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In this podcast episode, Dr. Matt DeVane and Dr. Carolyn Lacey discuss cardiovascular disease risk factors with their guest, Dr. Jason Liu. They emphasize the importance of understanding and managing risk factors such as high blood pressure, diabetes, smoking, and family history of heart disease. The doctors also mention the role of genetics and encourage listeners to be proactive in assessing and addressing their individual risks for heart disease.


Matthew DeVane, DO, FACC: [00:00:08] Hi, I'm Dr. Matt Devane.

Caroly Lacey, MD, FACC: [00:00:09] And I'm Dr. Carolyn Lacey. We are cardiologists at John Muir Health, and this is our podcast, Living Heart Smart.

Matthew DeVane, DO, FACC: [00:00:16] Our physician partners and colleagues are going to help guide you through many different and important cardiovascular topics to help keep your heart happy and healthy.

Caroly Lacey, MD, FACC: [00:00:24] Thank you for listening and we hope you enjoy our show.

Matthew DeVane, DO, FACC: [00:00:33] Today, [00:00:30] Dr. Carolyn Lacey and I would like to welcome to the program Dr. Jason Liu. Dr. Liu is a board-certified cardiologist. He did his undergrad work at UC Berkeley. He went to med school at Drexel University in Philadelphia. Went on to do his internal medicine training at UCLA, Ronald Reagan Medical Center, and then did his cardiology fellowship at Cal Pacific Medical Center in San Francisco. We're very fortunate to have him join us [00:01:00] today as he loves to educate patients. He loves to talk about cardiovascular disease and risk prevention. Today, we're going to be talking about coronary artery disease, risk factors. We're also going to talk a little bit about why    Dr. Liu likes to refer to cardiologists as masters of odds and what that means. Great term. We're going to talk about high blood pressure, diabetes, family history of heart disease, and a little bit about genetics. We really want you, the patient, to understand what your risks are. And I hope this program brings some of that to light. [00:01:30] All right. Let's dig in. Well, good morning. Super excited to be here this morning. And we have a guest with us today, Dr. Jason Liu. And we're going to talk all things cardiovascular this morning. Welcome to the show.

Jason Liu, MD: [00:01:45] Thank you. This is this is great. I'm looking forward to being the first guest.

Matthew DeVane, DO, FACC: [00:01:49] You are the first guest.

Matthew DeVane, DO, FACC: [00:01:50] Oh, it's amazing. A lot of preparation and work has gone into this and I think it's going to be really good for our patients. And the goal is just to keep our patients [00:02:00] in the loop, make them smarter, let them know who their doctors are here at John Muir Health, and hopefully, it'll be very helpful. So I think today what we wanted to talk to you about in specific is maybe cardiovascular risk factors and the cholesterol panel in specific. There's over a million heart attacks a year in the United States alone, as we all know, as cardiologists, is stuff that we deal with every single day is dealing with patients that have had heart attacks or are at risk for [00:02:30] heart attacks. And so a big part of our job is really to figure out who's at risk and how aggressive should we be in treating them. So let's talk about cardiovascular risks. So what, Jason, what do you think are the main cardiovascular risks, and how should people be thinking about it?

Jason Liu, MD: [00:02:47] Yeah. So just as you said, I think as cardiologists, what people may not appreciate is that we're actually masters of odds, right? And I think we go through our career seeing how people [00:03:00] turn out with the certain risk factors that they have. And we have this calculator that's built into our intuition that helps us decide whose high risk, who's low risk, and how aggressively we need to treat. And our job is to make sure that we figure out the hand that you've been dealt and how to play those cards the best you can in this game of life. And when I think about cardiovascular disease risk, it's not just cholesterol. I don't want you guys to think that it's only [00:03:30] cholesterol that I care about. But it's also a mechanism for that cholesterol to really develop into these dangerous plaques. And so what are those risk factors and those risk factors that you hear us talk about often are those risk factors that we include in our risk calculators. You've all heard about our calculators that calculate atherosclerotic cardiovascular disease risk based off this equation called the pooled [00:04:00] cohort equation. But those main risk factors hypertension, diabetes, smoking, and the biggest of all, of course, age that really influences this. Those are those are mechanisms whereby cholesterol can promote these plaque formations.

Speaker3: [00:04:19] And just to kind of give you a sense of this, right, there needs to be some sort of mechanism of injury to the artery, some sort of stress on the artery wall that makes it possible [00:04:30] for LDL to really stick to it and really, really develop into plaque. And those risk factors are the ones that do it. And you can think about, for example, diabetes. You know, a kid spilled a sugary drink on the floor. The moment you step on it sounds like Velcro, but sugar very much does the same thing in the artery. It allows the LDL to stick throughout the artery walls. Right. Hypertension. There's a lot of stress. You know, think about a think about a water pipe with water running at high pressure. It's more prone to burst, [00:05:00] more prone to leaks. And that's what allows those little injuries, little stresses on those artery walls is what allows LDL to really stick there. So it's not just simply how high your cholesterol is, how high your bad cholesterol is, but really how it interacts with some of your other risk factors and family history. Right. So we'll talk a little bit more about family history. It is built into my background as a cardiologist, and I'm sure [00:05:30] we'll explore it more.

Matthew DeVane, DO, FACC: [00:05:33] Perfect. Yeah. No, that's very well said. Wow.

Matthew DeVane, DO, FACC: [00:05:36] That is excellent.

Matthew DeVane, DO, FACC: [00:05:38] What was the thing you said were masters of what was it?

Caroly Lacey, MD, FACC: [00:05:41] Masters of odds.

Matthew DeVane, DO, FACC: [00:05:42] Masters of odds.

Matthew DeVane, DO, FACC: [00:05:43] That's great. Wow. That's really, really insightful.

Caroly Lacey, MD, FACC: [00:05:46] I do like how you also say. That we are playing the cards that you've been given. I mean, I have patients say, well, why is medicine just a practice? It's not. It's because biology is pretty [00:06:00] messy, actually. And so you're kind of dealt these cards. The other thing I always like to talk about talk to patients about not only with their traditional risk factors are the things that we can't control. We can't control our environment, we can't control pollution, we can't control our genetics, which I know you're going to talk a lot about a whole lot more. And the arteries just age. That's part of the body. Some of these microstresses are going to happen so early in our life that we're not even aware [00:06:30] of because we don't really grow new arteries specifically.

Matthew DeVane, DO, FACC: [00:06:35] And I think one of the one of the things that sticks in my mind is somebody said cardiovascular disease and atherosclerosis in particular is inevitable and is ubiquitous. So the process is going to happen as a chronic process. So the question is, what are these other risk factors going to do to your arteries to make them more prone to having cardiovascular events? [00:07:00] What we really care about is events, right? Heart attacks, strokes, and death. So those are the outcomes from all these bad things. So how do we keep putting each individual putting their risk in perspective for them in the long term? So that's kind of our job, I think, as cardiologists. So the biggest point I'd love to make for our patients is the sooner we can get you, the better. We want you in when you're 25, not when you're 60 after you've had your first event. So the question, how do we change the mindset of people in general and get them into our office [00:07:30] just for basic cholesterol panels and at least the discussion about how we go about assessing your overall risk over your lifetime. So okay, well said there. Let's talk family history to me is always kind of an interesting topic with patients. I mean, I hear a lot about, oh, my dad had a heart attack, my grandfather had a heart attack. It's runs in my family. But then when you probe just a tiniest bit, you hear that, well, the grandfather did die of a heart attack, but he was a lifelong smoker. And, you know, he came from Nebraska, and [00:08:00] who knows what he ate. And he was actually 78 when he died and that was his first event. So technically, we don't really count any of that as a family history. So, Doctor Liu, if you wouldn't mind just diving into a little bit more about what exactly are we talking about when we say family history of cardiovascular disease?

Jason Liu, MD: [00:08:17] You're right. So so as you remember, we talked about sort of cardiovascular disease risk. One of the things that we brought up is age. You know, age is a huge component of how we calculate risk. Now, the problem is the [00:08:30] pooled cohort equation really looks only looks like short-term risk. So the younger you are, the less likely it's going to give you, you know, a number that's considered high risk. And where family history really comes into play is understanding what you sort of coined as lifetime risk, right? When do we start treating them despite what the pooled cohort equation may say this is where family history really comes in handy because we're trying to get a sense, try to get a prediction of what direction you're going to take down the line and when we should soon intervene [00:09:00] the soonest. And so, you know, we think of premature coronary artery disease as, you know, patients for men having an event at less than around the age of 45 and for women less than around the age of 55. But beyond that, the way I think of family history is I ask you about, you know, the number of immediate family members, first-degree relatives that had MI's in their history, how old they were. And the way I think about it, the more first-degree relatives [00:09:30] you have that have histories of a cardiovascular disease event or the younger they are, the higher risk you are. And it makes me it picks up my it perks my ears because I'm listening for this and it's changing again. How I think about your odds, despite what your numbers may tell me. And it makes me think, should I be looking for things, You know, risk factors that may not be easily picked up on our lipid panels really [00:10:00] broaden where we should be searching. Should we be thinking about imaging modalities like coronary calcium scoring to help anticipate those risks where our equations may not necessarily pick it up?

Caroly Lacey, MD, FACC: [00:10:14] I think when it comes to family history too, I get pretty detailed when I'm seeing a patient in the office for the first time trying to go through their family history. It's more than just, Oh, my dad had a heart problem. What kind of heart problem? How old [00:10:30] was he when it started? What were sort of the circumstances leading up to that? And then just asking further very specifically, mom, dad, brothers, sisters and the and then beyond that, Oh, all my uncles died. Oh, uncles on the same side of the family or a different side of the family. And the more that patients are aware of those details really help us sort of put their entire risk for coronary disease or maybe other heart issues, [00:11:00] heart problems into perspective.

Jason Liu, MD: [00:11:04] Absolutely.

Matthew DeVane, DO, FACC: [00:11:05] So, yeah, that's well said. And so let's take one step back here. So big picture, someone comes in, they're 40 years old. We want to talk to them, their first visit with the cardiologist. So we're going to ask them about their cardiovascular risk factors. So we're going to look at high blood pressure. We're going to look at their blood sugar level, whether or not they have diabetes or the metabolic syndrome. We're going to look at whether or not they're smokers, family [00:11:30] history, their weight. I think those are the big check marks is vaping and marijuana. Are those considered cardiovascular risks, yeah, because now we're getting a lot of patients admitting up to the fact that they are using these things. And quite frankly, I don't really know if we have enough data to tell them I'm in general, I'd say it's probably going to increase your cardiovascular risk, but I'm sort of making that up as I go along. Do you guys know of any real data that suggests those things are not good for your heart?

Jason Liu, MD: [00:11:58] Let's see. I'm not sure if we've had you. If [00:12:00] you think about it, you know, cardiovascular disease develops over years. And, you know, with vaping being relatively recent, it's hard to really tell. But I can tell you that there's already data suggesting that there's risk of lung injury. So that alone is already, I think, reason enough to stop marijuana. I'm not sure if you guys have, any comments on that one.

Caroly Lacey, MD, FACC: [00:12:26] I just did a little look.

Matthew DeVane, DO, FACC: [00:12:27] Oh, okay.

Matthew DeVane, DO, FACC: [00:12:28] Hit me with the newest data. [00:12:30]

Caroly Lacey, MD, FACC: [00:12:30] Okay. This is from October 2022, from the NIH. NIH-funded studies showed damaging effect of vaping and smoking on blood vessels. Long-term use of electronic cigarettes or vaping products can significantly impair the function of the body's blood vessels, increasing the risk for cardiovascular disease.

Matthew DeVane, DO, FACC: [00:12:50] Beautiful. Wow. That's up-to-date data. Thank you, Dr. Lacey. So that's what we probably figured, but it's going to take a while for the data to keep coming out, especially, [00:13:00] like Dr. Liu said, long-term stuff. So we'll see. But it's not going to be healthy for your arteries, period. Okay. So is anything else that you guys want to comment on? I mean, we're going to take a little deeper dive into the lipid panel, which for cardiologists kind of, you know, is one of the key components of what we like to dig into as far as cardiovascular health and your risk goes. Anything else that we want to say about other risks that we haven't talked about just yet?

Caroly Lacey, MD, FACC: [00:13:29] We didn't [00:13:30] really talk too much about hypertension or diabetes. I don't know how you explain them to patients, but when I explain these two different processes to patients, when it comes to blood pressure, it doesn't matter how you get there. It's you have to have normal blood pressure. And if you need lots of medicine to do it or no medicine to do it, that's all that matters. It's just the blood pressure has to be. Same thing with the glucose. I think for now, although we'll see as data comes on.

Matthew DeVane, DO, FACC: [00:13:57] I think the nice thing about blood pressure for me [00:14:00] is the numbers tell the story. So patients say, Am I on this forever? If you start a medication and I say, I don't know, for blood pressure, the numbers tell the story so we can start a medication, see if your numbers come down. Ultimately, wean off the medication, recheck the numbers, see where you stand. A little bit different for most of the time when we're treating cholesterol, especially in a secondary prevention setting, which we'll talk about later. But for blood pressure and blood sugar, those tests are so easily available and obviously need a home blood pressure cuff. You need [00:14:30] to track it like crazy and then work with your doctor on minimizing medications. If we can't.

Jason Liu, MD: [00:14:35] The most satisfying thing is, you know, as patients that are overweight, as they start to lose weight, their blood pressures get better and they're coming off their medications. And so I think it's you're right, it's something that we track and something that we can modify to, to some degree.

Matthew DeVane, DO, FACC: [00:14:52] And for diabetes is one of the bigger risks for atherosclerotic disease and events as cardiologists, [00:15:00] as at least personally speaking, I used to want to push that all that stuff off to the primary care doctor or to the endocrinologist. As soon as I hear the word like punt, punt, punt to other physicians. But these days we're getting because of some of the newer medications for heart failure and weight loss and other things, cardiologists are becoming more and more interwoven with this diabetes things. I know, Doctor Liu, you have some interest along those lines. What are you seeing.

Jason Liu, MD: [00:15:28] Oh, yeah, absolutely. And [00:15:30] really, I think what the way I would phrase it and or the way I would view it is that some of the most devastating long-term consequences of diabetes are the cardiovascular and complications. And so we'll see a lot of the medications, especially more recent medications, is that there are some classes that are associated with decreased cardiovascular disease risk. And really, sometimes cardiologists are the first [00:16:00] ones to catch this. And, you know, sometimes the first person that we see with a heart attack may have had an undiagnosed type two diabetes. And so we should really be at the forefront of offering to at least initiate therapy. And I think it's something that, you know, between yourself and the primary care doctor as a team can sort of address together and keep a close eye on the patient.

Matthew DeVane, DO, FACC: [00:16:23] Excellent. Yes, totally agree. Doctor Liu, I really appreciate you being here. And I think the insights [00:16:30] that you brought about all these risks are really important for patients to listen to and to learn about. I just urge all our patients out there to be super aggressive about learning what your coronary artery disease risks are, how to identify them, how to treat them, working with your doctor closely to get these things under control, you can and will beat heart disease. If you look at these risk factors and take care of them.

Matthew DeVane, DO, FACC: [00:16:56] This is Dr. Matt Devane, and on behalf of my co-host, [00:17:00] Dr. Carolyn Lacey, and our partners at John Muir Health, we hope that you enjoyed this show and we really hope that you keep living heart smart.

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