Heart Care Has Changed Forever — What's New in Cardiology (3 Cardiologists, Part 1)

Heart care today looks completely different than it did just 10–20 years ago. 

In Part 1 of this 2-part conversation, cardiac electrophysiologist Dr. Abhishek Bhagat is joined by two fellow cardiologists to break down what's actually new in heart medicine, what's changed forever, and what it means for your long-term health — all in plain English.

From GLP-1 medications and pacemakers the size of a bullet, to minimally invasive procedures replacing open-heart surgery, to AI now shaping how we diagnose and treat patients — modern cardiology is evolving faster than most people realize.

In this episode, we cover:

• How heart care has transformed over the past 20 years
• New cholesterol insights (beyond LDL)
• New tech: advances in cardiac procedures and devices
• How AI is transforming heart care
• Cardiac imaging advances: coronary artery calcium score and cardiac MRI

Guests:

Dr. Amin Kashef — Interventional & Structural Cardiologist 

Dr. David Lee — General & Preventive Cardiologist 

Whether you're focused on prevention, treatment, or just want to better understand your health, this conversation gives you a clear, real-world look at where heart medicine is today.

Part 2 drops next Sunday — follow the show so you don't miss it.

Prefer video? Watch the full conversation here: https://youtu.be/IplTaYZ2D54

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About Dr. Abhishek Bhagat, MD:
Triple board-certified in Internal Medicine, Cardiology, and Cardiac Electrophysiology. My work has been published in numerous peer-reviewed medical journals. I create content focused on science-based, practical strategies to improve your health and longevity.

Disclaimer: The information in this episode is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider before making changes to your diet, exercise routine, or medical treatment.

Transcript

SPEAKER_01 0:00

We have all these fancy technologies and all these new medications and all this investment in cardiology, but heart disease still remains the number one cause of death.

SPEAKER_00 0:10

According to a new survey, many people actually underestimate the threat of heart disease.

SPEAKER_01 0:15

Why do you guys think heart disease is still the number one cause of death?

SPEAKER_02 0:21

I'm not surprised. And then the other thing is that despite all the technologies, you know, treating you know what we call cardiometabolic syndrome, that has been not very successful.

SPEAKER_03 0:34

Depending on your socioeconomic status, your culture, and depending on your genetics, especially with a Western diet.

SPEAKER_00 0:44

You can blame the so-called Western diet for part of the problem.

SPEAKER_03 0:48

High carb, high fat, high salt, that has an effect of a cardiovascular disease.

SPEAKER_01 0:55

Reimbursement for prevention, unfortunately, tends to be lacking behind compared to acute issues like fixing a heart attack. Good evening. So I'll have our guests introduce ourselves. So we can start with Dr. Kashef.

SPEAKER_02 1:10

Hi, thanks for having me here. I'm Dr. Kashew. I'm an interventional and a structural cardiologist, and I practice in Hartford and uh water breeding, Connecticut. What about you, David?

SPEAKER_03 1:20

So I'm Dr. David Lee. I am a general and preventive cardiologist, currently based in New York City.

SPEAKER_01 1:29

Perfect. So we have an expert panel here. We have a general cardiologist who's also delving into preventive cardiology. We have Dr. Khashev, who's also an interventional structural cardiologist. I myself, I'm more so focused towards the electrical side of things, so cardiac electrophysiology. So we'll touch upon different cardiology-related topics and why heart disease still remains the number one killer in the US. So to get things started, let's think about why we chose our respective fields. So, Dr. Koshiff, why did you choose interventional structural cardiology in comparison to other fields you could have gone into?

SPEAKER_02 2:05

Well, I liked interventional because, you know, in addition to being able to practice clinical and general cardiology, I like to do procedures. And what was uh what was really fascinating for me in interventional cardiology was the procedures that can rapidly improve the outcome and the um health of the patient. You know, for example, in the setting of a heart attack. And you know, later on when I started doing structural heart, doing procedures like uh transcathetary aortic valve replacement or TAVER that can really significantly improve the symptoms and longevity of the patients. In addition to being a field that's very dynamic and evolving, there's a lot of innovations coming, new technologies and devices that really made me choose uh interventional and then a structural cardiology.

SPEAKER_01 2:48

Perfect. What about you, Dr.

SPEAKER_03 2:50

Lee? So, cardiology has always been a passion of mine, especially in terms of medicine. Uh, I was part of a cardiology lab through a summer high school research program, and that really sparked my interest. And then, especially going through med school and residency, the cardiology rotations or blocks were always the most interesting and appealing to me. My belief is a doctor is there to take care of patients' health and try to keep them as healthy as possible. And I think prevention does that in a longitudinal way. So Dr. Kashev will get them healthy in a quick way. And then I try to step in before or afterwards to make sure that their health is maintained. And I feel like this way I can build patient connections. And I'm always gratified when I see patients improve overall in terms of their health. Uh, and I feel like that means I'm doing my job.

SPEAKER_01 3:53

Exactly. And we'll talk about that, you know, how the current kind of healthcare model, at least in the US, focuses a bit more towards fixing or treating an acute disease, but less so on prevention. The other question I have for you guys is what does a typical day look like for both of you in terms of your day-to-day routine, in terms of inpatient versus outpatient, lab days, how many hours you're working, weekends off, things like that. So, Dr. Kosh, if are you doing like two days in the lab, rest out outpatient, rounding-wise? How is it kind of structured for you at present?

SPEAKER_02 4:22

Yeah, so usually two, two and a half days, uh sometimes three days in the lab. Other days will be either clinic or rounding in hospital or CCU. And there's obviously some c on call days, you know, um during the week or weekends.

SPEAKER_01 4:38

And as an interventionist, I'm sure you're taking STEMI call like once a month or something like that, right?

SPEAKER_02 4:43

Yeah, you know, it depends on the number of people who are in the pool, but you know, roughly once a month, you know, like uh a week a month.

SPEAKER_01 4:49

So STEMI's that's kind of the most major cardiac-related emergency that can kind of happen when an interventional cardiologist such as Dr. Koshev has to rush into the hospital and fix a heart attack emergently. What about you, David? How is your sort of day-to-day routine structured these days?

SPEAKER_03 5:05

So I'm mostly in clinic these days. I'm seeing my share of general cardiology patients and specific prevention patients all mixed in together. I have an afternoon of being in cardiac rehab, making sure we know patients' histories before they start rehab and seeing what their uh beginning point is in terms of their ability to participate. And then every few weekends, I'm either on consults, staffing the weekend consults or the uh step-down unit for specifically for cardiology. So that keeps my impatient side tuned up.

SPEAKER_01 5:46

Very nice. And also, are you reading stresses and echoes and stuff in between these hours or is that kind of separate? That's separate.

SPEAKER_03 5:53

So, my particular job right now, I was hired to do was to focus on prevention. Stresses and echoes are definitely part of my wheelhouse.

SPEAKER_01 6:04

Perfect, perfect. So for me, it's something like one and a half to two days in the lab, where from the electrical side, I'm putting in pacemakers or performing ablation for certain heart rhythm disorders. Besides that, the other days I'm either rounding in the hospital seeing patients with heart-related issues, or I'm in the clinic and addressing less sick patients with their heart-related problems. So that's how my day-to-day is kind of structured and it varies. The hours vary depending on if I'm doing procedures, then it's kind of a little bit of a longer typical work hour shift versus if I'm in the clinic, then it's more so something like A to four or A to 5 p.m. kind of a thing. So, one question I have for both of you guys is in the last, let's say, 20 years or so, we've seen cardiology evolve quite rapidly and dynamically. When you look at how things were, let's say 20 years ago, like stents or valve procedures or pacemakers and things like that, they were quite basic and rudimentary. Now things are much more sophisticated. We have better technologies and safer procedures and so forth. How has this kind of change in cardiology over the years affected how you practice today? What sort of significant changes have you guys felt in each of your disciplines? We can start with you, Dr. Koshw.

SPEAKER_02 7:21

I agree with you. The change has been really fast. Um, I would say since I started working um over the past, you know, seven to eight years, medical therapy definitely improved. There are better medications for treatment of you know heart disease, plaque buildup, heart failure, prevention. You know, in terms of procedure sites, stance improved, um, the devices improved, the imaging that we use and the physiologic tests that we do gives us more precise information. So I'll say we are more precise in terms of treating um arteries of the heart. And then also, as you mentioned, treatment of heart valve disease, you know, kind of uh moving toward less invasive procedures and you know, giving the options to patients that before did not have any options. Uh, you know, these definitely have really progressed a lot. Um, you know, in terms of the structural sphere, you know, um transcatteric valve replacement has expanded a lot. Um there are more patients getting tavern now than surgery, meaning uh open heart surgery. So there are options, as you know, before patients who had atrial fibrillation, which is an irregular heartbeat, and there is a risk of a stroke with it. If patients could not take the blood thinner, then they would be at a risk of a stroke. Now there's an option of a procedure which is called you know lithial appendage occlusion, or Watchman is one of the companies. That's another thing that came and really uh give option to the people who need it cannot take the blood thinner. Then, you know, the option of you know uh repairing the valve uh without open heart surgery minimally invasively and using transcatheter, that also expanded and it keeps expanding.

SPEAKER_01 8:58

Yeah, I think I I completely agree with you. So the TAVI procedure, you know, transcatheteric valve implantation. We're seeing at least over the last five, maybe ten years, it's being utilized much more frequently now. And it was primarily saved for kind of high surgical risk patients. And now it's used for even moderate, you know, risk patients. And there's some safety studies indicating that it's even you know okay for low surgical risk patients. So that's definitely in the world of structural and interventional cardiology. I think that's definitely been a game changer for you guys. What about you, Dr. Lee?

SPEAKER_03 9:32

So I want to echo what Dr. Khashiv said in terms of uh medical management, especially in patients with hypercholesteremia, hypertriglyceridemia leading to coronary artery disease and further major adverse cardiovascular uh events. Even if you think about it, statins, which are so ubiquitous now, they have only been really around for the past 20 to 30 years. They've been more popular in the past 20 to 30 years. And the trials and studies have continued to improve and show Rasuvastatin and atorvastatin as the high-intensity statins. And then even further than that, over the past half a decade or so, the PCSK9 inhibitors with evaluumab, allurocumab, those trials have shown that these cholesterol-lowering medications, not only do they lower cholesterol by 50%, but there's also cardioprotective uh benefits to these medications. And then furthermore, there's in clisteran the twice-yearly injection that you can do that is just as efficacious. And further studies are being done in the uh hyperlipidemia space.

SPEAKER_01 10:48

Right.

SPEAKER_03 10:48

Uh, not to mention other trials and other uh GLP1 agonists for diabetes, but also for cardioprotective benefits and weight loss, which can help with the cardiovascular events and renal artery uh denervation for hypertension, which is also a risk factor for cardiology and cardiovascular events as well. So I think cardiology in general, not just general uh prevention, interventional structural EP as well, it's continuing to grow exponentially.

SPEAKER_01 11:20

From a medication standpoint, there's been a robust increase in the cholesterol medication realm. So now not only LDL cholesterol, we're targeting, you know, as you mentioned, LP Little A, Apo B, all these kind of things. And there's more and more studies being done on how we can reduce not only your LDL cholesterol, but these other kind of concerning cholesterol markers as well. And of course, the GLP space is exploding right now, and there's robust research behind it now from the electrical side of things. I would say that ablations are now much safer compared to how they were done maybe 20 years ago. So previously, how we treated heart rhythm issues, especially certain heart rhythmia, let's say like atrial fibrillation or atrial flutter, would be either radio frequency in which we're causing thermal injury to the heart cells or the freezing technologies. So now, more recently, with this pulse feel ablation, which is more specific for the heart cells and you have less collateral damage to the nearby tissues, so this pulse feel ablation has really been kind of the game changer in the EP world. It's a method how we're fixing these arrhythmias in a safer and more efficient manner compared to how we were doing things five, 10 years ago. And with the pacemakers, which we implant for patients who have slow heart rhythm issues, previously, like the first generation pacemakers, they were the size of like a smartphone. They were bulky and big and thick. So now that technology has continuously evolved and it's, you know, now you have pacemakers that are leadless. So you have certain pacemakers that are the size of, you know, like a bullet and they sit within the heart. So that's definitely exciting and how this evolving technology has kind of has changed how maybe our attendings used to practice 20 years ago and how we're practicing today. Touching on this, what advancement or technology would you say has completely changed how you practice today compared to something like 10 years ago? So, what new, whether it's a medication, whether it's a technology, that has been a real game changer in how you're practicing in the interventional space, structural space, or preventative cardiology space, what would you guys say, Dr. Kashef?

SPEAKER_02 13:25

So, you know, um, we're talking more about like a technology and devices, or overall how we approach and how to treat the patient, or both.

SPEAKER_01 13:33

So probably both, whichever one you feel has made the biggest impact towards how things were done in the past compared to, let's say, now. Right. And I know we touched upon this, so Tavi or Tavers are probably one of them. Anything else besides this that you would say that as, hey, this is tremendously kind of added value and changed in how we used to do things for you?

SPEAKER_02 13:53

Yeah, you know, definitely. You know, I think in a in a in a bigger picture, I think we are what changed in our practice, we're also doing more of a personalized medicine, you know, a medicine that's more patient-centered and tailored toward each patient. We are using, you know, in the field of structural and interventional, we're doing more of a collaborative work. Uh, you know, we're having more team meetings and involving other cardiologists or cardiac surgeons. You know, uh and in terms of the what procedure specifics, obviously, Taver started almost 20 years ago and kept expanding. So as you mentioned, even low-risk patients um can get a Taver procedure if their anatomy is good. Um there are obviously some some ages, younger patients are still better treated with open heart surgery. You know, then when we get to the um the other heart valve disease, the the mitroclip is one of them, is uh a repair of the mitral valve or what we call edge-to-edge repair of the mitral valve without open heart surgery and using a transcatheter. The same is being done for um tracospid valve, which you know is a valve um on the right side of the heart, which also touched base about you know left atrial appendage occlusion or watchment. And obviously, the probably what's right now really moving and um expanding is uh is the implementation of AI in in cardiology as a general in interventional EP. Um and I I'm I'm sure we're gonna talk about it more uh in in this podcast today.

SPEAKER_01 15:23

Perfect. What about you, Dr. Lee? What would you say has kind of changed things? So I know we discussed GLP1s and some of the new cholesterol medications. Anything besides this that's really shaping or or impacting on how things are being practiced today compared to five, ten years ago?

SPEAKER_03 15:41

I think, yeah, like you said, the cholesterol and the weight loss uh slash diabetes medications, it's been pretty well known that cholesterol has been a risk factor for um heart disease. But if you dive into it a little more, it's not just the LDL. LDL is a great marker, it's a very cheap test. It's honestly pretty standard for all of us cardiologists and general internists as well. But also, if you look at some subsets of cholesterol, such as LP little A lipoprotein A, which is not measured in your typical cholesterol panel, but it has been shown to have a higher risk of atherosclerosis and thus heart disease, higher risk of aortic stenosis, mitrostenosis, peripheral artery disease, and it's inherited if we can catch those patients before they start having possible premature, especially premature heart disease, and we know their family history, that could be a game changer in terms of improving their quality of life, making sure that they don't need to come to the hospital with a myocardial infarction, a heart attack, uh, so to speak. And then there are medications that are currently, there are four medications, I believe, where there are just finished phase two or undergoing phase three, currently undergoing phase three trials to lower LP little A. So I think that's something that's very exciting. Uh, we touched upon AI as well, and using, we use a lot of uh risk factor calculations. Uh, I mean, the very basic one is ASCVD risk, which I'm sure we all use. Uh what seeing what patients' hemoglobin A1C is, hypertension, blood pressure, lipid level, even their race and uh their diet exercise, and putting all in there and trying to come up with and genetics as well, trying to see what their risk factor is for getting a heart attack or stroke in the future, and trying to minimize that as much as possible. So, which leads into personalized medicine, which I know we've talked about as well, because not everybody is built the same. You have the very the patients who have the most horrible habits, most horrible body habitus who are doing okay. And surprisingly, their calcium score is zero. And then you have the patients who do everything correctly, and then they still come in and need multiple stents and bypasses. So really tailoring care, I think, has been the biggest thing, as Dr. Khashev mentioned, uh, to each individual and making sure that every person, it's not a one size fits all as it may have been in the past.

SPEAKER_01 18:30

Right. So definitely a shift towards precision medicine. I completely agree with you. And yeah, you're right. So the statin medications, often people don't realize that statins will definitely lower your LDLC and all those kind of things, but they don't really touch your LP little A. Right. So these newer medications that are being studied, and hopefully, you know, there's promising results with those, but they hopefully can lower your LP little E, which is another risk factor for heart attacks and so forth. So that's you know, definitely an exciting space to see how those medications come through from the trials and hopefully they have promising results. And I'm sure they'll be super expensive when they do come out. Probably initially. Hopefully they go down as time goes on. So yeah, we touched upon AI a little bit. So, how is AI impacting your guys' everyday practice? In the EP world, for us, AI is being integrated now into smartwatches. So it's going to tell you whether or not you have certain hard rhythmia, like AFib, or if your heart rate's dangerously low, things of that nature, it'll give you alerts. It's being utilized in our electronic medical records to give us alerts and prompts about certain risky things that some patients may have or some things which we may forget about, it'll give us a prompt like, hey, make sure you address smoking cessation with this patient and so forth. And for kind of the day-to-day EP practice, at least from a procedural standpoint, it's definitely had a huge impact in how we fix certain arrhythmias with ablations, let's say. So uh when we do something called mapping, which we're trying to localize where the abnormally firing heart cells are coming from, this is helping us sort of fine-tune the signals better and kind of like a sniper go to those abnormal cells more quickly and we can target the ablation and fix the patient sooner and with sort of a more precise outcome. So that's how it's sort of impacting and really optimizing things from the electrical standpoint. How do you feel that it has or it may affect your practice, Dr. Khashiv?

SPEAKER_02 20:28

You know, I I agree with you. It it has already affected um our practice as well. And uh it is definitely gonna expand. Um, for example, some of the you know um the ways that we use it. We use it for uh procedure planning, reviewing the CT scans, planning uh in terms of you know Taver procedure. There are risk models that can predict the outcomes, especially the the outcomes that we want to avoid that will give us information, you know, to discuss with the patient um before the procedure as well. Other ways that we use it, um there are it's giving us non-invasive ways to assess uh, for example, severity of stenosis in the arteries of the heart. You know, either it's I CT scan or any type of imaging, or during the angiogram, there are kind of less invasive ways to uh assess the physiological significance of plaque in the arteries of the heart. These are these are the procedural planning or procedural side of things, but even in a bigger picture, we see it in a workflow, how it, you know, we use it in the EMR, you know, electronic medical records. It helps uh take some of the burden off the physician so instead it can focus more on a patient and spend more time with the patient.

SPEAKER_01 21:41

Yeah, so I think that's a good point that when you're looking at blocked heart arteries, of course, you know, the tried and tested and the default approach tends to be a coronary angiogram. But there's also that CT angiogram, right? And that CT test to look at blocked heart arteries that is utilizing AI, that hard. Flow company. They're using certain algorithms to predict the significance and whether or not there's truly a blocked heart arteries. If there is, what is that lesion, that blockage, is it truly significant or not? And hemodynamically, you know, their algorithms. So yeah. So in the imaging space, let's say when you're looking at heart arteries, I think it's I agree. I think it definitely has an important role there. What about you, Dr. Lee?

SPEAKER_03 22:26

So I yeah, I again, um, I agree with both of you the imaging, the coronary artery calcium score, seeing how calcified those arteries are, seeing how extensive the calcifications are. That helps um with our risk factor determination with someone needs a statin, someone needs aspirin. I was actually just in a meeting earlier today with some of my colleagues, and we were not to give too much away, but we were discussing diet and how patients can put in whatever they ate, keep a food diary, and they would calculate calories or calculate sugar, calculate nutrition values, and tell patients, okay, this is what you're putting into your body. This is what you need to watch out for. So even on an everyday scale, or the Apple Watches, Dr. Pagata, like you mentioned, uh, giving not just rhythms, but also blood pressure, heart rate, the diabetes monitors can calculate your hemoglobin A1C, your glucose levels, and then show how controlled or uncontrolled you are. Or even just going back to basic general cardiology and looking at stress tests or echoes and those donuts that we learned in uh fellowship, um, seeing whether, and then they'll give us an idea of okay, is this area ischemic, getting enough blood or not? Is this an area that a Dr. Khashiv may need to go in and look at and possibly stent? Is it a viable myocardium? If the muscle is, if it's worth saving or not, or in echoes, seeing the a flow of the color, seeing how bad the um the backflow is, the regurgitation of blood, or if there's or how fast it's going, if the um through a valve, if it's stenotic or not. So I think artificial intelligence has played a huge role in not just in prevention, but all of our uh uh careers and our and our training.

SPEAKER_01 24:25

And the ever so increasing use of technology. So I'm sure you guys remember maybe like 10, 15 years ago, we barely used cardiac MRIs, right? Like I kind of remember getting a cardiac MRI like 10 years ago. It was rarely used. Now, cardiac MRIs, we get them so frequently, A, to assess for viability, that whether or not this area you're thinking about stenting, this opening up the heart artery, is that will be beneficial with a stent. And B, from the electrical side of things, how much scarring or fibrosis is there within the heart? And does this patient, you know, kind of have have a higher risk for deadly heart rhythms? And does this person need a defibrillator system and all these kinds of things? So, all these people, a lot of patients that we treat that have, you know, weakened heart pump function or heart failure, especially for non-achemic people whose heart pump function is weak and they don't have blocked heart arteries, to explain that finding. So cardiac MRI is almost done as default now for a lot of these patients to look at why their heart's pump function is weak. If it's not blocked artery, is it something hereditary or something else? What's going on exactly and guide our decision making going forward based on this cardiac MRI results? You know, when I'm thinking about it, like, yeah, 10, 15 years ago, we never really used this as much. We were getting MRIs with the brain and other parts, but for the heart, it wasn't really utilized nearly as much as it is now.