Q&A with Drs. Alexander Postalian and Briana Costello

On this epsiode of Asked and Answered,  Dr. Alexander Postalian sits down with Dr. Briana Costello to answer questions given to them live from patients.

Some of the topics that they discuss include:

• Their thoughts of the role of statins to treat cardiovascular issues.
• Managing Muscle Aches
• Alternative Medications to Statins

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Transcript

0:03

Good morning, everyone. Welcome to our second Q&A event. I hope you're enjoying these scorching heat out of here in Houston. This is Dr. Brianna, Costello or Texas. Super doctor Russian star Brianna Costello, I'm Alexander postalan. We're both cardiologists International cardiologists Rising Superstar. Okay, so we're gonna answer some questions and as once I started come in we'll we'll get going, but I think we can get started with a Relatively controversial topic very common question that we hear in clinic multiple times a day multiple times a day, which is cholesterol meds and particularly Statin medications. Who are they good for are they problematic? Are they really beneficial? What do you think that so? That hit the nail right on the head, you know statins by far are one of the major topics in our conversations with our patients every day. And there's a I think that's because there's so much Media or literature that you can find online or from friends. Even that might question statins and their utility in heart disease when I'm discussing with patients in the office, especially those who've already had a heart attack or already we know have coronary artery disease or plaque in the arteries of their hearts. It is a no-brainer that statins are our first drug to go to and that's because they've been tried tested intrude and shown to be beneficial over many many years the one one caveat to that and I'm sure that you experience this a lot as the muscle aches or the quote unquote myalges is what we call them that patients often report after starting them. So how do you handle that? When you start a patient on say a tour of a Statin or Avatar you guys might know it as and they come back and say Dr. Patel in my legs have been aching or my legs my muscles hurt. Yeah, you know, it's very important issue and I think not to have a little bit of background on this when students first came out. We thought they cost muscle pain in about 30% of people so very common very frequent something that we you know were managing for a long time but then we've had a bunch of studies come out and essentially you can't imagine that we had a bunch of people and we gave him a Statin and told him this is a Statin and then we had a another bunch of people and we gave him a Tic-Tac and told him this is a Statin. And then the amount of people that had to stop the Tic Tac for muscle pain was very very close to the amount of people that stopped the Statin due to muscle pain. So that's important to keep in mind and it's not really 30% It's closer to maybe two to five percent in reality. So once that that data, you know people are aware of this. Sometimes they you know, there's a lot of things I can give you muscle pain that are transient, you know exercise that day, you know, you slapped poorly Etc. That's one thing to consider and I think it's good to remember that from those trials we can take and just tell our patients exactly what he said in life. We have muscle pain or muscle aches. So just knowing that sentence can cause muscle pain doesn't mean that that's what's causing it. But there's a really easy way to test that theory for yourself, which is another trial that just came out and it basically gives the power to the patient to say if you think it's the Statin and we're reasonable we think that if it is a Statin then we should try a different one maybe or try a different drug, but there's an easy way to test is this pain from my stat and that is discontinuing it for three to five days and seeing what happens now if you stop that the drug and your muscle pain on too is gone or day three is gone then perhaps it was that particular cholesterol medicine that Statin but if your pain is still there, it's we're pretty confident when we tell you it's not likely the Statin we were saying it's always important that And not everybody benefits to the same degree from a Statin. Okay. So yes, maybe you don't think statins are. Beneficial there's a lot of studies out there showing they might have some problems and you don't want to take them and the only reason you take them is because you have a moderately elevated cholesterol. I think that's that's okay, but there are other groups of patients. If you had a heart attack, you've got a stent implanter. You've got a stroke then the risk benefit ratio. They're really really tells in favor of taking statins. So that's something to keep in mind if the symptoms are mild and you had a significant cardiovascular issue. I think that's an important thing to give more. You should probably be on a Statin if you can but if you cannot And you stopped it into the payment went away. You tried it again and the paint came back and you stopped it again and the pain it went away. What can you do? Okay, my first always may go to is trying an alternative Statin and you can see a theme because we know statins work, especially in those higher if you're a higher risk patient, you've had a heart attack or stroke. Okay, so I will always suggest that we switched the Statin first with the within mind that if it doesn't work or you have muscle aches and we can try different drug, but if we go through our Statin, you know the packet of statins and we can't find one that works. Then we have also very good alternative meds that have data for you know outcomes meaning reducing risk of heart attack and stroke for the future and my second go-to is always a PCS kind of inhibitor. So what can we tell the group that's a whole lot of letters and words numbers. What does it mean? What does it do? And so that's a relatively new drug. It is injectable. You give it to yourself about every two weeks on average. And what it does is that it increases your body's capacity your liver's capacity of essentially taking bad cholesterol from your blood into your liver and metabolizing it so it lowers the bad cholesterol that is circulating. Hence, there is less cholesterol accumulation in the vessel walls. Fewer heart attacks fewer Strokes, the meds are very very effective. They're not only lower cholesterol, but we know that they also lower strokes and heart attacks. So we have all the data that we need and the most important side effect is a reaction at the injection side, which is also not super common. So it is a very very Good drug that we use in our high risk patients. And the reason I say high risk is it's only approved. If you really have a very very high cholesterol or if you have a high cholesterol. And you had a big event like a stroke or heart attack and you still need to bring it lower. And now if you're not in that category, there's a simpler drug that we use all the time, which is zetamide. Okay, the brand name is Zetia and what it does it is we first it's cheap. So patients are like, oh no Alternatives how expensive zeady is pretty he's just gonna Inhibitors are very expensive. Sometimes you have issues getting them covered by insurance is very cheap. But what I say, so Zenia actually is a completely different mechanism or way of acting to decrease your cholesterol. It actually works in your gut. So it decreases the uptake of cholesterol so that your body doesn't have it to float around in the blood. So it's a simple drug this side effect profile of Zetia. Meaning what side effects you get. I virtually say there's not many these GI basically even if any gastrointestinal, right so it's very well tolerated the only downside or the con to the shrug is it doesn't achieve the cholesterol lowering like those other drugs. We talked about like statins and pcsk9 Inhibitors. So if you're really trying to modify someone's bad cholesterol, you might not achieve your goal. So you might not be if your doctor says, you're not at school. What does that mean? 70 70 that number for your bad cholesterol the LDL. So I always think LDL L. Want to keep it low. So seven zero is your goal. So zettium might not get you there. Now if you can get their anxiety and you tolerate that and nothing else then perhaps your dog might leave you alone. And just keep you on that and this is a very active research field. There's a lot of new drugs in the pipeline some that came out that are very recent that seemed very promising one is called vampadoic acid. Another one is in glycerin, which is a shot that you give yourself every six months only. So I think we're gonna have a lot of options in the next few years and that the tempoic acid is actually pretty efficacious. Now it's newer so unlike the pcsk9 Inhibitors and the statins that we talked about the longer meaning years of follow-up that we have patients on that drug for we don't quite have yet. So it's not our first the first one we pick you know off the shelf for patients. But again, it works it decreases cholesterol pretty significantly in sometimes we'll combine it with the Zetia or zetamide to get a really good reduction in cholesterol. So those are you have lots of options you shouldn't feel discouraged. If you can't do a Statin and you're like I'm doomed no your doctor should talk with you about all the Alternatives and just be mindful that no side effect. Generally. Nothing is never but most side effects. None of them are permanent, right? So you try to drug you don't like it you switch it. Yeah, there's a lot of options. So if you think status are not for you just have an honest conversation with your doctor. But having said that statins work and benefit most people on the side effect profile is truly not as bad as we used to think I would say I think this kind of goes into another really good topic called aspirin therapy, which is that a lot of social media coverage or I have patients often at least one a day in the office say well, my doctor told me I don't need Aspirin anymore because in the new guidelines or I read something online that said I don't need us friends. So imagine what type of conversation are you having or what should audience know about aspirins usefulness now? Yeah, there's another major major topic. We see pictures all the time that you know, we're taking aspirin and they stopped it because of whatever came out recently talking about aspirin, so We have known for a long time. Well, first of all the way we used to do it is everybody that was essentially about the age of 55 would get a load those aspirin just in case, you know the prevent and but we've known for a long time over 10 years that that is probably not the way to go because it doesn't really make a difference in benefit and there's some small risks to load those aspirin therapy namely bleeding. Okay. But some patients do benefit from aspirin. There was a benefit the most or the ones that had a heart attack already. There was a had a stent implanted. There was had a stroke those should definitely be on aspirin. So this recommendation of stopping aspirin does not apply. To that group of individuals and then there's smaller subgroups that may also Benefit Management. If you have diabetes in a certain risk profile if your coronary calcium score is greater than 100, you know, we've done some studies showing that some patients have a net benefit from low dose aspirin therapy. So if you think about if you're thinking about stopping your aspirin, just ask your doctor. Yeah, don't just stop it and that I love the word that you are the two words the coronary calcium so someone some listeners might be saying what is going what my favorite one of my favorite topics so coronary calcium score. It's really a score that is taken for you after you get a CAT scan of your chest. And you might say well I thought calcium is just on my blood work. I have a calcium level that they check every year at my primary care doctor. No, the calcium coronary calcium is actually the calcium that lights up or Shines on a CAT scan in the heart arteries. So I love this. test mostly for patients who are kind of intermediate risk, maybe a female who's 50 or more or even a female who's in her 40s with a really strong family history who has maybe intermediate elevations in her cholesterol or a male who's 50 or in his 40s with a strong family history with cholesterol and he doesn't want to be on a Statin. So what a calcium score is that the plain CAT scan you go sit in a CT scan or tube for less than five minutes. They told us and cheap. Yeah, you know, not a full-on CAT scan expensive Services. Yep, and it's no insurance covers it at this point. Yeah, mostly but it's a hundred bucks. Mostly a hundred a hundred fifty and you get a CAT scan and calcium Sparkles. So if you have plaque and the arteries of your heart calcium follows that plaque and it'll Sparkle on a cat scanner so we can some meaning add up all the calcium that you have if you have it and give you a score and we have there's a large database called the Mesa database that looked at everyone's kind of calcium scores across ages and sexes. races and said, what is your risk with a calcium score of this so we can kind of risk stratify you meaning put you in a percentile of You know Mrs. Smith or Mr. Smith, you're in the 50th percentile. So 50% of people your age have more calcium and 50% have less or surprise. Your score is zero. You don't have any identifiable plaque on a calcium score. So that number is really helpful for primary prevention, meaning identifying you have some disease and perhaps increase later in life. And then we do something about it sooner instead of you popping into our office when you're 80 with the heart attack or with a heart that has had a previous heart attack definitely helps us establish your level of cardiovascular risk. Okay, so it can help answer questions. Like should we put you an aspirin should we put you on instead and can we lower the dough? So if you're standing that you're already on it's not for everybody. For example, if you're young. And you're probably have not developed calcium yet. Even if you have cholesterol plaque, so it don't think it's for everybody but it is a useful test if we know how to how to use it. And then this brings up a really another good point does all plaque Sparkle on a calcium score. No custom score like the results explains shows you the counseling but you can have black that is not calcified and that is common in younger patients that have really high cholesterol values for example, so it's not a hundred percent guarantee, but we have looked at large patients. Numbers and we see okay. If you have a local custom score, you're likely safe for the next couple of years and that's kind of how we base our decision making. Okay. So we want one of the other questions that we have online. What do you think about the keto diet? I love that so so another one of my fun topics. So I don't know what you tell your patients about diet. But I generally say well the word diet in general makes people like already feel defeated. So it's more about I try to encourage a Mediterranean lifestyle or meditating food. So go to Greece your life and Southern States, so we have really good Resources. By the way. I'm the Texas Heart website about the Mediterranean diet. So if you are like, whoa, I've never heard of that then you can pop in and Google that for us. Okay, but the meditating diet I say focus on what sounds like it's probably healthy fruits and vegetables go for it vegetables fresh vegetables, of course or steamed vegetables deep frying or is never a great idea for anything that you're eating and then meets or fish so fish is a really big component of the Mediterranean diet as you might you might Guests, but any type of fish I encourage patients to try I don't say you have to have you know Cod or to love whatever tilapia or well try fish find something you like and try to at least put it in your dinner plans. Once a week red meats is a a big part of the ketogenic diet because red meats are very low in carbs high in fat, but for a Mediterranean diet not so great and we know that increased red meat over time not only increases your risk for heart disease, but also cancer there's a really interesting article about France putting out of the France the government or the, you know, equivalent of the FDA and France saying that eating foods high and nitrates is really bad decision and obviously in France, they have a lot of charcuterie boards and meats. And so I think that focusing on fresh and green and fish is a what I would recommend all my patients and I do um, I think specific comment on keto is that it helps you lose weight, but I think it might be a little bit too heavy on the fat side and what we look at the Patients called cholesterol and a lot of times it erases the back cholesterol quite a bit. If you are a little bit too liberal with, you know, bacon and things of the sort that are okay for the keto diet but not for the other diets. You know, actually I've seen patients liver enzymes go up on the keto diet and not insignificantly and that ties into fatty liver, which is a whole another discussion we can talk about later but what else have a diet is do things. So first of all, the weight part is easier said than done but the way way to get to accumulated is how many calories go in with diet versus how many go out with exercise and Metabolism. Okay, that's the kind of the easy formula so lowering. The total calorie amount is important. That's one thing. And you don't have to be super dogmatic about it. That's one basic principle. and then the other one which fits into the Mediterranean diet topic is The enemy for bad cholesterol other than fats it's actually the simple carbohydrates. So the ones that are easy to digest they raise your blood sugar. They raise your bad cholesterol. Any type of sugar added to anything so sweets sodas juices Etc. Then the big ones that everybody likes rice pasta bread potatoes tortillas because a lot of times in here, I don't need sugar but then you have a lot of rice, etc. Etc. So those are not the best I think a diet should mostly be based on lean protein. So grilled fish grilled chicken and saying and vegetables and be careful with the dressing because dressing they have a ton of calories. Sometimes you go to a fast food place and the salad may have more calories and hamburgers. And you know, you can always we have really good as I mentioned before about looking at Mediterranean diet on our website Straight Talk is a newsletter that we put out Dr. Stephanie Coulter. You can find it at texasheart.org forward slash Straight Talk and a lot of these topics even the calcium score topic is on there too. So if you can't jot it all down now or you don't want to come back and watch us again. You can take a peek there as well. What about another topic that comes up frequently in the office? Somebody is relatively healthy no major issues and they start having leg swelling. That's not your process it. Son with their sexes not to be sexists in the leg swelling category, but I have been kind of surprised at how many women who have either had children or have had jobs that have kept them on their feet for a long period of time. For example, I had a flight attendant who said, you know, I turned 16. I feel like my legs are just always swollen and there are a few baskets to think about why spelling happens in the Cardiology office. One of those is a little more not to say serious to downplay what the other leg spelling is, but one is heart failure, right? So we're always on the lookout for if you have leg swelling. Do you have signs of quote unquote heart failure where the fluid is backing up? Because your heart's not functioning correctly. The second basket is a little less medically urgent or emergent and that's Venus insufficiency which in women by and far especially with children is a problem, especially in Houston because it's so hot in your veins that are already perhaps Not working right are now dilated because you're outside standing watching your kids play games or your exercising one for a run. So yes, leg swelling is a big topic and we fortunately have good therapies for both of those little baskets that like swelling. So depending on what it is your doctor might discuss medical therapy versus procedures. It's very common again, most of the time it is benign. But of course are once you see that you have to rule out some potentially dangerous things because you can think okay. My legs are swollen. There's more fluid in my legs right except because you have fluid all over and if that is the case that could be potentially your heart could be potentially your kidneys some other things that are less common or is the fluid only in my legs in which case it might be an issue with Venus drainage and there's many reasons for it. And the most common one is the veins have valves that allow blood to go from the feet to the heart and not go down again, you know, so help Against Gravity, but that's you know time goes by Age gets up there the valves get damaged. So the blood tends to pool in the legs and that was a relatively very very common reason and most of the time we can do it. We can manage that with compression stockings just use socks that press your leg and take care of the issue which is painful in Houston in the Heat and when you want to wear shorts back as good. Yeah, so but you know, they they help prevent it from getting worse and sometimes you have discomforts or helps with discomfort. And then there's some invasive. Therapies that can be done to help ameliorate it but we usually Reserve those if the more conservative stuff doesn't work like the stockings which work and you know exercise actually helps venous insufficiency and I try to remind people that you know it maybe if you're an avid Runner where the compression stocks when you run but also the physical the squeezing of your leg muscles helps that Venus blood flow or the pool blood in your legs. Get back to the heart. So exercise is still on the table and should be done for patients that have this different All right, we have another question from Facebook. So what is the best way to talk to my Invincible teen about heart health? I love this. Yeah, great question. So that is obviously hard. I feel the frustration through the question. honestly most of heart disease is Commonly seen in older patients. Okay, one of the in younger people we worry about different things like congenital heart disease. Is there something going on with your heart? That would make it high risk for you to exercise, etc. Etc. But the overall recommendation is we probably don't do a lot of testing in young people unless there is a problem meaning do they have a symptom do they get tired with physical activity at a lower level than you think? Or there's something going on now having said that it is always good to start. I think the most important part is healthy habits at an early age because if for if if you're not following them when you're young, it makes it much more difficult to do when you're older. And so if you get if you can start, you know at home with trying to eat and follow healthy diet of that I think would be the most bang for your bug rather than aggressive testing or or regular follow-up with the cardiologist and I think that you you really hit the nail on head with the healthy habits at home. We know and there is there's plenty of research especially in the Peds world that childhood obesity significantly increases your risk for having diabetes later in life. Yeah. So if you have if you have your child and you're worried about weight, you need to go to the pediatrician and really they have Diet counseling even for kids because later in life diabetes is one of the biggest risk factors for heart disease. So if you have already predisposed, To having diabetes when you're maybe 30 and we're seeing younger and younger patients come to the hospital with heart attacks, right? So in their 30s or 40s, so getting that kind of right at the beginning so that later in life. It doesn't sneak up on you is a big Big yeah, if you have the chance, it's a big burden to remove from the future right if possible at least. All right, we got let's see here. We have another question here. So we publish articles on trendy cardiovascular topics or topics about the heart quarterly on our Tha website called Straight Talk, which I mentioned with Dr Coulter. So let's talk about one of the Articles which is hot. I guess it might be getting hot again as covid waves go up and down. But what about myocarditis in the era of covid? Yeah. Well, we know that it can happen. It is more common with covid itself than with vaccination. Even though vaccination may do it in a very small number of patients particularly young men, but it's not something that I think you should be terribly concerned about I think. I wouldn't necessarily worry about this honestly. Yeah, and it's for the general public and myocarditis if it happens to you the most common cause of myocarditis is viruses, right? So if you had myocarditis because of covid that is not we know that's not uncommon per se but if you have my carditis and it's not covid viruses are still the number one cause so it can happen the good news about my reditus from viruses in general is that generally people improve over time the symptoms that's a short amount of time most recover fully in just a couple days. So a few days two weeks. It's actually a not severe type of Micro artist and most patients, right? What do you think what else questions what other questions you see in clinic that? Okay, you know really we've We As and we're both Interventional cardiologists. So we do procedures and we do stents. So one of my common topics in patients who perhaps needed to stent is well do I have to be on these blood thinners for life so simple so blood thinners. I want when you talk to your cardiologist. I want or your heart or your primary care doctor. Whoever it is you follow up with closely the men that we put patients on after a stent or not technically blood thinners. So when we say you're not honorable at thinner or you shouldn't be in a blood thinner. That doesn't mean you shouldn't be on your aspirin and your platics per se or your clothes put a girl or your essay or your professor girl preserve to category, but now back to the beginning you have a scent. How long do you expect to be on these blood thinners? It's a great question. So like you said there's Types of blood thinners there's anti-plate lit agents which are the ones that we use if you had a stent for example and an anticoagulant which are used if you have multiple things the most common ones are thrombosis of the veins, for example, or atrial fibrillation. That's a separate topic now talk about if you had a stand to your doctor gave you two anti-platelets to take to keep the stent open. in general you should there's a few ways of going about this. It's very very active topic of conversation and scientific research. The basic principle is you have to continue both for if you can at least one year, so it gives your body time to initially when you got to stand implanted. It's a metal thing. It's a foreign body your body wants to attack it. Okay. So you the anti play Let's prevent your platelets from attaching to it and blocking the step and giving you a heart attack. But your body slowly covers the stent with its own cells over time making the body the standard seem less foreign over time. So at a one year that should be relatively complete so you can stop at least one of the anti-plated agents, but that risk doesn't go down to zero. So if the procedure was complicated if this tent is very long. If you are very high risk individual. Sometimes we continue both on the playlist for a long period of time and sometimes we stop them before a year. If you are at high risk of complications from the Antebellum, it's like bleeding. So it is a it is really an individual decision and that brings up a really good point as cardiologists. We actually do want to know your GI meaning your stomach is tree or you're bleeding history. So please if you're going to see a cardiologist and you're writing down your list of Prior health issues don't leave out the systemic issues or that you know, bowel issues actually is very important to the medications that we pick and you know, I I actually browse Facebook. Groups, you know patients that also take Physicians to sort of understand the patient experience and the question that pops up frequently is, you know, I'm taking all these meds. I feel really bad taking all these meds. I'm just gonna stop them and you know, I did it and I feel great and that may happen because meds have side effects but not all medications are in the same level of importance. Okay. So stopping a Statin with your cholesterol. It's almost normal. It's not the same as stopping one of these anti-plated agents actually. Yeah a month after you had a standard. So that is a major major risk. So if you really want to Stop a lot of meds. You're the boss. You know, you decide maybe we think this is useful, but you don't want to take it. I you should definitely have a an honest again honest conversation with your doctor about hey, I want to be honest a few minutes that is reasonably possible that it's not gonna, you know cost me to have a heart attack and a week and there's some that can be dropped but some that are really really critical. So be careful about just blade, you know blank stopping everything. Yeah and truly the drugs that we prescribed or all Specialties really there should be one of two goals doesn't make you feel better. If it does great and does it make your life, is it prolonging your life? Is it going to make you live longer and in the Cardiology world? That's really what we're doing every day when we're titrating or messing with meds. So patient might get very frustrated that maybe I'm changing this blood pressure medicine or I'm adding one instead of just maxing out the other one, but there's there's data behind the reasons that we make these decisions. So maybe you'll be on a combination of pills but those combinations have been proven with science and proven with studies to make you live longer or feel better. So there is definitely a trade-off and there's always a written the benefits and the risks of everything that you have to weigh, but your doctor should be trying to achieve one of those two things. so a little bit of a philosophical topic, but people tend to support the evidence of things that you already believe okay and reject the things that you don't think work and going back to status. For example, there's studies are well conducted studies that show that standards have some problems. So that's that's fair. But our job is to look at the evidence and it's totality step back from one study and look at all the thousands of studies and come up with a conclusion. So every time that we're assessing the benefit or the risk of a drug, that's how we should do. It. Not just focus on one study that said this or another study. That's right or your friend who had this happen when they all right? Okay. So let's move on. I know this person so our bicuspid aortic valves hereditary. This is a very good question. What is the first what is because okay so fun. I wish we had a picture that we can Flash up for you guys. First of all, what is your aortic valve? Okay. So I'm Aaron you're aortic valve is how I describe it the gatekeeper from the blood coming from your heart to the rest of your organs. Okay. The aortic valve is usually has three leaflets, which kind of what does it look like a Mercedes that sounds ridiculous, but our Mercedes ben, If you looked at that, that's what your hair could have actually looks like that's right sponsorship from Mercedes-Benz. Yes. So if anyone knows, okay, so so that is what your valve looks like when you're looking down on it. Okay, it has three leaflets those leaflets open every time your heart squeezes. Okay, when it's normal, it has three leaflets and they open very easily. Okay, as you age that can change where you have maybe motion of that the leaflets that aren't so good that would be aortic stenosis. But now let's go to what is a bicuspense so usually it's tricuspid. But if you have by cuspid you have only two functional leaflets, you may have had three-ish leaflets, but they fused and it's usually you're born with bicuspid. Okay, so by custody two leaflets as you can imagine, it's not how it's supposed to be so it doesn't work perfectly normally so One are they hereditary they can be and the it. The percentage of which are hereditary can vary if you Google by cuspid valve, but I would say between the order of 30 to 50 maybe and it depends on your genetics. So if you're just unfortunate and you were born with a bicuspid and you don't have any family history of it, you might not have the same risk of passing that on to your progeny. I think a fair way of saying it is congenital meaning it is there when you were born and there is a higher risk that you it was hereditary from the top and you may pass it on but it doesn't happen 100% of the time and the biggest thing to take away from from it is if you have a bifested or your mom or dad had a bicuspid you should have an ultrasound of your heart go to check because guess what by cuspids put you at higher risk of having that valve kind of become stiff earlier, right? So the two issues with my customer well getting stuff earlier stiff earlier and actually your aorta the big the big artery the biggest artery in their body being dilated and those why we care it goes back to why we put people on medicines because those two things in order to make you live longer and feel better. We want to make sure nothing goes wrong with those and that can happen earlier in patients with a bicuspid valve. Okay, so it's to prolong life. Yeah, so if you have been diagnosed with a bicuspid aortic valve You should do a few things and one is you may need. Echocardiographic surveillance of the function of the well, which means ultrasound of your heart, correct? We just checked if it's opening. Okay. Is it getting Tighter? And we do that over time if you feel fine, it's usually not a major concern but we have to keep an eye on it. And then the other one is that we have to keep an eye on the aortic size and we can do that multiple ways. At least one time. You should probably get an image of your whole chest being either a CT scan or an MRI to look at your entire aorta. and then We can see some parts of the aorta with the ultrasound so we can follow it long-term weather. You may have to repeat another CT scan in the future. But essentially you just have to keep an eye on it. Don't think it's gonna impact your lifestyle. You have to do some sort of limitation, you know, but to keep it from getting worse than there are some medications that may help the aorta from getting bigger. And that's a little bit controversial there. Usually the ones that we use for hypertension some of them work to keep the aortic size as normal. So that's another thing to maybe consider with your doctor. Not very good question. You know another Hot Topic we can since we're already talking about aortic valves. You are your family members might know someone who's had a quote Tavern or a catheter based valve place instead of having their chest open for valve replacement that is where we actually go through the arteries and the groin most commonly the groin and we've delivered a valve without opening your chest and that's something we do here. Of course that Texas Art Institute and you can many other Institute institutions are also doing it but we're really proud of the program here at Texas hard at Baylor Saint Luke's really started these yeah many years ago now, I guess it's been many years those Intense or something. We used to have to open the chest and everybody that needed a valve in order to take valve and now we can do it through the world. So it's not for everybody yet and it's actually a very good procedure. But the way we like to do things is we like to do it test things out a long period of time and then expand its use So right now it is mostly reserved for people that are over the age of 65. So if you're younger than that, it may not be the best for you. But it's definitely an option out there that if you were diagnosed with aortic stenosis, you should ask about yeah and it's durable now that we have, you know, 10 years 10 plus years of data. We know that they are durable the more data that comes out the more we're convinced that it's actually very good. Yeah. Okay. Next question. What do you think the role of gastric bypass surgery is for heart patients diabetic patients patients of hypertension Etc. Alright. So one this this question, you can kind of sum it up a you have if you have type 2 diabetes. And you've quote unquote diastolic dysfunction at heart failure. Okay. Do you think that do we think they would benefit from gastric bypass? If you're at a point where you're diabetes it you've been diagnosed and your weight is now at the point where you're considering bypass. I always think it is important to assess your ability to achieve your weight goals or your diabetes control goals, and if you think you need help and bypass might be beneficial to get there than yes. Diastolic dysfunction or diastolic heart failure is a very complex diagnosis and disease because it actually is influenced by Sleep Apnea by weight by blood pressure, which all we often see kind of together in this in a group of people who have maybe diabetes and obesity and symptoms of heart failure. So yeah, I think absolutely I'm pretty pro-gastric bypass. I'm often supporting patients who want to be quote unquote cleared for bypass surgery and this this is evolved over time, but in general Who is the candidate for gastric bypass surgery? If your body mass index is about 40 and you are unable to lose the weight with a structured program, then you can be a candidate for it. Or if your body mass index is more than 35 and you have what we call another condition that sort of amplifies your risk like that these and then you were also a candidate for it now. And in very interesting thing that has been called by Psalm as bypass surgery in Esther Ridge the new meds for weight loss but I perhaps what he thought yeah, but I heard yes. Okay. What do you think about this? I love these things. Honestly. I wish someone from that drug company would be listening to this send us some for patients. But so these drugs They not only in the big trial for one of the major drugs. I'm not going to promote any of them. But you know somebody so these drugs have been shown to have patients lose up to 15% of their body weight, which is a lot so you take someone who's 200 pounds and you help them lose 30 pounds just by using this drug, which is really pretty well tolerated with minimal at all side effects the side effects of the drug actually help you lose weight. I think it's a no-brainer. I think that the weight loss these companies have struck gold and the companies that give these drugs out are actually diabetes. Companies so they didn't even know what they were finding. They were testing a diabetes drug and they said wow, our patients are losing weight. This is amazing. So they've now used it as a weight loss drug. So I love the drugs. There are not only good for weight loss, but they are good for cardiovascular profile. Meaning they also can affect have good beneficial effects for your cardiac profile long term. So I'm a huge proponent. What about you? So we've had weight loss drugs for some time, but they're not really the safest a lot of them have been sort of stimulants that reduce your appetite but those have side effects, you know, they ramp you up and everybody, you know, so it's not the best for your body overall, even though they made you lose weight. So this is actually really really interesting. It seems the drug is very safe, very effective and very good the main problem now. Well, if you're a diabetic, you're a good candidate for these and insurance, you know, what usually cover it but This indication for just wait came out very recently. And right now the company's charging a lot of money for the drug. If it's only for weight loss and insurance are getting used to this and so right now it's very hard to actually get it but in the future thing is gonna become more accessible and it's gonna be a much more. Available option. Okay. So if you want To try this. Yeah, definitely ask your dog, if you're diabetic and you have elevated weight you particularly important for you. Yeah, no brainer. So no brainer next one from Facebook. So at what age should you start seeing a cardiologist or at any age? Okay, let's say let's give us scenario. No significant family history of heart attacks hard stroke heart failure or whatever and you have someone ask you this question. What's a pretty general rule? Yeah. So I think you need to start being more mindful of your cardiovascular health, maybe starting around 30 and then particularly after 40 not necessarily see a cardiologist per say if you see a primary care doctor, you can check of you know, the usual things that we check like cholesterol. For example, we might go a little bit deeper and do some additional testing that that may be useful. So I think 30 you have to be pay more attention and then that 40, I would definitely see someone and if you can see a cardi The thing don't be great. Yeah, and then of course if you have a strong family history mom dad or brothers or sisters who had early bypass surgery early stents early, whatever it might be. It is never a bad idea to check in with a cardiologist and hopefully they say you're great. I'm not worried about you yet and see me in a couple years, but you never know if you might be missing something. So it's not harmful to see a cardiologist if you're worried. If you have a concern do it and I just have to plug this because one thing that in women's heart health that we really do not focus on and should and part of that is you know on our end. We should be talking to OBGYNs more if you have a history of preeclampsia or a clampsia or gestational diabetes, you're at higher risk of having hypertension later in life and diabetes. If you have the gestational diabetes later in life, so knowing that is important and often as moms or you know, you're busy you're at work and Mom and you're not thinking about yourself all the time. You should keep this in the back of your mind and just be mindful of your numbers your blood pressure your weight Etc. Well, it's like we're getting close to wrapping up. So thank you for joining in remember that a lot of these topics. We have information in our website hypertension cholesterol management. What is body mass? Index? And what is a good diet? Etc, etc. So be sure to log in Texas heart that Oregon and check it out. And thank you super doctor Costello for join me. And yeah, whatever thing it up. We look forward to the next one. Thanks everyone for joining and we hope we had a little bit of fun on this Friday. We're talking 45 minutes straight. I need a coffee.