Doc Discussions with Dr. Jason Edwards
THIS is the podcast you have been looking for! "Doc Discussions" are just what the title says they are: physicians from a wide range of specialties, talking about relevant, up-to-date medical topics, not to mention tips on habits to help you live your best life. Your host, Jason Edwards, MD, is a board-certified radiation oncologist with a PhD in cellular and integrative physiology at St. Luke's Hospital in St. Louis, Missouri. Dr. Edwards explores not only diseases but also suggests techniques to optimize mental and physical health for a long and good life. Real people. Real advice. Real good. This is Doc Discussions, with Dr. Jason Edwards!
Doc Discussions with Dr. Jason Edwards
Redefining Heart Health: Innovations and Insights with Dr. Craig Reiss
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.
Welcome to Doc Discussions. So today I'm going to talk with Dr Craig Reese, a cardiologist, here at St Luke's, about diet, medication and heart disease and ways to reduce your risk of heart disease. Craig, how are you doing today?
Speaker 2:Thank you, and thank you so much for asking me to be on your podcast.
Speaker 1:Yeah, it's my pleasure for sure. Now, first tell me where are you from, craig.
Speaker 2:I'm from St Louis, st Louis. Yeah, and you know the famous St Louis, st Louis. And yeah, and you know the famous St Louis question, right?
Speaker 1:Yeah, when he went to high school, so you know.
Speaker 2:I went to Ladue Very good and came back home.
Speaker 1:I'm not from St Louis, so I kind of know some of the high schools and so I'm learning over time, though Very good it's very important in St Louis to know that One of the most important things Absolutely. And you did your training. Where did you go to school?
Speaker 2:So I went from high school, I went to a six-year med program at University of Missouri and then I trained at Harvard, at the Brigham, and I was there for six years and I did my medicine, my cardiology, and a chief residency and then I came back to St Louis, all in Boston. How about that?
Speaker 1:Yeah, yeah, came back to St Louis afterwards, and then you were at WashU for a while and then came to St Luke's.
Speaker 2:I was a professor at WashU for 24 years or 23 years, I guess and then saw the opportunity at St Luke's and couldn't pass it up.
Speaker 1:And have a look back and love every minute of it. And you're not going to say this, so I will, but you're one of the most beloved physicians at St Luke's. Anybody who's your patient has a strong relationship with you, and I think that's kind of one of the things that makes St Luke's special.
Speaker 2: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 that doctors that are at St Luke's really love to take care of patients. They love their patients and having that philosophy is what attracted me here and keeps me here.
Speaker 1:Yeah, very good. So today I want to talk about coronary artery disease and ways to coronary artery disease and ways to well, first of all, you know what is coronary artery disease and what's the prevalence, and then ways to reduce our risk.
Speaker 2:Coronary artery disease and heart disease overall is by far the most common cause of death in the United States, in both men and, importantly, in women. And coronary artery disease is when one develops areas of cholesterol buildup and blockage within the arteries. As that progresses at some point in time, that can lead to a total blockage or near total blockage of the arteries and that can cause sudden cardiac death and it can lead to heart failure. It can lead to, of course, acute heart attacks In addition to disability and people that just can't do what they'd like to do in life.
Speaker 1:And so it certainly can decrease the length of your life and the quality of your life. It certainly can decrease the length of your life and the quality of your life, and so I'm a big proponent of doing things without medication first, if you can and for some people I think that will work by changing diet and exercise habits and things like that.
Speaker 2:But there's certainly a percentage of the population that despite doing kind of all that due to their genetics and things like that, they still can have high blood pressure and coronary artery disease. Very important, you know. I think it's important to discuss sort of what are the risk factors? And then when we look at what those risk factors are, we can figure out what we as individuals can do to decrease those risk factors and where we really have to rely on our physicians. And the first thing is to realize are you at risk for heart disease? And really everyone's at risk for heart disease what are the risk factors that really are present that can increase those risks?
Speaker 2:First and foremost, just like in cancer, cigarette smoking, cigarette smokers have a tremendously increased risk of heart disease and that goes on for periods of time after one stops smoking. So if one is a smoker currently, obviously you got to stop. And then the second thing is if you've had a history of cigarette smoking. Cigarette smoking directly damages actually the lining of the blood vessels and leads to this early process of developing blockages. So that's number one. Number two is that high blood pressure is very important, that the stress of the high blood pressure on those blood vessels over time can lead to further blockages and can also lead to other problems with strokes, in addition to weakness or thickness of the heart muscle over time. The third is having a high cholesterol, and again there's a little bit of a problem with high cholesterols because cholesterols have different particles that are present, so it's more than just knowing your cholesterol. It's knowing your cholesterol profile, which is very important.
Speaker 2:And the next is diabetes, and knowing whether or not that you have diabetes and the appropriate treatment of it. That also increases one risk, the appropriate treatment of it. That also increases wound risk. And lastly, but really really really very, very important, is actually a family history of heart disease, and did other family members have heart disease? What age were they when they had heart disease? You know, if you know, was there something else on top of it to family history? You know? Was the loved one that had heart disease, was somebody that smoked, had diabetes and had high blood pressure, or was it somebody that just started having heart disease young? These are all critical. So once one knows that, then it's important to talk with your physician regarding how do you attack it.
Speaker 1:Yeah, yeah, I mean it's, and you know, kind of going through this. You know I have kind of a vague understanding of coronary artery disease but like everything in life, it's way more complex than you would think. With the, you know, some of the modifiable risk factors can be diet. Is there a specific diet you recommend to patients, either before they have an event or after?
Speaker 2:Well, our Western diet, our fast food diet, is very unhealthy in general, not just for heart disease but, in your territory, of cancer and other things. But you know, having more of a plant-based diet is an important way to prevent heart disease. In addition to that, a Mediterranean-type diet which is 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:Yeah, the stats I have on that are Mediterranean diet gives you about a 25% to 30% reduction. A low salt diet or the DASH diet, which contributes to high blood pressure, reduces it about 25%. A vegan diet gives you the strongest reduction at about 35% to 40% Vegetarian. So it's no meat but you do have. Dairy is 25% to 30%. Pescatarian fish only is about the same, and so you know this is. You know that it's, but it's hard to develop new habits.
Speaker 2:Right, it's hard. It's hard to make those changes. Making the changes slowly is easy and unfortunately, once my patients do have problems, they're pretty good about making those changes, you know. But the idea is to make those changes before there's problems. Yeah, particularly, you know. If you know that you know one's father had, you know, heart disease in their 50s and you're in your 20s and 30s, you should be making changes, you should be, going to this before it's too late.
Speaker 2:So the diet is very important. The other thing we haven't really talked about, jason, is also exercise, for sure you know. So exercise is incredibly important. You know we are now realizing it doesn't take a lot. So there were some recent studies that actually said as little as five minutes of exercise a day is important for some reduction. Yeah, what we recommend in general for our patients once you know that you don't have heart disease if you're sitting there having chest discomfort, you have strong all these risk factors then we want you to talk to their doctor before exercising. But once you know that that's not the case, we like at least about 150 minutes of exercise a day.
Speaker 2:And this is a lot of people recommend this kind of like zone two, like brisk walking things like that, you know one thing that I like to tell my patients actually once heard it from our head of cardiac rehab here who's wonderful is that your patients should be able to when they're walking, 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, but that gives you some idea. You want to go ahead and you want to have some degree of activity and you know again, for me and for you, you have to find something that you like and what'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 the time.
Speaker 1:No.
Speaker 2:It's really sunny. I mean, you know I wake up, you know, before five o'clock every day. You know, and I'm on that elliptical, you know, for my six days a week of exercise.
Speaker 1:And that's low impact. It's low impact.
Speaker 2: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'm doing it. That adds to the enrichment of my day and if you put that as part of your schedule and it becomes part of your life, it's amazing what it can do for your health and also your mental well-being.
Speaker 1:Yeah, earlier this year a report came out I believe it was the New England Journal of Medicine showing that exercise is about twice as good as antidepressant medications for depression which is not surprising. I mean me and you both get mental health benefits from working out Absolutely. And then I've actually seen some reports where sauna, due to the vasodilation from the heat, can improve endothelial function, reduce all-cause mortality, and they think it's mediated through the cardiovascular system, yes, and again, you want to make sure you don't have critical heart disease before that.
Speaker 2:And there is the thing that makes me nervous Some people are on the ice sort of approach of things, of going into ice baths For cardiovascular disease. That scares me, especially once at risk, so that's something that is a fad that does disturb me.
Speaker 1:Yeah, and I think that the data for the sauna is much better than the ice baths, absolutely. And sauna's been around for a long time. With ice baths you're going to have at least peripheral vasoconstriction, which is going to put some stress on the heart Absolutely, and a sauna's much more palatable than an ice bath yes, it is Love.
Speaker 2:A sauna is much more palatable than an ice bath.
Speaker 1:Yes, it is. Love a sauna. Okay, so now two things. Some patients can eat an optimal diet or exercise appropriately and still be at a significant risk, and some of the predictors for this would be high triglycerides, high cholesterol. And then there's this ApoB protein. Can you talk a little bit about these patients and those markers?
Speaker 2:Really there's another incredibly important marker that I've been involved in looking at for many, many years since the 1990s and now it's ready for prime time. So one has to look at what is their overall LDL cholesterol, which is the overall bad cholesterol, the overall HDL cholesterol. Hdl is best looked at as a scavenger cholesterol, a good cholesterol okay, it sort of cleans up those arteries. Okay. Triglycerides is another lipid particle that at high levels can also lead to early atherosclerosis, those blockages in those arteries. But another one which is very, very powerful and important in family history is something called LP little a, apob. We measure in patients that have high triglycerides in particular. That's important.
Speaker 2:But LP little a is critical when we find out that patients that have high LP little a's have a marked increase in early heart disease and strokes. So I've known this and was involved through the Lipid Center at WashU for many years. So I started measuring this in my patients very, very early and found this in many of the patients that have early onset of heart disease and family histories. And now we have three agents that are in clinical trials. I'm hoping the first agent may be available as soon as next year. Wow, that dramatically decreases. This soon as next year. That dramatically decreases this, and what this is is sort of a sticky particle that's a part of the that has the cholesterol is carried in the body. That allows it to get right into the blood vessel and is handled and can cause increased strokes and increased heart disease.
Speaker 1:So not only is it a marker, but it's also a causative agent.
Speaker 2:It is a causative agent. What we're waiting for we know that these agents right now and the first agent likely to come out is going to be a once a month shot. Okay, but we know that it definitely is causative. We know that these agents decrease this way over 90% as far as what the LP little a is. What we're waiting on is outcome data, and I'm hopeful the outcome data is going to be out in the spring of next year.
Speaker 1:That's great. And so the link between the diet and the cholesterol really is the trans fats and the saturated fats? Yeah, it is, and the simple sugars too.
Speaker 2:It is, and even you know. Again, one thing that I'd like to concentrate on, in addition to prevention and diet is, as you mentioned very early on, is that medicines are required in a lot of patients. So this is a genetic problem. This is a genetic problem of how our liver produces and how much our liver produces these particles. And how much our liver produces these particles, and in some patients about 25% of patients may be what we call hyperresorbers, and I can actually test for that with specialized testing where we know that well, it's actually more what you're eating and we've heard it doesn't matter how much eggs you eat, et cetera. 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 that the HDLs are low or you have high LP, little A's. That group of patients has to be on medicines.
Speaker 1:So you take in cholesterol but the liver, even if you're a vegan and take in almost no cholesterol the liver is going to make cholesterol and in some patients, a large amount.
Speaker 2:Yeah, it's going to produce and that's where you have to do it. And you know, really, statins have been the most important preventative for heart disease and also for secondary prevention. What does secondary prevention mean? That means that once somebody has actually had a cardiac event or been diagnosed with cardiac disease, being on them dramatically decreases risk.
Speaker 1:And so they came out with these statins that lower cholesterol and I know you know pharmacy it was pharmacy of Pfizer at the time here in town, you know made like Lip and it did an excellent job at reducing that. But the medications have become much more sophisticated, like the ones you were talking about in the clinical trials.
Speaker 2:Yeah, so we have many medications. There's statins still are the mainstay. Okay, and with statins as the mainstay, they have gotten a hideous press. You know somebody who may be president was they have gotten a hideous press, Somebody who?
Speaker 1:may be.
Speaker 2:President was talking about fake news a lot Fake news, for statins has really, really cost lives. Statins are extremely well tolerated by probably 95% of the people that are on them. Most cardiologists, if you ask around, including me, we're on statins.
Speaker 1:Okay, but what is the five percent? What are the reasons that they can't take the statins? It's usually muscle aches and pains.
Speaker 2:Yeah, yeah, so if you have some people, virtually everybody has a little bit of spasms occasionally. Some really feel like they have the flu, they really have really awful aches and pains and we 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 inhibitors that the patient simply gives themselves a shot twice a month.
Speaker 1:Okay.
Speaker 2:It's an auto injector and it drops cholesterol like nothing. Okay, it also does drop LP little a, about 20-25%. There is another agent that we use, believe it or not, that we give twice a year and again for patients that don't tolerate it or they don't want to take medicines or can't inject themselves. They go to an infusion center or to some physician offices and 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:Again, dramatic effects on LDL cholesterol, really lowering it dramatically, in addition to having a 25 to 30 percent reduction in LP little a's and so and so, and I want to kind of zoom out and kind of take a bigger look at you know we were talking about people being skeptical, which is okay. It's okay to be skeptical, but the clinical trials kind of give you what you need and it's you get the drug or you don't get the drug. And then they measure some metric down the road like survival. Get the drug, and then they measure some metric down the road like survival, and so it doesn't mean that the drug doesn't have any side effects, but it means that the risks and benefits of taking the drug for these patients outweigh the risks and benefits of any side effects from the drug. Is that accurate?
Speaker 2:It's not even close you know, so that if you look at the overall benefits of our protection against heart attacks and death, they're game changers and there's no increased mortality. There's a lot of false data about oh, it causes Alzheimer's or memory problems. That's wrong. It actually decreases vascular dementia. So, as far as the tolerability, I have thousands of patients probably that are on statins and tolerate them very, very well, and the important thing is, if you don't tolerate, you work with your physician. There's also one thing that I'd like to talk about at some point, jason. It's also what are some of the newer techniques? So how do we detect? Do we have a problem and what are we talking about?
Speaker 1: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 old catheterization and like actually look at the artery, but there's some new imaging techniques where you can look at what is it calcium scores and things like that. Yeah, absolutely.
Speaker 2:So. You know, the important thing is not to only be aware that you are at risk, but do you have a problem? Aware that you are at risk, but do you have a problem? Okay, because, um, you know, putting your head in the sand and not looking, uh, can lead to very bad outcomes. Yeah, so, um, we have um, advanced imaging. I'm practicing cardiology different now than I was eight years ago, okay, because of the new techniques that we have. So, the new techniques we'll start with, one is not a new technique. One is a calcium CT scan. Okay, and a calcium CT scan is cheap. I think St Luke's does it, for I don't know, don't quote me on this maybe $125. That sort of range is an out-of-pocket expense. Don't ask me why insurance companies don't cover it, because it's been proven to identify patients at risk tremendously.
Speaker 1:It seems like it would be cost-effective.
Speaker 2: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-pocket expense that's very, very small, and what that tells us is is there calcium in the arteries? Is there calcium in the arteries? Mainly helpful in people over 40 and probably less than 70, that can identify whether or not there's calcium buildup. Calcium, though, is not really the blockage. Calcium is a marker that somebody has had plaques in their arteries and the body in healing it then forms a calcium. Okay, so then the next step is how much is there, and depending on how much there is, determines what one's risk is.
Speaker 2:But in addition to that, I like to explain to my patients the following. I like to say that when cholesterol 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 the calcium like a road where there's no blockages, or you can have it like a mountain where there is a degree of blockage, and if it really heaps up, then it can interfere with blood flow. When it interferes with blood flow, that's when somebody can have chest discomfort with activity, that's what can predispose to heart attacks. There are patients 25 to 40 percent of patients, more in patients that have diabetes that can have significant blockages and have zero symptoms, and that is also something that has to be identified.
Speaker 2:So once we have whether or not there's calcium present or not, there are other tests that we do. We have nuclear stress testing where first of all it was simple stress testing, so one can get on a treadmill under doctor's supervision and we can look for whether or not there is any problems with their exercise. That picks up heart disease about 65% of the time if it's present. Not very good. If we add an echo to that and we do an ultrasound of the heart while they're exercising, that increases us to about 75% accuracy.
Speaker 1:Okay, so getting better yeah.
Speaker 2:If we then go to nuclear testing we may go to 80%. The newest is the stress PET scan. The stress PET scan has 75% less radiation increases us to about 92%. And one of the very, very, very exciting areas right now is CAT scanning of the arteries with intravenous dye called CT angiography. That's almost as good as a heart catheterization. So we can do everything that I just said to identify heart disease and risk stratify without a heart catheterization.
Speaker 1:You know, I'm going to kind of go back, and that's excellent news, especially if you can avoid a procedure.
Speaker 1:Going to kind of go back, and that's that's excellent news, especially if you can avoid a procedure.
Speaker 1:Um, I want to go back to something that you said earlier, and I often say this to patients if you have plaque in the arteries of your heart, you probably have plaque in the arteries of your brain, and so, uh, I, I, I I'm if you're a neurologist and you're, you know, don't scream at me, but I think a lot of dementia is called a lot of things and ends up being vascular dementia, correct, and that's something that can dramatically reduce the quality of your life.
Speaker 1:And you know, in general it's difficult to make these lifestyle changes or to go into a cardiologist when you feel totally normal. But I think it has to be some emotional event in your life that can kind of push you towards that. Whether it's a medical scare with you or a family member, or maybe you're pregnant, or maybe you have cancer. You have something that kind of triggers some emotion that causes you to say, hey, you know what I need to kind of look out for my long-term health, not only for my cardiac health, but for the health of my brain. And I mean, if you have plaque in the arteries of your heart, you probably are going to have some sort of arterial disease that can cause kidney disease, and so in many ways your blood flow is your health.
Speaker 2:Absolutely. And again, a huge percentage of our patients that have MRIs don't have the brain. They have something called small vessel disease. If you're more extensive of that, you have small strokes everywhere and that leads to dementia. What's the treatment for small vessel disease? Same thing it is for heart disease. We lower cholesterols, we lower blood pressures. We look at these risk factors. I want to come back to one more thing. I was talking about my volcano. Okay, yeah. So the reason why that's important is that there is a mountain, okay, and a volcano, okay. If it's a mountain doesn't do anything if there's no magna underneath the surface, if there's no lava, that would come to the surface. So what the treatments do that I'm talking about? When we drop those cholesterols, we start getting rid of the soft cholesterol gunk underneath the volcano that we get rid of the lava, we turn that magna into rock and when that happens, within a month of lowering it, event rates, which includes heart attacks and strokes, come down dramatically.
Speaker 1:That's surprising that it works that quickly.
Speaker 2:It can start within a month.
Speaker 1:Now people can have—OK, so we're jumping back and forth, but, but, but, which is fine. Um, so the the artery, which is like a tube. You can have plaque that can narrow the artery, but you can also have plaque that goes into the artery. And then there are stable plaques, which correct, and then you can have unstable plaques where, if, so if and I might be wrong on this, but you can have an unstable plaque that grows into the artery so you don't see narrowing, but if it breaks off, the platelets immediately adhere to it. And you have this acute event where, all of a sudden, the artery was, the blood was flowing fine through the artery. Now the plaque breaks off, the platelets adhere to it and you immediately have a blockage.
Speaker 2:Exactly right. So that's what we're talking about. So if the volcano erupts and you get the gunk that comes to the surface, or you have a crack in the surface like an earthquake, then that soft plaque comes to the surface. Then the blood starts clotting and you go from a 50% or 60% to 99% or 100%, that's a heart attack.
Speaker 1:Or God forbid, that's sudden death, and quickly, that's quickly. That, or God forbid, that's sudden death and quickly, that's quickly, that's very quickly. And sudden death is one of the leading. If you say what's the first symptom of a heart attack, a lot of people may say chest pain and that may be number one, but sudden death is up there.
Speaker 2:Absolutely. First, I like to never say chest pain. Okay, so what I tell my patients and I tell my residents and my fellows when I teach them never say chest pain, because my patients will say to me very, very frequently I never have chest pain. Do you ever have an uncomfortableness in your chest? Do you ever have fullness? Do you ever have an indigestion, discomfort? Physicians have been known to think they have indigestion when it's really their heart. Okay, so first of all, yes, so the onset of some kind of uncomfortableness or shortness of breath with activity or uncomfortableness, pressure is something that absolutely is a marker of heart. But sudden death, yes, unfortunately, can be the first manifestation.
Speaker 1:And then the incidence of this increases with each decade of life. Yes, the incidence within the 40s is not very high, but once you get to the 60s, your likelihood is what? 20% to 40%, depending on whether you're a man or no? Sorry, I have 21% in men and 11% in women. In the 70s, it goes from 35% in men to 24% in women. So that's a generalization.
Speaker 2:Yeah, that's a rough idea as to where it is, but yes, it becomes more frequent and it's also I've also unfortunately for the listeners I've taken care of many patients in their 20s yeah, sure you know, in 30s with early onset of heart disease, including women.
Speaker 1:And with diets getting worse over time. You know, I think that's a trend. When they update the data, they're going to see that there's more heart disease in the young. Yes, and so all right. Well, craig, fascinating talk. I feel like we could talk all day, but I very much appreciate your time, sir, and thank you for being a great colleague. And thank you for your time, thank.