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Scott Webb (Host): Preventing heart disease is perhaps easier said than done for many of us, but it's one of the keys to not meeting my guest today in the operating room. And I'm joined today by Dr. Vincent DeFilippi for a wide ranging discussion on all things heart and vascular. And he's the perfect guest for this discussion since he's a Cardiac and Thoracic Surgeon and the Medical Director of Cardiac Surgery at SVMH. This is Ask the Experts, a podcast from Salinas Valley Memorial Healthcare System. I'm Scott Webb. So, doctor, thanks so much for joining me today. Let's start here. Let's talk about the importance of not delaying care if people are suffering from symptoms of stroke, heart attack, whatever it might be, we definitely don't want people not going to the ER, not going to the hospital, just because of the pandemic, right?

Vincent DeFilippi, MD, FACS (Guest): Yeah. What we've found is that there's a lot of people that are coming now to the hospital with heart attacks, are coming at a later stage. What this means is that a lot of these people have already suffered damage to their heart that could have been avoided. And this was just because they were scared to come to the hospital, I think that it's important that people are scared to come to the hospital because I think people with COVID are in the hospital, but the hospital is actually one of the safer places to be because everybody's checked, everybody's got all the garments and PPE and everything on. And so, it's actually a safer place to be than most places. And, by delaying care, you could risk your life.

Host: Yeah, you're so right. We know the expressions are a time is brain, time is heart and time is of the essence with some of these emergent, emergent types of things like heart attacks. And, you know, people go to the grocery store, right? And they put a mask on and they go to the grocery store. And most of us don't worry too much about that. So, if you're worried about, or you're wondering where the safest place to be is, it's definitely the hospital, right?

Dr. DeFilippi: Yes. And just back on that point is that we've looked at the studies now and that in this time of COVID that the risks of dying of heart disease are higher now than they've been before. And it's because some of the people aren't even getting to the hospital, they're not coming because they're so scared. And it's not just that you lose some of your heart. You could lose your life. So, definitely don't delay care, call 9-1-1, get to the emergency room.

Host: Yeah. That's the best advice. And that's the best takeaway here is if you feel like something's wrong and you feel like you probably should go to the hospital or you should probably should call 9-1-1, then we definitely want people to do that. And doctor, we've got so much to cover today. We tend to do that when we get a heart guy on, we tend to want to ask them, you know, every question we've ever had about, you know, hearts and heart disease and procedures and everything else. So let's get going here. Let's start with what is cardiovascular disease?

Dr. DeFilippi: Well, if you just look at the word cardiovascular, it's actually a very broad spectrum, the cardio of the heart, you know, like cardiac and vascular, that's your blood vessels. So, it can really be a wide range of things that are, things wrong with your heart, but even things that are wrong, or diseases of the blood vessels throughout your entire body. So, it's a very kind of broad spectrum of issues when you use that word. Most people though, when they talk about cardiovascular disease are talking about heart disease, which is the cardio part of that.

Host: Yeah, it does seem so that they seem to be used almost interchangeably at times. So, let's talk specifically about heart disease. What are the risk factors for heart disease?

Dr. DeFilippi: So, again, there's all kinds of heart disease. The same way cardiovascular is kind of a broad spectrum word, heart disease, kind of a broad spectrum. But when we specifically talk about cardiac disease as related to the arteries in the heart or coronary artery disease, we have some pretty specific known risk factors. They fall into two buckets. One are sort of ones that you can't change, things like your genes, being a male, getting older; those are all risk factors you can't change. Then there's a modifiable risk factors, to some degree things like, diabetes, cholesterol, which are partly, can be genetic, but also can partly be based on your activities. The most obvious one that is significant and alterable is not smoking. Things like stress, are also difficult to change, but there is some data to show that if you do mental yoga type, activities that this can reduce your incidence of heart disease.

Host: Yeah, it does seem like there are things that we can control and things that we can't, things definitely like smoking. That's something we just don't need to do. It's easier said than done to quit, but a major, you know, as you say, the biggest risk factor there, and we're going to come back to diabetes in a second, but first in Monterey County, in terms of race, who are the most prone to heart disease?

Dr. DeFilippi: Well, actually, we found at the hospital here that we've got about 50% of our people, slightly higher, that are undergoing heart bypass surgery are Latina, Hispanic patients. We have, a very high incidence of that within the population here. And whether this is in part related to the diet or part related to genetics, it's always difficult to separate those out. But we do know that, dieting and exercise and things can be a benefit to any race, but, specifically to the patient population we have here it could be even more beneficial.

Host: Yeah. It sounds like it, and back to diabetes, what's the connection between Type 2 diabetes and heart

Dr. DeFilippi: disease?

There's a strong connection between Type 2 diabetes and getting coronary artery disease. Again, using that for heart disease and that it is a somewhat modifiable, that is, that we can treat it with medications, but there's a certain subset of the population that if they get on an appropriate diet and exercise regimen that they can eliminate and certainly reduce the effects of diabetes. The effects of the diabetes are basically you get what some people refer to as hardening of the arteries. They get plaques that build up in the arteries, and this is the things that cause heart attacks, but also as part of cardiovascular disease, especially in diabetes, there's a high incidence of other arteries in the body, in the legs that can be affected. It affects all the arteries in the body to some degree.

Host: And sticking with diabetes, let's talk about in terms of people you see and people you've operated on, let's talk about the youngest oldest. Do you operate on young patients? And if you do, what does it mean for younger patients and the rest of their lives? Their quality of life, if you will.

Dr. DeFilippi: So, again, in sticking to the coronary artery disease part of this, because you can do heart surgery on newborns that have certain defects that are genetic, that changes the anatomy of their heart, that surgery needs to fix. But in talking specifically about coronary artery disease, we've now operated on people in their late twenties, early thirties. Some of this has to do, like I said, with the diet and exercise component of this, which is, kids are getting diabetes at a higher and higher incidence. And so, if you take someone who's been on insulin say since they were 10 years old, well, by the time that they're 32 years old, they've been a diabetic for 22 years.

And so, this would translate into, let's say if somebody became a diabetic at 45, that 22 years later, that'd be 67. That sounds much more usual, but, it's basically that now people are getting the diseases younger, they're getting the effects of the diseases for a longer period of time. And so they are coming in younger and younger.

Host: Yeah. That's kind of alarming and sticking with cardiovascular disease, what are the symptoms for people to be on the lookout for.

Dr. DeFilippi: Not everybody is like on TV, where they grab their chest and they go call 9-1-1, and that's the classic, somebody is sitting on my chest or getting a pain down my arm, and those are the classic. Sometimes the pain goes up in their neck. It could be much more subtle than not, especially in people with diabetes. Some people with diabetes have almost no symptoms at all. They maybe just feel a little bit off, the classic heart burn is called heartburn because it mimics a heart attack.

And so some people will think it's just heartburn and I've had lots of people that have come in and they're just taking Tums. And for whatever reason, their heartburn is not getting better and it doesn't get better because it's a heart attack. And when you get those kinds of symptoms, it's always important to keep on your mind that it may not be the heartburn that you think it is.

Also, I think that there's a large subset of people that maybe get short of breath. There's some that just feel off a little bit and they'll just sit on their sofas and have a heart attack because they just aren't feeling right. So, I think it's really important to have a heightened awareness that it doesn't have to be just like it is on a TV where somebody's grabbing their chest, that if you're feeling off that way and it doesn't get better quickly that you need to think this could be a heart attack.

Host: It's interesting to me that you mentioned heartburn. I had a friend whose dad thought he was having heartburn one night when my friend was a kid and he took some Tums and he went to bed and of course it was a heart attack and he did pass away. And I've never forgotten that story. And I am always conscious of that, you know, when I have heartburn, I think to myself, is this heartburn, or could this be something else? And if it's not accompanied, you know, by other symptoms than I generally assume if the antacids work, then it probably was just heartburn. Is that kind of a good way, a good approach?

Dr. DeFilippi: Not always because some of the medications that we treat heartburn with also can help with the pain that you can get from heart disease. So, if it's positional like lying down, which would be heartburn, sometimes you get reflux from lying down and, it can be more comfortable saying, okay, this probably isn't a heart attack, but, I think it's always better to hope for the best, but assume the worst. And it's worth getting it checked out, especially if you have any risk factors.

Host: Yeah. I think that's key. If you have risk factors, you know, as you say, it could be positional or contextual, but in the end, if you're worried, if you're concerned, don't sit on your couch. Don't go back to bed. Call 9-1-1. And when we talk about the signs and symptoms of heart attack, are they different for men and women?

Dr. DeFilippi: They're not necessarily different. Although some people think that there's a higher incidence of what we just said, the non classic chest pain in women. I think that the issues and it's a little bit uncertain why that women tend to present at a later stage of heart disease. There's some that think that because it tends to be thought of as a disease of men, which it's not; the number one killer of women is also heart disease. But it's thought that sometimes they'll say, oh, they're just having some kind of anxiety and they don't give them the appropriate testing and things to identify that it is heart disease and not something else.

Host: Yeah. That is an interesting and a bit alarming that you’re seeing women later in the process because they don't associate it or chalk it up to what it probably is. And that's one of the questions I wanted to ask you when a patient comes to see you, man or a woman, how bad typically is the damage to their hearts.

Dr. DeFilippi: Just back for one second on the men and women thing, because being a man is a risk factor for heart disease; but especially when women are post-menopausal, the incidence of heart disease comes right back up to where men are. So, there's no reason to think it's a disease, just of men. It's really important for women to be aware that it can be just as equally deadly in a woman as a man. Now in some patients that come in, damage to their heart can range a lot from you can have heart disease and a normal heart, as far as heart function goes. They can come in and you just get some chest pain. And, it can be because of blocked arteries, but they haven't had the heart attack yet, so that their heart's still strong and that's really important. And that's the whole piece of what we're talking about in the COVID; not waiting because if you wait until after the heart attack, okay, damage to their heart can be so severe that there's nothing you can do to help them. You just say, this heart cannot survive any kind of procedure or the heart's all dead now.

So, there's no point in getting new blood vessels in there because you're just supplying a dead heart. The heart's a muscle, and you're just supplying that dead heart muscle with more blood and it doesn't help their heart at all. And so, the damage can be range from none to a situation where they're not going to be able to ever function again in a meaningful way. So, it's a wide spectrum.

Host: Yeah. It sounds like it. And you know, you specialize in cardiac surgery, thoracic surgery, and I'm sure the surgeries and procedures have changed a lot over the years. So, let's talk about some of those changes, especially with respect to advances in technology.

Dr. DeFilippi: It's definitely a procedure that over time has improved. As the patients are getting sicker and older, we're still maintaining excellent survival rates with bypass surgery. It's still, on the order of 98% survival, despite the fact that the patients, like I said, have gotten older and sicker. Some of the advances in the machinery that we have, some of the recovery is better because we'll do say taking veins out of the leg, when we do that, we can do it in a minimally invasive way, so that the walking, which is an important part of recovery is almost pain-free because we were able to not have the big incisions that some places or sometimes were done. And so, some of these technological advantages will help with the recovery after surgery, as well as with the overall survival and results of the surgery.

Host: Yeah, my dad had a quadruple bypass, last summer. So, between COVID and this major open-heart procedure, it was pretty scary. Couldn't be in the hospital with him. My mom was the only one who could be in with him and he's doing great. Seventy-five years old, quadruple bypass. He's doing great. And you're so right. The minimally invasive approach, really does work, especially for that quality of life afterwards.

And, this story, I read about this story, and I want to have you talk about this. A couple of years ago, you did a triple bypass on a 98 year old Salinas man. In 2020, he celebrated his 100th birthday soon he is going to be 101, a hundred and one. Amazing. So, how do you make a decision to operate on a person of that age? And who's a good candidate for bypass procedures, surgery?

Dr. DeFilippi: Well, certainly bypass surgery is a big surgery in any case. When it starts to hit some of these limits of the function of the person and the age, it's, you don't just look at age as just a number to some degree although 98 certainly was a very big number. I've operated on a number of people in their nineties. But with him, he was there, he was having, chest pain at rest, you know, couldn't basically do anything and he didn't have any other options. The thing that really pushed me over the edge as far as agreeing was they had a video of him several months before, at a wedding, dancing.

So, they showed me on their phone, look at this was him just a few months ago because I was asking how active he was and he was dancing at the wedding and he told me that he wanted to dance at more of his family members' weddings in the future. And we took it on and he was great. And I've seen him a number of times and he has danced at more weddings since then and had his hundredth birthday. And yeah, so that was a that was a good choice for him.

Host: Really amazing. And as you say, you can do heart surgery on infants, and apparently you can do heart surgery on 98 year old men and everybody in between. And I'm sure it's very gratifying for you to see that he's still out there at 101 dancing at weddings. And I don't want to let this go by. I think we all sort of think we know what bypass surgery is, but maybe you can take us through that a little bit. What does that mean exactly?

Dr. DeFilippi: So, basically the people with coronary artery disease have blockages in the arteries in their heart. And what we do when we do a bypass is, we take an artery or vein from somewhere else in their body, and we put it on the other side of the blockage. And so it's not like when you get stents or other things where they actually address the blockage, you go around the blockage, almost like on the highway, if you take a detour. And so, it's another blood supply to that part of the heart through another vessel. And so, you've bypassed the blockage. You don't remove it. And that's why it's called a bypass.

Host: Really amazing. And as I said, my dad is 75 and he's doing great. And you know, this great story of this guy, that Salinas man is going to be 101 years old. So, obviously it's a sort of a tried and true, you know, procedure that's still working today. And we talk about open heart surgery, how often does that take place? Is more and more, are more and more things being done, minimally invasive, where you don't have to open the chest? Maybe just take us through that a bit.

Dr. DeFilippi: Sure. Especially as the population ages, there's more people who are going to have coronary artery disease. When we talk about bypass surgery, what we found is that in patients, especially ones with diabetes, and if they have multi-vessel disease, that bypass surgery in the long term, meaning five years on for patients they'll have a higher chance of being alive if they've had bypass surgery, then other options like stents.

And at one time, bypass surgery was thought to be something that was not going to be okay as needed anymore, but instead it's the opposite. It's more needed, it's withstood the test of time. And so, I think about 500,000 people had it last year. It's, it's one of the most common procedures performed. And so it's something that's really been helpful for a lot of people and prolonged a lot of lives, increased a lot of quality of life. And so, I think that, it's an important piece of treating these patients. Now, ultimately the hope would be that as we institute more and more preventative measures, that the incidence of this will go down and that's okay with me, even though I love doing surgery, it would be great to know that the population is getting healthier because they're doing preventative measures to keep people out of the operating room.

Host: Yeah. I mean, we don't want to put you out of business. We don't want to, you know, have you looking for work or anything, but, interesting that you say that there was a time when it seemed like there was a push to kind of eliminate bypasses. And the reality is it's still the gold standard. It still works, half a million people last year alone. So, pretty amazing that's something, that the procedure technologies that have been around for so long are still the gold standard for many people, that the open heart approach is still so common and good that you still have work, because you're really good at what you do. As we get close to wrapping up here and we've covered a lot of ground today.

And I just love when I get a heart surgeon on, because I can ask him all the questions. Let's go back over again the importance of not delaying medical care, any signs and symptoms, heart, stroke, whatever it might be, get to the hospital, right?

Dr. DeFilippi: Yeah. Again, any fears that they may have of getting anything else from going to the hospital are certainly going to be less than not being alive because they didn't go to the hospital or having a heart attack that's going to affect their quality of life for the rest of their lives. And, like I said, I've seen patients now that have come in and they'll be, well, three days ago, I was having some really bad chest pain and I'm still having some, and then we looked, and as you said, the damage to their heart is so severe that now we've taken a potentially low risk situation and something that could make the rest of their lives much more high quality of life, and we turn it into a high risk and a situation where we don't know how much we can help them. So, getting in early is really important in this problem. And so, any other fears, like I said, the hospital is one of the safest places to be. Everybody's got all the gear on and all the patients that come in are getting tested. So, anyone else that's in their area, any of the patients that test positive are in an isolated, total different section of the hospital. You don't even come into contact with them in the hospital. So, it's a safe place to be. And certainly when your life's on the line, you should be there too.

Host: Yeah. That's great advice and great advice from a great surgeon and doctor, as we wrap up here today, anything else you want to tell people about heart disease, cardiovascular disease, modern procedures, old school bypass, like what else do we want to tell people today?

Dr. DeFilippi: I think that the key of this is I don't mind going out of business for it, if I thought that everybody was getting the best lives. And if, preventing this disease is the key to all of this. And even though I don't think that will with the technology that we have right now, that it's going to go away, you can prolong it, but you can get a better quality of life by dieting, exercising, seeing your doctor, taking your medications and just being on your own health and aware of your own health. I think educating yourself about these things is going to give you a better life and a higher chance of not meeting me that way.

Host: Yeah, I think you're so right. I think prevention is key and there are things that we can control, right? There are modifiable behaviors that we can control. We can't fight necessarily genetics or age, but there are things that we can do. So, eating healthy, exercising, quitting smoking, all the things we've discussed today. So, great having you on. Look forward to speaking with you again in the future and you stay well.

Dr. DeFilippi: You too. Thanks.

Host: For up-to-date information on COVID-19 please visit svmh.com/coronavirus, and we hope you found this podcast to be helpful and informative. This is Ask the Experts from Salinas Valley Memorial Healthcare System. I'm Scott Webb. Stay well, and we'll talk again, next time.