Cardiac Issues: Prevention and Testing by Dr. Alan Heldman (2009)


So, cardiology is all about movies. The heart is the coolest organ in the body because it does move. So that means it is sort of PowerPoint intensive. If I hit a glitch and I crash the computer because of these movies, bear with me.

What I am going to talk about today is cardiovascular health, but also cardiovascular disease. Plus I’ll make a few connections to the world of swimming, some of which may surprise you.

Just to give our own plug, the University of Miami has had some interesting things happening in the last couple of years, beginning with the arrival of Dr. Pascal Goldschmidt. He is Dean of the Medical School, a Cardiologist, a Cell Biologist, and a world renowned scientist. He’s joined by Dr. William O’Neil, the father of Interventional Cardiology, the pioneer of treating heart attacks with angioplasty. They recruited me and my partner, Josh Hare. from Johns Hopkins and we brought our program in stem cell therapy for heart failure. Joining us in cardiovascular genetic medicine are Dr. David Seo from Duke and Dr. Ray Hershberger.

About a year and a half ago the University of Miami bought Cedars Hospital. So we have now really become quite a power-house in cardiovascular innovation at the University of Miami Hospital.

This photo is Dr. Goldschmidt, Dean of the Medical School. As you can see, the leadership, from the very top down of our medical enterprise believes in cardiovascular fitness as part of our program, despite the fact that Dr. Goldschmidt only sleeps about four hours a night. He is kind of a stud there on the road.

This may be my coolest movie of all.

The heart sits in the middle of the chest. Everybody knows where it is and basically what it does. It circulates the blood.

There are really two phases to the heart circulation. What you are seeing here is an MRI Scan. There is a dye that is being shot into an IV. It comes into the right arm, up the right arm, and then it goes to the lungs and then to the body: lungs first, then to the body. The right heart pumps blood to the lungs where it turns from blue blood to red blood (gets oxygenated). Then it comes back to the left heart where it is circulated out via the aorta. Oxygen rich blood is pumped to the brain, kidneys, shoulder muscles, quadriceps muscles; to the things that you care very much about.

The heart and the blood vessels that carry the blood have a tremendously central role in all sorts of physical performance.

The most common thing to go wrong with the heart, what you think of, when somebody has heart disease, is clogged coronary arteries.
Those coronary arteries sit on the outside of the heart and are like little fuel lines. There are several of them and they are only about 3 mm. in diameter. They are tiny little tubes and they get clogged up with cholesterol. They are just so small that it doesn’t take a whole lot of cholesterol build-up in them before they are seriously narrowed.

This photo is a new, fancy kind of CAT scan. To get this picture of the heart only takes about 10 seconds when lying in a very expensive scanner.
This patient had blockages in the coronary arteries and subsequent bypass surgery. You can see a graft artery that has been plugged into the heart to bypass around blockages.

Coronary artery disease is the most common thing to go wrong with the heart. It has serious complications. And it is not just old, fat people and not just smokers, and not just 80 year olds who get this.

It is in fact, unfortunately, the #1 killer in America.
Fortunately, it is almost entirely preventable. There is really no reason for any of us to have what happened to this guy.

This is a patient of mine. He wasn’t a patient of mine until one spring morning when he woke up with an elephant sitting on his chest. He had been absolutely fit, exercised, did not smoke, took care of himself, and didn’t have a clue that anything was going on until that early morning when he got the elephant sitting on his chest.

What happened was that the coronary artery here, the left coronary artery has become clotted off. A little speck of cholesterol build-up there and one day it popped like a bad zit or like a kernel of pop corn, POW. It got a fever, it got inflamed, it popped and a clot formed on top of it. And that clot closed off the blood flow. When that happens, the coronary artery cannot carry the oxygen rich blood to the heart muscle itself and the heart muscle starts to die.

Almost instantly he has got that oppressive feeling of discomfort in the chest. He went to a hospital and they gave him clot- dissolving drugs. But, it didn’t work. He continued to have chest pain. Fortunately, it was a pretty morning so the helicopter got up quickly, scooped him up and brought him to us. I met him on the roof of Johns Hopkins Hospital.
So, what are we going to do? Well, obviously, we are going to try and treat this.
But what I am going to show you, in addition, is how he might have prevented this in the first place.

The first thing we want to do is to get that artery that is 100% blocked, opened up. We have taken a little wire and threaded it into the artery then used the wire as a guide to introduce a balloon catheter. Then we blow up the balloon and where it was totally blocked, we have now restored blood flow into this area of the heart muscle.

As coaches, trainers, athletes, you are on the front line of community awareness about many of the things that are good and bad about the heart.

I guess, one of the first lessons I want to convey to you is: time is really of the essence. We beg people “Please don’t discount, please don’t wait.” “Please don’t think, ‘Oh, it might be heartburn.” Because the faster we can provide treatment, the faster we can get that artery opened up and the better chance we have to save that life.

This patient, because we were quickly able to restore good blood flow, has a 30 day mortality risk less than 1%. Despite the fact that this guy started out the morning having a big bad heart attack, we converted it into something with less than 1% chance of him dying in the next 30 days. Very, very likely he will walk out of the hospital and be able to recuperate from it.

Now, here is another patient of mine who did not present with such a dramatic story as the elephant sitting on the chest.

She had something that we call angina. Angina means chest discomfort, particularly related to exercise.

If someone tells me, “Doc, reproducibly, I know that I am going to get this discomfort in my chest when I climb two flights of stairs or I walk up a hill or I do something that requires a little bit more than the usual kind of exercise.” we call that angina. That’s a hallmark of a coronary artery being suddenly clotted off or having an artery that is partially blocked. It is narrowed. It has a blockage or a stenosis in it. She had chest discomfort when she took her evening walk. And sure enough, when we go into the scanner, we see that in her right coronary artery there is a spot where it seems to be narrowed. That artery is bringing blood to the bottom wall of the heart.

From the CAT scanner we then went into the catheterization laboratory. This is just a cartoon of a catheterization. A needle is placed into the femoral artery, (right here at the crease in the hip) through which we would thread this catheter or plastic tube, up to the heart. Then we squirt x-ray dye into the coronary artery that had given us an indication it was blocked. And sure enough, I think even the non-Cardiologist can see this artery is not normal.

This artery is pinched in the middle. It has got a narrowing. Now we understand why she felt unwell when she exercised and when the heart cried out for more oxygen. It has no blood supply. It’s working extra hard and beating faster. It needs more oxygen. The coronary artery could not deliver it because there is a kink in the garden hose. There is a blockage in the faucet. It can only drip at a certain rate. We will treat that by opening it up. Here is the blockage and here it is after we have treated it by implanting a little device called a stent. We have opened the blockage and restored blood flow.

Now I can ask you the question, “We have opened that blockage, she feels better, she’s now able to walk without having that chest discomfort.” “Have we saved her life?” “Have we prevented her from having a heart attack in the future?” “Have we done anything to change her risk of having a heart attack?”

Surprisingly, I think the answer is no. We do these treatments, the angioplasties and stents and bypasses really to fix the immediate problem. But the underlying problem is an iceberg and that blockage was really only the tip of the iceberg.

Now let’s take the picture that I have been showing you and look at it from the inside. Imagine I’m going to drive inside the artery with an ultrasound and actually look at the spot where the stent is.

I can look at the inside of the artery in these different spots.

Here is a spot that is relatively normal on the ultrasound. This is the ultrasound probe itself. Here is the blood flow and here is the wall of the blood vessel. On the other hand, here is a spot that looks normal on the x-ray picture, but with ultrasound you see a big deposit of cholesterol built up into the wall. You do not see a blockage. It is not causing a narrowing, but there is plenty of cholesterol deposited in the vessel wall.

The blood vessel is smart. It expands. It actually grows. Look at how much bigger it is here than it is down here. The blood vessel expands to accommodate that buildup of cholesterol. It tries to keep the lumen, the area that carries oxygen rich blood, big for as long as possible because there is this plaque. It’s what’s called an atherosclerotic plaque in the artery. That patient remains at risk for a future event. One day, if we do not do the right things, that one may pop like a bad pimple. A clot may form on it and cause a heart attack.

There are many things that we want to do for prevention of future events in both patients: this one who we know has coronary artery disease and like my first patient who didn’t know they had any problem.

Can we do something to prevent their future risk? The answer is absolutely, “Yes.”

Think about cholesterol as the first thing if you want to modify your own risk, the risk of the people you care about and the risk of the athletes that are under your care.

Cholesterol is related to heart disease so a lot of people tell me, “My cholesterol is normal. It is 200. That means I am okay, right?” And the answer is probably, “Not.”

Framingham, Massachusetts is a little town that has, for the last 40 years, been collecting information on its residents about their development of cardiovascular disease. Over their lifetimes we have learned a tremendous amount from the town of Framingham.

Looking at this graph from Framingham, one bar shows the cholesterol values for patients who did not have coronary heart disease. The average total cholestrol, the mean, is about 210. About half the people have a cholesterol less than 200 and half of them have a cholesterol greater than 200.

This next bar represents the patients who did, over long-term follow-up, have a heart disease event. They had something happen in their coronary arteries. Their cholesterols are higher for sure, but they are not that much higher. A third of patients with cholesterol less than 200 had a coronary artery event, meaning a heart attack or unstable angina or they had to have an angioplasty or they had to have a bypass or they died suddenly.

So there is more to it than just saying “My cholesterol is okay – it is less than 200”.
We need to drill down and get a little more detailed information besides cholesterol.

What else can you think of that might be a risk factor for heart disease, in yourselves and in your athletes?

I bet, if you take a minute, you can probably come up with this list.

1. Cigarette smoking. Everybody gets that, right? It doesn’t just cause lung cancer. It is very, very bad for the arteries. It damages the lining of the arteries.

2. Hyperlipidemia is a fancy way of saying high cholesterol.

3. Diabetes is a very powerful risk factor.

4. High blood pressure or hypertension.

5. Obesity and a sedentary lifestyle.

Those are all risk factors and interestingly, they are all things that we could do something about.

There are only two important risk factors that we can’t do anything about and one is genetics. You cannot pick new parents.

If you have a family history of heart disease your risk is increased.

But the truth is, even those who have a bad family history are not doomed to develop heart disease. For the most part, family history is modulated through the cholesterol, the blood pressure and the diabetes. So if your parents had high cholesterol and had diabetes, then you are more likely to get those things. But you can prevent them by living right, eating right and taking the right medicines, if necessary.

The other thing that you cannot do anything about is aging and enough said about that. Aging is a risk factor for everything.

While I am on the topic of risk factors I want to make a point and I am going to come back to it a little bit further down the line.

Ventricular arrhythmias are something that you as swim coaches need to be particularly mindful of.

What is a ventricular arrhythmia?

Well, if you are watching ER, Grey’s Anatomy or whatever’s your favorite show, (mine is House because House is so cool isn’t he? He is my hero, I want to be just like him) you see the monitor. You see the monitor right there monitoring the EKG. It’s going beep, beep, beep, beep, right? A beep is the spiky part on the EKG.

Then you hear, “Code Blue.” What does Code Blue mean? It means that it’s not going beep, beep, beep any more. It’s going bzzz-bzzz-bzzz-bzzz-bzzz (faster beeps). The heart is beating at 250–300 times a minute. So fast, that it cannot pump effectively.

That is a ventricular arrhythmia and it can cause you to faint or to die, quickly.

The reason this is important to you is because there are certain things that you need to think about in your pre-participation physical screening programs and in your awareness of your athletes. There are certain people who have an increased risk of that happening during exercise and during swimming in particular. We will return to that.

I mention it now, while discussing risk factors because the most powerful risk factors for those ventricular arrhythmias is to have something wrong with the heart to start with. So if you had a big heart attack a month ago and you have got a weak heart now, guess what? Your risk of ventricular arrhythmia is higher.

In fact, in some people, it is so high that we will implant an automatic device so that they do not have to call House to come in and shock the patient. This little device will monitor the heart beat and if necessary, if the heart beat starts to go too fast, it will charge and shock from the inside. The patient then says, “Oh, I got kicked by a mule.” But aren’t they glad they had it because it saved their life?

So, cholesterol “less than 200 is okay?” We have dispelled that myth. How low do we want the cholesterol to be? Well, pretty much the lower the better. As Cardiologists we focus not on the total cholesterol but much more on the LDL cholesterol or low density lipoprotein. That is the bad cholesterol.

Have your cholesterol checked! If you haven’t, you should.
Everybody should!

Because, if you have got a cholesterol of 350, now is your opportunity to do something about it? If you have had that cholesterol measured, hopefully you didn’t just get the total cholesterol, but you got the fractions: the HDL (the good cholesterol) and the LDL (the bad cholesterol). There is really a linear relationship between LDL cholesterol and the risk of CHD or coronary heart disease and something bad happening in the coronary arteries. The lower the better.

By the way, the same thing can be said for blood pressure. “My blood pressure is okay because it is just 135/88, right?” Well 120/70 is a hell of a lot better and 110/65 is probably even better than that.

Less than 120 for the systolic number and less than 75 for the diastolic number is associated with the lowest risk of having a coronary heart disease event.
This is the data in men. But pretty much the same thing would be shown for women. And it’s true no matter whether you are 20 years old or you are talking about your Masters athletes in their 70’s, 80’s and 90’s. Lower blood pressure is better. It is associated with a lower risk.

Now, there are some emerging risk factors that we might just touch on; some ways that we can look at that family history for example or look at the genetic profile.

On the ‘cutting edge’, we have a genetic test that David Seo in my lab has developed. He will draw blood and with one test gets a molecular signature that can map a million genes, and can predict, with very high accuracy, who is going to get coronary artery disease, or not.

Let me shift gears a little bit from the coronary arteries and talk about some of the other parts of the heart that go bad.

Aortic Stenosis is one of the most common things to happen in the Masters athlete group, as we get over 65, 70, 80 years old. By that time, if you look at a population over 80 years old, as many as 10% will have the disease called aortic stenosis.

The aortic valve is the main one-way valve that lets blood out, but not fall back into the heart.

But if the leaflets of that valve get obstructed, get calcified and hardened they may not open any more than a pin hole. If the heart is trying to eject through a pin hole, “Whoosh.” I say that noise because it makes a murmur? Have you heard of a heart murmur, know what it is? It is blood being ejected through a tiny orifice. It makes a noise and you can hear it with a stethoscope.

One of the neat things now going on at the University of Miami is the replacement of the aortic valve with a non-surgical technique.

This is still an experimental tool. But we can take a catheter, thread it up into the heart and implant an artificial valve by expanding this metal frame. Within an hour the orifice that was a pin hole is now a normal size. The murmur is gone.

Aortic Stenosis, and other heart murmur kinds of diseases, are important for you to think about. In both your young athletes, as well as your old ones because they are associated with an increased risk of exercise-related events.

If a patient comes with a history and says, “During exercise I fainted.” that sets off all kinds of alarm bells in the Cardiologist’s office. One of the classic things it might be is: obstruction of the valve. Again, the body is asking for more blood flow. The heart cannot deliver it because of this valve narrowing. What is the result? It’s not enough oxygen to the brain: fainting and, if we’re lucky, it wasn’t sudden death.

I told you earlier that sudden death, because of ventricular arrhythmias, has a particular interest for swimming coaches.

Here is an example of a case that was published in Circulation, The Journal of the American Heart Association.
It is not that common, but it is common enough that about 6 out of 100,000 people have a disease called the long QT Syndrome. A Cardiologist should recognize immediately that it’s a very abnormal EKG.
This person might have a family history of fainting. This person is walking around and has nothing outwardly wrong with him. But there is a history of a lot of people in the family who fainted or who died suddenly. Sudden unexpected death, examples being walking down the street and dropping dead or not waking up one morning.

There is a particular genetic mutation called the long QT Syndrome. For reasons that nobody yet understands it’s powerfully associated with a risk of this arrhythmia. It’s what I remarked to you that happens on House when they have to come running to shock it, that rhythm disturbance happening during swimming.

Nobody knows why. Whether it has to do with the breathing or the position of the body during swimming, nobody knows.

Swimming is an unusual exercise, as you all know. It is the only exercise where the breathing has to be a certain rhythmic pattern and where you are supine instead of upright. Nobody knows, but it is clearly a trigger of ventricular arrhythmias in patients who have this particular genetic mutation.

So again, a lesson for you is: “If you have got an athlete who faints during swimming and has to be pulled out of the pool, this is probably what they have.” You may go your whole career and never see one, but if you do see one, you’re going to know to think of this.

Among athletes in general that is one of the things that may cause serious events. What are some of the others? What else might happen during the time of exercise? What bad might go wrong with the heart during exercise?

This is a difficult topic for Cardiologists to talk through because we all know and we all want to believe that exercise is good for us.

Exercise is good for your heart. And it is undoubtedly true that real exercise, moderate daily aerobic exercise to get the heart rate up is good for you. It is protective. It reduces your risk of having heart attacks and things like that happening. At the same time it is also true that during the moments of vigorous exercise there is an increased risk of heart attacks, strokes and sudden deaths. It is just true.
I mean you have all heard of the guy who died in the gym, the guy who died on the track, the guy who went out for a run and didn’t come back. Right?
And it is true that because of the stress that is being put on the heart during that period of vigorous exercise, it unmasks disease that wasn’t apparent before. And that is really the purpose of the pre-participation physical exam and screening.

In some countries, Italy is really particularly well known for this, they take it very seriously. Before anybody gets into collegiate level athletics they undergo a detailed cardiovascular examination.

In this country, what? They go see the Pediatrician who puts a stethoscope on their chest for three minutes or three seconds, checks for a hernia, slaps them on the ass and tells them they are good to go.

Before my kid gets on the cross-country team, my kid is going to have a little bit more done than that.

Here is a longitudinal study from France where they looked at cardiovascular events: heart attacks, strokes, sudden deaths, rhythm disturbances, things clearly related to the cardiovascular system and associated with athletic activity.

Running, swimming and cycling are the activities that lead the list. Why is that? Again, it is because of what I said before. During those activities that really demand the most of our cardiovascular system, someone who has a hidden and previously unrecognized cardiovascular problem, it may be unmasked.

It’s during exercise that they may present with the first manifestation of their disease. And it is not just in old people. It is not just the older athletes who are getting events.

On this chart the bottom axis is by age. The black bars are sudden death events and the grey bars are heart attack events. For sure, heart attacks are more likely. Here’s an unlucky guy who has a heart attack in his 30’s. Others in their 40’s, 50’s. But as we all know, 50 to 60 year old men, those are the guys who are more likely to have heart attacks. On the other hand, look at sudden death. Sudden death was actually more common, most common in the younger and even in the very young. There are teenagers having exercise related sudden cardiac death. One reason that might happen, I have already told you about. It’s the long QT syndrome.

But probably the most common cause of exercise related sudden death or sudden death in a young athlete is the disease called hypertrophic cardiomyopathy.

It is another genetic disorder, a mutation in the gene that makes heart muscle protein. In a normal heart muscle (here we have sliced open the heart and this is the pumping chamber of the heart) Normal wall thickness is 1.2 cm. In a patient with hypertrophic cardiomyopathy, it may get to 2 or 3 cm.

Hypertrophic means extra thick so this is sort of like the Arnold Schwarzenegger muscle bound heart? It has become very thick and very strong, but also very stiff and inflexible. Because of a disorder of the heart muscle proteins, hearts with this condition are particularly susceptible to certain things that can cause them to die suddenly.

Here is a patient of mine who has hypertrophic cardiomyopathy. In particular, his heart had become thick in a certain spot such that it was actually obstructing blood flow out of the heart. Like the aortic valve narrowing, that created a murmur.

He had a narrowed spot inside the heart because it had grown so thick.

This visual illustrates a technique to treat him by actually injecting alcohol into the heart muscle.
Through this tiny little catheter, we are going to inject the heart muscle with alcohol. This picture is before the alcohol and here it is after the alcohol. You can see the spot that we are treating lit up bright. What we are doing is creating a controlled heart attack. We are actually going to kill part of the heart muscle and make it get a bit thinner. In the ‘before’ picture you can see the bulge in this patient’s heart. It had gotten very, very thick and was obstructing the blood flow from leaving the heart. After we have treated it with this technique called alcohol ablation, the muscle is thinned out and the blood is able to leave the heart normally.

Still in all, I am not going to let this guy return to competitive athletics. It’s often really heartbreaking. Just in the last week I have seen two Division I level collegiate athletes whose careers are ended by this diagnosis. But it’s a lot better to know than to be surprised by a sudden death event. You wouldn’t pick this up just by having the pediatrician put the stethoscope in the chest. You would only pick this disease up by having some more advanced screening such as having an EKG, an ultrasound or an echocardiogram study of the heart. This disease is not that rare.

Somebody in this symposium has hypertrophic cardiomyopathy.

How many people are attending this meeting, 1,800? So if 1 out of 500 people has hypertrophic cardiomyopathy, statistically speaking there are three people walking around here who have hypertrophic cardiomyopathy. And none probably know about it because it is under-diagnosed. So the alcohol ablation is one time that a heart attack can be good for you.

But most of the time heart attacks are bad for you because the area of the heart muscle affected, (like that first patient I showed you with the elephant sitting on his chest one morning) begins to die. And where the heart muscle dies, it turns into scar. Over weeks and months it is scarred and thinned and the heart muscle, instead of ejecting, instead of pumping, becomes weakened. It’s weakened because the scar cannot squeeze.

Now, the brave New World that we are launching upon is the hope of actually being able to restore that heart function by putting stem cells into the heart.

Thank goodness we have a new horizon. Federal involvement or lack of restrictions in our scientific progress is allowing us to do these sorts of stem cell experiments.

We will take a catheter, a steerable catheter that has a little corkscrew shaped needle on the end of it, and I will actually put this in the heart. I’ll push this right up against the heart muscle, push the button and, “POW”, out comes the little needle. Then we will inject stem cells right into the heart muscle.

This is a pig heart, but it could just as well be a human heart where we have injected these black spots. We have injected stem cells into the heart muscle after a heart attack to treat it and see if we can re-grow new heart muscle.

Now, this is the hardest slide of my talk. I guess I am the last talk on the Saturday afternoon? This is the doomsday lecture, but I get my first year medical students through this. I can get you through this too, okay?

A pressure volume loop is one heartbeat or one cardiac cycle.

If you understand this, you actually really understand how the heart works.

On this axis here is the pressure inside the heart. On this axis is the volume of blood inside the heart. Let’s do one loop.

The heart relaxes and it fills. The heart relaxes and it fills with blood and it gets bigger and bigger. The volume grows and then ‘beep’ goes the EKG on the monitor and the heart begins to squeeze. As it squeezes the pressure in the heart goes up.

What is your blood pressure? For sake of discussion, say it’s 110.

The pressure in the heart rises to 110 and when the pressure inside the heart is just higher than the pressure in the arteries in the aorta and body, the valve opens. That magic valve, the aortic valve opens and blood is able to leave the heart and go to the body. When the heart ejects the blood out to the body, the volume within the heart goes down.

We move from right to left until the blank space in between the beeps on the EKG: the part we call diastole. The heart relaxes and it relaxes quickly. The pressure falls until the pressure has fallen so low that the heart begins to fill again.

One loop is one cardiac cycle. From these loops in the experimental laboratory I can tell everything I want to know about a heart.

Here is a heart that has just had a big heart attack. 8 weeks later, here is the same heart. The loops are smaller. Why is that? Well, it is because the heart is doing less work. It is now a weak, damaged heart. It has gone into heart failure.

Here is a heart that has just had a heart attack and was then treated with stem cells. We injected stem cells into the heart muscle to rebuild it and 8 weeks later what has happened? The loops are bigger. The slope of this line, that is the strength of the heart, is stronger. This heart is completely recovered.

I can show you what those hearts look like because this is a pig.

Here is a heart. We have sliced it open like a bagel and here is the heart attack. You can see a very, very bright scar there. This is the animal that didn’t get stem cells.

This is the animal that did get stem cells, big difference.

These pigs are really giving us a gift because they have shown us that stem cells are going to work to repair a damaged heart muscle.

We have taken this data to the FDA and the FDA gave us permission to begin treating humans.
We are now conducting a human clinical trial of this exact therapy, using that exact catheter with a needle on it to treat patients who have had a heart attack.

This is my last swimming slide. It is good to be among friends. You can always count on your friends, right? They push you in for a swim.

I hope that was at least entertaining for you.
I gave you a quick survey through a lot of what is going on in cardiovascular disease. I tried to show you a lot of cool pictures and make some of it relevant to you.

It is important I think for anybody who is involved in fitness and athletics and coaching to have more than a cursory understanding of the heart. Because if you are ever going to have a tragedy in your coaching career… it is what? It is either going to be somebody bumps their head and breaks their neck or it is going to be a cardiovascular event.

Thank you. Questions??
Question/Answer: The first one is just to be mindful of those risk factors, because those risk factors, as I said, are all modifiable. Smoking: don’t smoke. Being fat: don’t be fat. Sitting around watching TV: get up and do some exercise. Exercise is protective. The things that require you to go to a doctor are: Measure your blood pressure. If it’s high, deal with it. Treat it either with medicines or with diet and exercise changes. Measure the cholesterol. Every American should have a cholesterol panel and not just when they are old but kids too. Because early on is where we have the opportunity to really completely prevent these diseases. Check the cholesterol. Know what it is and don’t be afraid to treat it.

As athletes and coaches you are probably particularly conscious of the whole issue of muscle pains associated with cholesterol lowering drugs. I will bet you everybody has heard about that right? You take something, a statin drug such as Lipitor, Zocor, Pravachol or one of those drugs and a certain number of people will complain of muscle soreness and probably decreased athletic performance as a result. But those drugs save lives by getting the cholesterol down. It doesn’t really matter how you get the cholesterol down, but those drugs are the most powerful way to do it. So, detect high cholesterol. If it’s there, deal with it. Get it down.

Diabetes; consider it the same way. Screen for it. Check for it. Deal with it if it is there. Measure your waist. Male waists over 35 inches counts as a cardiovascular risk factor. I have a closet full of trousers that go from 30 to 36 inches. And I am always trying to get back to the 32 or 33 that I wore when I was fit.

Those are the basic things that you can do to reduce cardiovascular risk.

For the athlete, I recommend a pre-participation physical exam by somebody who actually takes that as a serious responsibility and gives that athlete some thoughtful attention.

Question/Answer: That is a great question and it is a little bit loaded. What about anti-oxidant vitamins? Everybody knows those are good for you, right? NOT!
The benchmark that we use in science to answer a question of whether something is good for you or not would be a randomized controlled trial. We would take a thousand patients and we would randomize them, toss a coin. The patient wouldn’t know if they were getting anti-oxidant vitamins or a placebo. Then we would follow those subjects in the trial and find out. It’s been done. Take people who were at risk for cardiovascular disease because they had high cholesterol or smoked or had diabetes and randomize them and give half of them Vitamin E and Vitamin C and give half of them a placebo. Guess what? More deaths reported in the Vitamin E and Vitamin C group. So everything that you think about vitamins can potentially be turned on its head. I think much, much more than vitamins, we can all agree on the importance of healthy nutrition. So, avoid diets that are rich in saturated fats, trans fats. That means hydrogenated fats. When you are reading the labels and you see hydrogenated, RUN, FLEE. Twinkies and Oreos are the work of the devil. Those are the fats that are particularly prone to settle into the blood vessels. As a society we probably do eat too much meat, too much fats, too much dairy and not enough fruits and vegetables.

I believe, and this has got some data to back it up, that if you are looking for vitamins and that antioxidant boost, the antioxidant value of fruits and vegetables is probably more real than those pills that didn’t fare so well in a clinical trial.

Deeply colored fruits and vegetables, things with color in them tend to have good stuff. Examples are blueberries, raspberries, Acai juice, pomegranate juice; all that kind of stuff. The color is there. Red wine, right? Same story. The color is there. It’s good for you. I think you eat enough blueberries and broccoli and salmon you will probably live forever.

Question/Answer: No, the HDL is the good cholesterol and I didn’t focus on it because there is a lot less you can do about it. It is sort of predetermined by your genetics, although exercise will get the good cholesterol, the HDL, up a bit. HDL is good because it takes cholesterol out of your body, puts it in the bile where it goes into your intestines where you can flush it down the toilet. That is how cholesterol leaves the body and HDL helps it go that way. Other things that help cholesterol leave the body through the poop, down the toilet, are soluble fiber. So, to my blueberries, broccoli and salmon diet I would add oatmeal.

Bran muffins / good fiber also helps prevent colon cancer and a lot of other things, plus it does help cholesterol leave the body.

Question/Answer: That is right. If the HDL, the good cholesterol is less than 35, that is a risk factor. Again, there is not a terrible lot you can do about it. It is more common in certain populations. Indians, Pakistanis other South Asian people are very, very prone to have a very low number for the good cholesterol. That sort of runs along with this thing we call the metabolic syndrome. They tend to put on fat around the middle. If they get fat they get round and it is worse to be an apple. It’s better to be a pear if you are going to get fat. Put it on in your ass. If you put it on in your belly that is worse for your heart. People who, because of a genetic pre-disposition, put on weight around their middle are the same people who are likely to get diabetes and likely to have a low value for the good cholesterol, a high value for the triglycerides, the other fat in the blood stream. Those are all risk factors for heart disease.

Question/Answer: It depends. Wheat that we get is really pretty refined stuff, even the whole wheat, something that is nominally whole wheat. The dietary pyramid has been revised recently, right? They really don’t want us having cereal grains, pasta and bread be the dominant stuff in our diet. So a bagel, I think is actually pretty much the equivalent of a potato or a piece of candy. It’s rapidly metabolized by the body. It is pretty heavily processed food. It is absorbed quickly. It is a carbohydrate. It’s the stuff that your body will burn up quickly and turn into fat stores if possible. Real fiber is in fresh fruits and vegetables. It is in oatmeal, is in bran or is in Metamucil. If you want to go just buy some fiber, you buy a big can of Metamucil and stir that into your juice in the morning.

SPICES??: In some cultures I have heard a real fervent belief that the temperature of food or the spice level of food matters. Similarly, whether the alcohol was served with ice or without ice. A lot of different things played into a risk for heart disease. I don’t really think there is lot of data and because I am standing here trying to be your, you know, ‘hard-assed scientist guy’ today, I would have to say. “I don’t know.”

I don’t really see anything published that I can hang my hat on that says that spicy food or not spicy food matters. But if you call salt a spice, then for sure. That is an important one. What is the story with salt? Regarding salt: where salt goes… so goes the water. Probably more likely the women in the audience have noticed this than the men. But if you eat a salty food, you cannot get your ring off the next day or your feet are just a little swollen. That’s because as you put salt into the body you have retained water. Your body is trying to dilute that salt. Now, as your body retains that fluid volume, the blood pressure goes up as well. So anyone who is prone to have high blood pressure should really focus on staying away from salt. Similarly, anyone who has got heart disease, has had heart failure or has a damaged heart cannot handle the fluid load that goes with salt.

In Baltimore where I spent the last 20 years, the classic story was the guy who went out for crabs and beer. Crabs in Baltimore are crusted in salt. And the next day he came into the hospital gurgling, full of fluid, in heart failure and had to go into the Intensive Care Unit for a few days. So, salt is a spice that can be very bad for you indeed.
A prudent diet for us all is in the range of 3 grams of sodium per day. If you start reading labels and looking at things, that 3 grams of sodium can add up pretty quickly. If you eat a bag of chips, you are well on your way to having gotten your total daily load of
salt / sodium.

LAST QUESTION: Fabulous question and one that I spend hours worrying about. We were talking about hypertrophic cardiomyopathy, this genetic disorder where the heart muscle gets too thick. There are other things that make the heart muscle get thick and one of them is exercise. A problem that I often am presented with as the consultant Cardiologist is: here is an athlete whose heart muscle is thicker than normal. Is this the athlete’s heart? Is this just a thick heart because he or she is really, really fit? Or is this the genetic abnormality of hypertrophic cardiomyopathy? It is really hard sometimes to tell them apart.

There are other things that are interesting and known because Italy takes this screening process so seriously. In Italy they do an echo ultrasound measurement of the heart thickness on all of their athletes. They have learned that certain athletic activities like rowing, canoeing and cycling are particularly prone to make the heart muscle thick. So, Lance Armstrong’s heart has probably got a pretty thick wall. That does not predict any particular risk. It is a healthy adaptation and once Lance stops training so hard his heart will probably return to a normal thickness. But telling them apart sometimes is really hard and takes some advanced testing.

Alright, thanks everybody.

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