Michael Miedema, MD, MPH, discusses the different aspects of preventive cardiovascular care.
Welcome to cardiovascular conversations with Minneapolis Heart Institute. Your podcast for the best and cardiovascular content. Cardiovascular Conversations is a new, creative and engaging content source for the latest and greatest in cardiology topics and innovation. Way are your hosts, Fred, Um, use and I'm Jason Hicks. Enjoy the podcast. Dr. Michael Madama is one of the foremost experts in preventive cardiovascular care. Besides being an excellent cardiologists, he also holds an M. P. H. From Harvard and did his Preventive Cardiology Fellowship at Brigham and Women's Hospital. Dr. Minima is widely published, and notably as well. He is on the Committee for the 2019 a. C. C. H. A Guidelines on the primary prevention of cardiovascular disease. Enjoy this Cardiovascular conversations podcast with Dr Madama Chapter one. Everybody, Let's Talk Aspirin. There have been some pretty big studies looking at aspirin in the last 5 to 10 years, and where are we at with that? In terms of recommending it to our patients? Three initial aspirin studies in the eighties and nineties looked pretty promising to the point where, even in the late nineties, there was consideration that, you know, if you're a 50 year old male, maybe just be on an aspirin, you know, just to be safe. And now, when we repeat the studies a couple decades later, with risk factors that are much better controlled and other treatments available, the rate of M I is much, much lower than what it used to be. The absolute benefit of the aspirin is much, much smaller, but in reality the risk of the aspirin is higher than most those other medications. The bleeding risk is very real. It's very undefinable. In the trials, about one in 300 people one in 400 people that you treat with an aspirin will have a major bleed because of that aspirin. Once you get to that small benefit in terms of reducing am I and Stroke starts to get a little equivocal of how to know what to do with the aspirin, you know we're gonna prevent this. Many heart attacks are caused this many major bleeds. Is that really worth it? And so the recent trials have said, you know, if your risk factors or well controlled, if you're not a high risk person, it's probably not worth it. The current approach would be that most people probably don't need an aspirin a day on to say, you know, taking aspirin. Just be safe. It's probably a safe decision. We're talking primary primary prevention, right? So if you haven't had a heart attack or stroke, if you don't have a stent, that's the group we're talking, which is most middle aged adults. If you've had a heart attack. If you had a bypass, if you had a stent, then it's different than we do. Think a baby aspirin today still makes sense, So if you've had an event, it's reasonable to take it. If you haven't but you're high risk, then the guidelines give it a two B, which is like it's an option. So if you really value, I wanted to use my car Gavaskar risk as much as I can. It's reasonable to take an aspirin every day. Uh, dad would still say, Even in that group, though, it's a little bit murky whether there's a true benefit. And so that's where some of our research research has been. You know, can we take that group and help define who actually gonna be more likely to benefit with a calcium score with a heart scan and We just published an update on that recently using the newer guidelines. And we found that, you know, if your high risk and you have a lot of plaque in your arteries, your likelihood of the benefit is is pretty reasonable. Whereas if you're high risk but have no plaque, um, you're very unlikely to benefit from the aspirin. Anything else in terms of aspirin, anything that's on the horizon is faras refuting some of this primary prevention. Are there any ongoing trials right now re looking at that? Or do you feel like the trials that have been done in recent years? Pretty definitively. We're done. Yeah. I mean, we don't want to do a major trials just in the last three years where you had a group of people with diabetes, you know who we considered a high risk group and in that study, So just a very small benefit, uh, group of people above age 70 which I mentioned before, which was there was no benefit they could define. And then the other one was kind of the broader, you know, 50 to 60 with a couple risk factors, kind of the classic patient we see in prevention clinic where I'm 50 years old. I got a family history, a little bit high blood pressure. What should I do to me? That's the most kind of informative trial. You know, aspirin hasn't changed. We've changed, right? Our population rates of heart attack have change. And how we do these studies has changed. That's what changed Dr E mean, why didn't you also allude to when one of the trials to there was the actual risk stratification groups? Some of these groups were actually lower risks, too. So that was a piece of it as well, where they're on aspirin and like, it doesn't It doesn't really diminish events because you're not gonna have them in the first place. But that's kind of another. And so that is a recurring theme in all our prevention trials right now is that the event rates that we expect to happen aren't happening at that level. They're having a much lower level. So if you go to your doctor right now and they put you into this risk calculator and they say your risk is 15% in the next decade for a heart attack or stroke, it's probably half that you know, it's a multifactorial disease, and so the rates of blood pressure are better than what they used to be. Rates of cholesterol, high cholesterol better than what used to be smoking is definitely lower than it used to be. Trans fats is lower than what it used to be. The diabetes thing is still coming. Eso the obesity epidemic, you know, is mainly in a lot of youth and middle aged people that diabetes isn't quite there yet, you know. So this last round from the H A in terms of cardiovascular stats did show an uptick in cardiovascular tal ity. For the first time in a long time. That's probably the obesity epidemic starting to kick in, and the more I do prevention clinic, the more I see this is a very important thing. The psychology of preventive medications is really important, you know, for the patient to go to the store and buy the aspirin themselves because they want to do it because it's their choice that is empowering, right. They feel like I'm taking control of my health versus to go to the doctor and get prescribed something and says you have to take this Now it's disempowering. And so this shared decision making concept, which they always talk about initially, always like it's kind of Foo Foo. I'm not sure that matters too much. I think it matters a lot to have the patient be their decision. So you know what? I'm gonna give you the evidence. You make the call. I think that's really makes a difference in terms of them actually wanting to take the staten or the blood pressure pill or the other preventive medication. Um, versus, you know, when they go into a settlement store and they get a look at everything and decide what they want. It's very empowering, you know, versus being prescribed something they don't like. That's got a negative energy to it on. So I think that's really important. When we talk about these medications, that should be the patient's choice. We just wanted to be uneducated choice, Chapter two, cholesterol, cholesterol. We're looking way back, and we have the Framingham study, which is ages old now, and obviously there have been a bunch since then. What did that give us and what did that really changed for? Just going historically a little bit on bond how How do we view it nowadays? Well, I think that's an important point that if you look at cardiovascular prevention, historically the data comes from population health studies. I mean, the main take home from Framingham, we're number one is that it's a multifactorial disease. It's not just cholesterol that causes heart attacks and strokes. It's cholesterol, but also your blood pressure and your blood sugar and what you eat and how active you are and smoking and your stress level in 10 other things. And so, if you're gonna look at somebody's risk for heart attack, you can't just look at their cholesterol. That won't tell you very much. Most heart attacks happening people with relatively normal cholesterol levels. If you're a 65 year old male smoker with diabetes and gorgeous cholesterol numbers, you're very high risk. If you're a 35 year old female with high cholesterol, no other risk factors. You're not high risk it all, so using cholesterol to assess risk is a really bad idea. However, the Framingham study and all these other studies also showed us that the relationship between cholesterol and heart disease is linear, meaning as it goes up your risk goes up, and as it goes down, your risk goes down with no magical thresholds. And so if you have normal cholesterol and you lower it, you lower your risk for heart attack and stroke. And in the most recent studies with the newer meds, If you have low cholesterol and you lower it further, you lower your risk of heart attack and stroke. We know when we get to L deals levels less than 100 ideally less than 70 and maybe even lower. We start to see plaque regression. If they think of it as a plaque regressing pill versus a cholesterol pill, they get more excited to take it. What are what are the guidelines telling us? How are you approaching? So the first kind of caveat. What I said earlier about you know, it's not really about your cholesterol is about your level of risk. The one group that doesn't apply to is people with familial hypercholesterolemia. So if you have a genetically high cholesterol, where your LDL is it around 200 or greater? Um, that group, that linear relationship start to get more exponential, and so in that group, we don't need any other risk factors. We don't need any other testing that's a genetic group, or we got to treat them aggressively. The guidelines are very clear about that. So it's a small portion of the population for everybody else for the average middle aged person, then it's about assessment of risk. And you know, the guidelines set a 70% risk threshold. You know, if your if your 10 year risk is more than 70% you should think about a Staten blow that you probably old off. That's very arbitrary. You know. It's all about the discussion with the patient questions. How much how benefit, What's the magnitude of the benefit and allow these people is pretty small. However, If you look at the population level data, the more we use status, the more we lower cholesterol. The population level benefit is quite large. You know the number of heart attacks avoided nationwide is huge. Zetia and then some of the like, the bigger bulk. You're the EPA fish oil products. Yeah, so we have other options now, you know, if you go back to the 2013 guidelines, it said, we have evidence for statins and that's it that was pretty much it and I. Just five years later, we have a PCSK nine inhibitor, which is an injection that dramatically lowers cholesterol similar to a Staten. We have zero, which is now generic, so it's cheap. It's very safe. The response is a little bit variable, so not everybody gets a huge benefit. But the trial showed very clearly that if you're on a staten versus a placebo vs a statin, the onset of my if your cholesterol goes down a little bit further with you that you have less heart attacks and strokes. And then now we have a CPA, which is basically like fish oil on steroids. You know it's purified E P. A and the magnitude of benefit with that. And the trial was quite large. You know, it targets triglycerides and targets, you know, kind of non HDL cholesterol that's remnant cholesterol. The benefit was pretty impressive. There's a lot of heart attacks and strokes avoided, so we have some cost issues. The PCSK nine and the gossip are both pretty expensive, so we probably can't use both in the same patient. The algorithm is you know, all these trials were in addition to statin therapy and maximally tolerated statin therapy. So you still want to go to the staten first? Um, but then after that, you it doesn't mean the risk is now zero, right? You check their cholesterol again, you check their level of risk again. And if they're LDL still elevated, you think about the is that of my first because it's the cheapest and easiest. Um, if they have genetically really high cholesterol and you know you're not even close to your goal, the PCSK nine makes sense. And if they're just that overall cardiovascular risk and if they have diabetes, um, that's where the masipa probably makes more sense if they're trying to size, are elevated. Interesting thing you said. I remember you saying this once about triglycerides is these folks who have really high triglycerides a supposed to sort of moderately elevated are not at as high risk. And what is the reason for that? Exactly. So if you have genetically high triglycerides in the thousands, the trajectories tend to be big and fluffy and not very athletic. Um, it's the it's the more remnant cholesterol we call it were actually involved in some research on this now where if you look at kind of the non h d. L minus your LDL, thes cholesterol particles seem to be more anthropogenic and triglycerides kind of factor into that. And so it's It's the diabetic with metabolic syndrome who has triggered a series of 300. Um, they're the ones that actually at more risk than if the person is genetically high triglycerides. Just purely s's. Initially, we thought, maybe just to be a marker of the other things like the diabetes and the metabolic risk. But with the Masipa trial, you know the people that struggle strides lowered and non HDL lowered, they seem to have benefit prognostic Lee. Um, people who struggles right spike more after a meal are at higher risk than people who don't eso that does factor into prognosis. In terms of clinical decision making, it's a little bit different. Maybe we bring up risk your calculated risk over and over. Is there a standard calculator like What do you recommend? So with the 2013 guidelines, they created their own calculator, so it's called the Pool Cohorts equation. So they took data from Framingham and from a few of the older kind of big chords. Cardiovascular health study. These courts have been around a long time, and they use that data to create this calculator. And it was, I think, the best one that we could have available based on long term data. One of the issues, though, is that the data those data come from populations in the eighties and nineties, and some are not seventies in the eighties and nineties and again, event rates were a little different then. And so that's one of the reasons for overestimation of risk is that using data from older generations to be nice to use more modern data to create that calculator? It's hard to do, though it's complicated imaginable. So in general, in your practice or using that calculator, do you? I mean, do you even probably probably e you use it. And importantly, this is probably the key point. It's the starting point. It's not the decision point, right, So you start with that. Here's your risk. Let's go from there. These PCs K nine monoclonal antibodies do they have the same impact of some of these other monoclonal antibodies that we're using for other diseases? Well, I mean is or is this completely a different? It's It's a different mechanism of action. You know, It's kind of like a vaccine to PCs canine. And so we've got about 600 people in our clinics that are on one now. Um, and in general, the other reduction is substantial. It's about a 50% reduction. We don't see a lot in the way of side effects. And in the trial, and the trial was 27,000 people, and we have two different ones. Both had 27 plus 1000 patients in them, and the safety data look great. And so they're an option. They're expensive, you know. Price is an issue. Um, there's now a six month one that's coming out where every six months you get the injection and it lasts that long. It's got a durable effect. And so if you look at some populations that have issues with adherents and issues with cost, if we could get in terms of proof of that, they come into clinic and get it every six months. You got their cholesterol treated for the year. Beyond that, this is getting out a little science fiction, but it's I think it's riel When I was out in Boston, I came across a guy who does a lot of research and cardiovascular genetics, and they recently published one of the first studies. And they've got a little, almost like a virus that goes into the liver cells. And it edits the DNA at the PCs canine gene, so it takes out their PCSK nine. And so there's a chance in the future that in your twenties or thirties, if you have high family risk and we can calculate your genetic risk and you have high cholesterol, we can edit your genes in. The cholesterol is gone. It's a long way from being ready for prime time. And you know we can't get people to take a stand, and I can't imagine we start talking about getting their genes, So that's gonna be oh, come on in for this. We're part of a trial right now that we started on our own about a year ago. They come into the clinic and we enroll them in the study, and over six months they get 5 28 days supplies and medications. Two of them are a Super Staten at 20 mg. The other three are placebo. If at any point they're feeling poorly, they could stop it. They wait a week and they start the next one. So they go through all five trials, and it's called an end of one study, because the patient is both the intervention and control right there each they're kind of their own trial, basically. And then at the end of the six months, they come back in and we go over the results. And so far, um, we have not had a lot of people that it was the Staten interesting eso and we then could say, OK, now we know that. Let's try the staff again. You know, the subconscious is powerful if you suggest that might make you sick and start to make you feel sick. One of the things I would like to recap to about cholesterol before we move on to the next subject is and you've touched on it a number of times. Calcium scoring, who actually benefits then from being started on a staten? Is there a particular age group risk strategy? What we call that intermediate risk group, you know. So if your 10 year risk is above 20% That's a pretty high risk group. Uh, not doing this that And that's saying it's probably a bad idea, regardless, what their calcium score is. If you're less than 5% you know you're a low risk individual. If you have a family history, it may be reasonable to check it out. Then that's probably able to say, You know, let's just leave this alone for now. So, like a low risk, low risk individual, you just have like a family history. You're like, Well, and these risk calculators age dominates the risk calculator, right? So if you're in your forties, you're probably low risk, you know? And so the risk calculator is the starting point probably isn't the end point, because we can do better with assessing risk. And so you know, if you want to do what you can, reduce your risk, take the staten and then you're done. But if you're not sure that you wanna take it or maybe you had a reaction before, we're not sure we wanna try it again, then the calcium score to say, Hey, let's decide about what your actual personalized level risk actually is because we know if you're a zero. If you don't have any plaque in your arteries, it's really hard to a heart attack anytime soon. That's not impossible, but it's really hard. And so if you're seven and 8% and we got to score zero, your risk is not. 70% of all is probably like two or 3% and so it dramatically lowers your risk if you're a zero. Isn't it true, though, that a number of people in their forties let's say, if you do the calcium score, they're not gonna have any calcium? But they could still have plaque eso the soft, soft? Exactly. So from a physiology standpoint, it makes sense, right? We know people diabetes and smokers are more likely to have soft black. We know that people with counselors zeros can have heart attack. And so if you're having symptoms, your score zero doesn't mean anything, right? You know, this is for asymptomatic people who feel great. That's really where the most value is with the test. I shouldn't say it doesn't mean anything, but it's it's less prognostic in that setting. Um, despite that concern for the soft plaque in the big databases, the people have scores of zero who we know some of them have soft black. Overall, the event rates are really, really low. The in May. So one of the big horse that we follow, the two groups that really came out of there is being. If you're a zero, but you're a smoker or if you're a zero, but you have diabetes, then the zero doesn't mean as much. Those two groups, we probably shouldn't pay too much attention to it. That's why the guidelines say, if you're a diabetic, you probably need the category. Probably just take the Staten Chapter three Diabetes Way were taught. And, I think reinforced time and again throughout our practice that if you have diabetes, that's the equivalent of coronary artery disease. Does that still hold true? And or And if it doesn't, why, yeah, so this kind of gets the same thing with the aspirin of the history of this, you know? How did this all come to be? And so so Type one. Diabetes was the predominant form of diabetes in the fifties sixties seventies. It was a lack of insulin, and so when you gave people insulin, they did better, Um, but managing that insulin was really hard with injections and stuff, and so their cardiovascular risk was really, really high. And so, for Type one diabetes for that large population, most likely a CHD risk equivalent. You know, in the eighties and nineties, the data would say, the type one diabetics had rates that were Samos having heart disease. The concept that if you have Type two diabetes well, we better get on insulin pretty soon here to make you healthier. That's not the case. And so the modern data would suggest that if you have Type two diabetes, especially its earlier onset, you're not a CHD risk equivalent at all. Um, you could be relatively low risk on DSO to say that you're a ticking time because you have diabetes. I don't know if that's the case, Dabbing said. We know the long term risk is incredibly high on DSO. It needs to be approached as the condition that is a metabolic issue, right? It's an issue of metabolism. You know, the cholesterol medication that we have. Basically, if you lower your cholesterol, your risk goes down. There's less heart attacks and strokes for blood pressure. The blood pressure, as we have If you lower your blood pressure, you have less heart attacks and strokes for diabetes. The initial data wasn't that way. It wasn't that people that lowered their blood sugar and then had less heart attacks and strokes. You know, Accord was looking at Let's be really aggressive with your blood sugar control on. Let's compare it to being less aggressive. And those people didn't seem to have any better cardiovascular health despite having a lower A one c, you know, And so lowering your blood sugar, um, is about how you do it. You know, um, if you lower with insulin, your blood sugar goes down. I'm not sure that makes you healthier. Um, and now the newer class of medications we have seem to help metabolism. It seems to make people healthier. Most of the Type two diabetes we see, especially in younger people, lifestyle intervention is the way to go. So, you know, lifestyle matters for everything. Of course, it matters for blood pressure and cholesterol as well. But for diabetes, it's unbelievably important, and we know it can really have a market response. You know, physical activity can have a market response and diet, and the combination especially, could really change a one c and change your overall diabetic parameters a lot. And so patient, you know, for certain that that's the main thing to focus on by a mile to start. We don't have to get super granular about diet and exercise, but I know that we always throw that out of health care providers. Are you paying attention, your diet and your exercise? Because we don't really? Well, it does, because it works. I mean, if you actually do it but work the question I think a lot of patients have is, well, okay, it's It's all good and fine for you to say diet and exercise. But they're like a million different kinds of diets out there that are all highly touted. Their million different kinds of, you know, exercise regimens that are out there. Is there anything that you guys either tell your patients to do? Our or resource is that you provide for your patients about exercise. You're both right in that, um, diet exercise works, and it works unbelievably well. So whether it's running or swimming or yoga or hiking or anything, I get some active. It works, and so you know, the H A. Guidelines for diet are incredibly complex. For fiscal activity. It's 150 minutes a week, or whatever you wanna do. Moderate activity for diet. It's way more complicated. If you're on the Internet, you type in healthy diet. You could read for a year straight and not know which way's up. And there's so much marketing. And there's so many fad diets. And there's so many, you know, week science, and it's so hard to to do good nutritional research right. You can't compare it to a placebo. You have to eat something else. Eso What's reading is that something else really matters. You know, you compare most things to a Western diet, and it looks amazing. So Western diets not so healthy. There's very little data comparing healthier things to healthier things. And you know the finances behind it are so complex that it's just it's really hard to know what to recommend in terms of, you know, the nutritional science is complicated, and so we have a dietary booklet that we put together. The number one way for your body to make fat is to take in sugar. If you take in fat and protein. You tend to burn it. You taking sugar, you tend to store it. And so these low carb approach is definitely have some benefit to them. Um, it also depends what you're eating with a low carb approach, because we know processed meats are probably not good for us. And so avoiding processed meats and simple carbohydrates, lots of health, fruits and vegetables and then healthy fats. You know, olive oil, nuts and seeds. Avocados. Ah, high fat diet is not necessarily a bad thing. You know, the Mediterranean diet every year is I'm fascinated that it's constantly kicking out people that are in there there late, you know, late hundreds kind of thing. But I think it's the It's a cultural thing, right? They have grown up a certain way. Apparently, Yoda was on the Mediterranean diet. A little known fact still is still U S for his CrossFit competition. S. O r r dietary book that we hand out is basically a Mediterranean style diet. Okay, we have these new treatment options of SGL T two inhibitors and GLP one agonists and minor saying, as you pointed out, is these air for quite a bit higher risk patients, but they actually do have other incidental benefits. So the S D. L T two's are unique in that it works in the kidney and that you typically filter out a fair amount of blood sugar in the urine and then re absorb a fair amount of it back it blocks that re absorption back. And so you end up being out a lot of blood sugar, and so that has the benefit of lowering your blood sugar. But it also has the benefit of being kind of a diuretic and natural Reddick, and so people will get rid of volume. And so the clear benefit that they've seen in these trials is that diabetes outcomes are improved. But almost more importantly, heart failure outcomes are improved. And that's really the main benefit with these medications that the SDLP, too, so this would be Dapd Lifson and Canon Lifson and MPEG Lifson or the three ones with you. The benefit is a reduction in heart failure, you know, they reduce heart fire admissions and heart fire deaths. And so we even have a recent trial looking at people with heart fire with and without diabetes, and they're still was benefit. So it's not just about lowering the blood sugar is about improving heart failure outcomes. And so we're getting the point. Now if you have a patient with diabetes and with heart failure, Um, guidelines have given a Class one recommendation, but it's pretty close. I think you know, they should be on an SGL t to I think that's pretty. We have enough evidence now to support that. They do seem to work well, okay, And then finally the GLP ones basically, they improve. Metabolic health is the way I think about it. They do cause increased early safety. And so some people feel full earlier. Some people feel nauseous, you know. So it does have some potential for G i side effects, whereas the SDLP to air pretty safe in terms of side effect profile. But in the GOP one trials, very clearly, cardiovascular events went down. If you got the medication less heart attacks and strokes eso again a proven cardiovascular benefit, which is the opposite. What we have for some of the other diabetes medications earlier on primary care is really busy. It's gonna be hard for them to take kind of ownership of these medications. We probably don't have enough endocrinologist to do this. We have a lot of people with cardiovascular and diabetes. We want the cardiologists to prescribe these medications. Eso I've given a couple talks, my partners about that. I think the initial one was pretty lukewarm received, like we don't want to get back in that field. More recently, it's, you know, it's becoming the standard of care. Chapter four. Essential hypertension. Okay, way do need to touch on hypertension. Has anything changed there and then any major changes in terms of treatment of hypertension, I would say there hasn't been any major change. There has been an increased focus on a certain things. One again. If you look at the relationship between systolic blood pressure and cardiovascular risk, it's linear. So we could talk about 1 40/90 all we want. But if you lower your blood pressure from 1 30 to 1 25 your risk goes down. And for blood pressure, especially patients gonna be very numbers focused. You know, I'm 1 20 over over 80. I'm fine. I'm 1 35 Oh, no, that's bad. Well, everything matters else that your risk matters more than what your actual numbers dio If you look at non Westernized populations, so you look at Aborigines and the blue zones and different things like that. Their average blood pressure in their elderly population is frequently 90/60 100 over 65. You know, very low blood pressures where if we see that clinic Oh, that's too low. You gotta be higher. Probably not on DSO. The idea that we're gonna lower blood pressure too much with these blood pressure pills is probably not the case and three other key component that if you look at the epidemiologic data, is that normal and healthy or not always the same thing. Unfortunately, in the US, the normal blood pressure is about 1 25/85 or 1 25 or 80. You know, that doesn't mean that that's healthy. And so the fact that has a population are blood pressure is not great. Doesn't mean that when the blood pressure guidelines set aggressive goals that they're being too aggressive, you know, um, they can't ignore the data. The data would say that the lower the blood pressure goes, the healthier people are the less heart attacks the less strokes and less heart failure. And so if somebody wants to lower the risk for cardiovascular disease and their blood pressure is 1 38/89 that doesn't mean there well controlled. They could lower the risk if they took the medications. And so to ignore that, I think is not right. Um, now when the guys come out and 60% of people above age 50 I'll qualify for blood pressure pills. That seems pretty daunting. Like, Wow, everybody has to be medicated a same time. If they come and say I don't have a heart attack or stroke in the next five years, that's an option to reduce that risk, No doubt about it. We have really good evidence, um, that it's way better to use one or two medications at a low dose than one medication at a high dose. You know, typically for most primary mention for cholesterol uses that were done, um, for blood pressure, it's way better. Attack it on multiple fronts. You know your kidneys play a role in your blood pressure, but so does your heart and so different hormone levels, and so does the tone of vessels central nervous system matters, and so it's a complex system. It's way better to attack it on multiple fronts with low doses of my pills than it is to go to a high dose of a single pill. And so that I take it is how you typically address the combination pills. A really good idea, a low dose of life center pro with a low dose of hydrochlorothiazide that's perfect in general. The vast majority hypertension we see is essential hypertension. So you know TSH and going to get those things, get the basics to start. But after that, it's about lowering it with lifestyle in with the medications. And again, the lifestyle can really matter. Here. People that go to a low salt Mediterranean style diet can lower the blood pressure more than they can with any pill, and then the blood pressure pills again. We have three classes now, so we have the diuretics and the aces and ARBs and the calcium channel blockers that have long term data that show excellent safety profiles. They're very cheap. Um, they're very reasonable to try. And unfortunately for quite a few patients, they need to be on all three and they don't like to hear that, and I don't like to prescribe them like that way. But that's where we end up most of time. You did not mention beta blockers, so the beta blockers come in fourth pretty clearly by the data. They do come with a little bit of risk, and they do come with a little potential for side effects. They don't lower blood pressure quite as much. And that's not for the beta blockers or not for initial game for blood pressure, right? There are a lot of times there used just for Is it in some cases for people who have known coronary artery disease and corn previous? Yeah, maybe for remodeling issues of cardiomyopathy. Or, if you have heart failure, the beta blockers, the first line indication That's completely different. Okay, very good. Chapter five. What's on the horizon? The epidemiology of cardiovascular disease? How do things look to you right now and and where we headed overall as a society? Yeah, there is is plenty of reason for optimism. There's a few reasons to be not so optimistic. Um, you know, to me, one of the main themes in the last decade has been We need to get better at understanding of risk, right? You know, if we had a crystal ball, it would be so much easier to make treatment decisions because we have the 50 year old comes into. You know, Doc, my dad had a heart attack when he was 50. To my grandpa. Heart attack was 48. I don't wanna have that happen. How do we do this? You know, And so it's allocating the treatment of the people who need it the most is really the goal, But we're getting better at understanding risk. And that's that calcium scoring, um, that we do a fair amount of we've got some genetic markers now. They're getting better, and we probably have a apologetic risk or relatively soon at the same time. You know, you don't need to assess risk to decide if you should eat healthy or if you should exercise. We know that already, and so that's gonna be more like I said, driven from a policy level, and we definitely have some initiatives. They're doing that there's a whole food as medicine movement looking at, you know, if you get especially sicker people, hard player if you could get him to eat healthy can dramatically reduce the risk for readmission. You know, there's a lot of nutritional things and a lot of lifestyle. Things don't have a significant impact if we could implement them successfully. And that's where the spot right now is that we know the data. You know, the lifestyle matters. How do we get patients to actually do it? And how do we give patients the environment where they can do it on? That's that's that research is just important. Anything we do clinically, it can't be all medications, obviously right. Medications for the people who are at highest risk. But we need the lifestyle interventions for everyone. No matter what you know, you don't need a calcium score. Decide if you should smoke. I think, finally, Thio and to just conclude things here. The service that you provide your particular practice and Minneapolis Heart Institute in general, in terms of cardiovascular prevention, anything that you'd like to say about that for prospective patients for, um, your peers. We have a large prevention clinic. If you have a risk factor and you're concerned about it, that's what we're for. And primary care You know, there's definitely a lot of overlap with what we do compared to family practice, internal medicine. But you know, it's our specialty and, you know, for annual physical in, a doctor has 10 minutes with a patient. The idea that you're gonna talk about a statin a thorough way and get the patient to understand the risk and benefits that's pretty hard to dio. You know, I frequent spend a half hour of patients talking about this, that because I think if it's their choice, and if they truly understand the risk and benefits, they often make a different decision than what they're thinking they're gonna make when they came in. Is there a time where you feel that some family physicians should be referring patients to the preventative clinic where they, some of these patients just kind of have too many? Um, outlying factors or risk factors that may be can't be met by the primary care. Yeah, you feel like they do a fairly good job. Overall, I really think it's a knowledge thing. I think it's a time thing, you know, again, if you want the patient to be empowered and if you want them to understand why they're doing what they're doing, which I think makes it much more likely for them to do it. Then they need to be educated that education takes time, and it's hard to get that education on the Internet, probably better to get it from somebody in person. It's a complex topic that can't be covered in 10 minutes. You know, with office visits. E think it's important that we're doing the intelligence issue, but again, thank you very much. Dr. Mike Madama, cardiologists with Minneapolis Our institute, Minneapolis Heart Institute, has a large cardiovascular prevention clinic. They can and will take the time to thoroughly discuss with patients their risk factors, medication options and how to improve lifestyle to overall increase quality of life and longevity. We really want to thank Dr Madama for taking the time to address cardiovascular prevention with us today and to help unmuddied the waters of cardiovascular prevention and optimize your risks or those of your patients. Doctor Media and the rest of his colleagues at Minneapolis Heart Institute are here to help have a great day and be well, we'll see you next time. Thanks for listening to cardiovascular conversations with Minneapolis Heart Institute. If you haven't already done so, be sure to subscribe to the podcast. And for lots of excellent clinical tools, be sure to check out the APP for Minneapolis Heart. For more information, please also visit Minneapolis Heart Institute at Minneapolis heart dot com. That's mpls heart dot com And don't forget to review us a swell. This is Jason Hicks, and I'm Fred Meuse signing off until next time. See you soon. Mm hmm. Use a reproduction of cardiovascular conversations is forbidden without the express written consent of Minneapolis Heart Institute or Align a Health. Cardiovascular conversations should not be used for legal purposes, and it does not take advertising money. The content is informational only and is not to be used as a substitute for medical decision making or as medical advice. Some of the opinions of the hosts and guests are their own and not those of Minneapolis Heart Institute or align a Health
