During American Heart Month, we take a look at the differences between men and women when it comes to preventing, diagnosing and treating heart disease. Join host, Jonathan Fialkow, M.D., and his guest, interventional cardiologist Marcus St. John, M.D., for a wide-ranging discussion about heart health for men.
During American Heart Month, we take a look at the differences between men and women when it comes to preventing, diagnosing and treating heart disease. Join host, Jonathan Fialkow, M.D., and his guest, interventional cardiologist Marcus St. John, M.D., for a wide-ranging discussion about heart health for men.
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Dr. Fialkow:
Welcome Baptist HealthTalk Podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a preventative cardiologist and lipidologist at Miami Cardiac & Vascular Institute where I'm also Chief of Cardiology at Baptist Hospital and the Chief Population Health Officer at Baptist Health.
Dr. Fialkow:
Heart disease is the leading cause of death for men and women in the United States, though it tends to affect men at an earlier age and with higher rates than women. We now know more than ever before about not only diagnosing and treating cardiovascular disease, but also how we can prevent it.
Dr. Fialkow:
February is American Heart Month, and today we're focusing on men's heart health with an episode later this month addressing heart disease in women. The discussion took place on an episode of Baptist Health Resource live program. My guest was Dr. Marcus St. John, an interventional cardiologist with the Institute and Director of the Cardiac Cath Lab at Baptist Hospital. Let's listen in.
Dr. Fialkow:
We use the term heart disease quite indistinctly, and obviously there are many components of heart disease. So talk a little bit when we're talking about heart disease, what does the conventional wisdom to the public represent, but what are the other components of heart disease that certainly would come under that umbrella?
Dr. St. John:
I think when we talk about heart disease, certainly among professionals and we talk to our patients, I think we can think of it as sort of three or so main components. The heart is a muscle. Its main job is to pump blood and oxygen to the body. As with most muscles, it has a blood supply. So probably the leading cause of heart disease is when narrowings develop in the arteries, the blood supply to the heart muscle. I'm sure we'll talk more about how those narrowings develop, how we detect them and how we treat them, but basically blockages in the pipes to the heart muscle are the main form of heart disease that we think about. One manifestation of heart disease is when those blockages rupture and cause a heart attack.
Dr. St. John:
Then there are other forms of heart disease where the valves in the heart, they direct the blood flow in the right direction, they can become leaky or blocked and then just weakness of the heart muscle. So I think those are the three umbrella parts of heart disease. If we think of the heart as a muscle and its component, that helps put it in context.
Dr. Fialkow:
I think that's well said. The blockage of the arteries leads to heart attack damage, lethal arrhythmias, weakening of the heart muscles. That's the bulk of it. But other things can happen to the heart independent of blockages, but for the purposes of certainly the majority of this conversation. You also mentioned the heart muscle, Marcus, and this is something where again, I appreciate our dialogue. If we think about everything we do in society and as practitioners to prevent heart disease: eat properly, whatever that means, don't smoke exercise, we'll get into some of those ... But even what we do to recognize people who may have symptoms, it's to preserve that heart muscle. We can bypass arteries or open up arteries, we can put people on medicines for rhythms, we can help take stress off the valves, although sometimes they need surgery. But we can't bring that muscle back, so everything really is predicated on that. Blocked arteries are the most common reason.
Dr. St. John:
Excellent point and one that I try to tell patients every day. We'll talk about this more in this session ... We talk a lot about numbers and this and that, but it's what we're trying to prevent is the real things. We want to keep that muscle health, we want to prevent a heart attack. So the numbers are the numbers, but it's what we prevent is what really people should be interested in.
Dr. Fialkow:
We will come back to that, I think with another component. So let's talk about differences between men and women in heart disease. Does it affect men differently than women in terms of general numbers? Are presentations different? Speak a little bit about the specifics in men and heart disease.
Dr. St. John:
Yeah. So I think, John, in thinking about this question, I think the most important thing to address up front is that heart disease is the leading cause of death in both genders, independent of your gender, and that's why it's so important. That's why we have Heart Month. Many of the same risk factors affect men and women, and we'll come to these so I won't enumerate them here.
Dr. St. John:
I think one of the bigger differences is that heart disease, again, talking mostly about blockages and heart attacks and so on, tends to manifest earlier in men than women, usually in the fourth and fifth decades, so 40s and 50s. I might have gotten my decades slightly off. Then in women, fifth and sixth decades, 50s and 60s, and some of that has to do with the protective effects of estrogen on the heart in women and so on.
Dr. St. John:
Then the other factor that can be distinguishing between men and women is sometimes the presentation itself. This perhaps is more related to sort of the male view of the heart and heart disease that was so sort of prevalent until fairly recently and the male centric approach to studies and so on. So the more typical signs and symptoms of heart disease, chest tightness or pain, are common in both genders, but women are more likely to have less typical presentations, just a sense of fatigue or shortness of breath. That is one factor why women's heart disease presentations are more commonly missed and not treated as aggressively.
Dr. Fialkow:
That's reported, but do you see that in your practice? Certainly you have a large medical cardiology practice, but as an interventionalist and the head of the cath lab, you're seeing people acutely having heart attacks. You're being called within minutes and taking the cath lab. Do you see that, that the men have the more classic symptoms, but women may, I mean, from your personal experience?
Dr. St. John:
I think we do see that, and we really have to keep our guard up that we're not underrecognizing. I really do think here at Baptist we have so many protocols in place so that we are not reliant only on a physician's sense of a patient's history, but we're checking blood tests, we're doing EKGs. But we do see symptoms that on the surface seem less compelling, and then we are sometimes surprised by the amount of disease that someone has. So while the most common presentations are with chest pain and shortness of breath, less common ones can actually be a manifestation and can sometimes warrant careful attention.
Dr. Fialkow:
Do you find ... Again, I'm asking from your personal experience ... Do you find that the men that you see with early heart disease or with more symptomatic heart disease or even frankly having heart attacks, are they the ones that are driving themselves to come in? Is a portion of them, "My wife's making me come in?" In other words, do the men tend to take their symptoms as seriously, or are they kind of pushed to get help when they may have signs or symptoms of heart disease?
Dr. St. John:
It's a mixture. I think there are studies that say it is heart healthy to be married or to have a spouse or a partner these days. I think, John, we really see a combination. So some men, but both genders sort of ignore symptoms, "Well, it's just indigestion," or, "It's just heartburn." Or, "Boy, I must have worked myself too hard at the gym," and so spend a few days, a week or two, not thinking it's their heart and then show up sometimes too late to get the most benefit. But on the flip side, and I think you'll cover this in the session on women's heart disease, many times women are so busy caring for others that they suppress their symptoms or ignore them because it's just too difficult when you're dealing with a sick mother and a teenage daughter, et cetera. So I think both genders have to figure out a strategy to sort of turn the focus on themselves and not deny or ignore or put their symptoms in second place.
Dr. Fialkow:
So with those points, let's move into the prevention conversation a little bit. I always challenge patients, "What do you want to prevent when you have preventive therapies?"
Dr. Fialkow:
"Heart health."
Dr. Fialkow:
"Well, you want to prevent death. That's the goal. We're not going to, let it be a long time from now. But let's avoid a preventable death," of which heart attacks would be a leader in those areas. So first, as far as the contributors, the things that contribute to heart disease, how much are things we can't control and what would those be and how many are results of lifestyle and things that would be more modifiable?
Dr. St. John:
I'll start with the things we can control or affect, and even some of the things we can have genetic components. When we talk about knowing your numbers, and I think we come to that even later on in the program, the numbers really are speaking about risk factors. So blood pressure is a number, the pressure of the blood in the blood vessels in your body. So the higher that number is beyond a certain level, the more stress it puts on organs, the brain, the heart itself, the kidneys as well. So that's a risk factor, something that increases the likelihood of heart disease.
Dr. St. John:
High cholesterol itself, and you're certainly an expert in cholesterol, but ultimately and what I try to share with patients is that bad cholesterol, LDL, is fundamentally what accumulates in the heart arteries with a lot of influencers to that. But that is almost a sine qua non of heart disease.
Dr. St. John:
High blood sugar or diabetes is another big one. Its influence again, is that it increases the likelihood of bad cholesterol collecting. Then smoking, it's another facilitator of getting that cholesterol into the arteries. It damages the lining of the arteries, what we call the endothelium. Sedentary lifestyle, so not enough activity. Then more recently recognized things such as just stress, environmental stress, personal stress, poor sleep, hygiene, untreated sleep apnea. These are all things that affect the heart.
Dr. St. John:
Then as your question suggested, there are some things that are out of our control. So family history more than anything. That really speaks to the genetic component within some families for premature coronary disease and in some families for extremely high cholesterol levels.
Dr. Fialkow:
I always tell people, "The joke is you want to avoid a heart attack, pick the right parents." Getting older, also being a risk factor, one we can't do anything about, better than the alternative. That was a great list. I think if I could put in context to follow the conversation, it's not even any one of those things obviously, it's the constellation of those things.
Dr. St. John:
Yes.
Dr. Fialkow:
That's when we come in and when you see a doctor, it's part of that full assessment of your lifestyle, your risk factors, your numbers that assess what the risk is of a heart attack. Of course, if it's relatively high, we want to lower it by whatever means. So again, well-established things we look at.
Dr. Fialkow:
The other thing to think about, Marcus, is cholesterol, blood pressure, even diabetes. You don't wake up and say, "Hmm, I think my cholesterol is high today," these are things you actively have to seek out and check and see if you have. Hence, visit the doctor and get the preventive checkups.
Dr. St. John:
I think there's going to be increasing, and again, you're more expert in this than I, but the increasing ability for people, and I don't even call them patients, just humans, to know their numbers without reliance on a healthcare system that in some ways is broken. Most of us can fairly easily check our blood pressure either with a home monitor or at the nearest fire station or supermarket. Maybe slightly less easily check our cholesterol and blood sugars. But I think we need to work towards democratizing easy access to those numbers so people can more easily take action.
Dr. Fialkow:
When we look at the statistics, we do see that heart disease remains prevalent. In fact, after a few years of decreasing heart disease, it's now increasing again for reasons we could discuss: older population, more overweight population, what have you. But we're seeing less deaths from heart attacks, and you're a paradigm of why that's the case. Someone having a heart attack, we can address it quite quickly, open the artery, preventive strategies. But there's a category of younger people, over 40, who seem to be increasing in, in prevalence and incidence of heart disease. Can you speak to why we're seeing more young people with heart disease and heart attacks than we'll say ever before?
Dr. St. John:
I think that is likely related to, and the jury may still be out, just an increase in sedentary lifestyle and obesity. That factors into many of the same risk factors we just talked about, diabetes in particular, high blood pressure. I think some of that traces back to just the ready access to sort of the highly processed foods that we can easily and cheaply access. It really becomes a self-fulfilling cycle and a lot of overlap and sort of multiple risk factors all altogether. I think those are felt to be some of the likely causes of the increase in younger people having heart disease.
Dr. Fialkow:
I kind of think that's true. I mean, I even think of, let's say a generation older than me ... I'm half a generation older than you ... Where a lot of them would grow up, 20s, 30s, 40s, 50s, and food was pretty fresh from the markets. Then I grew up in the generation that started with ultra processed, highly sugared foods when I was a kid. It's only gotten worse. So I think we're seeing the disease earlier-
Dr. St. John:
There's a book shot on your bookshelf here in the office that basically speaks to the fact that if your grandmother couldn't recognize it as food, it probably isn't good for you.
Dr. Fialkow:
So you did mention the process-
Dr. St. John:
I hear what you're saying.
Dr. Fialkow:
For fine foods. So know your numbers is a great first step. What is my cholesterol profile? What is my sugar? Interestingly, to note to the viewers, the sugar in the diabetes is not what necessarily drives the heart disease. The diabetic process, the abnormal metabolism, leads to the inflammation of the arteries and the sugar. So when one controls their sugar, that's great, but if they're diabetic, they still need other therapies, blood pressure, lipid management. But when you know your numbers, "What's my sugar? Is it going up? Am I heading towards diabetes and insulin, heart disease, blood pressure," et cetera, those are great, but speak a little bit towards a tool that we have now and we use quite readily that's better able to take an individual and predict their risk of a heart attack. We call it the heart scan or the coronary calcium score. Talk a little bit about what it is and how you use it in your practice and why it's so valuable.
Dr. St. John:
So the calcium score is really a remarkable tool, and may be one of the biggest changes in how we practice medicine in my professional lifetime. It's a CT scan, it's not a blood test, which many patients sometimes think. I like to tell patients it's quick and it's painless. There's no IV, there's no contrast, you're in and out of the scanner in probably under five minutes. The result's usually available by the end of the day. It is a CT scan that's looking for evidence of calcification or hardening of the arteries.
Dr. St. John:
How I explain the process is cholesterol, when it builds up in the arteries, starts as what we call soft plaque. Then once it's been there long enough under sort of complex mechanisms and interactions, calcium can deposit. So an assessment of the calcium in your arteries is really an assessment of your burden of coronary artery disease.
Dr. St. John:
The first thing I like to do when I'm ordering a calcium score is just tell patients what to expect and what we do with the results. The best use of the calcium score is for the asymptomatic person who is just worried about their heart disease and may be at low or intermediate risk. We can talk about how we measure that risk. But a typical person might be a young woman or a man in their 40s, "Hey, doc. I'm just worried about my heart. My dad had a heart attack at 52. Should be worried? My LDL maybe is a little bit above ideal. I don't smoke. I exercise every weekend." We can have a conversation, and then I will often say, "One additional way to assess you ... Your blood pressure is good, your numbers look pretty good. I know you're not having symptoms, but the calcium score for me is a way," the way I phrase it to patients, "Looking under the hood. Are there things in your arteries or things about your risk that we wish that we could know now to help us better treat you?"
Dr. St. John:
So ultimately the calcium score can be a tool to help us make a decision. Is this a person who would benefit from being on statin therapy who we need to push their risk lower with statin therapy? Or is this a person who is unlikely to be benefited from statins and who we can get to avoid it?
Dr. St. John:
Then it can also be a useful tool in helping us decide who should be on an aspirin a day because even that is not a necessarily benign treatment. So a little bit of a long-winded answer, but that's sort of how I use it in my practice day to day quite frankly.
Dr. Fialkow:
I think it's a great approach. Again, similar but different perspective in the sense that we just went through risk factors, which is how does my blood pressure compare to others? How's my LDL cholesterol compared to others? But the calcium score, it's actually me. It's something in the individual that we can take that information, put it into certain data that we have and say, "This is your actual risk of a heart attack in the future if we don't change anything." If that risk is elevated, we lower it. If the risk is really low, speak to that a little bit. What if the calcium score is zero? What does that tell us? How powerful is that to not treat? Talk about that.
Dr. St. John:
The power of zero, as we say in cardiology is really, I find it liberating, and it's my favorite visit or conversation with patients. I tell them, for those who played monopoly growing up, it's not quite the equivalent of a get out of jail free card. You still have to work on your risk factors, but it gives us the luxury of knowing that you really are at very low risk in the near future. Most of us say zero to five years and maybe at five years repeat the calcium score if it were zero. But it really suggests for that individual that they're unlikely to gain benefit ... Now, there are exceptions to every rule and you're the expert in cholesterol ... But you're unlikely to gain benefit from statin therapy. So I like the calcium score and the zero score in that it helps us avoid overtreating patients.
Dr. Fialkow:
It provides, as you said, your favorite visit. It gives a lot of reassurance that there might be people otherwise healthy, but the cholesterol is a little bit high, and the calcium score is zero basically says don't worry about it. The calcium score is not ... It's inflammation of the arteries. You've already articulated how the plaque develops a soft plaque. That's what we care about. A calcium score of zero doesn't mean your artery is normal, but you have such minimal disease and so early in the process, you don't really have to deal with it at that point. Stay healthy and then repeat it in a couple of years to see if that changes. So well said. An elevated score can trigger being more aggressive with one to lower their risk factors, control their plaque progression. A score of zero is, "You got a get out of jail free card." I kind of like that analogy, which is one-
Dr. St. John:
I always say ... Forgive me for interrupting ... One of the things I find important as a cardiologist, I try not to worry patients or at least I want them to worry about the right thing. So having calcium in your arteries is one thing. We address that. But the real thing that we're trying to work with, with that knowledge is prevent that heart attack. So if you die with calcium in your arteries but never have a heart attack, then we've done our jobs.
Dr. Fialkow:
God bless. God bless. So to that end, and I'm glad you mentioned that ... I remember a few years ago when there were sites that were doing free calcium scores ... Just a little marketing tool, and people would get their tests and it'd be elevated and they would wind up going to the emergency room, take themselves to the emergency room. That's not what this shows. It's not a sign of blockage. So speak a little bit quickly before we move to, well not quickly, who shouldn't get a calcium score? Where does it not help? If you have an elevated calcium score, when, if ever, should you repeat it? Where is it not beneficial?
Dr. St. John:
So I feel like these might be trick questions because you are the expert, but certainly-
Dr. Fialkow:
That's okay.
Dr. St. John:
Anyone with established coronary disease, you've had stents, you have had a heart attack, you've had bypass surgery, does not need a calcium score. I have this conversation several times a week. Those people don't need calcium scores. People with rock solid indications for statin or aspirin therapy can best avoid the calcium score. There're starting to be gray areas such as patients with diabetes and maybe good [inaudible 00:20:58] cholesterol. Maybe we still want to do a calcium score in them because if the calcium score is zero, then maybe we hold off on when we start it. Those are gray areas, but the non-gray areas are people who have established coronary disease don't need a calcium score.
Dr. Fialkow:
Well said. Calcium score is a marker of inflammation, which leads to risk. If we already know you've got disease, you don't need a calcium score. It's not something that quantifies blockages or anything like that.
Dr. Fialkow:
So moving on from the calcium score, which I think we both recognize how important it is in our armamentarium of weapons to recognize who's at risk for heart disease in order to lower the risk, something pandemic related. We bring it up at a lot of our Facebook Live sessions, but it's still relevant where through the pandemic people avoided going to doctors for a period of time. Maybe not as bad now. I mean, I'm certainly seeing people, they gained a lot of weight through the pandemic and they haven't brought their lifestyle back. Some even ran out of medications for a period of time. As a practitioner and someone who deals with those acute emergencies that potentially could have been prevented, speak a little bit about how important it is to maintain your cardiac prevention lifestyle and follow up with your practitioners.
Dr. St. John:
Absolutely. Very important. I think you and I talked about this on one of your podcasts towards the beginning of the pandemic. I remember commenting that the waiting room was empty. So the waiting rooms are full again, but even with each wave, people sort of shrink back again from the healthcare system and then sort of venture back out.
Dr. St. John:
I think one thing to let patients and people know is that healthcare system has learned how to walk and chew gum. We can manage surges and safely take care of you. It's never a good time to ignore your symptoms of chest pain or shortness of breath. You should always come to the ED and be very comfortable knowing that you'll be screened for COVID, and you'll be protected from patients who may have COVID, but you don't want to die at home of a heart attack because you were afraid of COVID. That's not a good outcome. Then all the screenings that may have been delayed and deferred, well now is the time to do your other health screenings, your mammography, your colonoscopies. So we can safely manage patients even in the midst of a COVID surge.
Dr. Fialkow:
So this is a message I fear we'll both be giving as will many others for some time. But it's an important one and one that we shouldn't take for granted. Last question before we have time, some questions from the viewers, if someone has heart disease, does that means they have it for the rest of their life. So maybe another way is heart disease reversible? Speak to that a little bit.
Dr. St. John:
So I think, again, a nuanced answer here I think it's not entirely black and white, but for most of my patients, it is sort of a chronic condition. So think of it as you might some other chronic condition, maybe asthma, or I don't know, rheumatoid arthritis, but as with many of these chronic conditions, you can control things and really be asymptomatic. So I think the more important thing to focus on is what steps you can take, and that includes lifestyle modification, adherence to medications, and in some cases, the invasive interventional help of people like me with stents and with Dr. McGinn with surgery.
Dr. St. John:
You and I can both attest to patients in their 80s and 90s who've had stents and bypass surgery and now TAVRs and other things. So it is largely a chronic condition, but one that could be managed and one with which you can live a long, healthy lifestyle. If we get into the nitty-gritty, there's some data on plaque regression and so on, and that's all well and good, but for the majority of our patients, it's something chronic, but we can manage it, and you can live even and die of something else.
Dr. Fialkow:
Yeah. I mean, I'll pick up on a comment you made earlier, which was astute, which is it's okay to die at a ripe old age with calcium in arteries of something else. If you have heart disease, we stabilize it, you live with it, you prevent it from getting worse, but we don't have to get rid of it as long as it's not causing any issues at that particular time. Hopefully you'll die at a ripe old age of something else under your own terms. Great conversation.
Dr. Fialkow:
Couple of quick questions from the audience. Answer to whatever level of detail you want. I'll throw the first one at you. I'm laughing because I know how often we get these questions and how we have to answer them. But do you advise a daily aspirin as a good way to prevent heart attacks?
Dr. St. John:
No, absolutely not. Again, maybe 10, 20 years ago, the answer would've been different. It would've still been nuanced. So the answer 10 years ago might have been, well after 50, yes, before 50 with certain risk factors. Now the answer is really it is an individualized discussion between patient and provider, and it takes into account what you commented on, the global risk. So one 62-year-old with hypertension might not need an aspirin a day. The other 62-year-old who's already had a stent or has advanced diabetes or peripheral arterial disease, for sure.
Dr. St. John:
So this is a question that I deal with daily in my practice and the answer really just, you have to talk with your physician. There's no other way at this point to sort it out because it is a complex potential question.
Dr. Fialkow:
As you said, it's not, as you mentioned earlier, it's not that aspirin may not have a small benefit, but you can also bleed and have other side effects from aspirin so that's why you have to weigh those consequences.
Dr. Fialkow:
Here's one. Is there any information that any supplements or vitamins can prevent a heart attack?
Dr. St. John:
The short answer again, maybe slightly nuanced, the short answer is the vitamins and supplements mostly have fallen short time and again when we've studied them. That probably is the short answer.
Dr. Fialkow:
Go on.
Dr. St. John:
There's some things that started in the supplement world, and again, you're more expert at this, certain Omega-3 fatty acids that some people view as supplements, but now are prescription grade medications again, for the right indications. But I think for the general audience, no to supplements mostly with perhaps one or two caveats after conversation with your doctor.
Dr. Fialkow:
I'm glad you brought that up. There's a pure EPA form of an Omega-3 fatty acid prescription medication, which actually has very profound cardiovascular benefits in certain populations. But that doesn't mean over-the-counter or supplement fish oils or anything else have ever been shown to have a benefit. Diets high in Omega-3s might be worthwhile. A great one.
Dr. Fialkow:
Last question in the interest of time, can stress cause heart disease?
Dr. St. John:
Yeah. I think we see this in our practice, I would say it's sort of three manifestations. One is sort of the most overt dramatic one, what we call a stress cardiomyopathy. Someone just lost a loved one, or was in a car accident, come in with symptoms and signs mimicking a heart attack. That's one sort of smallish category. The general influence of just the day-to-day stress, the daily grind of life probably affects heart disease in at least sort of two ways. It sort of just lowers your threshold to making good decisions. So it's going to feel easier to eat a cupcake than something else when you're worried about the bills or when you're worried about junior's, I don't know, impending surgery or when you don't have a job. Then probably at a physiologic level, how it affects cortisol and other things that can then influence risk factors, more traditional ones that we just talked about. The short answer is yes, it can and really working on that and getting help with stress is an important thing that we should be encouraging our patients to do.
Dr. Fialkow:
To our listeners, remember that you can send us your comments and suggestions for future topics at baptisthealthtalk@baptisthealth.net. That's baptisthealthtalk@baptisthealth.net. On behalf of everyone at Baptist Health, thanks for listening and stay safe.
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