Drs. Mehta, Suhar and Uddin answer questions from course participants.
So doctor. So hard question for you regarding the threshold for the amount. Um, and or distance for exercise training? You mentioned some of the risks related to potentially extreme athletes, but what about patients who, you know, say, hey, I'm going to train for a half marathon marathon. Is there a distance where you think there it becomes more dangerous? I mean, ultra marathons or a thing now, extreme distance triathlons, what do you tell patients when they start trying to really crank up the distance? Yeah, Thanks for that question again. Um, the data is not really looked at specific distances, but what we know is they did look at, you know, triathlon, full triathlons, half triathlons, marathons, half marathons and the half marathons and half triathlons. Their incidence of sudden cardiac death was about half of the full events, so less seemed to really significantly decrease that risk. And again, the overall risk is still rare as long as you appropriately plan for that. So is there a magic number? No, but as soon as the patient starts mentioning the word marathon, even half marathon, If they start talking about longer distances where I start reaching that point where I'm like, oh, that's more intense form of exercise. That really is the trigger for me to counsel about proper training. I really question them on their approach and and remind them of some of the risks that are associated with those events. Thank you. Um, I'm gonna ask you another question here that came in, um, exercise regiments, post PC. I or post cabbage. A lot of patients say, hey, you know, Uh, not to get my heart rate of 130 days. Is that evidence based? Is that what you recommend following a revascularization of coronary arteries? Yeah, I'm gonna just clarify the question cause you glimpsed for a second. So I'm sorry. Yeah, let me see. I the question is Sorry, excuse me. The question just to rephrase the question is recommendations on exercise. Post per cutaneous intervention or post bypass surgery. So post coronary revascularization is their data to say you should not get your heart rate above 100 beats per minute for the 1st 30 days. A lot of patients have been advised accordingly. Yes, I've been running our cardiac rehab program here at scripts for about the past 10 years or so. Our standard of care has been to limit the heart rate immediately following piece uh in my Pc. I. Or cabbage. Uh I think that's an industry standard. As far as the data, I'm not really, I don't know uh tons of data that really would justify a certain number, but kind of, the industry standard has been around 100 beats a minute or under um for about that first month, once you get past that month is when we start loosening that up. The safest approach for these patients is cardiac rehab. And it really should be pushed. Unfortunately, participation in rehab nationally, the numbers are still very low. Um you know, maybe it's a little hard higher to start, but then completing cardiac rehab, very poor completion rates. And there needs to be a bigger effort to get our patients through cardiac rehab because that's that's going to guide our patients the safest way. But in that first month, yeah, I definitely recommend limiting the amount of exertion. Yeah. Perfect. Thank you. Yeah. And some data for mortality, cardiac rehab, post coronary of actualization with surgery anyway, so I think that's a great point. Um, dr Dean and a couple questions for you um first is regarding hormone replacement therapy. Um a lot of patients come in. They really want to be on this therapy if that's the case. They really want. This therapy is their data regarding bioidentical hormone replacement therapy. What's the data? How do you how do you uh council these patients and you're in your practice? You know, that's a really great question actually. See that quite a bit, probably at least once or twice a week. Um And so um so what I tell people, so fortunately, um the first thing I tell them is as a cardiologist, I'm not comfortable prescribing hormone replacement therapy, so so I don't actually prescribe it. I tell them either to get it from their primary or the O. B. G. Y. N. Or whatever. However, what I do tell them is what we currently know, which is if you are a low risk individual. So the first question is why do you want the hormone replacement therapy? So, if they're saying I have terrible menopause symptoms or low libido or you know, whatever, I'm having hot flashes. So, so at first I tell them it's really only for symptom management. We don't have any data that shows that it's going to make you live longer or prevent a heart attack. So, so if it's purely for symptoms, we think it's safe in low risk individuals for up to five years. So I tell them, don't just go on it and stay on indefinitely, but check in with whoever is prescribing it. And once you hit that five year mark, really reassessed, can we start to peel back? Are you still having those symptoms and buy low risk? I mean, someone who hasn't had a known thrombosis or blood clot or DVT known stroke or known history of breast or endometrial cancer. So if they meet that criteria where they're like, I just feel terrible and I want to use it for symptoms. They don't have any of those risk factors. I say that's fine, but don't do it indefinitely. And that usually is fairly satisfying. We don't, we we don't have data to say that, you know, this brand or this particular hormone is better than that brand. We just know that there is a big difference between hormone replacement therapy and exogenous hormones versus having, you know, having your own estrogen or something like that. Now, interestingly, there's a little bit of data lately that the hormonal fluctuations during menopause can increase the risk of arrhythmia. So, people with a known history of super ventricular tachycardia or terrible pVcs, not a fib necessarily, but super ventricular tachycardia sometimes do worse during menopause. And so sometimes, um, adding a little progesterone in that situation can help with those arrhythmia symptoms. But again, the lowest people, not indefinitely just to get them through that transition is actually something that can be tried at times. Okay, thank you so much. If you have a chance, I want to ask you one more question that came through from the audience. Um, is the cardiovascular risk from breast cancer only applicable to patients that had chemo and or XRT or is it also related inside two? Or mastectomy? Only cases. That's a good question. It kind of piggy backs onto the previous. So we don't necessarily have data that shows that just because a woman had breast cancer, they're at increased risk for heart attack and stroke. So that data doesn't necessarily exist. I suppose the concern would be, do you have any recurrent breast cancer that maybe you don't know about? Um, which would make them technically a little more pro thrombosis stick or something like that. So the risk in that regard would simply come into the hormone replacement therapy aspect of it. Um in terms of maybe the hormone replacement therapy could cause problems with their history of breast cancer, but not in a cardiovascular standpoint. But what we do know is that um women who have had radiation do have increased inflammation and coronary calcification, plaque deposition. So the radiation itself can can increase plaque burden down the road. So those people sometimes I would get a calcium score on or something like that or a cardiac ct and then sometimes they don't know but certain, you know, like an three cyclones or chemotherapy agents increased significantly the risk of cardiomyopathy down the road. So, so um oftentimes I'll at least get a baseline eco um even if it's been several years. So for the chemo, I look for cardiomyopathy is with radiation. I look for coronary calcification and then the breast cancer itself. It's more having to do with the hormone replacement therapy aspect of it as far as the downstream risk. Perfect. Thank you so much. Doctor meta. You gave an outstanding comprehensive talk. Thank you again. You generated a lot of questions. One question was basically, how much protein do you recommend patients try to consume per day? Um And I'm gonna add on specifically. What variety of that. If you recommend this particular quantity? What's the source? Is it animal based, plant based poultry fish? It sounds like you like fish. Can you tell us how you counsel patients? So if you look at the kind of US kind of dietary recommendations for protein intake, it's roughly around for men. It ends up being about like 0.8 g per kilogram, which ends up being about like you know, 50 to 60 g for men and about 40 to 50 from him. And I actually read concert like patients and probably a bit higher protein intake and focusing on you know, good sources like you know, nuts, fish and actually mostly plant based sources of protein. If you have to choose, there's data that plant based sources of protein have lower cardiovascular risk and people patients with very very high amounts of animal sources, you know, particularly the non fish ones. Okay, Another question is is there an optimal range or value for hemoglobin? A one C for overall cardiovascular health? It's actually a pretty interesting questions. So we actually looked at a lot of the data is looking at diabetes management. You know from an A one C standpoint, I think some of you might correct me if I'm wrong. But the more intensive, especially if you drove a one C below seven towards low six range actually was like higher cardiovascular mortality with really really hyper aggressive for the diabetic patients being really hyper aggressive in terms of cardiovascular outcomes in terms of being really aggressive with their diabetes management. Yeah, that's great. And we can see if dr Einhorn has more to add when he gets his talk in a few minutes. Um one of the diabetic specialists um wanted to uh also another, you know, kind of ketogenic diet. One of the fad diets we clear read a lot about right in patients. There's some data in the literature regarding protection and a pediatric cohort of patients from an epilepsy perspective, there's some data there. Um But what if you're dealing with a 70 year old patient with complex coronary, vast coronary heart disease? And I tell you I want on the keto diet, What do you say? Do you, are you happy or you you uh ashamed them? What is that your approach? It kind of depends on what their approach is going to be. No, I have some people who who have that kind of same history and our energy mosquito giant, but they do it right. You know, they pick their still eating non starchy, high amounts of plant material, getting still getting nuts and seeds and they're still eating good protein sources and trying to have plant based protein sources. And I think that's actually if you look at it that actually still fits in line with the mediterranean or a plant based or that type of eating pattern. Um I think it's the people who come in saying I'm gonna do a ketogenic diet and 20 like bacon and lard and that kind of stuff and butter all day. Um Those people, I really have to be a little bit more firm, that's actually not going to be helpful for you. So in picking your kind of counseling your patient and you you've got to say I got to talk to you about your diet. Let me address your diet on this initial visit with you, you have underlying coronary disease. What is the what is your preferred approach? Do you think enough data to say you must become vegan, you must become mediterranean, you must become plant based. What kind of what is the dietary pattern that you generally like to advise patients? And so usually a lot of it's actually gonna be depending on what they're like kind of baseline, you know, ethnic background. It's really hard if you were to have someone who is from the Middle East or south indian to say you're going to do a mediterranean diet, you know? But I think you know I focus more on plant based, I think all of these diets mediterranean dash you can mediterranee, they're all very very plant based and minimally processed. And that's kind of the framework that I use, you know, starting with the goal is to be very plant based, minimally processed nuts and seeds, high dietary fiber, you know good amounts of lean protein sources and or plant based sources of protein. Um They're just minimizing you know, all the all the refined stuff that most people eat, right? That seems to be what the guidelines are recommending. Um I think with that I'm gonna wrap up this Q and a session with I think you've answered the audience queries and um really appreciate all of you participating and getting great talks. Yeah, thank you.