Transcription:
Cardiovascular Medicine at UK

Melanie Cole, MS (Host): Heart disease is the nation's leading cause of death and a major cause of disability around the world. That's why it's so important to have a state-of-the-art cardiology department. Today we're talking about cardiovascular medicine at UK Healthcare. My guests in this panel discussion are Dr. Francisco Hidalgo, he’s a general cardiologist, and Dr. Thomas Whayne, he’s a cardiologist and the director the Lipid Management Clinic. They're both at UK Healthcare. Dr. Hidalgo, I’d like to start with you. Tell us a little bit about the current state of heart disease today. What’s the prevalence and awareness as you see it? What’s different now about what we know about this disease?

L. Francisco Hidalgo, MD, FACC (Guest): Well I think I would like to start talking really about the region of Kentucky. I think like currently the situation of Kentucky is that there’s a very high prevalence of people smoking. As well as people being overweight or with obesity. So I think that there’s some modifiable risk factors of coronary artery disease or cardiovascular disease that can be modified. As compared to other states, I will say that the prevalence of either smoking or being overweight is pretty very high in Kentucky.

Thomas Whayne, MD, PhD (Guest): So I will certainly agree, if I can jump in. Unfortunately there’s still a lack of full awareness, including on the part of primary care providers in terms of the importance of the things that we have to offer. Because we do have so much to offer now with statins, these newer injections, the PCSK9 inhibitors that really can help prevent or delay the occurrence of coronary disease. Yet, it’s still incredible the number of times I see patients where the right thing has not been done. Constant education is critical.

Host: I couldn’t agree more. Education would seem to be the crux of the understanding of heart disease, whether it’s in Kentucky or really anywhere else in the country. One thing that I don’t know people really understand when they're looking for a provider, even to get tested, Dr. Whayne, is the difference between you all. Can you tell the listeners what is a cardiologist versus a cardiac surgeon or a cardiothoracic surgeon? Or they hear the term interventional cardiologist and they don’t know what that means either.

Dr. Whayne: Alright. Well a general clinical cardiologist, or we just even refer to ourselves as a clinical cardiologist, is that we are specialized in the care of patients with cardiovascular medicine. Really, we don’t limit ourselves just to the heart. Most of us, the whole vascular system is at risk. But we are specialized in terms of making decisions of when to refer the patient on, and I’ll explain to whom we refer. Then what we can do with the very best prevention, like the use of these statins to try to delay the occurrence of coronary disease and specific medication treatments, which we will manage. On the other hand, a cardiac surgeon or cardiothoracic surgeon is specialized just in surgical procedures on the heart. A lot of them when we say cardiothoracic, they do some other chest procedures, but they are surgeons. They will not see the patient unless someone like us or an internist or primary care provider has referred that patient.

The interventional cardiologist is one that is most highly specialized in doing percutaneous procedures on the heart that can help avoid the need for surgery. Such as with a patient having a severe coronary disease and symptoms, doing an angioplasty with a balloon and with a stent placed over that to help keep the lesion open. That is the interventional cardiologist. A lot of interventional cardiologists do see patients, but their practice is directed at doing these, they are procedures. And they help avoid the need to do a more extreme procedures, which would be cardiothoracic or cardiac surgery.

Dr. Hidalgo: I would like to add, I agree with Dr. Whayne’s description of each of these physicians. The way that I see it is that as general cardiologists, we are treating the patients medically with medications trying to modify lifestyle, provide medications as Dr. Whayne was pointing out. We also try to prevent heart disease. We prescribe medication statins to decrease the risk of cardiovascular disease. But obviously as any other fields in medicine, unfortunately we cannot manage everything just by medications and prevention. Sometimes we have to escalate to other options.

So from one standpoint, we have interventional cardiologists, as Dr. Whayne explained, who is the person who is specialized on doing interventions on the heart. Specifically doing stents or balloon angioplasties. Obviously there have been new advances on what interventional cardiologists can provide to the patients. Now there’s included interventional cardiologists with no surprise who are focused on doing valve replacement.

On the other side, we have the thoracic surgeon, which is the surgical option. The surgical approach. Obviously if medications don’t work anymore on the patient or it is deemed that the patient will not be a good candidate for being treated by interventional cardiologist, we have the option from surgeon standpoint. So that’s kind of maybe the difference in between these fields. I think that the most important thing about these is that all of us work together. We work as a team. Obviously, we coordinate well the care of the patient. We work mainly as a team rather than just working as an individual.

Host: It’s very collaborative, and that multidisciplinary care is so important when it comes to patients with heart disease or preventing it. Dr. Whayne, tell us a little bit about the Lipid Management Clinic. How do you go about treating your patients? What can they expect from you?

Dr. Whayne: As far as the clinic, I don’t run a specific clinic. I see patients four days a week and I have built a reputation for the referral of these patients. So it’s really more of a general term, but there is so much we have to offer now. I mean you still always want, as a classic term, a therapeutic lifestyle change. But you still want the patient to start with that where they improve their diet. A perfect diet I suggest as a very general, easy to look up type of diet is the Mediterranean diet. Even a diabetic can modify their sugar content and follow a Mediterranean diet, which has several very healthy components. So you want them to start with that. Obviously controlling and losing a lot of weight, which is a major problem here in Kentucky, which would help also control their diabetes. We have an incredibly high instance of diabetes here.

Then exercise. We don’t want to forget about the value of exercise. Actually when the patient is exercising, this cardiovascular risk does go up during that interval. Otherwise, the proof is solid that exercise in and of itself helps decrease your cardiovascular risk. That is so important. Even though, right now, we have an emphasis on lowering the LDL.

So in terms of lipids, the bad guy, you’ve heard of the HDL. In most cases the HDL, which is the high-density lipoprotein, is the good guy, and it’s generally protective. Although there’s subtleties and not always so. The LDL is the low-density lipoprotein. That is the bad guy that is the principle carrier of cholesterol. For right now, in terms of cardiovascular disease prevention, over and above these therapeutic lifestyle changes and controlling the blood pressure, the major thing we have to offer is a marked lowering of the LDL and the data is very clear that lower is better. So, of course, you have to balance benefit versus risk in terms of our medications.

Unfortunately, the statins, which are really the greatest contribution to cardiovascular disease prevention in the past century, they're fantastic. But nevertheless, 10% of people still get some muscle symptoms. So you have to work carefully and make sure that you still have the equation in favor of the benefit versus the risk of what you're doing. But without any question, we are prolonging lives, delaying the development of cardiovascular disease, and prolonging lives by these aggressive treatments. I, for the most extreme risk, I cannot get the LDL too low.

Yet, as an example, last week I had a patient who did have a heart attack and I had the LDL in a high-risk patient down at 55. So there’s an example of how we still have so much to learn, such as inflammation and other things. But right now, getting the LDL down lower is better. Makes a major difference. I think we’re saving a lot of lives that way.

Host: Certainly is the case. There are, Dr. Whayne, so many new theories. It’s an exciting time to be a cardiologist. As you mentioned, inflammation, that is always fascinating to me as an exercise physiologist to see the new ways that we’re looking at heart disease and inflammation. Dr. Hidalgo, next question to you. Do you see that in Kentucky there is a disparity issue where people— ‘cause Dr. Whayne mentioned the obesity epidemic and diabetes and smoking and all of these things. Do you think that there is a disparity in awareness and the ability to seek out providers? While you're answering that question, tell us how you want patients to reach out to UK Healthcare, and why it’s so important that you both are there to help them with some of these issues.

Dr. Hidalgo: Yeah. Well I think that there’s a significant… Well, I would say that there’s no awareness of how bad can be smoking for the people’s health. I feel that mainly in Kentucky and other areas of probably West Virginia and Virginia where there has been a lot of tobacco fields, we see a lot of people smoking from early ages. It doesn’t seem to them, it seems to people, that smoking is something bad. Unfortunately, here in this region, in this area, we see many people not only with cardiovascular conditions, we also see people with lung conditions. With COPD and other conditions in related to smoking. As you point out, I think there’s lack of awareness or what is the long-term damage from smoking.

In regards also to diet, Dr. Whayne was talking about diet. I feel that there’s also lack of awareness of what will be a healthy diet. I think that what is more prevalent in the region is having food that is more consistent with high calorie intake or either with high content of lipids, cholesterol. A lot of people are consuming like fast food. So I think that there is, for sure, a lack of awareness of these factors that can be modified. Not only just with medications, but just from a preventive perspective.

In regards to how they can approach this, so I think UK has many options from a cardiology standpoint. We have either a clinic at Chandler Hospital. We’ll have clinic at Maxwell. Also UK has different outreach clinics in Kentucky region. I go to Mount Vernon, Kentucky which is like around 50 miles away from Lexington to see patients. I think that’s from the option standpoint, I don’t feel it will be difficult for a patient to reach us. We see patients that are self-refer, new patients, or patients that are referred by their primary care. So I think that there’s many options. Like definitely the most important thing is that the patient needs to rely on somebody. I feel that we should be provided more location or some kind of seminars to people so that they kind of get idea of what is not healthy for them from a cardiac standpoint.

Dr. Whayne: I agree completely with that. It’s really education in the public for the patient. Patients, I feel very strongly, they need for their own protection to be strong advocates for their care and to know what to ask for because there really is still an educational gap with physicians and other providers, of being so busy in a big office and not either having the knowledge or not being willing to take the time to push the very best and latest treatments. So it’s constantly hitting these points with those who provide the care. Because if we don’t reach the primary care provider, that care is not gonna get given unless the patient happens to request a referral on their own. So we need both the patient and the provider to be aware of what is the standard of care and what is evidence based.

Host: It certainly is true. That cross collaboration between providers if what impresses me so much about the way that you two work together. So I’d like to give you each a last word to offer your best advice. Dr. Whayne, I’d like to start with you. Looking forward to the next 10 years, what do you think is going to be some of the most exciting areas of research in the field of cardiology?

Dr. Whayne: Well the best one I can mention, and that you mentioned also, is your interest in inflammation. There’s actually a study with one of these chemotherapy type agents—canakinumab. It was called the Cantos Study. It was strictly directed at decreasing inflammation. There was a statistically significant reduction in cardiovascular events. Now for that patient of mine who had the infarct with the LDL of 55, I can't justify from an evidence based even giving him NSAID medication because the evidence isn’t there and those medications have their risk given chronically for causing kidney problems. This is clearly a beautiful example of the future.

I suspect 10 years from now, we will still be continuing with—The statins will still be of value. These new injections, the PCSK9 inhibitors will also be having a lot of use because LDL lower is still better. But there will be other things that I can offer that patient of mine who had the heart attack when he should not have had it from his LDL and his blood pressure. So that inflammation is an example that right now for that gentleman, all I have to offer him is thinking of any additional medication that I can do to drop his LDL even lower and continuing to emphasize to him his healthy lifestyle and controlling his weight. So things will change.

A beautiful example is my career spans over 50 years in cardiology. When we started cardiac surgery, 50% of the patients died from having the surgery. Now if we lose a patient at cardiac surgery, somebody has some big explaining to do. Of course it happens, there’s a risk. But now we send a patient to cardiac surgery, we expect them to live and do well.

Host: Isn’t that amazing? I just absolutely love to hear that Dr. Whayne. I can hear the passion in your voice from your so many years in the field. It’s really exciting to hear you speak about what you think is coming in the future. Dr. Hidalgo, as you wrap up for us, please tell us what you would like to know about cardiovascular medicine heart disease with UK Healthcare. Center a little bit for us on women. Because as we know, and we’re learning more and more, heart disease prevents itself and heart attacks present themselves differently in women. So what would you like patients to take away from this segment of listening to you charming gentlemen speak about this field? What would you like them to take away from the awareness part of it all? What would you like them to know?

Dr. Hidalgo: So, once again, I feel like what I would like them to know is that obviously throughout their life that smoking is a bad thing. That we do have options to help people quit smoking. We can provide counseling to people in the cardiology clinic at Maxwell or at Chandler. We provider counseling or we have medications that we can try in patients to help them quit smoking. Also I would like them to take away about trying to read more about a healthy diet, heart healthy diet. I think it’s very important to keep that in mind. As well of having a more healthy lifestyle including exercise under daily activities.

I think I agree a lot with Dr. Whayne’s prediction of the future where cardiovascular research is going go on. I think that most of what we are going to see in the future is mainly focus on prevention. From statins research, from cholesterol medication research with PCSK9s as we are seeing now, from the inflammatory standpoint. I think the most important thing is prevention. That’s the most important thing that I will like the people here in this podcast to take home.

Dr. Whayne: This is something that I would—I call it a joke with my interventional and cardiac surgery colleagues, but it really isn’t. I'm here to try to rob them of getting procedures, but they still have enough business. The one other point I wanted to make is about women because my career goes back so many years where there was almost an attitude of well little lady, you can't possibly have coronary disease. Now we know that women, when they do have a heart attack, a young woman to me is age 50. If she has a heart attack, she has twice the chance as a man of dying from that event. Now she gets it, as an average, later in life after menopause, and then she catches up.

So we need to, as part of education, have women understand that they are very much at risk. Especially the trick with women is that they present with very different symptoms. They also don’t tend to be as susceptible to pain as men. But their myocardial infarction is much less likely to present in the classic way with a midsternal heavy chest pain and diaphoresis. They may just not feel good, for an example, and be a little weak and shortness of breath. So they present differently. The woman needs to understand that basically she is just at much at risk, and if she does get coronary disease, her risk is extreme.

Host: It’s certainly true and those studies were done on mostly men, as you say. I just want to thank you both so much for joining us today. It’s such important information for patients to hear and to hear all of the exciting things that are going on at UK Healthcare. Thank you, again, for joining us. This is UK Healthcast with the University of Kentucky Healthcare. For more information on cardiovascular medicine at the UK Healthcare, you can go to ukhealthcare.uky.edu. That’s ukhealthcare.uky.edu. I'm Melanie Cole. Thanks so much for tuning in.