Joey Wahler (Host): It's an improved way of diagnosing heart issues. So, we're discussing Non-Invasive Cardiology. Our guest, Dr. Ludhwani, is the Medical Director for Non-Invasive Cardiology at UM Shore Medical Group Cardiology.

Welcome to the Live Greater podcast series, information for a Healthier You from the University of Maryland Medical System. Thanks for joining us. I am Joey Wahler. Hi, Dr. Ludhwani. Welcome.

Dipesh Ludhwani, MD: Hi, Joey. Thank you for having me. I'm excited to be here.

Host: Great to have you aboard. Excited here as well. So first, in a nutshell, what exactly do we mean by Non-Invasive Cardiology? And how would you say it mainly differs from other prior types of heart care?

Dipesh Ludhwani, MD: So, Cardiology is an umbrella term. And you basically categorize anything as invasive or non-invasive. The term invasive in general, in the field of medicine, it makes incisions, introducing anything foreign in the body. That includes surgeries, endoscopies, heart categorization, ablations. Non-Invasive Cardiology, basically, we are using various tools to diagnose and, to an extent, manage cardiac conditions without having to do any of the procedures that I mentioned.

Host: And so, why would someone typically be referred to someone such as yourself?

Dipesh Ludhwani, MD: So, there could be various reasons. It could be spanning from hypertension or dyslipidemia, which is just a cholesterol problem, to more extensive conditions such as coronary artery disease, heart failure, cardiomyopathy, arrhythmias, valve problems. So, there's a wide breadth of conditions why somebody would see a cardiologist. It depends based on when they are seeing us and the condition that they are seeking care for.

Host: Gotcha. So, what would you say are some of the more common tests and procedures used to diagnose and treat heart conditions without surgery?

Dipesh Ludhwani, MD: So, more than treatment, I think I would say the main role of Non-Invasive Cardiology is to diagnose, help with diagnosis. And that in a way can aid with management, which would mean with medications and not necessarily doing any intervention. We commonly do EKGs, echocardiograms, stress testing, cardiac CTs, cardiac MRIs. Those are typically the commonly utilized testing that we use under the field of Non-Invasive Cardiology.

Host: And how about other non-invasive approaches, like for instance, recommending changes in lifestyle for a patient?

Dipesh Ludhwani, MD: Yeah. So, lifestyle changes are cornerstone to managing any hot condition. And we really started focusing on lifestyle as a significant factor in cardiovascular health after an old study that was published in JAMA in 1998. The trial itself was called the Lifestyle Trial. And what they did was they randomized people to two arms: intensive lifestyle changes, which included a 10% fat diet, vegetarian diet, aerobic exercises, stress management, smoking cessation, some psychosocial support; and the other arm: routine cardiovascular care. And at the end of the study, we saw there was some regression of coronary atherosclerosis after five years of being in the lifestyle arm.

That definitely raised a big concern as to how much things we are overlooking when we manage coronary artery disease. And not just for coronary artery disease, even for commonly encountered arrhythmias such as atrial fibrillation. And we have seen 10% weight loss can increase your likelihood of being in a normal rhythm. Similarly, doing 210 minutes of exercise per week, which essentially comes to 30 minutes a day; smoking cessation, especially to slow down the process of atherosclerosis.

So, all these interventions not only improve your overall cardiovascular health. But it is also important in general for non-cardiovascular purposes for your body. We see from time to time where smoking not only causes cardiovascular problems, but increases your risk of having cancer and other conditions. So certainly, there is a big role in doing lifestyle modifications, not only for heart perspective, but for your overall health in general.

Host: Absolutely. And so what kind of advice, guidance, do you and yours offer when it comes to making some of these changes, which as we know for so many people are difficult to get started with, right?

Dipesh Ludhwani, MD: Right. So, the two diets that we have seen-- I'll talk about initially weight loss. So, the diets, which we have seen in studies that have shown to have the best benefit for your cardiovascular health are the DASH diet and the Mediterranean diet. Essentially, we are talking about avoiding any fatty food and red meat, and using more white lean meat, if you're eating, say chicken or salmon, which is good for you, with good omega-3 fatty acids; smoking cessation. Mediterranean diet also includes using your vegetable protein like lentils and chickpeas. And we've seen Mediterranean that has improved overall cardiovascular outcomes, whether we are dealing with coronary artery disease, whether we are dealing with other cardiovascular conditions.

So as a basic step, I always think the biggest, I would say, difficulty people have is they try to make too many changes at once. And oftentimes that knocks you down too much and we go back and then we crash and we are back to our old lifestyle. So, it's always the little changes that I recommend people to start with. If somebody's cutting down on smoking, with regards to food, if they eat a lot of fast food, first, doing it in moderation. Limiting it, rather than just saying, "You know what? You can't eat it, period."

So oftentimes, it's slowly getting to that point, reducing the amount of, I wouldn't say unhealthy, but I would say notorious things that can cause cardiovascular issues. Limiting them from your diet in the beginning, and then slowly getting to the point where you are more comfortable at this level and you make further changes.

Host: So slow, gradual steps to make these changes. And it sounds as if you're saying, Doctor, that heart health, to some degree, is in our own hands, isn't It?

Dipesh Ludhwani, MD: It is, to a certain extent, it certainly is. There are certain times when you could have the most healthiest people who exercise and they still tend to have genetic predisposition where you can have cholesterol disorders, which are more genetic and they tend to have a higher cholesterol level, and that predisposes them to coronary artery disease. Similarly cardiomyopathy where people with heart failure, they can have genetic predisposition. And those certainly are not within the realm of everyone's control. But a larger chunk of the conditions that we see are mostly something that can-- I wouldn't necessarily say completely be avoided, but definitely can be prevented to a certain extent.

Host: Gotcha. Switching gears a little bit, how about advancements in Non-Invasive Cardiology that are making it easier for experts like yourself to detect heart disease.

Dipesh Ludhwani, MD: So in the last decade or so, we've been exposed to this entire new world of cardiac imaging, and that has certainly minimized the need for a lot of these invasive procedures. Cardiac CT, for example, it can give us an assessment about coronary artery disease, assessment for blockages, which traditionally we used to rely on heart catheterization and stress testing. But cardiac CT has told us about how you can reliably diagnose conditions with a very high negative predictive value, which certainly you can avoid that small but possible risk of heart attack, stroke, or death while somebody's getting a heart catheterization. And oftentimes, we are dealing with conditions that are not even related to heart blockages. And in such cases, doing a cardiac MRI or echocardiogram, those are the things that might actually help us come to the diagnosis than just doing an invasive procedure. And although these testings may not necessarily be therapeutic, but they're oftentimes diagnostic, which can certainly aid in coming up with a good therapeutic strategy, which could be medication or it could be an intervention.

Host: Couple of other things. If a patient is told they need further testing or treatment, what's your advice on them advocating for the least invasive options when that's appropriate in their case?

Dipesh Ludhwani, MD: So, the need for further testing depends on multiple factors such as the presence of their chronic conditions, age, the nature of the symptoms, clinical context in what we are dealing with. So if somebody has been recommended, the need for further testing, understanding what the condition we are trying to diagnose or even rule out will help make a better decision. American College of Cardiology has always advocated for shared decision-making, risk-benefit discussion, before pursuing anything invasive or even non-invasive.

So, I think expressing your opinion and your personal preference to your provider, to your cardiologist saying what are other ways that we can evaluate this condition, I think opens that avenue where they can have that discussion. And with the shared decision-making, they can come to a point which would not only help the condition, but also help the patient and make them feel better that they were heard. And that this is more of a mutual decision rather than a one-sided approach. So rather than saying that they should always advocate for non-invasive testing, I think it's good to raise questions and have a healthy discussion, and then whatever the right treatment option is, proceed accordingly.

Host: It certainly sounds like great advice there. How about instances in which non-invasive treatments might not be appropriate for a patient? You touched on it a moment ago, age, for instance. What would a couple of other examples there be?

Dipesh Ludhwani, MD: As much as we would want to treat all cardiac conditions with lowest possible risk, we have to acknowledge that there are certain things that need intervention. Advanced cardiac imaging in form of CT, cardiac MRI, they should always be used as a diagnostic tool, which may or may not evade the need for you to get an invasive procedure.

Heart rhythm conditions such as heart blocks or having acute heart attack, advanced congestive heart failure. These are the type of conditions that you cannot just manage with medications or talk about noninvasive management. You need interventions for them, and there are times when your medical management is not sufficient and it affects your quality of life. In those case, doing heart catheterization, trying to open up that narrowed artery is important, not only for symptom relief, but overall quality of life. So, there's always a place. And I would say a context with which we would say that certainly invasive route is the best strategy. And this is often in the hospital when somebody's coming in with an acute heart attack or they're coming in with heart rhythm problems, where their electrical conduction is disrupted. Those conditions, they have to go for an invasive strategy rather than hoping for some non-invasive options.

So, those are the few things that I would say certainly we shouldn't negate the fact that invasive is the first strategy. So, it all depends on the clinical context at the end of the day.

Host: Okay. And then in summary here, Doctor, what's your main message for those joining us about what you do about Non-Invasive Cardiology? What are you most passionate about-- you obviously have a great passion for this-- that you want to share with people?

Dipesh Ludhwani, MD: So, I would say a non-invasive cardiologist doesn't necessarily mean that we are opposed to procedures. I feel that we have new technology out there that we can utilize and sometimes provide the same level of care without having to go for invasive options and which is what I would want people to be open about. We have had multiple recent trials, which have shown that oftentimes doing conservative management tends to have a similar outcome compared to an invasive strategy.

So, I would advise everybody to keep an open mind whenever they go to see a cardiologist. Oftentimes, we have had experiences from our close relatives or neighbors, or they had a heart catheterization, they got a stent, and everything got better, "I think I need a stent as well." This is not the case with everyone. Every person is different, and I feel a healthy discussion with your provider is going to be a key in deciding what would be the best strategy for you, individualized for you, and not necessarily one-approach-fits-all.

Host: Hey, you've certainly made it clear, Doctor, that open discussion is very important when it comes to everything you've just discussed. Well, folks, we trust you are now more familiar with Non-Invasive Cardiology. Dr. Dipesh Ludhwani, a pleasure. Keep up all your great work. And thanks so much again.

Dipesh Ludhwani, MD: Thank you for having me.

Host: Absolutely. And folks, please share this episode on your social media to help spread the knowledge and power of healthy living. And you can find more shows just like this one at umms.org/podcast, as well as on the YouTube channel. I'm Joey Wahler. And thanks so much again for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System.