Thank you for watching this program tonight with the best physicians of the region.

My name is Dr. Luis Munoz.

I'm the President of the El Paso County Medical Society.

It is our hope that you will find this program informative and interesting.

We at El Paso County Medical Society invest in community education with our programs.

I hope you'll find this program very informative, with great medical advice and great medical information.

Thank you again for watching this program tonight.

And have a great night.

There are a number of exciting advancements happening in cardiology, especially in the areas of diagnosis and imaging medications and interventions when it comes to the heart.

There are many heart conditions, but what qualifies actually as heart disease.

What are the signs and symptoms and when do you actually go and seek medical attention?

During the next hour, we have physicians talking about all the advancements that are happening in cardiology.

I'm excited to hear about that.

We've been talking quite a bit about it even before the show.

That's why I feel like I get all the good stuff.

This is underwritten by Hospitals of Providence.

And we also want to thank the El Paso County Medical Society for bringing this program to you.

I'm Kathrin Berg and this is the El Paso Physician.

Thank you for joining us.

I'm Kathrin Berg and we are doing a program this evening on advancements in cardiology.

And with us this evening, we have a veteran.

We have Dr. Chalam Mulukutla and he is a structural guru, so said by his colleague.

But he's an interventional cardiologist and he does a lot of the structural intervention that's happening with the heart.

So we're going to talk about that this evening.

And then we also have the newbie, Dr. Clifton Espinoza, and he is a noninvasive cardiologist.

So you're the guy that helps diagnose.

So when we were talking about the new things in cardiology, a lot of the imaging is relatively new and just a little bit more precise to help people with their diagnosis.

So on that note, Dr. Mulukutla, if you can describe what it is that your specialty is about, So the audience kind of knows where you're coming from when you answer a lot of these questions.

So my interest is in patients that have, as we talked about, structural heart disease.

But what I do basically is I'm an old fashioned plumber.

So basically the idea is we go in there and open up blockages or close them, and then you can add to closing holes or opening holes and trying to patch things up with a little hinge on an extra door or replacing the door all together.

Okay.

So not that I'm at home with handy stuff, but I'm a carpenter or a plumber or at work.--But it works.

It makes sense when everybody is listening to it.

And so then as a noninvasive cardiologist, Dr. Espinoza, how would you describe what you do?

So I would describe what I do as more of what people would think of as a traditional cardiologist, where I see patients in clinic, they come in with a variety of symptoms, and I go and evaluate symptoms and see if they're due to cardiac disease.

So mainly clinic based, you know, we do imaging echos, CT scans, things like that to figure out what's going on, EKGs as well.

So think more of the traditional aspect Then I'm going to ask you first.

The first question goes you as the traditional cardiologist.

So we talk about the heart being a muscle, and I don't think we give it its worth in how much it actually does.

So the amount of work that the heart does with the entire body explain to the audience why it's so important to take care of your heart.

Well, I mean, it's pretty much the essence of your body.

It's the pump that basically circulates blood to the rest of the body without the hard you know, your brain doesn't get blood flow, your kidneys don't get blood flow, your lungs don't get blood flow.

So I think of it as one of the more important organs, even at the most after the brain in terms of function and, you know, functionality and in essence, so it's the workhorse of your body.

Without it, you know, a lot of these things would be very hard to do.

You know, kidneys wouldn't function, brain wear and function.

So I think it's a very, very important organ.

So heart attacks, that's why death happens immediately, strokes too even though it's brain, it's also heart associated with that, too, because strokes are heart related.

And I think people sometimes just think, oh, that's brain related.

Dr. Mulukutla to here's the hard one.

So we have and thank you for bringing these we have structures of hearts on the table.

I would love for you to explain as we're going into everything, what's the best model for you to point out and say, this is what this does, this is what that does.

There's blue blood and red blood, why There's going up, going back and forth.

So I think we just all know it's a pumping machine.

But let's describe what parts of the heart does.

WHITE Sure.

Which one do.

Let me bring this to you.

Sure.

Yeah, right.

Bring that to you.

The simplest way to think about it is if you take your fist, your heart, usually the size of your fist.

So babies are smaller, obviously.

And then as they grow the the heart is the engine that works.

I like to describe it as twins.

So everyone well, I'm getting older, but Danny DeVito and Arnold Schwarzenegger were part of the movies.

So the way I think about it is the blue Blood, as you describe, will come to the right side of the heart and the right side of the heart, kind of Danny DeVito or a Vesper.

It's going to pump it to the lung arteries, which are going to go get oxygen, and then it's going to come back through the pulmonary veins to the left side of the heart and go down to Arnold Schwarzenegger or your your Harley and get pumped out to your body.

And that's what Dr. Espinoza was saying is the importance of the heart, because it's now bringing the oxygenated blood to the entire body.

And it's sort of like a washing machine.

It's rinse and repeat because this is doing it thousands and thousands of times during the day and millions of times over your lifetime.

And this is where the right side of the heart gets the blood and then pumps it to the lungs and then the left side of the heart, then pumps it to the body, and there's four chambers and four doors.

So say that again.

One side pumps to the lungs, the other side pumps to the entire body.

I've never heard it explained that way before, but that's really nice to picture it that way.

It's sort of like if you really wanted to go back to your engineering days or where they made is like in series and in parallel.

And so one side it's like your kids, I got two of them.

If they're locked in their room, they're not going to talk to each other.

And so one side is going to be doing its job and then the other side does its job, right?

And then you sort of pump through these rooms and these doors and at the end of the day, and the body gets what it needs, which is the oxygen.

And I love the way you explain these things.

Okay.

Nicely said.

I know I interrupted you.

Okay, keep going.

So valves when I say that too, you're looking at these.

We're going to talk about valves tonight.

And we also have some footage that's going to be interesting to see.

Yes.

So the other thing I was going to tell you is actually what we sometimes talk about is your your blood pressure.

Right.

So your blood pressure is real important to your your heart.

And what I was going to say is the the blood that's pumped out to the body, the heart actually, then the blood comes backwards to the heart, and then it goes into the coronary arteries, which is the arteries are kind of like the gas that feeds the injured.

Right.

And when you have a blockage in those pipes, then you get the heart attack or the problems that you're describing.

So on that note, and I have it further down on my notes, but let's talk about, we all know blood pressure readings, and there's the top number in the bottom number.

So the top number is systolic.

And then the bottom number is the diastolic.

Right.

So diastolic, when people are getting their blood pressure, describe what the top number is and what the bottom number is and physiologically what's being measured in the heart.

Dr. Espinoza, that's on your way.

So when I explain this to my patients, I usually tell them, yes, there's two numbers because they usually referred to it as the top in the bottom.

Exactly.

So the systolic blood pressure is a consequence of the pumping force of that left ventricle.

So it's that immediate pressure generated by that chamber and the blood leaving the heart and going to the aorta and to subsequent arteries over the rest of the body.

So that's your systolic blood pressure down.

Diastolic blood pressure is the relaxation phase of the heart.

So the blood is that pressure after the heart started relaxing and that aortic valve has closed.

And believe it or not, the blood that goes to the heart through the coronary arteries is dependent on your diastolic blood pressure.

And that's so that's why that one's important, because if you have a low diastolic blood pressure, then that means those coronary arteries aren't getting very good blood flow.

So that's the difference between your systolic and diastolic.

It really depends on the cardiac cycle.

So most times patients are worried about the top number, right.

Where, oh, my top number is very high, but diastolic blood pressure, with it being high, it can also cause problems as well.

So they're both equally important.

But that's the main difference between the two.

So if you had like the perfect specimen, not Arnold and not Danny, but the guy in between, what is the perfect blood pressure reading?

So classically they would say 120 over 80 is your perfect blood pressure.

But, you know, over the years there's been a lot of controversy as to what's normal or considered, you know, the the good blood pressure.

At one point, we're allowing blood pressure to go as high as 140 over 90, you know, about five years or five, ten years ago.

But then eventually we notice that, hey, you know, maybe this isn't the approach we want to take because we were noticing some detrimental effects of allowing the blood pressure to go that high.

So then we lowered down to 130 over 90 is more where we try to keep patients ideally, you know, the lower you have it, the better you do overall, right?

General level is too low.

And I feel like we never talk about those people, like I'm that person.

I have historically very low blood pressure, not in a good way, but oh, that's nice.

But they were worried when I was pregnant.

Have a baby.

It's like, Oh my God.

I'm like, I promise you, this is usually how I am.

But I'd like to incorporate that somewhere in the program because I'm not the only one.

There are people that just have, you know, they they feel faint a little bit more often.

They do gardening and stand up and they need to grab on to a tree, you know, and I'd like to know why and we can talk about that in a bit.

But you had something else you were going to add.

Yeah.

So blood pressure is really important.

And the part that we were going to talk about, I guess, is, you know, from the risk factors for the heart that I tell patients from this is that there's I call them the fab five.

I call them hypertension, cholesterol, diabetes, family history and smoking.

Those are my five for the heart that I'm always worried about.

And blood pressure is a very important one.

Controlling your blood pressure is is imperative because that if we did, that would reduce a lot of heart attacks.

The other thing that's really interesting that we don't do a lot of but has been studied is checking your blood pressure once in your lifetime, in your right arm and your left arm.

And the reason they found that is there is these three vessels that go and they go to your arm and they go to your arm on both sides.

If there's a difference in blood pressure of 10 to 20 millimeters of mercury difference, meaning this sides 140 and decides 120, that's a simple screening test to tell you that you may have blockages because if you're developing blockages in your arteries that are up here most likely, you may have blockages in your arteries of the heart.

So it's a simple way to do it.

And they found that this was very effective.

So we don't typically do it.

We just when you go somewhere, they check your blood pressure on the right or left arm -right.

But at some point do it.

You should do it and you should do it in the same setting and check both to see that they're the same.

Well, now I'm going to do that next time I go in.

Yeah, they may.

I may.

They may get mad at me.

But, you know, I'm totally going to blame it on you.

But it makes perfect sense.

I mean, just explaining it that way because you've got different pressures on different sides of the bodies for blockages.

So again, physiologically, it makes absolute sense when it comes to that.

When you say controlling your blood pressure, let's talk a little bit about medications, because I know that, you know, there's a little bit of controversy on that back and forth.

But in general, hypertension, how is that medicated and whoever wants to take that?

Well, it depends on where exactly you are in the spectrum of hypertension.

Right.

Because if you have a patient that comes in, you know, relatively young blood pressure is in the 130 systolic, you know, upper eighties, you know, diastolic, you wouldn't necessarily rush immediately to put them on medication.

Right.

You know, you would advise them to institute lifestyle modifications, reduce salt intake, increase your exercise, you give them a few months and see if the blood pressure normalizes with that.

If for whatever reason they're doing everything right, the blood pressure still remains high, then you may consider putting them on on medications.

Now, on the other end of the spectrum are those patients that, you know, come in with blood pressures above 140, 150, you know, and generally lifestyle modifications won't be enough to bring them back to where they need to be.

So those are the patients that you still are going to recommend that they diet and exercise, but you may consider certain medications and all the circumstances also depends because it's patient.

A patient, some patients might have issues with their kidneys where you may not want to use certain medications where otherwise the kidneys might be impacted or they might come in with, let's say, a low heart rate.

So beta blockers may not be a good option there.

So there's, you know, a different classes of medications that can be used.

You know, there's the ACE inhibitors that work in the kidneys.

Angiotensin receptor blockers are kind of cousins to the ACE inhibitors, and those work very well in controlling the blood pressure.

But again, you also have that impact to the kidney where you have a patient that already has chronic kidney disease, you may be limited in their use.

Same thing with the diuretics.

You know, diuretics like the thiazolidinediones are considered, you know, first line medications for controlling blood pressure.

But again, certain patients may not be able to tolerate those medications like patients that have gout, patients that have kidney dysfunction, electrolyte dysfunctions then.

So you would consider things like beta blockers or calcium channel blockers.

So it really depends on the circumstances.

Not everyone's going to have necessarily the same medications right off the bat.

So here's a question.

You use the word cousins a moment ago.

So when I think of hypertension, I think also of cholesterol.

Like are they do they go hand in hand are they siblings, are they cousins?

Does it always mean that if you have hypertension, that your cholesterol is something you have to look at?

Explain how that goes, Because I feel like they go hand in hand.

But maybe that's not always the case.

They can.

A lot of times these guys tend to be together, but they can be separate.

You know, if you have a family history of high cholesterol, you may be somebody who is prone to that.

And similarly, if you have a family history of blood pressure, you may be prone to that.

In patients that have diabetes, we are now very aggressive with treating them with cholesterol medicines because we know that diabetics, we explain it as if there are higher risk for heart disease.

But in reality, sometimes we even say a diabetic may be the equivalent to someone who's had a heart attack because the risk is so high as a result of that.

If you are a diabetic at a young age, you would be put on cholesterol medicine because of the risk over your lifetime.

So so the reality is a couple of-- or the other thing I'd also say is blood pressure is related to a lot of lifestyle changes or lifestyle issues.

People who have obstructive sleep apnea and tend to snore at night and may have the need for breathing machines like a CPAP machine that we talk about.

Even simple modifications where we treat that can lower their blood pressure and people who are out of shape and may be obese may as a result have a higher propensity for blood pressure, cholesterol or diabetes.

And so as a result of that, as you describe, those things may run hand in hand.

But treating sleep apnea could also be a reason in addition to medications that might help hypertension.

So it's sort of like a holistic approach, but there's a lot of things that sort of run together I am going to switch gears a little bit and talk a little bit about electricity in the heart, because I feel like there's so much involved there.

So this is like the structural stuff and now we're you were joking about not joking.

We were talking about AFib prior to the show.

There's arrhythmias, there's palpitations, there's AFib, which I guess is arrhythmia, palpitations.

Basically, you just feel your heart going in general.

And I'm going to take it to you for now to the general.

Or what did you say, the classic cardiologist.

When --we all have palpitations, we think sometimes we shouldn't feel our heart, but when we do, we get a little worried, like, Wow, my heart's beating really fast, but I'm not running.

I'm not doing anything.

Describe what that is and why people get concerned and then take it into arrhythmia, afib, etc., etc.

Because I feel like that's something that you hear about all day, every day right now.

You're going to be on podcasts, on everything.

So any you know, you go to any cardiologist office, you're going to have a patient that's going to come in complaining of palpitations, at least one, if not multiple times.

You know, during that clinic day.

So generally you ask them what what do you mean by palpitations?

So they'll tell you, Oh, I feel like my heart races or I feel like my heart is fluttering, or I just feel my heart just going at it.

So there are some arrhythmias that we consider benign.

There are some arythmias that we consider dangerous.

So some of the benign arrhythmias would be, you know, like your premature contractions to a certain degree, premature ventricular contractions.

So these are contractions are occurring when they shouldn't be from the top chambers or the bottom chambers.

So your natural pacemaker in the heart dictates your heart rate and how you know that electrical system is is working.

But all along that electrical system, there can be little spots that can fire prematurely.

And sometimes those can give you that sensation of a skipped beat.

And sometimes patients will feel that generally those are benign as long as they're not occurring at a very high burden, as we call them.

Now, your malignant arrhythmias are those that are your ventricular tachycardia, is meaning there is a focus in the bottom chamber that is just causing the heart to go really, really fast.

And the faster the heart goes, the less time that chamber has to fill with blood.

So then your blood pressure drops and patients can pass out.

And if that continues, the heart muscle will start suffering from inappropriate blood flow and oxygen.

And then they can, you know, have a cardiac arrest.

And are there any causes for that?

Is that just something that you have inside of your body when you're born?

Eventually it will show up, not show up or that I guess my question is, can you prevent that from happening?

I know we were talking about lifestyle, obesity, diabetes, etc., etc..

But in general, is that an inherited type of a condition?

Well, there can be inherited syndromes where you are prone to developing these malignant arrhythmias.

And one of them can be something called long QT syndrome, where there is a certain segment in the electrocardiogram that is prolonged and it's congenital, and that can increase your risk of having these bout arrhythmias.

But when you see a patient that comes in a ventricular tachycardia, one of the first things you want to think of is the re blocked coronary artery.

And that's one of the first things you want to evaluate.

You know, is this person having a heart attack?

Is there schema going on?

So right off the bat, in any cardiologist, are you okay, there's a tag or there's a ventricular arrhythmias.

Maybe I should start looking for, you know, some sort of a schemic event in that muscle.

Okay.

The what I usually like to tell patients is, well, I sort of use this same analogy, but I say the top part of the heart tells the bottom part what to do.

So I call the top part by the woman and the bottom part of the man.

And so goes boom, boom, boom, boom.

And that's what happens in my house.

But in any case, and we have one other woman, she's sitting on the counter here immediately she looked up like, what?

No, but this is a great description.

Exactly.

And so when what Dr. Espinoza is describing is a lot of different types of rhythms, but the basic idea is a top.

If you have abnormalities in the top part of the heart, generally those rhythms we call super ventricular above the heart, above the ventricle, those are not necessarily going to be life threatening.

Generally speaking.

And the ones that are in the bottom part, the ventricular arrhythmias can be life threatening.

And the other part to it is you sort of you evaluate this.

Sometimes people have their heart beating fast or not.

So then the other part is, is this normal fast or normal slow?

or abnormal Fast and abnormal slow?

And really, the way we do this is we do different tests.

We may do a heart monitor, do an EKG.

There's a lot of different ways we can evaluate it.

But we also want to make sure if it's something serious, that there's not structural problems with the arteries.

So then you might do stress tests and different other things.

There's a lot of ways we can evaluate the heart without going inside of it.

And so that's what we would do.

The majority of patients coming in, they probably don't have those significant issues, but there are a percentage of patients because when you're getting sent to of the heart, doctor, you're probably been seen by your general doctor.

Exactly.

Other people.

So there is a level of suspicion.

So there's a combination of things and I'm wearing one of these.

These apple watches are great.

I always joke they're good for business because they say all kinds of stuff.

And people come in saying, I've been monitoring my heart rate, but I never used to do all those things for ten years of or now we know every single thing that we're doing.

I slept 6 hours and it's my heart rate, you know.

So that's a lot of this stuff has created some angst, but it's also good because technology is getting better and better.

And so it's helpful.

But there's a lot of things in there that you have to pass out to figure out if it's real or not.

Exactly.

And I always think when I have that opportunity in any program, Doctor, Google can be a dangerous man, right?

And so, yeah, he can be.

So on that note, how many patients come to you and say, Hey, I looked this up, my watch doctor, Google says this and that and the other.

How do you usually or how do you usually address just generically those questions and those comments when they come to you?

Well, you're going to see the big picture, right?

You always have to see where the patient's getting their information sort the information or the source is a credible source.

Okay, fine.

Credible source.

Now, you have to see, are your symptoms really that consistent with what you looked up?

You always have to have a certain degree of suspicion.

Like Dr. Mulukutla said, you can't just, you know, nod off and disregard the patient.

You know, you always have to kind of take everything into account and then you explain to them, okay, this is what you have.

This is what I'm seeing.

This is what Google is saying, but this is what is correlating with it and this is the reasons why it's not correlating with it.

Right.

So you always have to kind of sit the patient down and explain to them, okay, I understand your concerns, but based on the testing that I've done and what I'm seeing, this is what I really think is happening.

And then I'll point you in the right direction where you can get more information about that.

But yes, Dr. Google can be very dangerous.

I've had so many patients come in already diagnosing themselves with certain syndromes that, you know, you be lucky if you see one in your lifetime.

And I do a lot of research on WebMD.

And honestly, that too, can be confusing because, number one, you have 20 million ads in there, right?

So the nice thing is to go to your clinics and find out from you all which Web based Q&A you should go to.

You said something earlier about how to evaluate different issues with the heart.

And I know that there are some just new imaging.

We're talking about that and beginning of the show, what type of imaging are we using now today compared to five or even ten years ago that's helping you, the man, that diagnoses stuff that's helping you find out what's going on with the heart.

So basically, any type of imaging modality that exists out there can be used for the heart.

So the premise, the most basic, you know, tool that we use is an electrocardiogram, and that's what we or is better known as an EKG.

And it's just the it's just mapping out the electrical activity of the heart right then and there.

And it can give you information in terms of arrhythmias.

Is this patient had a prior heart attack or are they having a heart attack, things like that.

Then you move to your more complex imaging modality.

So next up is your echocardiogram, which is essentially an ultrasound.

The way I explain it to patients is is the same machine that's used to look at a baby when they're in the mother's womb.

You're doing the exact same thing.

It's painless.

They put little gel in your chest, take pictures of your heart, and it gives us structure, information, how well the ventricles are squeezing, how well the heart's relaxing, how the valves look.

Is there a tight valve?

Is there a leaky valve, things like that.

Then you move to the more complex modality and now you have your C.T.

imaging, MRI imaging of the heart.

And each one looks at a different aspect of the heart.

So cardiac CT can look for certain structural abnormalities.

We use coronary CTAs to see if the anatomy of the coronary arteries is there plaque within the coronary arteries.

The other thing that we use is stress testing.

So we use a nuclear camera to determine what the blood flow to the heart tissue is looking like.

You know, based on that image, you can infer, okay, this person has a significant blockage in this artery of the heart.

If you want to take it a step further, is something called cardiac pat C.T.

That's a different stress testing modality, uses a little bit different medicines to stress the heart and images of heart.

But it does give very good image quality.

So all those modalities are available.

There's not really any guesswork in it anymore like there was in the past.

You you pretty much can, for the most part, diagnose things, he says.

A little balancing an art to it.

There is, you know, based on your symptoms and what you're looking for that will tell you one will use.

And even then, you know, you might not get the results that you expected.

So there is and I love the word symptoms because I feel that with cardiology sometimes there are no symptoms until there is an event.

And I would love for and I remember I was talking about this a couple of years ago, you so beautifully explains that, boom, there's a heart attack and people say, was it a big heart attack?

Was as a small heart.

Small heart attack.

Is that even the thing?

A heart attack is a heart attack.

And the person who eats well exercises is in good shape.

All of a sudden they have a heart attack.

And so nobody knew that there was a problem because the assumption was, well, I'm doing everything right.

I look right, I feel right.

But there could be, like you said, a blockage somewhere and nobody knows.

So talk about those types of cases.

Sure.

So when we're talking about patients and evaluating in the important symptoms that we talk about are shortness of breath, some fatigue, potentially.

We talk about chest pain or angina, which is two different people, different things, right?

That's true.

And so chest pain can be very challenging at times.

But when you have pain in your chest, it could be concerning because you really don't know.

And what I tell patients is between the skin and the heart, there's a lot of structures, there's the muscles, there's the rib cage, there's the lungs.

So you could have muscular pain that might be this.

And so you try to figure out, is it with movement, is it not?

It should not be reproducible, it should be pain that is there, that cannot be changed and it lasts for five, 10 minutes.

And it may feel like an elephant sitting on your chest.

There's all these terminologies, but the reality is some people have symptoms that are completely different and they could be having a heart attack.

And then there's also people that pass out and they don't wake up and then also is called syncope.

And that is I mean, they pass, they pass out and don't wake up for how long?

Depends.

Okay.

And these are all the major symptoms that we look at.

Okay.

But the most common symptom is really just fatigue or shortness of breath.

Okay.

The problem with the symptom is that it's a very common with everything that we do.

Right.

And the other part to it is the importance is when you have these symptoms and you have something like this happen and you want to be evaluated when you have a heart attack, there's two major arteries, there's three major arteries, but there's a left in the right order.

It's not simple.

And the left artery is like, if you're going up to Cruces and I-10 and I-25 split and then the right artery generally goes to the back part.

So if there's a heart attack, the first thing that someone does when they come to the emergency room is they get an EKG.

And the EKG is beautiful because it can tell us if there's an acute heart attack happening right then and there that we need to do something about.

You can have a silent heart attack, which means that maybe there's blockages, but it's not something the EKG is picking up.

And so over time, we get blood tests to look at your heart enzymes or damage to your heart muscle.

I remember that.

And then you can see over 24 hours as there is.

So we have two terminologies, heart attack, which is STEMI.

We use that which unfortunately I'm on call for tonight and then non ST elevation MI, which means that there isn't an acute, but it is still a heart attack that's occurred because of the damage that we can see with these enzymes are these lab tests - -Even though the person may not have- And they may present the same way.

Okay, they can present potentially the same way.

Okay.

But it's amazing to me that if someone has an acute STEMI, you can go in there and we'll have all these fancy tools that we talk about and go into the artery from our arm or from the leg and then go in with a little wire and a balloon and you just open up this vessel that's two, two and a half or three millimeters, and then all of a sudden their symptoms can go away.

That's amazing because the heart muscle is much like a plant.

If you don't water a plant and it's going to die, that's why there's no plants in El Paso.

There's no water.

But the point is, no, it is the same idea is if you don't get blood to that muscle and as you get that blood to the muscle, then it goes away.

So you hit on something beautiful that I have here, too, about the heart blockage treatment.

So one of the new treatments you were talking about is a balloon, but there's a drug coated balloon.

Oh, that's yeah.

So I would we talked about this a little bit last time.

And the way that you described what the medication on the balloon is doing, this is like I don't know if this is instead of stents or is this an additional treatment with stents?

I'm assuming it's instead of stents.

If you can explain, as the guy that does the procedures.

What's going on with the drug coated balloons is how I have it written down here.

Yeah.

So these are new technologies, to be clear that have come out in the last year that are still in the process of being used.

Currently, the FDA has recently approved some and I think in Europe they're using it more commonly for other things.

But the short of it is when there's a blockage, we take a wire that's 14 thousands of an inch tiny, tiny thing that goes past this blockage.

And then we usually balloon it with stiff balloons and soft balloons.

We open it up and then we put essentially a metal stent.

It's basically if you take your hand, it's a cage with metal scaffolds around it.

Okay.

On the metal scaffolds.

We determined over the years that if you had a drug on it, it helped the healing process so the body would accept it and wouldn't close the artery.

Oh, because in the past they would use balloons and they would close and they used stents, we call them bare metal, which is a funny word, but basically meant they didn't have drugs and then they closed.

Then they used drugs.

So that's been what we've been doing for many years now.

Recently, they found that you could use maybe a drug coated balloon without a stent, and you may be able to have results within arteries that had blockages within the stents, like, let's say a stent blocks up.

Okay.

Or now people are using in areas where you wouldn't want to put a stent.

Maybe there's two that are coming across like I talked about the bifurcation, maybe you could balloon this area of the stent or maybe the vessel is too small for a stent.

You could balloon it.

So there's a lot of applications that are exciting from that standpoint.

And it's it's a new technology that I think has a lot of promise because you may be able to leave no stent behind in certain situations because we know over time having less is more right.

Or at least that's what they say.

And I'm and I'm listening to with stents and I'm thinking to myself scar tissue is that's something that's in I'm now I'm thinking stents are old fashioned.

You know a long time ago when we did stents.

But is scar tissue ever an issue with stents?

Is that one of the reasons this is correct.

Okay.

So the short answer is stents are a workhorse if we got to do something because that helps keep the vessel open and from it collapsing.

So this is something in the future may change, but the stents sometimes can also have build up of schmutz or junk inside of it.

And that's the scar tissue you're talking to.

And there's different reasons for it.

But the drug coated balloons have been shown now, and there's a chance where they're FDA approved for in the US that you can put it and balloon those areas and then you might not no longer have that gunk built up again.

That's what we're talking about currently.

But the application of the future may be another spaces.

Okay.

And that's what I'd say in the next 3 to 5 years, you might see more of this course.

That's why I love doing these shows like right, February's always that and month, you know like what did we not talk about last year?

What's new this year?

I like to I'd like to transition a little bit on medications and what we're hearing a lot about these days.

So we're looking at diabetes.

Let's talk about that first.

So addressing diabetes medications and we talked a smidge about this before the show started, so SGLT two inhibitors, which is again, that's the Farxiga, a type of medication.

And then there's the ozempic type of medication, which we're hearing a lot about too, and that's the GLP one.

I would like to kind of clear myths.

I'd like to maybe set the record straight.

Why is there such an influx of people wanting to get these medications that don't necessarily need them?

Some think, well, I just want to lose my extra 10lbs I think medically it's really nice to talk about that this evening because I feel like every morning show, medical show, news show, it's being bombarded everywhere.

You know, we're running out of this drug.

We have too much.

We have too little.

Dr. Espinoza, I'd like for you just to start on it.

If you want to have been here and there, that would be great.

So the craze for these medication is particularly for that.

The weight loss looked great.

Yeah.

So originally these medications came to the market for managing diabetes, but one of the side effects that became desirable with these medications is that patients were losing a substantial amount of weight, mainly because these medications tend to curb appetite.

And there are some other metabolic effects that helps patients, you know, lose weight.

So that's why the craze for these medications is ongoing right now.

Now, it's not to say that these medications are bad.

No, they do have, you know, certain properties that make them desirable in certain cardiovascular patients.

Some the GLP-1 agonists have been shown to reduce mortality in patients that have both diabetes and coronary artery disease.

So they're helpful in that sense.

We have an obesity epidemic, so these medications are helping to control that in a sense.

You know, I've had certain patients that have gotten on the medications for managing the diabetes.

They've lost 30 plus pounds.

And I've actually had to cut back on some of their antihypertensive or blood pressure medications, because now their blood pressure is too low.

So They're very good medications.

Now, they do come with side effects.

You know, some patients can have nausea, vomiting, stomach upset on the injection knees.

There's always a possibility of developing gastroparesis as well with these medications, which is paralysis of the stomach.

But that's a very rare occurrence.

But that's really why these patients are looking for those medications, because they don't have to spend the 80 hours in the gym in order to lose weight.

You know, they basically inject themselves every week and they'll lose weight.

So they're kind of, in a sense, taking a shortcut.

But that's not what these medications were meant for.

They were meant to help these patients with diabetes to better control their symptoms.

And we quickly learned that, you know, as a side effect patients would lose a substantial amount of weight Now, on the other side are the STLG2 inhibitors.

Now, those also came to the market for managing diabetes.

Okay?

They work a little bit different.

They help eliminate excess glucose in the urine.

But the utility for them is actually in heart failure in those patients that have a weak pump.

Okay.

So the SGLT2 inhibitors are one of the four pillars that we consider that is the mainstay of treatment for patients who have pump failure.

So they help some the negative remodeling that occurs in these heart failure patients and it helps our heart function better and at the same time, it helps them eliminate excess fluids.

So you're able to cut back underwater pills.

In some patients.

It may help them lose a small amount of weight, but nothing compared to the GLP-1 Okay.

So, you know, that's where we we use these medications is not to say that we don't.

But predominantly those are kind of the realms where I use these medications for.

Okay.

Well, I appreciate you kind of explaining the difference between the two.

And do you feel that people are just using these for weight loss or are these people, for example, when they come to you all, but when they get their prescriptions, are they doing it partially diabetes?

Are some coming just for weight loss?

And is that something we see happening going forward in the future or developments of these type of of medications?

Because you said earlier too, your 5 you said hypertension, cholesterol, family history and diabetes and obesity.

So you were talking about the obesity.

That's that's one of the biggest one.

So if you look in at eliminating the obesity, you know, just in general, that helps with everything else.

To your point, you know, it's running and the gym and there are people who just have a much harder time losing weight than others do.

And I don't want to dismiss that in any way, shape or form, you know, because people with all of their might give it the college try and I've eaten right?

And I exercise and I just can't lose the weight.

Do you see these drugs being used in those cases, even if they do not have diabetes?

Yes.

Okay.

So the problem is that, yes, these medications, you'll get a prescription from your primary care.

Let's say you tell them, hey, I've tried everything I can.

I'm still overweight.

You know, I'm pre-diabetic.

Can I get a prescription or do you think this would be a helpful medication?

And most times a PCP will say, yes, absolutely.

It help you lose weight.

Here's the problem with those medications.

When they are prescribed in non diabetics, the insurances will not cover the cost of these medications.

They can be very expensive.

The other problem that is occurring and we see it in El Paso quite frequently is that now you have all these patients that are trying to use these medications for weight loss purposes and is making it difficult for the patients that have diabetes and need these medications to be able to find them.

I've had patients that have waited up to three months before they were able to receive their usual dosage for some of these.

And these are diabetic patients that really need it because they're being taken elsewhere.

Okay.

Yes.

Dr. Mulukutla?

the obesity epidemic drives blood pressure, cholesterol and diabetes.

And we call it metabolic syndrome, which are various ways to describe this.

As Dr. Espinoza was saying, as you lose weight, you tend to lose some of these problems.

So we've had to cut back on different medications for these patients.

The benefits of these medicines initially.

And when we talk about diabetes, there are other diabetic medicines that have come out.

And as a result of that with diabetes, we now have all diabetic medications have now been asked to do cardiovascular assessments because we are now finding that there's so many benefits that we didn't realize, you know, the SGLT-2s are beneficial in heart failure.

JLP one's work on the hypothalamus, that's why it decreases satiety.

So you get early satiety where you're not hungry.

The other things that we would like to say with these medicines is they are relatively new.

We're learning a lot.

Patients have to be very careful how they take them.

When you have the medicines, you may be titrated up to a certain level to maintain weight or lose weight or to improve your hemoglobin A1 C, which is the GLYCOSYLATED hemoglobin that we check to see.

Your diabetes is well controlled or not every three months.

The other thing we're finding is, yes, you may want to use this and it has the benefit of weight loss, but if you come off of these medicines, you may also gain the way.

So it is not that you can just take these medicines and come off it may be also a sustenance or a maintenance that you have to be on with these particular medications.

And we're still each person is different.

Is it okay to use it in this and that?

Those are all things that are open questions, right?

I think they have a great benefit.

But there's a simple study that was done in Britain which showed that even if you didn't lose weight and you did 15, 20 minutes of exercise, those people's cardiovascular benefit and mortality was less and those that didn't.

But the point is just being active is also beneficial.

So we want people to be up and moving regardless of their age group because walking and being active and exercising has benefits.

And as we discussed in the very beginning of the program, the heart is a muscle and you have to exercise the heart but not work it to heart.

That's right.

You know, not working it too hard.

I'd like to go back and talk a little bit more about valves.

We have a TAVR sub trans aortic valve replacement.

I know that in general there are like mitral valve there is replace.

I have a mitral valve issue.

I do have regurgitation.

For the most part, it's chronic, but relatively benign.

But it's something that I know I have.

And I'm always curious when these these issues come up.

And then there's also other valves that are frankly more important.

So in my opinion, I feel like if I'm going to have a valve issue, mitral valve is okay, but in schedule, actually, you know what, I'm going to stop for a second.

I'm going to go to this because we talked about the joke of this earlier.

Hold off on the valves for a second.

We got a whopping 30 minutes.

So let's talk about severe aortic stenosis.

And you said, okay, go ahead.

Should I should I do that?

Yeah, because the crew the crew really wanted us to do this.

Yes.

Okay.

They wanted you to put your finger in the bottom one.

It just sounds like a bad joke.

That's why I was like-- This is not a Bart Simpson joke All right, all right.

It's not going to electrocute me or anything, Right?

Okay.

Bottom one.

The bottom one is the.

The one that's normal.

Okay?

And then you take you can take your finger back.

All right, then fill.

Too bad.

And then the top one.

Oh, wow.

So what I find interesting is I can talk about all the stuff about every valve all day long.

So this is the normal one.

But patients really understand this more than anything else they could have.

The bottom one is opening normally, and they said, well, that's that's what's happening in my valve.

That's how it's getting it's not opening.

And so I say it's like a pinhole, whereas the other one is your valve.

When you were born or as you grew up as a teenager and flew in and out very easily or contract.

Okay.

So the reality is when you build a blockage or calcium mean you can do it everywhere.

In fact, they know by the age of 13 you're already building up certain blockages in your aorta and plaque.

And so this plaque and buildup is happening in the area of valve or the mitral, wherever it might be.

And this is a good example of where patients who are pumping through that pinhole.

Now, we understand why there's a high mortality and two or three years where 50% of the patients will die if we do nothing right or walking towards a cliff.

And if we didn't take care of you, you might fall off even though you might feel okay or you're having some mild shortness of breath.

And what happens with patients is very common.

You know, you can't do something.

So you've sort of ratcheted it down and you instead of one V-6 or v4 v two, and before you know it, you're not doing a whole lot.

So we teach our residents that rotate with us and they come in or the fellows and they say they're not having any symptoms.

So the question really is what are they doing?

Right?

Because if they're not doing a whole hell of a lot, then you're not taking the car out for a spin.

You're just basically jogging around and not doing much.

You might not be able to tell.

So that's why we talk about heart attacks and heart disease being a silent killer with high blood pressure and all these different risk factors.

Because if you don't mend it for a while or take care of it, at some point you've got to pay the piper.

And these are the things that are important for us, right?

Like you said, I'm glad that we talked about that.

And too, when you're looking at when you think of calcification, you know, you were talking about blockages and calcification and just building this up when you think and just for the audience, it just feels like very I don't know how to describe this is very software where you can go through and this just feels like hard nodule rubber.

You can't really get in there, nor can you pull your finger in or out nicely or easily.

And the way I describe it, it is like a door in winter that's getting stuck.

Yeah.

And then as it gets more stuck, it's harder to open.

And eventually, you know, for many years now, almost 50 years or longer, what we had was we had the surgeon take the door out and replace it.

They would put you on the heart lung machine, drain the blood out of the heart so they could work in a bloodless field, you know, then they would basically remove the door and put a new door here.

And so what's changed today is almost 65, 70% of all aortic valve replacements, which is the last stop on the train station before the bug outside of the heart is now replaced without doing open heart surgery.

But you can replace it by doing this TAVR tab or procedure where you go through the groin and you can replace the heart valve and I'll show you here so you can see it.

But basically you put one of these things and might be harder than what I can do even during the surgery.

But.

Well, it's going to go in right there.

I don't know.

Maybe this one doesn't fit correctly, but basically this valve is going to go in there and it's going to it's going to fit right where your old one was.

And for technical difficulties, you're not able to put it in.

But the short answer is you don't have to cut out the valve.

What this does is it pushes out the old valve and what you see is inside of it now, the new valve.

And this is made from the sack of a heart sack of a cow okay.

And it takes I think when I went and visited this lab in California was an old seamstresses that were who'd done this for a long time and takes about 12 hours to create this thing, each one working for an hour or two on their part.

And this is the thing that we have that we can blow up with a balloon now, much like we do the coronary arteries and do a life saving procedure.

And we can do it with the patient.

Come in today and gone tomorrow.

That's amazing to me that that's even an option now.

And so, yeah, Diego was just looking at this other one over here.

Let's see if we can pass this under this.

Oh, the one in the corner here.

Oh this is.

Yeah.

Is that the same.

This is different.

This is related to A-fib.

But I know if we would like to talk about it, but I did.

Well, let's do since we kind of-- Why doesn't Dr. Espinoza tell us about, you know, things that he how he treats A-fib?

Because this is one modality.

We did several of these today, but this is an option for patients to get off of blood thinners to prevent one of the concerns, which is stroke.

Right.

So there's a lot of things with atrial fibrillation that are important and it goes back to our palpitations discussion.

Okay.

Right.

I'm an AFib girl.

So again, I'm very curious about this and stroke is something I worry about.

Yeah.

So as Dr. Mulukutls says you know the top chamber basically tells the bottom chamber how to --so the top chambers usually pump in synchrony and then the bottom chambers pump.

With a fib They're basically quivering.

They're not pumping rhythmically, they're just quivering.

So what happens is that those electrical impulses is very disorganized.

So all those electrical impulses are bombarding the bottom chambers.

So it causes the bottom chambers to beat irregularly and fast, and that can cause symptoms.

The patient can feel palpitations, it might feel lightheaded, things like that.

Over time, if the heart is in that constant tachycardia and irregular rhythm, the heart can weaken so they can sometimes a type of heart failure called tachycardia induced cardiomyopathy, where all that irregularity in the rhythm and fast heart rates will cause the pump to weaken.

So that's one of the dangers of it.

The other danger of the A-fib is, like Dr. Mulukutla says, is that when the heart chambers are quivering, blood stays there a lot longer than it should.

So whenever blood is in one place for too long, it'll clot off and then those clots can then go out to the body and cause all sorts of problems.

The main problem that we fear is a stroke.

A clot makes it to the arteries of the brain, causes an exclusion, and now you have a cerebral infarction, a stroke.

So, you know, most patients that have a -fib have other co-morbidities high blood pressure, you know, coronary artery disease, diabetes.

Maybe they've had prior strokes already.

So the more of those entities that you have in one patient, the higher the stroke risk is.

So once a patient reaches a certain stroke risk, we would recommend blood thinners.

That would really be one of the few ways to reduce the chance of a clot forming in this chamber right here, which is the left atrium, there's this anterior portion of the left atrium called the left appendage.

And the majority of the clots that cause strokes in A-fib come from that particular area.

Interesting.

So, you know, now we're using a medication, a blood thinner, that helps reduce the chance of forming clots, but at the same time increases your chances of having spontaneous bleeds.

So you can have a spontaneous brain bleed bleed in the stomach.

So some patients, you know, they have a high bleeding risk.

So you have to kind of balance, you know, is the stroke risk higher or is bleeding risk higher?

In those patients that have a higher bleeding risk, than stroke risk, you would consider this device called a watchman, which Dr. Mulukutla also does.

And basically it's a plug.

It plugs up that area where those the majority of the clots form where they fit.

And it allows patients---- so to speak, or or to try to prevent the clots.

So the blood doesn't get in there and clot off, so it just plugs off that problematic area.

So it allows these patients to safely come off anticoagulation it substantially reduces stroke risk.

So that's what this is called the watchman device.

Okay.

And how difficult is it to place that in so today we did a few of them and one of them, to Dr. Espinoza's point, she had a brain bleed we call intracranial hemorrhage while being on blood thinners.

So as a result of that, she also had a stroke and so to get her off of the medicines we did this procedure today.

Then there's another gentleman who had a stomach quit and had needed transfusions of blood cells to make his blood counts come up.

And unfortunately, also patients, these are expensive medications that are hard to afford or obtain.

And that can also be a reason.

There's a lot of different reasons, and this will probably become more and more common as we do these things, but they can be challenging to put in.

But generally it's a procedure that we do today and then the patients can go home tomorrow, but it takes about an hour or two.

We put the patients to sleep and we end up basically putting this plug within the heart again, without opening the heart, which is an amazing thing to do.

Yeah, exactly.

And this has been around for how many years would you say about years?

About five years.

So it's still relatively new.

Yeah, it's not it's not very long.

Okay.

And this first patient actually I saw in clinic that we did here in the Borderland just this last week, she's doing great.

And I think now as a community, we probably done north of five or 600.

Oh, my goodness.

So it's it's not something that is for everyone.

But there is the benefits to these patients.

In the old days, we would just tell people, hey, just come off your blood thinner and just hope and pray.

What could have been done.

But now we have options.

So it's for certain patients.

But you know, you have to see about it.

And it's just our new technologies that we want to be able to have for our area and our community.

I think it's great that we're able to do these different things now so patients don't have to go elsewhere.

I thank you all so much for discussing this, but honestly, for bringing visuals, which is super helpful to everyone.

And Diego, who's the one that puts this program together and edits everything I keep saying his name is he's pointing at things around here too, and there's some stuff that we didn't even get to, so come back.

I kind of love that.

Thank you so much.

We've been speaking today with Dr. Mulukutla How you say his name differently than I do - -Mulukutla Mulukutla.

See, I can say it Had a sale on U's and we bought them all Had a sale on U's!

You are, do you do open mic night sometimes/ --Like my wife would say, my jokes are pretty stale.

Well it you describe things well and I think that's very helpful to the audience.

Dr. Espinoza, thank you so much for being here.

Again, this has been Advancements in Cardiology, and if you missed part of the show, you can always catch us in three different places.

There is on pbselpaso.org You can just look up the El Paso physician, also on the El Paso County Medical Society website and that is epcms.com or YouTube dot com and just put in the words the El Paso Physician and then often you can find whatever ailment that you're looking for, whatever the topic is and it will pop right up.

But we will see you next time.

Thanks again for joining us.

I'm Kathrin Berg and this has been the El Paso Physician.

Hello, I'm Dr. Alison Days, a past president of the El Paso County Medical Society.

The El Paso County Medical Society is a nonprofit organization established in 1898 that unites physicians to elevate the health of the El Paso community.

We have been bringing the El Paso physician to your home for the last 27 years on PBS, El Paso.

We hope that you've enjoyed this program and others we have previously recorded.

They're archived on our website at EPCMS.com, kcostv.org, or you can also locate them on YouTube by searching for the El Paso physician.

If you should have any questions relating to this program, please feel free to email us at EPMEDSOC@aol.com, and we will try to have our experts answer your questions.

Thank you for watching and please feel free to provide feedback at EPMEDSOC@aol.com.