Women and Heart Disease | El Camino Health

>>We are joined tonight
by Dr. Jane Lombard. She’s a very well regarded
cardiologist and also Debra. Debra is a woman much
like many of you. She is active in many
areas of her life. She is going to describe her
story to you and we would like to just thank you so
much for being willing to come and talk to us tonight
and tell your story. So if you don’t mind, we
just like to get started and I would love to know just
could you tell the group a little bit about yourself
and why you are here tonight?>>Sure. I was 53 years old
when my heart symptoms started. I’m 55 now and I have 2 twins. One set of twins, a boy
and a girl 14 years old which I swear is the cause of
my heart problem, teenagers. This is my daughter right
here and I taught aerobics. I still sub. Some of you might have seen
me at the Y across the street. And I have done that
for about 26 years. So–>>What kind of heart issues
did you have and tell us when they started and like
what you first noticed?>>What I first noticed was
fatigue, extreme fatigue and one day I was walking up to the 3rd floor I was taking
the stairs to my boss’ office, it is exercise and I
noticed this weird feeling on my left arm. It was like I was wearing
a blood pressure cuff. And then it just kind of flowed down after a while [inaudible]
shake it a little bit but then I would call into
work and I would say well, I’ll be in after lunch because
I just couldn’t get out of bed. I couldn’t get the air
anymore to get out of bed.>>How is it?>>Can you not hear me?>>No. We are not hearing you.>>Okay. How’s that? Okay.>>Fine.>>I just I couldn’t get
the air to get out of bed. So I would say I will
be in at 12 o’clock, I will be in at 1 o’clock
or I won’t be in at all. And eventually I just used
up all of my sick time because I was so fatigued. If I did go to work I
have to go and lay down. I have to tell somebody
to make sure and wake me up because I didn’t
want to be there when the groups would come in. And–>>How long did that go on?>>A good 6 months.>>A good 6 months and
fatigue could be from lots of different symptoms,
right Dr. Lombard?>>That is correct but you
know, when she tells us that she has a symptom in her
arm and every time she goes up the stair she gets worse. You got to really
think it is your heart but she didn’t know that then.>>That is why she is here.>>And I went to my PCP.>>Your primary care provider.>>Roll over my name list and
they thought it was muscular because I worked out so much
and was going to send me to physiatry and I
knew that wasn’t right so I went back 2 weeks later because my symptoms
were worsening. And I got the nurse practitioner
who said the doctor is going to be mad but I am
sending you to cardiology. And I got sent to Dr. Lombard
who said, “Let us do a stress or non-stress test
and echocardiogram.”>>A stress echo.>>We did just the echo first.>>We did just the echo just to make sure your heart
function was normal.>>And it showed nothing.>>Correct.>>So she said, let’s do
a stress echo which is where they take the echo
when you are laying down and then you run like heck
on this machine and you have to go back all dizzy
and lay down and then they take
your heart rate again. And I saw this, I could see it and everything else was going
boom, boom, boom and this one in front I could see it
was going umph, umph, and I said to the doctors,
that doesn’t look good. And he said it is not. So we scheduled about 2 weeks. I ended up in the ER,
I couldn’t breathe so we scheduled the next
week and I woke up and I have to tell you, I felt
differently like when I woke up.>>So we did an angiogram and
she had a blockage in the ostium or the very origin of one of the
largest arteries to her heart, it is called the left anterior
descending and we put a stent in Debra and she is
not seeing me now and she is back aerobicising
again. So I just want to, you know,
go over a few points that Debra so kindly illustrated for us. One, is that her symptoms
were very unusual. Fatigue, you know most people
think oh yes because I stay up too late or whatever,
but hers were as you know, particularly exertional fatigue
associated with the arm pain. And as she, you know,
you are smart, you insisted there was
something wrong with me and you have always exercised
and so you know that wasn’t like you were out of
shape or whatever. You know there is something
wrong so you insisted that you, you know, continue
to work up and–>>And you had shortness
of breath also is that what brought you to the ER?>>Not really. No.>>No shortness of breath.>>I just I couldn’t
get a satisfying breath if that makes sense but
I could breathe to walk or I even taught
aerobics during this year.>>I think you got really tired.>>Yeah, I got really tired.>>Oh my goodness. So and you had a stent
put in, is that right? So after the stent you said
you felt completely different. So what are you able to do now? Can you describe your life now?>>I can walk up 3
flights of stairs to my boss’ office
although a lot of times I don’t really want to. I can walk. I can walk the dog. I can walk with my kids. I am not fatigued anymore.>>What would you tell, what
would you tell other women? Can you guys hear? What would you tell
other women, Debra, who may be having
similar symptoms or things that they are worried about but really they don’t
have a definition for why this is happening?>>Pay attention to your body. Think of the things that
may be you don’t feel right that are new. If you don’t feel that your
health care provider is doing what you think is the
problem, keep at it. Don’t just settle
because I was guaranteed if I went another month I
would have had a heart attack. And I have got young kids so obviously I can’t
leave them yet.>>And this is a hard question
for me to ask Dr. Lombard because you are here and
your daughter is here. Dr. Lombard, what could have
happened had Deb ignored those symptoms even for another month?>>Well because the blockage
is in the artery that was, you know, that provides probably
50 percent of the blood flow to her heart, if that
artery would have shut off, she probably would have
had a massive heart attack with risk of death. And that would not be good
for the YMCA because nobody– that oh my God that is what
happens when you exercise>>Everyone is dying.>>Yeah.>>Now did you– do you
have high cholesterol?>>Not really. No.>>Not really?>>Never have.>>Never have and what about any
family history of heart disease?>>Oh my God. Everybody on my mother’s side
of the family either died young of a heart condition or
cirrhotic liver or both.>>So there is heart
disease in the family. Maybe a little bit of the
elevation of cholesterol or not much and did you
have high blood pressure?>>Not really. No.>>No. So a lot that describes
a lot of us in this room, right? A lot of us do not have a lot of high blood pressure,
high cholesterol. Is there a question?>>Did her problem
show up on an ECG?>>Did her problem show
up on an EKG or ECG, no.>>The EKG will only
pick up a heart attack. So if you don’t have
a heart attack but you are pre heart attack,
the EKG will be normal, okay? The reason the treadmill test,
she got a stress echo was because her symptoms
are very atypical. She was more exertional
fatigue and as Barb said, a lot of things can
cause fatigue so we want not just the EKG and actually I reviewed
your treadmill test, the EKG on the treadmill
wasn’t even that abnormal. But what happens is when you
don’t have enough blood flow to your heart, when you
stress the heart and such as we made Debra run or
jog on the treadmill. If the heart doesn’t
get enough– a normal heart pumps
like this, okay? So but if a heart
doesn’t get enough blood when it is being stressed,
so the normal part will pump like this and the front part
of her heart was stationary. And then immediately we
knew that was the artery to the front part of
her heart and we need to get her in right away.>>So you are saying
if I am correct, you can have normal testing, you can be told you have
normal testing but you need to dig deeper and you need
to be your own best advocate.>>Yes. You need– if you are
having exertional symptoms that is a sort of a,
you know red flag, if you have any exertional
chest pain, arm pain, shortness of breath–
you don’t have pain.>>I was wearing a
blood pressure cuff.>>Right. People say tightness. I ask a lot of patients
do you have pain? They will say, I don’t
have any pain even when they are having
a heart attack. They have tightness.>>I have a question?>>So is that the
same thing hardening of the arteries is it
totally different conditions?>>That is hardening
of the arteries, we will get to that later and we will see why call it
hardening of the arteries.>>So I think if you are okay
we are going to just thank you so much for coming
to talk with us. You are welcome to
stay and if you would like because we are
going to have question and answer at the end. But now Dr. Lombard
and I are going to give you some more
information about women and cardiovascular disease. So I want to thank you
so much, thank you.>>Thank you so much for coming. Before the [inaudible]
Debra [inaudible]. You know, one thing
you have done for yourself all this
time is you exercise. If you had never exercised,
you wouldn’t have known. And see that is another
key thing. That is why I always tell my
patients to exercise, you know, because if they if people say
how often should I get a screen? Well, you screen once a year,
once in every 5, whatever but it happens on
the wrong time. It doesn’t happen on the day you
want to go to see your doctor for a screening test you
are not going to catch it. But she is actually putting
herself out there exercising so she noted a difference. She noted the difference. She could always do this but suddenly one day
it was really hard. So you know, I think that know
your body, always exercise and when things don’t fit,
you know, keep pushing until you get the answer. I really appreciate you coming
to, you know, hear the story because I think it
is really different from when we tell the story versus people hear it
directly form the patient.>>And now Debra [inaudible]
here for herself and she watches and knows all the symptoms, there is obvious
difference [inaudible]>>She’s going to be the
next aerobics instructor. Thank you so much let’s give a–>>Thank you very much
we really appreciate. [ Applause ]>>Okay. We’d love
it, let us see what– All right so I think Deb you
were very generous of your time to come and sit with us
I think I’ll move over.>>I’m also a nurse
practitioner. I like to be closer
to Dr. Lombard. She is one of my favorite
doctors and I refer a lot of patients to her
mostly because she listens and she is the kind of physician
who leaves no stone unturned. So when I say, here is a
problem, she will say, “Yeah, I believe you and
we will keep digging until we find out what it is.” So Dr. Lombard, I think
Debra’s story is really, really important and it really
tells us that women can be, not always but can be
different from men. You know, most of us
associate a heart attack with that crushing
chest pain or pain in the shoulder or
pain down the arm. But when it comes
to heart attack, we are not always the same. Can you describe what women
should really watch out for?>>Yes. Let me see. I have some slides so yeah
practicing my yoga right now, turn around. So number one, there
is a misperception that women don’t get heart
disease but we do, you know. We just get it later. We are protected before
menopause and then it is because of this misconception,
a lot of times people are not like Debra and they don’t
listen to their body and they ignore their symptoms. The symptoms are
very different not– are very different
but a large number of women do have atypical
symptoms like Debra and only 30 percent, 1 out of 3
women have classical symptoms, the crushing chest
pain, et cetera, whereas 2 out of 3 men
will have the chest pain, substernal chest tightness, even when people are
having a heart attack, the chest pain is very atypical
and women have more shortness of breath, nausea,
vomiting, indigestion, fatigue that Debra
mentioned, sweating. I had women say, oh my
God, every time I go up the stairs I just break out
in a sweat and I get nauseated. A lot of them will give us,
you know, other symptoms such as arm pain and a third
of heart attacks in women are “silent” because they didn’t
recognize that these symptoms. They thought they
had indigestion. Maybe that is why we
call it, you know, some of us call it heartburn. And a lot of times women with
sort of the crushing chest pain, you know, is not
necessarily their heart. So– but always think that
if you do have chest pain that is particularly exertional
or any kind of symptoms that are exertional, you need
to do what Debra did which is to follow through and make
sure it is not your heart. If it is not your heart
then you don’t have to worry about it, okay. So here is the statistics. These are data that are
collected over 10 years ago but things haven’t
changed very much which is that the perception and the
reality of the incidence of heart disease doesn’t fit. So people a lot of
women still think that breast cancer is the number
one cause of death in women and actually, you know, heart
disease causes more deaths than all the cancers added. And most women are not cognizant
of the kind of symptoms that might be related
to having a heart attack or coronary insufficiency, okay. And here is the statistics,
as you see the incidence of heart disease goes
up us we get older. Like I said if you do
this slide in blue, you just shift everything
over a little bit but actually we have
made tremendous progress in heart disease in men. We have actually managed
to educate, you know, the public to take better care
of themselves be more aggressive about getting cholesterol
down, et cetera. We are still working
hard on women. The statistics were
obtained 10 years ago and so there is a huge campaign
to educate women and the public about taking better care
of themselves and getting to the doctor when they
have these symptoms. But in 2010, the statistic
haven’t changed that much so we are still trying. So here is the scope
of the problem. More women die of cardiovascular
disease than all cancers and about 2 and a half women
are hospitalized every year for cardiovascular illness and half a million women
would die every year from cardiovascular disease. And the sad thing
is the mortality where women just don’t
do as well even though when you adjust them all for
the risk for diabetes, age, et cetera, we still don’t do
as well as the men in blue. So you now, this is the
mortality rate so you want to be or death rate, so you want
to be as low as possible. And we are a little
higher than men. And so people say well maybe
it is because, you know, we don’t get treated as often, we don’t come to
the doctor sooner. I think it is multi
factorial ie there is a lot of causes why we don’t
do as well as men. But a big part of it this
disease is very aggressive in women.>>Could you explain what are
the initials stand for CHD, AMI?>>Oh thank you. Okay, so yeah. This is all from
cardiology study so, okay. CHD is Coronary Heart Disease and then AMI is Acute
Myocardial Infarction. Now I’m like where am I? But I don’t think–>>Here you go.>>Okay. Post AMI is acute
myocardial infarction. So, after you have a heart
attack, women don’t– the death rate is still higher. Does that make sense? It doesn’t but I mean that is
the reality, unfortunately. So the key thing right now is
we don’t want to even get there. We want to prevent
heart disease.>>And I think we have to
go back over this again. One of the most important
point that you are going to take away tonight is that women’s symptoms are
often different than men’s. So, a third of women are
going to have chest pain. But that means that two thirds
are not and I want to ask you. I am going to ask you
to raise your hand. Is shortness of breath a symptom of possible heart
disease in women?>>Yes.>>What about fatigue?>>Yes.>>Right. What about what are
some of the other– nausea?>>Sweating.>>Sweating. How about you exercise
and typically you are fine but sometime after you exercise,
you feel that shortness of breath or maybe
a pain in your arm. Could that be a symptom?>>Yes.>>Great. Could all those things
be symptoms of something else?>>Sure.>>Yeah. But, the key is to
go out and get it evaluated. Dr. Lombard, you know I have had
patients and I have sent them to you who have chest pain
on exertion or we call that with exercise and
I have suspected that. And so, I have sent them to
you or other cardiologists. So, what do you advise
women who suspect that they may have
coronary artery disease? What is the first step
that they should take?>>If they have symptoms, they should immediately
see a physician. And, you know, like
Debra illustrated, usually they will
get an EKG just to make sure there is
no acute heart attack or acute process
and that is normal. The doctor will usually follow
up with some other studies. We do the echocardiogram
and echocardiogram is like the ultrasound, very
similar to the ultrasound that we all know about babies. So– but it is a different probe
and you get to see your heart on TV and that would tell us
how well the heart is moving. Actually, we get a
ton of information. We can also tell if
your lungs work well because we can get a
pressure from that, et cetera. But, like in Debra’s case,
everything was normal. So I said, “Okay, your heart
is strong, it is working. Why are you so tired? It must be something else.” And the key trigger was she has
this horrible family history. You can’t do anything
about that. But you have to read all
the tests, all the symptoms and the context of the
patient’s family history and the other risk factors. So that is where I will start. And we have, you know, many
different ways of evaluating for coronary disease but
that is certainly a start.>>Can we keep going and
talk a little bit more about the differences
in men and women? I think you have some
cool slides here. Yeah.>>Okay. So– here we go. Oh, thank you. We needed some of them. So here is, you know, one thing
about women is that, you know, women, we are different,
thank goodness. It makes the world more
interesting, but we also have– there have been many studies. Women have a different
response to pain, okay? And our response to pain may
even vary depending on hormones. So they have done a study on
women and various, you know, phases of the menstrual cycle and they can feel
different pains depending on their hormones. But the other difference is that we deposit atherosclerosis
differently than men. So here is an– this is
coined by Dr. Noel Bairey Merz who is a very well
respected advocate for women in heart disease. She is at Cedars-Sinai at UCLA. And she called it the
Yentl syndrome, okay? Everybody seen Barbara Streisand
in the Yentl, she has to pretend to be a man, to be let into
not to [inaudible] school but you know, to become a Rabbi. So she had to pretend
to be a man because they would not
allow girls to go in. And she called it
the Yentl syndrome because Dr. Bairey Merz
thinks that women all have to have the classical symptoms of the men before
people recognize that they are having a problem. Well, you know, two thirds of us are not going
to have chest pain. We are going to present
like Debra with you know other symptoms. So, you know, so she started
this huge campaign while in conjunction with actually
the American Heart Association and the American
College of Cardiology to educate the public. So it is called the Yentl
syndrome and part of it is that we deposit atherosclerosis
differently than men. So these are [inaudible]
to work. So here is a nucleus
study, okay? So you see so what
is a nucleus study? A nucleus study is when
we exercise the patient and we inject an isotope into
the veins and it goes everywhere where the blood flows. So you see like a
full donut, okay? Like a full donut, so
this taking a heart and like a cucumber and slicing
it down so we you have this– you fill the round donuts. And here this patient has
a blockage in an artery and you see that
donut is thin now. It is like somebody took
a bite out of that donut. And that is because that patient
is not having any blood flow going down that– that artery. And the angiogram,
this is an angiogram. Okay, so these are the arteries
and you want to see this nice, the whiteness is the contrast so
you want this to be really big. But let me just go
ahead and this isn’t– these are all the different
tests we can do but I don’t know if this does show you here
is a post mortem study and here you see this– we
start laying cholesterol in the artery. So you want this
lumen to be very big. But what women do is that we
just sort of diffusely pack fat around the arteries, okay? So and then what happens is
when these arteries rupture like this, that causes
a heart attack. So it actually bleeds
inside the artery and you have the
blood clot closing up that artery giving
you a heart attack. So women, we pack the
fat all the way around. So Dr. Merz has this saying
that women we get fat all over, men they just get a beer belly. So this is what happens. In men, they get this
like little constriction. So the doctor will say, oh you got a narrowing
in that artery, okay? Women’s would pack it
all over, it just look like oh you got really
small arteries. The big arteries are not small. They only look that
way because the whole, the whole lumen is packed
with atherosclerosis. And later, I will show you
some slides but we are talking about hardening of the arteries? When you have all these packing
with this cholesterol stuff up here, cholesterol,
lipids attract calcium. Okay so then we have
this cholesterol and then you have
calcium on top of it and that is what causes
hardening of the artery. So that is sort of an
old fashioned term, hardening of the artery is
basically atherosclerosis. Okay, so that is the
difference how we respond to atherosclerosis. We pack it all over and men sort
of pack it in a focused spot. It is easier to identify and
actually it is easier to stent because you think, okay, we could just pop a stent
here whereas with this vessel, where do you put the stent? Okay, so you basically have
to get like to drain it all down to get rid of
all the stuff.>>So will you always have an
elevated cholesterol level?>>Not necessarily, there are
other factors and you think about all these risk factors as
being compounded like interest. Okay so it is like your– you have a 2-fold risk
and you have high– you know high blood pressure
and other 2 fold risk. Two times 2, blah blah
blah, so it just adds up and then you smoke, man that
shoots your risk way up. So people may have
the same cholesterol but not necessarily
the same risk.>>So I am sure a lot of you
cook maybe you make rigatoni, right, nice, big,
round rigatoni. So you want this nice,
big, round rigatoni. You don’t want it to be
like capellini or spaghetti. And that’s what happens
to the rigatoni. It gets filled with that
fat all the way around, so that the amount of blood flow
is not going through something as big as rigatoni, it is going
through something as narrow as spaghetti or capellini,
right? And in here, for women, it
is like we line our vessels. We line our vessels
with fat, right? And it goes all the way around. For men, they may be
making a bulge in an area so there is a narrowing
in that area. But for women, it can be
all the way down that artery and that is why, you
know women and men are– that is another way
that we are different. But it means that we want
to ask for specific testing because some of the
testing that is done for men and women is the same, but we should all be
doing that testing. But women may have to
take those extra steps and we are going
to talk about that. So let us start with what should
women start with, Dr. Lombard? You know if they are thinking
that there is an issue or they want to be screened, let
us say you have a family history of heart disease, maybe you have
got a little moderately elevated cholesterol, what
should you start with?>>Well, I think
you know, again, you should work with
your physician. Always get your blood
pressure checked. You can’t do anything about
your family history, right? You are what you are but
you can decrease your risks by changing your lifestyle. Okay so if you have
high cholesterol which is also genetically
related, just not fair, some people can eat all the
eggs and bacon they want and their cholesterol
still is okay. But you know, if you
do have propensity to have high cholesterol,
you should really watch out on your diet and you
should exercise a lot. You know and you can make
a big difference just with your lifestyle. So, you know, measuring things, one is so we always
check your blood pressure and check the cholesterol because those things we
can fairly easily treat. And then depending on what
your cholesterol shows, the doctor may choose to do
other tests to you know figure out how much risk your
cholesterol profile actually confers on your cardiac status.>>Well let’s talk about
cholesterol because I think that even though it is out
there and we hear a lot about cholesterol, can
you walk us through? I think you have
some good slides also about total cholesterol and some of the fractions
there, in there.>>Okay, so this is–
these are some numbers. Does everybody here know
what their cholesterol is? Good, who does not? Oh– Sure you are very young
so you are still growing, so. But you should, everybody should
know what their baseline is. If yours is normal, then
you don’t have to worry about it you know for– but
they’re recommending that you at least have a baseline
check when you go you know in your middle years just
to see where it is, okay? And so here is what happens when
your cholesterol is elevated. And here is, this two
theoretical patients and neither one of them smoke. Their blood pressure is
normal, okay, 120, 120. Here is a cholesterol that
is 220 and here is one that is less than 160. 160 is pretty low, okay? And the HDL here unfortunately
in that here, HDL is low and here is a person
where the HDL is high. And neither one are
like diabetic. So you have mildly elevated
cholesterol and a low HDL and this individual
has a 5 fold risk of having a coronary event
compared to this person who has a different
kind of profile. This again, just looking
at the general public and you know there are other– we don’t know anything about
their family or anything else but this is just
based on one feeding. So I think everybody should
get their cholesterol checked as to you know what
it is and you want to know all the different
sub types. Okay, this is– they are coming
out with new recommendations, but this is based on
again, population studies. So we want people to
have cholesterols– the LDL which is the bad
cholesterol less than a 160. Actually, we like prefer them
to be, if you have any risk to be less than 130, and if you
have several risk to be less than a 100, and we
want the triglyceride, those with triglyceride. Oh, I don’t have
it on this slide. Okay. So, but those
are the numbers. We want it to be– you want– it
is like money except in inverse, you want the lowest
of cholesterol that you can have, okay? And so what is all this
cholesterol business? How does cholesterol work? Well, believe it or not,
cholesterol, yeah, it all starts in your gut, whatever you eat. So here is in your intestine, okay so everything you eat
including fats, carbohydrates, sugars, anything, so
people don’t realize this. This is not just the fat
we eat it is everything because whatever you
don’t metabolize, it gets converted
into fat, right? If you are going to eat
large amount of food and you don’t work it off,
you are going to get fatter. Well, same as cholesterol,
if you don’t work out the extra sugars
or carbs, then it gets, it is getting transferred
into call it microns, it is just like little
bubbles of fat. So that if you like cream,
okay so you actually, if you eat ice cream and
then we draw your blood, your blood will sometimes have like little bubbles
of fat in them. That’s called the microns. They transport them to
the liver and that is where the cholesterol
is manufactured. And all those statins that you
hear about on TV, they all work in the liver trying to
prevent the metabolism of this little fat, you know
particles into cholesterol. But okay so if you’re not taking
the statins, it goes in here and it gets manufactured
into initially VLDL which is Very Low
Density Lipoprotein into the intermediate density. So they get sort
of like formatted and then they get bigger
and bigger into the LDL. Okay, that’s the
bad cholesterol.>>That’s the cholesterol that
deposits in the arteries, right?>>Correct, and then
it get shifted out into the extra
hepatic organs into everywhere else
including your arteries. So this LDL is shipped out,
okay and it goes everywhere. So there is too much of
it then it gets stuck in your arteries just like
the previous pictures. So what about the
good cholesterol, HDL? So what is HDL? It is High Density Lipoprotein. It is high density because it
has got extra proteins in it. And what it does, the
extra proteins are like the garbage collectors. They are like little Pac-Man. They go into the
arteries and say hey, we have got too much
garbage here. And so they gobble it
up and they take it back to the dump which is the liver. The liver is the source of all
this cholesterol metabolism and they get rid of it. And that’s why when
you have a high LDL, you need a high HDL
to balance it out. And Dean [inaudible] this
really cutely he said, do you have a lot of garbage, you need a lot of
garbage trucks. And that’s basically it. But if you have a low
[inaudible] people come to me and say, oh, my LDL is
60 but I’m so worried because my HDL is only 35. Well, you don’t have
a lot of garbage. You don’t need a lot
of garbage trucks. You are okay. Most of these people are on cholesterol medicines
already, okay? So here is a thing
about triglycerides. Triglycerides are
the smallest fat. It is like the earliest form of
fat before it gets metabolized into the LDL as in all
the other DLs, okay? We used to think
triglycerides are fairly benign, and triglycerides on
can go up in a thousand. Some people have familial
hypertriglyceridemia. And but now we know that triglycerides
can increase your risk of having heart disease. So I think nowadays, we’ll
look at the whole structure of what your total
cholesterol, your LDL and your triglycerides
and your HDL. Okay, and>>So, I think we are
going to go pass this. We are going to skip
this and we are going to go to the baby with a–>>That is going
to be– here we go.>>So when I see this–
this is basically, this is Dr. Lombard’s
quote, “You are what you eat and French fries
are great example of something that’s a
high carbohydrate food. And you know when we eat a lot
of carbs, carbs get converted into sugar and you will
notice triglycerides, “glycer” sounds a
lot like glucose. So carbohydrates get
converted to triglycerides. Triglycerides are the
building block for LDL. So I want you to walk us
through a couple more slides about high triglycerides
and HDL, if you don’t mind.>>Okay so, you know there
is a lot of you know, lot of people asking questions
about, do I really need to be on a statin and there are so
much bad press about statins and they keep you know,
I have a lot of patients who have very high
doses of statins but they have had
bypasses or stents before, and the reason we put
them on high doses is because we don’t want
them see them back again. And actually, it had the statins
have made a huge difference in our practice. We used to do a lot more
angiograms and put in stents and bypasses, now unfortunately
for surgeons are going out of business, they are doing
valves and we don’t do stents as often as anymore
because of this– because of the drugs, yeah. But statins do have side effects
and my motto has always been, if you can manage your,
you know conditions through lifestyle changes,
it is a much preferable way of taking care of yourself. And yes, you are what you eat
and people either they hear and they don’t get it but
here is some surprising facts about you know cholesterols. Okay, so I gave this talk to the
nutritionists and they wanted to know how do we manage high
cholesterol, high triglycerides. And you know for people with
very, very high triglycerides and this is usually in
patients who have diabetes as anybody you know, know that people have diabetes
can have high triglycerides?>>Yes.>>Yeah, and you
know why is that? Because with the sugars that you
can’t metabolize gets converted into triglyceride which is
like a very small fat, okay. The problem with
high triglycerides is that they could lead
to pancreatitis and that is a really nasty
thing, very, very painful. So for people who are very
ill [inaudible] triglycerides regardless of cause,
we want to lower down, so you don’t get pancreatitis. So you– they put them
on very low fat diets, okay and occasionally we have
to do drugs including fibrates which are special drugs to
lower their triglycerides. And occasionally, we have to use while we lower the
triglycerides before we add another drug to lower
the total cholesterol. Okay, so here it is so you know,
you can lower your cholesterol by diet but most
people did not realize that you can increase your
HDL by diet and exercise. Did anybody know that?>>Yes.>>Good then you guys have
been to my other classes or–>>I have a question though
on your triglycerides. Is it, it should be over
the 500 milligrams–>>No it should be less
that’s it, that’s it.>>No, I mean to cause
the pancreatitis.>>The pancreatitis, there
is– usually it is very high but I have seen patients–
yeah, but I have seen patients who have– it is not that
high and so again it depends on what other context
is in there, you know– other than that, a lot
of fatty liver is lost. So causes of lower HDL, while
your triglycerides are high, sometimes that could
cause your HDL to be low. Being overweight causes
your HDL to be low. If you are inactive, you don’t
make the good you know proteins that make HDL. Diabetes, cigarette smoking, it is amazing how many people
we see who smoke cigarettes and their HDL is like half
normal and once they quit, the HDL comes back up. People who eat a lot
of carbohydrates, the carbohydrates then causes
the elevated triglycerides and their obesity, well,
that makes your HDL go down, and then certain drugs,
hopefully you know, most of the people here
won’t be on those except for beta-blockers or
anabolic steroids and proges– you know these are
usually prescribed for very specific conditions. But you know a lot of these
things you could do things about to quit smoking, lose
weight, change your diet, low carb diet, exercise. Okay, so we are strong advocates
of you know lifestyle changes. Cut your dietary fat, lose
weight, even losing 10 to 20 pounds not a lot is
going to make a big difference, make a big difference in
your cholesterol metabolism. Exercise, just think about it. From millions of years, we are
running away to preserve life because that tiger or
whatever is going to eat us if we don’t, you
know if we stop. And all of a sudden a hundred
years ago we become sedentary. We have machines, in the last
20 years you know the average persons spends like 8 hours
a day in front of a screen. It is a computer, it
is your cellphone, it is your TV whatever. I mean we were not
made for this. We were made to run, to go
to aerobics class, okay? So what other things can you do? Well, you know if you do,
if you have done all these, and your cholesterol
is still high, then you can use plant stanols. Those are like Benecol,
those you know, there are things you can get over the counter in
the grocery store. And soluble fiber,
you can just get it from patients tell me it
is cheapest in Costco. I just saw a young man today,
my goodness, Peter is not even over 50 and he had
2 stents put in. And he has a horrible
family history as well. And I put him on maximum
doses of the Lipitor. His cholesterol is still like,
you know LDL is still over 100. And we have put him on you know
tablespoon of soluble fiber and it dropped down
by 30 points.>>Wow.>>Yeah. So I mean there are
lots of things you can do, okay. And then of course very, very
low fat diet is the Ornish diet but that is really hard for
most citizens to follow.>>Okay, what is the
example of soluble fiber? I don’t know, I have
never heard that.>>Soluble [inaudible]
or you could just go and they actually sell
them in the stores–>>They are just
called soluble fiber?>>Yeah soluble fiber.>>Or you can look
for bread that is like high protein bread
that has a lot fiber. So you read the labels to
make sure you know there is when you look for the number
of carbs, maybe you are looking for something that has
less than 15 grams of carbs and maybe 11 grams
of soluble fiber. So you are really going to look
for more fiber in your cereals, you know the brands those kinds of things will help your
body clear cholesterol.>>What do you think of the
South Beach diet, Dr. Lombard?>>Well I think it’s
an excellent diet. The South Beach diet is
basically lots of fresh fruits and vegetables and low
carbohydrates and I think that you know very few preserved
foods, and it’s a great diet.>>And when you are eating a
lot of fruits and vegetables, what else are you getting?>>You are getting fiber.>>You are getting tons of fiber
and your plate is full of fruits and vegetables, there is
lesser room for those carbs– there is less room
for high fat protein.>>Alright, no French fries.>>And you know, one French
fry a year, that’s it. So, a lot of patients that I
see coming in and they say well, I just have a high– you
know I have a family history, my cholesterol is
high, I am screwed. There is nothing I can do. What do you say to
that Dr. Lombard?>>There are lots of things, I just gave you a whole
list of things you can do.>>So you can be in
control of this situation?>>Yes.>>You can do a lot of things. The point is not to give up,
not to say okay I am 30, 40, 50 or 100 pounds overweight. The key is, even if you have
a lot of weight to loose, think about losing them
in 5 pound increment. Even small changes in your
weight will change your body mass index and it will help you
lose, help you decrease the rest so can you tell us about that.>>Here you go. Anyway so, we just go backwards. This is the definition,
although I think that you know, we may have to be
politically correct and not call people
obese these days. But the data is you know,
there is no advantage to be lower than 22 or so. And actually, they
found that even people who are mildly overweight
would be fine, okay? But what happens here is that you can see it is
like– so here is 22 to 25. Okay, so what is a 22 to
25 person looking like? So I am around here, okay? And as we see, I don’t get
any benefit and probably when you start getting
really skinny, your immune system starts you
know deteriorating, et cetera. So we don’t people to be,
it is what we call J curve and it starts your risks of something else
happens goes out here. But you can see that you
know this is over 35. So these are people who
are really overweight. But you know you
just lose 10 pounds, and then you drop down by a lot. And so you lose another 10
pounds and you drop down here. And then here, this is 27 to 30,
and so these people are so kind of over weight but look
at the big difference between here and here. So my point is that even
losing 10, 20 pounds is going to make a big difference. And you know again, like
Barb says, you know it is like running a marathon. You know you can’t
look at it like, oh my gosh, I can’t do all this. It is like, make one mile then
make the next mile and you find out that you have more and
more energy and you have when you lose weight,
it gets easier. So any way, every
little bit counts.>>And tell us about exercise
because I think some people feel like well I am kind of
overweight, I don’t want to get out there and exercise,
couldn’t I have a heart attack? What do you advice?>>Good point. You know, people who
exercise very vigorously, like they sprint or whatever,
you can increase their risk of having a heart attack because
vigorous exercise causes your blood to very sticky. Just think, you know, for
like again, millions of years, while you are running because
I say there are two tigers are going to kill you. Well, if he gets a chunk of you, you want to make sure your
blood clots really well. So your body is geared
when you are under physical stress
to clot, okay? And clotting we know
causes heart attacks. So I actually tell my patients
after they have a new stent, I don’t want them to be you
know running like racing. They can jog slowly
but the benefits of exercise are immense,
just that moderate exercise. So walking, okay,
brisk walking–>>Even walking your dog.>>Walking your dog also–>>How about when you check the
mail, walking around the block–>>Absolutely.>>Looking at the
neighbors gardens.>Yes, and all that well
if you do 30 minutes of moderate exercise everyday,
it will reduce your risk of having a heart attack by about you know
50 percent, by half. It is really great. And you know and I don’t know
if you guys know this but people who have dogs also live longer
and have fewer incidence than people who have a cat. Oh, because a dog makes him
out go out and exercise.>>So walking the cat?>>Does anybody done that? I have. It’s not easy.>>So speaking of weight loss,
there is a book here called “The Alpha Plan” by a local
doctor, Dr. Mariam Manoukian. And this book is geared
to her college students and it helps them decrease their
incidence of metabolic syndrome and for them having long
terms issues of heart disease. You can also go to my blog. Nursebarb.com, I
have all section and they are called
Weight Loss 101. So I have a couple of questions for you before we take
questions from the audience. Dr. Lombard tells us a little
bit about whether people, women especially should
be on baby aspirin. What’s your thought on that?>>Well if you have– if
you had an event, okay. So if you had a heart
attack or stent or bypass, you should be on baby aspirin. For prophylaxis, the studies
are not so, so convincing but we also know that
aspirin is good for stroke. So if you are, you know, in
your 60s or whatever, older, and you are concerned about the
risk of heart attack and stroke, definitely go, you can
take a baby aspirin. There are certain
[inaudible] down side you know with the baby aspirin.>>How about fish oil–
what is you thought on that?>>So fish oil, we were all like
really gung ho on the fish oil. So people know about the
background of the fish oil. So you know for a long time, cardiologist were
puzzled about Eskimos. Eskimos eat almost
no vegetables. Try to find vegetables
in Northern Alaska. There aren’t any. They eat– they’re almost
completely carnivorous but they don’t have
coronary disease. They have other things you know
they get depressed isn’t it? You know and they got frozen but they don’t get
coronary artery disease. And so they noticed that and it was probably they thought
it was related to their diet. Well they eat tons of fish of
fish related products, right? Even the seals and
whatever, the seals eat fish so they have a lot of
omega-3 fatty acids. So for a long time we thought
well maybe fish oils will be protective but they just came
out with a huge study and showed that fish oils do not seem to
even though fish oils seems to raise the HDL
and lower the LDL and the triglyceride make our
numbers all look much prettier. It didn’t seem to make an impact
on mortality and event rate. So we are not recommending
it for prevention anymore. But, it still seen to be
helpful in prevention of stroke but that is the background why
the whole fish oil thing came through is because looking
at studies of the Eskimos. So right now, I will say,
you know it hasn’t shown to be harmful like the
vitamin E study that came out about 10 years ago. So if you take fish oil, you can
continue taking it and it seems to be helpful for
prevention of stroke.>>Okay, so now I am going
to switch gears a little bit. I want to talk to you about– we
will get to that in just a sec. I want to talk to
you a little bit about coronary artery
calcium scores or coronary calcium scores
because I think for women, after you get your
cholesterol level checked and you know what
your triglycerides are and you are having a healthy
diet and you are exercising and you are doing
everything right, but you are still wondering,
I have a normal EKG, could there still be something
wrong how do we diagnose that in women.>>So let me just reframe,
that’s a great question. And this applies to the guys and by the way guys,
thanks for coming. You can take better
care of yourself and your significant other. So, this applies
to both genders. So here is a situation that
I encounter frequently. A patient comes in and their
cholesterol is mildly elevated but they said you know my
brother got a stent put in when he was 40. What should I do? Should I go on drugs and you
know I don’t have any symptoms. My EKG is normal. And you know because
I don’t want to put a stent in
them in any year. So Coronary CT is a great way of
risk stratifying to let us know in advance is that patient
already depositing cholesterol in their arteries? So let me just show
you some pictures. So here is a cardiac CT and
I forgot somebody mentioned about hardening of the arteries. So well calcium is white and
is also very radio opaque. So X-rays don’t go through
it so it looks white, right? Just like bone.>>What is a CT?>>Computerized tomography. So it is like X-rays
by a lot of X-rays and the computer slices it up, so it presents you know
basically it is like X-rays and the computer
regenerates these pictures.>>It use nuclear–>>No it is not nuclear. This is no nuclear,
it is radiation. It is just like getting
a bunch of X-rays and the computer rebuilds it into two dimensional,
three dimensional.>>Some people used
to call it a CAT scan.>>Oh yeah, good. CAT scan. Except there
are no cats involved.>>Right.>>You can’t hurt them. Okay so here is an artery and you can see this person has
here is your artery here, okay? So, when they have and it is
not deposited, just spotty. So that’s a high– this
person has calcium. When young people, okay,
so a calcium score of zero. We are born with a
calcium score of zero and you should have no calcium in your arteries
until you get older. And as you see the red bars,
this has a high calcium score, the red and the purple bars. So as you get older, that’s
the aging process, okay? You start depositing
calcium in all the places. You get it in your eyes and
call it cataracts, right? You get in your valves and
you have aortic stenosis or valvular problems. You get it in your arteries
and you have hardening of the arteries, okay?>>And this is not from taking
your calcium supplements for your bones–>>Thank you.>>Okay?>>Yeah.>>This is not from that.>>You can take no
calcium, and you still end up in all those weird places. You know people who don’t take
calcium still get cataracts, right? Okay. So but what happens if, if
you have early atherosclerosis, you will end up, you know,
you can be 30 years old and you can have a calcium
score of a hundred, okay? And then when we see
that– that’s bad. This person, we need to
do something about it. We need to get their
cholesterol lower than normal because we want it to
leach out of the arteries. So the calcium score, oh,
I think I include that. What happened with the slide?>>So, you want to
keep advancing it, it might put your–
if you go forward, no? It might give us the phases. So you don’t want to have a lot
of calcium in your arteries.>>And this slide, I don’t know
why it didn’t show up like this. I guess sometimes it reformats
and then it does not show up. But anyway there, it shows that
the graphs are very similar. But the higher your
calcium score, the greater the risk
you are going to die from a heart attack. So, my point is that if you– if a patient is sort of that
intermediate risk group, a calcium score can be
really helpful in determining if that patient is
actually high risk, and we should intervene early and treat them very
aggressively particularly with respect to their
cholesterol.>>How do you get
that calcium score?>>How do you get
the calcium score? So unfortunately, the side
effect is a really great task, Medicare won’t pay for
it which means none of the insurance will– occasionally they
will pay for it, okay? So, basically, it’s just like
a CAT, a CAT scan or X-ray. Yeah. And– it’s not a blood,
it’s not a blood calcium. It’s an X-ray.>>What is this called?>>Why did you say it’s not
covered by the insurance?>>Why is it– I think
eventually it will, because but at right now it is not. And you know Medicare
is very, very slow and they cover some–
it depends. It depends on where
you get it done. But usually, I think we
are charging at 400 dollars and I am trying to talk
to radiology to this to get it cut down even more.>>So you are saying it is
only indicated for people who are young and
you are suspecting?>>No, for intermediate–
intermediate risk and you want to decide whether, because you
know, if you already have a– had a heart attack, I don’t
care what your calcium score is. You already declared
yourself as high risk, right? So it is– we want to
check it and like a patient who maybe a particular
group of a people who have strong family
histories, because we want to know, should we intervene
early in these people to prevent them from
having an event.>>So, go ahead.>>How did we– is
the CRP– CRP?>>CRP? CRP, so, that’s a
completely different test. That is a C-reactive protein. That is what CRP stands for and
that’s a very good question. C-reactive protein is
an inflammatory protein that your body makes whenever
you get an inflammation. And atherosclerosis is
very inflammatory, okay? This shows a lot
of other things. You get a cold and your
inflammation index goes up. You get pneumonia, it goes up. So, it is helpful but
it’s not very specific. So, CRP is helpful but–
calcium, that’s a blood test.>>Okay.>>That is a blood test.>>And so, if someone has a
high CRP, we want to look at it in context with high blood. If they have high
blood pressure, their total cholesterol,
their triglycerides, so it is something to
be looked at in addition to a lot of other tests. You don’t want to just
take any test in by itself. What other questions do
you have in the back?>>She talked about the calcium
in relation to cross over the– when you talk about
calcium, that’s too or over the cholesterol,
that calcium go on the one in our artery and the veins. Do vitamin helps you that we
intake, what’s those different– difference in between dose?>>There is actually
no molecular difference but it is just how
it is metabolized. So the calcium in your blood
does not necessarily mean it is going to go into the arteries. If you have clean arteries, you won’t get any calcium
deposits no matter how high your calcium is. But if your arteries are
chockfull of cholesterol, it will stick right there. Like a sticky fat.>>So those people
shouldn’t take calcium?>>No, no, no. The calcium– no. The calcium– if you have
normal arteries, okay? And yo have no atherosclerosis,
you can take– you can– the calcium will not
go to your arteries. It is irrelevant. If you don’t take any calcium
and your arteries are full of atherosclerosis, your
body will still manage because your bones are
constantly being built and rebuilt, right? So the calcium from the bones
will end up in the arteries. So it doesn’t matter
what you eat. It is basically how that
the cholesterol kind of sucks up the calcium. The calcium, remember,
is not the cause of the problem, it
is an indicator. You have an atherosclerotic
problem.>>So we want to be very clear
you should take your calcium for your bones but
whether you take calcium or you don’t take calcium does
not influence whether it is going to be deposited
in your arteries. So it is very different. Do you have a question?>>There was a– there
was an article though about calcium and heart disease. Maybe she’s relating
for that kind–>>I didn’t see that article. Where was that?>>It was in the
British Medical Journal.>>It’s always been yeah
talked about the, you know, too much calcium
make– that [inaudible].>>Well, too much calcium,
it’s pretty unusual to take unless you have
like kidney issues. Most of us don’t
take calcium too. Yeah. But even– cause
your supplements. Yeah.>>There was a study from
the British Medical Journal and it was published last year. And basically, they said don’t
exceed 1500 milligrams a day. So– they say, be sure you
get it from dietary sources. And if you are getting it from
dietary sources you don’t need to take 2 or 3 supplements. You have a question.>>I have a question
for Dr. Lombard. Where do you come down
on drinking a glass of wine for a day?>>So, alcohol. That’s a very good question
because there’s a lot of study showing that alcohol
maybe beneficial for your heart. And alcohol changes how your
liver metabolizes cholesterol. So then, that may be the impact. And on, you know, initially,
it was like red alcohol but it seems like the study
show doesn’t really matter what it is. But I need to tell for men,
no more than 2 glasses, okay? And in this country like
a lot of other countries, they have a lot of problem
with the alcoholism. So I certainly don’t
tell people you have to drink alcohol to benefit. Because they are,
you know, even that– it is a very small
benefit unlike exercise and losing weight. So I much rather them do that
and drinking and then yeah, if you drink a lot of alcohol,
you end up getting fat, right? But for women, it is probably
closer to one glass a day because our body
mass is smaller. So, if you enjoy drinking, then
drink one if you are a woman and you can have two
if you are a guy.>>Okay. And back there? [ Inaudible Audience Question ]>>No. So– okay. The calcium is just indicative of whether you have any
coronary disease or not. It doesn’t tell us if there
is a significant blockage. Remember the picture I
showed you with the waste? Okay. So, you may have like,
you know, very mild blockage and it still wouldn’t– you still could have
very high calcium score. The times you put a stent in are
for people who have symptoms. So if you have any symptoms? You know they’ll make the
patient feel any better, right? So we don’t usually put
in or do bypass or put in a stent unless
there are some, we can make the patient
live longer or feel better.>>So once again the
cardiac CT would be a good– test to find out just–>>What your risks are.>>What your risk
are if you pass–>>So here’s a perfect case. You know I have a patient who
is probably, when did I meet him about 10 years ago maybe,
and he is into his 40s, you know he is a [inaudible], he is very well traveled
and everything. And exercises, runs you
know half marathons, he just came back from Everest. And his cholesterol
is kind of borderline and his uncle had a
heart attack in his 50s, no other risk factors. And he says, “You
know what should I do? I mean it is just my family
is riddled with this disease.” So he did his calcium
score in hand and his calcium score was 150, not real high but
he is 40, right? So I don’t want him to have
a heart attack when he is 50, particularly if his up
Everest, there is nobody up Everest to take care of it. So any way, we did start him on
statins and we debated this back and fourth, back and fourth. And after his calcium score was
200 which is like really high for somebody who is 40. So and the thing
about the calcium, it doesn’t go away even
though you get rid off the arthrosclerosis. It just stays there, but
at least I don’t want to go from 200 to 400 and it basically
stayed right there about 200.>>We only have a couple
of minutes and we’ll stay, won’t go outside but I
like to take a question from over here in the back.>>About estrogen? Does estrogen help?>>Estrogen we used to think
it helps but there are lots of data showing that it may
not necessarily be helpful. In fact, the Hertz study that
came out 5 years ago or so show that you know may increase the
incidence of heart attacks. And may be related to the fact that estrogen makes your blood
thicker too as in you clot.>>After 15 years
of estrogen and now that if I have a high CRP test,
if CRP and all for the estrogen.>>Another question
from the back?>>Yeah.>>What is the average for
a 50 to 60 year-old woman who have calcium score,
what would be the ideal?>>Zero. Yeah and you know I
think I have my graph back there but its– so, 50,
so you know it’s a– yeah so for 57 year old person,
less than a hundred for sure.>>So estro– I will take that. If women start estrogen– this is by urinalysis from North
American Menopause Society. If woman start estrogen early
in their late 40’s, early 50’s, there seems to be a slight
benefit for the heart, however, there is an increased
risk of stroke. So but it is not a good
idea, if a woman has been without a period and
no estrogen for 5 or more years not to start it. The risks are too high for
both heart attack and stroke. But younger women, there
seems to be a little benefit of the heart but no
benefit in terms of stroke.>>But it is not strong enough that we are recommending
people to go on estrogen–>>Yeah, we do not
recommend estrogen for heart– for prevention of heart disease. So I have time for one
question, one more.>>There’s an EBT–>>EBT–>>Screening. What is EBT?>>Electron beam tomography,
so it’s like CAT scan.>>We got to get one
more good question– I mean that was a good question
but anything related to–>>Yeah I won’t show
that slide because–>>I want to let you know that
there is something called “Day of Dance” and I’m
going to be there, it’s February 25
and we can do Zumba. So we can start exercising yeah. [Inaudible] it’s warmer there. I will use some exercise,
work out some calories. I also want you to know that
there is Health Perx and many of you are already
members of Health Perx. We have a wonderful
representative from the health library here. Health Perx, if you’re not
already a member, please join. And if you join and
you use Nurse Barb as the promotion
code, it is free. Now normally this is 25 dollars. They are going to be
offering, this is a secret, like free life line screening, a lot of cardiovascular
screening coming up in the next few weeks
through Health Perx. You also get a free consultation with the nutritionist,
free, free, free. And for those of us in
the sandwich generation, dealing with elderly parents
a free elder care consultation plus lots and lots of discounts. Also there is a couple
of whole apps. There is the family
medical officer app. If you have smart phone, I
would use this seriously. One of my friend’s parents
was going into septic shock on Christmas Eve, I opened up
this family medical officer app and found out the
wait time in the ER that night was 46 minutes
so guess what I did? 911. So we got here right away.>>Why I did not know that?>>Yeah.>>I was here on Christmas Eve.>>I knew that. I knew that out.>>So I just want
to say Dr. Lombard, it has been a pleasure
talking with you. You have given us all so
much information thank you. [ Applause ] We need to [inaudible] but
I’m pretty sure because she is so committed to help and
cardiovascular help will be out in the hallway
answering questions. Thank you. [Inaudible discussions]

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