[Music] good evening and welcome to doctors on call i'm dr mary owen faculty member at the university of minnesota medical school duluth campus and family medicine physician for the center for american indian resources fond du lac band of lake superior chippewa i'm your host for our program tonight on heart problems heart failure anemias and bleeding problems we'd be happy to take your questions on the diagnosis and treatment of heart problems high blood pressure bleeding disorders or other any other cardiology questions you might have success of this program depends on you our viewers please call or email your questions and we'll do our best to address them the telephone numbers for your questions can be found at the bottom of your screen our panelists this evening are dr mark earhart a cardiologist with st luke's cardiology associates and dr victoria herron a family physician with community memorial health raider family clinic in cloquet members of the wdsc staff are standing by to take your phone calls and now on to tonight's program good evening to both of you good evening thank you so i have lots of questions particularly of course around the impact on cardiology from uh from the covet from the pandemic and i'd like to know from you dr earhart are you seeing some sequelae of people not having gone in for their regular care during the pandemic yes it has been tough there's been a lot of fear of going to a physician's office or associating a location that that you could potentially pick up the disease i think some of it is unwarranted um that fear and i think that fear should definitely be as more and more people get vaccinated i think it'll be much easier and they'll be much less fear but i do believe there's also been some procrastination of of follow-up and and of continuity of care and some people fall through the cracks and and they're kind of afraid well i haven't been in for a long time now now what do i do and i think that's been a that's been a a complication of the fact that we have we have had this aversion to doing things in public and and to and to going in and being in a personal um contact with another individual and i think we're fortunately that's coming to a close and i think that we hopefully can be able to restore those relationships and that preventive health which is so critical for for the community and very critical for people that especially have advanced disease dr haron you and i were just talking before the show about one of the changes we saw with covid was changed to more virtual visits has that slowed have do you see any problems with that with cardiovascular disease or any other diseases virtual visits work fine for some things especially mental health and follow-ups but when it comes to a lot of things including cardiovascular disease being actually able to listen to somebody's lungs listen to their heart feel their pulse is very very important listen to somebody's breathing see how their exercise tolerance is meeting face to face can be very important and getting over the fear of coming to the clinic you know we're following the guidelines safety precautions more and more people are vaccinated it really can enhance somebody's health care and keep them out of trouble out of the hospital and you know from having to go see the cardiologist for a heart cath or worse if they'd come in and actually get checked out properly thank you thank you now enough of the coveted questions under other questions i hear from my patients all the time what did they do if they have a strong family history i'll start back with you dr herrera strong family history of heart disease or cholesterol problems does that mean that they are destined to have the same fortunately that's not true but i think it's important to look at what's your own individual risk factors you can't change your family i'd love to be able to one of my first common questions is pick your parents well did you pick your parents well well if your parents do have advanced disease at an early age you need to do something different so it's nice to look at their were your parents smokers were there diabetics that weren't under control did they exercise did they get plenty of sleep which is critically important for for long term survival especially as we age sleep is very very important and often underplayed those are those are the questions i ask but i if you have a deck that stacked against you you have to do something different different than the previous generations and we know many things you can do one of them is is eating right and exercising and being outside are so critically important for cardiovascular health is there any need to for some people with that strong family history i've seen some people talk about starting statins as early as 20 years old when people have we have guidelines on this now we now have some testing that can be done if you do have an early family history of coronary disease and finally after nearly 30 years of experience the american heart and american college have weighed in of doing coronary artery calcium scores if you have a strong family history of coronary disease and you're 40 or 45 years old and someone says well you just got to start this statin right away we have guidelines and as of 2018 those guidelines have been pretty much solidified which means if you have no coronary artery calcium and you're not a diabetic you need to continue to do lifestyle changes but you don't need to start a statin the statin therapy can be put off on those patients unless they're diabetic and and can make a tremendous difference one last question on the same topic are those tests hard to get if you're out in a rural area can't get in they are getting easier to get in uh they're in the state of minnesota at most major locations they're between 100 and 200 maximum and i don't recommend them getting more than every five years apart but it'll tell you exactly how with you're 55 years old and you have some coronary calcium it'll tell you are you the middle percentage are you the bottom percentage i get one on myself every five years so do all my family members you don't have stock in this company i have no stock in the company this is name one thing in medicine that was 395 dollars nearly 30 years ago and now is down to less than a half or a third of that price so it's a wonderful it also can pick up other things too as a bonus aneurysms cancers i've had a lot of people i've i have been a very strong advocate for the last seven or eight years on using this to decide who to start on statins and who who can who can defer that decision okay good to know thank you dr herron your turn we talked a little bit about the fact that there's a misconception that women don't have heart disease as often or don't have the same kind of outcomes as men do tell me more about how women differ than men or if they do in heart with heart disease well women do get their heart disease they tend to get later than men child bearing and estrogen seems to be protective earlier but then menopause comes along and women start catching up so they get their heart disease they get it just as much as men they just tend to get it later and they don't tend to have the classic signs that men do a lot of the things that a lot of people think about in terms of the elephant sitting on your chest or the pain and going down your left arm were standardized from men women can get anything from neck pain jaw pain very bad indigestion just feeling short of breath or very weak it can be a lot of things that women may just write off as oh i'm just not feeling well unless they're thinking you know that could be my heart i should maybe get this checked out i'm just not feeling well i've known people to sit home with horrible indigestion only to find out that when they went in they sat home with their heart attack are there some diseases where you might not have the same kind of even those symptoms you can have a totally silent heart attack okay thank you is there anything that puts you at uh more likely to have a silent heart attack than anything than other diseases or just you can't determine that well diabetics very often will have more silent heart attacks they have more chance of having some nerve damage so they just don't feel things the way they maybe ought to their body just doesn't tell them that okay thank you dr erhart back to you you'll get back to your turn here in a second dr herron this gentleman caller had a defibrillator put in in 2005 had there been any improvements since then significant improvements there's one of the things that used to limit defibrillator usage in the past is the batteries just didn't last very long so the batteries many times people that had the early defibrillators were getting new defibrillators new generators you don't change the battery change the whole generator so you get the new the new technology when that updates but the batteries have improved significantly and the detection ability of these devices going off inappropriately is so rare so i i think that the technologies of these major companies have improved because there are so many people that benefit from these technologies many people and it's really good to find people that have had 16 years ago i had a defibrillator and i'm still alive before that before that many years ago we had no technologies for those so this is one of the advances of and the fortunate things of living in this age dr herron is a heart rate over 100 a concern and what does it mean got to take everything in context if you're running up the stairs heart rate of 100 is perfectly normal if you just watched a really scary tv show it's fine there are a lot of instances where a fast heart rate is perfectly normal if you're sitting relaxing your heart rate is normally supposed to be under a hundred now if it's 101 102 probably not going to quibble about that if it's significantly higher than that you gotta wonder the normals are quoted as 60 to 100. it is kind of a bell-shaped curve so some people run higher some people run lower if you're running consistently over 100 you might want to get it checked out because there are a number of things that can cause a high heart rate that are actually significant problems and running a fast heart rate long term can be bad for your heart are there um how about exercise does that change your heart rate uh long-term say for um lance armstrong or someone else is maybe not the best idea but athlete athletes run really low heart rates okay that's something strong muscles their heart is very efficient and they just don't have to beat as much and their blood pressure does that change too and their blood pressure runs low and that's very good for them okay we talked before the show a little bit about hdl and ldl and what those mean for people and most people are aware now that hot really high ldl not so good a higher hdl pretty good the high density can you talk a little bit about that and are there exceptions to those rules well talking about the breakdown of the cholesterol it's always a good idea to get the breakdown because just the total doesn't tell you the whole story by any means your ldl or low density cholesterol can even be broken down further but that's kind of high tech and we don't usually do it is normally considered your bad cholesterol and the higher that is the worse it is and that's normally the target because we have a number of drugs that can control that your hdl or your high density is normally considered your good cholesterol because that's normally what takes the cholesterol out of your veins and brings it back to the liver kind of cleaning up so you want that kind of high there are instances where a high really high hdl can be indicative of a high density lipoprotein that is just not working correctly so sometimes the number can be really high and it's just not working so there can be instances where just having a oh my hdl is a hundred really doesn't mean that it's a good thing thank you dr earhart anything to add to that yeah i think in general we've we've looked for males to have hdls higher than 40 and for females to have hdls higher than 50 especially the premenopausal male and i agree that that magic formula of estrogen is cardio protective for most women up until when menopause takes place and then all of a sudden you lose your advantage and that advantage that helped your bones and also helped your coronary disease goes down and you start catching up with us and we're not diagnosed very well either so i would agree specifically there is the women are truly from venus and we are from mars and and and heart disease is definitely different um between the two and the discovery thereof but it's still the number one killer of both sexes so this clearly um good hdl cholesterols are usually cardio protective usually are but not not across the board and i agree however you can raise your hdl by exercising exercise can raise the hdl 20 percent eating right avoiding highly processed foods and eating in general the more man touches it the more we mess it up we want foods closer to the natural state that hasn't have not been distorted and have not been processed to a degree we take all the a lot of the nutrition out in processing so that's what we really want to go to is raising your hdl with exercise stopping smoking eating right sleeping right those are the things that we can but to some degree people are born with an hdl that can be a real bad and a very low problem we do see those people out there you know we talked a little bit about before the show as well we talked a lot before the show we talked a little bit about those medications that we commonly call statins now and i have had patients who for whatever reason they can't take statins they react poorly to them and you told us a little bit about some newer medications can you tell us about that right now yeah this the mainstay for many years for about 40 years has been statin therapies and they've been studied more than any drug in the history of the pharmaceutical industry they're mostly all now generic they're very inexpensive but there are clearly some people that don't tolerate or you may not tolerate your type of statin there are statins that dissolve in fat and satins that dissolve in water and sometimes the statins that dissolve in fat may have a reaction those that dissolve in water people tolerate very well however there are some new drugs that you may see advertised there specifically for a small percentage of patients either those patients would have advanced coronary disease that can't tolerate any statins and those are called the pcsk9 inhibitors so far there are only injectable forms and primarily they're marketed to those that cannot tolerate with advanced disease or they're born with a certain genetic predisposition called familial hypercholesterolemia and those people often have ldl cholesterols two to three four times what is normal and those are what those drugs were developed for but we've now used them in patients that can't tolerate statins that clearly need a statin okay so there have been good therapies that are coming that are newer okay thank you dr haron there a lot of questions out there about um heart the how the heart's working so someone has a question they have occasional skipped beat they're 75 years old how serious is that pretty much everybody has skipped beats some people feel them and some people don't i can only feel mine if i take my pulse and especially after exercise other people can feel them just sitting there an occasional skip beat is absolutely nothing serious if it's an occasional skipped beat nothing to worry about at all if it gets to the point where your pulse is very irregular not just skipping a beat now and then and regular in between if you have just a very irregular pulse that could be a serious arrhythmia and you should get it checked out good anything different dad i agree i think that physicians 30 years ago looked at premature beats in a different way now after a major study was chained called the cardiac arrhythmia suppression trial we don't treat those premature beets like we used to in general there they are not have nothing to do with life lifestyle they do not need to be treated unless they are interfering with your activity or or they affect your dizziness or your hemodynamic component that may be a different situation but those are rare thank you dr haron i have a patient who has atrial fibrillation and has not been able to get it under control despite different interventions including cardiac ablation thank you ablation oh talk to dr erhardt dr earhart what are their options atrial fibrillation is a disease of advancing age 96 of atrial fibrillation occurs after age 60. it's a disease as we get older both of my parents had that before they died and the big concern with atrial fibrillation is stroke risk that's the concern our blood is designed to move and when it god only knows why i put it there but in the top of the heart there's a little appendage that tends to harbor clots and that appendage is the clot that killed my mother okay so there's no question that that is something that we worry about but ablations have gotten better significantly better over the years but there are still some people that don't respond and when they become completely disabling you can have what they call an av node ablation and a pacemaker and then the atrial fibrillation does not cause any further symptoms in those patients but we do have a scoring system that every doctor in the united states uses and it decides who needs to be on a blood thinner it's called the chad's vast scoring system and no matter where you go in the country they'll talk about what is your risk of stroke and the higher that risk is the more people benefit from being on a blood thinner and i'm not talking aspirin i'm talking a medication called warfarin or many other we have three or four other drugs that we now use that are similar to warfarin to protect those patients against strokes a lot of people have been taken off warframe in the last few years and put on another kind of medication similar to morphine another blood thinner but they don't have to go in for the testing as frequently can you either of you want to take that one on why why i should have my mom take one or the other generally it comes down to cost warfarin's been around for a very long time it's cheap but you do have to go in for the blood tests there are some people that it works wonderfully for they are very well controlled they don't mind going in for the tests their blood stays right where it should be and it works other people even though they try or they don't try their blood does not stay in the nice range because warfarin does have to be adjusted foods affect it other things can make it get thinner or thicker so it's touchy and for some people it just doesn't work if it's not working if it's not staying in the range that it should be if it's too low you can get clots if it's too high you can bleed and those people are much better off on the newer ones that are not nearly as touchy the problem with the newer ones is they're new their brand name there's no generic and they're pricey if you have to pay out of pocket they are extremely pricey and insurance companies cover them to various extents and for some people price is the make or break if your insurances cover them the newer ones actually have some good data on preventing strokes and that's why you take them preventing strokes just as well if not better and having less bleeding risk i mean hey if you're gonna pay the same out of pocket why not easier to take less monitoring less risk of bleeding same stroke protection if not better go for the newer ones unless it's going to cost you an arm or a leg good thank you there this is a family doctor question i think someone wants to know what is it is there any significance to high calcium levels when a person gets their blood drawn depends on how high and there's a multiple reasons to have high cholesterol high calcium levels some of them can be some other drugs you're taking hormone imbalance all the way down to cancer so yes possibly and certainly depending on the calcium level lots of uh it depends questions tonight dr erhart just a clarification you had said that you had some a test done every five years on yourself can you remind the audience yeah that's called a cac or a coronary artery calcium score it's a cat scan that is now offered by most hospitals in the united states it is it is offered at a at a price that is less than the cost of doing the test as a service to the community and that test in the state of minnesota is now between 100 and 200 dollars and it's a once every five year test that can really help guide your care and your cholesterol and reassure many patients so i find it very therapeutic for people that have early family history cac coronary artery calcium score thank you for that um i think we have a time for at least one more question what is left anterior fascicular block and is there a treatment for it yes there is a treatment for it you ignore it this heart if i could show it here has a bottom chamber called the left ventricle and when the at the top of the heart when the sinus node which is our body's pacemaker communicates to the bottom and tells the bottom to squeeze it has three pathways to get the impulse of the bottom part of the heart man has not designed a pacemaker as good as the heart comes with and the left anterior physical fascicle is part of those three pathways is the right bundle the left bundle which is made up of the anterior and posterior fascicles and having one fascicle out means nothing negative for anybody at all so don't it's not a problem with their heart if all three are out you have no communication to the bottom and those people need a pacemaker okay dr herron sorry gonna throw you one here last question uh a patient had her left knee replaced then went back in for heart failure and pneumonia and now has to do breathing exercises why do you think that she got some of those or what are some possible reasons that she might have gotten that from the knee replacement actually either of you well knee surgery gets you in the hospital and makes you not move so well if you're not moving so well you often don't breathe as well and that can set you up for getting pneumonia which is why they have you do incentive spirometry or at least try to and i'm not sure how the heart failure can tie into that one assumes some underlying heart disease the pneumonia does not help because if you get lung congestion it makes harder for the heart to pump blood around and puts more strain on the heart so that can be tied into the pneumonia yeah it gets down to all parts of your body are related well said anything to add to that dr erhard i thought that was well done it doesn't take long for us to get out of shape and a knee uh injury that's why one of the things with orthopedics we get them up very quickly after and get them moving and that's what we want to do all right um one last question on uh hdl and ldl ratio is there any benefit to other was how should that look well if you're blessed and your hdl and ldo are the same you almost never get heart disease so the the and most people that have coronary disease are three to one bad cholesterol or four to one ratio or five to one six to one or ten to one any last words as we tie up i think from my aspect go to the things you can change which is exercise eating right sleeping right and and doing our best to avoid the toxins that we have around us i want to thank our panelists dr mark earhart and dr victoria herron and our wdsc phone staff this is our last program of the season and thanks to all the doctors and phone volunteers who have been with us throughout the season of doctors on call we hope you've enjoyed the program thank you for watching and good night [Music] you