Transcription:
Is it Possible to Have Heart Disease Without Knowing

Scott Webb (Host):  With heart disease on the rise and so much discussion about factors contributing to heart disease; how would someone know if they had it in the early stages without having any symptoms? Talking about heart disease to day is Interventional Cardiologist Dr. Jeffrey Schussler on the Medical Staff and the Medical Director at Baylor Scott & White Heart & Vascular Hospital in Dallas for the Critical Care Unit and also Cardiac Rehabilitation. Dr. Schussler has published many articles and speaks across the country and he joins us today to help us understand how heart disease can be present without a person having any symptoms and how heart disease can be diagnosed.

This is HeartSpeak with Baylor Scott & White Heart and Vascular Hospital in Dallas and Fort Worth. I’m Scott Webb. Doctor, thanks for joining me today. I want to have you start by reviewing the early signs for heart disease. What are the general most common symptoms to not ignore?

Jeffrey M. Schussler, MD, FACC, FSCAI, FSCCT, FACP (Guest):  Early signs of heart disease unfortunately are none. You can have early heart disease and never know that you do. Id you are at the point where you are actually having symptoms from heart disease or God forbid a heart attack; they can present in a lot of different ways. The classic symptoms are pressure in your chest, it doesn’t necessarily need to be on the left side or the right side. It can be in the center of the chest. Some people describe this as a heaviness. The classic example is people say that they feel like an elephant is sitting on their chest. Other people described it as a band around their chest. But oftentimes, people can feel like this is similar to their indigestion or some people present with back pain or jaw pain or shoulder pain and it can get very confusing because sometimes people say well, I just thought that was my tennis elbow or I thought that was my shoulder.

Probably twice a year I have people come in where they think they are having angina and it really the rotator cuff. But there’s a lot of overlap as far as symptoms. I think the best thing is if you have some type of let me give you an example, if every time you raise your arm up, it hurts; it’s probably just your arm or if every time you eat a chili dog you get burning in your chest; that’s probably the chili dog. If every time you walk down the street to get the chili dog, you start getting burning in your chest; that might be angina. It may be a problem with your heart not getting enough oxygen.

The ultimate issue and the reason that hearts hurt is that they are not getting the oxygen that they need and that usually is due to a blockage in the arteries that supply the blood to the heart. And that is what coronary disease is.

Host:  Yeah, that’s a great way to think of it Doctor, if you are having a chili dog and you have indigestion then it’s probably the chili dog, right, but if you are walking to get the chili dog and you are out of breath; it may be your heart, right. Do you think that people maybe just self-diagnose too much one way or the other?

Dr. Schussler:  It goes both ways. I mean I have people who they’ve been having what they thought was indigestion for three months and you are like my goodness, why didn’t you come in and see somebody. You’ve been having indigestion as you walk. And I get a lot of people who come in and say look, every time I took a breath and it hurt and I thought it was my heart, and I say no, no, it’s probably just ribs or muscles or something like that. So, it’s very hard for people to diagnose themselves with heart pain. Ironically, until they’ve actually had some kind of event where they recognize okay this was my heart pain. So, for people who have been through it, one of the – I say a patient today where they had a heart attack about ten years ago and they had very classic symptoms of pressure in their chest, aching in their left arm and jaw pain, kind of a constellation of symptoms and it kept on hurting until they got medical attention and ended up with getting a stent in their arteries. I said look, for you, that is your symptom of angina. If you ever have that again, then you need to let somebody know.

If you take ten different people, they are going to have ten different ways that they feel angina but in any given individual, usually if it happened once one way, it’s going to happen again the next time the same way. So, if you are a person who has had it before, and it happens again; that’s clearly you need something done. But if you’ve never had any kind of cardiac problems it may be very unclear. So, if you are having problems where you are exercising and you get symptoms; that’s a good easy thing, you got to go get checked out. And there’s lots of different ways of checking the hearts out if you are having symptoms.

What’s more concerning for people are the vast pool of people before they have their cardiac event where they have no idea they might even be at risk. And that’s sort of why we’re here today to talk about the vast untapped question mark, heh, I’m worried I might, what do I do? But I feel fine. If you feel bad; it’s easy, you go seek medical attention. If you feel fine, do you wait for there to be a problem or what can you do to sort of see whether you’re high risk, low risk, or medium risk or whatever. That’s a bigger unknown.

Host:  Yeah along the lines of what you are saying, I want to talk more about diagnosis and the types of tests that you can do. We hear about the tests whether it’s a CT scan or a stress test. Let’s get into that. Let’s talk about diagnosing heart disease.

Dr. Schussler:  There’s lots of different ways before you ever get to testing though, you sort of have to know what is your risk pool. The most common thing is family history. So, if you knew that everybody in your family had a heart attack before age 50; you’d be foolish to think, because we’re not smart enough to know genetics quite yet; but you’d be foolish to think that you are completely immune if everybody in your gene pool was at risk. So, if you know you are at risk from a genetics standpoint; you probably need to think about it. There’s also some very obvious things. if you smoke, which is terrible, you are very high risk for heart disease. And that includes chewing tobacco. So, any kind of tobacco and unfortunately, these days, no one is going to be really excited to hear about it but smoking marijuana is actually a risk factor for atherosclerosis and heart disease.

And it’s not been studies as well because we have not had a lot of years of looking at this. but they are starting to see that using those substances actually does contribute to this. So, smoking is smoking. It’s bad for the heart. End of story. So, if you are a smoker; you are at risk. If you have diabetes; you’re at risk for heart disease. If you have high blood pressure; you are at risk for heart disease. If you are obese; you are at risk for heart disease. If you are an obese smoker with diabetes with family history; no one is surprised when people like that actually end up with heart problems. But if you are at risk, if you are at one of those at risk groups; you should probably think about getting checked out. Okay.

So, let’s say you said I’m one of those people who may have a couple of risk factors, but you feel fine, what are some things you can do? Interestingly, doing stress tests is not that helpful for discovering someone who is asymptomatic, having no symptoms whether they are at risk or not. And part of the problem lies with how stress tests work. Stress tests work because they look for objective and subjective signs of blockages in the heart arteries and the tests themselves are prone to both false positives and false negatives.

So, let me give you an extreme example. You have a young woman 18 year old woman who comes in and they are having no symptoms, but you want to check them out. You wouldn’t do this, but I’m just saying what if. And you put them on the treadmill, and they walk for ten minutes and when we do this, we check to see number one can you walk on a treadmill, can you exercise a certain amount, can you get your target heartrate and then how do you feel. Do you have chest pain, do you have shortness of breath? And then we look at objective things like how does the EKG look. Well there are some people, through no fault of their own, that their EKG looks abnormal when they walk on a treadmill. It’s just how they are put together. So, if you get an 18 year old woman who comes in who should not have coronary disease, very few 18 year old women have heart disease. And they have an abnormality on their EKG when they walk on the treadmill, you are going to scratch your head and say well what’s more likely. Is it that the 18 year old woman has heart disease and the stress test found that or is it the stress test is just wrong? It’s usually that the stress test is wrong.

So, taking it out of the 18 year old woman arena, there are a lot of people who are running around who could be at risk, they still have false positive stress tests and so if you feel fine; and you get a stress test and it says there might be a problem; there’s a reasonable possibility that the stress test is the part that has the problem not the person. So, you don’t really necessarily know what to do with it. And it’s one of the reasons that screening for heart disease with stress tests is a bit problematic.

So, when someone comes to me and they say I’m worried that I might have heart disease and they say do I need a stress test; the first question I ask them is do you exercise. They say oh yeah, I play tennis three times a week, I go for jogs, I swim. I go well, even if you had plaque you probably don’t have anything that’s that bad because you really couldn’t do those things if you had bad heart disease. That’s a pretty good litmus test and one of the reasons again, exercise is healthy and helpful for lots of reasons but it’s a really good way of checking how your heart is doing. If your heart is functioning poorly; you normally can’t do moderate exercise. So, there are people walking around who have plaque that is not bad enough to warrant anything done.

So an example. So, Bill Clinton is a great example. He walked around for many, many years, leader of the free world before they suddenly discovered that he needed open heart surgery. And everybody always asks me how did I end up with all these blockages? Well Bill Clinton ended up with a ton of blockages and you got to expect someone was keeping an eye on him, right? So, you can go through life with a lot of blockage and your heart has a lot of reserve. So, you can go through – you can have blockages up to 75% in any given artery before it really starts to impede the flow of blood. So, that’s the good news. You can deal with a lot before it becomes a crisis. But it doesn’t necessarily help you as a person or me as a doctor, figure out who is walking around with plaque that hasn’t caused a problem yet. Okay.

So, there are some screening tests that we can do to see if you’re at high risk. And part of that is lipids. So, most people get their cholesterol checked at the doctor. So, we talked about the fact that you can have risk factors, are you diabetic, do you smoke, do you have family history? Well when you go in for your routine physical, and you get cholesterol numbers done; one of the things they look at is your cholesterol, your good cholesterol, your bad cholesterol, your triglycerides and if you have very high cholesterol or triglycerides; it’s yet another piece of information that you might be a person who is at risk for having heart disease. So, that’s something that everybody should get checked on a semi routine basis. And if your cholesterol is high enough, one of the things you do is you get treated. There’s good medications for it, there’s diet, exercise again, helps with that.

So, the best test probably for checking whether or not you really do have plaque or not in an asymptomatic, no symptoms individual is something called a calcium score. And this actually a CT scan of the heart. It’s low dose radiation. It’s usually pretty inexpensive. I think they charge at most places less than a few hundred dollars for this. And for people who are they kind of fit the profile. We don’t screen any 18 year old women, but we do screen men over age 40 to 45, women over age 45 or 50 especially if they have at least one risk factor. Again, family history, history of smoking, et cetera, et cetera. And you can get a non-contrast CT that very quickly looks to see if you have plaque in the arteries that has been there long enough to harden. This is the old hardening of the arteries.

And CT scans are very, very sensitive for picking up hardening or calcification of the arteries. And if you’ve got calcium in your arteries; it doesn’t necessarily mean you’ve got a blockage. It doesn’t necessarily mean you’re going to have a heart attack. But it absolutely means that you have plaque in your arteries and you probably should be on treatment. So, of all of the things, if you really want to know yeah or nah and you are both of an age and you have at least one risk factor; that’s a pretty good screening test, far better than stress tests as far as do you have plaque. We’re really talking about people who are not having symptoms.

Host:  Absolutely Doctor. You and I were discussing before we got started whether it’s an apple a day or an aspirin a day what the saying is exactly. But I wanted you to share with listeners your thoughts about taking an aspirin a day especially when it hasn’t been prescribed to you by a doctor.

Dr. Schussler:  So, just an aspirin a day if you don’t know what’s going on under the hood, it’s a little bit problematic. Everything that we do, every medicine we have has both a pro side and a con side. And even though aspirin is over-the-counter, one of the very real risks of taking an aspirin is an increased risk of bleeding. So, interesting study that came our within the last two years was that men – it’s a little specific but for example men age 70 who have never been diagnosed with heart disease don’t seem to gain a benefit from being on an aspirin. You ask yourself, well why not. And the why not is because any benefit that they might get is actually overwhelmed by the detriment of potential bleeding. So, to gain a benefit from anything we do; you have got to number one gain the benefit and number two, avoid the detriment.

So, if you are really 70 and you have lived your whole life and never had any inkling of heart disease; you are probably more likely one of the lucky people that age who don’t have heart disease and the aspirin is all to your detriment not your benefit. So, if your friend for example who is just taking an aspirin for no specific reason; they are probably – they are not sure they even have a reason to be on the aspirin, but they are exposing themselves to the risk of bleeding.

On the flip side, we get a lot of people who come in, they are completely asymptomatic, maybe they got one of these calcium scores and they actually have plaque in their arteries; that’s a different story. Because they are now a person who absolutely has the process, they are at risk for heart disease or consequences of heart disease so being on an aspirin makes sense. Just a baby aspirin.

Host:  Yeah, there’s no doubt Doctor that people really need to know what’s going on under the hood before they start doing things like taking an aspirin a day. Though I’m sure the apple would be fine, no problem there. How do you know when your heart is healthy? We’ve talked about risk factors and family history and those types of things. But how do you know when you are walking down the street, you know what, I’m good?

Dr. Schussler:  So first of all, there’s a – there are easy tests to check the strength of your heart. If you really needed to know, there’s a simple test called an echocardiogram, it’s a sound wave test. There is almost like no risk in doing the test. There’s a cost but there’s not necessarily any risk. And it can very easily within a few minutes tell us if the strength of your heart is okay. The bigger question is why do you need to know? So, if you’re doing your normal routines and you are feeling fine and you are able to exercise, it’s hard to know why knowing that your heart is strong is any better than feeling good et cetera and treating your risk factors, et cetera. If you are not feeling well, you are short of breath, you can’t lie flat without breathing heavily, you are having chest pain every time you walk; then doing some testing, these sort of things make more sense.

The question I get sometimes from people is a fairly common one like I ran to catch the bus the other day and I was short of breath. So, a lot of people come in because they are short of breath and they want to know does that mean that their heart is the problem. My usual follow up is well when was the last time you ran to catch the bus? And if they have not run to catch the bus in a while; that’s the first activity they’ve done it makes sense that they would be short of breath. They probably need to catch more buses if you know what I mean.

But if there’s a pattern, if you look at a pattern you used to be able to do regular routines and something has changed and now all of the sudden playing golf is an issue or lying flat is an issue, if there has been a clinical change then you absolutely should bring that up and there are some very easy quick tests to check and see if the heart looks like it’s contributing to the problem or maybe is the problem or maybe is not the problem at all.

Host:  Doctor, thanks so much for your time and expertise today. that’s Dr. Jeffrey Schussler a Medical Director and on the Medical Staff at Baylor Scott & White Heart & Vascular Hospital Dallas. And thanks for checking out this episode of HeartSpeak. To find a specialist on the medical staff please call 1-844-279-3627 or visit www.baylorhearthospital.com. And if you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks and we’ll talk again soon.

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