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

My name is Dr. Luis Munoz in the president of El Paso County Medical Society.

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

We at the 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.

One in four people die of heart disease in the United States.

There are many heart conditions, but what qualifies is heart disease?

What are the signs?

What are the symptoms?

What do we look for and when do we ask for medical attention?

During the next hour, we have experts answering questions about early detection and possible prevention of heart disease.

This evening program is called The INS and Outs of Heart Disease and is underwritten by the hospitals of Providence and specifically The Center of Heart Practice, which is predominantly located at the Trans Mountain campus.

A huge thank you also goes to the El Paso County Medical Society for bringing the show to you since 1997.

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

Thank you again for joining us.

This program is called The INS and Outs of Heart Disease.

And with us this evening, we have a veteran who is Byomesh Tripathi and he is an invasive interventional cardiologist.

And we also had someone new to the stage and this is Tariq, and it's Siddiqui , is that correct?

And he is an invasive and structural interventional cardiologist.

Dear Lord, that's a lot to say.

So what I'd like to do is actually talk about there are different disciplines and specializing in cardiology and Dr. Tripathi, I would like to I would like for you to talk about what it is that your specialty does specifically.

And then we're going to talk to Dr. Siddiqui as well and talk about the differences that you guys have together within your practice.

So feel free to start with that.

Sure.

Thanks for having me here.

So I'm a cardiologist, so I specialize specifically in treating heart conditions, using cats and wires.

And I was trained in treating something called coronary artery disease.

That was the main thing that we were trained on.

What it means is that we can treat heart blockages and heart attacks using just wires, catheter.

We can go inside, open the blockages using balloon and stents.

So this is something I do, but I see.

Are there other heart problems as well?

For example, I see, you know, conduction problems in the heart.

I can put pacemakers.

Richard General conditions for prevention of heart disease, for example.

We manage blood pressure.

We manage.

There are several conditions that we manage.

But as far as interventional cardiology is concerned, mostly coronary artery disease, conduction problems.

And then we also treat peripheral artery disease as well.

Okay.

And we may talk a little bit more about that.

I'm glad that you mention that, cause I don't have that down here.

So we'll get to that in a little while.

To Dr. Siddiqui, let's talk about you.

So you added the word structural into your your discipline, so to speak.

So explain what the differences are between you and Dr. Tripathi in your practice.

Oh, thank you for having me.

So over the last decade, in fact, a little bit more than a decade, we have advanced a lot in cardiology field, especially in the area of structural.

And when we use structural, basically that's part of the heart which we deal with, which includes closing the openings and holes in the heart, which in the beginning used to be fixed by surgery, open heart surgery.

Now we do it minimally invasive recall, which means without opening the chest, we go through the rain and we go to the artery and try to open these holes.

And it's a wide spectrum.

When we call structure, we take care of the valves which are blocked.

We try to open with the balloon.

So we can fix put the stent.

And their stents has a valve implanted so that the flow can stay or maintain in the forward flow.

We also have some time leakage in the valves because of different reasons.

And we put the valves in those cases.

And some time, if the valve is not needed, we put a clips so that it can it does not trap so which so it does not it decreases the leakage, not completely, but to the level where a patient would not feel symptoms.

Also now we have been doing which we call it, people who are at a risk of bleeding and people older population who are sometimes not the greatest candidate to be on a blood thinner for the long term.

We have other options where we can take them off from the blood thinner and plug those those structures which build the clot and prevent them to have a stroke.

So I writing all these these little diamonds that you're throwing my way because we're going to talk later, A lot of people are on blood thinners.

And before there are procedures, before you go off of your blood thinners for a little while.

So we're going to we're going to intertwine some of these things that you're talking about.

What I'd like to do, again, you all are invasive interventional, cardiology.

And a lot of times we hear the word on invasive.

But when you say invasive, and I guess the key word here is interventional, you're trying to prevent something bad from happening.

You know, people come to you.

There are obviously symptoms and signs, but we're trying to prevent the really, really bad things from happening.

So what I like to do just for a second, because people think about cardiologists and it's just a heart doctor.

So even though we describe what you do, what are some other specialties that are in the world of cardiology, just so when the audience is listening to so like, okay, these guys are the interventionalists.

So from there and Dr. Tripathi, feel free to just throw that out there and we don't spend a lot of time on that, but it's just kind of a curious thing.

Sure.

Yeah.

Broadly we can divide cardiologists into, I would say, four categories, but there are several new new categories as well.

But broadly, you can see how general cardiologists, they basically focus on preventing, you know, heart problems.

They treat patients with medication.

They counsel them, they make sure that they don't develop anything that requires a procedure or surgery.

That's their goal.

We are then interventional cardiologist, as we described.

We are able to just go inside with twice catheters, you know, fix different things.

Then we have a category called electrophysiologist.

They are again trained into treating electrical problems in the heart.

So they treat fibrillation.

They do a lot of ablations and stuff.

And then we have heart failure specialists.

So once your heart is weak, they'll figure out why it's weak, whether you can be treated with medications or says you need a heart transplant.

Our devices.

So so they are very advanced specialist in terms of cardiologists as well.

Okay.

And I want to say that because I know that we're going to be concentrating on intervention, biology.

Intervention.

Oh, my God.

I'm going to try try it four or five times to say that.

But again, we've we're going to talk a little bit about electrophysiologist, too, just because it's part of what we hear about all day, every day.

But if we're looking at heart disease, like if you're going to describe or define what heart disease is we have in our populous, oh, I've got high blood pressure in.

My doctor wants me to bring that down.

Oh, I've got high cholesterol and my doctor wants me to bring that down.

When is there a definition of, okay, I've got heart disease and I'm going to throw that to whoever wants to take that.

Who wants to take that question?

Sure.

No, sure.

Okay.

Dr. Tripathi?

So, you know, before you we can define heart disease.

You need to understand the structure of heart, right?

So you can just to simplify things.

Heart can be considered as a four bedroom house.

Okay.

It has two upper bedrooms, two lower bedrooms, then it has pipes and then it has electrical channels.

And then walls are made up of muscles.

Right.

So, you know, we can have problem anywhere in the bedrooms, in the doors of bedrooms, in the pipes.

You know, they doctor wires, depending on what kind of problem we are having, we'll get that sort of heart problem.

So, for example, if you have a problem with the pipe, which is the blood vessel in the heart, then we'll get something called coronary artery disease.

It's very common.

It's number one killer in the world.

So if we get problem in the electrode channels, then we'll have arrhythmias, basically heart rhythm problems, right?

If you have problem in the muscles, we'll get heart failure, cardiomyopathy.

And then when we talk about blood pressure, technically it is part of heart.

That's why we call our system cardiovascular system, not just cardiology, right?

We are cardiovascular specialist.

We treat cardiology as well as the vessels.

So when you have high blood pressure, eventually it can lead to heart problems.

So we treat that portion as well.

We prevent people from having heart diseases by treating their high blood pressure.

And that's beautifully explained to.

And Dr. Siddiqui, let's let's talk about like the most common heart issues, cardiology issues, cardiology, cardiovascular issues that you see on a daily basis or on a weekly basis, What is the most common that you see?

And then we're going to talk about more what is dangerous and what is okay, at least for now, and until we talk about behavioral health.

Yeah.

So I think before we even talk about heart disease, I think main thing is that how you can prevent that.

And so we do come across a lot of patients with hypertension as we talk about, and that's the most important thing to address so that you don't deal with the problem with the heart.

Yes.

If you are not taking care of yourself and the blood pressure medications or you are taking care with the diet and not taking care of with exercise and everything, then you would deal with the situation where you have other problem.

as Dr. Tripathi was mentioning that can result into the pipe getting clogged and or buildup of calcium or buildup of plaque which recall and as a result the artery can get blocked.

And that's one of the most common things which we see every day in our practice to the level of the majority of cardiologists see that more commonly.

And we need to prevent that before we can really treat that.

So I'm going to break that down to someone who doesn't know that there is clogging going on.

And let's talk about some symptoms of what it is that brings people to someone like yourself that okay, I'm not feeling right.

I'm out of breath all the time.

I know I have high blood pressure, but when do people actually come to see you so that there is a test, some kind of procedure, that diagnosis, what's happening?

And again, I'll go through that to you first, and I'd love for you to tag on to that as well.

So so a lot of times, as I said, like we people of people come even before they feel any symptoms.

So those are the area where we need to focus by thinking when that family had a disease.

So how we can prevent them to have a disease if they're if they if they are prone to get premature disease because of the family, then we need to make sure that we make sure we do some testing to to enhance their risk factors so they can start treating earlier than later.

Majority of the time when these patient comes, they come with a chest pain and the described doctor feel chest pressure in our chest, predominantly left sided when we walk, we cannot walk.

We start feeling chest.

Sometimes it goes to our neck, sometimes it goes toward jaw, even sometimes to the left arm, and sometimes especially female or older ladies or older men.

They don't present with this classic chest pain.

They come with short of breath or fatigue, tiredness.

Sometimes we feel pain in the arm.

Sometimes we feel that our joints hurting.

So those are some of the early signs.

When we think about, okay, we need to do some workup in the direction.

And I think apart from that medication, we want to do some testing.

And this is one of the other area where we have specialty, which is imaging.

There are different kind of imaging we can do to look into the heart disease even before we can go and fix it, which is more invasive.

And that's what we come, which our interventional cardiologist and Dr. Tripathi, let's let's talk about when people don't really feel anything.

So to your point, sometimes there is all of a sudden there's a heart attack and sometimes the heart attack is the first time somebody realizes I have a problem.

I my heart's not in great condition.

So once we get to the center of heart practice where you all are at, what what is the pipeline of getting to you?

So these are people who kind of know they're not feeling good, etc., etc., etc..

The majority of your patients come from where do they come from?

The hospital because they've had a heart attack.

Are they people that do have these issues and then they come to you?

So kind of take it from that angle.

Yeah.

So okay, well, so we get two types of patients, right?

So one that we see in the hospital for first time and they had some acute event, for example, that heart attack or they were admitted with some sort of heart problem.

We take care of them in the hospital and then we make sure that they see us in our office so that we can make sure they are stable, not things are not getting worse and they're stabilizing.

There's other category that comes to us where either they're referred by or very intelligent.

PCP is our primary care doctors, where they identify the risk factors that patient have.

For example, somebody comes to them, he's like smoking, has diabetes, have high cholesterol and high blood pressure and his likeness forties in forties.

They understand that this guy is at very high risk of developing plaque in the coronary arteries and having heart attacks.

So many of them who are very vigilant, they just send those patients to us for early testing and then we take the history.

If we identify any, you know, flag signs, we we do a lot of heart testing on them.

And to identify whether they need any medication from heart perspective.

So that's one category.

In other cases, you know, a lot of patients are very intelligent.

You know, they just Google things online.

They have family history where somebody died of a heart attack.

They just want to see cardiologist no matter what.

You know, they don't have any symptoms.

They want to make sure things are going fine.

So these are the categories that we see a lot.

I like the you brought that up because we kind of have a joke on this program.

Again, we've been around for 20 some odd years.

And when people come and present to doctors, it's like, well, doctor, Google told me this and Doctor M.D., you know, told me this.

So when people come to you and they present to you all the stuff that they think they have because they saw it on the Internet, etc., how do you handle patients that come to you?

And they've already self-diagnosed without having real tests done in those situations, in cases, how do you handle that and what tests are like some of the preliminary tests that you take and I know we've already talked a little bit about this, but for example, when you're looking at arteries, right, if you have the narrowing of the arteries, how do you find that out?

What is the diagnosis test?

To find that out?

Then you put a very good point right now.

And, you know, a lot of time, as you were asking doctor quality how we get these patients, a lot of these patients when they're in the hospital, the whole family is there, you know, and when you discuss, I at least like the whole family's there because they have younger kids, their cousins, their younger family.

So these are the people who learn a little bit not only from the Google, also learn from probably.

And then and then over a period of time, they get inquisitive, should I look or cardiologists, how can I prevent heart disease, primary care?

They go to the primary care and they say, okay, or EKG is abnormal.

You need to see your cardiologist, your blood pressure is not getting controlled.

You need to see your cardiologist, your blood pressure is poorly controlled.

Could be you should go and see your cardiologist for you.

Don't get this.

So I think these are some of the other sources where you get get patients through that education.

And education is more important, as you just mentioned, that these these are the people who who knows and want to take care of them.

These are patients who it's easier to take care of them and make make them sure that lifestyle and preventing disease is more important than when they have that natural curiosity of what's what's happening, what's going on.

Taking that one step further and we were talking about you were talking about smoking, overweight, hypertension in general.

What causes the narrowing of the arteries?

I know we talked a little bit about family history, would say you don't know an adopted individual, for example, you don't know if there is a family history of this.

What is it that causes the narrowing of arteries, risk factors.

But the reason I'm saying this, too, is it if people are doing certain behaviors, maybe we can throw something their way and think, well, maybe don't do A, B, C, So what is it that that causes the narrowing of the arteries?

Sure.

Okay.

So, you know, from there.

Sorry.

No, it's okay.

So, you know, when you see a patient of it, obviously, you know, the good est So, you know, when you see a patient of it, obviously, you know, the good est is very, very important that we also look for the risk factors.

So when we talk about risk factors for, you know, blockages, we can broadly divide them into major risk factors and minor risk factors.

All nicely said.

Okay.

So major risk factors are four of them, right?

Smoking, high blood pressure, high cholesterol and diabetes, High diabetes.

We haven't mentioned that yet tonight.

That's so these are the major ones.

If somebody has it and his story is convincing, I don't leave any stone unturned and I just do the test just to make sure he does not have any, you know, severe blockages that requires an intervention versus medication and that we need to figure out.

Right.

And then there are minor risk factors which can help you decide whether a patient needs testing or not.

And many factors could be several.

For example, aging itself is a risk factor.

If somebody comes in seven days, you know, then he'd more likely to have some sort of blockage, may be less or more.

It could not be obstructing, you know, to the extent where it can cause symptoms, but he might have some blockages.

So that raises a suspicion.

Then there are several others, you know, postmenopausal women have more likely to have blockages.

And then there are certain, you know, autoimmune diseases that can cause blockages.

But these are minor ones.

We mainly focus I mean, I don't I'm not saying that we don't focus on these ones, but we mostly see patients who have these major risk factors.

They have severe blockages.

Okay.

Yeah.

And when you're you were talking about testing, right.

What are the procedures to find out what that is?

I mean, is there.

Yeah, by all means, please.

So good.

Good points.

He mentioned I think we have a lot of testing, which we do.

We, we do ultrasound of the heart, which we call to the echo or echocardiogram to look at the structure of the heart.

Look the heart.

The valve is tight.

How the muscle is moving and of valves are leaking, all those things.

And there's other thing which we do is a stress testing.

There are different way of doing stress testing.

Some of them, we meet them, run on a treadmill and we monitor the EKG.

If there is any changes, some some of them we combine exercise with imaging perfusion study to stress the heart to see if there is any any area of the heart which shows a defect or area of the heart, which shows less oxygen.

We call it ischemia.

Those are some of the things which makes us realize that this person should be on good medical management if they continue to have chest pain after being on medication, then we go a little bit beyond and which that's what we were talking about.

We we go into your arteries, we try to look into your arteries, which arteries are blocked.

And if there is a narrowing or there's a blockage, we just expand that area.

So that we can put a stent.

See, you mentioned two different things that I want to go back to.

So we talked about a leaky heart that you hear about here and there.

So I do want to talk about that.

And then we're going to go into stents from there and the balloon angioplasty as well.

So first, since you mentioned leaky heart, leaky valves, we hear that is layman.

Don't know exactly what that means.

So let's describe as cardiologists what what is a leaky valve or a leaky heart?

You hear it Leaky heart.

But it's a leaky valve, right?

Yes.

If you can describe what that is.

Right.

So, you know, every heart has four valves, you know, one, two on the upper chambers and two in the lower chambers.

Right.

Sorry.

No, I said it wrong.

Two that separate upper and lower chambers.

And there are two other which separate lower chambers from the great blood vessels that originate from the lower chambers.

You get the purple blood and the red balloon.

Yes, but expand that, too.

So.

So when we talk about leaky hearts, it can be any of those.

And, you know, in at least 2 hours, I can say small leak is physiological, meaning it's normal for everybody.

Those valves on the right side, they can be leaky like they stress leaking or mild leaking.

And that's completely normal.

When we talk about when when we should be treating leaking out, it's mostly when it's in the severe range, meaning it you know, the role of our is to guard the blood flow.

It allows blood to flow forward and influence from it.

Going back once valve is leaky, heart will pump the blood, it will go far away, but then come back again because the bag is not function.

If that happens, patient will have severe symptoms.

That's mostly in terms of heart failure, shortness of breath.

They can be dizzy, they can just faint.

And it's mostly happens on when the valves on the left side, something called a valve.

It's very commonly treated valve in our like structure failed.

Dr. Siddiqui sspecializes treating that valve through groin.

Right.

When it's leaky, it can lead to the symptoms that I described.

Right.

If it's tied, it can lead to death.

And what side is a mitral valve on?

Because full disclosure in mitral valve regurgitation, leaky valve kind of a gap.

Right?

Right.

So my two line is on the left side.

It separates the left upper chamber from the left lower chamber.

When it's leaky in the severe range, mild to moderate, it's usually treated by medication and usually doesn't cause any symptoms when it's in the severe range, it can lead to a lot of symptoms, shortness of breath.

You can sleep slurred because you'll feel short of breath.

You'll have, you know, sometimes, you know, chest pain or dizziness as well, right?

Yeah.

And I'm 57 years old.

I was diagnosed with this when I was pregnant with my daughter at the age of 30.

And so the way my cardiologist described it, it's chronic, but it's so far benign.

So it's just something we're just looking at.

But I just I know that that's if there's going to be a valve, that's an.

Okay.

Well, to have a problem with.

So I appreciate you describing what that is.

I don't know if we want to talk any more about valves while we're on this subject.

I want to move on, but think so.

So I think Dr. Tripathi mentioned it very, very nicely that, you know, he was giving an example of four rooms, two on the left side and two on the right side.

So the red blood is on the left side, a little blue blood is on the right side.

So the mitral valve is basically separating two rooms on the left side and the tricuspid valve separating two two rooms in the right side.

Okay.

So these valves can be tight or these valve could be very leaky and tight, especially they see some of the patients over here not very common.

But since we live in the border town.

Right.

You see a lot of people with rheumatic heart disease.

And that's a problem where with a rheumatic , rheumatic heart disease because of the infection and they come with the valve being tight, especially the mitral road that you're talking about.

In those cases, we try to open with the balloon.

Okay.

They can be open with the help of the balloon.

And and there are valves which are leaky.

We can open by surgery, which is in the standard, but now we can do something unique.

As you mentioned, that you were diagnosed with mitral valve, that these are the leaky roof over a period of time you'll see this will get worse.

And in the past, we just used to cut the chest and fix it.

But now we can take by putting a clip.

It's like a like putting a clip just like a staple, you know, to bring to leaflet closer to shore.

And you do that through the veins.

We go from the lung for you to, like walk through the process of how you do that.

And I know we don't have a structural heart, but maybe we can flash it up on the screen a little bit, but walk through the process of how you do that.

Where in the body do you go in?

Be that guy.

Give us I think again, again, the same thing as Doctor Tripathi said.

Do two rooms on the right.

Two rooms on the left side, we go from from the groin in the vein And the vein takes the blue blood to the right side of the heart.

So we put and you've got the catheter.

So we go in the catheter to the right side of the heart.

We don't have to go to the right bottom part of the heart.

We cross to making a hole between the top part of the heart from the right to the left.

Once we go to the left side, then we can see the valve on the left side, which we call the mitral wall.

And we we can image with the help of imaging.

That's why it's a team work.

So one person is doing this, other person is showing where to go by looking at the echo ultrasound and guiding us where to go and then showing us where you want to put a clear because leakage could be anywhere.

It could be in the middle, it could be on the side.

And then you just go and put a clip where there is the majority of the leakage.

So I'm trying to picture what you're saying in my head.

So you're going into the wall you're in.

This is one of the four rooms in there, and you're putting the clip where the valve is to keep because of our still has to move with every beat.

So.

Correct.

Exactly.

So if you see this is my hand, these are two leaflets, right?

So what's happening is it's separating the top part of the room and the bottom part of the floor should go forward from the top to the bottom.

As you mentioned, the block does not go to forwardly, but sometimes it comes back and we don't like we don't like workflow.

Right.

So why is happening?

Could be the valve is separate, it could be the valve is not closing appropriately.

So what we do, we put a clip in between so that it can all be approximated and the clip adheres to what to me, leaflets of the valve Very good question They adhere to one leaflet and the other leaflet and that come close.

Now you would put if you're coming close, it might tight, might get too tight.

Too tight.

Right.

But we take into consideration by measuring, by certain measurement, if we are too tight we release it.

Okay.

And then we put another, another clip in a way that it does not make too tight.

So while you're in this procedure, you are depending on an echo to find out once you put the clip in place and now you're trying to figure out where and how much the valve is still leaking or not for the lack of a better word.

Is that bragged and then you get out of there.

And when I say that to the procedure was done three, four or five weeks ago at this point, is there a follow up with that patient?

And how do you see, after putting the clip in how the heart is functioning?

So so what we follow with the patients in that patient who come with this problem, they usually have a lot of shortness of breath.

They come in with palpitations, coming with dizziness, they're coming with with fatigue.

There's some tiredness because they're not giving getting their blood supply to.

right organ, because majority of the blood which has to go out, is going into the top room.

So that's why we follow the symptom.

Sometimes we go and look into the ultrasound again, but mainly symptom.

We follow the symptoms that there are symptomatically okay, we don't go and try to look for it because we know we are not completely abort or we are not completely curing the leak.

There's still a little bit leak.

Course there is, but we are taking care of the majority of leak so the patient can feel better.

Okay.

And over a period of time, the heart function does not get worse or even it start getting improved.

Okay.

And then here's another question, and then I'll leave that one alone for a while.

This clip.

How long does this clip last?

Does it last forever?

It lasts forever.

Yeah, it's once it's inside, we don't take it out.

And what's the material that it's made out of?

It is metal It's a metal clip.

In your heart.

In the heart there.

Okay.

All right.

So when you fly to Paris is an issue.

No.

You can get an MRI or anything.

It won't ding.

I want to go from the clips now is stents.

Stents are such a big deal in the world of cardiology.

And I know we talked a lot about this last time that we were on the program together.

So when it does, somebody need should have consider a stent.

When do you look at a patient and think, okay, these are things happening within their heart.

This could be an option for a stent.

Right.

So, you know, we put stent in patients with blockages in the coronary arteries.

We can broadly divide them into two categories.

Okay.

One, those who come with heart attack.

Then there's no question if you find a blockage and he's a suitable candidate, we have to put a stent to save his life.

Okay.

So that's an acute condition.

And then we see some patients who are who have something called stable coronary artery disease, meaning stable corner of coronary artery disease, meaning they have certain degree of blockage in the coronary artery, which is giving them symptoms only when they exert.

Okay.

But gets better when they rest or take nitroglycerin.

Okay.

So those patients, we initially you know, we do different testing.

If you don't see any high risk features on any of the test, we try to treat them with medications first, as you said before, you know, their symptoms go away and they're feeling better.

We don't do anything beyond that.

But let's say we are treating them with medications and their symptoms are still there.

They are not able to do things that they enjoy.

Then we discuss about putting a stent in there.

Okay.

And if they're agreeable, if they understand this can benefit, then we put a stent there.

Well, where are their symptoms?

You also hit on something there when you look at risk and benefit.

Right.

We did completely on a different situation, but we just had a prostate cancer program.

Right.

And a lot of that program was risk and benefit in the world of cardiac cardiology, I feel like that's not necessarily the case.

There are certain things that you need, but in what you're talking about, when is there a risk and benefit?

And this is kind of not the negative part, but there is a tiny bit of a risk with everything that we do.

What are some of the questions that you get from patients before you do a procedure?

This some of the common questions, and I like for actually both of you all to chime in on that, because you talk to patients and to your point and their families, all 20 of them are asking you questions.

And I always curious of what kind of the questions are you are receiving before a procedure?

How do you put them at ease?

How do you calm them down and say, no, these are the things that are really good and I'll start with you and I definitely want you to chime in.

Sure.

Yeah.

So, you know, first of all, when we talk about Stent, the first question is how do you do it?

So we explain them what we do, we puncture you here, are in the groin and then go inside it, wires and catheters, and then they start talking about what are the risks.

So we tell them about, you know, the risk of, you know, the anomaly, the stenting that we do.

It's less than 1%.

But majority of risk I mean, majority of the risk are very like complications of a simple we took them originally, but in rare cases, extremely rare cases, one in 1000 cases, people can die while having a procedure because again, it's a procedure, right?

We go inside, we are advancing wires, catheters that can go in sometimes in different direction that we would not want called dissection, can close the vessel, cause injury to the heart.

So they need to know that that, hey, there's 0.1% risk of death while doing the procedure.

If they understand and accept the risk, then they offer them to stent.

And there are other common like not very common, but there are other risk which can be managed easily.

For example, bleeding.

They can have swelling pigmentation, they can have kidney injury because of the contrast that we use.

So there are other other things that can happen happens in very small percentage of patients, but we need to tell them what they need.

You know what what that reality.

Exactly.

So, yeah, so I'm I also make make sure that they understand the risks and benefits.

So because it's important there's every procedure has a risk.

The risk doesn't negate I always tell them that you know, you drive from the hospital home, something can happen, right?

But still you go over there and because there's benefit of you going to hope, right.

So we do the same thing.

If we would not have any benefit of the procedure, we would not do this procedure.

But it comes with the risk.

The risk could depend on the condition you come in.

If you come with the condition of a heart attack, which is more an acute situation, your risks are higher of having complication.

And one of the complication which is unavoidable is death.

Right.

Which can happen in certain situation when somebody coming with a heart attack, the risk is dying is 50% by not doing anything and by doing something.

and that's the benefit of the risk.

Something.

Exactly.

And somebody who's coming not an acute situation in a more chronic situation, then that risk is limited for.

And as you mentioned, one in 100,000 people can have the risk of having a complication.

I'd like to talk about because Dr. Tripathi, we talked a little bit about this in the last program, but drug eluting stents, which I thought was fascinating.

So you have a stent, but it's doing more than just keeping something open.

It is providing treatment, so to speak, in the heart.

Describe what that is.

So our stent basically that we use, it's a middle tube that sits on the balloon and we go to the coronary artery and we find the location and then we basically inflate the balloon and that deploys the stent.

Right?

That's how it works.

Now, in in, I would say ten years back, you know, there was something called bare metal stent where we did not have drug inside the stent.

It was a good option because we just started doing this procedures in 1990 and we do not have a lot of technology.

Those are good.

But the problem was that scar tissue would grow on days.

I couldn't block the stent after six months to one year to, you know, the potential date was very low.

Okay, then now we have like in a lot of research going on now, we have third generation drug eluting stent.

And what they do is that they're like different drugs on the dead metal, too, that will prevent scar tissue to grow.

And that that's how it will keep that metal tube open and will allow the blood to flow for a long period of time.

So a lot of time.

So a lot of time, we call it that the metal has a polymer and it releases a drug.

The main reason is this drug give time for the artery to heal and B and the stent can.

Be part of that, your own artery.

So you were talking about stents are in there also forever.

How how much of this drug or this medication is there in other words, how long does it elude this medication?

I'm assuming there's a certain point where, okay, we're done now, it's a stent, but the medications all gone.

Is that a couple of months?

You said the healing period, Couple of years.

How does that usually work?

The initial phase where the most drug is releases is within the first month.

Okay.

And that's why a lot of a lot of time, if anything happened, it happened during the first month.

The block the chaplain or anything, but and the majority of the scarring happened in the first month, more than the later part of the year.

We have stents now where we call it bioabsorbable stent, which bioabsorbable stents.

Okay.

Again, this is a stent, which or it's a delivery system where the drug is given.

But over a period of time, the stents absorb and you don't see this thing, huh?

But we have this came into the system for the last three or four years.

We are learning that there's still more room to grow in that Medicare in that part of the stent.

So we are still using it, supported stent.

And what we have learned that there are stents which are called bioabsorbable.

And in future, we learn more about it.

But it's not very common in the US right now.

Okay.

There are different kind of so part of this program also is trying to figure out what's happening in the future.

So what I hear that the stent is being absorbed by the body.

Does the artery, then little by little start to close again, something in stents that are in there forever.

And I don't know.

So let's say somebody in the forties, unfortunately, but this is something they're having.

So now they're in their sixties.

This is a stent that's been in 20 years.

Give me an example or a case study or two where someone has had to go in and either replace a stent.

If it's a bioabsorbable stent, does the artery then just stay open because there was that medication that were talking about.

And I'm just looking for what you all have noticed and what might be natural questions for the audience to ask why you're speaking about this.

So these metal stents, which we are talking about, the usual drug coated stent, these or are metallic, they're all this stays in this.

I see it never get reabsorbed.

Okay.

They can get to it.

They can get occluded over a period of time or they can get occluded suddenly if it suddenly is different mechanism, which means the crop is formed in their artery because you are not taking medication, it can block over a period of time because you were not taking good care of yourself.

You were not can tarry, you were not controlling a diabetes.

You were taking care of your blood pressure, you were not taking good care of your of your cholesterol.

So this built up over a period of time can block.

And if they come some time, we have an option to put another stent inside the stent or we have an option, then we can get a bypass surgery.

Okay.

And all of the bioabsorbable stents, if they are absorbed, the artery stays open.

But the only way the artery would close is the same reason.

If they're not taking care of your of their conditions, diabetes, high blood pressure, cholesterol, same thing which we get the disease the first time.

They also get the disease the first time the same year.

So it's not like you guys go in.

Yes.

You fix things for that time, but they still have to make sure that their behavioral health, so to speak, of how what they're doing in that area makes sense.

We talked a little bit about, but we haven't really I feel like haven't completely explained the balloon angioplasty procedure.

So compared to stents, what is that procedure?

And again, I'm like because you guys both kind of do the same thing.

I know you're more structural.

Explain that first and then we'll go from there.

So balloon into place is actually part of putting stent.

Okay.

So that is how you get this?

Yeah.

If we see a blockage there?

Okay, We first go inside, prepare the lesion, For example.

We go inside with the balloon, inflate the balloon to four to allow room for a stent to deliver.

And then we do different testing to see the size and all that.

So balloon angioplasty is not a separate procedure.

It's before we had stent in 1990.

That's what we used to do, I think, when we did not have stent, we'll just go and balloon it and open it and just live it.

But that has we lowered it and the rate of patency, basically the blood vessel in close over a period of time.

Okay.

Now we do balloon angioplasty followed by stenting with a stent.

In my head, When you were saying the bioabsorbable stent, I thought to that point, you're putting a stent in and then your body just absorbed.

But that's not necessarily the case then.

So I'm not saying that, but which is not available in America.

And that's what I wanted to talk about.

Let's do that because we've got 16 minutes left.

So let Dr. Saddiqui talk about it.

But I think our decoded balloon and I think this is something that slowly it's called what is called drug coated stent, drug coated balloon drug coated.

So it's not a stent.

There's no metal.

It's just a balloon coated with the drug.

And this is the future.

This is the future.

A lot of trials has been done, especially coming from your country.

It's already getting it done over there in Germany and other European countries, as we have to go through a lot of trials and study before we can do it.

And you'll see in the next two months, November 2024, that it's going to start drug coated balloon.

Yes.

Oh, my goodness.

This is right now it's already approved here in the US.

And this will make a big changes that you don't have to put a stent in these arteries, which are smaller arteries and which can be fixed just by balloon or arteries, which are a longer diseased artery where you put such a long metallic stent we can just treat with the balloon and then they stay open.

So when you say the balloon, the balloon is not staying there.

You're going in there.

You're drug like drug coated balloon.

You are diffusing the medication within the artery is not what I'm standing.

So you're doing that and it's a procedure.

And then the medication stays in, the balloon comes out, and then life is good.

And we are already using this balloon in the in the arteries of the legs.

Okay.

But we have been used in the arteries of the heart.

You all have this conversation, because I'm going to sit back and listen for was I really don't know what was asked by our means.

No, I mean, as you said, I mean, this thing has been the European has been using the coated balloon for like three years, but it's not approved in the US for some reason.

Now they realize, oh, this is a good option.

Now it's FDA approved couple of months back.

So hopefully we'll have to put it within ourselves probably November 2024 and then we'll start using it and see how how does it work with it's useful, you know, we're going to get experience of it and then decide if it has good long term benefits.

This may be an unfair question to ask.

So when when FDA, etc., when something is being used somewhere else in the world and FDA approval, which is great and very important because we need to make sure it works, how then does the process of getting something that's happening somewhere else come to America, which you said is approved, but now we're looking at El Paso.

Who gets it?

Are there grants that will be applied for?

Are there is there equipment that comes in like talk about how in the next two, three, four months, you said two months, how that enters into our system here?

in El Paso, I think people are fascinated, like all of a sudden it's there.

But how do you get there?

Mm hmm.

So just just like how all these other devices come and has to go through the the brand new committee meetings.

It has to go over the protocol and it has to go at the administrative level of the hospital and then come to our cath lab.

And then we are ready to use the science.

So when you said in the next two months, are these already in place?

No.

And let's talk about training, because training is a whole thing.

And what I love about especially our community, there are trainings constantly and it's not like you're a doctor, you got your degree, your doctor, you got, you're getting trained constantly.

Every several months you're going to a training.

What is it training specifically on this procedure?

I don't think we need special training.

Just a balloon for us.

Just as it's something drug put it on it.

So we have been using this forever, so there's no special training needed for us, I guess.

But.

But any time you have to bring in the cath lab, you have to educate, educate, because it's teamwork.

It's not just us, the technicians who are working the carpet, not just the nurses.

So we do in services before we do it.

And again, once it comes in the United States, then it will make its way to El Paso.

Once it comes to the El Paso, it has to go through the process.

And for the hospital to have all the things taken care of before it can come to the hospital.

And once we know it comes to the hospital, then we do specific education for ourself.

And because a lot of time it's the same thing.

But there are different ways of putting it right.

Just like we we put the balloon right now on the legs.

We have to open the balloon slowly.

Right.

And not in 10 seconds.

Over the 2 minutes, we have to leave it.

So the city is happy to leave it open for 2 minutes again in the leg.

Our we can keep it longer in the heart artery.

We cannot keep it that longer.

So all these things has to be taught to the technician for the cardiologist.

And and we got him in service from the companies who is providing this this device.

But again, it has to go through a lot of rigorous process before we can start doing it.

I love that explanation.

Do you have anything to add on that?

I know we are kind of at that and I promise you all that.

Usually about the 15 or ten minute mark that I stop all the questions for me and ask what it is that we have not spoken about yet this evening.

So I feel like this is one of those I mean, we can continue doing that as well.

But is there anything else we have not spoken about yet this evening that you really want to talk about before we start wrapping up the program?

And we can totally continue going on this?

This is brand new to me.

I mean, I think we already covered I mean, I think this was something that could have been the answer to this question.

Right.

But we just spoke about it otherwise.

I mean, we just like every aspect of interventional cardiology, especially cardiology.

I think there's a lot.

What do you see?

And I know I'm I'm pie in the sky, but 20 years from now, I mean, really, this is something you guys are doing.

And 20 years from now, I feel like it's a really long time in the future because we're looking at things that happened the last five years that we didn't expect to be happening five years ago.

So if you had a pie in the sky, I would love to be able to A, B, and C 20 years from now.

What would that be that you do see as a bit of a possibility in treatment of heart disease, arteries, etc.?

Valves even, you know, I think medicine is growing and we would be seeing so many development over time.

We are already seeing in the genetics like is such a such a game.

And I think now we are seeing, you know, not only fixing the valves, not only fixing the arteries by using minimal device, putting putting a pacemaker, which one one time it used to be such a big write generator.

Now it's like a small generator.

Now we don't even have to put a wire and we can put a pacemaker in the right side of the heart and talk about the phone to that.

You can you can explain exactly what's happening with my heart right now.

Exactly.

You know, you can talk about you can put a patch, you can have a watch and you can see what's your heart rate, what's your blood pressure, what's your rhythm?

And you can and now we are heading into artificial intelligence.

And you would see that they will help us in diagnosing and we would just be the cath lab we were doing the procedure on on patients lot things going on, robotic surgeries are going on, gene therapy is going on, STEM cells are going on.

I think in ten years we're going to see more right translation from from animal to human.

And it's already more maturation in in that area where we would be able to give different treatment by genes and by the stem cells.

So we joked a little bit before we went on the air about your Star Wars cap.

But when you talk about that and AI, I think about Star Trek, if you remember, and we're all people, I'm old, I'm 57 years old, and the Bones was on that show and Bones had let's pretend it's a phone and it go over the body and he was able to diagnose everything.

And in my head I thought, yeah, right, whatever.

But we're almost there on that note, you know, we're always at the point where we have ways of diagnosing people that we didn't think about way back when.

And so when I asked earlier, when someone is having a problem and you have we were talking about contrast, it's going into the body and you're able to follow all these things.

And and I'm going to go back almost to the simplicity of this program and ask, how is it that you diagnose somebody with heart disease that doesn't have symptoms?

I know there's not a screening per se, but I feel like when Bones did this, it was kind of like the screening.

So is that something that you see in the future that there is like you go the Mayo Clinic and they do 12,000 tests on you that day?

What do you see in the future as far as finding out if you are someone who's prone to heart disease, if you've had no family history, if you have no idea someone who's in appears to be in perfect health and then boom, they drop dead of a heart attack while they're on a run on a Saturday.

How Do you know?

And how can we find out these issues with people on both?

You guys are nodding off.

I've gone to other not only to that, but I'm just throwing out there who wants to take it like, how do we know?

It's it's it's very it's very difficult as of now at least.

You know, it's very difficult to there are certain conditions where you just can't predict going to happen.

There are a lot of, you know, young people dying of sudden cardiac death.

They don't have any risk factors.

Exactly.

Yeah, I just I just I think two months back, I just did a STEMI on a guy.

He was just STEMI is a basically a heart attack.

He was just 34.

He was a marathon runner.

Oh, my.

Yeah.

No risk factors at all.

No family history.

Not a smoker.

He was a physician, actually, in El Paso.

I wouldn't.

I can take the name, but he can withstand me into a STEMI.

The lady was blocked.

He had cardiac arrest in the E.R.. We took him to the couple hundred percent blocked artery.

It was like 100, 100%.

I checked his laps.

Cholesterol completely normal.

LDL was like 67 or something.

Notice after that, I could identify it.

We don't have tools yet, honestly, to identify these people, but maybe in future we have certain certain things.

There's a lot of things that we don't know yet Lipoprotein A that we really don't utilize.

Now, people have been talking about that team.

Mm hmm.

So honestly, there are a lot of research going on and probably will have more markers in future than what we use here right now.

You know, the LDL and the traditional markers are bloodwork and there are some certain tools that we use right now.

We'll have more of them.

A lot of research going on there, a lot of things that we don't know yet, huh?

Yeah, but yeah, honestly, I don't.

I think it will take time, but it'll happen.

I know.

I'm going to ask.

Go ahead, please.

So I think we follow the guidelines which are being built on the basis of multiple studies which have shown benefit of multiple studies.

I think if you start doing testing on people who don't have a disease and don't have a symptom, you're going to put a lot of equipment.

There's going to be panic.

And not only if you try to find certain things, you would overdo things which might not be necessary.

I still feel preventive cardiology and treating.

If something feel somebody feel something is more important, Right.

Than just looking for the disease.

If somebody doesn't have a disease, you're right.

You can put anybody in a patch, you can do a stress test on 100 people.

There might be one person or ten people might have a disease.

You do a CT scan, coronary calcium score, you might find the score is 1800.

Again, that might help us to to change their lifestyle.

But what does that mean?

That we need to look more if they're not feeling symptoms?

I think that's we are so we still need evidence for that before we even go that far.

I want to do a quick public service, really quick and the AEDs that people see all around.

And I just want to ask really quickly, cause I know we don't have a lot of time, but the automated external defibrillators, we see them in airports, you see them in shopping malls, we just see them around what are they?

And in the general populace, is there any kind of training that when are they used?

I guess that's the question, right?

You see them around like, oh, somebody's having a heart attack, get one of those.

But what do you do?

Because there's a lot of medical person around.

I don't want to spend a lot of time on it, maybe a minute or two.

Who wants to take that really quick?

But sure.

Yeah.

So, you know, so we undergo training something called, BLS, basic life support and advanced life support.

And we as physicians, our medical professionals, we are trained to identify who is having cardiac arrest and who will benefit from getting shocked so that we can bring them from, from death, virtually.

Right.

Mhm.

So this is what AEDs does.

Yeah.

Automatic defibrillators do basically if somebody just collapses let's say is walking in our airport or whatever collapses.

He does not have a pulse.

If I know that a lot of general population is now trained in these things as well, they can identify the patient and they can bring that device connected to him and that device will guide them.

Whether a patient needs shock or not identify the rhythm, they will tell, okay, rhythm is checkable.

You can shock patient now and this can make a lot of difference.

It will guide them to do CPR at certain times.

Stop when whenever.

You know, a patient needs to be shocked.

So I think it's a very good device.

It has saved a lot of lives.

But I don't I don't really know what is the education for this device in general and should I just thought I'd bring it up and I and that's on me, really, Because when I came into this program, I thought, I want to spend at least 5 minutes on describing what that is.

So we'll do that.

Another cardiology program because we got all excited about this other stuff.

But I'd like to at least when people see that for them to know what it is and maybe a cardiology show in the future, we can actually spend a little bit of time, bring one in, show people what it's for.

Again, it's not necessarily for the layperson, but maybe there's someone who's worked a little bit in health care that kind of understands it and we can kind of take it from there.

But anyway, I just want to say thank you so much again, Dr. Tripathy and Dr. Siddiqui.

Siddiqui you guys have been wonderful.

I've learned a lot during this program.

And in case you tuned in late or want to watch the show again, there are three different platforms you can do that on, and I love that ones.

The once this airs, you can go back and link to this program.

It's going to be there forever.

But PBSElPaso.org just look for the words the El Paso physician.

The logo will be on that screen.

Also EPCMS, which is the El Paso County Medical Society website and that's EPCMS.com and then YouTube.

This has been around forever.

And with YouTube, you just have to type in the words the El Paso physician.

And it usually comes up with not just this show, maybe this show, it'll be the show that we did back in February, all the different programs that the El Paso County Medical Society does with the El Paso Physician So I think that's so super important.

And if you ever have a question also about the program, feel free to email the El Paso County Medical Society, but I know that we're running out of time.

Thank you so much for being here.

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

Good evening.

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

The El Paso County Medical Society has put on the El Paso physician TV program for the last 26 years.

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