Ep. 39: What’s New In Cardiology? with Dr. Beth Abramson
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Heart disease remains the second highest cause of death of Canadians, behind cancer. About 63,000 Canadians have heart attacks every year. Dr. Beth Abramson is a Toronto cardiologist and the head of cardiac prevention and rehabilitation at St. Michael’s Hospital. She argues that recent advances in cardiology are changing the way we understand life after heart attacks. Statins, pills of concentrated fish oil and COVID’s effect on the heart round out her conversation with our guest host, Dr. Peter Nord, chief medical director of Medcan.
LINKS AND HIGHLIGHTS:
The app Dr. Beth Abramson helped to develop is called My HeartPath. Here’s the news release about it. Download it at the Apple App Store or Google Apps.
The book Dr. Beth Abramson wrote is called Heart Health for Canadians.
Dr. Abramson spoke of four medical therapies that are extending lifespans for people who have had heart attacks. Those are:
new injectable drugs, like PCSK9 inhibitors, which change the way the body recycles cholesterol
new low-dose blood thinners
diabetes pills for heart disease patients, such as empagliflozin and liraglutide. Here is a release detailing one Health Canada announcement
the drug, icosapent ethyl, trade name Vascepa, a super-concentrated form of fish oil that reduces the risk of heart attack
Eat Move Think S01E39 - What’s New in Cardiology (w/ Dr. Beth Abramson) final web transcript
Christopher Shulgan: Christopher Shulgan here, executive producer of Eat Move Think. Our guest today is Dr. Beth Abramson, the Toronto cardiologist who is the director of the Cardiac Prevention and Rehabilitation Centre, and Women’s Cardiovascular Health, at St. Michael’s Hospital.
Christopher Shulgan: Heart disease remains the second highest cause of death of Canadians, behind cancer. About 63,000 Canadians have heart attacks every year. But Dr. Abramson argues that recent advances in cardiology are changing the way we understand heart attacks. In fact, with the right mix of medications, someone who has had a heart attack can have a similar life expectancy to someone who hasn’t.
Christopher Shulgan: She also talks in this episode about the latest evidence on how COVID-19 affects the heart. She provides the latest guidance on statins. And she talks about a new medication based on an extremely concentrated dose of fish oil.
Christopher Shulgan: In this episode of Eat Move Think, Dr. Abramson is interviewed by our guest host, Dr. Peter Nord, the chief medical director of Medcan. Here’s their conversation.
Peter Nord: Welcome, everybody. It's great to welcome today Dr. Beth Abramson. Beth, great to have you here. And, you know, one of the things that I respected about you for a number of years is your leadership in the field of cardiology. Way back in med school, I was going to be a pediatric cardiologist. And so I've loved cardiology for so many years, and chose a different path, but you chose cardiology. What was it about cardiology that really piqued your interest?
Beth Abramson: Well, to be honest, Peter, the only thing I wasn't going to be do was be a heart doctor like my dad. So I come through a long generation of cardiologists, and I wanted to be my own person. But I actually fell in love with it. I remember as a trainee, as an intern, years ago, before technology had changed, we were taking care of patients with heart attacks in the middle the night by giving them clot-busting medications. And we really had to watch those patients carefully. I just remember sitting there and caring for patients and saying, "Wow, we can make a difference. This is—this is exciting." And it captured my captured my enthusiasm. And a lot of what we do in medicine is for the quality of life, which is so important, and quantity of life. And I think in cardiology, we can improve both. And so that's my passion.
Peter Nord: Well, that's great. And certainly a lot of changes. I know when I was starting, it was very much low tech, especially in cardiology. You're diagnosing with a stethoscope, and so so much of that now has transitioned to high technology as well. What are some of the high points in your career as you've seen it develop?
Beth Abramson: We've seen the evolution of the ability to take technology and make it work for us. So in cardiology, we know from a treatment perspective when someone has a heart attack, there's a clot that has formed in a narrowing. And we can open up that narrowing clot by taking people to the heart catheterization lab and opening up that artery with what we call a balloon angioplasty and putting a strut or stent in. We have amazing technologies now for treating. We also have good evidence for prevention. And, you know, I hate to say this, but we're in such a high-tech world, my goal upon reflection over the last two decades is to embrace the technology, but make sure we don't throw out the baby with the bathwater, because the low-tech interventions with lifestyle are still so important. Because preventing that heart attack in the first place is a critical, critical piece of cardiology and preventive cardiology. So we've made such strides with technology, but I think it's important that we embrace the low tech as well.
Peter Nord: I think you wrote a book recently, Heart Health for Canadians, and you've even developed an app. Maybe speak to that just for a second. And how does the book and how does the app kind of get to that same idea of low-tech prevention, including the high-tech sort of treatments that we've been able to develop recently?
Beth Abramson: Yeah. So with this shameless self promotion, I did write a book supported by the Heart and Stroke Foundation. If someone buys it, I get one penny. So it was a labour of love. That's my disclaimer. And the first half of the book is how we can prevent heart disease with lifestyle interventions, what our tests mean, going through the system, what this means. And the second half of the book is really geared to patients living with heart disease. What does this mean for me? What other tests or treatments are available for me? Those sorts of questions are really important. So the book still holds true, and there's chapters on healthy eating and helping people quit smoking and being active. And what risk factors for heart disease are: high blood pressure, hypertension, treating diabetes, cholesterol, those sorts of things. And the second half really does talk about treatments, because we have a lot of good treatments that are, as we say, evidence-based in cardiology, and we can prolong lives. And the goal is to prevent the heart attack in the first place.
Beth Abramson: But if someone comes in with a heart attack a woman or man, in my practice, I want to make sure that their life expectancy is as good as yours or mine. Because people who have a heart attack have ongoing increased risk, and we want to lower that risk. So the concept of risk reduction is so important in cardiology. The app that I helped develop in the last while is to help people who have had a heart attack navigate the system. It's My HeartPath— H-E-A-R-T-P-A-T-H, all one word, app. And it's asking people to talk about their issues and make choices and ask the right questions. And I think in an electronic world, knowing where to go and navigate the system is important. So this does not replace cardiac rehab programs, but helps people go on a path so that they can get the help they need.
Peter Nord: That's great. Certainly, we can make those links available to everybody. The coronavirus this year obviously has had an effect on all of our careers. And how has it affected your practice from a cardiology standpoint?
Beth Abramson: Well, you know, it is interesting from a patient interaction perspective, we've been forced to think in a very smart and efficient way very quickly about how we can provide the best care at a distance. And so, you know, many of the patients I see who come in with risk problems or chest pain problems in an ambulatory or office setting are now being seen virtually. In fact, you know, at Medcan we have the ability to use holter monitors or ECG monitors of the heart where we ship off the monitor to a patient's home, and it comes back and I get the data with the patient not having even to come into clinic to see me directly. So it's impacted the way we practice ambulatory care.
Beth Abramson: But I think importantly, COVID has had an impact in cardiology, that has been, in some ways, quite concerning and negative, because people are avoiding getting the care they need in what we say the acute care setting. So if you have symptoms of a heart attack, it's not always the Hollywood heart attack, but often the elephant on the chest or you're short of breath or sweaty, something is wrong in the middle of the night, you need to seek medical attention right away. And time is heart muscle in cardiology. And what we're seeing in Canada to some degree, and certainly south of the border and internationally, is that people are avoiding going to the emergency rooms when they really need to. Now you don't need to go to the emergency room if you think you have a mild headache or you're just not feeling well, but if you're having an elephant on your chest and something is wrong, especially if you're at midlife or have some risk for heart disease, you need to get this checked out to make sure this isn't a heart attack. And if it is a heart attack, get the care you need right away. We are seeing a delay in care during COVID. We are seeing patients come to the hospital later than they should. And that's a concern. And in the last, dare I say it's eight months now that we've been living in this pandemic, on the various times I've been on call for cardiology we are seeing patients present or come to hospital sicker and later than they should. And if I can get a message out to everyone there, if someone is very unwell hospital emergency rooms are safe.
Peter Nord: Yeah, that's a great takeaway message. Certainly, the COVID has affected, again, everybody in in different ways. And from a cardiology perspective, there's been a number of recent reports of heart abnormalities that have persisted in people who have recovered from COVID. What's your take on this?
Beth Abramson: Yeah, so it's very interesting. The answer is we don't know, and I'll explain a little bit of the data in a minute. But we don't know what the future brings. There is no doubt that when patients and people are infected with the coronavirus, it doesn't just affect the lungs. And we are seeing heart muscle damage. So we see an inflammation of the heart muscle, and there have been various studies with sophisticated modern testing like MRIs of the heart, showing that even after an infection, people are left with signs of inflammation in the heart. What that means in the long run is not entirely clear, but it is entirely a concern. So if you or I catch a cold, usually we get better. People died in the flu pandemic many, many, many years ago—not coronavirus pandemic—from heart muscle problems. And so to have an inflammation of the heart or myocarditis is a concern. There are several studies out there that suggest if you end up having heart muscle problems during an episode of coronavirus, you are much more likely to be very sick or even potentially die.
Beth Abramson: But what it means for people who recover, who are left with some—I would use the term almost microscopic heart muscle damage, because our technology is so good that with MRIs, we pick up information that we might not pick up with other modern tests or you know to your stethoscope or just a cardiogram where we get a good sense of heart muscle function. But this is really fine-tuned heart muscle function that we're seeing damaged initially with coronavirus. What the long term implications of that really aren't known, and it is a concern that I think we'll be living with coronavirus effect on the heart. There's concerns for the lungs. I'm not a respirologist, but as a cardiologist in the long run, and that remains to be seen.
Peter Nord: Lots of good studies ongoing right now, and the results will be coming in over the next number of years. And so certainly our recommendations based on the knowledge that we have will definitely change over time. What about the whole ACE inhibitor receptor? That's one of the knowledge improvements that I think we've had over the last eight months that, you know, initially we thought coronavirus was purely a respiratory condition, and now we're recognizing that it's highly vascular.
Beth Abramson: Yeah. So for the audience that isn't as trained as you and I, what we're talking about is that blood vessels are organs. They're sophisticated parts of the body. And there are all sorts of receptors on our blood vessels that interplay with other parts of the body. And we know in cardiology, there are a class of drugs that help protect the blood vessels if you've had a heart attack. And as Peter has mentioned, these ACE inhibitor drugs, which are drugs we use for high blood pressure, hypertension, and we use for preventing a future heart attack in cardiology, were felt to be somehow be implicated in terms of how the coronavirus attacks the body.
Beth Abramson: And at the beginning of the pandemic, there was a concern that if you were on these types of drugs for other reasons, because they're very important drugs we use in cardiology, there may be harm to be had. What we now know—and there's good evidence—is that if you were a patient, either living with heart disease on an ACE inhibitor drug, or have high blood pressure or hypertension, on a class of drugs called ACE inhibitors, it is actually safe to stay on these drugs. There's no additional harm to yourself should you contact coronavirus, and it's actually more harmful to stop these medications. These drugs that affect the blood vessels, as coronavirus can affect the blood vessels, are not ones that we should stop, should people get sick or during a pandemic.
Peter Nord: Just in terms of younger, healthier people that might be quite active, does the potential for this lingering, myocarditis or this inflammation of the muscle tissue, is that creating problems or risk for young athletes?
Beth Abramson: That's a great question. We don't know yet, because the initial studies, as you said the MRI studies show there's ongoing inflammation. Now if a high performance athlete has one percent of their heart muscle function change and they are at a better starting point than most of the population, will that make a big difference? I'm not sure, you know, if we're out and we're fit. If you were actually training for the Olympics, it might. Again, we don't know. I am hoping, it is my hope it is not a medical piece of knowledge I have, that the situation we are seeing with the data showing some effects on the heart with a coronavirus will be relatively small in the population. And it may be those patients who are—and people who are not patients who are used to being high-performance athletes that may actually feel it, feel the differences. So it remains to be seen.
Peter Nord: You mentioned a little earlier about the prevention side of cardiology as opposed to the treatment side. And obviously, that's where a lot of work and a lot of great research has been over the last couple of decades. I think a lot of people know about statins; they've sort of heard this term statins. And we've got some recent reports that are suggesting benefits for people that go beyond just the cholesterol -lowering effects of this class of medications. What are your thoughts about some of this more recent research?
Beth Abramson: Well, you know, there's been a lot of research over many decades looking at this group of cholesterol-lowering medications, and they reduce heart attack, death, stroke and improve the wellness of the population. Despite that, there is I'd almost say—I daresay in media, a conspiracy theory out there that these drugs are somehow hard to take and harmful. And I have—I spend a lot of my time discussing the benefit weighed against any minor risk of these drugs in my daily practice. And I spend a lot of time in every clinic talking to patients, because there's a lot of data that these drugs are effective. We think they're effective by lowering cholesterol, but we also know that there are other mechanisms by which these drugs can be preventive. You know, there was an interesting study that came out in the New England Journal of Medicine a few years ago, taking people who are sort of at midlife, dare I say men over 55 and women over 65, who didn't have any traditional risk factors for coronary heart disease, but were overweight and out of shape. And this was a large study in which people who had we call central abdominal obesity, I jokingly call it the Canadian Tire, that little beer belly that some people get. And these people got put in a study and half of them got randomized to a fake drug or placebo. And half the people got randomized to the statin drug that you're talking about, Peter.
Beth Abramson: And over the course of seven years, people who were put on these cholesterol pills had less heart attack, stroke, death, bypass surgery, compared to those on a placebo or fake pill. And it speaks to the fact that we're at risk for coronary heart disease as we age. Now certainly, if we can work on that central abdominal obesity and work on lifestyle changes, that's tremendously important. But in addition to working on that, there's good evidence that these statin drugs are protective in the population. So again, I'm not surprised by the newer data suggesting other mechanisms. We know these drugs are effective.
Peter Nord: Yeah, and I guess in my patient population like yours, there's a bit of a fear factor as people think, "Oh, this is bad for my liver and I have muscle cramping." What are the common side effects that people should be watching out for? And maybe just a comment about, you know, if they do show up what what the next steps can be?
Beth Abramson: Sure, I say this to my patients every day, and it is a true statement. The commonest side effect is no side effect. The risk of having a liver abnormality with these drugs is exceedingly low. In the lower doses of the cholesterol statin drugs that we're prescribing, do not even recommend routine screening, but I practice what I preach in medicine, which is to make people feel comfortable. So when I prescribe these drugs, I say look, I'm not walking away and prescribing and you're not being seen again. We'll get some blood work in two to three months, we'll make sure everything's okay because by and large it is okay. These drugs are safe and well tolerated.
Beth Abramson: There are a certain percentage of patients—about three people in a hundred will have a muscle ache on a certain statin drug. Those aches can actually go away with a different drug within the class, or taking a holiday and trying a lower dose or a different dose because—and I even have identical twins in my practice. I jokingly call them the Juicy Fruit twins because I bring them in to show my residents that two people genetically the same can have different environmental factors. And one has high cholesterol and one doesn't, but they're both on statin drugs now because of their family history. And, you know, some people, one tolerates one statin and the other tolerates another statin. But by and large, I think this requires a conversation with a physician if you're not feeling well. Not just stopping it and walking away from this, but entertaining the possibility that there's another good option out there for you.
Beth Abramson: In reality, these are safe and well tolerated drugs and the benefit to people outweigh risk. And that's what we do in medicine, right? It's not so that everything is perfect, everything is very safe and well-tolerated or everything is toxic. We discuss risk versus benefit. And we're doing that every day. Whether it's taking an aspirin, which is appropriate if you've had a heart attack, the risk of bleeding is low, versus the risk to someone who doesn't need it is higher because there's a risk of bleeding without benefit. So risk-benefit ratios for statins favour statin therapy for most patients we're prescribing these to.
Peter Nord: And that's an incredibly important message, really important takeaway on statins. Just pivoting a little bit to blood pressure as well. So obviously, people I think are aware of what the systolic and diastolic blood pressures are. You know, we have an upper number and a lower number. And in the past, we were thinking, you know, 140 over 90 is probably okay. Higher than that's bad, lower than that is, you know, better. I think we're starting to realize now that lower systolic blood pressure, even less than, like, 120 which used to be that sort of magical 120 over 80 was the target. What are the targets now? What are we seeing in terms of research around blood pressure and where the target should be?
Beth Abramson: So targets, as in everything in life about blood pressure, depends. It all depends, right? So if you're an otherwise well individual, we want lower blood pressures in the population in general if they can be achieved with lifestyle and dietary interventions. And let me remind you that one of the best blood pressure-lowering drugs out there is exercise. So walking or getting short of breath three times a week for a minimum of 15 to 20 minutes at a time. That doesn't mean you have to—well, we can't—some of us can't go to the gym during COVID, but it doesn't mean going to the gym or putting on spandex. It means going for a brisk walk so you're sweaty and short of breath, can lower blood pressure significantly. Trying to maintain a healthy body weight. So even five to 10 pounds of weight loss for patients. And individuals who—you know, some of us are never going to be skinny Minnies and we don't expect that, but weight loss to a healthier body weight range is really important at controlling blood pressure. So is, in certain individuals who are what we call salt sensitive, cutting out some of the salt or sodium in your diet. So there are some important lifestyle interventions when I get back to your answer about targets that we want for the general population.
Beth Abramson: Actual targets for blood pressure depend on if you have heart disease or diabetes. So if you actually have diabetes, our targets are more aggressive. We are still aiming for blood pressures of the top number or systolic under 130, and the bottom number or diastolic under 80 in an ambulatory setting. So let's remember that when a patient comes into your or my office, they may be a little nervous. An office blood pressure is not always reflective of a home or out of office blood pressure. And we've really gone to home blood pressure monitoring I think, as a standard in the last decade or so. In Canada, we're ahead of the game. I don't think our American cousins are as on top of or have accessibility to home blood pressure monitors as we do. But, you know, when available—not during a pandemic—even going to the local drugstore, without a doctor or nurse in your environment is important to check blood pressure. Targets vary depending on whether you have heart disease or kidney disease, but lower is in general better.
Peter Nord: Just to move up to more recent advances in cardiology, things like the PCSK9, low-dose blood thinners, and there's been a lot of press around diabetes pill for non-diabetics, what are the sort of hot button topics that have just been coming up over the last months and over this year, other than, obviously, the COVID-related issues?
Beth Abramson: So it's an exciting time to be a preventive cardiologist, because prevention happens in two folds. There's the population prevention, so we all need to work on lifestyle, and I've talked about that. But then there's preventing the second heart attack. Preventing the second heart attack is called secondary prevention. And we have so much evidence out there in 2020 that we didn't have five or 10 years ago for treating people. The price is we call pill count, it means that our patients are on some medications. But again, if I can get my patients on the right medication so that their life expectancy is similar to someone who's not had a heart attack, then we're doing a great job. And so we know that when someone has a heart attack, I've mentioned there's a blood clot that forms in a narrowing. Usually there's a bit of junk or plaque in your heart artery to the heart that has broken off or ruptured, and then a blood clot forms.
Beth Abramson: We now have evidence that low-dose blood thinners, in addition to low-dose aspirin, very specific combination of drugs, reduce risk of heart attack and stroke after that first heart attack. It's data we didn't have in the past. And so we have a whole class of drugs that are even funded for over age 65 in the province of Ontario by the government, because they are so effective at reducing that second heart attack. The other issue is that cholesterol, although often treated and mostly treated well by the statin drugs as you and I have just talked about, sometimes it's difficult to manage in certain patients. Some people are born with a genetic predisposition to high cholesterol, we call that familial—runs in the family—hyperlipidemia, high cholesterol in the blood, or FH. And these patients need more than statin-based drugs. The side effect of these drugs is the cost. That's the only side effect: they're expensive. But injectable cholesterol-lowering drugs that are very effective at reducing and almost eliminating cholesterol from the body. And what we have found is that if we lower cholesterol very quickly and very effectively after a heart attack, and with these newer drugs called PCSK9 inhibitors, your risk of a future heart attack comes down significantly.
Beth Abramson: The other new thing we found out in cardiology is that there are a whole host of pills out there that we've been using for diabetes that we think protect the heart now. In fact, we know they protect the heart. There are people who have had problems with heart muscle function and fluid buildup, and we call that congestive heart failure. And there's a class of diabetes drugs that were studied in people with congestive heart failure and diabetes that have been shown to be effective. But what's been really interesting is that in the last year, we're using these diabetes drugs in people without diabetes. So we've actually made a shift. These diabetic drugs are now considered heart drugs. So if you are a person who is living with congestive heart failure or have had a problem, I'd talk to your doctor about these diabetes drugs, because they're safe and well-tolerated, they're oral medications we take once a day by mouth, and that's really exciting and new.
Beth Abramson: The other newest thing to hit us all in the cardiovascular world is a drug that is a very highly-concentrated form of almost a fish oil. So we have newer drugs available to us, and it's not a fish oil itself. It's concentrated. You'd probably have to eat about, I don't know, 200 pounds of sushi or fish to get what you get in that one pill. But there's a new medication out there that's a twice-a-day medication for people living with heart disease and high triglycerides. Triglycerides are a fat in the blood that's often associated with diet and being a little overweight. It's also associated with having a low good cholesterol, a low HDL. And for many years we have not found any medications that make a difference above and beyond the statin drugs to reduce future heart attack or risk in our patients even with high triglycerides. But this new drug and class of drug that has come to market, is available in Canada, it's a tongue twister, but it's icosapent ethyl. The trade name is Vascepa. It's available to us now, and has been shown to reduce future heart attack, future heart bypass surgery intervention, and people living with heart disease who have high triglycerides. So again, that's just new on the horizon and is starting to be used in our world.
Beth Abramson: So we have four or five different medications that we didn't have five years ago to make sure that people who've had the first heart attack, prevent the second. It does mean that I'm seeing a patient every year and they're on a lot of pills, and they're saying, "Doc, can I stop my pills? I hate taking my pills." Well, the conversation is, "Have you had a heart attack in the last year? Have you had a stroke? How are you feeling?" Well, if you're feeling well, and you're on your medication, then these medications are doing their jobs right. The problem with prevention is that it's an uphill battle. We don't see what we're preventing if we're doing our job right. As opposed to taking nitroglycerin, which is a medication for chest pain, you take a little bit of nitroglycerin and the chest pain goes away. You see the effect of the drug. If we're doing our job right with preventive medications, we don't see what we're preventing.
Peter Nord: That's great advice as well. And just super interesting and lots of exciting things happening in cardiology now and well into the future, clearly. Dr. Abramson, thank you so much for your time today. Really appreciate it. I know our listeners will really enjoy all you've had to say thank you so much.
Beth Abramson: My pleasure.
Christopher Shulgan: That’s it for this episode of Eat Move Think. As always, we’ll post highlights and the full episode transcript on our website at eatmovethinkpodcast.com, including links to Dr. Beth Abramson’s book, Heart Health for Canadians and her medical app, My HeartPath.
Christopher Shulgan: Eat Move Think is produced by Ghost Bureau. Senior producer is Russell Gragg. Social media support from Emily Mannella. Editorial direction from Chantel Guertin.
Christopher Shulgan: Remember to rate and subscribe to Eat Move Think on your favourite podcast platform. Follow Shaun on Twitter and Instagram @shauncfrancis—that's Shaun with a U—and Medcan @medcanlivewell. We'll be back soon with a new episode examining the latest in health and wellness.
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