🎙Follow up Questions from Exploring Cardiac Health: Acute Coronary Syndrome, Gender Differences, and Cholesterol Management Ep 148

With the expertise of top cardiologists and medical researchers Dr. Michael Koren and Dr. Miciah Jones we follow up on the October 18, 2023 podcast Exploring Cardiac Health: Acute Coronary Syndrome, Gender Differences, and Cholesterol Management Ep 148. We uncover the truth about Plavix and its role in treating, not preventing, heart disease. We also shed light on the overlooked signs of heart disease in women and how the medical community is stepping up its game in diagnosis. Dive into hospital procedures for heart attack assessment and the potential lifelong use of cholesterol drugs.

Ever wondered about the complexities of stress testing in heart disease diagnosis? We unravel these intricacies, discuss the pros and cons of various tests, and emphasize the importance of collaborating with the right healthcare professionals. Highlighting how a deep understanding of your body's anatomy and physiology can help detect potential health issues, we walk you through the labyrinth of diagnostic options. Don't miss out on this enlightening and potentially life-saving discussion as we delve into heart disease and its management.

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Have a question for Dr. Koren? Email him at askDrKoren@MedEvidence.com

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Chapters

• 0:00 Plavix and Heart Disease in Women
• 8:19 Understanding Stress Testing and Diagnostic Options

Transcript

Narrator: 0:00

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts, powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr. Michael Koren. Here are several questions posed by MedEvidence listeners from October 18, 2023's podcast. What is Plavix? Can it be used in place of a statin?

Dr. Miciah Jones: 0:26

What we're addressing here today predominantly is prevention of coronary disease and plaque buildup. The basis for that is a statin and modifying the risk Once you identify that the disease process is present. You then switch from prevention to treatment. Statins are both prevention and part of the treatment. The additional part of the treatment, if you identify any plaque buildup in the arteries, then becomes a medication like aspirin or, if you're not able to tolerate the aspirin, a medication like Plavix or Clopidogrel. Aspirin is the cornerstone of therapy, but in some patients who can't tolerate the aspirin for whatever reason, Plavix or Clopidogrel is that next option. But that is a treatment strategy. So you're moving on to treatment right, and they work together for treatment rather than prevention. There is not any evidence to tell us yet that Plavix is successful as a preventive strategy for the coronary disease.

Dr. Michael Koren: 1:28

That's correct. Yeah, so Plavix does not affect cholesterol. It's an anti-platelet drug which reduces the stickiness of the blood. It's very important if you've had a stent in. It's very important if you have peripheral vascular disease. But it's a little bit different than statin. So most people, in fact everybody who's on Plavix, should be on a statin.

Narrator: 1:50

Yes, is heart disease more difficult to notice in women than in men?

Dr. Miciah Jones: 1:53

The evidence does support out that we're missing acute coronary syndromes in females. Right, the data is there that they are not presenting in that kind of typical fashion. So there oftentimes may be a delay in that immediate therapy and having what we call a very high index of suspicion, meaning you have to suspect it. Does somebody come in with the risk factors that we talked about In the history? Right, for males, I'm sorry, if you're over 55, your risk is there. Females, if you're over 65, that's a knock against you when it comes to coronary disease, diabetes, do you have a history of stroke? These are all these things, and if you start hitting on those risk factors, go ahead and start the therapy because, as Dr. Koren said, the risk is very minimal, particularly in the short term. Right?

Dr. Michael Koren: 2:44

Right, exactly, yeah, I would say that cardiologists in general are doing a much better job at diagnosing women than we did 20 years ago. It's been a point of emphasis in our training, it's been a point of emphasis on our meetings and I think, frankly, we're just doing a better job than we used to. We have a high index of suspicion, to use Dr. Jones's term. The other thing is that we have very good tests in the emergency room to know if somebody's having a heart attack. We can know if you're having a heart attack within minutes, and we didn't have that 10, 15, 20 years ago. So that has changed the whole landscape for diagnosing heart disease earlier rather than later. So there are still some differences between our ability to diagnose men and women, but it's a lot less than it used to be.

Dr. Miciah Jones: 3:26

Yeah, absolutely I agree with that. When it comes to the infrastructure medicine now that is at the forefront of the minds we have a whole protocol that we use at the hospital that I work at now, Flagler Hospital. But when someone comes in with chest pain, immediately we start down that pathway to assess them for a heart attack. That includes many things right up front the blood work, the EKG. So we have a very good idea within a very short period of time if that's what's going on.

Dr. Michael Koren: 3:58

Yeah, and we're also suspicious for funny kind of feelings that are anywhere between the shoulder and the belly button. That could be heart disease, so it's not just classic chest pain.

Narrator: 4:07

Can you stay on cholesterol medications indefinitely?

Dr. Miciah Jones: 4:11

You know I get that question frequently, doc, am I going to have to be on this for the rest of my life? Right, right. Often the answer is yes, yes. Often the answer is yes, right. So the interesting thing about the risk of cardiovascular disease is that as you get older it's only going to become higher. So as you get older your risk isn't going to go down. So oftentimes, coming off of that cholesterol medication as you get older is not the right thing to do. And then, certainly, if you have a diagnosis or somebody's told you hey, you have a heart attack, you have coronary disease, you have a stroke, you have vascular disease, you have peripheral vascular disease, which is plaque buildup in the arteries of the legs or the arm. Now you're moving to that treatment phase and that disease is with you for life. I often tell my patients that coronary disease and vascular disease is a disease of decades. Right, it starts in adolescence. It really only starts to bother you after several decades, though.

Dr. Michael Koren: 5:11

Right. Yeah, it's not hopeless though. So, for example, one of the stories that has come out recently is the use of aspirin as a preventative. So there was a study that was done back in the 1980s called the Physician Health Study, and they took basically healthy physicians and they treated them with an aspirin every other day, and they found that it helped prevent heart attacks for physicians male physicians between the ages of 50 and 80. And so that was a cornerstone recommendation.

Dr. Michael Koren: 5:41

But more recent data shows that if you get to age 70 without any heart disease and we have much better ways of detecting heart disease now than we did in the 1980s then you're probably not going to die of a heart attack, and so we can kind of back off a little bit if you're lucky enough.

Dr. Michael Koren: 5:57

On the other hand, as Dr. Jones mentioned, if you already have heart disease and you have plaques in different parts of your body, they don't go away completely. We're managing them, and it's probably not a great idea to come off of things. The other scenario where you can come off of things is that if you change your lifestyle dramatically. So we've had people that have had high cholesterol because of dietary indiscretion. They just don't eat right and you change your life. You start exercising, you start eating the correct things and then, lo and behold, you don't need that cholesterol medication anymore. Or some people who are very overweight find that they have high blood pressure and cholesterol issues because of their weight and you correct that and then you don't need the medicine anymore. So there are circumstances where we can take away the medicine, but if you have established vascular disease, it's usually in your best interest to stick with the therapy.

Dr. Miciah Jones: 6:47

Yeah, absolutely. And that's where that education becomes important. On those lifestyle changes, because if I can get somebody off of some medication, I'll take them off of the medication, all right. I want to make everybody's life simple. I don't want to burden them with unnecessary medications. It's not necessary, all right. So if we can get them off of those medications because they make lifestyle changes, more than happy to do that, absolutely.

Narrator: 7:08

What are the symptoms of cardiac events in women?

Dr. Miciah Jones: 7:11

For the females. It isn't always that crushing chest pain that you read about. Sometimes it's a vague feeling of unwellness, it may be just shortness of breath, feeling a little more fatigued than usual, all right, and that makes it a lot more difficult. And, as I said before, you have to have a high index of suspicion for that and screen appropriately for those things. Now there are some females who will get that crushing chest pressure right, who will get that radiation or discomfort to the left arm or to the jaw, but sometimes it's hey, I feel like I have some heartburn. I think it's something I eat, right. It's getting worse when I walk around. All these symptoms are getting worse when I move around or when I do anything physically active, so that tends to be a little more consistent across genders. Is the worsening with activity right? The actual character and quality of the pain and discomfort? That's the thing that seems to be a little bit different.

Dr. Michael Koren: 8:10

Yeah, another thing is a choking sensation. Actually, the word angina pectoris means choking in Greek, where it came from, so everybody describes it a little bit differently. But if you have a family history, you have risk factors and you're having some weird feelings between your neck and your belly button that are triggered by stress or physical activity. Get it checked out.

Dr. Miciah Jones: 8:33

When it comes to stress testing, you've got to kind of break it up into how are you stressing the person and how are you assessing them for the blockages, and that may be imaging or an EKG, if at all feasible and someone is able to do it. The treadmill test certainly gives us the most information, okay, so that is by far and away gives us the most bang for our buck. You can actually make pretty strong predictions on somebody's risk of having an event, on their ability to survive the next five years, based on how far they go on the treadmill. Okay. When it comes to the other studies, sometimes we use a chemical to simulate exercise. Okay, and that comes with its own risk with that. For some of them

Dr. Miciah Jones: 9:22

You know, if somebody has asthma, okay. If somebody has, you know, heart block, we don't use those kind of chemicals on them. Okay, that's not a good person to do that. I think the best thing to do is have a very frank discussion with you know, your cardiologist or whoever's ordering that stress test, and say, okay, you know, what do I really need? What's going to give us the most information? Right? Just like any medical therapy, your diagnostic test needs to be just as well thought out.

Dr. Michael Koren: 9:51

Yeah, and that those are great. Those are great points and this is a very complicated area. When we go to our national meetings, there are sections and sections and sections on these questions and, just as a general sense, some of the ways that we diagnose things are based on physiology what you can do. Other ways are based on anatomy, where the blockages are, and they complement each other, but they're not exactly the same, and so that's why, again, you need to work with the right physician and hopefully have that person guide you. But it's a great question to ask, and a good cardiologist will explain the difference between a CAT scan or an angiogram versus a stress test, which is a physiology test, and they both give us information, but it's slightly different information that should be complementary in most cases.