Intro: Duly Noted, a health and care podcast, is the official podcast series of Duly Health and Care. Each podcast features physicians or team members discussing groundbreaking topics and innovations that help listeners re-imagine and better understand an extraordinary health and care experience.

Amanda Wilde (Host): According to the CDC, coronary heart disease, or CHD, is the leading cause of death for men in the U.S. On this episode of Duly Noted, cardiologist Dr. Ryan Lahey shares his expertise about CHD from prevention strategies to treatment options. I'm Amanda Wilde. And a heartfelt welcome to you, Dr. Lahey.

Ryan Lahey: Great to be here, thanks for having me.

Host: Well, this is a really concerning subject and a really important discussion. Can you talk about what is CHD and why it is particularly prevalent in men?

Ryan Lahey: So CHD, coronary heart disease, or as it is sometimes also called coronary artery disease, is the process by which fatty cholesterol-rich plaque builds up on the walls of the arteries, the blood vessels that supply blood to the heart muscle. And these blockages can progress over time to the point where they limit the blood flow, causing symptoms like chest pain or shortness of breath, particularly when a person exerts themselves. And when this progresses even further, it can lead to complications such as a heart attack, dangerous heart rhythms, or can even cause sudden cardiac death.

So, it's particularly prevalent in the U.S. population at large, because the risk factors for coronary heart disease are so prevalent. Diabetes; hypertension, which is high blood pressure; high cholesterol, obesity, sedentary lifestyle. And why it is of particular concern for men, I think, as compared to women is that, over the course of the lifespan, men are generally at higher risk for developing coronary heart disease than women. We think part of the reason for that is because of protective effects of estrogen and other hormones earlier in life. Women kind of catch up to men later in life in their risk for coronary heart disease.

But a particular concern to me is that men are much less likely to engage with the healthcare system generally than women are. The CDC estimates that women are 33% more likely to go and visit a doctor than men, and women are about twice as likely than men to follow and comply with preventive screening and healthcare maintenance generally. So because men are at increased risk compared to women and because men in general are less likely to engage with health care professionals, I think, this is of particular interest and concern for men in the U.S. population.

Host: And as we know, the earlier we can get at a disease, the more beneficial the treatment is likely to be. So, it's really important that we talk about the risk factors that you just did, obesity, diabetes, and other risk factors. Also, let's talk about signs and symptoms of CHD. And so, that might help someone who's distinguishing when it is time to get checked out.

Ryan Lahey: Sure. So, the classic signs and symptoms of coronary heart disease would be chest pain, left-sided of the chest, and brought on by exertion and relieved by rest. Now, this chest pain can sometimes radiate or travel down the left arm or up into the left side of the neck. The pain can also be a little bit less localized and can present as epigastric pain, which is pain in the upper part of the abdomen, which is why sometimes we confuse chest pain related to the heart with acid reflux. But some people present atypically. Their symptoms can be more shortness of breath with exertion; abdominal pain, which I mentioned; palpitations, which is an irregular heartbeat or an awareness of your heartbeat. And sometimes these symptoms can also be accompanied by others, like nausea, vomiting, sweating.

Host: Well, these seem like pretty unusual symptoms. Why do you think it is that men don't react to those in general and see their doctor?

Ryan Lahey: I wish I had the answer. I've seen some people in my clinic who've had very concerning symptoms months prior to seeing me. So, there are people who, for lack of a better way to put it, might minimize their symptoms or might think that something is not concerning and/or for whatever reason they're hesitant or reluctant to engage with the healthcare system. And then, there are other people that we see who are very in tune with their bodies and sometimes are apologetic in my office, "I feel like this is nothing, but I want to come get checked out." I tell people there is absolutely no wrong reason to see a healthcare provider in the clinic setting, whether it's your primary doctor, a nurse practitioner, a specialist, that's where we can do our best work in working up and treating people for heart disease. It's when people wait and it ends up sending them to the emergency department that I think the cat kind of gets out of the bag and we're fighting a losing battle.

Host: Yeah. So, it's about prevention, if that can at least be employed. It doesn't mean you won't get CHD, but your chances are lower. Now, how is CHD diagnosed in men? What are the tests or procedures that you use?

Ryan Lahey: So as with many things in medicine, your provider will start by taking a very detailed history. They'll ask about your family, they'll ask about your lifestyle, your daily habits, and they'll really try to probe the nature of your symptoms and determine what, if any, additional testing might be necessary. Something that might get done that day in the doctor's office would be an EKG, an electrocardiogram, which gives us a tracing of the heart rhythm. And from that simple piece of paper, a cardiologist can determine if there has maybe been some damage to the heart over time, or if the heart is enlarged and responding to stress, a chronic stress like high blood pressure or if the person is in an abnormal heart rhythm.

More in depth and detailed tests might be something like a stress test where the patient is asked to come back and do exercise on a treadmill or undergo stress testing with the administration of a medicine which stresses the heart. And often, we pair stress testing with imaging, either a nuclear scan or echocardiography, which is an ultrasound of the heart, to see how the heart reacts to that stress.

Additional tests might include something called a coronary angiogram or coronary angiography. This is where specialized cardiologists will use wires and catheters often inserted through an artery in the wrist and moved up towards the heart to get very detailed pictures of the heart blood vessels and the anatomy of the blood supply to the heart under special x-ray.

And one particular imaging technique which we are expanding our capacity for in the Duly organization is cardiac CT, and this is a specialized CT scan which can actually give us much of the same information as a coronary angiogram. It's less invasive and can actually be more sensitive, meaning that it's more likely to pick up severe coronary heart disease than a stress testing would be. So, I think that this is going to be practice-changing over the next five, ten years. We're going to see CT scan continue to play a much bigger role in the detection and diagnosis of coronary heart disease.

Host: Yeah. The technology is advancing and non-invasive procedures are happening more and more. And if CHD is diagnosed, what are the available treatment options?

Ryan Lahey: So depending on the severity of the disease, the treatment strategy is something that will be formulated between the patient and their cardiologist. At the time of diagnosis, for instance, if it's in the cath lab during coronary angiogram, the cardiologist might decide right then and there to put a stent, which is a small metal tube, into an artery to help alleviate a blockage and hold it open.

If the disease is also severe enough, there might be a recommendation for bypass surgery. And at that point, a cardiothoracic surgeon would become involved in the patient care. And for more mild to moderate disease, we often take a step back, and we have a discussion with a patient about how we can use medications and lifestyle changes to prevent the progression of coronary heart disease to manage the symptoms of angina or chest pain or shortness of breath with exertion if they do exist. And often, our treatments, if they're effectively employed, can stop the progression of coronary heart disease or even lead, in some cases, to regression of that fatty cholesterol-ridden plaque that ends up on the sides of the arteries causing blockages.

Host: Okay. So, I was just going to ask if that is reversible. It can be, it sounds like.

Ryan Lahey: It can be, it isn't in all cases, and we don't fully understand the biology behind it. But the CDC estimates that about 90% of cardiovascular disease is preventable. So, you mentioned prevention before. Prevention is the name of the game. I try not to wow my patients with all the technology and the fancy techniques that we have now for diagnosing and treating coronary heart disease, because I think it takes emphasis sometimes away from the fact that prevention is still the most powerful tool that we have to help people lead longer, healthier lives free of heart disease.

Host: If someone suspects that they do have a heart condition, should they see a cardiologist or their primary care provider?

Ryan Lahey: So, I always think that a primary care provider is the best step for any patient who is worried about their heart. Heart disease is so prevalent in this country and the risk factors are so prevalent in the people in this country that primary care doctors are very attuned to picking up what are concerning symptoms and knowing when to refer to cardiologists. And in many cases, primary care doctors themselves are comfortable with ordering some of the tests that a cardiologist would, like an EKG, a stress test, or an echocardiogram, an ultrasound of the heart. So, I see many patients who don't have a primary care doctor who come to me directly, which is fine. But I also see a lot of patients who, by the time they come to me, their primary doctor has already ordered a lot of the testing that I would have and what I'm doing is just having a discussion with the patient about those test results, having a discussion about if any additional testing is necessary and formulating a treatment plan.

So, the nature of the United States healthcare system is that there's a lot of specialties, and even within those specialties, there are subspecialists. And I think that the primary care doctor needs to be kind of at the center, the conductor of the patient's care. And so, they are always the best portal of entry when something is going on in the patient's life, and their concern over their heart is no exception.

Host: And Dr. Lahey, can you talk a little about the medications you use to manage CHD?

Ryan Lahey: Sure. So, in addition to using medications to manage the risk factors, such as high blood pressure, diabetes, high blood sugar, the cornerstone of treatment of coronary heart disease is the management of cholesterol levels and we use a class of medications called statins for those. And now, I know many people in my office do often come in saying they're concerned about side effects of statins or that they feel like they've not been able to tolerate statins in the past.

And we really work hard with them to find some dose of some statin that they can tolerate. And there are truly people that are statin intolerant. It's very rare, but it does occur. And the exciting thing from my standpoint is that there are emerging therapies coming onto the market now. Both in pill form and injectable form that we can now offer to patients in order to get their cholesterol levels under control and prevent the progression of coronary heart disease.

Host: This is really crucial information for men to hear. Do you have any other messages for men, heart disease and perhaps establishing care?

Ryan Lahey: What I talk to a lot of my patients about are the elements of a heart-healthy lifestyle. I don't think that there's any age that is too young to engage in those habits. And I always hold up my hand in clinic and I go through one, two, three, four and five. Not smoking, so between one in 8 and one in 10 U.S. adults still smokes in this country, which is mind boggling to me. Really trying to minimize the amount of alcohol that a person is drinking. We say moderate alcohol intake is probably one to two drinks, one to two occasions per week.

And then, engaging in regular exercise. I don't get fancy with my recommendations for people's exercise. I say try to exercise two to three hours a week. Something you enjoy, something where you're raising your heart rate and breaking a sweat, whether that's an uphill walk, a treadmill, stationary bike, rowing machine, just get moving. It's better than not exercising at all. And then, trying to maintain a healthy weight, which should be a discussion between that person and their doctor what that exactly means. And then, following a heart-healthy diet, which is a diet that emphasizes the consumption of plants, fruits, vegetables, whole grains, trying really hard to refrain from meat and animal products.

Host: Healthy lifestyle is where it all starts, right?

Ryan Lahey: Yeah. And then, one other thing I wanted to say to kind of circle back to women versus men and their engagement in the healthcare system. I think part of the reason is that women become very used to going to a doctor early on in adulthood for reproductive health. So, a woman's OB-GYN often becomes her primary doctor as she engages that provider for discussions about whether it be contraceptive health, birth control or care during pregnancy.

And so, that pattern and that habit of engaging with a physician and going in regularly for checkups becomes second nature to a woman, whereas men don't face similar health concerns earlier in their life. And so, sometimes the only time they're coming in is later in life when something has gone wrong.

Host: Right. So, it's really important to establish healthy habits, including engaging regularly with a primary care physician. Well, Dr. Lahey, thank you for sharing this important, possibly life-saving discussion.

Ryan Lahey: You're very welcome. And thanks for having me.

Host: That was Dr. Ryan Lahey, cardiologist at Duly Health and Care. For more information, visit dulyhealthandcare.com. And if you found this podcast helpful, please share it on your social channels and check out our full podcast library for additional topics of interest. This is Duly Noted, a health and care podcast from Duly Health and Care.