In this episode of PodMD, cardiac imaging specialist Dr Jason Kaplan will be discussing the practical advice you can provide to your patients for living a heart healthy lifestyle, including the main factors that can impact heart disease, what advice we can give to patients to reduce their risk, when medication is required, what a GP can do to assess their patients and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Jason Kaplan
Dr Jason Kaplan is a cardiac imaging specialist who studied Medicine at UNSW and graduated with Honours in 1999, completing his Internal Medicine Training at St George and Prince of Wales hospitals and Adult Cardiology training at Royal Prince Alfred Hospital.
Dr Kaplan has done additional training in all aspects of echocardiography at international centres including the Mayo Clinic and has been involved in training echo sonographers for the last 10 years. He is currently a senior clinical lecturer in Medicine in the Faculty of Medicine and Health Sciences at Macquarie University teaching undergraduate and postgraduate students.
Today, we’ll be discussing practical advice you can provide to your patients for living a heart healthy lifestyle
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Jason, thanks for talking with us on PodMD today.
Jason : Thank you for having me.
The topic of today’s discussion is practical advice healthcare professionals can provide to patients for living a heart healthy lifestyle.
Jason, can you give us a brief overview about why it is so important to encourage patients about the importance of proactively living a heart healthy lifestyle?
Jason: That is a great question and one of the really important points that I try to pass on to both primary care doctors and my patients is that the risk factors for heart disease have their origins early in life. We’ve seen from autopsies of young men killed in war zones that atherosclerosis, or the early buildup of fibro fatty plaque in artery walls, actually starts in the teenage years, and when most of us or when most people in our society start worrying about their health or worrying about their cardiovascular risk factors, often may be in their 40s and 40s and 50s when some of their friends and relatives are getting heart disease. But for some people, they’ve been exposed to many years of both unhealthy lifestyle habits ,they’ve been exposed to genetic challenges that they may have inherited from from family members, and the opportunity to live a heart healthy life gives you many more years of Healthy, of Healthy Living to reduce these risk factors over the total course of one lifetime.
And they’ve been one of the most amazing studies that have been published over the last few years, was called the Cardia study that looked at very people earlier in their life between the ages of 20 and 40 years old, and looked they did a baseline set of risk factors including bad cholesterol, LDLC, blood pressure, triglycerides and also pulse pressure, which is the difference between the top systolic pressure and the bottom diastolic pressure, and then they follow these people for many years down the track and they saw that the people at the highest levels of LDL earlier in life than their 20s, higher levels of blood pressure, higher levels of triglycerides had worse cardiovascular outcomes in the middle life. And so these studies guide us to tell us that, you know, looking at cardiovascular risk factors early in life is really important.
In a way, it’s never too early to start. And one of one of my great idols in and if you can say as a cardiologist, you can have idols and preventative cardiology professor called Valence and Fuster is currently the editor in chief of the Journal of American College of Cardiology. I was lucky enough to go to my elective with him in 1999 and Mount Sinai. But he believes that we actually need to think earlier. We have to start thinking about primordial prevention. So how can we get people to and how can we get teenagers or children to adopt healthy lifestyle habits in their teenage years to help prevent the subsequent accumulation of the subsequent development of heart disease later in life. And so I guess the key message, it’s never really early, early to start the food. We feed our children, and our teenagers may have significant impacts in their lives later in life.
What are the main factors that can impact an individuals risk of heart disease?
Jason: So there are multiple factors that can impact an individual’s risk of heart disease, and I like to think about some of those as genetic or inherited. And some of those modifiable. Now as much as we at the moment we can’t really change our genetic makeup and we can’t choose our parents to some of our cardiovascular risk comes from our underlying genetic makeup that we inherited from our parents and their parents.
But, there was the most amazing study published in the New England Journal of Medicine around seven years ago that looked at how you were able to modify your underlying genetic risk. And if you had bad genes and a bad lifestyle, you were going to be in trouble and you were going to have a much higher rate of cardiovascular events. And an increased rate of atherosclerosis or plaque progression. But what they found was that if you had an underlying high genetic risk, very strong family history of heart disease, but you were able to modify the major cardiovascular risk factors. So this includes blood pressure, so you had to have a normal blood pressure, you have the absence of type 2 diabetes. You are a non-smoker. You’re exercised on a on a regular basis. And you had a healthful diet. You were able to reduce your underlying genetic risk by over 50%, which is remarkable. And it just shows the effect of often lifestyle factors at reducing underlying genetic risk.
And I think just underpins for those of us who do have a positive family history of heart disease, that lifestyle factors become even more important. So there is a genetic risk, and there are sometimes inherited disorders of cholesterol metabolism that people with very high cholesterols or they occur on multiple genes. And a lot of coronary disease and heart disease is not just one genetic abnormality, but there are there are multiple genes that are inherited in families.
So the other traditional risk factors include blood pressure and the most common cause of blood pressure in our society is essential hypertension. But some of these are contributed by lifestyle factors as well. Obesity is another risk factor for heart disease. Smoking is another risk factor. Type one or type 2 diabetes is also is also another risk. But we also know there are now some more novel risk factors for heart disease and there’s been a lot of talk in, in the medical literature this year about lipoprotein (a) which is something that I have would recommend that primary care doctors start to measure in all of their patients at least once over the age of 35. And LP(a) is a lipoprotein that I like to think about it, it sticks to the LDL and causes increased deposition of plaquing in arterial walls.
And more and more, we’re coming to see the role of inflammation as well, that people who have high inflammatory burdens. I know we’re talking about atherosclerosis in another podcast, but people that have a high burden of inflammation, whether it be due to underlying inflammatory disease, such as autoimmune disease, chronic infection or by our lifestyle habits, all of this can contribute to accelerated plant buildup and accelerated atherosclerosis in in our arteries.
So one of the last things I want to talk about is as risk as I guess is risk factors as and it’s not talked about often. But I would say that physical inactivity is a major risk factor for development of heart disease and also for a shortened lifespan. So when I evaluate patients in my room is one of the key things that I look for, is their level of aerobic exercise capacity or some of the new smart watches you’re even measuring your cumulative VO2 Max and outdoes on the Apple Watch. But people who don’t exercise are at significant risk for subsequent heart event and if your level of fitness is in the lowest 20% for age and sex match controls, you will not do well from a cardiovascular point of view.
What advice can we give to patients to reduce their risk?
Jason: So my advice to patients is to reduce their risk of developing heart disease. I’ll give this a paradigm. When people smoke cigarettes, they smoke for many years and often people up smoke up to a packet a day, and then we count. Often when we take a history from people, we count the amount of years they’ve been exposed to nicotine and harmful substances. And we call that, you know, the number of pack years. In a way similar exposure to harmful levels of cholesterol, blood sugar, higher blood pressure, can also have an have an impact. And the more years you’re exposed, the more likely you are to damage not just your heart, but when we talk about the cardiovascular system, it’s all the blood vessels. It’s the blood vessels to our eyes, the blood vessels to the brain, the same risk factors, they cause stroke, the same risk factors that can cause kidney disease.
The American Heart Association has come up with lifes essential 8 and these are the 8 components of cardiovascular health that we think people should adopt early in life to try and achieve optimum cardiovascular health later in life, and this includes a healthy dietary pattern. And more and more we are starting to find out that a PESCO Mediterranean style diet. That is, that is abundant in in vegetables and whole grains is one of the best dietary patterns for heart disease prevention. As I said before, engaging in physical activity, avoidance of nicotine. Sleep healthy sleep patterns have become one of the important pillars as well. The healthy weight, healthy level of blood lipids, blood glucose and healthy blood pressure, and if earlier in life from the first few decades of life, people can achieve all of these eight metrics. If all of these eight are kept, your chance of developing significant heart disease will be significantly reduced over the course of your lifetime.
At what point is medication required to manage some of these risks?
Jason: Medication is required to manage cardiovascular risks if people are deemed high, risk enough, or if we think that the that the intervention being offered will provide a greater advantage than either lifestyle or dietary patterns, or if we know an intervention will significantly reduce their risk. So the most common disease or causing heart disease is the buildup of plaque or atherosclerosis. So this is something that we tend to look for in both invasive and non-invasive cardiac imaging, but in anyone going to see there, one of the most important things that I do in every visit is to perform a thorough cardiovascular risk assessment.
Generally when people have established disease or established plaque or atherosclerosis, and often in the primary care setting when someone has a coronary calcium score of greater than 100, or someone who is deemed high risk enough. Or if there is evidence of end organ damage to someone has presence of hypertensive heart disease, has the over development of type 2 diabetes that’s difficult to manage or diet alone, has established atherosclerosis, has proteinuria, has left ventricular hypertrophy. Often these indicators of end organ dysfunction suggests medication is required to manage some of the some of these risks and provides a significant advantage.
The great thing about cardiovascular medicine and our long history of clinical trials is we not only when we prescribe a medication, we not only think it’s going to achieve a physiological effect in the body, but often we know that is going to is going to lead to a reduction in cardiovascular events, and that’s one of the most important things that we should be asking both ourselves and our patients is the. Intervention that I am suggesting going to lead to reduction in events. We know if we can reduce bad cholesterol by over 25% and that’s the LDL we can lead to a 25% reduction in the subsequent risk of a heart attack. We know that if we can reduce blood pressure to closer to 120 on on 80 as opposed to the target of over 140 or 90, we will significantly reduce the chance of developing heart failure and stroke related related to high blood pressure.
If we can bring down someone’s weight significantly. Or reduce their fasting blood sugar. Right, HB A1C, we know we can reduce the chance of diet diabetic complications. And we also know that someone improves their cardiovascular fitness significantly they will have a significant reduction in cardiovascular events as well. So there are people that would definitely well studied meditation is will reduce the risk and the best thing that’s done on an individual basis.
What can a GP do to assess a patients risk of heart disease?
Jason: The first thing to do is at every opportunity when people come in for a yearly check-up is to assess is to make sure we take down these metrics. And I think over the age of 18, people should have their blood pressure recorded, they should have their weight recorded. They should get a fasting lipid panel, a fasting, fasting, blood sugar and a family history of heart disease to get an idea of what their cardiovascular risks are. And if there’s any change in baseline to allow earlier intervention and the younger phase of life we would I would usually recommend you know lifestyle and dietary and dietary factors and I would use one of the risk score calculators that as we as we mentioned as I mentioned before.
I think it’s worth checking the lipoprotein (a) at least once in patients. And if it’s elevated, it is a marker about the future development of atherosclerosis independent of other traditional risk factor markers. I think when someone starts to approach their in in their 40 for men in their 40s for women in their 50s, I would be encouraging a test of atherosclerosis such as for most useful via coronary artery calcium score and to see if people are at risk and if they’ve already started the build up of atherosclerosis in their arteries. It’s quite difficult to assess someone’s exercise capacity in most GP practices, but I would highly recommend including some history about how the underlying level of fitness or what current level of physical activity they are doing, because I think it is something that we don’t do enough in histories and lack of exercise is a major risk factor and also in to include one of the newest risk factors which is which is sleep as well.
I think it all starts with the risk factor assessment. And then as that progresses, when we start to see the people are at higher risk than to think about appropriate screening, screening for end organ, for end organ dysfunctional changes such as a, you know, such as doing a urine, looking for looking for proteinuria, if someone’s got high blood pressure, thinking about an echocardiogram. Looking for an underlying left ventricular hypertrophy or the development of hypertensive heart disease. In fact, most of these primordial or the prevention risk factors should ideally be managed in the in the primary should ideally be managed in the primary care primary care setting, but I think I see every visit would be an opportunity to look at underlying risk factors. And even if you can’t cover all of them, adiscussion around one of the one of the risk factors.
I also want to I think the key message is that I think we need to be thinking about as clinicians is where our patients get their information about heart disease and there is so much out there about diet and lifestyle and certain supplements that I think it behoves us to be to know what our patients are looking at on the Internet and to be able to be a filter,for their information, to help provide, you know, an evidence based approach to some of the some of the things that they may bring toward bring to us and help guide them on healthy lifestyle choices, especially in well for all parts of their lifespan.
And what if a patient already is showing symptoms or risk factors of heart disease?
Jason: So if from the initial screen patients is already showing symptoms or risk factors for heart disease, then I would recommend further evaluation to look at the extent of disease and then which therapeutic modalities would be best would be best suited. There has been a landmark trial published in the last few years in cardiology and it came out around the time of the COVID pandemic called the ischemia trial. And the ischemia trial has also been followed by a smaller interesting trial called the Orbital trial. But the ischemia trial looked at treating a severe coronary stenosis in an artery in artery blood that’s blocked over 70% and looked at treating that with either you know guideline directed medical therapy, so statins, aspirin if necessary, anti-hypertensive medications and anti-anginal, or by stenting or if necessary bypass. And the outcome at five years was the same. That interventional therapies did not provide any advantage over guideline directed medical therapy in stable coronary artery disease. This is not for someone who’s having a heart attack or unstable angina. However, this is for stable disease.
And the orbital trial followed this and it showed that stenting did not make such a difference to underlying symptoms of underlying symptoms of angina and. I think it underscores the need for both for, especially in primary care, to encourage patients to take the medication. We know that guideline directed medical therapy works. It’s a step when we’ve done studies about people, about how compliant they are with medication that often they won’t they won’t have filled a few months worth of statin scripts, or they might. One may last two months or they’re not taking all their medications or they missed some days. So we know that the medical therapy works, and it’s really important that patients take take them, take the medication.
Once I do think that patients require further extensive testing, especially if they have signs and symptoms. And the really great thing that I like about how cardiology is evolving in terms of a lot of the care is it’s now very team based. So often over the more complex decisions about patient care get discussed in a multi-disciplinary room with interventional cardiologists, non-invasive cardiologists like myself, cardiothoracic surgeon. And cardiac imaging doctors and we have a discussion around what would be the best, the best treat treatment options for the for the patient in, in front of us. The amazing thing is that we have incredible ways to non-invasively image to heart from [inaudible] where we can, where the technology is getting better and better each year, we can see inside people’s arteries to cardiac MRI, where e can where we can look for subtle signs of scarring, fibrosis, fibrosis or inflammation. And with this information, we better we are better geared towards providing personalised therapy for the patient, for the patient in front of us. So it’s a very exciting time in cardiology.
What role does the GP play in the treatment of heart disease?
Jason: So the GP plays a really important role in the management of chronic cardiovascular conditions and risk factors and really, as a as a specialist, the primary care doctor is our key partner in both ensuring compliance in medications and being able to monitor the for appropriate targets. Now we know when patients get to appropriate targets in the prevention of certain heart diseases and clearly, in secondary prevention, one of the most one of the strongest relationships in all cardiovascular medicine is getting an lower we get the LDLC in someone who’s had a myocardial event or is at high risk or had a stroke. Lower risk of subsequent events, and we rely on primary care doctors to help uptight rate both the medications and in particular add any additional medications that that may be needed, or if they are thinking about some of the more advanced therapies such as PCSK 9 inhibition that we that we talked about, you know to contact us so we can initiate there.
It’s also important as the as the GP to continue to enforce, continue to you know encourage lifestyle and dietary change and always tell my patients that you are you know you can’t out supplement or out medicate poor lifestyle choices. So keep on putting all these meds, but if you continue to, you know, to eat badly and don’t exercise and smoke, you’ll still you’ll still be running, running up to running trouble. And I also see the well and primary cares to monitor for any complications of some therapies. So sometimes the therapies that we that we have will cause patient side effects, some of these some people do get side effects on statin therapies, sometimes some antihypertensives such as diuretics cause electrolyte abnormalities. And I see that the care is as a team effort. And so GPs play a really important role in the management of people’s cardiovascular risk factors and underlying cardiovascular disease.
You see patients more often than we would and. And I also think that as a primary care doctor, there’s often much more knowledge about their underlying life, and especially some of their social circumstances. You know, there’s been some recent studies that have looked at the role of stress and family stress and work stress and financial stress on cardiovascular outcomes, and that people have been shown to worse. And especially, I guess, I mean, we haven’t talked about mood and depression, but this is one of the other things that I’m I would find really helpful to know about. We know that patients who are depressed, who have low levels of optimism do worse from heart from a heart point of view, and Martin Seligman, one of the founders of positive psychology, has shown that people that men are at heart attacks who didn’t have high levels of optimism, did poorly over the course of the course when you followed them, followed them for years.
So really, I see the GPs rolls as a team. And I would encourage ship is to speak to their speak to the specialists and cardiology doctors and keep in touch about how patients are doing. I really like hearing about how my patients are doing. I like being copied in on blood tests, even if I’m not due to see patients again for a few months’ time. I like knowing about changes in medications and just to see I like yeah, keeping track and seeing how.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on health heart lifestyle.
Jason: So I would say that healthier choices earlier in life impacts our long term cardiovascular health #2 being proactive about heart, heart health, having knowledge about where your underlying risk factors are, including your genetic factors and getting regular heart health checks are really import. And also that the development of most of the common forms of heart disease in Western society is accumulation over many years, and we have many opportunities to prevent the development of heart, heart disease in our patients. And don’t forget the, I guess, some of the important more risk factors that are not traditionally included on risk factor calculators, including lack of physical exercise, sleep and mood.
Thanks for your time and the insights you’ve provided.
Jason: Thank you