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Dr. John Reilly
February is American Heart Month, and Dr. John P. Reilly — chief of cardiology at Stony Brook Southampton Hospital, co-director of the hospital’s Cardiac Catheterization Laboratory, director of cardiology endovascular intervention at the Heart Institute at Stony Brook University Hospital, and president of Meeting House Lane Physicians Group — took a few minutes to discuss why cardiovascular disease and heart heath are important enough to dedicate a month of attention to.
Q: I’ve always been struck by the fact that, in a notable percentage of cases, a patient’s first symptom of cardiovascular disease is a fatal heart attack. And it’s a fairly sizable number, right?
That’s right. I do know that for people having their first heart attack, 50 percent of them had no idea they had heart disease before that. So, exactly right. And exactly the percentage of people who presented as fatal heart attacks is a proportion of that.
But 50 percent of the people, their first presentation, they had no idea they had heart disease before they have that heart attack. That’s the signal.
Q: And that’s the key: This is a disease that’s not only prevalent, it’s not always easy for a patient to identify it early, because the symptoms are so varied and can be kind of broad, right?
The symptoms can be varied, and they can certainly be broad. And part of the problem with plaque disease, coronary disease, is that it doesn’t grow predictably, like our beards or hair, where, you know, I’m going to shave every morning, I get to the barber every few weeks. Coronary plaque and cholesterol plaque … they’re more like small eruptions or inflammations, like when you get a pimple all of a sudden.
And so that’s why people can have no symptoms from a blockage that is moderate, 50 or 60 percent blocked, but not enough to create restriction of flow down that artery. Then, over the course of a couple of days, or even a day, you get this little eruption in the plaque, and it jumps from being a 50 or 60 percent blockage to a 70 or 80 percent blockage, or more — and that is restricting flow. And that’s why all of a sudden people start having symptoms.
Q: So what are some of the symptoms and how do they vary from men to women? Because I understand it can show up differently in men and women, right?
Right. So the classic description of heart pain, or the pain of a heart attack or angina, is a squeezing pressure or tightness in the chest. And this kind of squeezing fist maneuver that I’m making as I’m describing that, people often used to kind of say, “This feels tight here.” They may point out that it’s not actually painful, it’s more of an ache or a discomfort or an uneasy feeling there. That’s the central symptom in the classic description of angina.
Some of that tightness may come up to your throat or may move over to the left arm. People may get short of breath with it or some palpitations or sweaty with it. They all may be associated with that central squeezing or pressure.
That’s true for the majority of people, 60 to 70 percent. A quarter or a third of people don’t give that classic description — they may recognize or focus more on describing the palpitations or the shortness of breath, or only feeling it in their throat or their arm.
Some people really describe it as an indigestion or dyspepsia: a “If I could just belch and get it out, I think I would feel better,” type of thing. And women more commonly than men will give those other descriptions of the discomfort they’re having with heart pain rather than that squeezing pressure or tightness right in the middle [of the chest] that’s sort of the classic description of heart pain.
Q: What I find so interesting is that cardiovascular disease is such a prevalent problem in Americans, and yet American Heart Month is an opportunity to really sort of give attention to the problem, because I think it’s under the radar for a lot of people. What’s the big message to send when it comes to cardiovascular health? What do people need to know?
You’re right, it’s very prevalent. Heart disease, cardiovascular disease, is responsible for 40 percent of the deaths in this country. That’s more than all cancers and pulmonary diseases combined. So, it’s very prevalent.
It doesn’t mean we can’t do anything about it, and it doesn’t mean that that’s normal. And some people think, “Well, that’s just sort of part of aging.” It’s not. There are many people I have done angiograms on at 70 or 80 years or older who actually have a very normal looking heart. And so normal is normal.
I think that the American Heart Association has the “perfect seven” as the keys to a healthy life to reduce people’s risk for heart disease. And so I think being focused on that is very important.
Q: And what is the “perfect seven”?
So the “perfect seven” would be largely leading a heart healthy lifestyle, right? That means exercising regularly, five days a week, doing 20 to 30 minutes of moderate intensity activity. That just may be a modest, brisk walk every day. You don’t have to be hitting the exercise bike or climbing mountains. A 20- or 30-minute walk every day.
Eating healthy. That’s five portions of fruits and vegetables daily in your diet. In diet, low unsaturated fat. So avoiding red meat, sticking to lean cuts of protein is helpful.
And ideal blood pressure. Ideally, blood pressure should be less than 120 over 80. There was a recent JAAC article that said for every 10 millimeters of blood pressure above 90, our risk for heart attack or stroke or heart failure increases. So, in fact, people whose blood pressure is 130, just a little bit over ideal, their risk is four and a half times higher compared to people whose blood pressure is 90. So, lower is really better for our blood pressure.
Where were we … Ideal body mass, right? Being at a good, healthy weight. And it’s easy to find calculators on our phone to see what is our body mass index. That’s scaling our weight for our height and body size. So, that BMI should be less than 25, ideally.
You want to know what your cholesterol is. The lower the better. We want to avoid diabetes, or have that under control.
Smoking is a big one, right? People who smoke are at three or four times the risk of heart attack, of stroke, of having a limb amputated due to peripheral arterial disease. So, it’s really critical.
Q: And how about vaping? Is vaping different from smoking?
Not really, no. We don’t necessarily know what goes into what it is about smoking. It may be the tobacco products, but the nicotine itself is a vasomotor reactive agent. Creates, I don’t want to say spasm, but contractions and increases vasomotor tone. So, I think that vaping has its own negative pulmonary effects on the lungs itself.
I think if people use vaping as a tool to help them transition off smoking cigarettes, good. I think there’s a lot of other tools to help people stop smoking, but I don’t think that consumption of nicotine is healthy for your heart, either.
Q: Hypertension seems to be, is it fair to say, the most important factor?
Hypertension certainly is very important. Right. One in three Americans have high blood pressure. Of people who are being treated for high blood pressure, probably one in three aren’t getting to their goal blood pressure. So, it is an important factor.
Q: Maybe that’s an easy first step — that people should certainly be aware of their blood pressure. That’s something they should be monitoring at home even, right?
Yeah. I think that’s a great point, because even the people who are diligent about going to their doctor, on average they’re probably going … If they went once a month, that would be a lot, right? That’d be really often. But that’s getting your blood pressure measured 12 times out of a whole year. And is that really representative of where your blood pressure is?
So I think, yes, knowing what your blood pressure is, and if it’s high, keeping track of it. And doing that at home, there are plenty of monitors that are available on our shelves, in the pharmacies. So, they can all at least give us a good idea of where our blood pressure is. So I think that is very good. … I think checking blood pressure more frequently probably does help a lot.
Q: And cholesterol is another arm of this, right? It’s just another factor that people need to keep a close eye on and make sure their cholesterol is under control. What are the current guidelines for cholesterol?
Yeah. So I think it probably depends. So, I think lower is better, right? And I think that when we look at cholesterol numbers and compare the lab values on the paper, it often comes with a normal range. I think we should keep in mind that those normal ranges are for Americans or for Western civilization.
If we talk to our friends in less industrialized countries, where there isn’t a fast food spot, at least one on every corner, their average cholesterol is probably 50 points lower than what you’ll see in America.
For example, LDL. So there’s total cholesterol, there’s the HDL, the high density particle and the LDL, the low density particle. And the more the low density particle you have, that’s more cholesterol per particle. The more of that you have, the higher your risk.
In the United States, we would say that your risk increases when your LDL is above 100 for the general population. But for people who have had a heart attack, who have had bypass surgery, our goal is to get that LDL below 70, and sometimes even lower. And we have people who we’re driving that LDL down to 50 or 40 in order to prevent them from having bad events in the future, because that’s the group we want to be most aggressive with.
So truthfully, even though the normal range would say it’s up to 100, probably as a species, our healthy numbers that LDL’s probably more in that 50 or 70 range or lower if possible to reduce our risks.
Q: What about aspirin therapy? What’s the latest on that? Because I know that just in the last few months or so, that’s changed. If you’re just an average American, you’re not currently seeing a cardiologist, you haven’t had cardiovascular issues — should you take an aspirin a day as a precaution, or a baby aspirin?
You don’t have to take an aspirin a day just because you went to your 30th reunion for high school, or just because you hit a certain age, right? Which at some point we thought that made sense, that because heart disease was so prevalent, let’s just give everybody an aspirin. Turns out that that’s not benefiting that other half of the population or proportional population who don’t actually have heart disease. So, no.
For people who have heart disease, who have had a stent, who have had bypass surgery, you should continue taking your aspirin. Absolutely. But for other people who have not yet been demonstrated to or know that they have heart disease, we don’t recommend taking an aspirin just in case.
Q: Finally, when you talk about finding issues, the number of options for a cardiologist to address cardiovascular disease in patients has gone up exponentially in the last couple of decades, hasn’t it? I mean, that was practically a death sentence a few decades ago, but you have so many different options for dealing with cardiovascular disease now. Is that a fair statement?
I think it is. First of all, I think that the medications have done a lot of benefit. Even before that, are reminding people about heart healthy lifestyles, exercising, eating right, because those type of things are working on the whole body and helping the whole body work to prevent or control heart disease. I think the medications have made a tremendous difference.
The development of statins over the last 30 or 40 years, people who are on statin medicines have a 30 percent lower risk of having a heart attack, a 30 percent lower risk of having a stroke, compared to people who weren’t. So compared to before we had statins, that’s a huge difference.
There are other classes of medications, beta blockers and ACE inhibitors in the right groups of patients, those medications are proven to save lives and make people live longer. So I think the medications have made a big difference.
On the procedure side, what are our options for people who have heart blockages in the 60s or early 70s? If you had a heart block and the only treatment for that was open heart bypass surgery or medications, until angioplasty got invented 40, 45 years ago, that was limited somewhat, until stents were developed maybe 20 years ago. Since stents have been developed, we’ve been able to offer a lot more people a less invasive way to treat their heart disease, certainly as compared to open heart bypass surgery.
Today, we’ve been focusing a lot on coronary disease and cholesterol blockages. But today, if we’re talking about heart disease and valvular disease, aortic valve surgery, when that main valve of the heart becomes narrowed and tightened and not letting the blood flow out of the heart, that had then required open heart surgery for everybody until 10 years ago.
And now, the aortic valve can get replaced through a catheter-based procedure going up through the artery in the leg to replace that whole valve. Mick Jagger had it done two years ago. So, he was open that he had that. That was in the press. Everybody I think saw. So, it is amazing what we’re doing and what we can offer people now.
Q: But prevention is still the key.
Prevention is still the key. Let’s take care of it before you get to the point where you have to have these incredible yet still invasive procedures. Let’s prevent it and eat right, don’t smoke, exercise.
I always say that people who I’m seeing in my office who are still enjoying long walks on the beach and playing golf or tennis well into their 80s and longer are the people who’ve always been doing that through their life. And I think it’s all that exercise through their life that’s kept them healthy until 80 or 90 years old.
