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You NEED to know this about heart disease, Part 1

Interventional and preventative cardiologist
Dr. Heather Shenkman, Cardiologist

De. Shenkman | 00:00

80% of the diseases of the heart are related to lifestyle

Dr. Doshi | 00:10

C p R. It's what happens after someone dies as a last ditch high intensity effort. Unlike the movies, it usually fails. What if we used that drive while we're still alive to heal ourselves? Welcome to C P R for life, where we help you understand how to reclaim your health by changing your everyday life. I'm Dr. Sagar Doshi, board certified in both lifestyle and emergency medicine and certified Health Coach. Our health is like a vehicle. I've seen too many people, including my own family, crash their health because they don't realize they are the ones driving. This podcast aims to help each of us take the wheel and learn where to go, but even though these conversations are evidence based, they are just for your education. So please talk with your physician before making changes.

Dr. Doshi | 01:17

So today we're gonna talk about heart attacks and all that goes into it so that you can take this knowledge and start changing your life right away. My father and other family members have suffered from heart disease. Some lost their life while others were luckier. I remember looking at my dad after his emergency heart bypass surgery, still sedated and intubated, and now I was feeling helpless and all I knew how to do back then was hope for the best. And this series we're starting on heart disease. It's for everyone out there who's had to deal with heart disease in any way. And to start off, we're lucky enough to be talking to, I think possibly the best person to be talking to. Leading expert on this Dr. Heather Shankman. She's the interventional and preventative cardiologist practicing in the LA area. She's also a firm proponent of lifestyle change. Importantly, she's also been in the shoes of a patient as well. And on top of that, she's a competitive endurance athlete, mother and author. And much of what we're gonna talk about today can be found in her excellent book titled The Vegan Heart Doctor's Guide to Reversing Heart Disease, losing Weight, and Reclaiming Your Life. Dr. Shankman, welcome and thank you for coming on the show.

De. Shenkman | 02:23

Thanks for having me. And thank you for the very kind introduction.

Dr. Doshi | 02:26

Something I like to ask everybody that comes on is, what is your definition of health?

De. Shenkman | 02:31

My definition of health is really being able to do the things that you wanna do without the limitations of your, your body. That's really the short of it for me.

Dr. Doshi | 02:43

Yeah. Okay. That's a nice succinct answer that really captures it. And later we're gonna go into the nitty gritty of heart disease and what we can and cannot control. But as a fellow six year programmer who went BS to MD and had time to come up, you know, to go in into any specialty that you might have wanted to, why did you pick the heart? Why'd you pick cardiology?

De. Shenkman | 03:05

I picked cardiology because I just felt like it really was somewhere where I could put all of my passions. Um, for a long time, been somebody who's very passionate about lifestyle. I'm a long time vegetarian and then vegan, and I've always been somebody who's been very passionate about exercise. Ultimately taking that on a personal level to competing in triathlons and in Ironman distance races. But being able to use all of that lifestyle stuff and add that to being able to do procedures like angioplasties to open blocked arteries to save lives. And cardiology is like the perfect specialty to combine both of those things

Dr. Doshi | 03:45

To drive yourself out of business. If you're trying to, if you're trying

De. Shenkman | 03:47

To, no, there's, there's enough out there. I'm not gonna drive myself out for

Dr. Doshi | 03:51

Those that you could change <laugh>. So tell me more also about when you were had to wear the shoes of a patient.

De. Shenkman | 03:59

Ah, I had an arrhythmia, something called super ventricular tachycardia. This, this goes back now almost 14 years. When I was exercising, I would at times notice like a sudden change in my heartbeat where it would suddenly race and I feel my heart beating very fast. And as a cardiologist, I knew the things that one can do to quickly slow your heart rate down. I, one of those is called a, a Valsalva maneuver where you'll, you'll bear down and you can suddenly make that fast heart rate stop. So I started doing that and I noticed it was very effective. So I self-diagnosed myself with super ventricular tachycardia, but of course I, I got a heart monitor to confirm this. And then I ultimately underwent a invasive procedure called an ablation with catheters that went from the leg up to the heart to find the arrhythmia and basically freeze the pathways and ultimately was, was cured of this.

De. Shenkman | 05:00

This was back in 2019 and I haven't had any issues or significant palpitations since, but it definitely gave me a certain sensitivity to when I'm telling my patients that they need to undergo something because I had to have the vulnerability of lying on a catheterization table. And granted, I knew everybody who's working on me, I even, um, had the audacity to pick out which staff members I wanted to be there. But I know what it feels like to be lying there, to not necessarily be able to see everything that's going on around you to every so often know that I'm being injected with medication to try to find this rhythm and to suddenly feel my heart racing and not know what's necessarily going on. And also that very narrow, very flat table. I'm not a big person, but lying on this very narrow table feels very awkward. And I can only imagine like somebody who's a bigger person lying there. That must feel so odd. So I feel like my experience has given me a little bit more of a sensitivity to my own patients who may need to have heart procedures. Granted, I didn't have anything life threatening thankfully, but I have a little bit of an understanding on a personal level of what it feels like.

Dr. Doshi | 06:18

No, and like I said, it's definitely not the exact same cuz lucky you, you got to know everybody was there and feel comfortable with that, knew what was happening. Just not at the moment, but how has it changed how you interact with people and how do they respond differently to you knowing that you've got to go through this as well?

De. Shenkman | 06:34

Well sometimes I, I tell my patients that I've been there, I've been on that cath lab table, especially those patients who have arrhythmias. I can tell them my own experience and say, I was in your shoes. These are what your options are. This is what I chose to do. You may have different feelings about what you would wanna do in your situation and that's certainly very reasonable.

Dr. Doshi | 06:57

Alright. Makes that conversation go more smoothly. And there are a lot of patients, as you were mentioning, especially with cardiovascular disease. Can you just tell us how big of a problem is this disease in this country?

De. Shenkman | 07:11

Coronary artery disease is a huge problem. It is the number one cause of death among men, among women, amongst all, all ethnicities. And I think it is driven much by lifestyle. It is said that 80% of the diseases of the heart are related to lifestyle and lifestyle, namely being diet, exercise, smoking, stress, drug use amongst other things. And it, it's a big problem. I think we know much of what people should be doing to reduce the risk of heart disease. We know that if you are eating better and maintaining healthy weight and getting your fruits and vegetables and exercising regularly, but most people aren't doing those things. But that said, it's not just lifestyle. There is definitely significant genetic factors that increase the risk of cardiovascular disease like inherited abnormalities in, in cholesterol. And there are also other issues such as ethnicity. For example, the Southeast Asian population tends to have more heart disease at younger ages, even amongst people who are so-called thin or normal weight.

Dr. Doshi | 08:28

Yep. That is uh, kind of a plague in that part of the world as even when people change what part of the world they're in. And have you noticed any differences amongst how we live in the United States and how heart disease affects us here versus what you might know about other places? Is this an American problem or is this kind of a global problem?

De. Shenkman | 08:47

I haven't practiced medicine anywhere outside of the United States. From what I know and have seen, this is definitely a problem elsewhere, especially, you know, as I mentioned, new Southeast Asia tends to have a high burden of, of diabetes and heart disease at younger ages. Um, and there are other parts of the world where, where smoking is much more common and certainly it's a big issue there as well. So I think really worldwide heart disease is a big problem.

Dr. Doshi | 09:14

Alright, so let's go through a little scenario and have you use kind of your x-ray and microscopic vision to tell me what's going on. So let's say I'm, right now I'm shoveling snow in my driveway, pretend it's not, hasn't been raining, it's actually been snowing nine inches and it just, ah, there's this terrible pressure in my chest. It's going to both arms, I'm sweating, I've got vomiting. What are the chances I actually make it to the hospital? <laugh>,

De. Shenkman | 09:41

That's a great question. It really depends on how quickly you act. If you're somebody who's out there who's feels like you're an otherwise healthy person, you start shoveling snow and suddenly you get chest pain, like that's not normal and you need to act on that immediately. The problem with heart attacks is one quarter of all people with heart attacks don't make it to the hospital, they die. So acting quickly can save your life and don't necessarily be afraid of being seen as a hypochondriac. You'd rather be a hypochondriac than be very sick or dead.

Dr. Doshi | 10:13

And so I've met people that are under the impression that C P R and just chest compressions can bring them back from anything and that it's a kind of a cure-all. What would you say to that?

De. Shenkman | 10:23

That's interesting. And if you watch television, you would think that C p R is this, this magical thing and brings you back and you're, you know, all back to normal. The majority of people, I mean, I forget the exact number, but if you undergo C P R or you need C P R, your risk of surviving isn't that great, particularly, let alone your risk of surviving and being a normal person thereafter. I wish I knew the statistics off the, off the top of my head, but, but I don't.

Dr. Doshi | 10:53

Yeah, I think it's something like 10%, but I could be wrong. So what's going on in my chest? If you could use your knowledge and your x-ray vision, what's going on in the blood vessel that's causing this total occlusion, tell me all the things. Well,

De. Shenkman | 11:09

Number one on my differential of things that I would want to make sure are not going on is I would wanna make sure you're not having acute heart attack. And when we say acute heart attack, the technical term is acute myocardial infarction. And typically that is a process in which an artery of the heart is completely occluded suddenly. So suddenly this, this artery that has normal blood flow going through it is suddenly occluded. Um, the process of that being most commonly thrombosis where a piece of plaque breaks off and travels and grows or propagates as it travels along and then suddenly blocks off the artery, um, hence leaving no blood flow to go down that artery. And that would be the first thing that I would think of in, in that type of situation.

Dr. Doshi | 11:55

So what is the plaque?

De. Shenkman | 11:57

So plaque is made up of all sorts of deb debris, it includes cholesterol and it's within the, the wall of the artery. There are several kinds of plaque that are present. There's soft plaque and then there's calcified plaque. Now calcified plaque tends to be covered with, with calcium and it's something that we can measure with a test called a coronary calcium scan. But this plaque, because it's covered in this calcium shell, tends to be more stable. It's the softer plaques in the arteries that may are more likely to be unstable or to break off and to cause coronary artery events or heart attacks.

Dr. Doshi | 12:36

So how does that happen? What causes there anything in particular that causes the rupture?

De. Shenkman | 12:42

That is a great question and I don't think we have the perfect answer as to why at some particular PO point something would happen. Certainly there's something that propagates something inflammatory or some sort of stress on the body that can cause this type of sudden event to happen.

Dr. Doshi | 13:01

And then if somebody, let's say me, I've gotten in the driveway, I've gotten the 9 1 1 call. Luckily ambulance has shown up, I've gotten to the emergency department. The emergency doctor taken a look at the EKG and said, oh, oh, you definitely have a heart attack. And it's the kind where I think this cardiologist can help and they call you in, they happen to be there. What happens from that point on? What can a person expect?

De. Shenkman | 13:23

So what would happen from there is if you are having a certain kind of heart attack called an ST elevation myocardial infarction, that's the type of heart attack where we have good data that if we get in, we open up the blocked artery and restore flow, we can save your life. What's what would happen in that situation is the emergency room would activate their team for the cardiac catheterization laboratory. That would include an interventional cardiologist like myself. It would also include a couple of nurses, a couple of technologists as well. And you would very quickly be brought to the cardiac catheterization laboratory. You'd be put on that, that narrow hard table, your

Dr. Doshi | 14:00

Wrist, the same table,

De. Shenkman | 14:01

Your wrist or your groin area would be prepared with iodine to sterilize the area. And then the doctor would perform a coronary angiogram. And what that would involve is a catheter going either through the radial artery in the wrist or the femoral artery in the leg, feeding that catheter up to the heart, injecting dye, taking x-ray pictures and looking for blockage. If that cardiologist sees that there is a blocked artery, then he or she would go ahead, feed a wire through the narrowing inflatable balloon, and then feed in a tube called a stent to hold that artery open

Dr. Doshi | 14:35

And restore that blood flow. And will the person feel immediately better and be able to skip out of the room?

De. Shenkman | 14:42

Usually? So yes, um, they, they come in clutching their chest in horrible pain, but by the end of the procedure they're very often with no pain at all.

Dr. Doshi | 14:52

Okay. Now what happens if it's not that st elevation mi it's a non ST elevation mi, what, how are they gonna get better?

De. Shenkman | 15:00

That's a good question. And there, there are other kinds of, of heart attacks. There's something called a non ST elevation myocardial infarction, which is similarly a heart attack and very often that can involve a completely blocked artery or a severely narrowed artery that also can benefit from an acute angioplasty or procedure to open up a blocked artery. But those more often than not do not need to be done like within 30 minutes that the something that often can wait a day or two. There's also something interesting that's, it's a, a less common type of heart attack, but it's something that we see with some regularity. It's called a attack at suo syndrome, which is actually a stress-induced heart attack. So those people can have the symptoms and the changes on their E K G seen with a traditional heart attack that involves an a blocked artery.

De. Shenkman | 15:52

But we may do an angiogram or inject dye into the arteries of the heart and see that the arteries of the heart look, look fine, but there's part of the heart that just isn't moving white. Right. And we call that a tatsuo syndrome because in Japanese tatsuo is this type of octopus pot where the, the tip of the pot is like this big balloon and the top of the pot is, is narrow. So the heart in this type of heart attack often looks like that octopus pot in that the, the bottom of the heart isn't squeezing, but the, the top of the heart is. And the prognosis with this type of heart attack is actually pretty good more often than not within 30 days that the heart does recover. But again, it is a heart attack, it's a stress on the body and it, it can, you know, increase your, your risk of, of dying.

Dr. Doshi | 16:38

And just to clarify, when you say stress induced, what kind of stress are you talking about?

De. Shenkman | 16:43

Emotional stress,

Dr. Doshi | 16:44

The broken heart

De. Shenkman | 16:46

<laugh>. Yeah. I've seen situations where like somebody who's just broken up with a significant other or they've had the death of a close one and they suddenly have this type of stress-induced heart attack.

Dr. Doshi | 16:57

Yeah. So what if you get in there and you know, it's not <unk> it's a, it's a STEMI or a non-stemi, but for whatever reason are there situations where you can't help, where you can't open it up and then something else has to happen?

De. Shenkman | 17:09

That is a great question. There are situations where I may go in and inject dye into the arteries and I may see that there's like severe blockages. For example, I may see that there's like a severe narrowing within the left main coronary artery or or severe complex narrowings within multiple arteries. If that is the case, then that might be somebody who should undergo a coronary artery bypass surgery. And that's a procedure that's done by a cardiothoracic surgeon. It involves cutting the chest open, spreading the ribs, and um, literally bypassing the blocked portions of the coronary tree. And the, the bypass is done with, um, typically the left internal memory artery, which is an artery that runs along the front wall of the heart also can be used one of the radial arteries, which is an artery that's of one of the arms or the greater saphenous vein, which can be removed from one of the legs and that can be cut into a, a few pieces and then sewn onto the aorta and then attached to the part of the heart that needs to be bypassed.

Dr. Doshi | 18:15

So definitely invasive, not a simple thing. Pretty

De. Shenkman | 18:20

Invasive. Yeah.

Dr. Doshi | 18:21

So it's best to just not have heart disease to begin with, one could say. So what does cause heart disease and how does it even come about?

De. Shenkman | 18:31

So that's a great question. So heart disease being as common as it is, it's important to know what causes it. There are things that we can control and there are things that we cannot control. So starting with things that we cannot control, we cannot control our genetics unfortunately. So if you have family members who've had heart disease at a young age, you are gonna be more likely to have an issue with your heart at a young age or at some point in your life. Also abnormalities in cholesterol, if you're somebody who's born with a, a metabolism that is what we call a familial hypercholesterolemia where your liver just likes to make a lot of cholesterol, having all that cholesterol running through your body as a consequence is gonna put you at increased risk. People as they get older, particularly in women, you know, having regular menstrual periods seems to be somewhat protective though I've seen women of young ages who who've had heart attacks.

De. Shenkman | 19:25

But it's, it's fairly uncommon. But after menopause risk definitely goes up. And then with both genders, age is definitely a risk factor. The older you are, the more likely you are to have coronary artery or disease or a heart attack, then there are the things you can control. And again, you know, 80% of heart disease is lifestyle. So it's the food we eat in particular, making sure you're getting plenty of fruits and vegetables, leaning more in the plant-based direction. Exercise, exercise is definitely a protective thing to reduce your risk of having a heart attack or a stroke. Um, the more you move up into a certain point is definitely predict, uh, protective of your heart but also controlling the traditional risk factors. So if you have high blood pressure, making sure that you're doing everything you can, whether that be medications or lifestyle to reduce your blood pressure to healthy levels.

De. Shenkman | 20:20

Hypercholesterolemia, if you have high cholesterol, making sure that you are controlling your cholesterol levels with lifestyle and sometimes medications. Diabetes, if you have diabetes, making sure that your blood sugars are under good control, that's gonna be very important. Smoking becoming less and less of a problem. Maybe it's cuz I'm in California, we don't see as many people who smoke. I know it's more prevalent elsewhere, but smoking is definitely a risk factor for heart disease. And if you're a smoker, it doesn't matter how long you've been smoking, if you can quit, you know, the sooner you can quit, the better for, for your heart.

Dr. Doshi | 20:56

Yeah, I come from the land of the, uh, 30 year old with lung disease because they've been smoking since they were 10. So <laugh>. So it's definitely still, I work in the part of the country that is still smoking. So how does that, how does smoking actually affect the heart? What's going on? Cellularly,

De. Shenkman | 21:12

Cellularly, well it's, it's an inflammatory process. It's something that affects really, I mean multiple organ systems, not just the heart but also the lungs. It increases the amount of plaque that's within the arteries, perhaps makes plaque more vulnerable.

Dr. Doshi | 21:27

So a lot of extra inflammation causing that smoking and just going on throughout the body. What about high blood pressure? How is that causing and attributing to heart disease? This kind

De. Shenkman | 21:37

Elevated blood pressure changes the structure of the arteries and the heart. It makes the heart stiffer. It also enlarges the heart because if you think about it this way, if you have a high herb blood pressure, you need to have more muscle to squeeze to push against that pressure. So it's like a bodybuilder.

Dr. Doshi | 21:55

But bodybuilders are healthy, aren't they? They

De. Shenkman | 21:57

Are. No, but I'm, I'm trying to use the analogy of, of muscle and getting bigger and why a muscle gets bigger. So if your body builder and you're lifting heavy things, your muscles are gonna get nice and big. It's like, just like the heart of it's gotta squeeze against a high pressure, it's gonna get bigger. But if that pressure comes down then that heart muscle can actually shrink back down in size.

Dr. Doshi | 22:20

And so we don't want the heart muscle to be all that big. We don't want it to be like biceps,

De. Shenkman | 22:26

<laugh>. No.

Dr. Doshi | 22:27

What happens if it doesn't get too big? What, why is that an issue?

De. Shenkman | 22:32

Well, an enlarged heart can lead to heart failure is something called diastolic dysfunction, which is poor functioning of the heart is a consequence of stiffening of the heart muscle, which can happen if the heart is, is enlarged over

Dr. Doshi | 22:48

Time. So that sounds terrible. Now tell me about cholesterol because for whatever reason that is still controversial. How is cholesterol playing a role here? Isn't cholesterol saving us

De. Shenkman | 23:00

<laugh>? That's a great question. So we need cholesterol, we'll start there. We absolutely need cholesterol. We need cholesterol for our sales function and for our brain to function and for our neurons to be healthy. But we don't need that much cholesterol. Our bodies make well, more than enough cholesterol for us to function. The dilemma is that if cholesterol levels are, are too high, that correlates with an increased risk of heart attack and stroke. And there are, you know, linear models that show that on one axis you have l d l cholesterol level on the other axis you have, you know, risk of heart attack and stroke. And it's, it's a linear correlation. The higher your cholesterol, the higher your risk of heart, heart attack and stroke.

Dr. Doshi | 23:45

And so if I am having excessive cholesterol in my body, what does that do to those, those plaques that you were mentioning earlier?

De. Shenkman | 23:53

Well it cholesterol can be deposited within that. Those plaques as well can lead them to growing, but also it leads to a more inflammatory milieu that increases the risk of of having something bad happen.

Dr. Doshi | 24:04

And do we have an idea yet about diabetes and its role in causing heart disease?

De. Shenkman | 24:10

Well, diabetes definitely increases the risk of a heart attack and stroke. And we know that by adding, um, a statin medication on, it's actually one of our, our class one recommendations from the American Heart Association in American College of Cardiology, that giving diabetics a statin medication, any diabetic between the age of 40 and 70, you can reduce their risk of developing, um, cardiovascular disease.

Dr. Doshi | 24:34

How much of a risk reduction is there?

De. Shenkman | 24:37

I don't know that I've got a perfect number. I don't know that I have a number for you. Um, but when it comes to risk reduction in statins, I don't know if that was something you you were gonna wanting to talk about later on in our interview, but you know, I'll, I'll just put the plug here cause I've started talking about statin medicines. I mean, statin medicines don't necessarily make a huge difference, especially in somebody who hasn't already had a heart attack or stroke, who doesn't have a familial hyper cholesterol in year isn't a diabetic, it's something that will incrementally reduce risk when we're talking about reducing risk. Lifestyle is, is probably the biggest thing. So it's probably diet and exercise and then statin add it on top of that in terms of being additive in reducing risk of heart disease.

Dr. Doshi | 25:19

Gotcha. So if you had to start in just, if you had to give an order to what people should be trying to do in priority, get their blood pressure under control or their cholesterol or their diabetes or their smoking or whatever, what should they be on top of first?

De. Shenkman | 25:35

I think if we're talking about all of those things in terms of priority of what is going to provide the biggest bang for the buck in terms of health benefit, I'd start with the smoking.

Dr. Doshi | 25:42

And then how is this all these risk factors typically addressed by just a regular non lifestyle informed cardiologist? What is the usual method?

De. Shenkman | 25:53

There'd probably be medications for blood pressure for cholesterol, but that said, all of our American college cardiology and American Heart Association talk about, they talk about the importance of urging patients to have better lifestyle in practice. I don't know how much that happens, how much time cardiologists or even primary care doctors devote to those conversations.

Dr. Doshi | 26:18

So really trying their best with medications and whenever intervention is necessary. So as someone like yourself who practices lifestyle interventions with their patients, how do you address things? Where do you go with patients when they show up and they have all these problems and heart disease

De. Shenkman | 26:35

<laugh>? Right. Well, I try not to overwhelm people. I try to start with number one, is there like something that is going on that I need to act on in order to save this person's life? So if they're coming in and they have like this severely abnormal valvular issue or a severe heart rhythm abnormality or recently, you know, somebody who's having symptoms of like for example, passing out every time he's getting up working on telephone poles and I need to, you know, prep, diagnose his severe carotid stenosis that needs to be operated on so that he doesn't, you know, pass out and die or have a massive stroke. Like that's, I start there like if something really big is going on, I address that first and more often than not that happens. Um, but if it's somebody who comes into me who's not having significant symptoms, who's got multiple risk factors and maybe their diabetic is not under the best of control, they may have high blood pressure, cholesterol, maybe even have had a heart issue and, and I know that their lifestyle's gotta be better and I know there's so many things that we need to do.

De. Shenkman | 27:45

I try to start small. I'll say, you know, I ideally these are the things you should be doing, but let's start with like this one thing. So let's say we're talking about diet and like all of their meals are are from restaurants, which we know that restaurants don't have our health in mind when they're preparing their food. Mm-hmm. <affirmative>. So we might start there. Okay, so how can we maybe get some healthier meals into your diet? Um, is Meals on Wheels an option? Do you do any cooking? Do you have family members who do any cooking? Can you grocery shop? So I mean, I might give them something that's that's small and actionable. Like maybe rather than eat lunch at a restaurant every day at work, bring your lunch to work three days out of the week and that's something that's actionable and we can talk about that at the next visit. That's, um, just one example of, of a way I might approach things, but I I try not to overwhelm my patients.

Dr. Doshi | 28:38

Let's say you had someone super motivated, ready to just jump on and follow everything you tell them right away, what would you tell them what's ideal?

De. Shenkman | 28:47

I would ask them what unicorn village they come from, but no, no, seriously, I think I'd, I'd lay it out all out for them if they feel like they're like Doctor I wanna do everything and say, okay, well here the things you can do follow up with me and it would be a pretty short follow up and you know, talk to me about at the return visit about how things went and, and from there we can kind of troubleshoot and, and go from there.

Dr. Doshi | 29:11

What would you tell them the ideal things that they should be putting in their body and the ideal things not to be putting in their body?

De. Shenkman | 29:17

I would say that ideally they should be eating a more, a more plant-based type of diet. So minimal animal products, if any, getting plenty of fruits and vegetables, you know, rather than telling them what to exclude. I like to talk about what to include in the diet because I think most people aren't getting enough fruits and vegetables in their diet. So I would say start there. So more, more fruits and vegetables. They can be cooked, they can raw, just get, just get some, some vegetables and some fruit into your diet. Get your meals at home, look towards things that are less processed or you know, shall we say smartly processed sources of protein that are more plant-based. Things like beans, lentils, tofu, even yo some of the so-called fake meats I think are are reasonable. They're, they do tend to be a little bit higher in sodium and a little bit more processed, but they can be, I think they can be a healthy part of a diet, you know, minimizing sugary snacks.

Dr. Doshi | 30:12

Yeah, that actually raises a question for me. Where do you see as the harm of things like saturated fat, unsaturated fat, refined sugars? How does that play a role?

De. Shenkman | 30:23

It's a good question. In diets that are higher in saturated fats and in refined sugars do tend to have an increased risk of, of heart disease.

Dr. Doshi | 30:32

And then as far as looking at the evidence, what kind of things do you see in the research that tell you that, oh yes, this is the best thing for my patients to be eating. I want them on this kind of plant-based diet.

De. Shenkman | 30:44

I, I think that you look at, you know, some of the, the epidemiologic data for example, you look at what we consider to be the blue zones and those are areas of the world where people tend to live the healthiest and live the longest and they all have certain things in common. Smoking is rare, they move around a lot. They have close family connections, but what most of them also tend to have is fairly healthy diets. They eat plenty of fruits and vegetables. They don't eat much, much animal product or meat in their diets. So to me I think that's, you know, that's strong evidence.

Dr. Doshi | 31:20

In your book you also cite some studies the ordinance trial that actually talks about regression of coronary disease. Is that something that you see holding up in your practice when people are able to kind of change?

De. Shenkman | 31:33

I think you can. There have been studies that have demonstrated regression or reversal of plaque in the arteries and the best studies that have have involved statin medications or patient, you definitely can see regression of plaque even, you know, Dr. Caldwell Essen has some studies where they used a technique called quantitative coronary angiography, which may not be the most perfect way of looking at the coronary arteries and measuring plaque. But based on their measurements, um, particularly Dr. Ornish's study, looking at patients before and after, he did see that with that particular technique that there was some degree of reversal of coronary disease. In fact, from what I recall from Dean Ornish's studies, 82% of all patients actually had regression or reversal of plaque in the arteries. Whereas the standard of care is that over time plaque builds up and increases. So seeing regression is, is a pretty big deal.

Dr. Doshi | 32:29

Do you have any thoughts on statin regression versus lifestyle regression versus both?

De. Shenkman | 32:37

I, I think, you know, depending on the person, I think the answer's gonna be both. Quite honestly, if you do already have plaque within your arteries, oftentimes it's appropriate and helpful to be on a statin medication. And keep in mind that statins and lifestyle go hand in hand. I know there's a lot of bad press, shall we say about statin medications and quite frankly a lot of misinformation about them. The majority of people who take statin medicines do perfectly fine. It is said in the literature that about five to 10% of people have muscle aches that are caused by statin medications. The vast majority of those are temporary and you stop the statin medication and, and the muscle aches get better. Statins do not cause overt liver failure. There's never been a person who has required a liver transplant as a consequence of a statin problem. Um, the majority of people who are on statins who have liver abnormalities tend to have liver, liver abnormalities for other reasons, for example, such as fatty liver and not because of the statin medication itself.

Dr. Doshi | 33:42

Okay. What about things like increasing the chance for diabetes from a statin?

De. Shenkman | 33:46

That is an excellent question and the short answer is that yes, a statin medication does increase the risk of diabetes, but the nuance of that answer is it's far more complex than that because yes, statins do slightly increase, increase, increase your glucose levels, and if you are somebody who's right on that borderline a statin medication, if it pushes your glucose levels up, a couple of points you over to be technically a diabetic person, but importantly has a benefit on the inside of the body of stabilizing and reversing plaque that's in the arteries and long-term reducing the risk of heart attack or stroke.

Dr. Doshi | 34:28

So really if it's, if the concern is development of diabetes, that's gonna happen in people who already in that pre-diabetic range

De. Shenkman | 34:36

More often than not, yes, it's not typically the statin is not gonna make a huge difference, shall we say. It's not gonna take somebody with normal glucose levels and suddenly make them a horribly uncontrolled diabetic. It doesn't work that way.

Dr. Doshi | 34:50

Okay. So if somebody is not even close to diabetes, then that risk is close to nil.

De. Shenkman | 34:55

I would agree with that, yes.

Dr. Doshi | 34:57

Now since we are talking about plant-based nutrition and heart disease, what happens if somebody goes the exact opposite direction because they spend a lot of time on social media and now they're taking in a high fat, high protein, low vegetable diet <laugh> fiber?

De. Shenkman | 35:12

Uh, that is, it's a good question and unfortunately it's something that I'm sure you, you and I see all too often is that those types of diets, unfortunately being higher in saturated fat, higher in cholesterol can actually increase the risk of progression of coronary disease and increase the risk of heart attack and stroke.

Dr. Doshi | 35:33

Okay, so it's not going to help. No. Even if it lends up, up uh, shedding a few pounds?

De. Shenkman | 35:38

No, I think, I think it's Michael Gregor who, who said this, it's like your goal is not to die in a smaller coffin

Dr. Doshi | 35:46


De. Shenkman | 35:48


Dr. Doshi | 35:49

I like that. Yeah, definitely. Please don't go keto is what I'm hearing.

De. Shenkman | 35:53

I would agree. Please don't go keto. Well I think there's some nuance to that as well. Cause the vast majority of ketogenic diets are animal protein-based. There is, I've seen on social media a little bit about vegan keto diets. I don't think there's any data on vegan keto diets. To my knowledge. I don't see that they've had the same negative consequences, but I don't know.

Dr. Doshi | 36:19

Fair enough. Now how do you see, when you talk to people about trying to get them started in exercise, how do you start a person that has just recently had a heart attack, what's safe for them to do? What do you tell them?

De. Shenkman | 36:29

So if somebody has just had a heart attack, I don't want them going out and training for a marathon. Um, that's just not gonna be good for them. <laugh> I would say that start by walking. So when, when somebody's being discharged from the hospital and I'm seeing them right before they leave, I'll talk to them about exercise and I'll talk to them about a program called Cardiac Rehabilitation, which is a great supervised educational and exercise program that people just really get a lot out of. And if they go through it, they, you know, they do better in the long term. But I'll say until you see me in the office in one to two weeks, I, I want you doing nothing more than gentle walking. And if with that you are having chest pain or shortness of breath or anything that seems out of the ordinary, I wanna know about it

Dr. Doshi | 37:09

Immediately. So don't overdo it. It's still possible to overdo it even in that vulnerable stage of the recovery really maybe at any point. And then also in your book, I'm glad to see that you also address sleep, stress management, relationships, nature. How do you see those playing a role in the causation or prevention of heart disease?

De. Shenkman | 37:30

I think that's all very important stuff. I think that making sure that you're a happy and well balanced and that you're stressing your life is controlled, it will reduce your risk of having problems. Cuz when you're, when your stress levels are are under control, you know, theoretically your inflammation in your body is less, but also you're making better lifestyle choices when you're stressed out, you're gonna be more likely to grab the donut, um, rather than the, you know, apple or which you otherwise would eat if you were, you know, a well rested, not stressed person who had a little bit more time to make some, some good diet choices, for example. Also, if you're, you're less stressed out, you've got more time to get the exercise that you need.

Dr. Doshi | 38:18

Yeah, that makes sense. Now, in your book, just to play right off that, cuz none of us for the most part are doing those things like we need to be, you talk about a culture that promotes heart attacks and living in that culture. What do you mean by that? I,

De. Shenkman | 38:33

I mean that like our, our culture, like for example, you, you go out and you go to like, uh, you know, baseball game or football games, like what are people eating? They're eating, they're eating hotdogs, you know, they're drinking sodas, they're eating french fries, you know, things that are not necessarily health promoting foods. And there isn't necessarily a, a culture that promotes exercise. Even like for example, here in Los Angeles, I'm somebody who likes riding my bike. There aren't a lot of bike lanes available within City of Los Angeles. It's like, if you wanna go somewhere to safely ride your bicycle, you gotta drive to a park or go to a more rural area, for example. You know, and also things like that, you need a car to get everywhere. At least here in Los Angeles, it's hard to navigate public transportation. Whereas in other places in in the country, you know, you can, you know that if you walk one or two blocks, you can get to a bus stop that'll take you to the place that you need to go. You know, cities that are, that are more walkable and certainly being somewhere where you have the space to exercise and you have the resources to eat good food, you're gonna do better. The other thing about certain parts of, of this country, particularly urban areas, that is, they're considered to be food deserts. Even though there's like a McDonald's or a KFC or a Burger King on every corner, there aren't grocery stores where you can find plentiful produce and healthier food choices. So your selection of what you can eat is going to be limited.

Dr. Doshi | 40:03

Yeah. So how do you help people or advise people that are in those situations? Either you know that they live in the food desert or maybe their entire family lives in the culture that promotes heart disease.

De. Shenkman | 40:14

Right. That's and that's always tough. No, I, I really try to help encourage my patients to be advocates for themselves. So, you know, if they're, they're with family and their families, like, well how come you're not eating this? You know, ribs one, one of the things I tell my patients, and I actually got this from a, a personal trainer who I used to work with is, you know, tell them to blame me. Blame your cardiologist. Tell them that. Like, I can't eat that. Cause if I eat that my cardiologist is really mean and she's gonna scream at me

Dr. Doshi | 40:43

<laugh>, she's gonna fire me. I'm not gonna be able to see her anymore.

De. Shenkman | 40:46

<laugh>. Yeah,

Dr. Doshi | 40:47

That's good. And that takes all the pressure off them at least.

De. Shenkman | 40:50


Dr. Doshi | 40:51

There is much more to this conversation, so much more. I split it off into another episode. That episode will speak much more on the rest of the process in diagnosing and treating heart disease. It's essential information if this is happening to you or someone you care about. So I hope you'll listen. Thank you to Dr. Shankman for taking time during your busy clinic schedule to start this primer on heart disease with us. Check out her book, the Vegan Heart Doctor's Guide to Reversing Heart Disease, losing Weight, and Reclaiming Your Life. Also, thank you to you, the listener, for sharing your time with us today. Now I'd like to take a moment and describe for you a poorly vetted analogy. I don't know my Star Wars very well, but I have seen most of it and I think I'll try that general theme to explain how a heart attack happens. Star Wars is the one with Rick Morans, right?

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