Joey Wahler (Host): It's the leading cause of death in the United States. So, we're discussing heart disease and St. Clair Health's Cardiometabolic Clinic. Our guest is Dr. Nikos Pappan. He's a cardiologist. This is Curating Care, a podcast from St. Clair, health expert care from people who care. Thanks so much for joining us. I'm Joey Wahler. Hi there, Dr. Pappan. Welcome.

Nikos Pappan, MD: Hey, Joey. How's it going?

Host: Good. Yourself?

Nikos Pappan, MD: Good. Very good

Host: Great. We really appreciate the time. So first, how long have you been with St. Clair Health, and what first drew you here?

Nikos Pappan, MD: Yeah. So, I finished my training at Allegheny General Hospital June of 2025. In July of 2025, right after training, started at St. Clair. So, I've been there coming up on about a year so far. I think the one thing that really drew me to the hospital system was the support from the administration, on innovation, and kind of what I wanted to do with my career as a non-invasive cardiologist, one of them being prevention. And that's why, you know, we started the St. Clair Center for Cardiometabolic Prevention.

Host: When you mention prevention there, tell us a little bit more please about your role at St. Clair in terms of making prevention effective.

Nikos Pappan, MD: I think, you know, starting with cardiology and who we generally see is important to identify. So typical or as history kind of evolved, cardiologists see the patient who already has chest pain, who then gets sent for a stress test. And then, we find disease. And then, they get a procedure which they may require a stent.

I want to shift that model into, "Hey, why don't we try to identify these patients before that chest pain occurs or before that plaque builds up?" And so, my focus is on identifying this disease early on in the patient's life. And I think one of the most important things is innovation within the cardiology field. You know, St. Clair is fortunate enough to have CT coronary. Also, they have a contract, they just brought in HeartFlow, which is a company that can assess plaque in the coronary arteries.

So, there's so much advancements in technology in the cardiology field to identify these younger patients before they really have clinical disease and heart attacks. And so, my focus is trying to identify those younger patients that really need prevention. And so, they don't have that heart attack at age 65.

Host: You mentioned CT coronary. For those unfamiliar, what is that exactly?

Nikos Pappan, MD: Yeah, absolutely. So traditionally, we send patients for stress tests, which just identifies blockages that might be greater than 75%. But we actually don't visualize the arteries around the heart or the arteries that supply the heart muscle, the coronary arteries.

And so with CT coronary, it's basically—well, it is a CT scan of the heart, and we're able to really visualize the arteries, and we're able to see if there's blockages, and we're able to tell the degree of blockage. So, we can say there's ten percent plaque in one of the arteries. And so, it puts that patient into a different category of prevention. So, they no longer have zero coronary artery disease. They now have coronary artery disease. It's not greater than 70%, but it does elevate the risk of that patient. And so, that's a really unique test that really allows us to visualize and identify risk factors early on in the patient's life.

Host: I want to go back to something you mentioned a moment ago. Many people, of course, think heart disease mainly affects older adults, but how much are you seeing risk factors develop earlier in life, and what are some of the warning signs people should pay attention to?

Nikos Pappan, MD: Absolutely. I think more and more we're seeing the younger patient with heart disease, and maybe that's a result of having better tests and better technology, so we're able to really see, for instance, like I had mentioned, the CT coronary. But, regardless, younger and younger patients are getting heart disease.

And the American Heart Association came out with staging criteria, okay, for cardiovascular disease. And it's basically a spectrum. So when we look at stage IV, which is the end of the spectrum, that's the blockages, the people who have the heart attacks. But now with technology, what we're identifying is this stage I and stage II patients, which actually is a factor of increasing adiposity tissue or inflammation in the body, and we kind of get an insulin resistance. You might not have full diabetes, you might not even be pre-diabetes. But on the molecular level, you're starting to see some insulin resistance and maybe the cholesterol is going up. And that's what you'll identify, and that's what these patients need to look out for, is the weight starts to go up a little bit, the BMI creeps up to maybe thirty, and that cholesterol starts to go up a little bit. It might not be to the scary levels, but you're seeing subtle shifts in the molecular level in the cholesterol panel. Maybe the A1c is starting to creep up. And so, they don't have symptoms in the stage I or stage II, but we're really starting to see some of these warning signs that, hey, if a patient doesn't change their lifestyle, then when they're older, unfortunately, they are at higher risk of having those events. And so, I think the most important is really identifying those really early signs and then changing the lifestyle to prevent events in the future. And that's what we're trying to build.

Host: Absolutely. And you led me beautifully there, Doc, into my next question. As mentioned, heart disease does remain one of the leading health concerns in our country. So from your perspective, what are a couple of the biggest contributors to cardiovascular disease these days?

Nikos Pappan, MD: I think diet is huge. you know, with the fast food era and all these, you know, processed foods, I really do think that diet and lifestyle has a huge impact on cardiovascular health. I think another subtle, but very important risk factor is family history. I really do.

I think oftentimes we'll see a patient that the lifestyle has maybe crept away a little bit. You know, maybe they're 45, and they have this really strong family history of their father having an MI at 45. That is such a big impact, and I think that patients don't realize that. So, not only is the lifestyle creeping, but you have kind of on the molecular level some sort of genetic inheritance that you're at higher risk no matter what you do. And so, if you fall off a little bit with the lifestyle, things can escalate. And that's how people, you know, have MIs at a young age.

Host: Of course, when we talk about lifestyle changes, especially as we get older, making those changes certainly easier said than done, as we all know. So if you had to give people joining us, Doc, just one or two things that most anyone, regardless of their situation, can do starting today to take a step or two toward preventing heart disease, what would it be?

Nikos Pappan, MD: I think that is such an important question because oftentimes patients will come in and they'll get the classic response of, "Oh, go do the Mediterranean diet." And that is just so not practical and extremely hard with our busy lifestyles, and living in PA, right?

And so, what I often tell people is try to identify their bad habits. Maybe it's eating out five times a week. Maybe it's eating bread three times a day or, you know, other carbohydrates three times a day. And I will tell them we are trying to change their lifestyle. And so, you don't need to go from zero to 100 in one day. It's about slow steps. So, what I'll say is, let's say if someone's eating bread every single meal three times a day, then I'll say, "Hey, for the next two weeks, why don't you not do bread for lunch and see how you do? And then, after two weeks, stop it at dinner and maybe just do one meal." So, something so simple like that really tries to create lifelong changes and lifelong habits, not these fad diets that people often do well with, lose a bunch of weight. But unfortunately, you didn't change the lifestyle and the weight just comes right back. So, I really try to simplify it, to that just small goals, small goals that in the big, grand scheme of things really make a difference. And so, that's what I usually tell my patients.

Host: And no question that whether it's diet or exercise, if you have realistic goals, especially in the beginning, certainly a much better chance that you're going to follow through and not fall off the wagon, as they say, right? So, let me ask you just to backtrack for a moment about screening. What does heart screening these days consist of? I don't know if it's changed at all in recent years, but what does it consist of and how often should people typically go for that, whether they're at risk or not? And what's the difference there?

Nikos Pappan, MD: Yeah. I think the most important screening is the cholesterol panel or lipid panel, the A1c. And I think that patients don't realize that when they go to their PCP's office, we're screening the blood pressure, we're screening the weight. So, those simple things are actually a cardiology evaluation. And you go to your PCP at least once a year, and they should get those labs once a year.

Again, going back to what I said, those subtle changes, we'll see those. And those, you know, four things that I just mentioned, we'll see if the blood pressure is creeping up. And if it's creeped up at that office visit, hey, maybe start checking it at home to see if this is actually creeping up or it's just because you're at the doctor's office.

The weight, "Oh, hey, we've noticed, you know, last visit a year ago, you were 10 pounds lighter." So, we see those subtle changes. And then again, in the lab work, the A1c, which is just a screening for diabetes, and as well the cholesterol panel, which is obviously screening for cholesterol. So, those subtle changes should be yearly, often done by your PCP.

Host: Which brings us to the Cardiometabolic Prevention Clinic at St. Clair Health. So, what first inspired the creation of this program, Doctor, and who exactly is it designed for?

Nikos Pappan, MD: Absolutely. The whole idea behind this was prevention. Going back to kind of what I originally said, cardiologists often see people when the disease has already happened. Either it's, let's say, after a stent or right before a stent when they have symptoms.

And so, everything I think is shifting to prevention, and I wanted to be part of that movement. And I think St. Clair wanted to be part of that movement to really make a change in the younger population so that we prevent those events in the future. And people, I think, are getting more educated on nutrition. They're more conscious about what they're eating. There's so much information nowadays with, you know, the social media apps, et cetera, about food, exercise, I mean, you name it, that people, they want early identification, and they want resources to help change their lifestyle. I think the worst thing that we can do in the healthcare system is take a high-risk young patient and make them feel helpless, make them feel like they don't have any resources.

And so, I wanted to change that. And that's what, you know, really shifted, the thought into starting this clinic, is to really give a lending hand to that patient that they know they're at high risk, and the PCP's doing a great job, you know, identifying those risk factors, but sometimes they just need a little bit extra. And so, that's what I'm trying to build here

Host: And speaking of which, what would you say makes this clinic different from a traditional cardiology facility and visit? And what can patients typically expect during their first appointment?

Nikos Pappan, MD: Absolutely. So, this is, again, like I said, really focused for that high-risk younger patient that really needs to make lifestyle modifications. So when the patient comes in, they're evaluated by me or Dr. Katherine Shreyder as well, both non-invasive cardiologists. We identify their number one risk factors, whether it be the cholesterol is not at goal, they have underlying, coronary artery disease, the blood pressure's not at goal, the BMI is elevated, and we kind of put them into treatment algorithms based on those risk factors.

I think the best thing that we're doing, and that's really a differentiator, is everyone is getting a nutrition consult. And so, we partnered with a company called Nimbus Health that actually makes personalized practical nutrition plans, which I think is fantastic. And they check in with the patients on a monthly basis to see how the nutrition plan is going to keep the patients engaged.

And I think that's kind of the differentiator as well. Patients will come and see their PCP on month one, and then maybe not again until month six, or they'll come see us month one and then a year later, right? And we have no idea what the patient is doing in between those visits. We're hopeful that they're following, you know, what we had discussed in the 30-minute visit, but it's just not enough.

And so, with this nutrition plan, touching base with the patient between visits, keeping them engaged in their care plan, I think is going to be huge, and I'm hopeful that it does make an impact on the patient that really wants to change.

Host: In summary here, Doc, for those joining us who may be putting off addressing their heart health, you've done a great job of breaking down some of the details of what they need to do. What would you say to encourage them to take that first step?

Nikos Pappan, MD: Ask your PCP. You know, I think the most important thing is talking to your PCP and really asking, "What are my cardiovascular risk factors?" And walking through the cholesterol panel that we get. I think it's so important to get educated on what those numbers mean, what the goals are, what we think the goals are, specifically maybe with that LDL, which is that bad cholesterol everyone talks about.

So, understanding what we're trying to achieve as physicians to the patient, I think, is very important it allows the patient to take control of their health. When they know that, oh, let's say the LDL goal is 70, and they look at their last cholesterol panel and maybe it's 92. It keeps them engaged because they know what the goal is. And so, they strive to achieve that goal. So, it really gives the patient ownership. And so, asking your PCP, you know, "What are my risk factors? Can we go through these labs in a little bit more detail?" Rather than just saying, "The cholesterol is good. The blood pressure is good." "Well, what would you like my blood pressure to be at?" You know, those simple questions helps a lot, I believe

Host: I'm sure it does. Well, folks, we trust you're now more familiar with heart disease and St. Clair's Cardiometabolic Clinic. Dr. Pappan, valuable information for all of us really. Continued success with the clinic, and thanks so much again

Nikos Pappan, MD: Absolutely. Thanks for having me, Joey

Host: Same here. And for more information, please visit stclair.org/heart. If you found this podcast helpful, please do share it on your social media. Thanks so much again for being part of Curating Care, a podcast from St. Clair, health expert care from people who care