The Healthy Heart Trust Podcast
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The Healthy Heart Trust Podcast
Heart Attack! (Myocardial Infarction)
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In this episode of the Healthy Heart Trust podcast, Albert dives deep into coronary heart disease with Dr. Jubin Joseph, an interventional cardiologist. We explore its two main forms: acute heart attacks, characterized by sudden, severe symptoms, and chronic stable coronary disease, which develops slowly over time. They discuss the importance of recognizing symptoms, conducting timely investigations like ECGs, and the role of treatments such as medications and procedures like angioplasty. Jubin emphasizes the need for effective risk management, as well as the evolving landscape of treatments available today. Together, they highlight the crucial need for awareness and prevention in combating this leading health issue.
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Hello and welcome to the latest episode of the Healthy Heart Trust podcast. I'm Albert Ferrari, I'm the chair of the Healthy Heart Trust. And this is episode eight, which is going to be all about Connery Heart Disease, otherwise known as ischemic heart disease, and it goes by various other names as well, as we'll explore during uh this podcast. I'm delighted to be joined by Dr. Jubin Joseph. Welcome, Jubin. Thank you, Albert, and thank you for the kind invitation to come and talk. Great to talk with you, Jubin. Um, this is actually the first time we're doing this uh transatlantically, because you are based in Los Angeles, aren't you, Jubin? Tell us a bit about who you are and what you do.
SPEAKER_01Yeah, so thank you. So, yeah, my name's Jubin Joseph. I'm an interventional cardiologist. I'm at the University of Southern California in Sunny, Los Angeles, uh, where I serve as director of the cardiometrization labs and also director of the structural heart program.
SPEAKER_00Great. So um, and we used to be colleagues some years ago, but uh you decided to make the move across the ocean. So it's great to catch up with you. Uh so let's maybe just start off uh talking about uh the the subject of this this podcast. Um and in previous episodes we've talked about risk factors, uh we talked about how to prevent heart disease. Uh but of course uh some people do go on to develop this condition. Um and maybe we could start off, Juben, by just saying a little bit about what it is um and how it might present in in people.
SPEAKER_01So coronary artery disease really presents as one of two main syndromes. We have what we people may know as the classical heart attack, which people are aware of with that crushing chest pain, the sweating patient feeling very unwell. That's an emergency. And what that typically represents is some cholesterol plast that's within a heart artery that's become unstable and resulted in a blood clot forming with that plus that has an abrupt um problem with regards to blood supply to the heart, which causes the heart to struggle for oxygen. When the heart doesn't have enough oxygen, patients often experience chest pain and the heart may struggle to pump both mechanically and also electrically. And in those situations, in these heart attack situations, we treat these patients as an emergency and rapidly assess them to see if we need to emergently open up to have locked arteries. That's one extreme end of the spectrum. The other more common spectrum is what we call chronic coronary disease or stable coronary artery disease. This is the slow buildup of cholesterol deficits within the heart arteries that happen over time. And as you mentioned on your previous podcast, this is governed by a number of refactors like high blood pressure, high cholesterol, and a family history or genetic predisposition to developing heart artery disease. This is a slower, more indelibrious um process, but essentially over time may result in significant narrowings within the heart arteries that restrict blood supply to the heart muscle. And these patients, when those narrowings become bad enough, actually experience that lack of oxygen supply to the heart when the heart needs more oxygen. So typically when patients are exerting themselves or exercising, they may notice chest pain or shortness of breath. These symptoms get typically get worse in exertion and importantly improve when the heart needs less oxygen and the patient is resting. So the the two these are the two kind of main spectrums of heart artery disease. A chronic condition where we have slow progression of disease and cholesterol deposition. And in patients that have developed some degree of cholesterol deposition or plastic deposition in the heart arteries, they are some patients who have acute presentations, flash rupture events that result in heart attacks.
SPEAKER_00No, thanks very much, Jubin. Um and people may have come across um other terms as well. They may have heard of angina, or as you would say in the USA, angina. But I'm gonna stick with angina because we're in the UK here. Uh they they may have heard of angina and they may have heard of myocardial infarctions. The myocardial infarction, I think, is essentially the same thing as a heart attack, as you just mentioned. Uh, whereas angina is the more chronic syndrome where people are getting symptoms like chest pain and shortness of breath and so on, um, due to lack of oxygen to the um the heart uh muscle. Just checking I've got that right, is that is that correct, Juben?
SPEAKER_01Yeah, so uh for sure. So from in terms of clinical syndromes, we definitely talk about angina as that classical worsened on exertion, chest discomfort that's relieved by rest. Sometimes you can use medication like nitroglycerin sublingually to improve acute episodes of angina. Then there is these chest pain syndromes that happen due to problems with the heart, um, with the blood supply to the heart that happen at rest. And that can vary from unstable angina where you have chest pain at rest, or a myocardial infarction, where you have that same chest pain at rest, but that results in damage to the heart muscle itself.
SPEAKER_00Hmm, absolutely right. And the other thing to say, I guess, Juben, is that uh people can have significant ischemia, that is to say, lack of blood supply, with no symptoms at all. And that happens sometimes as well.
SPEAKER_01Yeah, and that is certainly a concern. So what we've talked so far about the classical symptoms, and they happen, thankfully, in the majority of patients, but there are some patients in whom they have the same underlying disease process, but don't necessarily have those same chest pain symptoms. This is particularly evident in patients who have diabetes that may not experience chest pain, and we're getting increasing awareness that actually women in general don't always present with the same classical symptoms that we've described with angina. Their symptoms may more be shortness of breath, and actually the nature of their chest pain may be different to these kind of classical dull central pressure-like sensations that we classically describe.
SPEAKER_00It's interesting because um w we were all taught in, I was taught in medical school what the classical symptoms are. Um, but that's absolutely right that it's become more evident that women can very often present in a different way. Do we have any clue as to why that might be?
SPEAKER_01And I think we are understanding different parts of the pathophysiology, and I think especially with regards to the function of the small blood vessels, say the capillary at the capillary level difference between men and women. And I think this is still a kind of topic of much research to try and understand why these sex-based differences truly do uh differ and how that should maybe alter our different treatment strategies.
SPEAKER_00Okay, so uh can present in a variety of ways, a classical way, as you said, is chest pain, shortest breath, and so on. So if a if a person presents to their doctor with these symptoms, then obviously one thing to think about, particularly if they have underlying risk factors, is whether they might have coronary heart disease. Um so what would happen next? What what how how would such a patient be uh be investigated further when they present to their doctor?
SPEAKER_01Yeah, so um, like at the beginning, we talked about there being two broad different presentations, the kind of chronic stable position presentation or the acute presentation. Whenever we see, as a physician, a patient with chest pain, our first priority is to try and differentiate between those two clinical syndromes. If we think that the patient may be having unstable symptoms or a current acute blockage of one of the heart arteries, that patient needs to be quickly triaged and essentially sent to either an appropriate emergency room or direct to a cardiology service to consider emergent treatment. Part of that is the clinical assessment of the patient and involves the history taking. And the key determinant there is does the pain happen at rest or is the pain ongoing while stems? If there's a suspicion that the pain may be happening at rest, the next test really is the electrocardiogram. Now, electrocardiogram measures the different electrical signals from various aspects of the heart, and we can use that to identify patterns that suggest areas that may be getting less oxygen supply than needed, amongst other things that we can tell from the electrochardiogram. But there are definitely certain patterns on there that help us identify if a patient is having a myocardial infarction or an acute heart attack as opposed to not. And so that is another very easy um non-invasive test that helps triage the patients into those kind of settings of deciding whether you're going to be looking at treating this emergently or treating this with more elective investigations.
SPEAKER_00And just to say, by elective, we're talking about uh non-emergency, in other words, planning uh uh uh investigations and treatment which will be down the line at some point.
SPEAKER_01Yeah, completely correct. So, like more of a risk assessment performed by the physician who then triages that and suggests the appropriate outpatient investigations, if any, in order to try and risk stratify the need for kind of further intensification of medication or invasive treatment.
SPEAKER_00So, like you say, the ETG can be very informative, the sorry, the ETG being the electrocardiogram uh or EKG, that's another Americanism, isn't it? Um but whatever it is, the electrical recording um will give information about whether there is or isn't lack of blood supply and will give information as to where it is as well. Probably important also to say, isn't it, that if somebody presents with chest pain but don't have pain at that point. The ECG may be normal even in the presence of coronary heart disease. But on the other hand, if the ECG is abnormal, then that's that's a very good uh indicator that something's wrong.
SPEAKER_01No, completely. A normal ECG does not exclude coronary artery disease, but we're only doing it in that initial setting to under to differentiate between the heart attack or not the heart attack. But even with an even with a completely normal ECG, um there still may be underlying black deposition in the heart arteries that still may be causing symptoms that require further treatment and investigation.
SPEAKER_00Okay. So um as you mentioned, Jubin, um sometimes the ECG might be normal. Um so a positive ECG can be very uh useful. But uh there are are there any other tests that can be done uh to say if somebody's having um a heart attack, destruction of heart muscle, an acute heart problem? Are there any other tests that are uh are available?
SPEAKER_01Yeah, um that's a really good point. So I guess in patients in whom we are worried that they are having a heart attack and the ECG doesn't show this STEMI syndrome or this complete heart artery blockage, we can then use a very specific blood test that identifies if there's evidence of heart muscle damage. It's typically something called a troponin, but again, over the last few decades, we've had multiple different blood tests trying to detect heart muscle damage, and we'll have multiple different ones in the years to come as people try to get this done as accurately as possible. Now, the troponin is a part of the heart muscle cell itself, and when that heart muscle cell is damaged, that leaks into the bloodstream. So by measuring this biomarker in the blood, it's a very good way for doctors to quickly differentiate if a patient is having chest pain with a heart attack or chest pain that doesn't involve a heart attack. And by that I mean chest pain that isn't at this moment in time causing destruction of the heart muscle. That being said, there is that is just one element of a multitude of different factors that we'll take into our consideration with regards to deciding on a treatment regime. A patient who has symptoms that are unstable with an abnormal ECG and a normal troponin still may require urgent in patient assessment. But definitely an abnormal troponin, an abnormal biomarker suggesting that there's heart muscle damage definitely increases the risk of this patient truly having a heart attack and needing more urgent treatment in a hospital setting.
SPEAKER_00So a a blockage of one of the arteries, uh myocardial infarction. Um You said that the the next step is really emergency treatment um in a in a cardiology center um or in a uh equivalent. Um what would happen then?
SPEAKER_01So there are broadly two different types of heart attacks, and we can differentiate those based on the electrocardiogram ECG. If the ECG suggests that there is a complete blockage of one of the heart arteries, that is typically an emergency. And in these situations, we have created networks of healthcare delivery that rapidly identify these patients and essentially take them directly to the cardiology service that will be able to open up that block out artery. These patients typically avoid interactions with the emergency room or um other kind of physicians, and kind of because we know that this is a time-critical uh problem, they go directly to see an interventional cardiologist with a team that's set up to open up the heart artery in a quick manner if that's needed. That's for a technical term is called a STEMI or ST elevation, myocardial infarction. Um amongst various terms, the nomenclature is constantly changing. Um but I think that's a kind of very accepted term for it. Um and in those set in those settings when when those that pattern is identified on the ECG, there really is an urgency to open up what we think is a blocked heart artery as soon as possible. In other patients who are having myocardial infarctions whose ECG does not show the signs of a complete heart artery blockage, the management is urgent but not emergent. So typically those patients go directly to either an emergency room or directly to a cardiology service where they can be assessed further and triaged further. There are, although we are talking exclusively right now about myocardial infarctions, heart attacks, and coronary artery disease, there are lots of other topologies, lots of other disease states that cause chest pain with abnormal ECGs. And so that in what and if if those symptoms are happening at rest and the ECG is concerning, these are symptoms that need to be evaluated urgently within the hospital.
SPEAKER_00Important to say that the uh emergency treatment that you talked about is available 24-7, isn't it? So basically, it is standard procedure now for patients to undergo this, whatever the time of day or night. Um and and that that's fairly standard now, isn't it?
SPEAKER_01Yeah, I mean, thankfully for patients and disastrously for the sleep health of interventional cardiologists, this is a very important thing to be done 24-7. So at any at any point, wherever you are, um if you develop chest pain that is worrying and an ECG suggests that there is a full occlusion of one of the heart arteries, you will be taken emergently to the cardiocatrization lab. Um, and the team will be there to open up your heart arteries 24-7, 365 days a year. And what we have demonstrated over the last 20 years is that if we can do this quickly and safely, we will both reduce the chance of patients dying from heart attacks and also significantly reduce their long-term morbidity or the long-term health implications patients face after heart attacks. So, although it's a big um organizational effort to have these networks running, the improvement in patient outcomes is definitely proven worthwhile.
SPEAKER_00So it's a very important point, isn't it, that the earlier this is done, um, the better the outcome. Uh because the the longer that that artery is blocked, the more heart muscle dies. So the sooner you can get it open, the better. And just to say a word about um again, just talking about the technical terms here, people may have heard of angioplasty, they may have heard about stent, they may even have heard about PCI, percutaneous cornery intervention. Um so uh perhaps just to sort of say a word or two about um what what happens when when the patient is in the cath lab and and the cardiologist is with them doing the test.
SPEAKER_01Yeah. So yeah, so now we're into the realm of the interventional cardiologist. And an interventional cardiologist essentially uses wires and catheters to diagnose and treat heart disease. When we're talking about heart artery disease or coronary artery disease, the aim of the interventional cardiologist is to diagnose the problem initially. So that involves taking pictures of the heart arteries using dye. We go via the artery in either the wrist or the top of the leg, and we feed a small tube from that artery access point to the heart arteries, which happen, which emerge just um at the beginning of the aorta, which is the main blood vessel in the body. Once we have that tube appropriately placed, we use dye and x-rays to take pictures of the heart arteries, and that gives us very useful diagnostic information. It tells us about the nature of an individual's heart arteries, and that they're essentially like thumbprints. Each patient's anatomy is different from the other, but they all follow a similar pattern in general. Not only can we see what the patient's initial anatomy was, we can see if there are any narrowings or blockages caused by plaque in the blood vessel. even blood clots. So that's the diagnosis part. It tells us the nature and extent of the disease. But the important thing is it then tells us how to manage it. Management of heart artery disease is always is one of three things. Either it is medical therapy alone, which just means that you don't need any procedure to open up a blocked heart artery and the blood supply as it is is fine. Or the other two treatment options include improving the blood supply to the heart. And that's done either through a percutaneous minimally invasive approach with the terms that you mentioned before and your plastic stense percutaneous coronary intervention. Or open heart surgery with coronary artery bypass surgery in which is a slightly it is a more involved ordeal but involves putting on new blood vessels from the main blood vessel, the aorta, to the diseased heart arteries to bypass them. Just to talk quickly about percutaneous coronary intervention because that is by far and away the most common treatment strategy for patients who have angina or heart attacks. That is done by the same approach with the minimally invasive procedure from either the wrist or the artery at the top of the groin to take pictures of the heart arteries and then use a similar tube to place wires down past any narrowings within the heart arteries and along that wire track balloons to perform angioplasty which is the stretching open of blood vessels typically with a balloon and if need be to perform a stent implantation and all of those terms together those those procedures in which we are modifying disease and facing stents that's called together percutaneous coronary intervention.
SPEAKER_00Great thank you very much. And you mentioned open heart surgery um I think it's true to say that the interventional approach with PCI um has has come on leaps and bounds over the years. I remember it wasn't really a thing when I was a young doctor but it's very much more common now and is it true to say that the surgeons have much less to do these days than than they did in the old days?
SPEAKER_01I think more and more as the procedural safety and long-term outcomes with PCI have improved, there has been less than need to expose the patient to the initial risk of coronary artery bypass surgery. That being said there's a number of anatomies and there's a number of patient factors in whom we know that coronary artery bypass grafting, open heart surgery is the best option for a long-term durable result for patients. So although there has definitely been an increase in the proportion of patients that we treat with stents, there's still a clear indication and role for bypass surgery that I think is going to be required in the long term.
SPEAKER_00Okay. So we talked a lot about the emergency treatment of STEMI heart attacks. And then you also mentioned that there will be the non-STEMIs or the acute syndromes where people don't necessarily need urgent or immediate intervention. They may need less immediate, more elective intervention. And then there's also those patients who just have the chronic syndrome the chronic angina they're not presenting acutely and so on. What about for them? I mean is PCI still something that's useful for them and you mentioned medical therapy as well. What's the place of medical therapy versus PCI in in somebody presenting with the more chronic types of um chronic coronary syndrome?
SPEAKER_01So I think once we've established that a patient has signs and symptoms of angina or um coronary artery disease then we medical therapy is essential. And that medical therapy is essential even with or without stents and that there's really the cornerstone of preventing disease progression. And I'm sure we've talked about this in previous podcasts that it's really about blood pressure control and cholesterol control and different lifestyle managements to try and encourage a heart healthy lifestyle. That being said there are some patients that despite have heart artery narrowings as a result of these block depositions and they result in symptoms of angina. That angina symptom essentially demonstrate a mismatch between oxygen demand of the heart and oxygen supply through a blocked vessel and those mismatches become more evident when the heart needs more oxygen typically when people are exerting themselves there are medications that help redress that balance and there's a lot of anti-anginal medication which is the first line treatment of to address the symptoms of angina that may actually totally alleviate um the symptoms associated with these heart artery narrowings and obviously that will provide great benefit to the patient. In patients who have symptoms of angina despite anti-anginal therapy there's a clear role for stents to improve patient symptoms and to improve the blood supply to these narrow cart arteries and reduce the amount of angina that patients experience. That being said the stent is just abandoning and the cornerstone to long-term management is the medical therapy we've talked about.
SPEAKER_00So that's an important point that optimizing risk factors treating the blood pressure treating the cholesterol all of that is really important. And I guess a lot of patients will ask okay well I'm on the medication my symptoms are much better now but I've still got this narrowing should I still have a stent inserted even though the medication is working what would you say to that sort of patient?
SPEAKER_01So that is very much a case by case discussion and depends a lot on the anatomy of a patient's individual heart arteries and the risk benefit to treating anything. Typically in patients who have non-high risk um patterns of heart artery disease in the absence of angina the real treatment is medication medical therapy to control risk factors and hopefully prevent progression. There are certain patterns of heart artery disease that we call prognostic disease which involve more proximal aspects of the heart arteries or indeed multiple vessels in whom we know that in the we have demonstrated in the past that patients do better with heart artery bypass as opposed to medical therapy. And so in these patients with high risk anatomy it might be that even in the absence of symptoms we would recommend debascularization with a procedure be it be it coronary artery bypass grafting or sometimes stem procedures.
SPEAKER_00So it sounds like it very much depends on what the arteries are looking like so even in the absence of symptoms it may be useful to have an angiogram to look at the what what the arteries look like in order to decide whether further intervention is possible.
SPEAKER_01Completely and I think over the last 10 years we've had real advances in non-invasive and anatomical evaluations. And so we don't always have to do the invasive angiogram to understand anatomy exactly or even rule out what we call as this high risk pattern. CT coronary angiography is now really the cornerstone of non-invasive investigations for patients with anginal like chest pain. And that can really help differentiate patients from having heart artery disease or not and also from identifying if the heart artery disease is occurring in a part of the heart arteries that we think are very high risk or prognostic.
SPEAKER_00So maybe just to sum up and conclude Jubin um we've talked a lot about different types of coronary syndromes. We've talked about chronic coronary syndrome or angina we've talked about STEMI we've talked about non-STEMI and I think it's fair to say that actually the what can be done now is is has hugely come on over the decades. I remember when I was a young doctor um BCI was still in its infancy you know and uh now it's there's so much more that's that's that's uh possible. We made the point I think that um treating uh early especially in the acute setting is really important. I think we've also talked about uh recognizing the symptoms early so that they can be investigated. And I think uh what we've also said is that managing the risk factors is integral to all of this. You can do all the stuff that you do in in the CAF lab and so on. But actually even after that it's really important to make sure that the risk factors are really well controlled. I think that's that's most of trying to capture the essence of what we've talked about over the last half hour or so. Anything else you wanted to add at this point?
SPEAKER_01No, I think you've really summarized what we've talked about very succinctly. And I think to from your point with regards to a historical perspective we've honestly come on leaps and bounds of our management of path artery disease over the last few decades. This used to be a condition where the treatment was to give a patient some morphine and some aspirin and to touch them in bed on bed rest. And we now have multiple ways to treat and have identified multiple ways to prevent this disease. Despite that schemic heart disease still remains the number one killer in the Western world and like we still kind of owe it to our patients to work hard on identifying risk factors really pushing for appropriate prevention and then having these systems and notebooks in place that when we identify that there is a problem we're rapidly able to treat it.
SPEAKER_00I think that's a really good place to end Juben and I think what you've said really uh supports the the race on detro the reason that we have the healthy heart trust and these podcasts so Juben thank you ever so much for joining me today it's been a fascinating discussion uh and uh yeah thank you very much thank you very much Albert it's been a pleasure to see the same
