Ep. 50: How to Prevent Heart Disease with Dr. Beth Abramson
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The point of preventive cardiology is to inform people they’re on a path toward developing heart disease and other cardiovascular problems—so that they can change their lifestyle and delay the onset of any issues. Recent advances in cardiology like new hs-Troponin testing are helping doctors detect heart health risks earlier than ever before. Heading into February’s Heart Health month, guest host Dr. Peter Nord talks about these advances with Dr. Beth Abramson, Medcan’s director of cardiology.
Guest bio:
Dr. Beth Abramson is associate professor of medicine at the University of Toronto. She is director of the Cardiac Prevention and Rehabilitation Centre and Women’s Cardiovascular Health in the Division of Cardiology at St. Michael’s Hospital. Learn more.
Links, references and highlights:
February is Heart Month. Learn about ways to control your heart health from the CDC and Canada’s Heart & Stroke.
Learn more about women’s heart health at a complimentary Medcan Presents webinar hosted by Dr. Beth Abramson. Date: Tuesday, Feb. 9, 2021, at 12:30 p.m. Register here.
The Canadian Women’s Heart Health Centre is promoting Wear Red Day for women’s heart health. It’s happening Feb. 13. Learn more here.
Drs. Abramson and Nord discussed four innovative ways to predict whether you’re headed toward heart disease. Including:
CIMT—Predicts future cardiac risk by examining the thickness of the carotid artery in the neck. CIMT stands for Carotid Intima-Media Thickness. Learn more about the test here or here.
hs-Troponin I—The High Sensitive Troponin-I test measures blood concentration of a biomarker that scientists believe is associated with stress on the heart muscle. The test can predict risk of future heart disease even in healthy people. (Medcan is the first clinic in Canada to provide it.) Learn more about the test in this article by Dr. Nord.
TMAO—The trimethylamine N-oxide test (TMAO) screens for a biomarker in the blood that is produced when digesting red meat, full-fat dairy, egg yolks and certain dietary supplements. Higher levels in the blood are associated with elevated risk for developing cardiovascular disease. Learn more about TMAO here.
Lp(a)—What Dr. Abramson refers to as “LP-little-a” is the short form of “lipoprotein-a,” a type of cholesterol in the blood. Doctors may order a test to measure levels of this cholesterol if you have normal cholesterol levels but a strong family history of cardiovascular disease. If your lp(a) levels are high, you too may be at elevated risk of developing heart disease. Learning that early enough can spur lifestyle changes that may help decrease your risks. Learn more here.
Dr. Beth Abramson helped to develop an app 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.
How to Prevent Heart Disease with Dr. Beth Abramson final web transcript
Christopher Shulgan: This is episode 50 of Eat Move Think, the podcast from Medcan that empowers people of all ages and cultures to live well for life. Today, we're talking about recent advances in heart health testing that can tell whether cardiovascular disease is in your future.
Christopher Shulgan: Heart attack, stroke, heart disease—these are cardiovascular health problems that are profoundly preventable. Eating better, getting more exercise, stopping smoking—all of it will reduce your risk.
Christopher Shulgan: Traditionally, doctors have detected your heart disease risk with things like cholesterol testing. But actually some really cool screening procedures are now available that can help to detect whether you're on the path toward developing heart disease earlier and with more accuracy than ever before. They tend to have obscure sounding names, like the hs-Troponin assay that Medcan just began offering as part of its Annual Health Assessment.
Christopher Shulgan: There’s also something called CIMT and TMAO. And to explain what all these mean, and to also give our listeners a pep talk about the things that can be done to avoid cardiovascular disease—the number two cause of death in Canada—we have Dr. Beth Abramson. In addition to her duties at Medcan, she is an associate professor of Medicine at the University of Toronto. She's also director of cardiac prevention and rehab and women’s cardiovascular health at St. Michael’s Hospital. And she's written a book, Heart Health for Canadians. Here she is in conversation with our guest host, Dr. Peter Nord, the chief medical officer at Medcan.
Peter Nord: Hi, it's Dr. Peter Nord, and it's a great pleasure today to be speaking with Dr. Beth Abramson. I think one of the things that I was particularly excited about in this topic, partially is because of the pandemic, and as we've gotten to know a little bit more about this COVID-19 virus, we initially were thinking it's purely a respiratory thing, and people are getting shortness of breath and fever, and it's sort of like a pneumonia and very much like some other viruses. We've really started to find out now increasingly, that it is a vascular impact. So there's this very interesting change which has happened over the last nine months, moving from respiratory concerns with the virus to vascular concerns. And so who better to talk to other than Dr. Abramson. So, welcome Dr. Abramson.
Beth Abramson: It's a pleasure to be here. You know, February is Heart Month. And it's a time for us to think about what's important in our health, especially when it comes to our hearts. And I look forward to chatting.
Peter Nord: Great. Well, let's just start with off the top thinking about some of the newer things that have popped up on the radar over the last couple of years. All of us are going to be impacted in some way or another by cardiovascular as we go forward. We're all are going to have a little bit of hardening of the arteries, a bit of plaque developing, how can we minimize that? How can we minimize the negative downstream effects of this essentially hardening of the arteries, to use a colloquial term? And what can we do at an early stage when we're actually quite young, to get a handle to assess where we are from a vascular perspective? And so maybe you could just walk us through what a couple of the newer, more innovative or more impactful aspects of preventative cardiology.
Beth Abramson: Absolutely. And you're right, heart disease is our leading health threat as Canadians and in Heart Month, I just want to remind us, it's an equal opportunity killer for women and men. And that's not a good thing for any of us. So actually, if I'm talking from a female perspective, one Canadian woman dies from heart disease every 20 minutes, and we really want to prevent this. Men and women are at risk. I will remind you that, as we're talking because we're living through unprecedented times in a pandemic, that the hidden deaths from the pandemic are related to not coming to hospital if you have chest pains, and you're worried you have a heart attack. So with that background, the more important issue is, can we prevent it in the first place?
Beth Abramson: There have been several interesting ways for us to detect early heart disease, and prevent it with the right medical therapies and lifestyle changes. So certainly, prevention is a lifestyle issue in terms of making sure we're eating a heart healthy life, healthy body weights, lower fat diets, going to your doctor and checking for your blood pressure and your cholesterol and checking that you don't have diabetes and controlling it, and not smoking or budding out if you smoke. Those are the risk factors we can control. But how can we detect earlier heart disease? And those patients in whom we detect earlier heart disease may need more intervention than the lifestyle change.
Beth Abramson: There have been several interesting tests that have been based on scientific evidence in the last few years that suggest we can pick up blood vessel and heart disease, because as you mentioned, blood vessel disease and heart disease go hand in hand. Heart disease is a disease of the arteries supplying blood to the heart. That's what happens when people have a heart attack, they get narrowed and blocked off. And so if we can test blood vessels elsewhere in the body and say, are they healthy, are they not? We can say, am I at risk for heart disease sort of looking under the microscope well in advance of developing that heart attack that we certainly want to avoid.
Beth Abramson: One of the tests that has been proven to be very effective over the last decade, is looking at the thickening of the arteries in your neck. And carotid intima-media thickness or CIMT is a well studied, we call it a validated way of saying, if my arteries in my neck are thicker than they should be for my age, there's a sign that the arteries are not as healthy as they can be. In fact, after the arteries get thick, the next step in development of disease is seeing a little junk or plaque in the arteries. And although we can't take an ultrasound easily to the arteries of our heart, we can put our fingers up to our neck—our neck is really accessible—and we can take an ultrasound of the arteries of our neck. And we can look at the thickening and seeing if there's junk or plaque in the carotid arteries in our neck. And so carotid IMT is a validated and well-described and used way to measure future risk for heart disease. Very exciting. Not used widely, I'm not really sure why. It's one of my favourite tests for predicting future heart disease that makes us potentially change our management.
Beth Abramson: We also have some other markers, and we call them biomarkers. So sometimes a blood test that says am I at future risk more so than the average person at my age and stage for the same traditional risk factors. One of those tests is something that we— it may sound confusing because we sometimes when we go to the hospital with chest pain to rule out a heart attack, we look at something called a troponin level. What we now found there are sensitive measures of this troponin test, we call it a troponin assay. In the chronic—we say chronic, it means you're not having chest pain and you're not going to the emergency room, you're not having a heart attack, but is this troponin marker or blood test abnormal? And if it is, we're starting to see increased evidence that your risk in the years to come of heart attack and blood vessel problems and stroke is actually higher than the average person.
Peter Nord: So Dr. Abramson, we're very excited about the high sensitivity troponin. We started looking at this at Medcan about a year ago. Obviously, the pandemic slowed things down a little bit, and so we picked up the ball in the fall and are excited now to be able to include that as part of our annual health assessment lab panel. So it is a blood sample. And we're really excited about it for a number of reasons. One of which is during the pandemic, we're actually not allowed to do exercise stress testing, and that's one of our screening tests. So having this novel, innovative, amazingly new test that we can offer—really were the only ones in Canada offering it—is something that will help our physicians to work with our patients to help identify very early on, way before there's any symptoms, if there's any potential for future cardiac issues. Maybe you could talk a little bit more about that in detail.
Beth Abramson: Sure, the high sensitivity troponin test, it's new and upcoming technology. And there is evidence that's evolving as we are utilizing this. So this is a test or a biomarker where you can check in the blood that says you're at risk in the future for heart disease. Not in the immediate throes of a heart attack, that's not what we're checking for. But what we're checking for is, is there some stress on your heart muscle that at a microscopic level, we are seeing a blood test abnormality that actually predicts heart disease in the future, in years to come? And so any test we can do to add to our predictive value, so whether it's, you know, this test or measuring the arteries in your neck or another test, adding them all together is better than just saying this is your initial risk assessment. And so it's exciting technology. It's new technology, it's evolving technology, and the science is backing up the use of this in the walk-in or I would say ambulatory setting.
Beth Abramson: The other really interesting marker that I think is something we need to think about is a test called TMAO. And TMAO actually is a test we can do that looks at how the body degrades what we eat. And it looks at how we're eating maybe not so healthy foods like red meats, and those byproducts of the way we digest our food are picked up in the blood, and also, these byproducts actually can harm the blood vessels. And it's really interesting science to see that we are what we eat in many ways. And so picking up a TMAO blood test and saying it's abnormal, has a lot of information for us that this patient whose TMAO level may be off is that future risk. Now you might say to me, well, that means we just have to be eating a healthier diet. Partially true, but it accepts and it identifies individuals who are at higher cardiac risk. Very, very important as we look at newer ways for identifying those people at higher risk for heart disease.
Peter Nord: These are all fascinating. We've talked about CIMT, we've talked about troponin and TMAO. Is there anything else we can do? Because most people think, from a biomarker perspective, that checking the cholesterol is a great way to do that. And certainly in the past, that's all we had. Is there anything else we can do on the cholesterol front that's a little more sensitive, or accurate or more novel?
Beth Abramson: I'm glad you brought up cholesterol and assessment of risk. There is no doubt that the way we look at cholesterol is still an important aspect to cardiovascular risk assessment. So I don't want us to throw out the baby with the bathwater in what I'm about to tell you, but there are newer markers and groups of cholesterol that we can measure in the blood, that say am I at much higher risk for heart disease? So in addition to saying, is my bad cholesterol or LDL high, or is my good cholesterol, or HDL low, and we now have more evidence that the blood fat called triglycerides being high also puts us at risk. There is a specific test called LP(a)—I call it LP(a) and it's drawn at most blood labs. And LP(a), if abnormal, does signify that you are at increased cardiovascular risk, and often genetic. It's not a test that we try and treat, in the sense that we try and change the LP(a) number, but if I have a patient, for example, who has a family history of heart disease, whose cholesterol looks okay, but is there something else going on? And that LP(a) is high, I know they're at genetic risk, and I know I'm going to have to treat them regardless of that cholesterol level that at first glance does not look that abnormal. So LP(a) is something that we're starting to use more and more of.
Peter Nord: Yeah, I think that's an important takeaway, that what we're talking about with these biomarkers aren't necessarily something like cholesterol that we can track and trend, and we can apply treatments and watch the numbers go down. Some of these are just to really get our attention and to look very early on. Rather than in the old days, basically, we were only intervening when people had symptoms. So sometimes the first symptom is a heart attack. And then we're doing secondary prevention, trying to drop cholesterol, manage diabetes, get them to stop smoking. Increasingly though, we can back the bus up years, decades, by looking at some of these biomarkers. And what I find with my patients is it just really gets their attention. So I kind of call some of these things red flags. And the red flags, when you start to add up some of these biomarkers, not only does it get everyone's attention, it actually increases the compliance for patients because they they're like, holy cow, none of these things have symptoms, and I'm a decade away from my first symptom, but we really need to double down in terms of managing my weight, my diet, all the lifestyle factors that we have to talk about. Medicines.
Peter Nord: So that's why I think when I look at some of these biomarkers, they're really important because they're just a red flag that will get everyone's attention and really improve compliance, so that longer term, we really see that positive outcome. So with that, let's go back to CIMT, or the carotid intima-media thickness ultrasound. So I had my annual health assessment in 2020, and my family history is a little borderline when it comes to vascular. So I said, you know, I want to get that. So I got the CIMT. And, you know, it showed there was some plaque there. And for some of my patients that we saw some thickening, a bit of plaque development, a common question that comes up is, wow, how can I reduce that plaque? Like, do you have like a pipe cleaner that I can use to kind of pipe clean that that plaque out of there? Maybe you could just comment on, you know, what can we do if we do see that thickening, or if there's plaque there.
Beth Abramson: Right. So I wish we had a pipe cleaner. We use the equivalent of pipe cleaners once you've had a heart attack in coming in, but we want to prevent that in the first place. So in life, like most things in medicine, in life it depends. So if I have a very fit individual in front of me, who has no other risk factors that need modifying, they're active, they're maintaining a healthy body weight, they're eating a low-fat diet, the blood pressure's good, the cholesterol is good, everything's good, and I still see this thickening or this plaque, we still need to treat it because, you know, heart disease is bad luck, bad living, bad genes. It means you've had a genetic tendency, despite your living. And you've got good luck, because you've had this test, saying, whoa! And actually, these patients are the patients I put on medications like cholesterol medications, regardless of your cholesterol level.
Beth Abramson: On the other hand, if I had a—Dr. Peter Nord, I'm not saying this is you at all. If I had a very overweight, out of shape, smoking patient in my practice, I would make sure that we were really working on changing the lifestyle together as a team. And it's hard. You know, to be honest, it's easier to take a pill than make a lifestyle change. But it is so important. So it depends on what the plan of action is for these two individuals with this abnormal test. In reality, the test says you're at increased risk. How we change the risk depends on what you're doing already. And many of these patients, we can change the trajectory of the disease. And many of these patients I see have a genetic tendency. So I can't change your genes, and we don't routinely in cardiology, do specific genetic testing for atherosclerosis, because it's due to multiple things. But at the end of the day, I can change—in 2021, simple medical interventions, I can change the trajectory of disease by that. In fact, it's actually interesting, for some of these patients, even if their cholesterol isn't that high, we can lower cholesterol. We're in an era, and I know we're talking about vaccines, and I know it's February, and it's Heart Month, but down the road, we may even have a vaccine to prevent heart disease. Because we have long-term injectable every six months. They're on the horizon. They're quite expensive and just being researched now, but injections to lower cholesterol from our body, because we actually really don't need bad cholesterol in our body after the age of two or three. And so if we do that, we could change the trajectory of heart disease for all of us.
Beth Abramson: So getting back to your question, if I see a patient with CIMT that's abnormal, I may be very aggressive about adding in—where appropriate—medications to lifestyle.
Peter Nord: That makes perfect sense. And on the TMAO, just for our listeners, that's trimethylamine oxide, which is why we just say TMAO, because that's really hard to say.
Beth Abramson: Yeah, TMAO is also hard to say. I tongue twist it sometimes, yeah.
Peter Nord: Yeah, it's a toughy. And you mentioned about eating and, you know, red meat and some other culprits that create this elevated levels of TMAO. How does that work with our gut physiology? So is there anything we can do other than reducing our red meat intake?
Beth Abramson: That's a really good question. I actually don't think we have the full answer to that scientifically, but there is no doubt that when one consumes more fruits and vegetables and plant-based proteins actually in vegetables than meats, the breakdown of these products is different in the gut. And these byproducts actually are toxic to our arteries. And that's actually one of the ways in which we develop heart disease. So it would be nice if we could just, you know, similar to the concept of taking a pipe cleaner, if we could change the—improve our gut flora, and our environment would allow us to eat all the things that people sometimes eat, that would be nice. We're not there yet. My motto is most things in moderation except smoking. So, you know, a little red meat now and then. But lower-fat meats, less processed foods, eating in a healthy way, really following the Food Guide, will allow us to have less of the TMAO levels elevated until we know that answer.
Peter Nord: Yeah, that's great. And I know some of my patients ask about that, in terms of them, you hear microbiome, and we've had some amazing podcasts from our nutritional experts, talking about diet, talking about microbiome, looking at your gut physiology and the importance of that. And so there's these interconnected circles too. You know, we talk about inflammation being bad for the body, and that if we have added inflammation in our body, we're going to age prematurely, we're going to have more likely other range of diseases, from cancer to heart disease to neuro changes. And so it's interesting that we've got this vascular overplay with a gut physiology and diet, and then even this inflammation that's going along.
Beth Abramson: Yeah, inflammation is really—sorry, it's really important in heart disease. We actually even have a study in the last few years saying that very potent anti-inflammatories can reduce your risk of heart disease. These are drugs that are used in other diseases that won't be used in cardiology, because when we reduce inflammation, we reduce the body's response to fight infection. And so in the large study, in this heart study, people were dying of infection. So it was what we call a proof of concept study. It's not something we'd treating right now with certain drugs, but inflammation, no doubt, plays its role in atherosclerosis and atherothrombosis or a disease of the blood vessels, absolutely.
Peter Nord: Yeah. And that's exactly where I was going, and connecting even the anti-inflammatory diet has been shown to be helpful. Medications can affect inflammation, but inflammation, if it gets into our endothelium or the lining of our vascular walls is just a bad thing. And I talked about that almost like a roughening of the surface, people think if you had to sort of picture what is this nice, smooth, vascular blood vessel? And it's nice and smooth. If inflammation roughens up that surface, it's more likely that plaque can lay down. So any comments around that?
Beth Abramson: Yeah. You know, we're talking about very high-tech testing, which is great, and I'm all for it in the right population. But I do want to remind people, that there are low-tech interventions to reduce inflammation. So if you're overweight, reducing weight will lower inflammation in your body. If you are a smoker, stopping smoking will lower inflammation in the body. If you have diabetes that's not well controlled, controlling that will reduce inflammation in your body. If you are not active and you start increasing your physical activity—and this does not mean necessarily putting on the spandex, it's getting out there and being active. And I'm glad that at least during this pandemic, many people have not had that COVID creep. Some of my patients have, and that can be changed. Nothing is forever. But have gone out and start walking. We're walking more. And regular activity reduces inflammation, which is probably the explanation for what we say—we call epidemiologic studies that show regular activity reduces your risk of heart attack and stroke. It probably is related to inflammation.
Peter Nord: Yeah, and that's a theme that weaves its way through so many topics, that connects so much of what we do in preventative health to everything we can do to try and reduce that common denominator amongst so many things. Even dementia. Alzheimer's, you know, there's that whole inflammatory thesis that goes behind even dementia. So again, all of these things are intertwined and can't be teased out and dealt with independently. And we love to be able to stand back and look at the whole person, and put together a bit of a future look for individuals way before they have any symptoms at all, whether it's heart disease, cognition changes, renal changes.
Peter Nord: And, you know, we talk about the arteries of the heart, which is obviously our focus today, but anything we do to benefit the arteries of our heart benefits the arteries to our brain, benefits the arteries to our kidneys, benefits the arteries that go down into our legs, so that we're not getting angina of our legs or claudication or pain in our legs because we have actually blood vessel compromise throughout that peripheral vascular system. So any other tests? And on the peripheral vascular, I'm just thinking of other things that we do, and ankle-brachial index is another common test that we're doing. It's been around for a while. Maybe just a comment for our listeners about that, because it may be something that—a test that their doctor, and certainly if they're here at Medcan that we would offer as well.
Beth Abramson: Sure. And I know you may not know this, this wasn't a plug, but I actually chair our Canadian Cardiovascular Society guidelines on peripheral arterial disease. And we're trying to create an environment where health care providers and patients are aware that a cramp in your legs or angina in your legs from a blood vessel problem your legs puts you at risk for a blood flow problem in your heart. Because as you've suggested, it's a disease of the arteries. And arteries are actually complex organs. So there are certain risk factors for diseases of the blood vessels. And they tend to be similar. People who have blood vessel disease in their legs which give them cramps when they're walking or tired when they're walking, first of all, people aren't aware this is an issue sometimes. They're not sure this is actually a serious thing. So if you are out there, or you know a friend or a family member who is walking and slows down because they just get fatigue in the back of their legs, they get a cramp in their calf that comes on with activity and goes away with with rest, that may be a blood flow problem in the legs. That tends to happen more frequently in people with diabetes and smoking, but it can happen in many people across the population. And those patients need to be treated with lifestyle and medications.
Beth Abramson: We have really good evidence now. In 2021, there's no excuse not to give people the best evidence-based medications to reduce their future risk. It's interesting, these patients with blood vessel disease in the legs don't have leg attacks, they end up having heart attacks and stroke. So we want to reduce your future risk of blood vessel disease elsewhere. The take home message is: think about it, talk to your doctor about it. And then the testing we have includes the testing of measuring the blood pressure in the legs and the arms as Peter has mentioned, your ankle-brachial index, and doing, where appropriate, sophisticated ultrasounds and blood flow assessments or dopplers of the legs to see if this is truly an issue. Because if it is, it needs to be dealt with with lifestyle changes and medications.
Peter Nord: Yeah. I didn't want to leave the whole discussion around vascular health and the heart without mentioning some of the other areas of the body that may be not be entirely to do with the heart, but they are all connected. Certainly the peripheral vascular disease is a real thing, and it's easy to pick up with those symptoms. So this has been terrific. We've covered a lot of ground: the CIMT the HS or high-sensitivity troponin, TMAO and the LP(a), as well as some of the other focused discussion around inflammation. Really appreciate your time and your expertise. And on behalf of everybody, thank you so much for the time that you've given to Medcan and for supporting us today on the podcast.
Beth Abramson: It's my pleasure. You know, it's Heart Month. February is Heart Month, and I'm just gonna shout out to everyone: do something for yourself for your heart. So if we can all think about one small but important lifestyle change—everyone listening today—be it taking a few more minutes to go for a walk, be it eating a little less higher-fat foods, working towards a healthy body weight, budding up with someone to make a healthy lifestyle change. It's small changes in our everyday routine that has a lasting impact in the long run. And we need to do this for ourselves and for our hearts, and for the hearts of our friends and family members.
Christopher Shulgan: That’s it for this episode of Eat Move Think. That was cardiologist Dr. Beth Abramson in conversation with Medcan chief medical officer Dr. Peter Nord. I’m Christopher Shulgan, the show's executive producer.
Christopher Shulgan: We post highlights and the episode transcript at eatmovethinkpodcast.com, including a link to further explainers for each of the tests discussed in this episode.
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. We'll be back soon with a new episode examining the latest in health and wellness.
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