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Scott Webb (Host): Surviving heart attacks is more common than ever before, but preventing a second heart attack requires diet, exercise, medications and regular visits with our heart doctors. And joining me today is one of those heart doctors. Dr. Duane Pool, is a cardiologist with Genesis Healthcare System. he's here today to help us understand that we can live normal, healthy lives after a heart attack. This is Sounds of Good Health with Genesis brought to you by Genesis Healthcare System. Scott Webb. Dr. Pool, thanks for your time today. And we were just discussing, this is a little different sort of take on heart attacks. We're not really talking about how to prevent them necessarily or how to treat them, but really we're proceeding from the assumption that someone's already had a heart attack and sort of now what, basically. So, want to start off by asking you can people lead a normal life after a heart attack, and if so, how do they do that?

Duane Pool M.D. (Guest): Yeah. Actually today, more so than probably any other time in our history of cardiac care, people can expect to lead a very normal life, following a heart attack, and most likely, you know, heart attack following revascularization. In fact, we want them to lead a completely normal lifestyle, including exercise, because in that situation, that's the best approach at preventing future problems from a cardiovascular standpoint.

Host: Yeah, that sounds right. Of course we should all exercise more than we do probably, but especially after a heart attack. So, in addition to that, what are some of the other important things we need to do, you know, for our physical and mental health after having a heart attack?

Dr. Pool: You know, after most myocardial infarctions, I mean, one of the things which is really a misnomer, a lot of people are really afraid to be active because they think that activity in itself is going to create a problem. Our literature really does not support that. In fact, there was a New England Journal of Medicine article published probably 30 years ago that looked at one of the better ways to prevent heart attacks and strokes. And it's kind of a more retrospective kind of clinical trial. And they looked at patients that exercised as compared to non exercisers, had a much decreased risk of an event rate. And the question is always, well, how about after a heart attack? Is there an additional benefit in regards to that? And we really have a lot of robust data to support that. And that data generally comes from our cardiac rehab programs that we enroll patients into after experiencing a heart attack, after undergoing a revascularization procedures, such as angioplasty, stenting, and even after bypass surgery. And a lot of this data comes from the Medicare database and there is a marked decrease in mortality in those patients that adopt an exercise program such as a program in cardiac rehab.

And what a lot of people don't understand, these cardiac rehab programs yes, they adopt an exercise program within the program, but it goes far more than just the exercise you get in those programs. There are educational programs in regards to diet, sleep, treatment of depression that is really common after having an event. And it's, you know, the diet thing is really, really cool.

If you can get patients on more a plant-based diet, more vegan diet, less animal protein, less red meat; you can really decrease their cholesterol levels. You can decrease inflammatory proteins are really important in causing cardiovascular disease and events and really decrease event rates. So, those programs are probably something that is extremely under utilized in the post MI patient. In fact, probably only one in three patients that have had an event or have had a heart attack actually are enrolled in these programs. And it's really a push that our program is trying to adopt more and more. If you have a patient that has had a heart attack and you do a heart catheterization on them, unless they have a 70% lesion somewhere in their coronary anatomy or a 70% blockage. The question always arises. Do you benefit that patient more by putting a stent in or do you benefit them more by incorporating them into a cardiac rehab program? And the answer is cardiac rehab program. Those patients that are enrolled in those programs compared to angioplasty are going to live longer and better lives and have less mortality.

Host: That's interesting. And you said one in three enroll in these programs. Do you have a sense, maybe, even if it's just anecdotal, a sense of why it's not three out of three, because it sounds like there's a lot of good reasons to be enrolled.

Dr. Pool: You're absolutely right. And a lot of it has to do that, you know, we're particularly in a rural community. And a lot of our patients live some distance and it's an inconvenience for them to drive. So, let's talk about the resources that Genesis has to offer to heart attack survivors.

If you look at what we offer, we offer actually quite a bit. We have an outstanding cardiac rehab program. And again, it incorporates exercise. And even in those patients that don't think they can exercise, we have a lot of different ways to pursue an exercise program such as cycling in those patients that can't walk. I think there's rowing machines, cycling, treadmill, lightweight lifting, or isometric exercises that are lighter in weight. And then within that program, education in regards to diet, treatment of cholesterol, smoking cessation, and that. The post MI care, is also physician-based. And most of our patients, which are post MI, get an appointment after their event within two to three weeks, and we follow them very closely in the clinic.

And again, those patients are reeducated in the importance of maintaining a healthy lifestyle, an active lifestyle, compliance to their medications, which have been prescribed in that hospital setting, and adherence to their medicines and a big educational role in regards to smoking cessation, which a lot of our cardiac event patients, if you look at them, the majority of them have been tobacco users of some sort.

We have excellent nursing support. We utilize a lot of educational resources, post MI, particularly in the hospital. The majority of the patients that end up getting stenting procedures or revascularization procedures, they are enrolled in a classroom prior to discharge. And again, that's education on the importance of smoking cessation and maintenance of their medical regimen that they're discharged home on. And we also utilize a lot of nurse practitioners for our nurse follow-up or for our hospital follow-up. So again, it's that getting them enrolled in cardiac rehab and really attention to follow up in the clinic afterwards.

Host: Yeah, it sounds really comprehensive and education as we've stressed is so key. And I was also reading in doing some prep for this, about the congestive heart failure clinic.

Dr. Pool: Yes.

Host: Maybe you could touch on that as well.

Dr. Pool: Yeah. You know, that's just something that is relatively new.

Particularly to us. Heart failure is something that can result from having a heart attack. It generally denotes a significant amount of muscle loss in the heart that leads to that. Our clinics are devised in a number of ways. They're kind of instrumental in those patients that are having excess fluid and shortness of breath associated with that fluid.

We can often circumvent an admission to the hospital, by having them come to the clinic. In the clinic, we can adjust their water medicine or diuretics and even use intravenous diuretics in that regard. So it's a good way to treat patients preventing hospitalization, but more importantly in the heart failure clinic is it, we know that there are certain medicines which are instrumental in those patients in regards to helping their heart muscle heal.

In some cases, making the heart function better and sometimes, actually utilizing devices to improve heart failure. And in those clinics, we kind of use all that information together. So, if someone has some weak heart muscle, and they have heart failure, that clinic is instrumental in the initiation and the titration up of medications which help prevent heart failure, prevent hospitalizations, but also decrease mortality and morbidity. So, we'll have patients that come to the heart failure clinic every two weeks, we'll increase their medicines and in regards to their tolerability. In regards to that, if they have a device such as a defibrillator that was placed to improve their heart failure, we can actually look at certain dynamics within that device to see how well we're doing in regards to the treatment of heart failure.

Two of those devices, they measure different things, but one of those devices measures something called OptiVol and that's a way we can assess whether the patient has too much volume just based on their device settings. The other one is something called HeartLogic, and it's another way to evaluate whether someone is getting in trouble in regards to heart failure and our heart failure clinic follows these patients.

And if we start to see those numbers increase; we can intervene even prior to the patient ever having symptoms in regards to that clinic. So as we grow as an institution, as we advance in regards to our cardiac care, our heart failure clinic is going to be extremely instrumental in improving the lives of our patients with heart failure, but also decreasing the hospitalization

Host: we talked earlier about the importance of exercise, perhaps the rehab program, all these amazing, amazing you know, drug therapies out there. Is there anything we can do, behavior, lifestyle besides what we've covered already to prevent that second heart attack?

Dr. Pool: Yeah. From the patient side of things, in regards to reducing risk of heart attack, I think, the number one thing, is the compliance to the medical regimen that the physicians have written. You know, we have a regimen of medications that have stood the time of research, double blind placebo controlled trials that have shown benefits and, in patients and to stay on those medicines, to adhere to those medicines and to be completely compliant.

That's the number one thing, particularly compliance to anti-platelet therapy that has been prescribed, whether that's aspirin and a combination TY2 inhibitor, such as Plavix, Brilinta, Effient, but aspirin, lifelong, it is so important. That's number one. Number two is basically a daily exercise program that is aerobic. It doesn't matter how sick the heart is. There's never been an exercise program that has increased mortality. Every exercise program that has ever been designed to treat the heart patient has always been beneficial. So, the type of exercise I tell patients to do, it's all I want them to do is do a walk as brisk as they can do for two miles or 30 minutes. If they do that five days a week, that's going to be a substantial benefit in their life. And, you know, you would say, well, how does that benefit someone just walking two miles? Well, the benefits are the following. We know that any type of depression or anxiety is very harmful for the long-term being of individuals, whether you're talking heart or any other type of medical issues, people that exercise have less anxiety and less depression.

In fact, it's a good treatment for that. As I said that most heart attacks are driven by an inflammatory response in our bodies. We measure that inflammatory response by measuring something called an hs-CRP or CRP C-reactive protein, exercise decreases CRP, so it stands to reason that exercises decreases inflammation. And if you decrease inflammation, you decrease the risk of a future event. That's probably why the New England Journal of Medicine article 30 years ago said that exercise decreases stroke and heart attack. We also know that exercise improves insulin metabolism or the metabolism of glucose. We know that hyperglycemia or diabetics are at higher risk for events and exercise makes that better, it improves glycemic control. So, that's another important role in regards to exercise. The other thing that exercise does is it decreases weight and it decreases blood pressure and it actually decreases cholesterol.

So, when you look at the overall benefits of exercise, it can improve the medicines we already put you on or limit the amount of medicines we put you on. So, the exercise is invaluable. And then the third thing that we've really learned, and this is really astonishing is that uninterrupted sleep in regards to decreasing cardiovascular events is very important. And we've really noticed this by our sleep specialists, but it is really important for our heart patients to eight to 10 hours of uninterrupted sleep. You know, we found that patients that sleep less than six hours or sleep more than 10 hours have an increased cardiovascular event rate. So, that would be about the third thing that I would really strongly recommend.

Host: I wanted to just finish up and have you talk about the emotional side of this.

Dr. Pool: Yeah.

Host: Whether it's support groups or anything else, services, you know, groups offered through Genesis, but just the importance of dealing mentally and emotionally with having a heart attack.

Dr. Pool: 90% of our personal psychological illness or problems and up in medical illnesses. And there's probably a lot of truth to that. And we know that emotional distress, we know anxiety, we know depression, they make the blood pressure go up. They can cause glycemic control to be poorly controlled. They can also increase hs-CRP and they can also impact our compliance to medications.

So, emotional stability is very, very important. There are a ton of support groups out there in regards to survivors of heart attacks and post MI events. And I can't go into all the support groups but they're very, very important because we find solace in people that have gone through things that we've gone through. And what's really important is it a lot of these support groups have patients that have already gone through the process. They've mended, now they've lived a complete normal life, and then they can give their information to people that are now walking through these initial steps by themselves.

They can say, listen, this guy made it. He's doing great. Now he's leading an active lifestyle. This isn't the end of the road. And I think that's very important in regards to emotional stability. The other thing that we rarely use, but we do, is that we do prescribe an antidepressant drugs to patients that are really struggling post MI.

Now we don't recommend these long-term, but we will prescribe them up to a year. It's always important for patients to let us know whether they're struggling with this. Cardiologists that are not generally the first ones that are doing psychological evaluations in the office. But if we see someone that is truly depressed and they're struggling, we do have the ability to write meds. I mean, we are physicians. We can write these medications and we do write these medications for sure.

Host: Well Dr. Pool, thank you so much. And you stay well.

Dr. Pool: Well thanks.

Host: For more information, go to genesishcs.org/heartandvascular. And thanks for listening to Sounds of Good Health with Genesis, brought to you by Genesis Healthcare System. If you found this podcast helpful, please be sure to tell a friend and subscribe, rate and review this podcast and check out the entire podcast library for additional topics of interest. I'm Scott Webb. Stay well.