Maggie McKay (Host): Welcome to Wellness in Reach, a Mount Carmel podcast. I'm your host, Maggie McKay. Joining us today is cardiologist, Dr. Kristopher Kline, to discuss heart health. Thank you so much for being here today, Dr. Kline.

Kristopher Kline, DO: Absolutely. Thank you for having me.

Host: As someone with a family full of heart issues, I can't wait to learn more today. So, what are the major risk factors for coronary artery disease?

Kristopher Kline, DO: Yeah, great question. So, the major risk factors are pretty well defined, but these include things like diabetes, hypertension, high cholesterol, or a family history of heart disease, older age. And then, things like tobacco use or inactivity can certainly be included in there.

There are some other non-traditional or minor risk factors that we also try to think of. So, chronic inflammatory conditions or autoimmune disorders. Sometimes things like chronic kidney disease or psychosocial stressors or any non-coronary vascular disease. So, there are some other things besides the traditional risk factors that we take into consideration.

Host: Are you totally out of luck if heart issues run in your family? Like, let's say both your parents had heart attack, but you live very healthy.

Kristopher Kline, DO: There are these modifiable risk factors, and then there's non-modifiable. So unfortunately, genetics is something we can't control. We were born the way we were and have these genes from our parents. But it's certainly an opportunity to make sure that our modifiable risk factors can be treated and optimized the best we can.

Host: What are typical versus atypical symptoms of coronary artery disease?

Kristopher Kline, DO: So when we think of typical chest pain or typical angina related to coronary artery disease, it's usually described as a substernal chest discomfort, sometimes a tightness or a heaviness or a pressure sensation, sometimes a squeezing. This can radiate up to the neck, to the back, or down the arms. It usually gradually worsens over about five to 15 minutes, often worsening with exercise or exertion, improving with rest or nitroglycerin use.

Now, the atypical symptoms, you should also be aware about. This includes things like shortness of breath, fatigue, maybe just an isolated pain between your shoulder blades or neck pain. Sometimes people get dizzy or pass out. And sometimes people just really think it's indigestion. So while typical symptoms are the most common, it's really important to recognize the atypical ones too. And that's certainly because a lot of patient populations will actually be more commonly to have atypical presentations. And we do see that in women and diabetics and in the elderly.

Host: Yeah, I always hear that symptoms can be different for women versus men. Is that accurate?

Kristopher Kline, DO: It is absolutely true. And it's funny, just even thinking about this discussion we're having today. In the last two days of my office patients, I've had a number of young women that presented atypically and that can really lead to misdiagnosis and delayed treatment in some cases, which can really lead to a poor outcome. So, certainly important to think of those atypical symptoms in those scenarios.

Host: Dr. Kline, so you get the calcium score and what does it mean?

Kristopher Kline, DO: Yeah. So, you get a score back and a score of zero is great. That means you have no calcified plaque seen on the study of the heart's arteries. So, that really dramatically reduces that risk of cardiac events, especially over the next five to up to 10 years. And sometimes that score can be really reassuring for the patient and clinician and help reclassify them into a lower risk category and maybe they don't need that medication that they were talking about and they can just work on lifestyle changes.

Now, having a positive number means that you do have some evidence of atherosclerosis or plaque buildup in the heart's arteries. That is common as we're all getting older, and it can be compared to the average patient of that age, gender, or race ethnicity. But in general, scores under a hundred is considered to be a mild amount of plaque. Scores in the 100 to 300 or 400 is a moderate amount. And then, once you do pass into that 300, 400 and above range, that is considered to be extensive plaque. And that is when we're really trying to make some major lifestyle changes and aggressively treating those risk factors. We do know that when you have a score above that 300 or 400 mark, that you're at a higher risk of future cardiac events, in fact, even the same amount of risk as someone that's had a previous cardiac event or heart attack in the past. So at that stage, we're treating them with very strict targets, trying to intensify blood pressure goals and cholesterol goals and really making sure we're not missing anything else.

Now, these abnormal scores, even if you do have a high score, it certainly does not mean that you're going to have a heart attack tomorrow, but it does help us clarify maybe how aggressive we want to be to treat one from happening in the future and really monitor those symptoms closer.

Host: What tests might be appropriate for an asymptomatic patient with risk factors?

Kristopher Kline, DO: Yeah. So, an asymptomatic patient, someone that has these risk factors but does not have coronary disease, our first step is usually just doing these routine checkups with your primary care doctor and looking at treating conditions like high blood pressure, diabetes, cholesterol issues, and also learning heart-healthy lifestyle changes for your long-term health.

But at that stage, sometimes we start seeing risk factors are increasing. We have risk stratification tools and calculators that can help categorize these patients and say, "What is your future risk of heart disease? " Often, this will put someone in a low, intermediate, or high-risk category over the next 10 years of having cardiac events. This really helps us guide discussions and treatment strategies and really intervene when appropriate. At this stage we see a lot of those patients that do end up in the borderline or intermediate risk categories. And so, oftentimes both the clinician and the patient really want more data and see maybe where they're at in terms of their risks. So, sometimes there's additional tests they can look at there. And one that's being more commonly used is something called a coronary artery calcium score. This is frequently ordered by primary care offices and cardiology offices alike, and it's really good in these patients that your borderline or intermediate risk, maybe in the ages of about 40 to 75, and it's not a universal screening tool, but certainly a very valuable tool that can help us.

Host: So, what's involved in a coronary artery calcium score test? It's a mouthful.

Kristopher Kline, DO: Yeah. So, it's a very easy study. It's a fast, non-contrasted CT scan, and it's basically giving us a snapshot of the heart's arteries. And what it's looking for is the calcified and hardened plaques that have already built up in your body. Calcium there is proof of atherosclerosis. So, the scan itself only takes a couple minutes. It's a non-invasive test. There's no needles, no dye, no treadmill. It is widely available. It is noted that it's not usually covered by medical insurance companies, but it's out-of-pocket expenses typically between $75 and $150, so not a particularly expensive test.

And when we finish that, we get something called a coronary artery calcium score. This is a direct measurement, quantifying your total calcified plaque area and density in the heart's arteries. And this really gives us additional value to add to those risk factors and really give us some clarity on whether you might be a lower or higher risk, and then help guide those discussions and treatment sessions.

Host: That's so amazing that they had that test. I can attest. I did it. It's so easy and fast and painless. And like you said, even though you have to pay for it, it's so well worth it if you have heart history in your family, at least. What tests may be appropriate for symptomatic patients?

Kristopher Kline, DO: So, a coronary artery calcium score is really towards the asymptomatic patient like you were mentioning. But when we have an acutely symptomatic patient, we're really looking at other studies. And the reason that is is a lot of times that can be from soft plaque formation or acute plaque rupture events, and those are noncalcified plaques. So, those are not seen on a normal calcium score test. So when we have a symptomatic patient, we're really looking at the traditional stress testing. There's a variety of different ways we can do that. Commonly, it's a treadmill stress test, sometimes a stress test with additional imaging that we do at the same time, whether an ultrasound or echocardiogram or nuclear perfusion imaging.

And there's even a different kind of a CAT scan, CT scan called a cardiac CT angiogram, which does use IV contrast and dye and allows us to look at the heart's arteries with a lot more detail than a regular flat calcium score. So, really, it depends on the patient's unique presentation. And oftentimes, there's something else we're looking for. And so, there's a reason we do one test over another. And it's just very unique, depending on their presentation.

Host: What about patients who feel fine? Should they get a routine stress test every year or two?

Kristopher Kline, DO: Good question. So, the short answer is no. Asymptomatic patients should not be getting routine stress tests. It really has not shown to improve any clinical outcomes and can lead to unnecessary procedures and even patient harm. Stress testing can certainly be appropriate in a lot of scenarios, especially if there's a concern of new worsening heart disease, helping rule out cardiac sources when you might have more ambiguous symptoms that don't have a source yet. We do them for assessing risk prior to surgeries. But in terms of just an asymptomatic, stable patient, typically not recommended.

Host: How can it be harmful?

Kristopher Kline, DO: Harmful because of unnecessary radiation exposures. It might lead to unnecessary testing procedures that have their own risks. So, for instance, a heart catheterization is considered to be a safe and routine procedure, but no invasive procedure where we're going into the body is without risk. And so, it leads to risks of infection, bleeding, perforation. So, we don't want to take those kind of risks unless we think it's really going to help the patient.

Host: And the big question, how can patients reduce their cardiovascular risks?

Kristopher Kline, DO: Yeah. So, those risk factors that we're talking about, treating them from early on is very important. So, the diabetes, the cholesterol, the blood pressure. In terms of heart-healthy lifestyle, I think consistent physical activity is certainly something that we need to do better of as a society.

The American College of Cardiology and American Heart Association, they really recommend at least 150 minutes a week of moderate vigorous activity, ideally up to 300. And so if you think about it, that's at least 30 minutes a day. And that's considered to be things like brisk walking, water aerobics, dancing, even bicycling in a leisurely fashion, something to get your target heart rate up a little bit though. The most important thing with the exercise part is there is no lower limit where those benefits start. So even if you're not an active person, getting involved, starting the walking is better than nothing. So, reducing that sedentary time and start working on increasing that slowly over time.

Other things we can do is dietary changes. So, really one of the strongest, evidence-based diets we have for the heart is the Mediterranean style diet. So, looking into that and following that is really good for reducing cardiovascular events, as well as the DASH diet or dietary approaches to stop hypertension is very heart healthy. I would certainly look at working on those. And then, staying away from those things like smoking and trying to have good sleep patterns, stress management strategies, that can all help your risks as well.

Host: In closing, this has been so informative, is there anything else you'd like to add that maybe we didn't cover that you'd like people to know?

Kristopher Kline, DO: You know, heart disease is very common. Unfortunately, it's still the leading cause of death in the U.S. But it usually doesn't show up out of nowhere. Oftentimes, it's quietly building over the years with those little risk factors. And they can add up. And so, that gives us a big opportunity here for the things we're discussing. So, knowing those risk factors, treating them early, paying attention to some of those symptoms we're discussing and just taking those small steps really can make a big difference.

Host: Well, thank you so much. This has been very educational and helpful. We really appreciate your time.

Kristopher Kline, DO: Absolutely. Thank you so much.

Host: Again, that's Dr. Kristopher Kline. To find out more, please visit mountcarmelhealth.com/services/heartandvascular, or just mountcarmelhealth.com. I'm Maggie McKay. Thank you for listening to Wellness in Reach, a Mount Carmel podcast presented by Mount Carmel Health System.