Dr. Michael Anderson (Host): Hello everyone and welcome to The FortCast, the official podcast for Fort HealthCare. I am your host, Dr. Michael Anderson, Ear, Nose, and Throat Physician and also serving as President and CEO of Fort HealthCare. On this episode of The FortCast, we are going to be talking about coronary artery disease. And I'm very happy to announce our guest today is Dr. Museitif, Fort HealthCare's Cardiologist. And Dr. Museitif, thank you for being with us today. And I just want to let our listeners know I've been with the organization for roughly 20 years, but Dr. Museitif, if you could please introduce yourself and give us a little bit of historical data on your background, that'd be wonderful.

Raaid Museitif, MD: Dr. Anderson how are you doing? Thank you for having me today. I appreciate it. I'm from Wisconsin as well. I was born and raised in Kenosha, Wisconsin, and I've actually never left the state. So I've gone to University of Wisconsin in Madison for undergrad, where I studied zoology and biochemistry. And then I went on to UW Medical School.

Since then, I completed a residency in internal medicine and served as a Chief Resident for a year. And then went on to do three years of cardiology, where I was a Chief Fellow for two years. And I went and completed after that interventional cardiology as well. I have Board Certifications in Cardiovascular Disease. I have a Board Certification in Interventional Cardiology. I have a Board Certification in Nuclear Cardiology. And I have a Board in Vascular Imaging called RPVI. So, born and raised here and I've never left. And I'm happy to be here at Fort with you.

Host: Well, that's fantastic, Dr. Museitif. You are definitely an expert and we thank you for being part of our healthcare team, our patients and community and medical staff, thank you as well. So, coronary artery disease. Now, I'm an ear, nose, and throat doc, so I would say my knowledge on this topic is pretty rudimentary, so I'm very happy to have my cardiology colleagues, but if, you could please educate us a little bit and our listeners on what exactly does coronary artery disease mean and what are some of the symptoms behind it.

Raaid Museitif, MD: So, coronary artery disease and cardiovascular disease is still the number one cause of death in the United States. And it's a worldwide problem. So I think it helps when people can actually visualize what this disease is. And it's really a rusting of our pipes in our body. And so when you think about your heart, your heart's main function is to pump blood around your whole body.

Every organ in our body needs a blood supply because that blood carries oxygen. And it also cleans out the waste system and it brings in energy and your heart is no different than every organ in our body. We actually have pipes that feed your heart blood. So even though your heart is pumping blood to your whole body, it actually gets its own supply of blood from these tubes that we call coronary arteries.

And when one of those is blocked, then an area of your heart doesn't get blood. That means it doesn't get oxygen. And that means it can die, and that's a heart attack. And so what happens is, even though the heart is pumping, it's not getting blood to a certain area of the muscle because it's blocked.

And it keeps beating, and it kills itself. And that's what we call a heart attack. See, your body is designed to stop that from happening. So, we played sports, you and I, but if you run really hard, your legs will build up something called lactic acid. And it can, it becomes very painful. Your legs start to hurt and that's a signal for us to stop running because if we kept running, we would kill the muscle in our legs.

Your heart, unfortunately, does not have an option of stopping. And so if one of the blood vessels that feed it with oxygen are blocked, the normal thing for the heart to do, the smart thing would for it to stop for a second and preserve itself kind of like a bear hibernates. And if it was able to do that, it would prevent itself from dying, but it can't stop because if the heart stops beating, like we're able to stop running, you're dead.

And so the heart keeps beating and you develop a heart attack. And everybody's watched shows or know what that sounds like. You're grabbing your chest, you can't breathe, you're sweaty, maybe you pass out. There's a lot of different symptoms, but that's what happens.

Host: So, leading up to that event, the heart attack, are there some warning signs that patients would have, some symptoms they would have, that they may experience prior to developing a full, a full on heart attack; some things that they may be able to pick up on that says, Hey, maybe I need to get my heart checked?

Raaid Museitif, MD: Yeah, absolutely. So you're asking about warning signs or signs before you get a heart attack. Unfortunately, a lot of people will present, the first time they present is in an ER with a heart attack. And some of them don't make it. So awareness is really important. And one of them is chest pain. So, if you feel any type of pain from your neck to your belly button that's new, you should discuss it with your provider.

Now, a lot of people get a little twinges and they kind of just blow it off, or they say it's heartburn, or maybe I ate too much last night, and it's understandable. I mean, I run and sometimes I get a little twinge and I'm like, wait a minute, is that the heart or am I going, you know, so I kind of blow it off.

People blow it off because they don't know and they don't want to believe it. But if you, whoever's listening, develops any type of symptoms, from the neck to the stomach, that's new, you should let your doctor know. Now, let me say this. We often, as doctors, use the word pain. And a lot of my patients will look at me and say, No, no, I don't have pain, Dr. Anderson. They'll say, I have tightness, I have a pressure, I have a squeeze. Sometimes it's hard for them to describe. So I just tell them, whatever you're feeling, kind of describe it. And thankfully and unthankfully, our brain is very poor at remembering pain and describing it. So you have to give them the opportunity to kind of describe what they're feeling.

Now the classic symptoms are increased with exertion. So you walk, you go upstairs, you get this feeling, whatever it is, a burning feeling, a squeezing feeling, a pressure like feeling. They're relieved with rest or with nitroglycerin. Sometimes they can have radiation. Radiation meaning the pain moves from your chest to your jaw or to your left arm.

You could be sweaty when these things happen. You could be nauseous. You could faint. So there's a lot of vague symptoms and women sometimes were not believed in the old days when they said that they had heart problems because nobody believed that women had heart disease and they would present with not typical men like symptoms.

So they could have simple symptoms like shortness of breath, or jaw pain, or even tooth pain. But their heart disease is equal to men. And so you have to be very careful. So, any questions, you should talk to your doctor right away.

Host: That's a wonderful summary of the symptoms that people can have. And sounds like coronary artery disease can present as a heart attack, which brings me to my next question. Are there ways that people can prevent coronary artery disease? I imagine there are some ways. If you could please touch base on that, that'd be wonderful for our listeners.

Raaid Museitif, MD: Sure, that's another excellent question. I'm going to tell you the risk factors of heart disease, but I'm also going to explain to people how this works. So, we all know smoking is probably the number one risk factor. So if you looked, we just talked about women versus men and in the old days, they wouldn't believe women when they had chest pain, but it turned out women didn't smoke. And then women started smoking. And when women started smoking, the rate of cardiovascular disease equaled that of men. And so as we get older, it's a risk factor for developing, we use the word atherosclerosis, which is just a fancy word for rusty pipe or plaque buildup. Smoking is number one, high cholesterol, diabetes, high blood pressure, inactivity, heavy drinking, obesity.

So those, and genetics, all those can act. And it turns out, Dr. Anderson, that these risk factors, not only we use the word additive. So in other words, if something increases, one of them increases your risk, by 10 percent and the second one increases by 10%. Additive would be like, well, 10 plus 10 is 20 percent increase.

But these, when they're together, they're like a light, a wick, and dynamite. They're bad together. They're worse than individual. We call that multiplicative. So it does not add up to 10 plus 10 is 20. It might add up to 10 plus 10 is 25, for example. So when you have obesity, when you have diabetes, high blood pressure, and hypercholesterolemia all together, they are bad actors.

And let me tell you how this works. It turns out that your blood vessels, we talked about earlier, that feed the heart, those pipes, they're not just pipes like a straw or a PVC pipe that you have in your house. They're actually dynamic structures that have multiple layers. So they have an inner layer we call an intima, and then they have muscular layers that can contract and expand the artery, and then they have a few other layers, and they have an external layer, kind of like the plastic on the outside of the pipe. And your blood vessels can expand and contract. They can allow things to come in and out. And we focus on that inner layer, the intimal layer. When you look at it through our little eyes, because we can't see, like we had a microscope on our eyes, we can't see it.

It looks like a very smooth, solid, plastic surface. But if you were able to look at that smooth surface under a microscope, you would see cells, little circular cells, that are holding each other's hands through something we call gap junctions. So if you look really, really deep, your inner layer that looks smooth like a piece of plastic, it's actually made up of a bunch of cells that are locked in with each other the way we would lock your fingers together, intertwine your fingers.

We call that gaps, gap junctions. So when you have all those problems we talked about, smoking, it causes inflammation, hypertension, diabetes, inactivity, excess alcohol, all those cause inflammation. Why is that important? Because inflammation will cause those cells to pull apart a little bit. They separate.

Now the space between each cell is bigger and in your body, you have cholesterol floating around and the bad cholesterol is called LDL. Good cholesterol is called HDL. The way I remember it is H is for high. You want that as high as you can get it, and L, LD, L for low. You want that as low as you can go.

What turns out that the LDLs are very small. Now when they're floating inside your blood, and remember, high cholesterol is bad because you'd have a lot of them. They're floating inside your heart cells. If the gaps between those cells are stretched open, it's like opening the door for those little fat cholesterol pills.

They will squeeze through. That's why smoking is bad and because it causes inflammation and then the cells on the inner layer are stretched and the little bad cholesterol will sneak in the door. Now it turns out the other fortunate and unfortunate thing is we have a very strong immune system that we've all heard about during COVID.

There's one part of our immune system that goes around like Pac Man, and they're called macrophages. That's Latin for macro is big and phage is an eater. They're called a big eater like Pac Man. They will be alerted that cholesterol has snuck in behind the inner layer of your arteries in your heart, and they go after it.

And they go right through the hole, the gap junction. And they swallow the cholesterol molecule. When they swallow it, just like Pac Man game, they get bigger. When they get bigger, guess what? Even though they snuck through the hole, the gap junction between cells, they can't get back out, and they die. Because they're trapped. And that's plaque. It's called a foam cell. And that happens over and over and over again. And it slowly starts to squeeze your blood vessels smaller and smaller and restrict it. And that's what ends up causing a heart attack. That's why we treat you with cholesterol medicines to prevent that.

That's why we tell our patients to stop smoking, to prevent inflammation. That's why exercise gets rid of inflammation. That's why treating your blood pressure helps the pounding of those blood vessels from getting damaged. All those things we do to prevent that process I just told you about.

Host: That's very fascinating. You know, when you were talking about those macrophages getting trapped, I couldn't help but think of Winnie the Pooh and how he ate too much honey and got stuck in the tree. That's what happened to those macrophages. I mean, I, I don't know why, but that definitely stuck in my brain, but, that's fascinating.

Okay, so let's say you have a patient that you're worried about coronary artery disease. What kind of diagnostic tests, imaging, x rays, procedures can you do to maybe not only define if they have it, but then also potentially treat it?

Raaid Museitif, MD: So the first thing you got to do is you have to see your provider and I would say 95% of my opinion happens with just listening to the patient and my physical exam. So, you have to get a provider that's going to listen to you. We had a patient here who came to us recently. She ended up going to a different doctor initially and she came to us and had complaints.

And I told her, hey, things don't match up, but I'm going to listen to you. You're really focused on this and you have a check engine light. And we did tests and that person ended up having bypass surgery at Madison. And came back to us last time I was here and thanked us. She said, quote, you listened to me when nobody else would listen to you.

So I would tell you the first thing is make sure your provider listens to you. And if you have a check engine light in your head that says you have a problem, listen to yourself first. After that, once you see a provider they'll do a basic EKG test after they do their physical exam. And that's that squiggly paper that people do with a bunch of stickers on your chest.

And that'll let us know if you've had a heart attack. Or if you're at risk of having a heart attack, that can show some of that. After that, a lot of times they'll do a stress test where they put you on a treadmill or they take images of your heart to look to see if you've had that buildup of plaque.

Other things you could do are certain CAT scans can show it. So definitely get a provider that listens to you and start with an EKG and then they'll assess you to see if you need any other types of tests that can give us a prognosis number.

Host: So you just touched on bypass surgery, so my assumption is, is that if the coronary arteries are just too darn blocked, you have to bypass them with a surgery. And I also hear a lot about coronary artery stenting. Can you talk a little bit about that?

Raaid Museitif, MD: Yeah, so now we're moving into the treatment. So let's say you are diagnosed with coronary artery disease and you have a blockage. Not all blockages need to be opened. So it depends on how blocked they are. We don't fix them physically unless they're blocked more than 70%. And the reason being is it turns out it's a hemodynamic thing.

Where it's kind of like, you know, when you watered your lawn or your plant and you would stick your finger over the hose and water would come out really fast. It turns out that our arteries of our heart can open up and you can block them up to 70 percent and they will still be able to deliver the same amount of blood as if they were never blocked.

And so we don't fix them physically unless they're blocked more than 70%. We would treat those people with medicine. We would adjust the risk factors that we talked about, the obesity, the smoking, the high cholesterol, the diabetes, the inactivity, the excess alcohol. We can't change your parents for genetics, but we would assess all that and treat that.

That would be the treatment. Now, if they're blocked more than 70 percent and they're on maximum treatment, then there's different ways to open those blood vessels up. And the way you got to think of it, I want everybody to visualize your sink. If your sink is clogged, so picture the sink and you have a big pipe underneath the sink. Pretend that that's the artery that's feeding blood to your heart. And remember those liquid Draino commercials where there'd be like a big ball gook inside the vessel and they would pour the liquid Draino down it and it would deteriorate. So imagine a focal blockage in that pipe. Now there's two ways we can do it.

One is, we can go right down the pipe like a Roto Rooter type person and put a balloon and open that up. A stent is literally a metal straw that's shaped like a chain link fence that we compress over a little balloon and we shove into that little blockage in that pipe and we blow up the balloon. And when that metal mesh, almost like chicken coop chain or chicken coop fence, expands, the little diamonds lock so it can't come back down and it pushes all the garbage out and it opens up the blood vessel.

That's how we stent you. A bypass would be okay, there's that pipe underneath your sink with the gook in the middle of the pipe. A bypass surgery is you drill a hole in the pipe above the blockage and you drill a hole in the pipe below the area of blockage and then you run a side pipe to it. That's why we call it a bypass.

So the blood goes down and it goes into the side pipe and around the blockage and down in. Bypass is open heart surgery. Stenting we can do right through your wrist, and you get up off the table and walk away. And by far, in the United States now, stenting far outnumbers open heart surgery, thankfully, and it's advanced a lot.

And so bypass surgery, depending on your anatomy, is really when stenting doesn't work. So first thing is addressing your cardiac risk factors, trying medical therapy, then considering stenting, and if that doesn't work, then we progress to bypass. Unless you have certain type of risks and certain anatomy and you need bypass right away, but that's less common than the other two.

Host: Yeah. Bypass surgery really has become less and less common over the last couple of decades versus the angioplasty and the stenting that goes on in today's world. So, Dr. Museitif, that was just a wonderful summary. I've learned a lot about coronary artery disease, listening to you talk about coronary artery disease, the risk factors, the symptoms, the treatments, and I just want to stress for our listeners be aware of coronary artery disease. It's very common. It does claim a lot of lives in the United States and around the world. As Dr. Museitif said, it's the number one medical reason for deaths in the United States. Is that correct, Dr. Museitif?

Raaid Museitif, MD: Yeah, unfortunately.

Host: Yeah. So, if you or your, one of your loved ones feels like they are experiencing symptoms, please get in to see your primary care physician or provider. Certainly if they are concerned, if your providers are concerned, they will likely refer you to somebody like Dr. Museitif, a Cardiologist for further workup and treatment. So Dr. Museitif, I want to thank you for being on this episode of the FortCast.

Raaid Museitif, MD: Hey, I appreciate you for having me. Thank you.

Host: And, I want to thank our listeners for listening, and if you found this podcast helpful, please share it on your social channels. If you want to learn more about our other podcasts, please feel free to visit the Fort Healthcare website. That's all for now. Thank you.