Kendal Williams, MD (Host): Welcome everyone to the Penn Primary Care podcast. I'm your host, Dr. Kendal Williams. So we're back with part two of our discussion of prevalent coronary artery disease. So this is patients who have established coronary artery disease, either asymptomatic or symptomatic. Last time we took a patient through an experience until they went into the cath lab and we went into the cath lab and talked about what happens in the cath lab and we're going to start there this time, and we're going to start right after the cath lab, right after the vessel's been opened. Patient has a stent in place, and how do you manage and manage the patient who's already had revascularization and now needs to be kept clean moving forward.

So with me to discuss that, again is Dr. Dan Kolansky and NP nurse practitioner Maureen Julian. Dr. Kolansky, I gave the full introduction last time. He's a Professor of Medicine at Penn, Senior Cardiologist, Interventional Cardiologist, has been doing this for decades now. Dan, thanks for coming back.

Daniel Kolansky, MD: Pleasure to be here. It's one of my favorite topics to talk about, so happy to share and answer some questions.

Host: And Maureen, thank you again for coming back. Maureen is also very experienced in the field of cardiology, managing cardiology patients through the practices at Penn. Maureen, thanks so much for coming.

Maureen Julien, NP: Thank you for having me back. I'm excited to be here. Thank you.

Host: So let's pick up our patient in the cath lab who has now has a stent in place. Dan, I'm going to throw this first question to you just about the types of stents. You know, We started with bare metal and there's a whole history here, right? With bare metal stents, we've kept them on Plavix, but after about a month or so, they were endothelialized and we thought we don't need the Plavix anymore and so forth, but then as we started to actually we had, I understand the process that they began to start over endothelializing, right? And so you ended up with in stent restenosis, so we developed drug eluting stents that had a small agent to reduce cell proliferation, but that left bare metal open to blood longer.

And so, you reduced restenosis, but you ended up with a higher risk of instant thrombosis, right? So we needed to keep the Plavix going for a longer period of time. But then they changed the stents on us, right? They changed the metal, they changed other things, and so I even don't know where we're at with the need for Plavix and other agents long term. So we'll start there.

Daniel Kolansky, MD: Great. Great. Kendal, that's a great question. So, and actually it sounds like you're thinking like a cardiologist. So I like that. Your little summary was actually fairly accurate. So stents have now been around for a long time and are the dominant treatment other than coronary bypass surgery for coronary artery disease, when you need revascularization.

Bare metal stents were the first iteration. We now almost never use those. Virtually everything is a medicated or drug coated stent or drug eluting stent, which we abbreviate as DES. So, almost everyone that goes through the cath lab and gets a stent will get a DES, a drug eluting stent.

There are several different companies and providers of these. But in general, they all work in the same way. They have a now more advanced metal platform and they're impregnated with a medication that helps to prevent cell proliferation or restenosis exactly as you said. What's improved over the recent years has been the that the stents have become thinner.

So the metal is thinner. There've been new designs in the stents. There have been some changes in the metal and then improvements in the drugs that are attached to them. All of which combined to make them safer, less prone to thrombosis and less prone to restenosis. So you appropriately distinguished two problems.

One is the early or late occurrence of stent thrombosis. And thrombosis means that usually platelet mediated, the stents will form blood clot within them and that becomes an acute problem. We treat or prevent, rather, stent thrombosis with antiplatelet agents and typically we use two together, aspirin plus a P2Y12 inhibitor. The three commonly used ones in this country are ticagrelor, prasugrel, and clopidogrel, and they all work well.

We can talk about timing in a moment. And then you also separated restenosis, which is really not a platelet issue as much as it is an atherosclerosis issue over time. So let's deal with those separately a little bit. And then part of the things we can get into for the primary care audience is how do we, once we've revascularized somebody, when we're thinking about preventing, thrombosis, but also restenosis; what are some of the long term medications and other risk factor modifiers? And Maureen is also an expert in that and can help us out.

So, in terms of the antiplatelet medications, the simplest way to think about it is to divide the patients into two categories. Those who come in with an acute coronary syndrome, and in general we say they should get all else being equal, a year of dual antiplatelet therapy, aspirin plus Plavix or one of the other agents.

After a year, they should remain on aspirin indefinitely and really should never stop it. The other category is people with chronic coronary disease, so they're not coming in with an acute MI, but they've had progressive angina, symptoms that you are concerned about that lead to stenting. And those patients it's recommended that they receive dual antiplatelet therapy for six months.

And then again, you can stop the Plavix, the prasugrel, the ticagrelor, and leave them on aspirin alone. So that's the easiest way to think about it. Divide them between the acute presentations and the chronic presentations, 12 months versus six months. Once we establish that, we get into the question of, well, who can stop one of those agents even sooner? And are there data around that? And in fact, there are a lot of data, been a number of trials that have shown that if necessary, you balance, you're always balancing risk versus benefit.

But if somebody has a higher bleeding risk or reasons to stop one of those agents because of an important surgery, it's probably safe to stop them at a shorter time. And again, how short a time? It depends on how much we're willing to bend that risk curve. We generally think that everybody should stay on at least for a month.

And with acute coronary syndromes, non STEMI, STEMI, longer is better, up to a year. But beginning at about three months, it's probably very reasonable to stop the second drug. There are also trials of one month dual antiplatelet therapy, and it's also reasonable, with today's current technology, to stop the second drug at a month.

What we would say is, if you're stopping earlier than either six or twelve months, talk to the patient's cardiologist, or to the interventionals who put in the stents. Try to identify if it was a relatively straightforward procedure. Are there specific risk factors you're worried about? And is it reasonable? And at what time is it reasonable to stop the second agent?

Host: This comes up fairly often, actually because we have patients that need elective surgeries. They want to get their hip replaced. It's killing them. They can't walk across the kitchen floor. And yeah, but they just got a stent two months ago. And can I still get my hip replacement? That kind of thing.

Daniel Kolansky, MD: Yes. And we weigh the risks and benefits. And, there are people who are extremely limited by a hip or a knee, and it's not really elective, it's urgent surgery. Or we see them who need a transplant, particularly a lung transplant, and had decompensated. You don't see that as much in the office practice, but, you know, they really need a more urgent surgery.

And in those cases, again, we will shorten the duration of dual antiplatelet therapy, but one needs to think about it. And, I guess the other really simple takeaway is almost every one of those surgeries, almost without excuse, can be done while taking 81 milligrams of aspirin. There are a couple of very high risk surgeries, perhaps some neurosurgeries, where that's not the case, but almost everybody can be done on aspirin.

So if we get out to three months or six months with dual antiplatelet therapy, we're feeling pretty comfortable as long as they stay on aspirin that they can get through the surgical procedure.

Maureen Julien, NP: We really do try to educate the patients after intervention that we're kind of their primary contact. If anybody wants to stop your Plavix, you, or your aspirin, you need to call us before you do that. Somebody wants to pull a tooth, you want to have a colonoscopy, we want to be involved in the decision making.

So, we really try to drive that home. I think, we have seen over the course of our careers, you know, maybe two handfuls of really devastating cases of stent thrombosis come to the cath lab when aspirin and second antiplatelet with no antiplatelet going into the operating room and, large MI's resulting in cardiac arrest.

Some survive, some don't. So, particularly when I'm teaching, I have a case that I show where somebody for a laminectomy, aspirin was stopped without any discussion. And he had an acute cardiac arrest. He survived and got to the cath lab, but he had to go on ECMO prior to that.

So, it's a small number, but certainly if it's you, it's certainly very devastating and we like to try to avoid that. And like Dan said, you know, I think in our careers, we've had very shared decision making, risk benefit with patients. I can remember one with a neurosurgeon with you know, excruciating back pain and the patient, more than anything, wanted to have back surgery and the neurosurgeon would not operate on the aspirin.

We all discussed it. Everybody was on the same page and he stopped aspirin and did well. The statistics will tell you most people will do well, but you don't want to be that minority.

Host: I'm glad you said that Maureen, because we don't see it very often. We don't see the bad things very often. And so you can get a little lazy about this and think, oh, you know, they can stop it. They're Fine. You know? So I'm actually glad you pointed that out that you've seen a couple dozen people in your career that have had bad outcomes if they're stopped early. So that gets to the time issue in terms of how long somebody needs to be on dual antiplatelet therapy. But now we have these newer agents, right?

It's not just Plavix. It's also prasugrel and ticagrelor. And can you educate us about those when you would choose to have somebody on one of these newer agents rather than Plavix?

Daniel Kolansky, MD: Sure, I'll take that to start, and I'll tell you that all three of those agents, which are oral agents and they're second anti platelet agents in addition to aspirin are effective. The two newer agents ticagrelor and prasugrel are not so new anymore, but they are the alternates and they have been shown to be slightly more beneficial in the acute coronary syndrome patients.

Not really a lot of data that they're, that they make a difference in the chronic coronary presentation. So when we put in a stent, if the patient is coming for a very elective stent after say a positive stress test, angina during exercise; we may well just use Plavix and still feel it, which is clopidogrel, and still feel that that's fine.

For the acute coronary syndrome patients; we will often start with one of the newer ones. Prasugrel has a few limitations because it has a little bit more bleeding risk and so ticagrelor has become one that is very popular and common. Its only downside is that it's a twice a day drug instead of a once a day drug as the others are.

And then often, after an acute coronary syndrome, at six months, we may downgrade them from the prasugrel or ticagrelor to back to Plavix. It's just a little more readily available. It's a little bit less bleeding and so we will sometimes downgrade to that without any concerns.

So that's how we make some of those choices.

Maureen Julien, NP: I would say there's also sometimes cost decisions. Ticagrelor and prasugrel on some prescription plans can be very costly. So, following ACS, maybe we'll get a month out of ticagrelor because maybe they were able to cover that cost and then switch over to clopidgrel for that reason. And the other thing I would say about ticagrelor is that there is a different side effect of shortness of breath. So, some people will have shortness of breath that really is unrelated to anything really physiologic and it's not well understood. And the medication, once you stop it, that shortness of breath gets better. Usually if you can push the patient out past two weeks, if they can tolerate some shortness of breath, that usually will resolve on its own. I've only really had to stop it a handful of times, but I've seen it.

Host: And I imagine that the decision to put somebody on the more potent agents comes down to your overall concern about in stent thrombosis. Like, I would assume if patients have multiple stents, they're higher risk for in stent thrombosis. And you might say, well, their bleeding risk is low. I've just put three or four stents in this person, we should go with something a little stronger. Is that kind of what informs that thinking?

Daniel Kolansky, MD: Sure, that absolutely plays into it as well as the acute presentation. And so both of those play in and that's why there is, a little bit of an art in addition to the science to some of this. And so we're happy to have conversations about it, or if they come back to the primary care provider who says, you know, the patient can't, is having trouble handling this, the cost of this prescription. Is there a reason? We're happy to talk about that and maybe switch.

Kendal, I'm going to throw out, just to make it more complicated, I'm going to throw out one more topic. We don't have to get into it too deeply, but it's the question of those patients who are also on oral anticoagulants.

We could do a whole nother podcast on it, but just to keep it simple, let's say the patient has atrial fib and is remaining on typically these days a DOAC so they're on apixaban or one of the others; what do we do when we stent them? And so there's this concept of not only dual antiplatlet therapy or DAPT, but also triple therapy.

And what the data has shown consistently is that triple therapy is great, but leads to more bleeding and probably excess bleeding. So we try to minimize this time of DAPT plus an oral anticoagulant, if you will, or triple therapy. We usually have minimized it to as little as seven days, sometimes even as little as a couple of days in the hospital.

Some people will go out to a month, but it's certainly no more than a month of triple therapy and usually shorter. And then what we typically drop is the aspirin. So the opposite of what we've been saying about going to single therapy. So we will often do say, apixaban plus clopidogrel as a long term set of agents.

So one oral anticoagulant, one antiplatelet agent and then at some point, we may even get rid of the Plavix and go back to aspirin because it's just so much easier in the long term if they need other procedures that you've been talking about, colonoscopy, et cetera, where you can just keep the aspirin going, whereas Plavix typically gets stopped in those settings.

So not trying to make it more complicated, but I throw it out there because it's a fairly common, bump in the road.

Host: That good old aspirin has really stood the test of time. You know, it's like going to Athens and seeing the Parthenon standing there and all these newer buildings all around it. It's really maintained its value despite all the other things that are happening around it.

Daniel Kolansky, MD: Yeah, it's a very good point.

Host: So the next thing that patients are going to leave the hospital on, I think, in terms of our prioritization are statins, right, and a high dose statin. Right. And so, let's talk about their value. We touched on this a little bit in our first podcast, but I want to come back to this, you know, so now we're trying, we've opened up a vessel, we're trying to keep it open.

What value do high dose statins play in the short term and then in the long term? And then we're going to get to really what our goals for LDL lowering and so forth are.

Maureen Julien, NP: Sure, statins are well studied. We have so many years of research and data. I think they get a bad rap. They're really, you know, the staple of our clinical practice. I mean, it's aspirin and statin is our number one and number two drugs. So, statins help to reduce cholesterol buildup, obviously, but they also help to stabilize plaque.

They help to make it less risk of plaque rupture that can become a myocardial infarction. So, in addition to just lowering the number, there's just so much benefit. So, I try to tell patients, that it's not just all about the cholesterol number, but there's stuff going on, internally that we're not seeing.

Daniel Kolansky, MD: Yeah, that's right. That's a great answer. And so I think, we're driving at the longterm secondary prevention at this point, right? Once we've got the stent in, we've reopened the vessel, we think about what are the risk factors we can impact. And that's where we really partner with the primary care folks as well.

So, the three or four or five things we always think about are lipids, hypertension, smoking, diabetes, exercise, right? Those are the holy grail. We try to hit on as many of those as we can after an interventional procedure. We always recommend cardiac rehab, for example, as an approach to modifying your lifestyle, increasing your activity levels. Statins, as we just talked about, and then some of the other risk factors.

Host: I ask this question with some trepidation because I don't want to go down the rabbit hole too much on this. I'm much more interested in plaque at the sort of cellular level, but then probably our audience, but I do want to ask a question just about the statin effect in the very short term.

Let's say you've put three stents in somebody. I imagine Dan, that somebody you put the stents in also has some minimal disease in other arteries and so forth. So there's value to the high dose statin and protection against those becoming a problem. But the actual vessel itself that you've stented, it's really preventing any new plaque within that, right?

And that's a process that probably would take some time I would imagine, but that's what I'm asking. Is there a short term risk?

Daniel Kolansky, MD: I, think you've hit on it very well, Kendal. There have been a couple of studies, one in particular a number of years ago, randomizing to high dose statin right after a PCI procedure and showing a reduction in secondary events. I'm not sure if most of those events are from other areas of plaque. It's probably not, as you suggest, from the stented area of the vessel. But we know from intravascular ultrasound and looking into these coronaries that, almost nobody has just one area of plaque. There's one that has now be either become a ruptured plaque and led to an acute coronary syndrome and a high grade narrowing and therefore a stent or something that has developed over time and slowly progressed 70, 80, 90 percent and then gets stented.

But everywhere else there are these 10, and 20 and 30 percent plaques waiting to change form and to become plaque ruptures. And so that's where I think the statins are really doing their job. So I think it's, as you point out, it's probably not in the stented segment, but maybe in another segment in the same vessel, maybe in other vessels and time and again any dose of statin and the lower the LDL, the better, to reduce recurrent events.

Host: Maureen, do you have a favorite statin that you use?

Maureen Julien, NP: I'm equal to atorvastatin and rosuvastatin. I'll go back and forth with either whatever gets people to goal. Some patients have preference, you know, my mom didn't do well on this, so, you know, I want this. So, I'm willing to negotiate.

Host: And for the atorvastatin, is it 40 or 80 milligrams that you start people on?

Maureen Julien, NP: I usually start based on kind of what their starting LDL is. If they're already at 80 or 90 as their baseline, I think 40 is totally reasonable and going to get them to goal. If they're over 100, you're probably going to need 80.

Host: The favorite seems to be rosuvastatin now. And that's what I use primarily. I'm not sure exactly why, except that you can eat grapefruit if you're on rosuvastatin. You can't eat grapefruit on atorvastatin. But Dan, is there any other reason that I should be favoring rosuvastatin?

Daniel Kolansky, MD: No, so those are, as you've pointed out and, you know, we're not promoting either one of these, obviously, but as you pointed out, those are the two high potency statins that are in the guidelines as being appropriate for patients with coronary disease or, active coronary disease.

And rosuvastatin probably has a slight edge in being a little bit more potent and even at slightly lower doses. And as you pointed out, there's different dose ranges. So, the top dose for for rosuvastatin, it's 40 milligrams. The top dose for atorva is 80. But even at 10 and 20 milligrams of rosuvastatin, we see a very big effect and a good bang for the buck.

So, I do think it's become a little bit more popular. But that doesn't mean that atorvastatin doesn't also do the job. It's been generic for a very long time. There's a lot of it available. And so patients can be on either one and we're comfortable. And when we get to relatively high doses, either the max dose or one below the max dose, and we're not getting to the kind of goals that we can talk about, then we're relatively quick to think about an additional agent, a second agent, or even a switch to some of the newer agents.

Host: Yeah, statins are remarkable drugs, and I came into medicine, I think, with a philosophy to avoid drugs if at all possible, and a lot of my patients share that belief. I think in many ways, those of us who are doctors, we would probably rather not take a medication. But statins are so marvelous in terms of their effects.

And, you know, I finally speak to patients with them now with enthusiasm whereas in the past I used to sort of say, well, you could take this drug.

Daniel Kolansky, MD: You know, I will echo that and say that those of us who've been doing this a long time have noticed really a significant trend in the fact that there's less and less sort of recurrent acute events over time. We have patients in our practice that we know have had coronary disease for 20 plus years and they don't come back every year with a new event.

They might have one more, they might have two more, they might have none, and they may go many, many years. And so I think whereas, a couple of decades ago, prior to rigorous statin use, perhaps there was more smoking as well, other risk factors. You would see recurrent events, and I think that's much less common these days.

We have whole practices full of stable coronary artery disease that are not progressing and I think that statins have a lot to do with that. So we encourage it. People are nervous. They're anxious. They've read everything on the internet about the bad effects of statins and granted, no drug is without side effects or potential side effects.

And there are several that can occur with statins. But in general, the majority of patients tolerate them. And if they don't, we have new alternatives that can substitute for them and do a really good job.

Host: We talked about this a little bit last time, but the goal LDL, I think per the AHA is still to be less than 70, although the Europeans get it less than 55, right? And I think the trend I see is among cardiologists is actually get it less than 55. Is that about right?

Maureen Julien, NP: Yeah, we really aim for around 50 or so. If it's more of a primary prevention and patients are hesitant, I'll hedge and start just at 70. But you know, and our patients who have severe coronary disease established, definitely driving that down.

Host: So when I was in training, everybody would leave on a beta blocker. And beta blockers were thought to have value as anti anginals. And my understanding at the time was that they reduced demand effectively. And so, in a supply demand mismatch problem, by reducing demand, you're good.

I do believe they're still part of the AHA guidelines for the management of ACS, for patients to go home on beta blockers. But if we're revascularizing so many more people now, do we need to do that? So where are beta blockers now in sort of the post-cath world management?

Daniel Kolansky, MD: Yeah, I think you're right. We still use them. They have some value in hypertension, not, perhaps not as much as others. They certainly have some value in helping left ventricular remodeling. So patients who have any degree of left ventricular dysfunction, it's part of the armamentarium.

And there's good science behind that with recruitment of receptors and those sorts of things. And in people who have some angina from some small degrees of unrevascularized areas, they can certainly help reduce angina. So I think that, but in the patient with normal left ventricular systolic function and who are active and want to get their heart rates up, et cetera, I think after the initial period, we certainly phase them out and wean them off easily. I think low dose beta blockers are pretty well tolerated for the most part, and it may just take the edge off a little bit of angina, a little bit of demand but certainly in the, in patients without a lot of ischemia not really clear that they're needed.

Host: You know, of course, the other scenario is where patients do have a reduction in their ejection fraction as a result of the event. And I think of those folks as, well, now I'm just treating heart failure. And I'm putting people on beta blockers. I'm, thinking about their RAS system, you know, and trying to reduce either with ACE inhibitors, ARBs, Tresto and so forth.

And I imagine some patients leave your hospital after catheterization on those agents as well.

Daniel Kolansky, MD: For sure. We actually work hard. Maureen, you might want to talk a little bit about, how we approach adding those agents in and how many we can do at a time.

Maureen Julien, NP: Yeah, the thought process is now, like, you can start them all at the same time and get out the door. The more drug you get the patient on in the hospital the more likely they're going to continue on that. It's harder, as we all know, in the outpatient world to get patients back to check labs, check blood pressures, you know, have conversations to slowly kind of add on and up titrate.

So, the guidelines really now suggest that you can start all four pillars of guideline directed medical therapy for heart failure at the same time. Which can seem overwhelming. And sometimes there are limitations. I know Dan and I have a handful of patients with MIs over the course of the last year who have some LV dysfunction and really have been limited in taking meds just based on their lower blood pressures.

So, we try to put a smidge on of Entresto and a little bit of beta blocker for the remodeling if tolerated. And we usually can't get to the, you know, a third and a fourth agent, those people who are hypotensive.

Daniel Kolansky, MD: But we've found really impressive results, particularly with Entresto as well as ACEs or ARBs before that. But we will start with low dose Entresto and after a short period of time, patients tolerate it, and we see some nice remodeling effects over time. So, we try to incorporate the heart failure pillars into the coronary artery disease practice as well.

Now if they have decompensated heart failure, we often turn to our heart failure expert colleagues to make some finer adjustments, but we will like you, make sure that they're on several of those foundational medications whether it's an ACE, an ARB, Entresto, plus a beta blocker, perhaps a small dose of diuretic, maybe spironolactone.

We can, patients can generally handle those. And then as we get into some of the other ones, it might get a little more sophisticated, but we are always on the lookout for who should be getting those as well.

Host: I was really wrong about Entresto. When it first came out, I think it was a New England Journal study, and I was thinking, oh, this isn't really impactful. I mean, it wasn't that dramatic. And I thought, but I think what happened and what developed the enthusiasm among our cardiology colleagues is they were really seeing in practice that getting people on Entresto, that patients were just doing a lot better when they were on this.

And that's the sort of the feedback I've gotten about this drug. And now I feel much more positive about it. I know this isn't a congestive heart failure podcast, but we went down this path and I have two cardiology experts here and I just wanted to highlight that a little bit.

Daniel Kolansky, MD: No, I think you're right. And I think it also goes to the bigger question of you started with, which is sort of chronic coronary disease and chronic heart disease, which is that patients live a long time now and do very well despite a diagnosis of either chronic coronary disease or chronic coronary disease plus left ventricular dysfunction or heart failure.

We have a lot of things to offer. Sometimes it seems overwhelming as Maureen just said that, you know, you're on four or five, six medications. And so we have to be thoughtful about that, but patients are doing very well. And so, we're partnering with primary care. We're partnering with heart failure.

We're partnering with the nephrologist to really try to help patients live a full, active, fun life, despite having had coronary events at an earlier age. And we've been very, I mean, that really keeps us going, right? We see patients who came in with an MI or unstable angina, may have had a couple of episodes had an episode of heart failure, and yet with the appropriate medications, sometimes they need a specialized pacemaker but they really do very well and go on to, to live long and productive lives.

Host: The other set of medications I wanted to talk to you about are some of these newer agents. And I think the one that I've seen, at least in the studies, is Wegovy, you know, semaglutide which is Ozempic, of course, but then was studied specifically in a risky cardiac population, a cardiac population as Wegovy at 2.4 milligrams, I believe and showed benefit. And that sort of pushed Medicare to have to cover it for that population. What surprised me a little bit about those studies is that that was really an atherosclerotic population if you will as opposed to a HFPEF population or even maybe a congestive heart failure population.

And so that surprised me a little bit just to, you know, because I don't think about those as having a tremendous impact. The GLPs specifically, I don't think about those as having a tremendous impact on the atherosclerotic disease, but maybe some of the risk factors and then maybe some of the cardiac dynamics associated with obesity. But nevertheless, I'm curious what your thoughts on the GLPs in the atherosclerotic population.

Maureen Julien, NP: Yeah, I mean, I tend to have discussions with patients, you know, about weight in general, right, we're always talking about, whether they're obese, whether they're active, get people moving more and, as we age, it's more challenging to try to lose weight. So, certainly that we know that the GLP 1s impact weight loss and whether, the downstream effect of that of lower blood pressure, better glucose, better lipids even, whether that's the result.

But I do offer it to my patients who have high BMIs and are particularly looking to try to lose weight and have been struggling. So I, we do offer them. I'll say, anecdotally, I've had some approved, I've had some with really high co-pays. You know, it's not across the board accepted, I think by all insurances at this point, depending on, there's sometimes very nuances of age and comorbidities.

Daniel Kolansky, MD: Yeah, it's, they have become so popular, they're so effective as to the point that they're sometimes not even available for periods of time and people are going to compounding agencies and the like. But this, the one major trial, you're talking about the SELECT trial, showed a 20 percent drop in cardiovascular incidents in patients at risk.

And those were patients without diabetes. I don't think we understand it. I, think as Maureen said, it probably gets to some of the secondary impacts of weight loss so that then you perhaps exercise more, maybe your overall metabolic profile is better. We certainly used to talk about the whole metabolic condition with inflammation and with low HDL and high LDL and overweight. And I think it all is part of that same syndrome. So I think reducing weight, increasing exercise by whatever means is impactful. Whether there's a specific reduction in sort of atherosclerotic factors; I don't think anybody knows. The authors of that study were careful to point out they didn't really know why this worked.

But it's an important observation and lots of room for more study. And I just think we see more and more patients. And, you know, in the beginning, we as clinicians said, well, we'll deal with the heart disease and let either the primary care or the maybe even the obesity doctors or the endocrinologist deal with your overweight, but we're seeing it as part of the practice now.

And so, we've begun to start these agents in the appropriate settings with the idea that we're helping overall cardiometabolic health. And I think that's going to be an increasing trend in doing that.

Host: These are another set of remarkable drugs that have come out. I probably prescribed, I think this week I prescribed it, maybe half a dozen patients, new patients, all of whom are appropriate for it. And I'm sure will do very well with them. So they really are remarkable. So, SGLT2 inhibitors are the newer agents as well.

So empagliflozin, dopagliflozin, Farxiga again, a set of drugs that when they came out, I looked at them. I said, that's. That's didn't have much effect. I mean, the hemoglobin A1c lowering was like a half a point and causes urinary tract infection. I said, I'm never going to use this drug. So boy, was I wrong. So we know that they have benefits in the congestive heart failure population, which is partly overlaps with the your population, right?

And then the patients with chronic kidney disease. I don't know that I've seen data for ASGLT2 inhibitors having an impact on atherosclerotic disease specifically. So I would imagine you're not using it just as anti ischemic agents, right?

Maureen Julien, NP: Agreed, yeah, we're saving that for our heart failure patients. Yeah, not our straightforward CAD.

Host: Yeah, but patients, that's part of the cocktail of medications who have had an event and now have a lower EF that are leaving the hospital on one of those agents, right?

Daniel Kolansky, MD: Yeah. It certainly is. And as we talked about a few minutes ago, we sort of go through that list. We had a patient together just yesterday who has some mild degree of coronary disease, has slowly developed some heart failure over time, ejection fraction is reduced. He's on almost all the other agents we've talked about tonight. And then we added an SGLT2 inhibitor in the hopes of sort of preventing heart failure admissions and treatment.

And we'll see. So we look through that list of opportunities. Again, as we talked about earlier, it's, overwhelming, right? You could send a patient home on 10 drugs and that's not the goal. The goal is not to have a complete polypharmacy, but I think the goal is to think about for a given patient, what's the dominant syndrome going on?

 How can we help them with the least number of medications? Unfortunately for us, that's always three or four anyway. It's a statin and an antiplatelet agent and then some form of an ACE or an ARB or something like that. But these newer agents as well play a role. So, we have to be careful and thoughtful about polypharmacy, but they have all sort of independently been shown to be helpful.

Host: There's two things I want to get to before we close. We want to talk about risk stratifying the patient who's going to surgery, but Dan, you brought up something that triggered in me a question and that has to do with exercise after having a stent. So you have two populations, I think, basically, that leave the hospital, patients who have had myocardial damage, you know, maybe portions of the wall affected. They may be now in that, again, that congestive heart failure bucket. And then you have the folks that actually got through this without a lot of myocardial damage. But now there's a question about how quickly can they get back to what may have been a very rigorous exercise program? So you mentioned cardiac rehab and you said most of your folks are going to be recommended to go to cardiac rehab afterwards. And so you're using that pretty liberally I imagine?

Daniel Kolansky, MD: Yeah. So it's part of, it's a great question. So cardiac rehab is part of the guidelines. It is in general paid for by most insurances after a specific event. So any revascularization or myocardial infarction, it is paid for. And you get a certain number of sessions, typically 30. And we look at it as a lifestyle modifier.

It isn't just the 20 minutes on the treadmill, but it's the fact that they are seeing professionals who are checking their blood pressure, educating them about sugar and diet and sleep and heart rate and encouraging exercise. That makes a huge fundamental difference. So we strongly encourage people, some say, it's okay, I have a treadmill at home, I'll just do that on my own.

And we typically say that's great, but why don't you do a few sessions of cardiac rehab to set some goals, get your baseline. And people really like it. They feel like they have a coach with them. So yes, we recommend cardiac rehab after virtually every revascularization or admission for an acute coronary syndrome or myocardial infarction.

And it's generally well received. And and I think there's a lot of value. There's value in the exercise itself, but as I said, there's value in the program.

Host: How about somebody who has an event, maybe out of the blue, ends up with a stent, not a lot of myocardial damage, but you know, some, and then goes through a cardiac rehab process. So I, what I envision is they're going in there, they're on a treadmill, they're being monitored, they, maybe even have an EKG hooked up when they're on their treadmill and they're going through a process and being coached.

And then I would imagine at some point they're graduated to they say, okay, now you can go back to your gym four days a week or whatever. Is that

Daniel Kolansky, MD: Right.

Host: basically how it works?

Daniel Kolansky, MD: Yeah, that's how it works. We often have patients who like it so much, they try to see if they can join the cardiac rehab in, but that's exactly how it works. It's also, Kendal, it's a confidence builder, right? You say, gee, I just had a heart attack and, we've known for years that people after they're in the hospital with a coronary event, there are psychological factors that occur.

There's some depression, there's some feelings of insecurity. And so it's a good way to combat that. And so yes, it gets them back to moving again. And assures them that if they were doing 20 minutes on a monitored treadmill and they didn't fall over, that they can do that at home and that they can slowly progress after that.

So we, we strongly recommend it. And for those who have really minimal disease, they had a single stent, good function, they may not really need it. They may go for a short time, but then we encourage them to strongly get back to exercise. The current recommendations are, I believe, 150 minutes of exercise a week.

You can divide that in many different ways. We know that short term, high intensity interval training is helpful. We know that, that slower walking is also very helpful. The longterm depends on your age, your state of conditioning. You know, if you were a couch potato, we're not going to high intensity interval training, but if you are somebody who was an athlete and we get those; we had a physician recently who was a bicyclist.

And for whatever reason, had a myocardial infarction, had a big heart attack, was, you know, very sick for a few days, but recovered and has really gotten back to full time cycling at a very high level. And it's, we've had to manage, how much beta blocker because they want to get up to a good heart rate and what's their ischemic threshold.

And so, sometimes we do some special testing for those things. But for the routine patient who's not a high end exerciser, just getting back to a reasonable level of exercise is great.

Host: And I guess the question you get a lot, Maureen, you probably get these a lot, is when can I get that hip replacement? And we talked about in that in relationship to antiplatelet therapy, but there's another issue of when can they be cleared for the surgery just from a cardiac perspective. So I guess you get those patients a lot. What goes into that thinking?

Maureen Julien, NP: Yeah, I think writing clearance letters is a full time job for me some days. I mean, what goes into it is when the patient's event was, what procedure are they having, how are they feeling? How are they clinically doing? Are they active? Somebody who is already six months out and is very active without any symptoms, they're probably pretty straightforward without any problems.

People who have LV dysfunction and have baseline shortness of breath, they may need more of an assessment whether that's a more recent echocardiogram, just to look at their LV function, look at their valve disease, make sure things haven't progressed. We write our clearance letters.

We like to call them risk assessments and not clearance, with a lot of caveats of there's going to be some risk, but, watch this, titrate this. We have valve disease patients, we got to watch blood pressure and volume status and and then our final line for our CAD patients is, aspirin must be continued without an interruption to prevent stent thrombosis.

I think, like Dan said, you very clearly stated the difference between stent thrombosis and in-stent restenosis, but I don't think it's very well understood, largely, and like I said, there can be devastating consequences. So there goes, a lot goes into that decision making so a lot of conversations with patients.

What are you back to doing? How are you feeling? Can you climb a flight of stairs? For somebody who isn't active and if all those things are okay, and it's a relatively low risk procedure. Now when we're talking more like vascular procedures those are higher risk and sometimes we have to think potentially about stress testing, but we kind of use that pretty carefully, judiciously, patient by patient basis depending on their history.

Host: That's another question I wanted to ask was the role of routine stress testing. Now you're outlining a situation where a patient's going to go for a non cardiac surgery or a vascular surgery and really you want to get a lot of clarity. But, you know, I remember a few years back that there was a study that came out that, came out of Columbia and was showing that patients who were followed up after events, were getting so many stress tests with nuclear imaging that they were getting the radiation equivalent to like Hiroshima or Nagasaki, and so there was this big, I think a spotlight was shown a little bit on all of this asymptomatic stress testing that was being done.

So, well, where are we at with that now? The patient who's had an event, is doing great. And, comes in maybe to see you and says, Doc, shouldn't I be getting a stress test?

Daniel Kolansky, MD: Yeah, that's a very common scenario, Kendal, and I think you've characterized it well. We tend, I tend, in my practice not to do a lot of routine stress testing after revascularization. Why? Because we know that stenting, revascularization, PCI is life saving in the acute setting, but in the chronic coronary disease setting, it's really more for symptom relief.

And if somebody is active doing what they want, not having symptoms; then routine stress testing, doesn't generally make a lot of sense to us. There are always exceptions. There are patients who aren't active, who don't exhibit typical symptoms or having big procedures. Any of those things can be reasonable exceptions, but, and we make them all the time.

But in general, if you've been revascularized, we don't necessarily just get a stress test at one year or three year or five years. It just doesn't seem to make a lot of sense. And then you get a minimally abnormal result, patient's asymptomatic, now we chase it, it leads to a second test, maybe a catheterization and so we don't find that's the best use of resources.

We want to use them judiciously. That doesn't say we don't do a lot of stress tests, we do, but we do them when there are unexplained symptoms or symptoms that we want to further chase down or people who are at particularly high risk, as we've talked about in other settings who have very high risk markers and high calcium scores and the like.

We may get a stratification via a stress test, but just the routine use of them as follow up, I don't think is needed anymore.

Host: And I do want to get you back at some point for another podcast on stress testing and, cardiac imaging and some of the specifics on that. But that's very helpful. I think that, we're seeing that as well, that as long as patients are doing well, and I think it gets back to the issue you said, Dan, that you know, folks that are adherent to their regimens, antiplatelet therapy, high dose statin, their LDLs are under control.

A lot of these patients are doing really well and they don't end up re closing those vessels again. So, yeah, I mean this has really been a remarkable success. Dan, I know and you, been, I know that been a couple of decades now but you've seen such remarkable improvement, right, just in the overall mortality rate with all of the things we've talked about, right?

Daniel Kolansky, MD: Absolutely. I mean, the national statistics are obvious. There's been a tremendous drop over the couple of decades in cardiovascular morbidity and mortality, recently, just a little bit of a slow rise again. And after COVID, et cetera, there's some interesting studies going on about that, but in general, a remarkable drop.

And I think it has to do with all of the things we talked about. I mean, patient awareness diet, lack of smoking, increased exercise and then medications are have really changed the landscape. We've also been able to treat more patients and treat them more effectively with both meds and revascularization.

So we, we don't take that out of it. I think it's a critical ongoing need. And interestingly, you know, in the big cities, there's plenty of cath labs and plenty of interventional cardiologists. Out in the faraway communities, there's still a need and acute MI care is still considered an underserved area in some places.

I don't mean to say that it's, there's not a need for it, but I think the whole package, medications, smoking reduction, all that has made a huge impact. And on the points we were just talking about, about routine stress testing and things, I mean, I think that, you know, as much as we can, the one to one interactions with the patient, come into the office, talk about it, see how you're doing, you're walking up and downstairs, you're doing groceries, you're carrying laundry, you're walking from the train station, any of those normal daily activities, those are stress tests for the patient.

And if they're feeling well it's important you hear them and take that into account and not necessarily over test. So that's what we're on the lookout for.

Host: Well, this has been a great discussion. I really appreciate it. Any closing thoughts? I always put people on the spot and I never tell them I'm going to ask this question at the end and I never give them a chance to, but, Maureen, is there anything that comes to mind that you'd like the primary care audience to know about?

Maureen Julien, NP: I think my biggest takeaway message is, have a good relationship with the cardiologist and stay in touch and we're happy to answer questions and before you make any decisions stopping aspirin, talk to your cardiologist.

Daniel Kolansky, MD: Yeah, I think that the team approach is really great when we can do that and stay connected for the health of our patients. So thanks for having us, Kendal. We uh, love talking about this. We feel very privileged to participate in the care of so many of these patients and helping in small ways and large ways to keep them going for many years.

And that's the, right, that's the fun of it. We've all been in this a long time and we really get a lot of gratification when patients us a note that says, you know, gee, I'm, many years out from my intervention and my blood pressure is under control or I just ran my marathon or whatever it is.

And we have a number of those and it brings a smile to our face because we're, that's what it's all about. It's trying to keep those folks healthy and active.

Host: I had a cardiology colleague tell me that recently he said, you know, when I was younger in practice, I didn't have anybody in 90 year old in my practice. He said, now I have lots of them.

Daniel Kolansky, MD: Yes.

Host: So, it's a tribute to all the work that you all are doing. So thank you again for joining us. And thank the audience again for joining the Penn Primary Care Podcast. Please come back again next time.

disclaimer: Please note that this podcast is for educational purposes only. For specific questions, please contact your physician. And if an emergency, please call 911 or go to the nearest emergency department.