Transcription:
The Latest Advances in Cardiology

Melanie Cole (Host):  The field of cardiology is advancing so rapidly to find answers to the prevention and treatment of heart disease, the number one killer in America. My guest today is Dr. Nickolas Juliano. He's a cardiologist at Summit Medical Group. Welcome to the show, Dr. Juliano. Tell us about the field of cardiology. What are we seeing as some of the most recent advances that are pretty exciting in prevention, guidelines and treating heart attack and stroke. Tell us about it.

Dr. Nickolas Juliano (Guest):  Hi, Melanie. Thank you for having me on. It's an interesting time in cardiology. There was a time not too long ago when what I do for a living was considered, informally, plumbing, which was just opening up clogged arteries in people who’d had a heart attack. We spent a lot of time, epidemiologists and cardiologists, working together to get people to understand the concept of risk and preventative medicine. This is something that can put people to sleep when they start talking about epidemiology and risk and you talk about statistics. These are things that most people don't really like and it's very exciting on TV when somebody is waiting for a cancer biopsy result and waiting to hear that “it's cancer” or “it's not cancer”. It's good news. It's a little less exciting to sit and have someone say, “Well, you have a 10-year risk of 3% of having a heart attack or stroke.” But, we're really in a golden age for cardiology in that our refinements are getting better but also that the population at large is becoming a lot savvier about understanding risk and understanding statistics. People will say they don't understand math, they don't understand statistics, but if you watch ESPN over the weekend and they talk about a baseball game, people will talk about, “Well, they should have pitch-run for that batter. It would have increased the odds of that runner getting on base. It would have increased the risk of double play” and these are things that people sort of understand intuitively now. People listen to the radio and they try to understand, “What are the odds that I'm going to get into a traffic jam on the way to work today? What can I do to minimize that risk?” That's a lot of what we're doing in cardiology. We can look at people and not just say, “You may or you may not have a heart attack. You're a man and you're 50,” but we can do more to predict someone's risk of having heart disease and then we can do something to prevent that risk. Instead of waiting until the plumbing is clogged and someone like me has to come in in the middle of the night to open up a blocked artery because you've had a heart attack, we can do more with medicines to prevent a heart attack. So much so, that we're starting to argue now, do we even need to do some of these invasive procedures? Can we not manage these chronic conditions with medicine and can we not identify people who are at high risk before they have problems and prevent these things?

Melanie:  Tell us how you, cardiologists do identify some of those risks and the methods of calculating 10-year risk, for example. People want to know, am I going to drop of a heart attack next week? How do you know?

Dr. Juliano:  To some degree, we don't and this is something that unsettles people. If you ask, “What are the odds that I'm going to get into a traffic jam on the way to work today?” I can give you an answer. I can say, “Well, if you go over the George Washington Bridge between 8 and 9 o'clock, the odds are very high.” But, if you ask the question, “What are the odds I'm going to get into an accident?” you can infer. You can say, “It's raining.” You can say, “I'm driving fast.” You can say, “I'm going through a high traffic area. There's a high risk.” But we can never really predict an event and that unsettles people but we can identify people who are at risk and help them modify their behavior. Now, for the longest time we've been doing this with a simple set of numbers. It was actually high blood pressure, which was the first thing that was identified as putting people at risk. It was actually accountants who were selling life insurance who first noticed that people who had high blood pressure were at a high risk of having heart disease. Now, over the course of the last several decades, we're able to refine those numbers and sort of say, “Well, if your blood pressure's above this number, you're at a certain degree of risk. If your blood pressure is in this range, then you're at a certain degree of risk and if your blood pressure's controlled but using some of these medications, your risk is different.” A lot of this came out of epidemiologic studies we've been doing and one of the largest and longest ongoing ones is the Framingham Study which is based on data collected from the community around Framingham, Massachusetts. From this, we've also become a lot more sophisticated at looking at the overall cholesterol numbers, not just their total cholesterol, but then, eventually, what has come to be known as good cholesterol and bad cholesterol--the so-called LDL and HDL. But, over the last few years we've actually become more specific. We've started to look at triglycerides as risk factors. We started to look at calculated LDL versus something called the LDL particle number which has become more and more specific towards recognizing people at high risk for disease. We've also recognized populations where people are at risk independent of their cholesterol. The other thing we've started to do is to equate cardiovascular disease with vascular disease in other parts of the body. I remember when I studied vascular surgery, we were doing a surgery on someone's leg and the patient was quite surprised to find out he was having a heart attack, which is something that was predictable based on the fact that the person had known vascular disease. So, we're starting to pool evidence. We start to treat anybody with diabetes as if they have vascular disease. We start to look at people who have had other types of complications related to having atherosclerosis, as having coronary artery disease. Obviously, quite a lot has been done with smokers and that relates back to the surgeon general's warnings in the ‘50s and ‘60s. So, we are able now to identify certain risk factors. The newest things that we've been looking at are the so-called sedentary lifestyles, diabetes--and not just diabetes but the pre-diabetic condition. We recognize a group of people who have a condition we call “the metabolic syndrome,” which is a combination of abdominal obesity, people who have the body types we refer to as apples, who tend to carry most of their weight around the middle and recognize that those people have a constellation of symptoms involving elevated triglycerides, pre-diabetes, pre-hypertension and a low good cholesterol/low HDL. We recognize these people at being particularly high risk. So, we do have guidelines now, refined risk calculators in which we can take a variety of epidemiological information:  a person's age, a person's blood pressure, bad cholesterol, a person's good cholesterol and even information about smoking, diabetes, pre-diabetes, triglycerides and other types of information. The one thing that we still struggle with a little bit is family history. Family history of heart disease can be defined in different ways. Obviously, there is a difference between having an older brother who had a heart attack at age 40 and having a great-grandfather who had a heart attack at age 80 who used to smoke. So, we are trying to quantify family history by identifying certain gene abnormalities and certain genetic markers independent of cholesterol that can put people at risk for heart disease. So, it's really with family history that we have the hardest amount of time making predictions. Most of these other things, we can give people a pretty accurate idea of their risk of heart disease and over a certain period of time. That's a very exciting thing for us. To some degree we're putting ourselves out of business. We're identifying high risk people earlier, getting them on medical therapy, effectively treating their disease and eliminating the risk down the line that they would need an emergency angioplasty or open heart surgery. Also we are able to do a lot of the procedures that we used to do surgically with minimally invasive procedures. So, it's a very exciting time to be a cardiologist. It's a very exciting time to have heart disease It's probably not a good time to be an accountant who's working for someone who's a cardiology group because to some degree, we're able to find that we can treat disease much more efficiently, much less invasively and much more cheaply which is very important to the government as well.

Melanie:  Dr. Juliano, where does inflammation – we're hearing more and more – and in our blood tests we get CRP and still a little bit homocysteine. Where are you cardiologists looking at inflammation as our risk of heart disease and where do our stress and cortisol come in?

Dr. Juliano:  Right. The short answer is we cannot identify high risk plaques yet. We can make good estimates and we can take guesses. Identifying markers and vessels that have the highest amount of inflammation and are at most risk for having a heart attack – what we call the vulnerable plaque – is a very difficult thing for us to do. We have known from looking at pathology slides of patients who have died of heart attacks that the plaques that rupture tend to have more inflammation, more white blood cell counts in the plaque. We have tried to find some circulating particle in the blood that lets us know someone has vulnerable plaque before that plaque ruptures. We have tried imaging; we have done MRI scans; we have done PET scans; we have looked at white blood cell counts. We have looked at bacteria; we've given people antibiotics. We have not been able to truly identify which people have plaques that are vulnerable and which people do not. The closest technology we have right now is something called intravascular ultrasound, which is to put a probe past a blocked artery while the person is still awake and to look at the artery with ultrasound and to make some kind of inferences about the risk of that plaque rupturing. However, what we've really found is that we can reduce inflammation with a set of drugs. One drug that's been very efficient is one of our oldest drugs, which is aspirin. This is why we often talk to people about being on aspirin who have known coronary disease. Another thing that we've found is statin therapy – Lipitor and its’ cousins – have been very important in reducing the risk of inflammation. To some degree, the benefit of these drugs is not so much in that they lower your serum cholesterol levels but that they stabilize the plaques that you have. What I try to tell people is that what I do is not plumbing. With plumbing, the pipes in your house are a thick size; they don't respond, they don't get better when there are blockages and, eventually, the plaque has to be cleaned out. Now, your arteries are living tissue. If we can reduce the inflammation, the arteries will heal. They'll expand; they'll allow more blood flow to go past the blockages and the arteries will heal. That is why we've been so pushy to some degree about getting patients who have coronary disease or vascular disease of any type on a cholesterol medication such as a statin, even if their cholesterol numbers aren't so bad. Now, for the longest time, statins were the only real options we had. There were other medicines that lowered your cholesterol but none that had such a remarkable effect on inflammation as the statins. But, in another example of why this is such an exciting time in cardiology, within the last few months, two drugs have come on the market and these are medications that are called PTSK9 antagonists. These are injectable drugs. They are not yet available in pill form. But, they are an alternative to statin therapy that has also been shown to reduce inflammation, to lower cholesterol and to effectively treat the not insignificant population we have of people who are not able to take a statin drug or people who are resistant to statin therapy or people who seem to have heart disease independent of their cholesterol. This is a second set of drugs that are on the market that we expect will have a very large benefit in reducing inflammation and protecting people from malignant cardiovascular outcomes.

Melanie:  Dr. Juliano, in just the last minute, please give the listeners your very best advice, because we're looking at combating childhood and early adulthood, heart and obesity epidemic and diabetes, pre-diabetes, as you say, and risk factors-- smoking and genetics – give your best advice for prevention of heart disease and why people should come to Summit Medical Group for their care.

Dr. Juliano:  Well, I think that to summarize quickly:  knowing your cholesterol numbers is important, knowing your blood pressure number is important, obviously, not smoking, an active lifestyle, and a healthy diet. Now, we could fill an hour just talking about what that means. While traditionally, we've recommended a low fat diet, there's been a lot to suggest recently that if you replace fat with carbohydrates, you're having similar problems. There's been an advancement in our understanding of what a healthy diet should be. It's a little bit more complicated than simply saying “Watch the cholesterol or read the labels.” We, here at Summit Medical Group, pride ourselves on taking the time to talk to people about what kind of diet and lifestyle changes, in terms of exercise and what foods they should be eating and what foods they shouldn't be eating. We try to take a, I hate to say “holistic approach,” but a practical approach tailoring your busy lifestyle to a healthier lifestyle. We like to take time in our Department of Cardiology not just to order tests and tell you what your numbers are and refer you to a table but to try and help you to really understand what your options are, what kind of medical therapy is available to you, what kind of lifestyle therapy is available to you and, hopefully, not but what kind of surgical and non-invasive therapies are available to you as well.

Melanie:  It is such great information and you are an amazing speaker and I am quite sure an amazing doctor as well. Thank you so much, Dr. Juliano for being with us.

Dr. Juliano:  Thank you for having me on, Melanie.

Melanie:  You're listening to SMG Radio and for more information you can go to SummitMedicalGroup.com. That's SummitMedicalGroup.com. This is Melanie Cole. Thanks so much for listening.