Dr. Mike Smith (Host): Welcome to Meaningful Medicine, the Novant Health Podcast that connects you with top doctors, doctors eager to answer the questions they wish you would ask. I'm Dr. Mike. And today, I am joined by Dr. Frederick Meine, an interventional cardiologist at Novant Health in Wilmington. Together, we're going to explore the compelling question, "Can stress kill?" And discuss the link specifically between stress and heart health? Welcome to the show.

Dr. Frederick Meine: Having me, Mike.

Host: I think most people are familiar with the idea that, if you have a family history of heart disease, right? Strokes, heart attacks, what have you, there's elevated risk there. I think most people understand that. But doctors like yourself often talk about modifiable risk factors. Could you discuss what that means, and what are those kind of risk factors for heart disease?

Dr. Frederick Meine: Sure. So, I always tell patients when I see them in the office that you can't do anything about who your parents are for good or for bad, but there's an awful lot of other things in our lives that contribute to your heart health, both good and bad, and those are the things that you really got to focus on.

And most of them are things that we all sort of in the back of our mind know we don't necessarily want to deal with, but we know. I mean, as easy as knowing what your blood pressure is, knowing what your cholesterol is, and treating your cholesterol if necessary, treating your blood pressure if necessary, knowing what your blood sugars are, and whether you're at risk for diabetes or whether you have diabetes. And those are the ones that are really pretty easy and easy to put on paper.

I think the ones that are a little tougher for us are the softer ones, the more amorphous ones. Things like how often do you exercise and what kind of exercise do you do? How do you handle the stress that you just mentioned a few minutes ago. Those are the ones that are a little bit tougher, because they're not as easy to put down on a piece of paper, like, my cholesterol is 220, but they're every bit as important and their every bit is modifiable when it comes to controlling your heart health and making sure that we all live to a ripe old age.

Host: Yeah. So, we're going to be talking about stress specifically, and that's one of the modifiable risk factors. But as you said, I mean, who doesn't have stress? How do you really rank that stress? How does that really impact heart health? So we're going to talk about that stuff. But the title of this show today is "Can Stress Kill?" Let me ask you, can stress kill?

Dr. Frederick Meine: Absolutely. Not only can, but does. And there's a bunch of different ways that it does that. And I think the simplest way to think about it is that when you're stressed, you have the same sort of fight or flight response. And ask your heart to do things that it shouldn't otherwise have to do. It has to go faster, it has to pump harder, it has to work harder. And all of those things over time contribute to more stress, strain on your heart. And in those ways, certainly stress can and does kill. I think that's the bad part, the bad news for all of us, right? Because as you said, everybody has stress.

I always joke about family friends I know. The husband is an investment banker in New York and the wife's a yoga instructor, and they argue every time I see them about which one has a more stressful job. So, I don't think it's necessarily only stressful jobs that have stress. We all have it, right? That's, as I said, the bad news.

The good news is all of those things that a lot of people do to relieve stress can actually not only relieve stress, but can relieve other strains on your heart as well. I mean, I think everybody would agree that getting out and doing some sort of exercise outdoors is a stress reliever. And in addition, it sort of works double to decrease your heart risk. So, I always tell people, "I can't tell you how to decrease your stress. Only you can tell me what things you can do to decrease your stress." But I guarantee you, we can all find things that decrease your stress that are good for your heart.

Host: No, that's fantastic. So, exercising helps both. That's an easy one, right? Get outside every day as much as you can. Before we dive into a little more detail here, I do want to talk about more of that association though between stress and heart health. How strong is that association? Is there a lot of evidence that stress could be bad for my heart in the literature?

Dr. Frederick Meine: A lot of evidence, and actually we see it a couple different ways in the cardiovascular realm. One, we see exactly what you talked about, sort of what you alluded to, is the sort of more chronic, long-term strains from stress, both with rises in catecholamines and rises in adrenaline and all those things we see that cause increase in heart rates and increase in heart work. And there's very good evidence that that stress contributes to premature heart disease.

There's also growing evidence for a more acute episode, something called Takutsubo cardiomyopathy or broken heart syndrome, which is more and more common every year. And it's an acute event where you end up with very decreased heart function and you actually think you're having a heart attack. And it typically comes from a very acute onset stress, like the death of a loved one or the death of a family pet, or a house fire or something that puts extreme stress on the heart all at one time. And we're seeing that more and more over the past few years. It was described about 20 or 30 years ago in Japan in the first, and that's why it had sort of an interesting name. It's the Japanese name for an octopus trap, believe it or not, because the heart takes on the shape of this ceramic octopus trap called Takutsubo. That's an acute way that we see stress on the heart causing decreases in heart function. But as you said before, there is really good evidence that long-term stress causes increased heart attacks and increased stress on the heart.

Host: What exactly is going on though? What is it about the stress response itself, especially the chronic stress we deal with that's impacting the heart? Is it the adrenalines and is it inflammation? I mean, what's actually going on, do you think?

Dr. Frederick Meine: I think a lot of it is just what you said. It's these chemicals that we excrete, these fight or flight chemicals, adrenaline, you mentioned, that really are asking your heart to do something that they're not designed to do long term. that your heart is not designed to be under that amount of chemical stress for extended periods of time. And from that standpoint, the more we can do to sort of calm the entire body in order to calm the heart is really beneficial.

Host: Yeah. So if somebody comes into your office, they're showing signs of some heart issues, whatever that may be. And you've already kind of looked at, you know, blood pressure, that kind of cholesterol, maybe it's being controlled, but they're still having issues. When do you start thinking about stress in that patient, like maybe there's stress here that's driving a lot of the issues?

Dr. Frederick Meine: So, yeah, I think that's a good point. When we talk about things from a cardiac standpoint, there's acute problems and there's chronic problems, right? So, the first thing you want to do is you want to make sure that you handle the acute problems. Does the person have an acute heart artery blockage that we need to take care of before dealing with chronic conditions? And you already mentioned some of those chronic conditions.

But really, it starts from minute one dealing with stress. There's really good evidence, for example, post heart attack patients that depression and stress cause worse outcomes. So, the same heart attack that two people have, one of them has depression or anxiety the other one doesn't. The person with the depression or anxiety actually does worse, both short and long term. So, once we get past the acute phase of taking care of heart problems, once you get past, for example, the acute heart attack, it's really, really important that we address those more chronic problems, not only the high blood pressure and the high cholesterol that you mentioned, but the psychological problems like anxiety, depression are every bit as important. The hard part for us as cardiologists is that that takes a little bit of everybody, right? That's where your primary care physician, or your therapist, or your walking partner, or your dog, or your husband or wife, are every bit is important in managing your stress as I am.

Host: Yeah. Very good.

Dr. Frederick Meine: So, it's really-- I don't want to say it takes a village, but it takes a village.

Host: No, I like that. I think a lot of, the stress, the chronic stress that we often feel, it's not just one thing, right? There's multiple things happening in our lives, multiple people, multiple interactions. And I think if that's the cause, the solutions's often going to be a village to help with that. So, we kind of already hinted at your answer to this question, but I'm going to ask it anyways. What do you recommend for people to reduce stress?

Dr. Frederick Meine: So, I think the first thing I ask people is what is your stressor, right? and in some of the cases, it's something that's temporary, and it's already going to get better on its own, right? And in some, you've got a sick family member at home and that person's recovering and you're having to help take care of them for six weeks. And as that gets better, you believe your stress is going to get better.

But I think the hardest part for me has always been making people sort of figure out for themselves what their stressors are, because a lot of people have never really thought through-- and you and I are probably the same way-- we have everyday stressors that we just think of as part of life, right? But the question is what are they? If necessary, put them down on paper and say, "These are the five things that most stress me every day." Some of them are completely reversible, right? Like I've got that annoying coworker that I just need to relocate my desk to the other part of the building. And some of them are not as easily removal, right? I don't have enough time to exercise every day. And then, I like to look at those things and say, "Which ones of those things are truly modifiable?" Meaning which ones can we make better, you know? If you tell me your stress is that you're getting older, I'm going to tell you, "I can't make you not get older," right? If you tell me your stress is, "I'm getting older and I don't have as much time to go walk the dog every afternoon as I did before," then we sit down and talk about what we got to do to find you 15 more minutes every afternoon to walk the dog, right? So, it's a lot about being able to recognize what your personal stressors are and why they're the way they are. Is it just that you agreed to have a 5:30 meeting every afternoon at work when you used to go work out? And what we need to do is figure out how to make that meeting either not happen or be 15 minutes shorter. or is it that it really isn't modifiable? And then, we need to think of coping strategies. And again, it's not something that your cardiologist is going to solve for you, right? It's going to be that that your cardiologist can help you figure out what they are. But each one of us needs to figure out not only what they are, but how we manage them. And it doesn't always mean make them go away. It means manage them.

Host: Right. Modifying them in such a way where maybe they're not so stressful. Something like that. I'm going to change topics just a little bit here because I'm curious. And I think a lot of other audience listeners are too. What exactly is the role of an interventional cardiologist?

Dr. Frederick Meine: Sure. So, Cardiology has a bunch of different subsets. So, without getting too deep into training, after college, you go to medical school. After medical school, you do Internal Medicine for three years. And then, you do three years of General Cardiology and that qualifies you to do see patients, do cardiology issues, read echocardiograms, do stress tests, even do heart catheterizations.

Beyond that, there's additional training you can do in a variety of different fields in Cardiology. One of which is, as you mentioned, Interventional Cardiology. It's typically an extra year, and to be very simple, it's doing balloons and stents for occluded arteries. So, I spend about half of my time in a cardiac catheterization lab where we do heart catheterizations, angiograms, and then open up occluded or blocked arteries with balloons and stents. And that typically takes an extra year of training beyond general Cardiology.

Host: Now, do most interventional cardiologists still practice just the basic Cardiology too, or is this just your focus?

Dr. Frederick Meine: So for me, it's about 50/50 and that's sort of standard in the country. Very few of us are in the cath lab all day, every day. For most of us here at Novant and around the country, it's about a 50/50 mix. So, I'm in clinic about half the time and in the cath lab about half the time.

Host: So when you talk about occluded arteries, all that kind of stuff, what does that mean to the listener? Like, so what are those conditions that you're treating?

Dr. Frederick Meine: Sure. So, the most obvious one is heart attacks, right? So, you have a heart attack from a completely blocked artery. You come into the cath lab emergently. We do a heart catheterization, we find a blocked artery, and we open it with balloons and stents. In addition, we have people who are not quite to the level of heart attack yet where they've got a partially blocked artery and they're having chest pain, what we call angina, right?

So, they have chest pain with exertion. They see their doctor who sends them to their cardiologist. Their cardiologist does, for example, a stress test and finds the worry that they've got a partially blocked artery. And then, we do a heart catheterization, find an artery that's partially blocked, and we open that to relieve their symptoms.

Host: Yeah. This is really fascinating, I think, for a lot of people. your big choices are you can place stents in to open up those arteries, right? Or there's also what everybody probably has heard bypass surgery. How do you decide between a stent and something that's much more invasive, like bypass surgery?

Dr. Frederick Meine: Sure. Great question, and I'll put a third category in there, which is you can have a partially blocked artery and be able to treat with medicines alone, right? So when we do a catheterization, you're thinking, does this person need medicines only? Does this person need medicines and a stent? Does this person need bypass surgery?

They're different, and I'll take those sort of separately. Medicines versus stent has historically been sort of how severely an artery was blocked. And that's always been sort of a difficult moving target in Cardiology, because it's a very subjective eyeball measure. I look at an artery and I say, "Oh, it looks 90% blocked, it needs fixed." And that's always sort of bothered us in medicine, mainly because most of us are very sort of scientific people who don't like the the subjectivity of that.

Over the past five to 10 years, we've developed very objective measures in the cath lab where we can tell for sure if an artery is better treated with opening it one way or another versus medicines. Specifically, we put a wire just as if we were going to stent it, just as if we were going to fix it. We put a wire down past the blockage and we measure the percentage of blood flow that that narrowing takes away from the artery. And just as an example, we put a wire down. And if a narrowing takes away more than 10% of the blood flow past that area, then we know that you are better off and likely to live longer with stenting than you are with medicines alone.

So, that's really been a wonderful change in the cath lab since I started doing this 20 years, some odd years ago, that we've gone from a very subjective measure of, "I'm a doctor and I'm pretty sure that that needs fixed" to being able to say, "I have very, very clear evidence that if I fix that artery, you're going to be better off than if I leave it alone."

The question between stents and bypass surgery has historically been when you have blockage in multiple arteries that would not be as well suited for stents. That's been a moving target as well over the past few years. As stents have developed and become better and better, we have more ability to stent more things that don't have to go to bypass surgery. But typically, we meet with the surgeons after doing a catheterization and seeing that somebody has blockage in multiple arteries. At Novant, we have a program where we have conference with the open heart surgeons, the bypass surgeons, and the cardiologists. And we review the cases and the films, the catheterization films, as well as the whole picture of the patient, how sick they are, how old they are, what other risk factors they have, make a determination whether those arteries are better suited for multiple stents or whether those arteries are better suited for bypass surgery.

As a general rule of thumb, if you have blockage of one or two arteries, you're typically better off with stents. If you have blockage of all three of your major heart arteries, then that opens the door for bypass surgery and we tend to have that back and forth discussion with our surgeons about what is better suited for that patient.

Host: So, you've been practicing and doing this for a long time, so I'm curious to hear what you have to say about this. And you've alluded a little bit to the idea that stents have gotten better. What does that mean? How have stents improved the 20 years or so you've been practicing?

Dr. Frederick Meine: Sure. So, I could spend hours doing this and I would probably put you and everybody else listening to it to sleep. But the general history catheterization and stents goes something like this. So, in the late '80s, early '90s, the balloon angioplasty was developed and that meant that the cardiologist had the ability to go in and balloon a blockage open. And that sounds awesome. It had a couple problems. One, it had somewhere around a 5% risk of acute closure of the artery requiring emergent bypass surgery, and it had about a 50%, 40% likelihood that over the next few months, that artery that you had ballooned open would collapse back down smaller than it was when you started. So, it still was the right thing to do for a completely blocked artery, but you were adding in about a 5% risk of needing emergent procedure and about a 40% or 50% risk of needing more and more balloon angioplasty. So obviously, not a great option.

In the mid '90s, about '95, '96, stents were developed and what that meant was basically a stent looks just very much like the spring on the inside of your ballpoint pan, a small metal scaffolding that holds an artery open. That did sort of two things. One, it eliminated mostly that 5% risk of acute vessel closure because the stent holds the artery open. And it decreased that likelihood that the artery could collapse back down because the stent is basically stronger than the wall of the artery. And so, it eliminated that 40% or so risk of vessel recoil is what we call it. So, all that sounds perfect. The problem was that you now have added in the body's desire to sort of overheal that. And we added in about a 20-25% risk of what we called re-stenosis, where you overgrow the scar tissue on the inside of the stent, closing off the artery again.

So again, better than balloons only, but still about a 20-25% risk of needing repeat procedures with something called re-stenosis. And basically, I always tell people, you're supposed to heal your stent just like you're supposed to heal the scar on the back of your hand. You should get a very thin layer of tissue on the inside of that stent when you heal it up. All of us have scars where it looks great. And then, other ones where it's a big, raised--

Host: It looks bad.

Dr. Frederick Meine: Yeah. And it was a raised welt. If you get that on the inside of that stent, that closes the artery back off. Then in about 2004, 2005, the next big new thing came along and that was called drug coated stents. And what that meant was they were the same bare-metal stents that we had in the '90s, but the companies were able to put very small little microchannels in the metal of the stent. and they put in those microchannels drugs that slowly leaked off the stent over the first month or so, and retarded that healing process. So, it eliminates most of that overgrowth of tissue on the inside of the stent. And that really took that 20-25% re-stenosis rate down to about 1%. So basically, you almost eliminated that problem with re-stenosis. So, you'd gotten rid of the acute problem, you'd gotten rid of the elastic recoil problem, and now you've gotten rid of the re-stenosis problem. And that's drug coated sense, and that really revolutionized everything.

Now, over the next 20 years, the stents have gotten better in that the metal has gotten thinner and thinner. The drugs have gotten better and better. There hasn't been one of those sea changes that occurred, which was life-altering for us like stents or like drug-coated stents, but the stents have continued to get better and better.

Host: Evolving themselves within that, the medicine, the metal, all that kind of stuff.

Dr. Frederick Meine: Yeah.

Host: That's fantastic. That didn't bore us. I think that was pretty cool. That's good. To kind of summarize, so we covered a lot of stuff here. We talked about heart, we talked about the impact on of stress, a little bit of what you do, the stents. But bringing it back to the main topic here, the stress kills, the association of stress on the heart. What last words do you have for the listening audience about that?

Dr. Frederick Meine: So, I think it's the same thing I'd say about all the other modified risk factors. The most important thing people can do is know what your risk factors are, right? So, know what your cholesterol is, know what your blood pressure is, know whether you're at risk for diabetes, and really be willing to know and deal with the fact that you are under some sort of stress and be willing to address that with your cardiologist, with your general practitioner, with your family. Ignoring your stress levels is just as bad as ignoring your cholesterol levels or your blood pressure.

Host: Yeah. Very good. Fantastic information. Thanks for coming on today. That was Dr. Frederick Meine sharing his valuable insights on heart health and stress management. For more information about finding a physician, you can go to novanthealth.org. If you enjoyed this episode, please consider sharing it on your social channels. And don't forget to explore our podcast library for many more health topics that matter to you. You've been listening to Meaningful Medicine. I'm Dr. Mike. Thanks for listening.