Who Should be on my Heart Health Team after a Heart Attack or Stroke
Aired June 18, 2022, Part 1
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, DO and Dr. Michael Koren. Dr. Michael Koren is a practicing cardiologist and CEO of ENCORE Research Group which conducts clinical trials across Florida. Also, Dr. Albert Lopez, DO joining us today practices internal medicine with Millennium Physician Group here in Jacksonville. He is also a principal investigator with ENCORE Research Group for many of the lipid clinical trials. Welcome, gentlemen.
Dr. Koren 1:05
Thank you.
Dr. Lopez, DO 1:05
Thank you.
Michelle McCormick 1:06
All right. Today we're talking about what to do after a heart attack or stroke. So we're assuming this person, this patient has already presented.
Dr. Koren 1:15
Exactly, and that's an important distinction. There's always the question for people who are uninitiated and who have never had a cardiovascular event. And they're worried about is this chest pain real is this funny feeling I'm having in my head, something to worry about. And that's a whole different element of thinking than somebody that actually has experience. So keep in mind, once you've had a heart attack and stroke, your risk for another heart attack and stroke is way higher than the general population. So today, we want to focus on that particular patient population. This is a great group to talk with. It's always a pleasure working with you, Michelle,
Michelle McCormick 1:53
Thank you. It's always great to be here.
Dr. Koren 1:55
We always have fun. And Al and I have worked together for many, many years. And we always have a lot of fun talking about things. Al has a very insightful way of thinking about things. And we both share this passion for looking at the evidence. So it's great to talk to people and give them our opinions. But it's even better if our opinion is based on evidence, right?
Michelle McCormick 2:14
And I think this is really a great conversation. Because, you know, there are times when you have chest pain, and it's scary, especially as a woman over 50. Is it indigestion? Is it a lack of sleep? Did I pull a muscle? You know, all these things present pain in that heart region?
Dr. Koren 2:48
I'm not talking about that today. No, because we're talking about people that have had heart attacks and strokes.
Michelle McCormick 2:53
I just want to make sure that I don't have one.
Dr. Koren 2:54
Okay. We'll talk later. Okay. All right.
Dr. Lopez, DO 3:00
Good point, because there is a whole workup for the atypical cardiac chest pain, right? Non-cardiac chest pain, it's better called now. We could have another whole hour podcast on that. Yeah, that's a lot of fun to talk about. Because there are really great evidence-based ways to do it, but this is somebody that, as you said, Dr. Koren has symptoms, they have recognition of what this feels like. And they can discern whether this is not my heartburn. This feels different. It almost feels like my heart attack, or when I had a stent put in. This is different chest pain. And they're pretty cognizant of what's going on.
Dr. Koren 3:36
I agree. And the key point, though, is that if you've had a previous event, your risk for another event is much higher than the general population. So we focus in medicine on what we call secondary prevention. That's the term that Dr. Lopez and I would use, and that is usually more intensive than primary prevention, because of the fact that the risk is higher. So one of the key elements of evidence-based medicine is that you gear the intensity of therapy with the intensity of risk. So with that, I guess we can talk a little bit about that. We both get those phone calls, somebody calls and says that, yeah, I've been having a lot more crazy indigestion pain when I walk. And Dr. Lopez and I look at the record and say, oh, let's go ahead and angioplasty, you know, three years ago had a stent to the LAD into a descending coronary artery. And, geez, this is serious. And if you want to comment on how you would advise a patient just to get them to respond to that without making them crazy, or start to freak out,
Dr. Lopez, DO 4:41
Right, I think one of the things we have to remember is you're right, you know, the risk is like a one in four recurrence rate. So your mind revs up, you know, exponentially, you're thinking much more differently than someone that never had an event. And in women, the question is going to be different than in men. Does it happen with exertion? If it does? And the question is what happened at rest as well, which is worst? As you exercise, or pressure bottom out, which you shouldn't do. You punch the gas in a car, that RPM goes up. But if your RPM goes down, we've got an engine failure; something's going on, right? So start thinking about that. And that way, Are you short of breath when you exert yourself? Now that could be lung disease, especially if you smoke, or that could be, you know, a lot of other reasons. But in this context, it becomes, a hair-raiser. And so we start thinking of things a little differently. So those are the questions I'll ask at that point. And then seeing this is a stable issue? Does it go away at rest? They do better or if it continues to have problems.
Dr. Koren 5:48
Yes. And so from the most pragmatic level, Michelle, when a patient is in the category of having a previous event and is having symptoms, they have to decide, do they call EMS?
Michelle McCormick 5:59
That was what I was gonna ask. When do you know? Call 911?
Dr. Koren 6:03
Your basic choices are - call EMS, call your primary physician, call your cardiologist or take a stiff drink of whiskey.
Michelle McCormick. 6:13
Maybe do that first. And then you made a call
Dr. Koren 6:15
We'll cross out the last option.
Dr. Lopez, DO 6:19
Last option unless you take it with aspirin,
Dr. Koren
Right. Well, there you go. Yeah, exactly, then that's okay.
Michelle McCormick 6:26
Well, that would calm the nerves.
Dr. Koren
It has its advantages, but obviously, it's not optimal. What we try to tell patients is that if you're having persistent symptoms in the chest, particularly if you've had a history of it, and it lasts for more than 20 minutes, you call EMS. That's the most important first phone call. Because over the phone, Dr. Lopez and I can be very limited. We give you advice. But the things that would actually intervene to make a difference have to happen in a medical facility, in an emergency room. So the rule of thumb, if you have nitroglycerin at home and you're having a typical feeling of angina or something you’re concerned about it pop a nitro to see if it goes away in five minutes, then you can call your doctor take a second nitro if it doesn't go away in five minutes. Take the third nitro if you start to feel some relief, but you're still not quite there. But if you pop three nitro and you have chest pain for 20 minutes, you call EMS. Let the paramedics get you to the emergency room. You need help.
Michelle McCormick 7:26
And most patients after they've had a heart attack or stroke in the past have these medications on hand.
Dr. Koren 7:32
Typically, yeah, typically they should. And the same applies for a stroke, even if you've had a heart attack or vice versa. So keep in mind that vascular disease tracks itself in the same patients typically. So let's say somebody's had a small stroke in the past, and now they're having chest discomfort. Well, they may not have nitroglycerin because they hadn't had that before, but they're at very high risk for heart attack. The flip side is also true. So for example, if you've had a heart attack in the past, and all of a sudden you can't move your right arm or have speech problems, or your legs are feeling very, very wobbly. And that lasts for more than 20 minutes called EMS. Again, just like with heart disease, Time matters. So there are interventions that can be done in acute neurological settings that can make a huge difference in terms of your ultimate outcome.
Michelle McCormick 8:16
Yeah. So what are the risks though, for that heart attack patient or even the stroke patient to have a reoccurring event
Dr. Koren 8:23
It is extremely high. As Dr. Lopez mentioned, it's over 25%.
Dr. Lopez, DO 8:27
It's about one in five, depending on what data you're looking at. But we divide those into modifiable and non-modifiable risk factors. Fixed risks that we can't change, and then risks that we can modify and change. Mike, do you want to start going there?
Dr. Koren 8:44
Yeah, we'll get to that. But I think one of the first things that people get confused about is who to call. Yeah, we mentioned that, if you're having acute symptoms that aren't going away, called EMS, and then let's say they go away. So then who do you call? So do you call your primary physician? Do you call your cardiologist? Do you call your priest? Who do you call? Unless your priest is board certified in cardiology, I probably wouldn't call him. Religion can do a lot of things, but probably not prescribe medication. On the other hand, I think there's some variability in terms of whether or not you would talk to your primary physician or cardiologist. So Al will you give us your philosophy? He's a very hands-on type of person. That part of this is an assessment of your team.
Dr. Lopez, DO 9:31
Yeah. And I think you're right, who is your team? What's the accessibility of that team? Right? There may be times when you may call your primary care office. You can't get in and then you make the next call. It's your cardiologist or vice versa. And I think you have to know who's on your team, right? So there are very aggressive primary care physicians out there that would be very adept at moving the balance forward and not having a problem picking up the phone and calling your colleague his cardiologist or her cardiologist and saying, hey, you know, I've got Mrs. Jones here, and I'm really concerned. But I think this is stable enough that we can work it as an outpatient and do the workup as an outpatient. On the other hand, you know, classically at 4:30, on Friday, somebody walks in and says they have chest pain. And that's not an uncommon scenario. And that's when you're just raising your eyebrows and going, Oh, my gosh, you know, this is calling EMS that should have been called two hours ago, or six hours ago, or three days ago. But I think, either way, you've just got to know who your team is in the accessibility. Right?
Dr. Koren 10:32
Exactly. That's the big key. That's exactly the point. That you made beautifully, which is that you have to know who is on your team, so if you've had a heart attack and stroke, you should know whose your team, you should know your primary physician and you should know who your specialist is. And if you don't, then that's your first step is to identify your team and feel good about the team. Now, if you're somebody that has never had a problem before, you don't need a cardiologist necessarily, you might have one, but you don't need one. You should have a primary physician. But if you've had a heart attack or a stroke, you should have a team. And you should be able to identify the team members. And you should know how to get in touch with them. And you should feel comfortable and confident that you can get in touch with them.
Dr. Lopez, DO 11:09
And that's a great point. It's not just knowing your team. It's also calling your team when the time's right. Because you can know whoever but if you're not making that call to the people that have the evidence to help you through that crisis or that near crisis, you're not going to get help, you know, you're not going to get better, right?
Michelle McCormick 11:26
Well, I think the patient needs to know and have that confidence that they do have these resources available to them upon their discharge after they've had this life-altering event. So it's up to the physician and the care team to really drive that point home to their patient as well.
Dr. Lopez, DO 11:42
And let me make mention, that it's not just physicians. We have teams of both Dr. Koren and I have ARPN we work with and PA who we work with that have worked with us long enough.
Dr. Koren 11:53
Nurse practitioners and physician assistants for people not familiar with the initials.
Dr. Lopez, DO 11:57
Somebody thinks like me, they know the protocols, they know the data, they know the evidence, I mean, both you and I drive the people we work with very hard because this is not the kind of job where you can make mistakes.
Dr. Koren 12:09
Exactly. So the point here is that the teams are not just the doctors, but there are a lot of other people involved. But the other part of the team is your family and the people around you. So for example, if you've had a stroke and you're prone to another one, you may not be functional, and the people around you need to know how to get help. And similar to a heart attack, obviously, the person who's suffering the symptoms may not have the capabilities to execute what's necessary to get the team involved. So it's important your family members are also familiar with the team players.
Dr. Lopez, DO 12:40
And I think it's knowing the extent of where your baseline is after your first event. So there are people that are damaged enough of their heart muscles that they're very short of breath just walking from the bathroom to the kitchen. But as difficult as it can be they could make it to the kitchen. Now they weren't able to make it. So your family members have to be very adept at knowing what your baseline is after that first event or second event, and that this is different, right? Or the person has a stroke; they can't articulate what's going on. So we had a gentleman that came yesterday, and I believe he was a college professor. And he just says 123 ABCD. That's all he ever says. And his wife can tell me what's going on and what's happening. It's heartbreaking to see him but he functions very well. She has a great knowledge base of what his baseline is. And she's very good at taking care of it.
Dr. Koren 13:34
And she would have to execute whatever was necessary to get the team involved if there is a change in his status so that it's a good example. So now that we know who the team is, we know basically what to do when you've already had a heart attack or stroke. We can tease for the next segment and say that we're now going to talk about what's modifiable and non-modifiable.
Michelle McCormick 13:57
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.
