901 Health - Cardiovascular

ANDOR BUJDOSO

901 Health: Matters of the Heart

Cardiovascular problems should always be taken seriously, and doctors are placing more emphasis on preventing them.

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Don’t drive yourself to the hospital if you think you’re having a heart attack. That’s really the only thing Memphian Peter Baker (not his real name) did wrong when he noticed persistent pains in his shoulder, of all places, after his exercise regimen one morning in December.

Baker had long maintained a healthy and active lifestyle. In his early 60s, though no longer a cross-country cyclist, he took three-mile walks daily. Already thin as a board, in recent years he began following a heart-healthy diet. “I try to eat organic,” he says. “For breakfast it’s a bowl of fruit with yogurt on it, and for lunch maybe rice and guacamole. At night, it’s usually salmon with rice or broccoli.”

Every morning Baker would rise at 4 and before he began his walk would do stretches and then situps and pushups. That particular morning, he noticed a sharp twinge in an unusual location. “When I stood up, I felt a pain on the top of my shoulder, so I thought I had pulled a muscle,” he says. He still went on his long walk and took an aspirin when he got home. That made the pain go away, but it came back. A few tablets of ibuprofen relieved the discomfort — but again it returned. “So I started debating,” he says. “Is it only a pulled muscle, or is it something else?”

That’s when he remembered a friend who had recently suffered a heart attack while driving, and her first clue was pain in her back. With her experience in mind (she survived, but required open-heart surgery) Baker began to take the persistent symptoms more seriously. That afternoon, some 12 hours after the pain first started, he drove to the nearest emergency room.

“It just didn’t seem like a muscle hurting,” he says, “and I thought, at least I’ll know what it is, even though they’ll tell me it’s a pulled muscle and give me more aspirin.”

At the hospital, nurses did preliminary tests, and a doctor asked Baker if he felt nauseous or short of breath. “I said no,” he says, “and since my EKG apparently looked fine, and they didn’t seem all that urgent — I mean, they didn’t call in the Harvey team or bring in a crash cart — I still thought it was a muscle.”

Then a nurse gave him the bad news. “She said, ‘We’re going to keep you in the hospital because your heart enzymes are elevated, and that indicates a heart attack,” says Baker. “And I thought, ‘Wow!’”

More bad news was to come. An angiogram — a procedure where a cardiologist injects dye into a patient’s bloodstream and watches a monitor to see the blood flow around the heart – revealed two cardiac arteries were blocked. Even worse, the blockages could not be cleared by stents — springy coils threaded into an artery through the femoral artery on a patient’s leg. Baker would require open-heart bypass surgery.

That operation was a success, and after a total of nine days in the hospital, Baker is recovering at home. For a few weeks, he was instructed not to drive, to sleep on his back so the chest incision would heal properly, and not to lift anything “heavier than a teacup,” but he is making slow but steady improvement.

“For me, this just shows that you can do everything that’s recommended — eat right and exercise — and you can still have a heart attack,” Baker says. “But I guess a healthy lifestyle lessens the severity if you do have one.”

“When I talk to patients, I try to make them understand that prevention is a lifetime endeavor. You don’t start in your 50s, or 40s, or 30s.” — Dr. Arie Szatkowski

A New Emphasis on Prevention

Despite the ordeal of the surgery, Baker is one of the lucky ones. He survived. Every year, cardiovascular events such as heart attacks and strokes kill more than a million people in the United States alone, according to the American Heart Association. Great advances have certainly been made in cardiac procedures. In Baker’s case, the surgeon closed his chest incision with a special adhesive; in the past, open-heart surgeries left patients with a disfiguring “zipper” of metal stitches. Even so, there is now a special emphasis on keeping patients from reaching that stage.

“As a result of recent trials, we’ve discovered new ideas and findings that change our approach towards cardiac disease,” says Dr. Arie Szatkowski, a cardiologist with Stern Cardiovascular Center and medical director of cardiac services for Baptist Hospital. “When I talk to patients, I try to make them understand that prevention is a lifetime endeavor. You don’t start in your 50s, or 40s, or even 30s. You have to start at a very young age, and if your parents make the extra effort about your future and your life, then they will establish a healthy environment for you.”

Some things are beyond a patient’s control. “There’s little we can do about gender or aging, and many of the diseases we develop — cancer or lung and kidney problems — are directly correlated to aging and even genetics,” says Szatkowski. “But in the general world of heart disease, there are indeed modifiable risk factors.”

Stay on a Healthy Diet

In the end, it really comes down to avoiding processed foods, fast foods, and the consumption of simple sugars and carbohydrates,” says Szatkowski. “Try to consume a balanced diet that’s made up of fresh fruit, fresh vegetables, chicken, legumes.” If patients want to follow a specific health diet, the Mediterranean diet, with its emphasis on olive oil, legumes, and unrefined grains, seems to be the best, he says.

Monitor Your Blood Pressure

In the past, optimum blood pressure was anything under 140/90. “More extensive data shows that a blood pressure of 130/80 is even better, and for certain populations, such as diabetics, those numbers should be even lower,” says Szatkowski. “Large trials support that, but with elderly people, if you drop that number too low, you can cause harm by making them lightheaded and even reduce bloodflow to their kidneys. So you have to approach each individual and understand what’s important to them. You want to reduce their risk of a cardiac outcome, but not impact the quality of their life.”

Ask about New Medications

More effective medicines have reached the market that have, as Szatkowski puts it, “changed the paradigm of treatment.” In the past, diabetic drugs controlled blood sugar levels but tended to have cardiac side effects. The first line of treatment is now Metformin, “the only drug that not only helped control diabetes but led to a reduction in cardiovascular events.”

Two other new classes of drugs are SGLT-2 inhibitors (Invokana or Jardiance) and  GLP-1 agonists (Trulicity, Ozempic). “It’s the first time that drugs solely focused on the treatment of diabetes have had an incredible impact on reducing death in patients with existing coronary artery disease,” says Szatkowski. What’s more, new trials are showing that these medications are even helping non-diabetic patients. “So we are adding these to our list of drugs we could use to prevent bad outcomes, and now we have multiple options for treatment.”

Check Your Cholesterol

Patients with coronary artery disease should be on a statin drug,” says Szatkowski, “and this is based on loads of data and trials.” Szatkowski believes anyone with LDL (low-density lipoprotein) higher than 190 should try statins, such as Lipitor or Crestor. These aren’t magic pills, however. “Just because you take this drug, it doesn’t mean you have no chance of having a problem,” he says. “But if five people out of a hundred have a cardiac event without the drug, maybe now it’s one out of a hundred. And you may be one of those four.”

He understands that many people are reluctant to ingest “chemicals” on a daily basis; they prefer something natural. “Most of the natural remedies may lower cholesterol, but they don’t lead to a reduction in heart attack, stroke, and death,” he says. “So what’s the point? If you want to eat red yeast or rice, that’s wonderful, but no trial has proven that these are effective.”

Using the Apple Watch, doctors tracked 500,000 patients. “It proved we could use this technology to monitor patients without having them set foot in a doctor’s office.” — Dr. Arie Szatkowski

Statins are usually taken once daily. A new class of medications for lowering LDL, such as Repatha, is injected once a week. An even newer drug that specifically targets high triglycerides, which is still going through patient trials, would be taken every six months. “So one subcutaneous injection, and your cholesterol is perfect,” says Szatkowski.

Go High Tech

Szatkowski has seen dramatic advances with implantable devices, such as pacemakers, which can be adjusted remotely so the patient doesn’t need to visit the cardiologist. Even heart rhythm problems can now be monitored by a device already worn on many patients’ wrists — the Apple Watch.

“It’s always hard to enroll people in medical trials,” says Szatkowski. “We can get 200 people, and sometimes up to 5,000.” Using the Apple Watch, cardiologists recently completed the Apple Heart Study, which tracked 500,000 patients. “Everyone got a text from Apple, asking if they could be remotely monitored for a heart rhythm problem,” says Szatkowski. “The response was amazing. Not only were we able to determine how many people had a condition like atrial fibrillation, we could see how long the episodes lasted. It proved we can use this technology to monitor and treat patients without having them set foot in a doctor’s office.”

Get Some Sleep

Perhaps the easiest thing anyone can do to prevent heart attacks is as simple as getting enough sleep. Studies have shown a direct correlation between sleep and cardiac events. But as with anything, moderation is key. 

“In a particular trial, folks who slept less than six hours a night had a substantially increased risk of a heart attack,” says Szatkowski. “On the other hand, people who slept more than nine hours a night trended towards an increase in heart attacks. So the ‘sweet spot’ is anywhere from six to nine hours.”

Into the Future

Current trials and studies are examining the impact of blood thinners, vitamins, and even genetics. The main thing, says Szatkowski, is to follow an active, healthy lifestyle, and to be aware of unusual symptoms. A heart attack — as Peter Baker learned — may not present as the typical chest pain.

“Suddenly, something changes,” says Szatkowski. “Maybe it’s a squeezing in your chest, or even in your shoulder or jaw. Maybe it’s something you’ve never felt before. Don’t sit around and think about it. It’s always better to get it checked out.”