 Hello everyone. Good morning. I'm Catherine and I'm the Community Relations Coordinator here at Gifford. Probably talked to a few of you on the phone. And just wanted to say thank you all for being here and spending part of your Friday morning with us, especially going into nice weather. Hi everyone. I see some familiar faces out there, but for those of you who don't know me, my name is Leslie Osterman and I'm a physician assistant here in cardiology with Dr. Andres. So while we wait for him, I'll just go ahead and get started on my presentation. So I'm presenting on atrial fibrillation and atrial flutter, which is a topic of interest to me and hopefully you'll find it helpful and interesting as well. So in this presentation, just an overview of what we're going to be talking about. So the normal electrical signal of the heart, what is atrial fibrillation, what is atrial flutter? What puts you at risk for these abnormal rhythms? How are they evaluated? How are they treated? And just some symptoms you might have if you have atrial fibrillation or flutter. So we'll start with just going, reviewing the normal electric signal of the heart. So the comping function of the heart really relies on electricity moving through the heart to allow it to contract. So the normal signal moves from the top of the heart called the sino atrial node or you might have heard the SA node. And then it moves through both of those top chambers of the heart called the atria in a very quick and linear way to allow those top chambers to contract. And then it moves down kind of to the center of the heart all the way to the bottom chambers called the ventricles. And we rely on this again for that normal pumping function of the heart. So the way that we can see if the normal electricity of the heart or the electricity is moving normally is by looking at an EKG or an electrocardiogram which you may have heard of. So down in the bottom part of my slide here you'll see four beats of an EKG. And that first little bump that you see on the EKG that's what we call the P wave. And the P wave is showing the electricity moving from that top chamber the atria. And so as it what's called depolarizes or the electricity moves through and that you get the contraction of that top chamber you get the P wave. And then the next little blip that you see we call the QRS complex. And that's what we see on an EKG when the electricity is moving through the bottom chambers of the heart or the ventricles. And then lastly you have the T wave which is repolarization or the heart relaxing and getting ready for another heartbeat. So what is atrial fibrillation? So atrial fibrillation is when the electricity is not moving through this nice to organized pattern and it's moving in those top chambers of the heart the atria in a very chaotic and disorganized way. So that signal is coming from a space that's other than the SA node and creating this quivering or fibrillation. And then with every so many beats sometimes it gets down into the ventricle that bottom chamber of the heart. And you can see on the EKG here you can see there's that fibrillation in that kind of straight line or sometimes there's you know there's not even anything clear there. And then in a very irregular pattern you can see when that electrical signal is getting down to the bottom chambers of the heart. And what is atrial flutter? So atrial flutter is similar in that that normal electrical conduction is not again coming from the SA node. It's coming from a different place in the atria. But unlike atrial fibrillation which is this chaotic you know random quivering it has more of a regular pattern than it's following but it's simply not following the pattern that it's supposed to be following. So it's following this loop and then much more regularly it's moving down to those bottom chambers of the heart and causing that contraction of the heart. And you can see that here on the bottom of the EKG it's much more regular but you can see in between that there's that really coarse we call it sawtooth pattern of the flutter waves. So that abnormal conduction through the loop. There's two different kinds of atrial flutter typical and atypical and that just is designating which loop it's going through. So what puts you at risk? What are the causes of atrial fibrillation? So we have a pretty good understanding of what disease processes put you at risk for atrial fibrillation or atrial flutter. The exact mechanism of what's happening to from these disease processes to cause this abnormal rhythm is a little less clear. But some of the the main hypotheses are that these diseases cause inflammation or they cause scar tissue or they cause an abnormal stretch of the heart which can lead to the cells that are supposed to be moving in this very you know coordinated way to not to not be sending the signals in coordination as they should be leading to these abnormal rhythms. So some of the diseases that we think about some of them are cardiovascular diseases like high blood pressure, coronary artery disease, problems with the valves of your heart. Other diseases are diabetes, obesity, thyroid disease, some things are untreated sleep apnea, some things are lifestyle related. So whether you're a smoker or excessive alcohol use all of those things can lead to that inflammation and scarring and sometimes stretching of the atria leading to these abnormal rhythms. So how do we evaluate atrial fibrillation and atrial flutter? So as I showed on that first slide an EKG often if we can catch atrial fibrillation or atrial flutter when it's happening we can see it simply on a few second EKG which is looking at the rhythm of your heart. For some reason that middle photo didn't show up but that should have been a picture of a rhythm monitor which is to put it simply almost like a sticker that you put on your chest and that can look at your heart rhythm anywhere from one day 24 hours up to 30 days so we can get a pretty big data set from that if you're wearing it for a longer period of time. We now have wearables that people wear smart watches that can help detect abnormal rhythms and sometimes they're picked up on that. For other people that their symptoms are so infrequent we can put in what's called an implantable loop recorder and this looks like a little bit smaller than a thumb drive. It's inserted into the chest wall into the subcutaneous tissue and that can be in place for up to three years to look for atrial fibrillation or atrial flutter or other abnormal rhythms of the heart. If we suspect that you have atrial fibrillation atrial flutter or we detected it one other thing that we like to do is an echocardiogram which is an ultrasound of your heart and that picture all the way on the left is showing that ultrasound or one view of the ultrasound and that's is looking at the overall structure of the heart whether those chambers are stretched in any way whether there's clot present which is a problem that can be related to these abnormal rhythms how the valves are working the overall pumping function of the heart whether you're really getting what you need for you know function and structure. How do we treat these abnormal rhythms? The treatment is often really patient specific so how symptomatic are you? How often is this happening? And personal choice so some things that we've you know the first thing that we really think about when we're treating these is going down either rate or rhythm control so for rate control what that means is that we're not attempting to stop this abnormal rhythm from happening. We just want to ensure that when you're in this abnormal rhythm that your heartbeat is not going so fast that you're you're not able to keep up with that good feeling and contracting of the heart which can lead you to symptoms and heart failure and that's often managed with just medication that you take just being a pill then if you go to the other side of the approach for treatment would be rhythm control so rhythm control is is a treatment that its goal is to get you out of this abnormal rhythm and into a normal rhythm that normal pattern that we like to see coming from the top chambers going down and that can be done in many different ways. Sometimes we recommend cardioversion which is essentially shocking the heart trying to bring it back to that normal pattern that we like to see coming from that top chamber going down so stopping that those abnormal rhythms from getting in the way of a normal electrical pathway. Other times we give you medication and sometimes that's taken as needed if you can feel your abnormal rhythm and that can bring you back. Other times you need to take it every day with medications. There's also ablation which is another option for some people to get you back into normal rhythm and that's essentially going with a catheter into the heart and creating a fence around where those abnormal focuses are coming from and stopping them from getting into the normal cycle and depending on what rhythm you have is where they will go within the heart. The other thing we think about when you have an abnormal rhythm like this is anti clotting medication or what we call anticoagulation. So as you can imagine you know the body is made so that if you're bleeding you clot and that's very protective and very important but when you are in one of these abnormal rhythms you can imagine thinking back to one of those first slides where that was the top chambers were very chaotic and fibrillating. You can imagine that the blood isn't filling and pumping through the heart as it should and with any kind of you know abnormal currents of the blood you can have a clot and that clot especially from the left side of the heart you know goes down to the bottom chamber and then has a direct pathway to the brain which can lead to a pretty significant stroke which is you know life changing. So what we do when we see you is we determine what's called your chest to VASC score. So this is a score that determines your risk of clotting and we compare that to your risk of bleeding because as you can imagine blood thinners you know will increase bleeding and if it's been determined that your risk of clotting is high enough then we will recommend these types of medications. So the way that these medications work that very busy picture on the left side is the way that we normally clot and these medications go into that pathway and they stop it in a certain section so that you have your less likely to clot less likely to create that thrombus that can lead to a stroke. Lastly for some people who aren't able to tolerate blood thinners because something has happened like a gastrointestinal bleed or bleed in their brain for some people there's a left atrial appendage occlusion. So on the left side of the heart we were born with this little pocket on the left atrium. I'm sorry I didn't include a picture of this but if you kind of imagine like an outpouching of the left side of the heart within that you can imagine that just like a current in the river if there's a spot that the current can move outside of the normal flow it's more likely to be you know a place that a clot could form. So the way the Watchman device, Watchman is a brand, apologies for that, but the way that this device works is they cover it, they insert a catheter and they within the catheter it almost looks like a butterfly comes out and they put it against that appendage that outpouching and close it off so that you no longer have that space in your heart that's more likely for a clot to form and that can be a way to avoid things like like warfarin or epixavans some of these clotting medications. So when when should we think about atrial fibrillation, atrial flutter, what are some of the signs and symptoms that you may be experiencing? So if you're feeling what we call palpitations of fluttering or abnormal rhythm in your chest then that would be a good reason to call. Some people feel lightheaded, some people have shortness of breath or just incredible fatigue if you're feeling really tired, dizzy that would be a good a good reason to call your primary care provider if you're already a patient of ours give us a call directly and we would be happy to see you and evaluate you for any of these abnormal rhythms in the cardiology clinic. Any questions for me? I know that was a lot and hopefully I didn't confuse you too much. Any questions about atrial fibrillation or atrial flutter or the normal conduction system of the heart? I'm going to take that as we got it. All right, thank you. Hi everyone. I'm Dr. Bruce Andrews and pleasure to see so many people here. I want to make this informal so if you have questions, I want to interrupt, that's fine. I want to talk about the things that are of interest to the audience. I'm taking a guess at that. Sorry for being late. My 8 o'clock patient is traveling from the Concord, New Hampshire area got lost and arrived here late and I said of course I'll see you put that pungal root behind. So I have an ambitious agenda here. I have agreed to talk about heart attacks, their cause and their treatment, about heart failure, the different types and how that's evaluated and treated and vagular heart disease as well and high blood pressure. So it's a little ambitious but I think we'll be able to get through the main points in an unhurried manner. Everyone can hear me okay in the back row so I'm going to walk around a little bit. So heart attacks, coronary disease really common condition in the Western world and now more and more kind of throughout the whole world as frankly Western lifestyle has been promulgated kind of throughout the world. So it's an issue in low-income countries as well as high-income countries and it's a condition that begins really early in life. Am I causing trouble? So the the underpinnings of common the common forms of heart attacks is really a process that begins in teenage years. There was a study called the P-day study that pathological determinants of atherosclerosis in youth. P-day is a abbreviation so it's an NIH sponsored trial where the investigators basically did autopsies on young people who had died in the accidents or because of homicide or suicide and looked at the condition of their aortas and their cornea arteries in their in their teens and 20s and 30s and found surprisingly high rate well over 50 percent of people having early stages of atherosclerosis beginning in the aorta and then moving into the coronaries starting in in late teenage and years in the 20s. This has been shown in other studies too of our servicemen who died in the Korean war of Vietnam war and looking at autopsies specimens. So it's a so the disease that starts in youth and then usually shows up 30s 40s 50s 60s but that this the arc of this disease begins very early in life and essentially the condition is death of a heart attack is death of heart muscle because of lack of blood flow that's the typical calm form of heart attack and the sensation that people get is is called angina or angina the word is pronounced both ways is acceptable and it's it's the that ache that that you get when the muscles aren't getting enough blood flow so if you put if someone put a tourniquet around your leg or around your arm they were going to draw blood and if put the tourniquet on your arm but forgot to take it off after a while your arm would start to ache or your leg would start to ache with a tourniquet on that that ache of the muscles not getting enough blood flow is is really the same thing that's happening at the at the level of the heart and this generally the approximate cause the immediate causes generally a interruption of blood flow the the blood vessels to our heart run on the surface of the heart they're the first exits off the the highway of the aorta so the heart gets blood before anyone else gets blood and then like the the fuel lines to an engine and if your fuel line to your note your lawn mower is is clogged it doesn't run well and the heart's the same so this is this is a busy slide but this is meant to show in a single slide the entire arc of development of atherosclerosis and black development so and it's sort of meant to move time-wise from left to right so that you know the kind of preconditions for vascular disease are some injury to the blood vessel wall the blood vessel this is the blood stream coming through here and this is the the top the lining of the blood vessel and this is the wall of the blood vessel so that's the orientation that there's a young healthy person will have just beautiful glistening smooth wall of vessels the single layer of cells of endothelial cells was acting like sort of like Teflon on a on a new frying pan nothing sticks to it but with high blood pressure with smoking with diabetes with stress you can insure that this lining and if in addition to that you have high level of cholesterol particles particularly small dense LDL particles those LDL particles can get some cholesterol is packaged into particles it doesn't flow freely through the blood stream it's collected it's it's trafficked in small particles those particles can get between the cells and take up resonance in the wall of the blood vessel and there they can be pretty inflammatory so they start to attract white blood cells particularly monocytes that migrate across the wall they get into the this subintimal layer and they start eating the cholesterol particles phagocytizing those monocytes become macrophages they get bigger become foam cells they they rupture and that creates more inflammation the body's hurts the white blood cells are producing single hormones that attract more white blood cells she had this inflammatory state you start to have migration of smooth muscle cells into this area and you start as these white blood cells which are in a pac-man type of fashion eating the cholesterol packets as they get bigger they start to coalesce and form lipid pools of cholesterol within the wall of the vessel meanwhile bloods just flowing through here and you don't know any different but if during a period of high stress where blood pressure is high perhaps you're exerting yourself and there's more hemodynamic stress or shear stress on the wall particularly if the covering of this lipid pool is thin you can have rupture of the the cap the layer over this cholesterol pool that's a pool of magma and now you have an open wound and the body reacts to that like any other wound and it's tries to form a scab and so your body starts forming a clot at the site of this plaque rupture so the the the immediate cellular basis for her attack is generally evil so your body has natural clot dissolving tendencies a body produces molecules that promote clot busting tissue plasmidogen activator in particular and sometimes those clot busting forces prevail and the your body will heal up that healed plaque you may have may go from a 20% narrowing to a 50% narrowing but no heart attack occurs and you don't you don't know that it ever happened another possibility is clot forms and then dissolves and clot forms and dissolves and it's sort of stuttering and people have unstable that's generally produces unstable angina there's sort of this intermittent interruption of flow and then sometimes a solid plug forms and that vessel is shut down and that's a the most serious form of a heart attack the ST elevation MI where there's no flow that's that's a medical emergency where minutes matter you know time is muscle so if someone arrives in the emergency room with unremitting chest discomfort and EKG suggesting that this vessel is completely blocked it's a written it's a red alarm it's a five alarm fire and we try to get that patient into a cath lab within 90 minutes if that can't be done because of distance or weather or transportation then patients given clot busting medications thrombolytic medications if they can get to a cath lab within 90 minutes that's generally thought to be safer and more effective than the clot busting medication and once it's in a stable position a thin flexible wire is advanced through the catheter and out the end of it and then down blood vessel and once a wire is on a blood vessel then a balloon which has a hole in the center can be tracked over the wire just goes with a wire goes tracks over it and is expanded to stretch open the the blockage to prepare it for a stent that balloons taken out over the wire the wire stays down the vessel and then another balloon goes in with it with a stent crimped onto the surface and it looks like chicken wire and it's been crimped onto the on to the balloon it's positioned in place and try to cover the whole area of badness from before the beginning to after the end and then that water is a water balloon so they have more oomph than a air filled balloon and the the stent is deployed and pushed firmly against the wall the water balloons withdrawn and the balloons taken out along with the wire the stent stays behind as a scaffolding it's there forever body slow grows over a period of time a layer of tissue over that stent and kind of grows a smooth layer there that and we give patients anti-platelet medications to prevent clot from forming so that's the causes the the path that kind of pathogenesis and the treatment of heart attack when someone has we know someone has heart disease we try to pull all the levers that promote heart disease we try to address what the American Heart Association terms life's essential eight and Emily will touch on that and has some handouts on kind of a modifiable risk factor you know conditions for promoting heart disease some some respects we can't do anything about we can't change our age which is a risk factor we can't change our family history or parents are who our parents are so these are kind of eight eight things we can do this is a patient my catheter is coming into the artery gently injecting iodine can train containing dye the iodine stops the x-ray it's very good at stopping x-rays so you get good contrast between where the dye is and isn't you can see is an abrupt and complete cut off here so that's causing a cute am I what in this this is the kind of the before and after so wires from place down the vessel that pulse-dent procedures been done and you have a nice happy ending here right thank you yeah situation where we can detect damage in a blood test represents a blocked artery type 1 infarction to generally heart attacks caused by blockage type 2 our heart our heart attacks that are generally occur when there's minimal plaque or there's plaque but the plaque hasn't changed it's been it's the same as it always been but the but there's been a demand side problem the heart has required more blood than it can deliver so you've had a surge in demand not a drop in supply so example would be your heart suddenly goes into a fast rhythm and your heart is beating 200 beats a minute and that goes on for an hour that's pretty unusual stress or your blood pressure goes to 180 200 and the demand for blood supply is very high so you it's a supply demand problem but it's it's primarily a demand problem so that's you may hear type type 2 am I I mentioned life's essential 8 this is reminds us to eat a healthy a heart healthy diet which is generally plant-based for the most part of though modest amounts of animal protein are okay this should be clean and modest size but you also get protein from from plants you want to try to get on 150 minutes or two and a half hours of physical activity per week so like 30 minutes five days a week would give you 150 minutes you want to have good blood sugar either not have diabetes or have diabetes under good control want treat try to maintain a healthy weight just much easier said than done want to keep your cholesterol numbers low trick of the LDL cholesterol or that particle number want to keep your blood pressure under control you don't want to smoke cigarettes and you and that knew this year is sleep so you want to get seven to nine hours of sleep is what studies have suggested more than nine hours sleep is actually not good less than seven not good so those are hard to tack in hard attack in 10 minutes any any questions about heart attacks for him move on yeah curious okay I might sense put in about 10 years ago or okay and I'm just curious any advanced advancements and there's advancement testing whether you've had a heart attack or not or what the symptoms are yeah so I think you're asking is there any advance about how to tell the status of those stents or whether other blockages are developing that too yeah or how the stents working yeah I was still under warranty this is one of those few situations where time is actually on your side the longer you go since your stent proceeded with no problems the kind of the less chance there are of having problem with those stents so stents are not perfect they have a thick they can fail they have two main failure modes one is stent thrombosis you can form clot on the stent and that generally is a risk in the first three months before the body has a chance to grow of this layer of new cells over the stent and that's why people are generally on two anti platelet medications so once you get past a year or even three months your chance of stent thrombosis drops off dramatically the other vulnerability is instant restinosis or scar tissue forming within the stent kind of rubbery tissue that's basically scar tissue some people will notice if they cut themselves they'll get a big scar kind of something called proud flesh or big heat up scar or cheloid that's just exuberant healing that can happen inside the stent they're drug-coded now they've been drug-coded since around 2003 and that drug coding is to prevent that scar tissue so that's a risk you know it's maybe one to five percent of people and that's in the first few years so if you make it past the first three years with no problem in that stent you're probably not going to have any problem with those stents you can have problems elsewhere in the circulation but those stents probably not going to give you trouble where as opposed to bypasses where the bypass the vein graphs the risk of blockage of a bypass graph increases with time to tell whether someone is developing blockages and other vessels we generally rely on on symptoms there people have asked the question is it a good it would be a good idea to do stress tests if someone had a stent put in last year should we do a stress test every six months or every year just for the rest of their life so that question was asked in the dyad trial so they took diabetics who were increased risk of recurrent events and randomized them half of them had stress tests on a regular basis the other one had a stress test only if they had symptoms and they just watched to see what happened over the next five years and doing routine stress tests and people who felt fine it didn't seem to reduce death at all it was the same death rates same heart attack rate in the two groups it led to more heart catheterizations and more repeat stenting but there was no benefit from that so a long-winded answer is we we have a lot I try to have a low threshold for doing testing but don't not do routine testing the the other thing I'd say is for people who are on the offense about whether they should take Medicaid strictly a statin medication to lower cholesterol they're not sure that they know they have someone increased risk but I want to take more pills I've heard bad things about statins I don't want to take that stuff sometimes I'll discuss the idea of doing a CAT scan of their heart arteries of coronary CT angiogram CAT scanners have gotten fast enough that we can see the blood vessels of the heart heart so only vessel it's moving in the body so it's harder to photo harder to photograph essentially but we can get reasonably good pictures of heart arteries now and CAT scan of the arteries can sometimes help someone decide whether they should take a statin or not because we can say you're already have plaque but we can see it on the CAT scan you have you have plaque in multiple vessels and your calcium score is 200 so this is not no longer a theoretical discussion like you have atherosclerosis does that answer the questions sort of yeah so heart failure another huge topic textbooks written on it heart failure is a terrible name it's scary as heck heart failure to you know I think to most people is synonymous with like cardiac arrest and it's an unfortunate name but that's the name was kind of that stuck and it that heart failure just means your heart's not working as well as it should it may be my very mild it may be very severe in your intensive care unit and looking at need for a heart transplant it's it's a huge spectrum in August the term heart failure I don't really I don't really love the term I think cardiomyopathy which is a mouthful but it's it's probably a better term just means cardio meaning heart my own meaning muscle pathi being the disease or condition so it's a heart muscle problem and a large percent of the population eventually if you live long enough have some limitations from your heart it's like you own a car long enough eventually the horsepower of that engine is going to diminish it's not going to generate the same horsepower it did when they rolled off the production they know that the assembly line so this is a reminder of this circulatory system of all mammals really as I as Leslie showed our heart has four chambers kind of the staging areas the atria and then the major pumping chambers and right ventricle left ventricle right ventricle generally has the easy job it pushes blood through the lungs there's not much blood pressure in the lungs it's pretty easy and so the right ventricle is pretty thin walled the disease valves that are one-way doors supposed to keep the blood going forward not going backwards they just open and close based on this based on the flow of the blood there's no one there's nothing actively closing them and then blood picks up becomes oxygenated carbon dioxide is expelled when we exhale and the blood takes on oxygen oxygen and binds to our hemoglobin the hemoglobin molecule changes color and we have nice red blood comes back to the heart and the heart pumps it out to all the organs of the body so there's an every cell in our body needs this fuel needs oxygen and these glucose really our bodies are really like internal combustion engines we're combusting carbohydrates we're burning gas kind of you can think of you gasoline kerosene that these are all hydrocarbons they're not dissimilar from glucose and turn and our body it's like a car engine or your chainsaw your wood splitter your car engine they're all you're you're using oxygen you're combusting carbon base fuel and you're producing carbon dioxide and our bodies are doing the same thing we're we're combusting fuel with oxygen and producing carbon dioxide so we have quite a quite a need for a strong pump to deliver that to deliver that oxygenated blood and the metabolic fuel so our heart is like it was really an engine that's trying to pull a train around and they the extent to which that engine is taxed is affects what your exercise tolerance is normal heart is not too thick not too thin it's a gaudy locks this is the gaudy locks of hearts it relaxes it's thin enough and subtle and subtle enough to relax and fill easily at low pressure and then contract and and squeeze well and the valves work normally they don't leak and electrical system works well but heart failure is generally divide into two types half ref and half pep half ref is heart failure with reduced ejection fraction it's also called systolic heart failure the problem is the squeezing phase of cardiac motion that that's the heart's been damaged or there's a genetic maybe a genetic condition or the electrical problem that has caused the heart to enlarge and weaken and it can't contract and that's why the cardiac output is diminished and have path which is actually put a little more common more common than half ref the heart does not relax well it can't get a full stroke so I often make the analogy between a heart and a black Smith's bellows so you can imagine a blacksmith with big burly biceps and he's got his bellows and he can squeeze the bellows great but if the small little bellows and you can't get a good stroke of air you're not going to fan the fire much you just you need to get a big fill in order to get forward motion so in half path the problem is is the filling phase the other form of heart failure doesn't really fit well into half ref half pep is is heart failure due to valve problems because that was not really it can it's not a problem with squeezing or relaxing it's a problem of inefficiency related to leaky valves the aortic valve can narrow and create an obstruction to flow out to the aorta it's a common condition it can also leak the indoor to let ventricle the micro valve the entrance can leak or be narrowed and then the same way the entrance valve and the exit valve of the right side of the heart can leak or be narrowed and that that's not a that's not a squeezing problem or a filling problem that's a that's a doorway problem this is a some people are born with instead of the normal three leaflets some people with just two leaflets of bicuspid valve fairly common about 1% of the population they're subject to somewhat premature narrowing of the aortic valve but narrowing the aortic valve is very common and and it creates resistance to blood flow this is an illustration of a leaky mitral valve so the this creates a volume load on the left ventricle the heart has to pump the same blood over and over again it's supposed to be all going out the exit but half it's going back through the indoor so it goes up and then comes back so the heart's you know disadvantaged and having to or repeatedly pump the same blood so the how do we evaluate this echocardiography is common first step in evaluating someone with shortness of breath and possible heart failure it has non-invasive gel ultrasound gel is put in the chest the and ultrasound waves are bounced into the patient and bounce back to the same probe and creating a picture and we get these pictures here we can look at blood flow which is color coded we can assess the blood flow of the heart in a variety of ways a nuclear stress test is a common way this is done radioactive tracer is injected into the vein of the arm it's taken up by the heart the tracer goes where the blood goes and there's two sets of pictures done one at stress and one at rest and then you lay out all the pictures side by side this is like slicing through a loaf of Italian bread and there should be uniform distribution of tracer kind of all walls of the heart and this top row is a stress row this is the rest series you see on the stress series on the bottom wall of the heart there is an area that's not as bright as the surrounding walls and but at rest it's fine so this looks like there's a blockage of blood flow to the bottom wall the heart you're comparing the distribution of tracer this is slicing the heart the other way like slicing vertically the length ways of the Italian loaf of bread and this is a horizontal long axis you're slicing the Italian bread sort of parallel to the table so it's a way to kind of confirm what you think you see in other views I mentioned we didn't like skin for a second or turned it off and so I mentioned cat scans cat scans have gotten faster contrast is injected in the arm that the timing of the pictures is such that they're trying to wait for that contrast to get to the arteries and then take the picture while the blood vessels are full of contrast you get a picture of the arteries not everyone is as beautiful as this picture but that's what you're hoping to see in this case you can see a little bit of flex of calcium here this is a pretty good look on blood vessels and then cardiac MRI is very useful to look at to characterize the tissue of the heart the tissue of the muscle itself for people this can be claustrophobic inducing the MRI is a more confined space than a cat scanner it doesn't involve radiation it involves magnetic fields and tilting the orientation of the hydrogen atoms in the in the tissue kind of tilt tilting those hydrogen atoms in one direction and then letting them relax and it generates very generally very sharp images of the heart can give you precise measurements of cardiac function cardiac volume size and look at the muscle itself great thanks so how do we treat heart failure try to identify the under what's causing it try to get the root cause that's kind of true of everything in medicine and then address the underlying cause if you can sometimes someone's is taking a medication that's harmful to the heart or they're drinking too much alcohol they're doing something that's that's straining the heart muscle try to address any associated disease that the person has a very overactive thyroid and that's causing it if they have severe elevated high blood pressure if they have heart failure because they're very anemic you address those those causes if the heart rhythm is out of whack try to get it back in the normal rhythm or slow it down if the problem is a plumbing problem of this lack of the fuel lines to the heart or plugged try to open fuel lines and if the valves aren't working fix the valves so it's sort of the treatments tailored to us which in in chronic when the heart is not working well the body stress hormones rev up and these fight or flight hormones are they're helpful in the short run like in few minutes or hours they're deleterious long-term so I tried to shield the heart from these stress hormones and and four people with weakened pumping action for half ref we generally try to get them on a beta blocker an angiotensin receptor and neprolysin inhibitor agent a mineralic cord receptor antagonist and a sodium glucose co-transport inhibitor so we try to get them on four class medications we try to if they're congested the lungs are full of fluid try to get them to pee off that extra fluid so diuretics are commonly used try to no matter what their initial level of health exercise is helpful try to promote fitness depression discouragement or common with our disease try to address the mental health issues and and throughout the entire course but especially the end of life really provide compassion and comfort so that's heart failure yeah any questions about heart failure heart valves as I would talk about but I kind of kind of wrap that in with heart failure so I'm going to finish with hypertension how am I doing time-wise maybe over about like 30 minutes I'll make this brief high blood pressure sometimes called a silent killer those who doesn't cause people mostly don't know we have high blood pressure unless it's really high and then we can get headaches or blurred vision or chest pain or shortness of breath but your blood pressure can be pretty high and you don't know it at all and no one really thanks you I got a complaint for a minute no one really thanks you for treating their blood pressure no they don't really thank you ever but we're doing it because we're trying to prevent stroke high blood pressure in the brain is a major risk for stroke we're trying to keep maintainable vision we're trying to prevent heart failure down the line long after you've forgotten us we're trying to prevent heart attacks we're trying to prevent kidney failure and we're trying to maintain blood flow to important organs so getting back to where I started here blood pressure was reported as two numbers systolic over diastolic and generally in home readings we'd like to see them with your average reading of being less than 130 on top and less than 80 on the bottom the top number is the blood pressure when the heart's squeezing and the low number is the blood pressure when the heart's refilling so if you measure blood pressure if you can measure blood pressure continuously like with a catheter in the artery it's a it's a sine wave right it's it's changing every second every tenth of a second and the systolic is the high number diastolic is a low number and it's the fourth it creates pressure on the wall of the vessel Emily and Leslie and I are big big proponents of home blood pressure readings because a lot of people do have some degree of office hypertension and unless you will Emily will get into this etc a little bit so that can this is a drill we that we recommend that you that you pick a time of day when you're not stressed when you can relax we haven't had a cup of coffee in in the last hour you haven't had a fight with with some loved one and you haven't just watched the news and you put the cuff on your arm sit at the kitchen table and just sit there in silence for a full five minutes go to your happy place and then push the button on your electric blood pressure cuff that fits on your upper arm then it's better than the rest and get a blood pressure reading wait two minutes do it again wait two minutes do it again so three readings after five minutes of rest if one arm is higher than the other use the higher arm so if you did that once a day for three or four days you'd have nine or 12 blood pressure readings and you add up this systolic numbers the top numbers and divide by nine add up the bottom numbers divide by nine you'll have your average and you know that's that's a good number to go by rather than the one reading you got in the doctor's office when you were like hustling it and you were later you were annoyed by kept being kept waiting so ideally what was your lesson 120 over 80 pretty hot pretty hard to achieve this I'm frankly happy if we can keep readings below 130 and 80 but that's technically considered elevated and then high blood pressure begins with a blood pressure above 130 and above 80 and stage two hypertension begins with blood pressure above 140 and then hypertensive prices above 180 that's not this distinct from hypertensive emergency which is different but that's that's a current classification system that's why we care and so medications are sometimes needed for high blood pressure but this things we can do lifestyle wise we can eat less salt we can walk we can avoid ibuprofen a leaf nuproxen these agents which can raise blood pressure and we can reduce or eliminate alcohol which if you're drinking more than you should which is two two servings for men and one serving for women drinking more than that you're at that can have an effect on elevating blood pressure many folks need more than one medication sometimes two doses too low a low dose of two meds is better than one sometimes you need to try different medications these are different classes for sometimes we choose based on what other medical problems you have and that's all take questions yet informally I guess later so next we have Emily Russell she's one of our heads so I am Emily and I am working in the cardiology department here at Gepard with both Bruce and Leslie and I'm going to keep the short and sweet you have a couple of things you can look at at the end if you're interested but I am going to sort of give my top three tips on how you can be your own best advocate at your doctor's visit and the first is being an active participant in the conversation versus just physically being present and not really taking in all of the information come with a list of questions if you feel like if you're going to go to the doctor's office and maybe you're not going to remember everything that you want to ask come with the list try to keep it maybe to the top three most important concerns that you have at the time and consider potentially bringing a family member or a friend who can be your support for San and extra set of ears you may be able to take notes for you again if you feel like you're not going to remember everything that has been talked about not a bad idea to have a second set of ears you know sometimes if you're feeling nervous or if you're not feeling well that day you may not be able to take in all the information that you need so having an extra set of ears there would be good my second tip here is probably the most important I think is coming prepared to your visit making sure you have a medication list with you that is current and up to date part of my job is before you see the doctor to verify your list of current medications and your list of allergies your medical history and things like that and if you come with a list whether it's handwritten or we have the ability to print out a list for you it makes it very simple and easy for everybody if you have that prepared and we do have a couple different styles these actually fold up into a nice little wallet size square here everyone offers more information this one I really I think is really helpful you can pitch a medication here and what is it for and I think knowing what you're taking and why you're taking it is really important there's a lot of people out there that don't necessarily know why they're taking certain medications so having a list that you can also look back on and say oh yeah I'm taking this because of my blood pressure very helpful for everybody and if you are a new patient to any clinic not just cardiology having maybe a brief little medical summary that lists maybe procedures that you've have done in the past if you are a patient at another hospital having some of their records available will also be helpful to the providers taking care of you so they can get the full picture and again if you are here for blood pressure having that home blood pressure log which there is a little handout in the back if you're interested in maybe starting that having your home blood pressure readings at your office visit so we can compare you know what is your office visit reading versus your home reading pretty important and then understanding using effective communication with your healthcare team and what sort of communication is available to you you can certainly call us on the phone to report any questions or concerns that you may have been having and there is a patient portal which we also have a little handout which I would recommend you can get lab results and direct communication with your providers that being said the portal is not to report emergent situations that is where you want to pick up the phone and call myself or your primary care and just say like hey you know I'm really not feeling well if you're having chest pain that's certainly not something you want to just type a message to your doctor to that requires more immediate intervention so that's all I have so being an active participant in being engaged coming prepared and knowing how to use your communication effectively good morning how's everybody doing do you need stretch breaks everyone's okay shift a little bit all right you look good I am Dr. Courtney Riley I am a pediatrician actually by training and I would love to talk to you today a little bit about a genetic cause of early heart disease and strokes and it's called lipoprotein a or LP little a you might hear me use them interchangeably today and if you're wondering why a pediatrician is talking to you about it well this runs in my family I first heard about this about 10 years ago when my dad was in his 40s and he was on his like fifth or sixth stent with relatively normal LDL levels and the doctors are like this doesn't make sense you should have your LP little a tested he had this tested and it was elevated because it's genetic they recommended that my brother sister and I also get tested and my brother and sister also had it elevated they were children at the time and so the doctor said don't worry about it there's really nothing you I need to do until you're older who this is my baby sister sorry it was not expecting about two years two years ago she went to sleep and never woke up she had a heart attack at 23 it was her first one so the advice we got to wait was wrong and I've since learned a lot about it and I really want to share that with you today so thank you this is a relatively old side but it's fascinating to me this is from 2016 and it talks about the causes of death in the United States and what we are interested in and what the media reports on so the first column is looking at what we die from heart disease is number one 30 over 30 percent of people in the US will die from heart disease the second column is what are we googling what are we afraid of what are we interested in 2% of Google searches are on heart disease a lot of it is cancer the media is the last two columns it's looking at two different magazines and what they looked at over a course of a year and again only about 2% of what they talk about is heart disease so there's obviously some room here and then a little bit more recently 2020 what were you watching on TV all the time what were we talking about all the time was COVID right but still even in 2020 COVID was only the third leading cause of death it was still heart disease and we're not really giving it enough attention so LP little a is incredibly common everybody has some LP little a but when it's elevated that's the problem and it is considered elevated in one in five people worldwide not just the United States so that means about 1.4 billion people worldwide has elevated LP little a I don't know about you but when it numbers that big it actually means nothing to me so I've broken it down to get a little closer to home so in Vermont over 600,000 people as of 2019 so one in five suggests that over 120,000 people has elevated LP little a if we're looking in our town of Randolph about 2,158 people were here in 2019 so 431 people in our town alone have that counted there's about 25 people in this room today so that means about five of you also have elevated LP little a and as in the case with any genetic condition if you catch one person you catch more who have this right so this is my family of five my mom dad brother and sister and in my family of five actually four of us have elevated LP little a so I think to help talk about what it is it helps to take a step back and look at what LDL is typically when we talk about cholesterol in like the public general sense what we're actually talking about is our LDL and our HDL these are terms you've probably heard many times right technically cholesterol is these little yellow particles that are in the center of this ball cholesterol is not a bad thing necessarily right our cells need cholesterol for our cell membranes it's important for hormone production but most of the cells actually make all the cholesterol they need we don't need all this extra cholesterol but we have it and when we have it it can't go through the bloodstream on its own because it's hydrophobic so it gets packaged into these little particles right and so that blue ApoB 100 is a protein that part of that for an LDL particle makes it so that that cholesterol can kind of run through the bloodstream they have more dense particles that are it's more tightly packed and those are called HDL your high density lipoproteins so lipoprotein A is actually like a LDL like particle so it's got is this a pointer yeah it's got this LDL like core with that same protein but then it's got this other thing called apolipoprotein A because they like to make things very long which is just all of these little cringles and so it's basically LDL with a twist they call these cringles because they look like a cringle so that's cute but it what happens here there are a bunch of repeats on here and this is really the part that can be variable this is the genetic part if there can be any number of copies from one to 40 of these in each individual person and so the reason that these cringles are really important is because they look like something else that our body also has so you may have noticed Dr. Idris mentioned plasminogen quickly you want to use talking about blood clotting so plasminogen is a precursor to plasmin and plasmin is important to break down blood clots well these cringles over here look a lot like this so they get in the way and so basically when you have a lot of these running around your LP little A's you're not getting that same blood clotting breakdown that you need so the blood clot stick around longer so it's generally well understood that LDL is bad you might have heard of say this is the bad cholesterol right well if LDL is bad then LP little a is also bad but maybe even worse and so it there's really a trifecta going on here with LP little a when it comes to heart disease so it has the lipid properties so it's getting deposited in the walls of the arteries just like we already talked about I don't talk about this too much but it also actually can deposit on the valves of the aorta as well and can it can lead to aortic stenosis but it also has these thrombotic properties which means it can cause blood clots because of inhibiting that breakdown and then this part I didn't even actually mention yet but it also has inflammatory properties and so if I go back this little sunburst here is an oxidized phospholipid that stays there and basically this particle is like a bomb that's carrying its own match this is just coming around it disrupting the endothelial layers like we already talked about and so it's it really is just like everything you need in one one particle it is genetically determined we get two one allele from each parent and both are expressed actually so you can have two different types of LPA particles in your blood system or you do have it in any time and again the part that is variable are these repeats when I first kind of heard about this I thought oh so the more of those repeats you have the worse your LPA is that's actually not true though it's because the ones that are smaller get reproduced faster in the lever so actually if you have the smaller number of repeats you're more likely to have a higher number of these particles floating around and this level remains we think relatively constant throughout life and it reaches this level by age five so if you get your LP little a tested or your lipoprotein a tested at any point in your life you can generally think that's you can figure out where you fall in that risk category so if this is so prevalent and it is so dangerous why don't more people know about it well testing is pretty controversial still in my training anytime you know in the lecture halls or on the words the kind of phrase that got repeated is if this is not going to change my management I'm not going to test for it if I can't offer my patients anything then why would I want to know that it exists that's a little paternalistic first of all but also yet there's nothing yet but things are definitely in the works and I will talk about one of them after but the other thing is we talked a lot about other things you would do to lower your risk factors keeping your LDL low avoiding medications and situations that increase your risk of blood clots and then I think also I didn't put on here before but empowering you to feel like especially like as my sister was a young woman who had symptoms but they were they were always like oh that's anxiety that's anxiety so I think it would have knowing this information would empower you to be like maybe it's anxiety but also can you check my heart and then the more we know the once it becomes more well known how widespread and deadly this is that's going to be what drives research and change it's sort of awful to think about money but that's what farthest pharmaceutical companies think of if they realize how many people would benefit from a medication like this I think then they'll start to notice might be worth their time so they are finding out that is a little bit hard understatement to break down LP little a but what they're finding improvement with is actually preventing the production in the first place and so they're doing a few different studies and they're actually having seemingly good tolerance and and some pretty good response rates so hopefully pretty soon we'll have some actual answers so I tried to tell you all the most important things but there's so much else to say so if you are interested in other lectures I found these ones to be the most helpful but I'm sure there there's plenty of other information out there for you and I it just feels so big to me right now that there's I feel like there's a lot of forward movement with this and change and so I'm excited to see kind of where it goes and these are my references are there any questions yes it's a blood test it's a blood test so it's a simple blood test you just need to test once in your life with a caveat that actually does go up in women after menopause so women maybe want to test twice and I asked the Gifford lab and out of the pocket would be a hundred and fourteen dollars you can order it through like quest or other places and it's as low as 30 I saw and actually Gifford has added it to our our like lipid screening that about once in every patient's life we would do an LP little ice screening so if you haven't had it done yet ask about it our providers are informed it is not a CBC but you could get it at the same time yeah if if you're having a venipuncture or a blood test for anything else you can ask your doctor to add it on I know that's why I'm here yes yeah but it really like I when I was a medical student is when my dad was diagnosed and I looked for it I listened for it and in four years of training and then three years of post training I heard it one time and it was a tiny two sentences in a Robin's pathology and it just said this is genetic might increase your risk and I was like oh that's fine that's not gonna change my life since the 60s that's kept secret until now tell your friends and your family one of the things you mentioned was avoiding or watching medications that might for blood clots etc is that not really our PCP or our pharmacists I mean how do we have a partnership for sure so in my case so I'm a pediatrician so I don't often put kids on things that would cause these but this is and this is a full disclosure my this is not studied yet but estrogen can cause blood clots so can this and so as a pediatrician birth control is what I prescribe kind of most I personally will not prescribe a birth control to a young woman unless I know she does not have this because I do think that that played a role in what happened with my sister so yes I think that is one thing that you can know and then have that conversation with your doctor like if you have that you can just say just throw it out there like if they're going to give you a new medication does this increase my risk of blood clots because I do have this and please do that because your doctor handling has like 15 minutes to see you so if you could throw in those important things that'd be great hi I'm Walter Ziske I'm a care coordinator it's a fancy title for a social work light a little bit down but I'm also a health coach so I'm going to talk to you about three concepts today which is nutrition self-management and health coaching as you can see that the middle one self-care is not selfish so where is my button zero I've moved it all right so nutrition talk about mediterranean healthy eating low sodium ultra processed food and processed foods my daughter there we go all right so the benefits of mediterranean mediterranean eating are the three do service for heart hypertension stroke some types of cancer and osteoporosis and we'll get to mediterranean eating a little bit lower sodium it's recommended for anybody who has high blood pressure or hypertension to consume no more than 1500 milligrams of sodium per day and that's not just the salt you might put on your food that's also what's included in any processed food that you might eat and we do find that you look on food labels sorry to look over here more so make sure you know calories are important but also looking at other factors so you want to start with what the serving size is this happens to be a mac and cheese check the calories there's there's two servings in this container and then you also want to limit the ones that have total fat saturated fat cholesterol as we heard about cholesterol sodium of course and then also get enough of your good nutrients which is dietary fiber and your vitamins of course the footnote which is your recommendations and the state of Vermont and food labels have actually on a little bit better where they've made the the most important things a little bit larger they've actually actually showed you how many servings are in a container and what the calories are we can talk a little bit about ultra processed and processed food so the three main ingredients that they put in processed foods to make them tasty and you want more of them is fat salt and sugar anything that's lower in fat that they call low fat usually has an increase in salt and sugar anything that's low sugar they usually increase the fat and the sodium anything that's what I miss that sugar anything that's low sugar they increase the other two so show our hands how many as how many of you have every in one donut in a sitting two three four okay reason why I say that is think about what we consume for sugar in this Dunkin Donuts that I'm not against Dunkin Donuts I actually used to work at Dunkin Donuts think about how many grams of sugar are in this drink so not only what we eat but also what we drink so thinking about that now it's like all right Walter now I can't eat anything I can't drink anything of course you can I missed like three slides hold on all my Mediterranean diet went away all right that's okay so how do you help how do we help you you've got a lot of information today so there's a few programs out there that can assist you with changing your lifestyle changing your diet dr. Andrews talked about that essential eight there's also a concept called lifestyle medicine which talks about whole food predominantly plant based talks about physical activity restorative sleep not just getting sleep but also restorative sleep stress management avoidance of risky substances and then also very good social interactions so one of the things that the state of Vermont says is we love our citizens we want them to be healthy so they've developed a number of programs which are clinically based which are studied and it's called self management so that's where the self-care comes in so this these are mostly online we've gone back into in person in some cases since COVID is diminished so these are a couple of the high blood pressure self management classes that are offered now the advantages these are free just takes a little bit of your time they generally run an hour to 90 minutes and eight classes and again it's free so high blood pressure management so these are some of the concepts that are gone over and actually this program was the one that the state of Vermont is using currently is the one that was developed by Clemson University and the workshops have met meet for 90 minutes for 90 minutes over eight weeks they talked about the banks basics of hypertension control they talk about nutrition they talk about physical activity talk about stopping tobacco stress management medication management and then at the last class class number seven may say well where's the where's the number eight but it's in there talk about long-term planning so you meet for the eight weeks and then you make a plan for the next six months because lifestyle change is not overnight it takes time so meeting for those eight weeks just gets you trying new things modifying things just a little bit small steps and then you think about the next six months what do you want what's one change you want to commit to so I do I am a lifestyle coach for the diet blood pressure management class I'm also diabetes prevention diabetes self-management I wear many hats my wife says why are you doing on the class Walter because I like to do I had one gentleman who came in his physical activity kind of stayed the same but he was able to lower his blood pressure his high number from 160 down to about 140 142 just in those eight weeks and that small change actually reduces your risk sorry I'm just trying to think of the statistics it's maybe a 10 to 15 point drop in your high number we did see your risk of stroke or heart attack by over 30% so just a small change so when he started reading labels he went oh my word he was eating dinty more hash and he looked at the sodium level in that 801 serving and then he looked at the serving size of his can two servings 1600 servings of sodium so sodium so sugar they all lead to high blood pressure and I can tell you why sugar leads to high blood pressure so you want a healthier heart sugar increases your insulin levels which in turn activates and motivates your nervous system which then increases your your your your heart rate so reducing the sodium reducing the sugar so he was able to reduce that and he also looked at what's my cereal oh I'm gonna go with this because that no no sodium in it that one had sodium so he was able to reduce it just by that so healthy eating reduces the risk for hypertension stroke did I go back all right here we go so one of the concepts that came out of the self-management glasses one for Clemson Clemson is a concept I really loved it's it's called go slow and low foods so go foods usually are low amounts of fat and added sugar and sodium you can almost enjoy these anytime so these are fruits and vegetables whole grain foods without added fats low fat milk and milk products and lean cuts of meat so the user yes I love graphics so I got this little stop sign that says go in a heart you're slow foods foods at high levels in fat and added sugars there there more than the go foods so vegetables that are prepared with fats and sauces canned vegetables one of the recommendations if you do enjoy canned vegetables I had one gentleman he says I love my canned peas like okay but look at the sodium continent so if you do get canned vegetables it's recommended to rinse them because that'll reduce some of the sodium in there white bread french toast things like that white rice brown rice has the same number of things it just has a little bit more fiber in it fruit that is canned in syrup versus fruits that's canned in juices 2% low fat milk whole eggs cooked without added fat those are your slow foods so I'll get into this your well foods fried foods baked goods going back to those doughnuts cake spies smoked or cured meats whole milk pickle vegetables pickles regular soda salty chips a food can be a go slow and low food so they could be chicken baked no skin that's the go category a potato potatoes good it's baked then it goes in the category if it's baked with skin potato if you add butter and sour cream the low food is when a chicken is fried or you turn it into french fries so health coaching this is my favorite topic actually health coaching is not somebody yelling at you with a microphone it's also not this you're not done when I tell you you're done if anybody knows this Jaleigh Michaels you know biggest loser health coaching is supportive it's empowering for you it's future focus as well we don't say oh why'd you do that kind of thing so this like ask the expert you're the expert I always tell people I'm in the expert in behavioral change because I've been trained in that you're the expert in your own life and what fits into your life what change you want to make you decide what path you want to make and we have two health coaches currently at Gifford myself and Carolyn Higgins so so we create a vision where you at and where do you want to go and how do we get you there we work out a plan all right we go out three months what behaviors do you want to see what things you want to be doing to be able to make improvements in your life that lifestyle change then we go weekly into creating that path we check in talk about goals is a goal too high is a goal too too easy it's always the simplest as easily the best you make those small changes and then we review the progress the goal of health coaching is for participants to learn that they can make small incremental changes that have a significant positive impact on their life long-term health you really have the majority of the power to make changes in your life the nice thing about health coaching is I'm free we're free so I like that I like this quote by I think Jim Rubin take care of your body is the only place you have to live which is very true questions one that you eat every day that works for you yeah that's healthy for you and it is it doing them any good I mean how much stuff is processed it's all based around something easy sure you know the eight-night go waffles in the morning is that is that a consider a good breakfast what's what's the balance if you so one of the concepts is is half of your plate low-starch vegetables or fruit is half a quarter of your plate a protein and is a quarter of your plate a grain so if you think about that throughout your day are you getting 50% of your calories from low-starch vegetables are you getting a quarter of your print your calories from some sort of protein healthy lean protein and then you incorporate a quarter so think about the process and this is an uphill battle because I'm gonna try to not go down too big of a tangent when the federal government went after the tobacco company the tobacco company said how can we make money so they buy a started buying up some of the food companies and they took the addictiveness that they created in the tobacco and they put it into the food industry think of your grocery store 20 30 40 years ago you really had mostly non-processed food but now you walk down the middle of grocery store and when you see process process process so thinking about everything in moderation and that's what we can help with you know you spend maybe 20 minutes maybe 40 minutes if you're lucky with your doctor with the self-management class you spend eight weeks with health coachings I've been health coaching some people for over a year and I usually do it 30 minutes a week sometimes we go every other week sometimes we go once a month I have one person we meet monthly and it's just making those changes so going back to your question of healthy breakfast there's so much study out there but within that frame 50% low starch vegetables and fruit quarter quarter protein and a quarter grain some sort of that and try to be as less processed as you can because all the additives and all of that and I won't get into the pesticides and all of that either but any other questions look at that I'm right on time thank you everybody well that's all we have for you today so thank you all for coming before we go are there any questions for any of our presenters I know they asked throughout okay there are some I have yes can I get one of just to mention SVT I knew to that and so even though it's been explained to me I don't feel like I totally understand yeah sure so SVT stands for super ventricle tachycardia and it's it's an umbrella term for a few different arrythmias but we all have in common that they're fast meaning the 100 and they're coming and they're coming from the upper chambers and they can they span quite a spectrum of severity some people have SVT with runs of extra beats that last as few as five or six beats other people will have runs of SVT that go on for half an hour an hour and they vary in how fast they are some may be very fast 180 190 beats a minute and very debilitating and others are much slower 110 beats a minute they're mostly nuisance arrythmias are generally not life-threatening arrythmias but they can be they can really compromise the most quality of life and the first step is to try to understand why it's happening and if are there any reversible causes and then that you address that first if that's not effective you consider medications and you can also talk to consider a catheter-blased based treatment where catheters are passed through a vein in the leg up into the heart and try to map that area to show exactly where the rhythm starts and then try to abolish it with with great general with radiofrequency energy but it's it covers a wide range of conditions yeah yeah so I think I've heard the questions does it always mean a back of oxygen no as you recall from Leslie's talk atrial fibrillation is our abnormal rhythm where the upper chambers have disorganized activity and the upper chambers are just quivering it can drive the heart to go too fast so some people show up be they know they have a fit because the heart rate is 130 150 beats per minute and that didn't usually does not cause low oxygen could low oxygen be a cause of a fib that's possible say you're in the hospital with severe pneumonia and your oxygen levels are low that could sometimes be a trigger for a fib a fib doesn't usually cause low oxygen level unless you were to develop you know severe congestive heart failure and then maybe the a fib is causing is that what you're asking of my I'm barking up the right tree okay any other questions for me yes Dr. Anders, where is the closest cath lab? Dartmouth Hitchcock closest and then UVM next closest yeah okay great thanks for everyone's attention and interest thank you everyone for just yes yes and there are some handouts in the back for you to take with you some are about nutrition and then there's some other that blood pressure and medication less yes so feel free to take those with you and please feel free to take any snacks with you or coffee healthy healthy healthy snacks yeah go snacks right Walter yeah yeah so and thank you for attending have a great rest of your day and a great weekend