll get going. But I think we can get started with a relatively controversial topic, very common question that we hear in clinic. Multiple times a day. Multiple times a day, which is cholesterol meds and particularly statin medications. Who are they good for? Are they problematic? Are they really beneficial? What do you think, Dr? So that hit the nail right on the head. Statins, by far, are one of the major topics in our conversations with our patients every day. And I think that's because there's so much media or literature that you can find online or from friends even that might question statins and their utility in heart disease. When I'm discussing with patients in the office, especially those who've already had a heart attack or already we know have coronary artery disease or plaque in the arteries of their hearts, it is a no brainer that statins are first drug to go to. And that's because they've been tried, tested, and true and shown to be beneficial over many, many years. The one caveat to that, and I'm sure that you experience this a lot, is the muscle aches or the quote unquote myalgias is what we call them, that patients often report after starting them. So how do you handle that when you start a patient on, say, a torvastatin or a libator, you guys might know it as. And they come back and say, Dr. Prostalian, my legs have been aching or my legs, my muscles hurt. Yeah, you know, it's a very important issue and I think I have to have a little bit of background on this, when statins first came out, we thought they caused muscle pain in about 30% of people. So very common, very frequent, something that we were managing for a long time. But then we've had a bunch of studies come out and essentially you can imagine that we had a bunch of people and we gave them a statin and told them this is a statin. And then we had another bunch of people and we gave them a tic-tac and told them this is a statin. And then the amount of people that had to stop the tic-tac for muscle pain was very, very close to the amount of people that stopped the statin due to muscle pain. So that's important to keep in mind and it's not really 30%, it's closer to maybe two to 5% in reality. So once that data, you know, people are aware of this, sometimes, you know, there's a lot of things that can give you muscle pain that are transient, you know, you exercise, bad day, you know, you slept poorly, et cetera, et cetera. So that's one thing to consider. And I think it's good to remember that from those trials we can take and just tell our patients exactly what you said. In life, we have muscle pain or muscle aches. So just knowing that statins can cause muscle pain doesn't mean that that's what's causing it. But there's a really easy way to test that theory for yourself, which is another trial that just came out. And it basically gives the power to the patient to say if you think it's a statin and we're reasonable, we think that if it is a statin then we should try a different one maybe or try a different drug. But there's an easy way to test, is this pain from my statin? And that is discontinuing it for three to five days and seeing what happens. Now, if you stop that, the drug and your muscle pain on day two is gone or day three is gone, then perhaps it was that particular cholesterol medicine, that statin. But if your pain is still there, we're pretty confident when we tell you it's not likely the statin. So what you were saying is also important. Not everybody benefits to the same degree from a statin. So yes, maybe you don't think statins are beneficial. There's a lot of studies out there showing they might have some problems and you don't wanna take them and the only reason you take them is because you have a moderately elevated cholesterol. I think that's okay. But there are other groups of patients. So if you had a heart attack, if you had a stent implanted, if you had a stroke, then the risk-benefit ratio there really, really tells in favor of taking statin. So that's something to keep in mind. If the symptoms are mild and you had a significant cardiovascular issue, I think that's an important thing to keep in mind. You should probably be on a statin if you can. But if you cannot and you stopped it and the pain went away, you tried it again and the pain came back and you stopped it again and the pain went away, what can you do? Okay, my first, always my go-to is trying an alternative statin and you can see a theme because we know statins work, especially in those higher, if you're a higher risk patient, you've had a heart attack or stroke. So I will always suggest that we switch the statin first with in mind that if it doesn't work or you have muscle aches, then we can try a different drug. But if we go through our statin, the packet of statins and we can't find one that works, then we have also very good alternative meds that have data for outcomes, meaning reducing risk of heart attack and stroke for the future. And my second go-to is always a PCS kind of inhibitor. So what can we tell the group? That's a whole lot of letters and words, numbers. What does it mean? What does it do? So that's a relatively new drug. It is injectable. You give it to yourself about every two weeks on average. And what it does is that it increases your body's capacity, your liver's capacity of essentially taking bad cholesterol from your blood into your liver and metabolizing it. So it lowers the bad cholesterol that is circulating. Hence, there is less cholesterol accumulation in the vessel walls, fewer heart attacks, fewer strokes. The meds are very, very effective. They're not only lower cholesterol, but we know that they also lower strokes and heart attacks. So we have all the data that we need. And the most important side effect is a reaction at the injection side, which is also not super common. So it is a very, very good drug that we use in our high risk patients. And the reason I say high risk is it's only approved if you really have a very, very high cholesterol or if you have a high cholesterol and you had a big event like a stroke or a heart attack and you still need to bring it lower. And now if you're not in that category, there's a simpler drug that we use all the time which is azetimide, okay? The brand name is Zettia. And what it does, it is, it will hit. First, it's cheap. So patients are like, oh no, alternatives. How expensive? Zettia is pretty cheap. PCSK9 inhibitors are very expensive. Sometimes we have issues getting them covered by insurance and Zettia is very cheap. But what does that do? So Zettia actually is a completely different mechanism or way of acting to decrease your cholesterol. It actually works in your gut. So it decreases the uptake of cholesterol so that your body doesn't have it to float around in the blood. So it's a simple drug. This side effect profile of Zettia, meaning what side effects do you get? I virtually say there's not many. This GI basically, if any? If any. Gastrointestinal. Right. So it's very well tolerated. The only downside or the con to this drug is it doesn't achieve the cholesterol lowering like those other drugs we talked about like statins and PCSK9 inhibitors. So if you're really trying to modify someone's bad cholesterol, you might not achieve your goal. So you might not be, if your doctor says you're not at goal, what does that mean? 70, 70, that number for your bad cholesterol, the LDL. So I always think LDL, L want to keep it low. So 70 is your goal. So Zettia might not get you there. Now, if you can get there on Zettia and you tolerate that and nothing else, then perhaps your doc might leave you alone and just keep you on that. And this is a very active research field. There's a lot of new drugs in the pipeline. Some that came out that are very recent that seem very promising. One is called Bempidoic Acid. Another one is Inclizaran, which is a shot that you give yourself every six months only. So I think we're gonna have a lot of options in the next few years. And the Bempidoic Acid is actually pretty efficacious. Now, it's newer. So unlike the PCSK9 inhibitors and the statins that we talked about, the longer, meaning years of follow-up that we have patients on that drug floor, we don't quite have yet. So it's not the first one we pick off the shelf for patients. But again, it works. It decreases cholesterol pretty significantly. And sometimes we'll combine it with the Zettia or Zetimibe to get a really good reduction in cholesterol. So you have lots of options. You shouldn't feel discouraged if you can't do a statin and you're like, oh, I'm doomed. No, your doctor should talk with you about all the alternatives. And just be mindful that no side effect generally, nothing is never. But most side effects, none of them are permanent, right? So you try a drug, you don't like it, you switch it. Yeah, there's a lot of options. You just have a, if you think statins are not for you, just have an honest conversation with your doctor. But having said that, statins work and benefit most people on the side effect profile is truly not as bad as we used to think, I would say. I think this kind of goes into another really good topic called aspirin therapy, which is at a lot of social media coverage, or I have patients often, at least one a day, in the office say, well, my doctor told me I don't need aspirin anymore because of the new guidelines. Or I read something online that said, I don't need aspirin. So what type of conversation are you having? Or what should the audience know about aspirin's usefulness now? Yeah, this is another major, major topic. I see patients all the time that were taking aspirin, and then they stopped it because of whatever came out recently talking about aspirin. We have known for a long time, but first of all, the way we used to do it is everybody that was essentially above the age of 55 would get a low-dose aspirin just in case to prevent. But we've known for a long time, over 10 years, that that is probably not the way to go because it doesn't really make a difference in benefit. And there are some small risks to low-dose aspirin therapy, namely bleeding, okay? But some patients do benefit from aspirin. The ones that benefit the most are the ones that had a heart attack already, the ones that had a stent implanted, the ones that had a stroke, those should definitely be on aspirin. So this recommendation of stopping aspirin does not apply to that group of individuals. And then there's smaller subgroups that may also benefit from aspirin. If you have diabetes in a certain risk profile, if your coronary calcium score is greater than 100, we've done some studies showing that some patients have a net benefit from low-dose aspirin therapy. So if you're thinking about stopping your aspirin, just ask your doctor. Yes. Don't just stop it. And I love the word that you used, or the two words, the coronary calcium. So some listeners might be saying, what is coronary calcium? Yeah, that's a good one. One of my favorite topics. So coronary calcium score, it's really a score that is taken for you after you get a CAT scan of your chest. And you might say, well, I thought calcium was just on my blood work. I have a calcium level that they check every year at my primary care doctor. No, the coronary calcium is actually the calcium that lights up or shines on a CAT scan in the heart arteries. So I love this test, mostly for patients who are kind of intermediate risk, maybe a female who's 50 or more, or even a female who's in her 40s with a really strong family history who has maybe intermediate elevations in her cholesterol or a male who's 50 or in his 40s with a strong family history with cholesterol and he doesn't wanna be on a statin. So what a calcium score is, it's a plain CAT scan. You go sit in a CT scan or tube for less than five minutes. Low dose and cheap is not a full-on CAT scan, expensive, et cetera. Yep, and no insurance covers it at this point mostly, but it's 100 bucks mostly, 100 to 150. And you get a CAT scan and calcium sparkles. So if you have plaque in the arteries of your heart, calcium follows that plaque and it'll sparkle on a CAT scanner. So we can add up all the calcium that you have if you have it and give you a score. And we have, there's a large database called the Mesa Database that looked at everyone's kind of calcium scores across ages and sexes and races and said, what is your risk with a calcium score of this? So we can kind of risk stratify you, meaning put you in a percentile of Mrs. Smith or Mr. Smith, you're in the 50th percentile. So 50% of people your age have more calcium and 50% have less. Or surprise, your score is zero. You don't have any identifiable plaque on a calcium score. So that number is really helpful for primary prevention, meaning identifying you have some disease and perhaps increased risk later in life. And then we do something about it sooner instead of you popping into our office when you're 80 with a heart attack or with a heart that has had a previous heart attack. Yeah, it definitely helps us establish your level of cardiovascular risk. Okay, so it can help answer questions like, should we put you on aspirin? Should we put you on a statin? Can we lower the dose of your statin that you're already on? It's not for everybody. For example, if you're young, you probably have not developed calcium yet, even if you have cholesterol plaque. So don't think it's for everybody, but it is a useful test if we know how to use it. And then this brings up a really another good point. Does all plaque sparkle on a calcium score? No, calcium score, like Dr. Rossell was explaining, shows you the calcium, but you can have plaque that is not calcified. That is more common in younger patients that have really high cholesterol values, for example. So it's not a 100% guarantee, but we have looked at large patient numbers, and we say, okay, if you have a low calcium score, you're likely safe for the next couple of years. And that's kind of how we base our decision-making, okay? So we'll go on to one of the other questions that we have online. What do you think about the keto diet? Oh, I love this. So another one of my fun topics. So I don't know what you tell your patients about diet, but I generally say, well, the word diet in general makes people already feel defeated. So it's more about I try to encourage a Mediterranean lifestyle, or Mediterranean food. So go to Greece, it's a good lifestyle, go to Southern Spain, Southern Italy. So we have really good resources, by the way, on the Texas Heart website about the Mediterranean diet. So if you are like, whoa, I've never heard of that, then you can pop in and Google that for us, okay? But the Mediterranean diet, I say focus on what sounds like it's probably healthy. Fruits and vegetables, go for it. Vegetables, fresh vegetables, of course, or steamed vegetables, deep frying, or is never a great idea for anything that you're eating. And then meats or fish. So fish is a really big component of the Mediterranean diet, as you might guess. But any type of fish, I encourage patients to try. I don't say you have to have cod, or whatever, tilapia, or well, try fish, find something you like, and try to at least put it in your dinner plans once a week. Red meats is a big part of the ketogenic diet because red meats are very low in carbs, high in fat. But for a Mediterranean diet, not so great. And we know that increased red meat over time not only increases your risk for heart disease, but also cancer. There's a really interesting article about France putting out the government, or the equivalent of the FDA in France, saying that eating foods high in nitrates is really a bad decision. And obviously in France, they have a lot of charcuterie boards and meats. And so I think that focusing on fresh and green and fish is what I would recommend to all my patients, and I do. I think a specific comment on keto is that it helps you lose weight. But I think it might be a little bit too heavy on the fat side. And when we look at the patients cholesterol, a lot of times it raises the bad cholesterol quite a bit if you are a little bit too liberal with bacon and things of the sort that are okay for the keto diet, but not for the other diets. And you know, I actually have seen patients liver enzymes go up on the keto diet. And not insignificantly. And that ties into fatty liver, which is a whole nother discussion we can talk about later. What I would say about diet is two things. So first of all, the weight part. It's easier said than done, but the way weight gets accumulated is how many calories go in with diet versus how many go out with exercise and metabolism. Okay, that's the kind of the easy formula. So lowering the total calorie amount is important. That's one thing. You don't have to be super dogmatic about it. That's one basic principle. And then the other one, which fits into the Mediterranean diet topic is, the enemy for bad cholesterol other than fats is actually the simple carbohydrates. So the ones that are easy to digest, they raise your blood sugar, they raise your bad cholesterol. Any type of sugar, how to do anything, so sweets, sodas, juices, et cetera. But then the big ones that everybody likes, rice, pasta, bread, potatoes, tortillas, because a lot of the times, hey, I don't need sugar, but then you have a lot of rice, et cetera, et cetera. So those are not the best. I think a diet should mostly be based on lean protein. So grilled fish, grilled chicken, as Dr. Costello was saying, and vegetables. And be careful with the dressing, because dressing could have a ton of calories. Sometimes you go to a fast food place, and the salad may have more calories than the hamburgers sometimes, so you gotta be careful. And you know, you can always, we have really good, as I mentioned before, about looking at Mediterranean diet on our website. Straight Talk is a newsletter that we put out Dr. Stephanie Coulter. You can find it at texasheart.org, forward slash straight talk. And a lot of these topics, even the calcium score topic is on there too. So if you can jot it all down now, or you don't wanna come back to watch us again, you can take a peek there as well. What about another topic that comes up frequently in the office? Somebody is relatively healthy, no major issues, and they start having leg swelling. Oh, that's good. How do you approach that? It depends on what their sex is. Not to be sexist in the leg swelling category, but I have been kind of surprised at how many women who have either had children or have had jobs that have kept them on their feet for a long period of time. For example, I had a flight attendant who said, you know, I turn 16, I feel like my legs are just always swollen. And there are a few baskets to think about why swelling happens in the cardiology office. One of those is a little more, not to say serious, to downplay what the other leg swelling is, but one is heart failure, right? So we're always on the lookout for if you have leg swelling, do you have signs of quote unquote heart failure where the fluid is backing up because your heart's not functioning correctly? The second basket is a little less medically urgent or emergent, and that's venous insufficiency, which in women, by and far, especially who have had children, is a problem, especially in Houston, because it's so hot in your veins that are already perhaps not working right, are now dilated because you're outside, standing, watching your kids play games, or you're exercising on for a run. So yes, leg swelling is a big topic, and we fortunately have good therapies for both of those little baskets of leg swelling. So depending on what it is, your doctor might discuss medical therapy versus procedures. Yeah, it's very common, okay? And most of the time it is benign, but of course, once you see that, you have to rule out some potentially dangerous things, because you can think, okay, my legs are swollen, there's more fluid in my legs, right? Is it because you have fluid all over? And if that is the case, that could be potentially your heart, could be potentially your kidneys, some other things that are less common. Or is the fluid only in my legs, in which case it might be an issue with venous drainage? And there's many reasons for it, and the most common one is the veins of valves that allow blood to go from the feet to the heart and not go down again, so help against gravity, but as time goes by, age gets up there, the valves get damaged, so the blood tends to pool in the legs. And that was a relatively very, very common reason. Most of the time we can do it, we can manage that with compression stoppings, which is use socks that press your leg and take care of the issue. Which is painful and Houston in the heat, and when you wanna wear shorts. They look as good, yeah. So, but they help prevent it from getting worse, and sometimes you have discomfort, so it helps with discomfort. And then there's some invasive therapies that can be done to help ameliorate it, but we usually reserve those if the more conservative stuff doesn't work. Like the stockings, which work. And exercise actually helps venous insufficiency, and I try to remind people that maybe if you're an avid runner, wear the compression socks when you run, but also the squeezing of your leg muscles helps that venous blood flow or the pooled blood in your legs go back to the heart. So exercise is still on the table and should be done for patients that have this. Definitely. All right, we have another question from Facebook. So, what is the best way to talk to my invincible teen about heart health? I love this. Yeah, great question. So that is obviously hard. I feel the frustration through the question. Honestly, most of heart disease is commonly seen in older patients, okay? One of the, in younger people, we worry about different things like congenital heart disease. Is there something going on with your heart that would make it high risk for your exercise, et cetera, et cetera? But the overall recommendation is we probably don't do a lot of testing in young people unless there is a problem. Meaning do they have a symptom? Do they get tired with physical activity at a lower level than you think? Or there's something going on. Now, having said that, it is always good to start. I think the most important part is healthy habits at an early age. Because if you're not following them when you're young, it makes it much more difficult to do when you're older. So if you can start at home with trying to eat and follow healthy diet, et cetera, et cetera, that, I think would be the most bang for your buck rather than aggressive testing or regular follow-up with a cardiologist. And I think that you really hit the nail on the head with the healthy habits at home. We know, and there's plenty of research, especially in the Peds world, that childhood obesity significantly increases your risk for having diabetes later in life. So if you have your child and you're worried about weight, you need to go to the pediatrician and really they have diet counseling even for kids. Because later in life, diabetes is one of the biggest risk factors for heart disease. So if you have already predisposed yourself to having diabetes when you're maybe 30 and we're seeing younger and younger patients come to the hospital with heart attacks, right? So when they're 30s or 40s, so getting that kind of right at the beginning so that later in life it doesn't sneak up on you is a big, big role. Yeah, if you have the chance, it's a big burden to remove from the future, if possible, at least. All right, we got, let's see here. We have another question here. So we published articles on trendy cardiovascular topics or topics about the heart quarterly on our THI website called Straight Talk, which I mentioned with Dr. Kulture. So let's talk about one of the articles which is hot. I guess it might be getting hot again as COVID waves go up and down, but what about myocarditis in the era of COVID? Yeah, well, we know that it can happen. It is more common with COVID itself than with vaccination, even though vaccination may do it in a very, very small number of patients, particularly young men, but it's not something that I think you should be terribly concerned about. I think I wouldn't necessarily worry about this, honestly. Yeah. And it's for the general public. And myocarditis, if it happens to you, the most common cause of myocarditis is viruses, right? So if you had myocarditis because of COVID, that is not, we know that's not uncommon per se, but if you have myocarditis and it's not COVID, viruses are still the number one cause. So it can happen. The good news about myocarditis from viruses in general is that generally people improve over time. The symptoms last a short amount of time, most recover fully in just a couple of days. So a few days, two weeks. It's actually a not severe type of myocarditis in most patients. Correct. What do you think? What else? Any other questions? What other questions do you see in clinic that kind of make more of that? You know, really, we as, we're both interventional cardiologists, so we do procedures and we do stents. So one of my common topics in patients who perhaps needed a stent is, well, do I have to be on these blood thinners for life? Just think about the same question. So blood thinners, I want, when you talk to your cardiologist, or your primary care doctor, whoever it is you follow up with closely, the meds that we put patients on after a stent are not technically blood thinners. So when we say you're not on a blood thinner or you shouldn't be on a blood thinner, that doesn't mean you shouldn't be on your aspirin and your plavix, per se, or your clopidogrel, or your effian, or your poracicrel, per se, or tachycagrelor. But now back to the beginning. You have a stent. How long do you expect to be on these quote-unquote blood thinners? That's a great question. Like you said, there's different types of blood thinners. There's anti-platelet agents, which are the ones that we use if you had a stent, for example, and then anti-coagulants, which are used if you have multiple things. The most common ones are thrombosis of the veins, for example, or atrial fibrillation. That's a separate topic. Now, talk about, if you had a stent, your doctor gave you two anti-platelets to take to keep the stent open. In general, you should, there's a few ways of going about this. It's a very, very active topic of conversation. And scientific research. The basic principle is you have to continue both for, if you can, at least one year. So it gives your body time to, initially, when you get a stent implanted, it's a metal thing. It's a foreign body. Your body wants to attack it, okay? So the anti-platelets prevent your platelets from attaching to it and blocking the stent and giving you a heart attack. But your body slowly covers the stent with its own cells over time, making the body, the stent, seem less foreign over time. So at a one year, that should be relatively complete, so you can stop at least one of the anti-platelet agents. But that risk doesn't go down to zero. So if the procedure was complicated, if the stent is very long, if you are a very high risk individual, sometimes we continue both anti-platelets for a long period of time. And sometimes we stop them before a year if you are at high risk of complications from the anti-platelets like bleeding. So it is really an individual decision. And that brings up a really good point. As cardiologists, we actually do wanna know your GI, meaning your stomach history or your bleeding history. So please, if you're going to see a cardiologist and you're writing down your list of prior health issues, don't leave out the stomach issues or the bowel issues. It actually is very pertinent to the medications that we pick. And I actually browse Facebook groups, I have patients that also take physicians to sort of understand the patient experience. And the question that pops up frequently is, you know, I'm taking all these meds. I feel really bad taking all these meds. I'm just gonna stop them. And you know, I did it and I feel great. And that may happen because meds have side effects. But not all medications are in the same level of importance, okay? So stopping a stent in your cholesterol is almost normal. It's not the same as stopping one of these anti-platelet agents. After your stent. Yeah, a month after you had a stent. So that is a major, major risk. So if you really wanna stop a lot of meds, you're the boss, you know, you decide, maybe we think this is useful, but you don't wanna take it. You should definitely have an honest, again, honest conversation with your doctor about, hey, I wanna be honest. Few meds, it is reasonably possible that it's not gonna, you know, cost me to have a heart attack in a week. And there's some that can be dropped, but some that are really, really critical. So be careful about just blank stopping everything. And truly the drugs that we prescribe or all specialties, really. There should be one of two goals. Does it make you feel better? If it does great. And does it make your life, is it prolonging your life? Is it gonna make you live longer? And in the cardiology world, that's really what we're doing every day when we're titrating or messing with meds. So a patient might get very frustrated that maybe I'm changing this blood pressure medicine or I'm adding one instead of just maxing out the other one. But there's data behind the reasons that we make these decisions. So maybe you'll be on a combination of pills, but those combinations have been proven with science and proven with studies to make you live longer or feel better. So there is definitely a trade-off and there's always the benefits and the risks of everything that you have to weigh. But your doctor should be trying to achieve one of those two things. You did. So a little bit of a philosophical topic, but people tend to support the evidence of things that you already believe. And reject the things that you don't think work. Going back to statins, for example, there's studies that are well-conducted studies that show that statins have some problems. So that's fair. But our job is to look at the evidence and its totality, step back from one study and look at all the thousands of studies and come up with a conclusion. So every time that we're assessing the benefit or the risk of a drug, that's how we should do it. Not just focus on one study that said this or another study that said that. Or your friend who had this happen when they took it. Okay, so let's move on. I know this person. So our bicuspid aortic valve's hereditary. This is a very good question. What is it first? What does that have to go through? Okay, so this is also fun. I wish we had a picture that we could flash up for you guys. First of all, what is your aortic valve? How about that? Okay, so let's back it up. So your aortic valve is how I describe it. The gatekeeper from the blood coming from your heart to the rest of your organs, okay? The aortic valve is usually has three leaflets, which kind of, what does it look like? Like a Mercedes, that sounds ridiculous. But our Mercedes Ben sign, if you looked at that, that's what your aortic valve actually looks like. We're waiting for a sponsorship from Mercedes Benz. Yes, so if anyone knows. Okay, so that is what your valve looks like when you're looking down on it. Okay, it has three leaflets. Those leaflets open every time your heart squeezes, okay? When it's normal, it has three leaflets and they open very easily, okay? As you age, that can change where you have maybe motion of the leaflets that aren't so good. That would be aortic stenosis. But now let's go to what is a bicuspid? So usually it's tricuspid, but if you have bicuspid, you have only two functional leaflets. You may have had threeish leaflets, but they've fused. And it's usually you're born with bicuspid. Okay, so bicuspid, two leaflets, as you can imagine. It's not how it's supposed to be, so it doesn't work perfectly normally. So one, are they hereditary? They can be. And the percentage of which are hereditary can vary if you Google bicuspid valve. But I would say between the order of 30 to 50, maybe. And it depends on your genetics. So if you're just unfortunate and you were born with a bicuspid and you don't have any family history of it, you might not have the same risk of passing that on to your progeny. I think a fair way of saying it is congenital, meaning it is there when you were born and there is a higher risk that you, it was hereditary from the top and you may pass it on, but it doesn't happen 100% of the time. And the biggest thing to take away from it is if you have a bicuspid or your mom or dad had a bicuspid, you should have an ultrasound of your heart. Because guess what? Bicuspids put you at higher risk of having that valve kind of become stiff earlier, right? So the two issues with bicuspid valve, getting stiff earlier? Stiff earlier and actually your aorta, the big artery, the biggest artery in their body, being dilated. And those, why we care, it goes back to why we put people on medicines because those two things in order to make you live longer and feel better, we wanna make sure nothing goes wrong with those. And that can happen earlier in patients with a bicuspid valve, okay? So it's to prolong life. Yeah, so if you have been diagnosed with a bicuspid aortic valve, you should do a few things. One is you may need echocardiographic surveillance of the function of the valve, okay? Which means ultrasound of your heart. Correct, we just checked, see if it's opening okay, is it getting tighter, and we do that over time. If you feel fine, it's usually not a major concern, but we have to keep an eye on it. And then the other one is that we have to keep an eye on the aortic size. And we can do that multiple ways. At least one time, you should probably get an image of your whole chest being either a CT scan or an MRI to look at your entire aorta. And then we can see some parts of the aorta with the ultrasound, so we can follow it long-term with it. You may have to repeat another CT scan in the future. But essentially, you just have to keep an eye on it. Don't think it's gonna impact your lifestyle, or you have to do some sort of limitation, you know, to keep it from getting worse. There are some medications that may help the aorta from getting bigger. That's a little bit controversial. Usually the ones that we use for hypertension, some of them work to keep the aortic size as normal. So that's another thing to maybe consider with your doctor. Very good question. You know, another hot topic we can, since we're already talking about aortic valves, you are your family members, might know someone who's had a, quote unquote, taver or a catheter-based valve placed instead of having their chest open for valve replacement. That is where we actually go through the arteries and the groin, most commonly the groin, and we deliver a valve without opening your chest. And that's something we do here, of course, at Texas Heart Institute, and you can, many other institutions are also doing it. But we're really proud of the program here at Texas Heart at Baylor St. Luke's, really started these many years ago now, I guess it's been many years. Yeah, from a dozen intents or something. We used to have to open the chest on everybody that needed a valve, in a aortic valve, and now we can do it through the groin. So it's not for everybody yet. It's actually a very good procedure, but the way we like to do things is we like to do it, test things out a long period of time, and then expand its use. So right now it is mostly reserved for people that are over the age of 65. So if you're younger than that, it may not be the best for you, but it's definitely an option out there that if you were diagnosed with aortic stenosis, you should ask about it. Yeah, and it's durable. Now that we have 10 years, 10 plus years of data, we know that they are durable. The more data that comes out, the more we're convinced that it's actually very good. Okay, next question. What do you think the role of gastric bypass surgery is for heart patients, diabetic patients, and patients with hypertension, et cetera? Oh, so one, this question, you can kind of sum it up if you have type two diabetes, and you have quote unquote, diastolic dysfunction or heart failure, okay? Do we think they would benefit from gastric bypass? If you're at a point where your diabetes, you've been diagnosed and your weight is now at the point where you're considering bypass, I always think it is important to assess your ability to achieve your weight goals or your diabetes control goals, and if you think you need help and bypass might be beneficial to get there, then yes. Diastolic dysfunction or diastolic heart failure is a very complex diagnosis and disease because it actually is influenced by sleep apnea, by weight, by blood pressure, which all we often see kind of together in this, in a group of people who have maybe diabetes and obesity and symptoms of heart failure. So yeah, I think absolutely. I'm pretty pro gastric bypass, I'm often supporting patients who want to be quote unquote cleared for bypass surgery. And this has evolved over time, but in general, who is the candidate for gastric bypass surgery? If your body mass index is above 40 and you are unable to lose the weight with a structured program, then you can be a candidate for it. Or if your body mass index is more than 35 and you have what we call another condition that sort of amplifies your risk like diabetes, then you're also a candidate for it. Now, a very interesting thing that has been called by some as bypass surgery in a syringe are the new men's for weight loss. Which I wouldn't, I perhaps wouldn't call it that. Me either, but I haven't heard it yet around. So what do you think about these? I love these drugs. Honestly, I wish someone from that drug company would be listening to this, send us some for our patients. But so these drugs, they, not only in the big trial for one of the major drugs, I'm not gonna promote any of them, but you know, semi-glutide, lyridlutide. So these drugs have been shown to have patients lose up to 15% of their body weight. Which is a lot. So you take someone who's 200 pounds and you help them lose 30 pounds just by using this drug, which is really pretty well tolerated with minimal at all side effects. The side effects of the drug actually help you lose weight. I think it's a no-brainer. I think that the weight loss, these companies have struck gold and the companies that give these drugs out are actually diabetes companies. So they didn't even know what they were finding. They were testing a diabetes drug and they said, wow, our patients are losing weight. This is amazing. So they've now used it as a weight loss drug. So I love the drugs. They're not only good for weight loss, but they are good for cardiovascular profile, meaning they also can have good beneficial effects for your cardiac profile long-term. So I'm a huge proponent. What about you? We've had weight loss drugs for some time, but they're not really the safest. A lot of them have been sort of stimulants that reduce your appetite, but those have side effects. They ramp you up. So it's not the best for your body overall, even though they made you lose weight. So this is actually really interesting. It seems the drug is very safe, very effective, and very good. The main problem now, well, if you're a diabetic, you're a good candidate for these and insurance would usually cover it, but this indication for just weight came out very recently. And right now the company is charging a lot of money for the drug, if it's only for weight loss and insurances are getting used to this. So right now it's very hard to actually get it, but in the future, I think it's gonna become more accessible and it's gonna be a much more available option. Okay, so if you want to try this, yeah, definitely ask your dog. And if you're a diabetic and you have elevated weight, this is particularly important for you. Yeah, no brainer, it's a no brainer. Next one from Facebook. So at what age should you start seeing a cardiologist? Or at any age? Okay, let's say, let's give a scenario. No significant family history of heart attacks, heart stroke, heart failure, whatever, and you have someone ask you this question. What's a pretty general role? Yeah, so I think you need to start being more mindful of your cardiovascular health. Maybe starting around 30 and then, particularly after 40, not necessarily see a cardiologist per se. I mean, if you see a primary care doctor, you can check of the usual things that we check like cholesterol, for example. We might go a little bit deeper and do some additional testing that may be useful. So I think 30, you have to pay more attention and then at 40, I would definitely see someone. And if you can't see a cardiologist, I think don't be afraid. Yeah, and then of course, if you have a strong family history, mom, dad, or brothers or sisters who had early bypass surgery, early stents, early whatever it might be, it is never a bad idea to check in with a cardiologist. And hopefully they say, you're great. I'm not worried about you yet and see me in a couple years, but you never know if you might be missing something. So it's not harmful to see a cardiologist if you're worried. If you have a concern, do it. And I just have to plug this because one thing that in women's heart health that we really do not focus on and should, and part of that is on our end, we should be talking to OBGYNs more. If you have a history of preeclampsia or eclampsia or gestational diabetes, you're at higher risk of having hypertension later in life and diabetes if you have the gestational diabetes later in life. So knowing that is important. And often as moms or you're busy, you're at work and you're a mom and you're not thinking about yourself all the time, you should keep this in the back of your mind and just be mindful of your numbers, your blood pressure, your weight, et cetera. Well, it looks like we're getting close to wrapping up. So thank you for joining in. Remember that a lot of these topics, we have information in our website, hypertension, cholesterol management, what is body mass index, what is a good diet, et cetera. So be sure to log in, texasheart.org and check it out. And thank you, Super Doctor Costello for joining me and everybody for setting it up. We look forward to the next one. Thanks everyone for joining and we hope we had a little bit of fun on this Friday. We talked for 45 minutes straight nonstop, so it wasn't any good. I need a coffee. Bye.