November 20, 2024 • 29 mins
Discover the surprising ways you can take control of your heart health as we welcome Dr. Craig Reiss, a leading cardiologist from St. Luke's with an impressive track record that spans WashU, the University of Missouri, and Harvard. With heart disease affecting millions, Dr. Reiss provides invaluable insights into prevention and management strategies that go beyond the basics. He breaks down essential lifestyle changes and underscores the role of medications for those facing genetic challenges. Our discussion sheds light on the common yet often overlooked risk factors like high blood pressure, smoking, and diabetes, empowering you to partner effectively with healthcare professionals in managing these risks.
We also explore the cutting-edge advancements shaping the future of heart disease prevention. From the role of statins in combating cholesterol to the innovative PCSK9 inhibitors for those unable to tolerate them, Dr. Reiss demystifies common misconceptions and reveals the promising technologies revolutionizing cardiac imaging. Calcium CT scans are paving the way for early detection of artery blockages, offering hope for improved outcomes. Finally, we touch on the alarming trends of heart disease in younger populations, driven by lifestyle changes, and the urgency it brings to the heart health conversation. Join us for an episode packed with expert insights, sure to leave you better informed and inspired to make heart-smart choices.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to Doc Discussions.
So today I'm going to talk withDr Craig Reese, a cardiologist,
here at St Luke's, about diet,medication and heart disease and
ways to reduce your risk ofheart disease.
Craig, how are you doing today?
Speaker 2 (00:12):
Thank you, and thank you so much for asking me to be
on your podcast.
Speaker 1 (00:16):
Yeah, it's my pleasure for sure.
Now, first tell me where areyou from, craig.
Speaker 2 (00:21):
I'm from St Louis, st Louis.
Yeah, and you know the famousSt Louis, st Louis.
And yeah, and you know thefamous St Louis question, right?
Speaker 1 (00:25):
Yeah, when he went to high school, so you know.
Speaker 2 (00:28):
I went to Ladue Very good and came back home.
Speaker 1 (00:32):
I'm not from St Louis , so I kind of know some of the
high schools and so I'm learningover time, though Very good
it's very important in St Louisto know that One of the most
important things Absolutely.
And you did your training.
Where did you go to school?
Speaker 2 (00:48):
So I went from high school, I went to a six-year med
program at University ofMissouri and then I trained at
Harvard, at the Brigham, and Iwas there for six years and I
did my medicine, my cardiology,and a chief residency and then I
came back to St Louis, all inBoston.
How about that?
Speaker 1 (01:06):
Yeah, yeah, came back to St Louis afterwards, and
then you were at WashU for awhile and then came to St Luke's
.
Speaker 2 (01:11):
I was a professor at WashU for 24 years or 23 years,
I guess and then saw theopportunity at St Luke's and
couldn't pass it up.
Speaker 1 (01:29):
And have a look back and love every minute of it.
And you're not going to saythis, so I will, but you're one
of the most beloved physiciansat St Luke's.
Anybody who's your patient hasa strong relationship with you,
and I think that's kind of oneof the things that makes St
Luke's special.
Speaker 2 (01:37):
Well, I appreciate it and that is actually said about
you universally.
So I appreciate you saying that, but it's what makes St Luke's
very, very special is thatdoctors that are at St Luke's
really love to take care ofpatients.
They love their patients andhaving that philosophy is what
attracted me here and keeps mehere.
Speaker 1 (01:56):
Yeah, very good.
So today I want to talk aboutcoronary artery disease and ways
to coronary artery disease andways to well, first of all, you
know what is coronary arterydisease and what's the
prevalence, and then ways toreduce our risk.
Speaker 2 (02:13):
Coronary artery disease and heart disease
overall is by far the mostcommon cause of death in the
United States, in both men and,importantly, in women.
And coronary artery disease iswhen one develops areas of
cholesterol buildup and blockagewithin the arteries.
(02:33):
As that progresses at somepoint in time, that can lead to
a total blockage or near totalblockage of the arteries and
that can cause sudden cardiacdeath and it can lead to heart
failure.
It can lead to, of course,acute heart attacks In addition
to disability and people thatjust can't do what they'd like
(02:58):
to do in life.
Speaker 1 (02:59):
And so it certainly can decrease the length of your
life and the quality of yourlife.
It certainly can decrease thelength of your life and the
quality of your life, and so I'ma big proponent of doing things
without medication first, ifyou can and for some people I
(03:28):
think that will work by changingdiet and exercise habits and
things like that.
Speaker 2 (03:30):
But there's certainly a percentage of the population
that despite doing kind of allthat due to their genetics and
things like that, they still canhave high blood pressure and
coronary artery disease.
Very important, you know.
I think it's important todiscuss sort of what are the
risk factors?
And then when we look at whatthose risk factors are, we can
figure out what we asindividuals can do to decrease
those risk factors and where wereally have to rely on our
physicians.
And the first thing is torealize are you at risk for
(03:50):
heart disease?
And really everyone's at riskfor heart disease what are the
risk factors that really arepresent that can increase those
risks?
First and foremost, just like incancer, cigarette smoking,
cigarette smokers have atremendously increased risk of
heart disease and that goes onfor periods of time after one
(04:11):
stops smoking.
So if one is a smoker currently, obviously you got to stop.
And then the second thing is ifyou've had a history of
cigarette smoking.
Cigarette smoking directlydamages actually the lining of
the blood vessels and leads tothis early process of developing
blockages.
So that's number one.
Number two is that high bloodpressure is very important, that
(04:38):
the stress of the high bloodpressure on those blood vessels
over time can lead to furtherblockages and can also lead to
other problems with strokes, inaddition to weakness or
thickness of the heart muscleover time.
The third is having a highcholesterol, and again there's a
(05:01):
little bit of a problem withhigh cholesterols because
cholesterols have differentparticles that are present, so
it's more than just knowing yourcholesterol.
It's knowing your cholesterolprofile, which is very important
.
And the next is diabetes, andknowing whether or not that you
have diabetes and theappropriate treatment of it.
(05:21):
That also increases one risk,the appropriate treatment of it.
That also increases wound risk.
And lastly, but really reallyreally very, very important, is
actually a family history ofheart disease, and did other
family members have heartdisease?
What age were they when theyhad heart disease?
You know, if you know, wasthere something else on top of
(05:41):
it to family history?
You know?
Was the loved one that hadheart disease, was somebody that
smoked, had diabetes and hadhigh blood pressure, or was it
somebody that just startedhaving heart disease young?
These are all critical.
So once one knows that, thenit's important to talk with your
physician regarding how do youattack it.
Speaker 1 (06:02):
Yeah, yeah, I mean it's, and you know, kind of
going through this.
You know I have kind of a vagueunderstanding of coronary
artery disease but likeeverything in life, it's way
more complex than you wouldthink.
With the, you know, some of themodifiable risk factors can be
diet.
Is there a specific diet yourecommend to patients, either
(06:26):
before they have an event orafter?
Speaker 2 (06:28):
Well, our Western diet, our fast food diet, is
very unhealthy in general, notjust for heart disease but, in
your territory, of cancer andother things.
But you know, having more of aplant-based diet is an important
way to prevent heart disease.
In addition to that, aMediterranean-type diet which is
(06:53):
again high in appropriate oils,such as olive oil, high in fish
intake, low in red meat intake,are important to help to
prevent heart disease.
Speaker 1 (07:06):
Yeah, the stats I have on that are Mediterranean
diet gives you about a 25% to30% reduction.
A low salt diet or the DASHdiet, which contributes to high
blood pressure, reduces it about25%.
A vegan diet gives you thestrongest reduction at about 35%
to 40% Vegetarian.
(07:27):
So it's no meat but you do have.
Dairy is 25% to 30%.
Pescatarian fish only is aboutthe same, and so you know this
is.
You know that it's, but it'shard to develop new habits.
Speaker 2 (07:39):
Right, it's hard.
It's hard to make those changes.
Making the changes slowly iseasy and unfortunately, once my
patients do have problems,they're pretty good about making
those changes, you know.
But the idea is to make thosechanges before there's problems.
Yeah, particularly, you know.
If you know that you know one'sfather had, you know, heart
(07:59):
disease in their 50s and you'rein your 20s and 30s, you should
be making changes, you should be, going to this before it's too
late.
So the diet is very important.
The other thing we haven'treally talked about, jason, is
also exercise, for sure you know.
So exercise is incrediblyimportant.
You know we are now realizingit doesn't take a lot.
(08:19):
So there were some recentstudies that actually said as
little as five minutes ofexercise a day is important for
some reduction.
Yeah, what we recommend ingeneral for our patients once
you know that you don't haveheart disease if you're sitting
there having chest discomfort,you have strong all these risk
factors then we want you to talkto their doctor before
(08:42):
exercising.
But once you know that that'snot the case, we like at least
about 150 minutes of exercise aday.
And this is a lot of peoplerecommend this kind of like zone
two, like brisk walking thingslike that, you know one thing
that I like to tell my patientsactually once heard it from our
(09:02):
head of cardiac rehab here who'swonderful is that your patients
should be able to when they'rewalking, should be able to carry
on a conversation, yeah, Okay,but you shouldn't be able to
sing, okay, okay.
Well, I can't sing anyway, butthat gives you some idea.
You want to go ahead and youwant to have some degree of
(09:23):
activity and you know again, forme and for you, you have to
find something that you like andwhat's good and put it into
your daily schedule.
It doesn't count that you well,I'm very active.
I always wear my feet all thetime.
Speaker 1 (09:34):
No.
Speaker 2 (09:35):
It's really sunny.
I mean, you know I wake up, youknow, before five o'clock every
day.
You know, and I'm on thatelliptical, you know, for my six
days a week of exercise.
Speaker 1 (09:46):
And that's low impact .
It's low impact.
Speaker 2 (09:49):
And you know I can read while I'm on that, I can
listen to a podcast.
You know I can do something.
You know something while I'mdoing it.
That adds to the enrichment ofmy day and if you put that as
part of your schedule and itbecomes part of your life, it's
amazing what it can do for yourhealth and also your mental
well-being.
Speaker 1 (10:07):
Yeah, earlier this year a report came out I believe
it was the New England Journalof Medicine showing that
exercise is about twice as goodas antidepressant medications
for depression which is notsurprising.
I mean me and you both getmental health benefits from
working out Absolutely.
And then I've actually seensome reports where sauna, due to
(10:28):
the vasodilation from the heat,can improve endothelial
function, reduce all-causemortality, and they think it's
mediated through thecardiovascular system, yes, and
again, you want to make sure youdon't have critical heart
disease before that.
Speaker 2 (10:41):
And there is the thing that makes me nervous Some
people are on the ice sort ofapproach of things, of going
into ice baths Forcardiovascular disease.
That scares me, especially onceat risk, so that's something
that is a fad that does disturbme.
Speaker 1 (10:58):
Yeah, and I think that the data for the sauna is
much better than the ice baths,absolutely.
And sauna's been around for along time.
With ice baths you're going tohave at least peripheral
vasoconstriction, which is goingto put some stress on the heart
Absolutely, and a sauna's muchmore palatable than an ice bath
yes, it is Love.
Speaker 2 (11:17):
A sauna is much more palatable than an ice bath.
Speaker 1 (11:18):
Yes, it is.
Love a sauna.
Okay, so now two things.
Some patients can eat anoptimal diet or exercise
appropriately and still be at asignificant risk, and some of
the predictors for this would behigh triglycerides, high
cholesterol.
(11:38):
And then there's this ApoBprotein.
Can you talk a little bit aboutthese patients and those
markers?
Speaker 2 (11:45):
Really there's another incredibly important
marker that I've been involvedin looking at for many, many
years since the 1990s and nowit's ready for prime time.
So one has to look at what istheir overall LDL cholesterol,
which is the overall badcholesterol, the overall HDL
(12:07):
cholesterol.
Hdl is best looked at as ascavenger cholesterol, a good
cholesterol okay, it sort ofcleans up those arteries.
Okay.
Triglycerides is another lipidparticle that at high levels can
also lead to earlyatherosclerosis, those blockages
in those arteries.
But another one which is very,very powerful and important in
(12:30):
family history is somethingcalled LP little a, apob.
We measure in patients thathave high triglycerides in
particular.
That's important.
But LP little a is critical whenwe find out that patients that
have high LP little a's have amarked increase in early heart
disease and strokes.
(12:50):
So I've known this and wasinvolved through the Lipid
Center at WashU for many years.
So I started measuring this inmy patients very, very early and
found this in many of thepatients that have early onset
of heart disease and familyhistories.
And now we have three agentsthat are in clinical trials.
I'm hoping the first agent maybe available as soon as next
(13:13):
year.
Wow, that dramaticallydecreases.
This soon as next year.
That dramatically decreasesthis, and what this is is sort
of a sticky particle that's apart of the that has the
cholesterol is carried in thebody.
That allows it to get rightinto the blood vessel and is
handled and can cause increasedstrokes and increased heart
disease.
Speaker 1 (13:31):
So not only is it a marker, but it's also a
causative agent.
Speaker 2 (13:36):
It is a causative agent.
What we're waiting for we knowthat these agents right now and
the first agent likely to comeout is going to be a once a
month shot.
Okay, but we know that itdefinitely is causative.
We know that these agentsdecrease this way over 90% as
far as what the LP little a is.
What we're waiting on isoutcome data, and I'm hopeful
(13:56):
the outcome data is going to beout in the spring of next year.
Speaker 1 (14:00):
That's great.
And so the link between thediet and the cholesterol really
is the trans fats and thesaturated fats?
Yeah, it is, and the simplesugars too.
Speaker 2 (14:12):
It is, and even you know.
Again, one thing that I'd liketo concentrate on, in addition
to prevention and diet is, asyou mentioned very early on, is
that medicines are required in alot of patients.
So this is a genetic problem.
This is a genetic problem ofhow our liver produces and how
(14:32):
much our liver produces theseparticles.
And how much our liver producesthese particles, and in some
patients about 25% of patientsmay be what we call
hyperresorbers, and I canactually test for that with
specialized testing where weknow that well, it's actually
more what you're eating andwe've heard it doesn't matter
how much eggs you eat, et cetera.
(14:53):
Well, it does in some people,but the important thing is
cutting down their production,and diet only does a small
percentage of that.
So if one is really at risk,let's say that there's an early
family history, let's say thatthe HDLs are low or you have
high LP, little A's.
That group of patients has tobe on medicines.
Speaker 1 (15:14):
So you take in cholesterol but the liver, even
if you're a vegan and take inalmost no cholesterol the liver
is going to make cholesterol andin some patients, a large
amount.
Speaker 2 (15:23):
Yeah, it's going to produce and that's where you
have to do it.
And you know, really, statinshave been the most important
preventative for heart diseaseand also for secondary
prevention.
What does secondary preventionmean?
That means that once somebodyhas actually had a cardiac event
or been diagnosed with cardiacdisease, being on them
(15:45):
dramatically decreases risk.
Speaker 1 (15:48):
And so they came out with these statins that lower
cholesterol and I know you knowpharmacy it was pharmacy of
Pfizer at the time here in town,you know made like Lip and it
did an excellent job at reducingthat.
But the medications have becomemuch more sophisticated, like
the ones you were talking aboutin the clinical trials.
Speaker 2 (16:07):
Yeah, so we have many medications.
There's statins still are themainstay.
Okay, and with statins as themainstay, they have gotten a
hideous press.
You know somebody who may bepresident was they have gotten a
hideous press, Somebody who?
Speaker 1 (16:21):
may be.
Speaker 2 (16:21):
President was talking about fake news a lot Fake news
, for statins has really, reallycost lives.
Statins are extremely welltolerated by probably 95% of the
people that are on them.
Most cardiologists, if you askaround, including me, we're on
statins.
Speaker 1 (16:37):
Okay, but what is the five percent?
What are the reasons that theycan't take the statins?
It's usually muscle aches andpains.
Speaker 2 (16:44):
Yeah, yeah, so if you have some people, virtually
everybody has a little bit ofspasms occasionally.
Some really feel like they havethe flu, they really have
really awful aches and pains andwe have so many other
alternatives right now.
You know so that you know,right now I frequently prescribe
really three agents.
Two are the same.
They're called PCSK9 inhibitorsthat the patient simply gives
(17:07):
themselves a shot twice a month.
Speaker 1 (17:10):
Okay.
Speaker 2 (17:10):
It's an auto injector and it drops cholesterol like
nothing.
Okay, it also does drop LPlittle a, about 20-25%.
There is another agent that weuse, believe it or not, that we
give twice a year and again forpatients that don't tolerate it
or they don't want to takemedicines or can't inject
themselves.
They go to an infusion centeror to some physician offices and
(17:33):
it's an infusion that goes on,just a shot that goes in.
Initially we give it twice,three times the first year and
then twice every year.
After that.
Speaker 1 (17:43):
Again, dramatic effects on LDL cholesterol,
really lowering it dramatically,in addition to having a 25 to
30 percent reduction in LPlittle a's and so and so, and I
want to kind of zoom out andkind of take a bigger look at
you know we were talking aboutpeople being skeptical, which is
(18:04):
okay.
It's okay to be skeptical, butthe clinical trials kind of give
you what you need and it's youget the drug or you don't get
the drug.
And then they measure somemetric down the road like
survival.
Get the drug, and then theymeasure some metric down the
road like survival, and so itdoesn't mean that the drug
doesn't have any side effects,but it means that the risks and
(18:24):
benefits of taking the drug forthese patients outweigh the
risks and benefits of any sideeffects from the drug.
Is that accurate?
Speaker 2 (18:32):
It's not even close you know, so that if you look at
the overall benefits of ourprotection against heart attacks
and death, they're gamechangers and there's no
increased mortality.
There's a lot of false dataabout oh, it causes Alzheimer's
or memory problems.
That's wrong.
It actually decreases vasculardementia.
(18:54):
So, as far as the tolerability,I have thousands of patients
probably that are on statins andtolerate them very, very well,
and the important thing is, ifyou don't tolerate, you work
with your physician.
There's also one thing that I'dlike to talk about at some
point, jason.
It's also what are some of thenewer techniques?
(19:15):
So how do we detect?
Do we have a problem and whatare we talking about?
Speaker 1 (19:18):
Yeah, so how do we detect?
Do we have a problem?
And what are we talking about?
Yeah, and so there's.
You know, there was the oldcatheterization and like
actually look at the artery, butthere's some new imaging
techniques where you can look atwhat is it calcium scores and
things like that.
Yeah, absolutely.
Speaker 2 (19:31):
So.
You know, the important thingis not to only be aware that you
are at risk, but do you have aproblem?
Aware that you are at risk, butdo you have a problem?
Okay, because, um, you know,putting your head in the sand
and not looking, uh, can lead tovery bad outcomes.
Yeah, so, um, we have um,advanced imaging.
I'm practicing cardiologydifferent now than I was eight
(19:54):
years ago, okay, because of thenew techniques that we have.
So, the new techniques we'llstart with, one is not a new
technique.
One is a calcium CT scan.
Okay, and a calcium CT scan ischeap.
I think St Luke's does it, forI don't know, don't quote me on
this maybe $125.
That sort of range is anout-of-pocket expense.
Don't ask me why insurancecompanies don't cover it,
(20:16):
because it's been proven toidentify patients at risk
tremendously.
Speaker 1 (20:22):
It seems like it would be cost-effective.
Speaker 2 (20:23):
We would think it would be cost-effective, but
there are fears.
It leads to other testing,which it can, which saves lives,
but it's an out-of-pocketexpense that's very, very small,
and what that tells us is isthere calcium in the arteries?
Is there calcium in thearteries?
Mainly helpful in people over40 and probably less than 70,
(20:44):
that can identify whether or notthere's calcium buildup.
Calcium, though, is not reallythe blockage.
Calcium is a marker thatsomebody has had plaques in
their arteries and the body inhealing it then forms a calcium.
Okay, so then the next step ishow much is there, and depending
on how much there is,determines what one's risk is.
(21:05):
But in addition to that, I liketo explain to my patients the
following.
I like to say that whencholesterol is deposited in
one's arteries, the calcium,it's sort of like a volcano,
it's like a mountain.
You can either put down thecalcium like a road where
there's no blockages, or you canhave it like a mountain where
there is a degree of blockage,and if it really heaps up, then
(21:28):
it can interfere with blood flow.
When it interferes with bloodflow, that's when somebody can
have chest discomfort withactivity, that's what can
predispose to heart attacks.
There are patients 25 to 40percent of patients, more in
patients that have diabetes thatcan have significant blockages
and have zero symptoms, and thatis also something that has to
(21:51):
be identified.
So once we have whether or notthere's calcium present or not,
there are other tests that we do.
We have nuclear stress testingwhere first of all it was simple
stress testing, so one can geton a treadmill under doctor's
supervision and we can look forwhether or not there is any
problems with their exercise.
(22:12):
That picks up heart diseaseabout 65% of the time if it's
present.
Not very good.
If we add an echo to that andwe do an ultrasound of the heart
while they're exercising, thatincreases us to about 75%
accuracy.
Speaker 1 (22:26):
Okay, so getting better yeah.
Speaker 2 (22:27):
If we then go to nuclear testing we may go to 80%
.
The newest is the stress PETscan.
The stress PET scan has 75%less radiation increases us to
about 92%.
And one of the very, very, veryexciting areas right now is CAT
scanning of the arteries withintravenous dye called CT
angiography.
(22:47):
That's almost as good as aheart catheterization.
So we can do everything that Ijust said to identify heart
disease and risk stratifywithout a heart catheterization.
Speaker 1 (22:56):
You know, I'm going to kind of go back, and that's
excellent news, especially ifyou can avoid a procedure.
Going to kind of go back, andthat's that's excellent news,
especially if you can avoid aprocedure.
Um, I want to go back tosomething that you said earlier,
and I often say this topatients if you have plaque in
the arteries of your heart, youprobably have plaque in the
arteries of your brain, and so,uh, I, I, I I'm if you're a
(23:17):
neurologist and you're, you know, don't scream at me, but I
think a lot of dementia iscalled a lot of things and ends
up being vascular dementia,correct, and that's something
that can dramatically reduce thequality of your life.
And you know, in general it'sdifficult to make these
lifestyle changes or to go intoa cardiologist when you feel
(23:41):
totally normal.
But I think it has to be someemotional event in your life
that can kind of push youtowards that.
Whether it's a medical scarewith you or a family member, or
maybe you're pregnant, or maybeyou have cancer.
You have something that kind oftriggers some emotion that
causes you to say, hey, you knowwhat I need to kind of look out
for my long-term health, notonly for my cardiac health, but
(24:03):
for the health of my brain.
And I mean, if you have plaquein the arteries of your heart,
you probably are going to havesome sort of arterial disease
that can cause kidney disease,and so in many ways your blood
flow is your health.
Speaker 2 (24:15):
Absolutely.
And again, a huge percentage ofour patients that have MRIs
don't have the brain.
They have something calledsmall vessel disease.
If you're more extensive ofthat, you have small strokes
everywhere and that leads todementia.
What's the treatment for smallvessel disease?
Same thing it is for heartdisease.
We lower cholesterols, we lowerblood pressures.
We look at these risk factors.
I want to come back to one morething.
I was talking about my volcano.
(24:36):
Okay, yeah.
So the reason why that'simportant is that there is a
mountain, okay, and a volcano,okay.
If it's a mountain doesn't doanything if there's no magna
underneath the surface, ifthere's no lava, that would come
to the surface.
So what the treatments do thatI'm talking about?
When we drop those cholesterols, we start getting rid of the
(24:57):
soft cholesterol gunk underneaththe volcano that we get rid of
the lava, we turn that magnainto rock and when that happens,
within a month of lowering it,event rates, which includes
heart attacks and strokes, comedown dramatically.
Speaker 1 (25:12):
That's surprising that it works that quickly.
Speaker 2 (25:14):
It can start within a month.
Speaker 1 (25:16):
Now people can have—OK, so we're jumping back
and forth, but, but, but, whichis fine.
Um, so the the artery, which islike a tube.
You can have plaque that cannarrow the artery, but you can
also have plaque that goes intothe artery.
And then there are stableplaques, which correct, and then
you can have unstable plaqueswhere, if, so if and I might be
(25:37):
wrong on this, but you can havean unstable plaque that grows
into the artery so you don't seenarrowing, but if it breaks off
, the platelets immediatelyadhere to it.
And you have this acute eventwhere, all of a sudden, the
artery was, the blood wasflowing fine through the artery.
Now the plaque breaks off, theplatelets adhere to it and you
immediately have a blockage.
Speaker 2 (25:57):
Exactly right.
So that's what we're talkingabout.
So if the volcano erupts andyou get the gunk that comes to
the surface, or you have a crackin the surface like an
earthquake, then that softplaque comes to the surface.
Then the blood starts clottingand you go from a 50% or 60% to
99% or 100%, that's a heartattack.
Speaker 1 (26:18):
Or God forbid, that's sudden death, and quickly,
that's quickly.
That, or God forbid, that'ssudden death and quickly, that's
quickly, that's very quickly.
And sudden death is one of theleading.
If you say what's the firstsymptom of a heart attack, a lot
of people may say chest painand that may be number one, but
sudden death is up there.
Speaker 2 (26:31):
Absolutely.
First, I like to never saychest pain.
Okay, so what I tell mypatients and I tell my residents
and my fellows when I teachthem never say chest pain,
because my patients will say tome very, very frequently I never
have chest pain.
Do you ever have anuncomfortableness in your chest?
Do you ever have fullness?
Do you ever have an indigestion, discomfort?
Physicians have been known tothink they have indigestion when
(26:55):
it's really their heart.
Okay, so first of all, yes, sothe onset of some kind of
uncomfortableness or shortnessof breath with activity or
uncomfortableness, pressure issomething that absolutely is a
marker of heart.
But sudden death, yes,unfortunately, can be the first
manifestation.
Speaker 1 (27:16):
And then the incidence of this increases with
each decade of life.
Yes, the incidence within the40s is not very high, but once
you get to the 60s, yourlikelihood is what?
20% to 40%, depending onwhether you're a man or no?
Sorry, I have 21% in men and11% in women.
(27:38):
In the 70s, it goes from 35% inmen to 24% in women.
So that's a generalization.
Speaker 2 (27:44):
Yeah, that's a rough idea as to where it is, but yes,
it becomes more frequent andit's also I've also
unfortunately for the listenersI've taken care of many patients
in their 20s yeah, sure youknow, in 30s with early onset of
heart disease, including women.
Speaker 1 (27:59):
And with diets getting worse over time.
You know, I think that's atrend.
When they update the data,they're going to see that
there's more heart disease inthe young.
Yes, and so all right.
Well, craig, fascinating talk.
I feel like we could talk allday, but I very much appreciate
your time, sir, and thank youfor being a great colleague.
And thank you for your time,thank.
Welcome to Doc Discussions.
So today I'm going to talk withDr Craig Reese, a cardiologist,
here at St Luke's, about diet,medication and heart disease and
ways to reduce your risk ofheart disease.
Craig, how are you doing today?
Speaker 2 (00:12):
Thank you, and thank you so much for asking me to be
on your podcast.
Speaker 1 (00:16):
Yeah, it's my pleasure for sure.
Now, first tell me where areyou from, craig.
Speaker 2 (00:21):
I'm from St Louis, st Louis.
Yeah, and you know the famousSt Louis, st Louis.
And yeah, and you know thefamous St Louis question, right?
Speaker 1 (00:25):
Yeah, when he went to high school, so you know.
Speaker 2 (00:28):
I went to Ladue Very good and came back home.
Speaker 1 (00:32):
I'm not from St Louis , so I kind of know some of the
high schools and so I'm learningover time, though Very good
it's very important in St Louisto know that One of the most
important things Absolutely.
And you did your training.
Where did you go to school?
Speaker 2 (00:48):
So I went from high school, I went to a six-year med
program at University ofMissouri and then I trained at
Harvard, at the Brigham, and Iwas there for six years and I
did my medicine, my cardiology,and a chief residency and then I
came back to St Louis, all inBoston.
How about that?
Speaker 1 (01:06):
Yeah, yeah, came back to St Louis afterwards, and
then you were at WashU for awhile and then came to St Luke's
.
Speaker 2 (01:11):
I was a professor at WashU for 24 years or 23 years,
I guess and then saw theopportunity at St Luke's and
couldn't pass it up.
Speaker 1 (01:29):
And have a look back and love every minute of it.
And you're not going to saythis, so I will, but you're one
of the most beloved physiciansat St Luke's.
Anybody who's your patient hasa strong relationship with you,
and I think that's kind of oneof the things that makes St
Luke's special.
Speaker 2 (01:37):
Well, I appreciate it and that is actually said about
you universally.
So I appreciate you saying that, but it's what makes St Luke's
very, very special is thatdoctors that are at St Luke's
really love to take care ofpatients.
They love their patients andhaving that philosophy is what
attracted me here and keeps mehere.
Speaker 1 (01:56):
Yeah, very good.
So today I want to talk aboutcoronary artery disease and ways
to coronary artery disease andways to well, first of all, you
know what is coronary arterydisease and what's the
prevalence, and then ways toreduce our risk.
Speaker 2 (02:13):
Coronary artery disease and heart disease
overall is by far the mostcommon cause of death in the
United States, in both men and,importantly, in women.
And coronary artery disease iswhen one develops areas of
cholesterol buildup and blockagewithin the arteries.
(02:33):
As that progresses at somepoint in time, that can lead to
a total blockage or near totalblockage of the arteries and
that can cause sudden cardiacdeath and it can lead to heart
failure.
It can lead to, of course,acute heart attacks In addition
to disability and people thatjust can't do what they'd like
(02:58):
to do in life.
Speaker 1 (02:59):
And so it certainly can decrease the length of your
life and the quality of yourlife.
It certainly can decrease thelength of your life and the
quality of your life, and so I'ma big proponent of doing things
without medication first, ifyou can and for some people I
(03:28):
think that will work by changingdiet and exercise habits and
things like that.
Speaker 2 (03:30):
But there's certainly a percentage of the population
that despite doing kind of allthat due to their genetics and
things like that, they still canhave high blood pressure and
coronary artery disease.
Very important, you know.
I think it's important todiscuss sort of what are the
risk factors?
And then when we look at whatthose risk factors are, we can
figure out what we asindividuals can do to decrease
those risk factors and where wereally have to rely on our
physicians.
And the first thing is torealize are you at risk for
(03:50):
heart disease?
And really everyone's at riskfor heart disease what are the
risk factors that really arepresent that can increase those
risks?
First and foremost, just like incancer, cigarette smoking,
cigarette smokers have atremendously increased risk of
heart disease and that goes onfor periods of time after one
(04:11):
stops smoking.
So if one is a smoker currently, obviously you got to stop.
And then the second thing is ifyou've had a history of
cigarette smoking.
Cigarette smoking directlydamages actually the lining of
the blood vessels and leads tothis early process of developing
blockages.
So that's number one.
Number two is that high bloodpressure is very important, that
(04:38):
the stress of the high bloodpressure on those blood vessels
over time can lead to furtherblockages and can also lead to
other problems with strokes, inaddition to weakness or
thickness of the heart muscleover time.
The third is having a highcholesterol, and again there's a
(05:01):
little bit of a problem withhigh cholesterols because
cholesterols have differentparticles that are present, so
it's more than just knowing yourcholesterol.
It's knowing your cholesterolprofile, which is very important
.
And the next is diabetes, andknowing whether or not that you
have diabetes and theappropriate treatment of it.
(05:21):
That also increases one risk,the appropriate treatment of it.
That also increases wound risk.
And lastly, but really reallyreally very, very important, is
actually a family history ofheart disease, and did other
family members have heartdisease?
What age were they when theyhad heart disease?
You know, if you know, wasthere something else on top of
(05:41):
it to family history?
You know?
Was the loved one that hadheart disease, was somebody that
smoked, had diabetes and hadhigh blood pressure, or was it
somebody that just startedhaving heart disease young?
These are all critical.
So once one knows that, thenit's important to talk with your
physician regarding how do youattack it.
Speaker 1 (06:02):
Yeah, yeah, I mean it's, and you know, kind of
going through this.
You know I have kind of a vagueunderstanding of coronary
artery disease but likeeverything in life, it's way
more complex than you wouldthink.
With the, you know, some of themodifiable risk factors can be
diet.
Is there a specific diet yourecommend to patients, either
(06:26):
before they have an event orafter?
Speaker 2 (06:28):
Well, our Western diet, our fast food diet, is
very unhealthy in general, notjust for heart disease but, in
your territory, of cancer andother things.
But you know, having more of aplant-based diet is an important
way to prevent heart disease.
In addition to that, aMediterranean-type diet which is
(06:53):
again high in appropriate oils,such as olive oil, high in fish
intake, low in red meat intake,are important to help to
prevent heart disease.
Speaker 1 (07:06):
Yeah, the stats I have on that are Mediterranean
diet gives you about a 25% to30% reduction.
A low salt diet or the DASHdiet, which contributes to high
blood pressure, reduces it about25%.
A vegan diet gives you thestrongest reduction at about 35%
to 40% Vegetarian.
(07:27):
So it's no meat but you do have.
Dairy is 25% to 30%.
Pescatarian fish only is aboutthe same, and so you know this
is.
You know that it's, but it'shard to develop new habits.
Speaker 2 (07:39):
Right, it's hard.
It's hard to make those changes.
Making the changes slowly iseasy and unfortunately, once my
patients do have problems,they're pretty good about making
those changes, you know.
But the idea is to make thosechanges before there's problems.
Yeah, particularly, you know.
If you know that you know one'sfather had, you know, heart
(07:59):
disease in their 50s and you'rein your 20s and 30s, you should
be making changes, you should be, going to this before it's too
late.
So the diet is very important.
The other thing we haven'treally talked about, jason, is
also exercise, for sure you know.
So exercise is incrediblyimportant.
You know we are now realizingit doesn't take a lot.
(08:19):
So there were some recentstudies that actually said as
little as five minutes ofexercise a day is important for
some reduction.
Yeah, what we recommend ingeneral for our patients once
you know that you don't haveheart disease if you're sitting
there having chest discomfort,you have strong all these risk
factors then we want you to talkto their doctor before
(08:42):
exercising.
But once you know that that'snot the case, we like at least
about 150 minutes of exercise aday.
And this is a lot of peoplerecommend this kind of like zone
two, like brisk walking thingslike that, you know one thing
that I like to tell my patientsactually once heard it from our
(09:02):
head of cardiac rehab here who'swonderful is that your patients
should be able to when they'rewalking, should be able to carry
on a conversation, yeah, Okay,but you shouldn't be able to
sing, okay, okay.
Well, I can't sing anyway, butthat gives you some idea.
You want to go ahead and youwant to have some degree of
(09:23):
activity and you know again, forme and for you, you have to
find something that you like andwhat's good and put it into
your daily schedule.
It doesn't count that you well,I'm very active.
I always wear my feet all thetime.
Speaker 1 (09:34):
No.
Speaker 2 (09:35):
It's really sunny.
I mean, you know I wake up, youknow, before five o'clock every
day.
You know, and I'm on thatelliptical, you know, for my six
days a week of exercise.
Speaker 1 (09:46):
And that's low impact .
It's low impact.
Speaker 2 (09:49):
And you know I can read while I'm on that, I can
listen to a podcast.
You know I can do something.
You know something while I'mdoing it.
That adds to the enrichment ofmy day and if you put that as
part of your schedule and itbecomes part of your life, it's
amazing what it can do for yourhealth and also your mental
well-being.
Speaker 1 (10:07):
Yeah, earlier this year a report came out I believe
it was the New England Journalof Medicine showing that
exercise is about twice as goodas antidepressant medications
for depression which is notsurprising.
I mean me and you both getmental health benefits from
working out Absolutely.
And then I've actually seensome reports where sauna, due to
(10:28):
the vasodilation from the heat,can improve endothelial
function, reduce all-causemortality, and they think it's
mediated through thecardiovascular system, yes, and
again, you want to make sure youdon't have critical heart
disease before that.
Speaker 2 (10:41):
And there is the thing that makes me nervous Some
people are on the ice sort ofapproach of things, of going
into ice baths Forcardiovascular disease.
That scares me, especially onceat risk, so that's something
that is a fad that does disturbme.
Speaker 1 (10:58):
Yeah, and I think that the data for the sauna is
much better than the ice baths,absolutely.
And sauna's been around for along time.
With ice baths you're going tohave at least peripheral
vasoconstriction, which is goingto put some stress on the heart
Absolutely, and a sauna's muchmore palatable than an ice bath
yes, it is Love.
Speaker 2 (11:17):
A sauna is much more palatable than an ice bath.
Speaker 1 (11:18):
Yes, it is.
Love a sauna.
Okay, so now two things.
Some patients can eat anoptimal diet or exercise
appropriately and still be at asignificant risk, and some of
the predictors for this would behigh triglycerides, high
cholesterol.
(11:38):
And then there's this ApoBprotein.
Can you talk a little bit aboutthese patients and those
markers?
Speaker 2 (11:45):
Really there's another incredibly important
marker that I've been involvedin looking at for many, many
years since the 1990s and nowit's ready for prime time.
So one has to look at what istheir overall LDL cholesterol,
which is the overall badcholesterol, the overall HDL
(12:07):
cholesterol.
Hdl is best looked at as ascavenger cholesterol, a good
cholesterol okay, it sort ofcleans up those arteries.
Okay.
Triglycerides is another lipidparticle that at high levels can
also lead to earlyatherosclerosis, those blockages
in those arteries.
But another one which is very,very powerful and important in
(12:30):
family history is somethingcalled LP little a, apob.
We measure in patients thathave high triglycerides in
particular.
That's important.
But LP little a is critical whenwe find out that patients that
have high LP little a's have amarked increase in early heart
disease and strokes.
(12:50):
So I've known this and wasinvolved through the Lipid
Center at WashU for many years.
So I started measuring this inmy patients very, very early and
found this in many of thepatients that have early onset
of heart disease and familyhistories.
And now we have three agentsthat are in clinical trials.
I'm hoping the first agent maybe available as soon as next
(13:13):
year.
Wow, that dramaticallydecreases.
This soon as next year.
That dramatically decreasesthis, and what this is is sort
of a sticky particle that's apart of the that has the
cholesterol is carried in thebody.
That allows it to get rightinto the blood vessel and is
handled and can cause increasedstrokes and increased heart
disease.
Speaker 1 (13:31):
So not only is it a marker, but it's also a
causative agent.
Speaker 2 (13:36):
It is a causative agent.
What we're waiting for we knowthat these agents right now and
the first agent likely to comeout is going to be a once a
month shot.
Okay, but we know that itdefinitely is causative.
We know that these agentsdecrease this way over 90% as
far as what the LP little a is.
What we're waiting on isoutcome data, and I'm hopeful
(13:56):
the outcome data is going to beout in the spring of next year.
Speaker 1 (14:00):
That's great.
And so the link between thediet and the cholesterol really
is the trans fats and thesaturated fats?
Yeah, it is, and the simplesugars too.
Speaker 2 (14:12):
It is, and even you know.
Again, one thing that I'd liketo concentrate on, in addition
to prevention and diet is, asyou mentioned very early on, is
that medicines are required in alot of patients.
So this is a genetic problem.
This is a genetic problem ofhow our liver produces and how
(14:32):
much our liver produces theseparticles.
And how much our liver producesthese particles, and in some
patients about 25% of patientsmay be what we call
hyperresorbers, and I canactually test for that with
specialized testing where weknow that well, it's actually
more what you're eating andwe've heard it doesn't matter
how much eggs you eat, et cetera.
(14:53):
Well, it does in some people,but the important thing is
cutting down their production,and diet only does a small
percentage of that.
So if one is really at risk,let's say that there's an early
family history, let's say thatthe HDLs are low or you have
high LP, little A's.
That group of patients has tobe on medicines.
Speaker 1 (15:14):
So you take in cholesterol but the liver, even
if you're a vegan and take inalmost no cholesterol the liver
is going to make cholesterol andin some patients, a large
amount.
Speaker 2 (15:23):
Yeah, it's going to produce and that's where you
have to do it.
And you know, really, statinshave been the most important
preventative for heart diseaseand also for secondary
prevention.
What does secondary preventionmean?
That means that once somebodyhas actually had a cardiac event
or been diagnosed with cardiacdisease, being on them
(15:45):
dramatically decreases risk.
Speaker 1 (15:48):
And so they came out with these statins that lower
cholesterol and I know you knowpharmacy it was pharmacy of
Pfizer at the time here in town,you know made like Lip and it
did an excellent job at reducingthat.
But the medications have becomemuch more sophisticated, like
the ones you were talking aboutin the clinical trials.
Speaker 2 (16:07):
Yeah, so we have many medications.
There's statins still are themainstay.
Okay, and with statins as themainstay, they have gotten a
hideous press.
You know somebody who may bepresident was they have gotten a
hideous press, Somebody who?
Speaker 1 (16:21):
may be.
Speaker 2 (16:21):
President was talking about fake news a lot Fake news
, for statins has really, reallycost lives.
Statins are extremely welltolerated by probably 95% of the
people that are on them.
Most cardiologists, if you askaround, including me, we're on
statins.
Speaker 1 (16:37):
Okay, but what is the five percent?
What are the reasons that theycan't take the statins?
It's usually muscle aches andpains.
Speaker 2 (16:44):
Yeah, yeah, so if you have some people, virtually
everybody has a little bit ofspasms occasionally.
Some really feel like they havethe flu, they really have
really awful aches and pains andwe have so many other
alternatives right now.
You know so that you know,right now I frequently prescribe
really three agents.
Two are the same.
They're called PCSK9 inhibitorsthat the patient simply gives
(17:07):
themselves a shot twice a month.
Speaker 1 (17:10):
Okay.
Speaker 2 (17:10):
It's an auto injector and it drops cholesterol like
nothing.
Okay, it also does drop LPlittle a, about 20-25%.
There is another agent that weuse, believe it or not, that we
give twice a year and again forpatients that don't tolerate it
or they don't want to takemedicines or can't inject
themselves.
They go to an infusion centeror to some physician offices and
(17:33):
it's an infusion that goes on,just a shot that goes in.
Initially we give it twice,three times the first year and
then twice every year.
After that.
Speaker 1 (17:43):
Again, dramatic effects on LDL cholesterol,
really lowering it dramatically,in addition to having a 25 to
30 percent reduction in LPlittle a's and so and so, and I
want to kind of zoom out andkind of take a bigger look at
you know we were talking aboutpeople being skeptical, which is
(18:04):
okay.
It's okay to be skeptical, butthe clinical trials kind of give
you what you need and it's youget the drug or you don't get
the drug.
And then they measure somemetric down the road like
survival.
Get the drug, and then theymeasure some metric down the
road like survival, and so itdoesn't mean that the drug
doesn't have any side effects,but it means that the risks and
(18:24):
benefits of taking the drug forthese patients outweigh the
risks and benefits of any sideeffects from the drug.
Is that accurate?
Speaker 2 (18:32):
It's not even close you know, so that if you look at
the overall benefits of ourprotection against heart attacks
and death, they're gamechangers and there's no
increased mortality.
There's a lot of false dataabout oh, it causes Alzheimer's
or memory problems.
That's wrong.
It actually decreases vasculardementia.
(18:54):
So, as far as the tolerability,I have thousands of patients
probably that are on statins andtolerate them very, very well,
and the important thing is, ifyou don't tolerate, you work
with your physician.
There's also one thing that I'dlike to talk about at some
point, jason.
It's also what are some of thenewer techniques?
(19:15):
So how do we detect?
Do we have a problem and whatare we talking about?
Speaker 1 (19:18):
Yeah, so how do we detect?
Do we have a problem?
And what are we talking about?
Yeah, and so there's.
You know, there was the oldcatheterization and like
actually look at the artery, butthere's some new imaging
techniques where you can look atwhat is it calcium scores and
things like that.
Yeah, absolutely.
Speaker 2 (19:31):
So.
You know, the important thingis not to only be aware that you
are at risk, but do you have aproblem?
Aware that you are at risk, butdo you have a problem?
Okay, because, um, you know,putting your head in the sand
and not looking, uh, can lead tovery bad outcomes.
Yeah, so, um, we have um,advanced imaging.
I'm practicing cardiologydifferent now than I was eight
(19:54):
years ago, okay, because of thenew techniques that we have.
So, the new techniques we'llstart with, one is not a new
technique.
One is a calcium CT scan.
Okay, and a calcium CT scan ischeap.
I think St Luke's does it, forI don't know, don't quote me on
this maybe $125.
That sort of range is anout-of-pocket expense.
Don't ask me why insurancecompanies don't cover it,
(20:16):
because it's been proven toidentify patients at risk
tremendously.
Speaker 1 (20:22):
It seems like it would be cost-effective.
Speaker 2 (20:23):
We would think it would be cost-effective, but
there are fears.
It leads to other testing,which it can, which saves lives,
but it's an out-of-pocketexpense that's very, very small,
and what that tells us is isthere calcium in the arteries?
Is there calcium in thearteries?
Mainly helpful in people over40 and probably less than 70,
(20:44):
that can identify whether or notthere's calcium buildup.
Calcium, though, is not reallythe blockage.
Calcium is a marker thatsomebody has had plaques in
their arteries and the body inhealing it then forms a calcium.
Okay, so then the next step ishow much is there, and depending
on how much there is,determines what one's risk is.
(21:05):
But in addition to that, I liketo explain to my patients the
following.
I like to say that whencholesterol is deposited in
one's arteries, the calcium,it's sort of like a volcano,
it's like a mountain.
You can either put down thecalcium like a road where
there's no blockages, or you canhave it like a mountain where
there is a degree of blockage,and if it really heaps up, then
(21:28):
it can interfere with blood flow.
When it interferes with bloodflow, that's when somebody can
have chest discomfort withactivity, that's what can
predispose to heart attacks.
There are patients 25 to 40percent of patients, more in
patients that have diabetes thatcan have significant blockages
and have zero symptoms, and thatis also something that has to
(21:51):
be identified.
So once we have whether or notthere's calcium present or not,
there are other tests that we do.
We have nuclear stress testingwhere first of all it was simple
stress testing, so one can geton a treadmill under doctor's
supervision and we can look forwhether or not there is any
problems with their exercise.
(22:12):
That picks up heart diseaseabout 65% of the time if it's
present.
Not very good.
If we add an echo to that andwe do an ultrasound of the heart
while they're exercising, thatincreases us to about 75%
accuracy.
Speaker 1 (22:26):
Okay, so getting better yeah.
Speaker 2 (22:27):
If we then go to nuclear testing we may go to 80%
.
The newest is the stress PETscan.
The stress PET scan has 75%less radiation increases us to
about 92%.
And one of the very, very, veryexciting areas right now is CAT
scanning of the arteries withintravenous dye called CT
angiography.
(22:47):
That's almost as good as aheart catheterization.
So we can do everything that Ijust said to identify heart
disease and risk stratifywithout a heart catheterization.
Speaker 1 (22:56):
You know, I'm going to kind of go back, and that's
excellent news, especially ifyou can avoid a procedure.
Going to kind of go back, andthat's that's excellent news,
especially if you can avoid aprocedure.
Um, I want to go back tosomething that you said earlier,
and I often say this topatients if you have plaque in
the arteries of your heart, youprobably have plaque in the
arteries of your brain, and so,uh, I, I, I I'm if you're a
(23:17):
neurologist and you're, you know, don't scream at me, but I
think a lot of dementia iscalled a lot of things and ends
up being vascular dementia,correct, and that's something
that can dramatically reduce thequality of your life.
And you know, in general it'sdifficult to make these
lifestyle changes or to go intoa cardiologist when you feel
(23:41):
totally normal.
But I think it has to be someemotional event in your life
that can kind of push youtowards that.
Whether it's a medical scarewith you or a family member, or
maybe you're pregnant, or maybeyou have cancer.
You have something that kind oftriggers some emotion that
causes you to say, hey, you knowwhat I need to kind of look out
for my long-term health, notonly for my cardiac health, but
(24:03):
for the health of my brain.
And I mean, if you have plaquein the arteries of your heart,
you probably are going to havesome sort of arterial disease
that can cause kidney disease,and so in many ways your blood
flow is your health.
Speaker 2 (24:15):
Absolutely.
And again, a huge percentage ofour patients that have MRIs
don't have the brain.
They have something calledsmall vessel disease.
If you're more extensive ofthat, you have small strokes
everywhere and that leads todementia.
What's the treatment for smallvessel disease?
Same thing it is for heartdisease.
We lower cholesterols, we lowerblood pressures.
We look at these risk factors.
I want to come back to one morething.
I was talking about my volcano.
(24:36):
Okay, yeah.
So the reason why that'simportant is that there is a
mountain, okay, and a volcano,okay.
If it's a mountain doesn't doanything if there's no magna
underneath the surface, ifthere's no lava, that would come
to the surface.
So what the treatments do thatI'm talking about?
When we drop those cholesterols, we start getting rid of the
(24:57):
soft cholesterol gunk underneaththe volcano that we get rid of
the lava, we turn that magnainto rock and when that happens,
within a month of lowering it,event rates, which includes
heart attacks and strokes, comedown dramatically.
Speaker 1 (25:12):
That's surprising that it works that quickly.
Speaker 2 (25:14):
It can start within a month.
Speaker 1 (25:16):
Now people can have—OK, so we're jumping back
and forth, but, but, but, whichis fine.
Um, so the the artery, which islike a tube.
You can have plaque that cannarrow the artery, but you can
also have plaque that goes intothe artery.
And then there are stableplaques, which correct, and then
you can have unstable plaqueswhere, if, so if and I might be
(25:37):
wrong on this, but you can havean unstable plaque that grows
into the artery so you don't seenarrowing, but if it breaks off
, the platelets immediatelyadhere to it.
And you have this acute eventwhere, all of a sudden, the
artery was, the blood wasflowing fine through the artery.
Now the plaque breaks off, theplatelets adhere to it and you
immediately have a blockage.
Speaker 2 (25:57):
Exactly right.
So that's what we're talkingabout.
So if the volcano erupts andyou get the gunk that comes to
the surface, or you have a crackin the surface like an
earthquake, then that softplaque comes to the surface.
Then the blood starts clottingand you go from a 50% or 60% to
99% or 100%, that's a heartattack.
Speaker 1 (26:18):
Or God forbid, that's sudden death, and quickly,
that's quickly.
That, or God forbid, that'ssudden death and quickly, that's
quickly, that's very quickly.
And sudden death is one of theleading.
If you say what's the firstsymptom of a heart attack, a lot
of people may say chest painand that may be number one, but
sudden death is up there.
Speaker 2 (26:31):
Absolutely.
First, I like to never saychest pain.
Okay, so what I tell mypatients and I tell my residents
and my fellows when I teachthem never say chest pain,
because my patients will say tome very, very frequently I never
have chest pain.
Do you ever have anuncomfortableness in your chest?
Do you ever have fullness?
Do you ever have an indigestion, discomfort?
Physicians have been known tothink they have indigestion when
(26:55):
it's really their heart.
Okay, so first of all, yes, sothe onset of some kind of
uncomfortableness or shortnessof breath with activity or
uncomfortableness, pressure issomething that absolutely is a
marker of heart.
But sudden death, yes,unfortunately, can be the first
manifestation.
Speaker 1 (27:16):
And then the incidence of this increases with
each decade of life.
Yes, the incidence within the40s is not very high, but once
you get to the 60s, yourlikelihood is what?
20% to 40%, depending onwhether you're a man or no?
Sorry, I have 21% in men and11% in women.
(27:38):
In the 70s, it goes from 35% inmen to 24% in women.
So that's a generalization.
Speaker 2 (27:44):
Yeah, that's a rough idea as to where it is, but yes,
it becomes more frequent andit's also I've also
unfortunately for the listenersI've taken care of many patients
in their 20s yeah, sure youknow, in 30s with early onset of
heart disease, including women.
Speaker 1 (27:59):
And with diets getting worse over time.
You know, I think that's atrend.
When they update the data,they're going to see that
there's more heart disease inthe young.
Yes, and so all right.
Well, craig, fascinating talk.
I feel like we could talk allday, but I very much appreciate
your time, sir, and thank youfor being a great colleague.
And thank you for your time,thank.
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