Risk Factors You Need to know for your Heart Health
Aired June 18, 2022, Part 2
Introduction 0:01
Welcome to the MedEvidence podcast hosted by Dr. Michael Koren and Michelle McCormick MedEvidence where we help you navigate the real truth behind medical research with both a clinical and research perspective. In this podcast, we'll have discussions with physicians that have extensive experience in patient care and research. How do you know that something works in medicine? We conduct clinical trials to see if things work. Now let's get the truth behind the data.
Michelle McCormick 0:33
Welcome to MedEvidence! Truth Behind the Data. Today we're talking about what to do after a heart attack or stroke. Joining us are Dr. Albert Lopez and Dr. Michael Koren. Well, in the first segment of MedEvidence! Truth Behind the Data what to do after a heart attack or stroke, we established that people who have had either of these events a heart attack or stroke have a high risk for a repeat procedure or repeat event. We talked a lot about the team, knowing who your PCP is and your specialist, your family needs to be aware of symptoms, what's abnormal, what is normal, and if the event lasts greater than 20 minutes, that's when you really need to make that emergency medical call. Now, let's move into how to make this different and better. We touched on it briefly on the modifiable and unmodified or non-modifiable risk factors. So let's dive into that a little bit.
Dr. Koren 1:31
And that's the way physicians think about things. There are things that we can change, and there are things that we cannot change, and we can only mitigate the consequences. So Dr. Lopez will give us a brief rundown on what's modifiable risk factors are and what non-modifiable risk factors.
Dr. Lopez, DO 1:45
So Dr. Koren and I always love to talk about lipids.
Michelle McCormick 1:49
I was gonna say; this is like in your wheelhouse guys.
Dr. Lopez, DO 1:53
Know your lipids. I really disliked the cholesterol name, but the lipid profile, we usually focus on those are very important.
Dr. Koren 2:02
And lipids, by the way, is just a word for blood flow. So blood fats, blood fats
Dr. Lopez, DO 2:07
Diabetes, or pre-diabetes. And we have to remember that diabetes has four to six times higher risk factors for cardiovascular events, and even pre-diabetes has doubled the risk factor. So just because your sugar is only 100, that still doubles the risk. It's doubled from what the average Joe. So you have to be really cognizant of that and want to bring that down. overweight, obesity, both of those are really significant. Not just for heart disease, but for many chronic diseases. So that's very important. And lack of physical exercise. So movement therapy, because a lot of people are allergic to exercise. movement therapy works very well. And there are all kinds of studies we can talk about that speak to how we eat or unhealthy diets, or eating lifestyles are very important. We're a fast-paced society. And with COVID, fast food is not your best friend. It's easy, but it's not good for you. And we can talk about that and then smoking. Smoking, lighting up a cigarette or cigar because people forget cigars, but it's also tobacco in oral form is a risk factor. And vaping is not good for you. It's actually been shown to be just as bad as smoking on many levels. Blood pressure, very, very important to know your numbers, and then stress. And then the other modifier risk factor we didn't list was inflammation. Chronic inflammation is an issue and we can go into detail as you're ready.
Dr. Koren 3:41
Sure. Yeah, so the modifiable risk factors are important from a clinical standpoint because we can make a difference. And there are things that we can correct. Now, this is going to blow your mind a little bit, but the relationship between the risk factor and changing the risk factor is not always straightforward. So for example, we know that there are certain risk factors that also are risk markers. Okay. So a risk marker means that there's an association. But the relationship between changing that parameter and improving things could be unclear. So for example, as we get older, our cholesterol levels actually tend to come down a little bit. But that doesn't mean that our risk comes down, right? Whereas cholesterol and lipids are one of those things that when we change them, particularly when we get them to very low levels, people just do better. They have fewer heart attacks, they have fewer strokes, and we can do it without generating side effects. So Dr. Lopez and I love to talk about that. And we'd love to talk to our patients about that because it makes a big, big difference. But what happens is sometimes people say, Oh, well, my cholesterol, when I was 30 years old, was 250 and now it's 200. So that's pretty good. I'm moving in the right direction. And meanwhile, between 30 and 50, their risk overall has gone up tremendously. So even though their cholesterol is now 200, and was 250 20 years ago, it's much more compelling to treat it now than it was when they were 30.
Michelle McCormick
So the bad cholesterol, what does that mean?
Dr. Lopez, DO 5:18
I think the other general sense is that people tell me oh, well, my cholesterol is always been high. And we have to remember, and it's not that bad. Well, we know that its long-term exposure to lipids is a problem. But also the intensity or how high that lipid is is also a risk factor. So even though it's only X amount x plus, if you've had that for 40 years, it's a risk factor.
Dr. Koren 5:45
There's no question; it's a risk factor.
Dr. Lopez, DO 5:47
You put metal in water for 30 years, even if it's mildly salivated, water, it's gonna rust, your arteries are going to rust with that high lipid level.
Dr. Koren 5:53
So so again, there's some discussion about when to initiate lipid there. But again, we're talking about people that have already had an event. So the point we're really making is that once you have an event, you want to focus on those things that we can change and be extremely aggressive. And because of some things, we can't change, and because there are some things that we can't do anything about, we as physicians are going to be really, really focused and work with you on the stuff that's really modifiable.
Michelle McCormick 6:22
Well, are patients, after they've had a heart attack or stroke more willing to make these modifiable changes?
Dr. Koren 6:30
You get people's attention after a heart attack and stroke. So typically, they're much more amenable to interventions, particularly in the period of time right after the event.
Dr. Lopez, DO 6:41
Yeah, that's so interesting that we see a huge spectrum of how people are willing to change, right? So people will say, I always ask, What's your why? Why do you want to change? Everybody has a why in their life, right? And maybe their grandchild and maybe their dog? And maybe they like to run? Maybe something? And I think you and I both have to touch on “What is your why? And usually, then you can ask them to do something. But you know, some people make paradigm changes. We've seen people go pure vegetarian, I mean, pure plant-based. And as we go, there's no way I'm doing that. I'm just not doing that. But then we'll start having a conversation. Well, how about reducing it to this much? And how about if we don't fry it, and sometimes baby steps work to get them to where we want to get them. Sometimes they can make this huge paradigm change all at once. But everybody's different and how they do that. But we're surprised sometimes that people don't make changes,
Dr. Koren 7:32
Right. The other thing that's very important about modifiable risk factors is that there's a lot of interplay between them. And so for example, people that have diabetes will develop vascular stiffness over time, which will raise their blood pressure. And, in turn, certain blood pressure medications happen to help people with diabetes actually help lower their sugar levels, whereas other blood pressure medications can raise your sugar levels. So this gets really, really complicated. Why you need a risk factor expert, because there's a tremendous amount of interplay; even with cholesterol medications, there are, certain cholesterol medications that seem to have other positive effects. We use the term Pleiad trophic effects, which is the fancy medical word for saying things that are outside of just what we can easily measure. But the point being is that this gets pretty complicated. And so you'll read a bunch of things on the internet and other places about this lowers my cholesterol in this way, and this lowers it in that way. But you really want to work with an expert on these things, because you'd be surprised at how things can play out. And it'd be very, very different than what you think.
Michelle McCormick 8:37
And medication can also, you know, different medications for different things can counter indicate each other and not work well together for that patient as well.
Dr. Koren 8:46
So let me give a very practical example of this. So we talked about being overweight as a modifiable risk factor. Interface this with high blood pressure, diabetes, and lipids. Okay, so do you treat each of the individual things? Or do you just help people lose weight, knowing that a lot of things will improve? And, you know, we haven't had great medicines for weight loss, but that's changing pretty quickly. So sometimes, the key for some people is getting way down. And sometimes people just can't do it and have to be considered for bariatric surgery, for example. So this is where the risk factor discussion gets really pretty complicated. You need somebody that can lead you through it.
Dr. Lopez, DO 9:28
Even we see this and medications in the diabetes realm, you know, if the mainstay for treating diabetes was the thought, even though your sugars are in a safer place, and that's not 100% true, right? So we've used insulins forever, but we know insulin increases weight gain, and it actually is not an anti-cardiovascular disease; it's actually pro-atherogenic. It'll make more plaque. And so the new paradigm is to move away from insulin and use some of the newer drugs that have a multiplicity of other beneficial effects. So you may use it for lowering sugar. But in may also have two new classes of drugs that lower cardiovascular events, lower stroke events, protect kidneys, and cause weight loss. But we finally have drugs that do that. And they're not just one-level drugs, and then they have risk factors. So we've, in the last 50 years, a lot has changed, and even 20 or 30 years, a lot has changed.
Dr. Koren 10:23
And the funny part about this is that we've learned these things through coincidence, and by doing experiments and finding that there are unintended consequences, both good and bad when we do research, and when we look at the evidence, so Dr. Lopez was alluding to this class of drugs called SGL 2 inhibitors. And these are drugs that help the kidney get rid of the extra glucose. So they were originally developed as treatments for diabetes, they help you get rid of glucose, and they lower your blood sugar. Great. Well, the FDA, in its wisdom, said, well, let's make sure this is really safe for heart disease patients. You know, we agree, and we believe the drug company, that it lowers the glucose, but does it really help people with heart disease? So the FDA actually mandated studies with these drugs, just to show that they were safe. They weren't expecting any real big benefits on heart disease. They just want to make sure it didn't make heart disease worse. But lo and behold, we do the studies, and all of sudden, we're seeing that people who take these drugs have less congestive heart failure, they have fewer heart attacks, and their blood pressure comes down a little bit. And so there were all these unintended positive consequences that we saw for these new class of drugs that we did not see for insulin. And we did not see some of the older diabetes medications. So the point there, of course, is that you learn and you get insight from these clinical trials. And you want to work with physicians that understand this evidence because it'll get you on the right thing.
Dr. Lopez, DO 11:51
Just a side cute story is as these drugs were coming out these SCL2 inhibitors, you know, it was used as a diabetes drug issue, as you mentioned. So it was endocrinologists, or diabetes specialists and primary care, you know, mainly internists, and family practice that were using them. And as data went out, then cardiologists had to go, Well, this is our drug. This is our drug. And then as soon as you know, it's our drug. I stepped up in a prevention meeting and said actually, it's an internal medicine job because we do all of this. Yeah, there you go. All you can step down.
Dr. Koren 12:23
So that's interesting, it gets back to our first segment, which talked about the fact you have to know your team. So there are some teams where the cardiologist just fixes things. And then the internist does everything else. There are other practices where the cardiologist gets much more involved, and cardiologists have to finish internal medicine training before they become cardiologists. So we have that background. But some of my colleagues have forgotten all that. And we have to trust other people that still do the day-to-day. So part of it is understanding the entire dynamics of your particular team and what each of the parties is going to be doing.
Dr. Lopez, DO 12:55
And I think what we've started to lose, and I don't think you and I don't have this problem is we don't interact as easily because we expect the electronic medical record to do that. But there's nothing like calling a colleague and I've done this with Dr. Koren before. Hey, I'm worried about Mrs. Jones. She's having symptoms that I'm not comfortable with. I want to initiate this; just give me your spin on it. And do you think that's a good thing? And that's a two-minute phone call, which gives the patient this huge exponential benefit. So sometimes we have to go back to basics, you know, we forget to call we forget to interact. And your EMR may take three weeks before he sees it because he's so busy because he's not seeing the patient for two months, right? And so you know, that one phone call makes a big difference. And again, know your team, you know, know your team, and know that the team has value with each other and can interact with each other.
Dr. Koren 13:47
Right. So and another example of this new class of drugs called the GLP-1 agonists. And this was originally developed, again, as a diabetes drug, with the advantage of being triggered by a meal. The problem with taking insulin is that it lowers your blood sugar all the time. And it's not triggered by a meal. Whereas a GLP-1 drug is actually triggered by a meal. So again, it was shown to be a good way of lowering blood glucose, particularly in response to people that were having elevated levels related to eating. But what we learned by doing the clinical trials is that it seems to have weight loss properties.
Michelle McCormick 14:20
Yeah, I've heard this. I've heard about this. Yeah.
Dr. Koren 14:23
And so they're saying that actually now approved for people that don't have diabetes for weight loss? Yeah. And they've worked pretty darn well. So turns out that this same mechanism of perhaps overeating and leading to higher glucose levels is related to this feedback loop between your gut, your liver, and your brain. And there are certain drugs that enhance that feedback loop to help people lose weight.
Dr. Lopez, DO 14:47
I'm gonna even throw another curveball in here. And we started with this class of drugs and looking at arthritis on certain patients, and I'll let you talk to what our evidence we started the trial with the same a drug for diabetes you know blood sugar drop we found that they lose weight we actually found has cardiovascular benefits and then we started doing this trial on arthritis and how is that looking? The final data isn't out but it's looking
Dr. Koren 15:17
and the fat in your liver goes away so oh my god. So it's very very interesting is that when you hit the right button, a lot of good things happen. So we'll talk about the right button during the next segment.
Michelle McCormick 15:32
I'm your host, Michelle McCormick and we want to thank Dr. Michael Koren for his clinical and research perspective in this episode of MedEvidence! the Truth Behind the Data.
