 Hello, and welcome to this episode of Quality of Life. Today's subject, we are going to be dealing with the cardiovascular system. And helping us discuss that part of the body is Dr. Robert Horth from Coolest Cardiology. Dr. Horth, welcome to the show. Oh, thanks for having me. Just to start out with what is your background in cardiology? You know, education and what you do now. Okay. I went to college at a school called King's College, which is in Wilkesbury, Pennsylvania. It's a sister school to Notre Dame. And then I went to medical school at the University of Pittsburgh in Pittsburgh, Pennsylvania. I then did my internal medicine residency at the University of Pittsburgh, and then I did my cardiology fellowship at the University of Miami. I then went forward with all of my board certification exams and board certified in internal medicine, cardiology, nuclear cardiology, cardiac CT, and echocardiography. I, after fellowship, was in practice out in Los Angeles, California, for about six years. And my family relocated here about four and a half years ago from Los Angeles. Okay. I suppose that was a big culture change. Yeah, but I think for, you know, as a guy who's originally from Pennsylvania, this is a lot more what I was accustomed to, for sure. Okay. Okay. The cardiovascular system. Can you give us just briefly what is it and why it's so important to the body? Well, as a cardiovascular specialist, you're dealing with obviously the heart. Anatomically, the chambers of the heart, the atria, the ventricles, the valves of the heart, the circulation around the heart, which are called the coronary arteries. You're also dealing with the main arteries and veins that leave the heart, the pulmonary arteries, the pulmonary veins. The main artery that leaves the heart is called the aorta. And that then will separate into your carotid arteries, your subclavian, which go to your shoulders and to the rest of your body. So when most people speak of cardiovascular, it's mainly the heart and then the arterial system of the body. Okay. What are the major types of heart disease? Well, I mean, obviously probably what's most prominent and prevalent in the population is coronary artery disease would be number one. So if you looked at, and along with coronary artery disease, I guess we'll be also talking about stroke, and a lot of them have a lot of common risk factors together. But we also can deal with congenital problems of the heart. So some people can be born with holes in their heart, abnormal heart valves. Sometimes these things can lead to arrhythmias, heart failure. As cardiologists, we also deal with the electrical system of the heart. So arrhythmias, different types of abnormal heart rhythms. Okay. One of the things that you hear common is what they call the widowmaker. What is the widowmaker? Well, you know, a lot of times patients, you know, will say, that's usually going to be defined when a cardiac catheterization, which a cardiac catheterization is where we go through either the main artery in the leg or in the wrist. We go up to the heart and then we inject dye into the arteries around the heart. For most patients, you have two main left coronary arteries, but it starts with one main left coronary artery, and that supplies the whole left side of the heart. If there's a blockage in what's called the left main coronary artery, if that blocks the whole left side of the heart would die, and that's lethal. So that's what's referred to as the widowmaker. It's a widowmaker. Okay. Are people born with these types of conditions which, you know, lead to the heart disease or does it happen over time? Well, I mean, when you speak of heart disease, I don't know if you're speaking of like coronary artery disease. Sure. Okay. Well, you know, interestingly, you know, when you look at most patients having heart attacks, you're seeing that starting to manifest itself in their 40s, 50s, 60s, 70s, 80s. But they did a very interesting study in the Vietnam era where they did autopsies on some of the young men that died over in Vietnam, and they actually found that the beginnings of atherosclerosis or buildup of plaque in the coronaries actually begins in, and they found in these young men, 18, 19 years old. What they've actually found now with the epidemic of diabetes is that now what they're finding is in young children that are developing diabetes at a young age that they actually are starting to develop what's called fatty streaks in the coronary arteries. Well, it's kind of like, so the heart attack is kind of like the proverbial iceberg, but the blockage in the coronary artery, it's gradually manifesting itself, getting bigger and bigger, and then the heart attack usually is going to occur later in life. So the problem didn't actually occur on the night of the heart attack. It probably started 50 to 60 years earlier. Okay. So basically what it sounds like you're saying is basically, anybody could develop a heart condition over time. Well, I mean, anyone can, but there are standard risks for heart disease. We usually refer to what are called the Big Five, which would be high blood pressure, diabetes, high cholesterol, smoking, and family history. So if there's a strong family history, you're genetically predisposed to coronary artery disease. Diabetes. Diabetes is a huge risk factor for heart disease. It is assumed a diabetic is assumed to have some degree of coronary artery disease before anything else would be present. A diabetic is as likely to have their first heart attack as someone who's had their first heart attack having a second heart attack. So if I have a patient who their father had a heart attack in his 50s, is that patient more predisposed to having a heart attack than someone that there's no family history? Absolutely. That being said, are there patients where there's no family history of coronary disease and then all of a sudden they have a heart attack in their 50s? The answer is yes. But for most of us, you know, if you look, most patients that are going to end up presenting with coronary disease are going to have one or multiple of those big five risk factors. Okay. By diabetes, is it type one and type two or is one more prone than the other? Well, I mean, when you look at the overall prevalence of diabetes, type two diabetes or adult onset diabetes is much more prevalent than type one. Type one diabetes is caused by a failure at the pancreas to produce insulin, and that's called juvenile onset diabetes. Type two diabetes is adult onset diabetes. Now, interestingly with the obesity epidemic in our country at this point, we're actually getting type two diabetics occurring in children, you know, eight, nine, ten years old. So to answer your question, you know, now if a type one diabetic, yes, they're going to be much more likely to develop coronary disease because they had diabetes at a younger age and that diabetes is going to start working on all the arteries in their body, including the arteries around their heart. Okay. Well, I'd probably make a good try in commercial because four out of five, I don't smoke, so at least I got that going for me. Okay. So, but anyway, so if somebody is, you know, a possible candidate of heart disease, what are the types of symptoms somebody should look for? Well, I mean, when you read the textbook, you know, the classic symptoms would be chest discomfort. So, you know, you know, classically a heaviness across the chest and usually it would be with exertion. So like, you know, when you're going for a walk and you're walking up a hill getting chest discomfort, that many will characterize as a heaviness. If it radiates to the neck or the jaw, the shoulder down the arm, usually when a patient rests, that pain will go away. Now, interestingly, diabetics are much more likely to have atypical symptoms or no symptoms at all and we're not really sure why that is. Now, along with diabetes, you can get vascular disease, you can get something called peripheral neuropathy which is abnormal nerve conduction and they think that potentially because of the neuropathy that maybe the pain fibers going to the heart are somewhat disturbed because at least 50% of patients, their first manifestation of heart disease is having a heart attack. But again, classically, the heaviness across the chest with exertion, shortness of breath, waking up at night, short of breath, those would be kind of classic symptoms of blocked arteries. Okay. Does stress play any factor into this? Well, you know, when you look at most heart attacks occur in the morning, but that's been tied to the fact that we have what are called adrenal glands which are glands on top of our kidneys and they secrete a hormone called cortisol. Our cortisol levels are highest in the morning and that tends to elevate our blood sugar and they think somehow that may destabilize plaque in your coronary arteries which would, when those rupture could make you prone to a heart attack. So when we're under stress, it ends up that our blood pressure goes up, our heart rate goes up, and there are certain hormone levels that will go up and those can potentially be tied to future risk of heart attack. Now the good news is there are certainly things that we can do to prevent a heart attack. You know, there are certain things that we also cannot control. Like, we can't control genetics at this point in time like what you inherited from your mom or your dad or your ancestors, but we can exercise and one of the most powerful things that we can do to prevent a heart disease, a half an hour of exercise a day will decrease your risk of a heart attack or stroke potentially up to as much as 70%. Now when we say exercise, that doesn't necessarily mean, you know, going out and walking your dog and taking a leisurely pace. We're usually looking at getting our heart rate up to 220 minus our age, that quantity times 85%. So for, we'll say example, a 60 year old patient. Well, we'd want your heart rate to get to 220 minus 60, which would be 160 times 85%. So getting your heart rate into the 140s or so. So now with every patient, that's going to be different on the amount of exertion that you need. But usually what I like to use as a standard benchmark for exercise for most patients is, you know, probably in a half an hour be able to walk one and a half to two miles, which would be three to four miles an hour of walking. But a stationary bike, an elliptical, a treadmill, walking fast, swimming, all of those things are fine. Commonly all have patients like, well, you know, I'm playing golf quite a bit. Well, that's being active, but not being cardiovascularly fit. The good news about the exercise is studies have shown within two weeks of starting exercise your risk goes down. Within two weeks of stopping, though, it goes away. Now, with exercise, our blood pressure will go down, our heart rate will go down, our cholesterol will go down, and our blood sugars will go down. So exercise would be one thing. The next thing, which is very difficult to do, potentially is weight loss. Getting back to diabetes and the big risk factors for heart disease are something called the metabolic syndrome. And what that is is as we carry extra weight, blood pressure, cholesterol, and blood sugar all go up. So if we can reverse that trend and lose weight in exercise, cholesterol, blood pressure, and blood sugars will go down. Nice. I know with two of the things that you had mentioned, with the blood sugars, you know, describing that with the adrenals and all that in the morning, that makes sense because whenever I check my blood sugars in the morning, it's like they're off the chart, but then as soon as I get going in active or later on, they come right back down. So with some diabetics, it depends on the medications you're taking in the evening. Sometimes with diabetic medication, if you take them in the evening, there's something called the Samoji effect that if you actually take too much medicine, your body will rebound and have high sugars in the morning. But as you said, your cortisol levels will be higher and that will drive your blood sugars up. The other thing I noticed too is I was a lot heavier than what I am now and I'm actually about a little over a year ago I started and I'm actually creeping up on 45 pounds so it's working pretty well too. Sure, yep. It's easier on the joints walking and everything you feel better and everything obviously, so as far as that goes. With heart disease or, you know, a cardiac type of an incident are coming, is there a way they can detect it? You know, other than symptoms, is there a test they can run? You know, if I got chest pains, what are the certain tests they can run? Well, I mean usually kind of the gold standard test is what's called an EKG or an electrocardiogram and what they can do is they can put leads on your chest. We have 12 leads and it tells us electrically what's going on with the heart and with the blocked artery there will be electrical changes. So an EKG is usually pretty standard. There are blood tests that can be done. There's a blood test called a troponin which is a protein that we can detect in the blood. When heart muscle dies, it releases this protein into the blood and when we check a blood test we can detect that. There's symptoms, a chest x-ray, again the routine blood work and EKG. Now, you know, what becomes somewhat controversial with medical care at this point is, well, if you have a patient that has a lot of risk, how can you look forward at preventing that problem in the future? Now we talked about modification of risk with exercise, blood sugars, cholesterol and blood pressure will go down. Well, there are certainly medications that can lower your blood pressure, medications that can lower your blood sugar and medications that can lower your cholesterol. Now with cholesterol being very aggressive about keeping our cholesterol down and in people who have diabetes or documented coronary artery disease we want their LDL or their bad cholesterol to be less than 70. Again, the exercise is going to be a strong proponent. There's something that, you know, a lot of the folks at home if they wanted to go online and Google called a Framing Ham Risk Score. A Framing Ham Risk Score you can type in your age, your cholesterol, your blood pressure and whether you smoke and it'll tell you what your 10-year aggregate risk is of having a heart attack. One of the other issues that we'll see on TV is people will say, should I be taking an aspirin a day? And the answer to that is if you went under Framing Ham Risk and if your risk is intermediate to high the answer is yes, you should be taking probably a baby aspirin and 81 milligram aspirin. But that doesn't mean everybody should be taking aspirin. Obviously they're going to be exceptions. But again you can go under and type in Framing Ham Risk and that'll kind of give you a global now part of the Framing Ham Risk did not include other things like as we said diabetes and kind of getting back to there really isn't a standard from the American College of Cardiology on should I just go in for a stress test and see if everything is okay. Unfortunately in this day and age the answer to that would be no. Right. So I know I've had a couple stress tests just for routine and then you do the Nuke Med Scan with all of that and both times I've had false positives. So then they weren't sure is it or isn't it so then I wound up getting a heart calf both times and then things were fine. Right. Well you know obviously with any testing there are going to be technical limitations. You're mentioning a nuclear stress test that tends to be our most accurate stress test that being said it has an accuracy of about 80 to 85 percent but there are other things that we can look at. You know when you look there are new imaging modalities that have come out in the last probably ten years one is called cardiac MRI one is called cardiac CT where we can actually image the coronary arteries. Now when you look at the guidelines for using that type of technology it's very limited and probably to consult your doctor your cardiologist on whether that would apply to you or not. Sure. Is there or what is the relationship between you know strokes because you're having strokes and then obviously heart attacks or blockages you know what is the relationship or which one will happen before the other or I guess what triggers or how can each occur. Well I mean with a stroke there are different types of strokes there's something called an embolic stroke which means either a clot from the heart or a piece of plaque breaks off from your carotid arteries and goes to your brain there's something called an ischemic stroke which could be any interference with blood flow low blood pressure could cause a stroke. Well it ends up that if you have blocked arteries around your heart that's usually an indicator that you probably have blocked arteries everywhere. Most commonly the carotid arteries in our neck would be a source of stroke and whenever someone has a stroke there are standard things that we look at one would be the carotids the other would be an ultrasound of the heart to make sure there are no blockages. Usually when we start seeing plaque build up in the carotid arteries also patients that have that are more likely to have coronary artery disease because you have blockage here it's probably there as well. Now interestingly your risk of stroke is much more highly correlated with blood pressure. Now blood pressure is a risk factor for coronary disease but it's much less than for stroke. So patients that are hypertensive or have high blood pressure that's a huge predisposing factor risk factor for stroke. Now again smoking, diabetes a lot of the risk factors for heart disease will carry into stroke and again you know modification of blood pressure modification of cholesterol lowering blood sugar and aspirin a day all of these things would help prevent that from happening. Now interestingly with coronary artery disease that is much more closely correlated with your cholesterol numbers that being said that having lower cholesterol will lower your risk of stroke and that is substantially as risk of heart attack. Okay you had mentioned medications obviously when does the physician usually put people on medications or start to you know saying well I think it's time you go on high blood pressure it's time you start doing diabetes I guess when does they start usually going on medications and then well you know I think it's kind of unfortunately it's not like a one size fits all type of approach it really kind of depends on the risk factors that you're bringing to the table. Again a diabetic it's assumed that that's what's called a coronary artery disease risk equivalent meaning we assume that they have coronary disease. So the American College of Cardiology suggests that a diabetic should have an LDL or bad cholesterol less than 100 or there's the option that your cardiologist could make it less than 70 because those are high they're considered very high risk. Now if you had your standard patient will say a 40 year old male with no risk of coronary artery disease and LDL cholesterol less than 160 is adequate and the more risk factors you have it gets ratcheted down. So patients that have had bypass surgery, stents are known coronary disease or diabetes in our practice we try to maintain an LDL or bad cholesterol less than 70. Getting to blood pressure. The standard lowering of blood pressure in all patients is around 140 over 90. Now that being said in diabetics we actually are shooting for lower blood pressure because the diabetes along with hypertension can affect the kidneys and the rest of the vascular system. So our goals and where we would implement medication kind of changes depending on the risk that you bring. So you may have a neighbor that you know the doctor's like well your LDL or bad cholesterol is 135 and he did nothing but you could have your other neighbor who has bypass surgery that they want the LDL cholesterol less than 70. Certainly once we know someone has coronary disease we need to help prevent that from progressing further in the future. Interestingly that when with diabetes we look at something called the hemoglobin A1C which tells us your average blood sugar over a 90 day period of time we usually shoot for the hemoglobin A1C to be less than seven ideally getting as close to six as possible studies have shown that when it goes from seven to eight to nine to ten that actually your risk for heart attack and stroke starts going up exponentially. So the implementation of medication is to answer your question is going to really depend on the risk globally that the doctor is seeing in that individual patient. Well I've always been a good one for going off the charts so that's why I kind of went like this because my A1C it was kind of high but it's we're getting it under control as long as as far as that you had mentioned the whole vasco system with the kidneys once we all hear people with blocked we have to put stents into the kidneys does that play into a role or is that not a much factor? Yeah it is when you look and that's called renal artery stenosis now with diabetes how it affects the kidneys is actually almost at a cellular level the filtering unit of the kidney is called the glomerulus and actually diabetes affects that but diabetes can certainly cause blocked arteries going to the kidneys and those are called your renal arteries. Now usually signs of blocked kidney arteries would be high blood pressure that's recalcitrant to any medications. Usually when a patient's on three to four medications to control their blood pressure it's something someone should think about could there be blockages to the arteries to the kidneys and the reason why that happens is that the kidneys will secrete a hormone to raise your blood pressure because they're blockages going to the kidneys the kidney sense they're not getting enough blood so then they secrete hormones to tell the body increase the pressure to get me more blood if a patient does have blockages to the arteries to the kidneys and that causes blood pressure problems that are resistant to medications that can require potentially stenting. Now if you look at the majority of patients that have high blood pressure they have what's called essential hypertension probably 80 to 90% of people have essential hypertension which just basically means as we get older the artery stiffen and as they stiffen our blood pressure goes up so it's the minority of patients that would have a blockage of an artery going to a kidney but it's something that doctor may think about especially in a younger patient where it requires more than three medications to control their blood pressure. You know what you just said that kind of makes sense because my dad had he had one of his kidneys taken out and then his other one and he had some blockages there too and he's always had high blood pressure so when you just sign that if the kidney wants more of the blockage that would make sense of his condition so interesting. So with all of that being said how often should I see a cardiologist what should I look for in a cardiologist you know and you know the type of relationship to form help you know keep my health of my cardio well I mean I think like do all patients need to see a cardiologist you know the answer would be no again it would depend on risk factors, symptomatology now that being said studies have shown patients to see cardiologists are less likely to have heart attacks and will live longer and I think that that's a good thing and that's one of the things that drove me to become a cardiologist that I think that we can have tremendous impact on the quality of life and how long people live and how well they live. Standard well we'll say we had a patient who had had bypass surgery well in a patient that's had bypass surgery we tend to see those patients about every six months we're wanting to check their cholesterol if they're diabetic they're hemoglobin a1c we want to make sure that they're exercising watching their weight so what we want to do is studies have shown by modifying their blood pressure their cholesterol their blood sugar their exercising losing weight that's going to decrease the likelihood of future events like also patients who have had stents well those are like springs to open the artery well we know they have blocked arteries and we don't want that to happen further because stents can also clot off they can start to get atherosclerosis or plaque build up within them but patients who exercise and lose weight and take their medications are much less likely to do so patients that have documented coronary disease other bypass or stents tend to see us about every six months where we're monitoring their cholesterol now with any of these medications we need to monitor blood work like with the cholesterol lowering medication the statins we follow liver function tests to make sure that those are okay certainly I think if a patient is having shortness of breath chest discomfort losing consciousness feeling like their heart's racing that's something obviously discussed with your primary physician and a lot of times the primary physicians are kind of the quote unquote gatekeeper to send patients to us certainly we're always happy to have patients just come on their own without referral as well sure could you go into possibly the type of exercise program I know you mentioned it earlier you know an example of let's say during the week the types of exercises I should do and you know kind of like that for just people to get started on and you know to get going on okay well again I think you would have to make sure with your physician that you're appropriate to begin an exercise regimen but that being said we'll say that you're a good candidate for that the eventual goal is a half an hour of cardiovascular exercise a day so that's walking riding a stationary bike or a regular bike an elliptical a stair climber going outside and walking running swimming we want exercises that will improve our cardiovascular health and raise our heart rate studies have shown that the more times a day that your heart rate goes on baseline to that number that we talked about earlier and then down the better so we're not expecting like if you have a patient that's not exercising a journey of a thousand miles begins with a single step sure again my goal for most patients would be walk two miles in a half an hour one and a half to two miles now that being said we may have patients that can run but studies have shown walking quickly is as good as running now obviously if people are looking at weight loss exercise and watching what we're eating that combination is going to be good I am a big fan of the equipment like treadmills stationary bikes ellipticals and stair climbers and the reason is you know after the horrific winter that we had there's not a lot of time to spend outside and we don't want to go outside so having equipment inside it never rains inside it's never snowy inside but you know if we can put it in our living room or our basement next to the TV in a half an hour just one show sure you could do the half an hour continuously or you could do fifteen minutes in the morning fifteen minutes in the evening people who exercise their blood pressure will go down by seven to ten points their blood sugar will go down so if you want to see a lot of your medications go away exercise weight loss is going to be the key to that okay excellent we're about ready to close we have about a minute or so left is there any other closing advice you have for people as far as being healthy yeah I think you know what I'm a strong proponent of is an ounce of prevention worth a pound of cure I think you know the challenge to everyone out there is we cannot do anything about our genetics but we can sure try to modify our behavior exercise weight loss not eating a lot of sodium all of those types of things because you know certainly I don't want to see a patient with a heart attack I would much rather you know see them at the mall healthy never having to see us at all and you know studies have definitely shown that our behavior very much can predict the future for us okay Doctor Horth I'd like to thank you for being on the show this is most interesting you know about the cardiovascular system that's pretty much our episode for this time for quality of life I'm your host Dave Augustine and we look forward to talking to you next time thank you