Shenkman Interview Part 2
[00:00:00] Dr. Sagar: how do you find out if you have heart disease? Once you have it what do you do about it
[00:01:17] If someone showed up in your office for chest pain and you were suspicious that it was cardiac, either stable or unstable, take us through both scenarios . How would you work that person up? What kind of diagnostics might that person find themselves undergoing?
[00:01:32] Dr. Shenkman: So let's say we've got somebody who comes into my office who is telling me that for the past, we'll say month or two months, when they go on their usual hike or their usual walk, that they get chest pain when they exert and they have to sit down or slow down, and then the pain gets better.
[00:01:49] Or even if the story isn't quite as straightforward as that, I would probably wanna do some kind of a stress test on that person. And there, there's a variety of stress tests. You know, an [00:02:00] exercise stress test is tends to be the ideal. If the person is able to exercise, it's always better to get them on a treadmill.
[00:02:07] And replicate that exertion and see what the heart does with that. So you can put a person on the treadmill and watch their EKG monitor their blood pressure, their heart rate response to exercise, their blood pressure response to exercise, see if the, they, there are any changes in the EKG when they exert themselves.
[00:02:24] In addition to that, we can do imaging, either an echocardiogram to look at the movement of the heart before and after exercise to see if there are abnormalities or there are nuclear tests. They can look at perfusion or blood flow to portions of the heart, both before and after exercise.
[00:02:42] Dr. Sagar: If somebody Passes these tests, what are the chances of them actually having some sort of heart event?
[00:02:48] Dr. Shenkman: That is a good question. And un unfortunately, there is, there is no perfect answer. There's no perfect test that's gonna tell me a hundred percent. You have blockage. You don't have blockage short of [00:03:00] an actual coronary angiogram where you're injecting, dying to the arteries of the heart.
[00:03:04] But it gives us additional information. That said, if somebody has, has one stress test that somehow comes back abnormal, but my index of suspicion is still high, I might go to other modalities. And one of those modalities that we have that's relatively new, that's not terribly invasive as a, a CT coronary angiogram, it's a CAT scan that can be done of the arteries of the heart with, with dye in an outpatient setting in an imaging center.
[00:03:33] And it, it. It helps to measure calcium and it gives us a, a sense of whether or not there's, there's plaque or not plaque that's, that's present. An invasive coronary angiogram inside a hospital setting is, is gonna give us more, more data, but that's another thing that we can use.
[00:03:51] Dr. Sagar: And then how good is that coronary angiogram that is invasive?
[00:03:57] Because I've heard of some places [00:04:00] starting to do it with ultrasound because of plaques being in the walls that they wanna see. Is that something that's common now?
[00:04:07] Dr. Shenkman: Okay. You may be talking about intravascular ultrasound, perhaps. Yes. Okay, so that's, that's an additional modality. So with a coronary angiogram, what we're doing is we're injecting dye into the arteries of the heart.
[00:04:19] We're taking x-ray pictures, like moving X-ray pictures, so we can get a good sense of, you know, in different angles whether or not there's narrowing. Now you can actually do techniques where you're looking at the walls of the arteries from the inside. One of those is ivus, also called inter intravascular ultrasound, and there's also something called O C T or OC optical co Tomography, which is another way of looking at the arteries from the inside.
[00:04:44] And we can better differentiate what type of plaque is present, whether or not a narrowing is more eccentric, more calcified. And that's, that's good data that we use in our procedures. Is that
[00:04:55] Dr. Sagar: something that people should be asking about, [00:05:00] inquiring about when they see their cardiologist?
[00:05:01] Dr. Shenkman: I'm gonna, I'm gonna say no.
[00:05:03] That's, that tends those invasive procedures looking at the inside of the artery, that's typically done when we're, we're doing an invasive procedure and patients on our table and we're trying to get a better sense of the
[00:05:13] The anatomy of the artery.
[00:05:15] Dr. Sagar: Okay, so it's, they're already on your table, you see something that's suspicious that needs more information and then you pull out these extra tools.
[00:05:22] Yes. Those are definitely
[00:05:22] Dr. Shenkman: within my tools
[00:05:23] Dr. Sagar: for that, yes. To give you more information. And then you mentioned already the calcium score. What is the calcium score and how is it used?
[00:05:30] Dr. Shenkman: Okay, so a coronary calcium score can be obtained by a pretty quick CAT scan of the chest. Fairly low radiation, pretty quick test.
[00:05:39] And it just measures how much calcium is in the arteries of the heart. And it gives you, you get a score, you can have a score of zero, which would be the best score you can get, which would indicate that there is a. Zero detected calcified plaque in the arteries of the heart. The higher the score, the greater the risk.
[00:05:58] Particularly if somebody [00:06:00] gets a score that is greater than 400, that's pretty concerning. If somebody who's gonna be higher risk of, of having events that said, a coronary calcium of score of zero, while it is, it does indicate low risk, the risk of having a heart attack or stroke in the next four years is almost zero.
[00:06:18] It does not necessarily mean there's no plaque in the arteries. It just means there's no calcified plaque in the arteries because younger people, for example, may tend to develop plaque, that softer plaque that may not yet be calcified and calcium tends to be something that we see with with
[00:06:33] Dr. Sagar: age. So it takes time for a plaque that's developed to get its eggshell, to get that calcium covering often.
[00:06:40] So, yes, and somebody might have a low score of something like zero, but they may still have plaque inside their heart vessels, but they're still not at risk of a heart attack. Is that what you're saying? With that score of zero
[00:06:54] Dr. Shenkman: for four years? It's, it's not quite what I'm saying. I'm saying that, you know, if, if your coronary calcium [00:07:00] score is zero, statistically your risk of having a heart attack in the next 4 0 4 years is very, very low.
[00:07:05] It's close to zero, but that person may have soft plaque and may have the beginnings of, may have some degree of coronary artery disease that isn't being picked up with the coronary calcium scan. And later on down the line, there's somebody who very well could be at risk. So that's why we, for one thing, we don't.
[00:07:26] Typically do coronary calcium scans until people are are age 40 or older, because younger people, you're not, you're just not gonna get, you're not gonna get good information because again, they may have soft plaque that we're not seeing. Okay. So
[00:07:38] Dr. Sagar: be reassured if your score is zero, but don't be invincible.
[00:07:42] You're not invincible at that point. It may be in a state where disease may progress and then you are at a higher risk, and that could happen within four years.
[00:07:50] Dr. Shenkman: I think that's a, a pretty accurate assessment. Yes. What are these
[00:07:54] Dr. Sagar: things called carotid intima measurements that are seeming to pop up in offices around, is that a useful test?
[00:07:59] [00:08:00] What's going on there?
[00:08:01] Dr. Shenkman: So, carotid intimal me media thickening. It can be measured, it can be a, a measure of risk, but it doesn't, it doesn't necessarily add much more than checking cholesterol checking like LP little A and, and other markers. So it's just not a test that we routinely do and it's not routinely recommended by our societies
[00:08:24] Dr. Sagar: because I just as I.
[00:08:26] Go round and see doctor's offices, sometimes it seems to be popping up more and more that they'll do it right there in the office for you.
[00:08:33] Dr. Shenkman: Yeah. And your insurance might not cover it.
[00:08:35] Dr. Sagar: Okay. Good to know that that's not helping more than the other modalities. And now as far as cholesterol, we've talked about it not being a myth that it is strongly related to heart disease.
[00:08:49] What are the different kinds of cholesterol that somebody's gonna look at when they get their cholesterol tested? So when
[00:08:54] Dr. Shenkman: we do a standard lipid panel, and I know there are these kind of like Boston Heart and these fairly complex lipid panels that look [00:09:00] at all these various subfractions, we don't have a whole lot of data on what to to do with that information.
[00:09:07] So, I mean, it's not something that I routinely will order. When we look at, you know, a traditional lipid panel we look at, we look at really four major things. We look at total cholesterol level, we look at H D L cholesterol, which is the so-called. Good cholesterol. The L ldl, which is the so-called bad cholesterol, we look at the triglycerides, which is basically the fat and the blood.
[00:09:30] So what is definitely predictive of of heart diseases, elevated L LDL and elevated triglycerides as is low HDL cholesterol. People with lower HDL cholesterol, so when with hdl, under 50 men with HDL under 40 are at higher risks.
[00:09:47] Dr. Sagar: What about if the HDL is high?
[00:09:50] Dr. Shenkman: That's not necessarily protective. In fact, we see that people who have these super high HDL cholesterol levels that approach a hundred or [00:10:00] higher, they actually have higher risks of developing coronary disease. And we think that perhaps a lot of that HDL cholesterol is what we call non-functioning.
[00:10:10] So HDL cholesterol is supposed to be good cholesterol. It's supposed to help reverse transport the cholesterol particles from the artery to be removed from the body. So perhaps those people with the, the higher HDLs, their HDL perhaps isn't functioning in that manner, are functioning
[00:10:26] Dr. Sagar: properly. That is not what many people have come across.
[00:10:29] Cuz I know that when I get my insurance exams and whatnot, it's just a pure, is your HDL high enough? Is your HDL high enough? Yeah. And there's never a consideration of, is your HDL too high? Now when you see plant-based people as maybe you do or maybe you don't. I don't know. You tell me. Do they have any issues with.
[00:10:46] HDL being too low. And does that cause any
[00:10:48] Dr. Shenkman: problems? It's, it's a good question because you know, from what I've seen, I think there's some data to support it. People who go from eating standard American diet to going on a whole food plant-based diet, [00:11:00] their HDL cholesterol may drop, but their other parameters, their triglycerides or L LDL cholesterol also drops as well.
[00:11:08] There really is no evidence that they need to be doing anything to raise that cholesterol or that they necessarily need to worry. Because reading a plant-based diet and your other parameters are, you're getting better, you're gonna do better in the long term. And when it comes to DL cholesterol, there actually have been studies looking at, at medications for of a class called C E T P inhibitors that are supposed to specifically be targeted at raising HDL cholesterol.
[00:11:35] And those studies actually show the opposite. You give those medications to people to raise their cholesterol, you actually increase their risk of heart related event. So it is not indicated that we target medications to specifically raise the H dl. I tell my patients, you know, the HDL is what it is. The vast majority of what your h DL cholesterol is genetically driven with lifestyle quitting smoking.
[00:11:57] You may budge that number a little bit, [00:12:00] but it's just something that we just don't worry about it. We just don't have the data to support doing anything to specifically target that number, that
[00:12:06] Dr. Sagar: HDL number. Correct? Correct. What about VL dl? How's that different from regular L ldl and does it carry any different significance?
[00:12:14] If it's high but the regular LDL is not as high?
[00:12:18] Dr. Shenkman: Does does make a difference Off the top of my head, I don't have a really awesome answer to your question though. Fair
[00:12:23] Dr. Sagar: enough. Are these two things, these LDL and these triglycerides, are they gonna travel together? If someone is successful at getting one of those down, is the other one gonna go with it?
[00:12:32] Dr. Shenkman: necessarily. Doesn't necessarily work that way.
[00:12:36] Dr. Sagar: Might take some extra effort. Is there any difference in what they should be doing if they're trying to get their L D L down versus their triglycerides versus both?
[00:12:46] Dr. Shenkman: I think that the recommendations are gonna be similar exercise, eating healthy, minimizing saturated fat, you know, eating more plant-based, more fruits, more vegetables.
[00:12:58] I, I don't, I really [00:13:00] honestly don't think you need to gear advice towards one of those versus the other. I think, you know, good advice should help both of those numbers.
[00:13:08] Dr. Sagar: And if a person is looking at their panel of numbers, how should they see their numbers and think about them, what numbers should be worrying to them and what numbers should be reassuring to them?
[00:13:18] Dr. Shenkman: So I would say the, the most important number probably to look at in that lipid panel is gonna be the L D L cholesterol. If, if you are somebody who is not an otherwise healthy person, you really want your l d l cholesterol to preferably be under 100. And if it's not there, look at your lifestyle or the things that you can do better to try to improve your cholesterol numbers.
[00:13:42] Triglycerides, ideally you want that number to be under like one 50. Lower being better, higher triglyceride levels can be associated with increased risk, but the concern with triglycerides is if your level is greater than 500 and a triglyceride level greater than 500, yes, it's [00:14:00] associated with higher heart risk, but it's also associated with an increased risk of pancreatitis.
[00:14:06] So you don't want your, your triglycerides being that high for any period of time, and that's. Something that definitely would need medication treatment to specifically target those triglycerides
[00:14:17] Dr. Sagar: and pancreatitis, just for anyone that doesn't know is inflammation of the pancreas, which lives just under your chest wall and can be terribly, terribly painful.
[00:14:27] And if you get your blood drawn out and your blood doesn't look red, but rather looks white, you may be in trouble and need to get your lips checked. This is true. This happens not infrequently where I work. Now, I've heard of a concept where if your cholesterol is low enough, you don't have to worry about heart attacks.
[00:14:45] What do you make of that?
[00:14:47] Dr. Shenkman: I think there's a little bit of nuance to that. I know that in some circles it is, there's the statement that if your total cholesterol is under one 50, you are heart attack proof. I don't think that that's necessarily [00:15:00] a hundred percent. I think lower your, your cholesterol, the lower your risk.
[00:15:03] But I don't think that a total cholesterol under 150 is like your green light, that you're never gonna have any problems.
[00:15:10] Dr. Sagar: Is there a heart attack proof level for your ldl?
[00:15:15] Dr. Shenkman: Typically, the, the recommendation is that if we're treating LDL cholesterol, lower is always better and there really is no threshold be below which we see problems.
[00:15:26] Otherwise. There there've been medications. They're called PCSK nine inhibitors. They go by the names of Prou and Repatha. There've been studies with those medicines where they've driven l LDL cholesterol, super low. We're talking like tens and twenties. And there've been no effects. Yeah, that low.
[00:15:43] And there are also people who have these gene genetic mutations where their, where their PCSK nine mechanism doesn't work properly. And as a consequence, their LDL cholesterol is super low. And, and these people have a very, very low risk of heart attack and stroke. And they also have very low [00:16:00] cholesterol levels, but they don't have any issues that are negative, that are a consequence of their cholesterol being
[00:16:08] Dr. Sagar: But if someone has had heart disease or is worried about getting heart disease, where should they really optimally have their LDL below?
[00:16:15] Dr. Shenkman: Right. It, it really depends. If it's somebody with risk factors, there, there are guidelines that suggest that you really want your LDL cholesterol below 50. But if you are somebody who doesn't have specific risk factors, probably aiming for an L D L under 100 should be sufficient.
[00:16:31] Dr. Sagar: Getting an LDL below 50, that's a, that seems really hard. Have you been able to see people successful in doing that with just lifestyle or do they require medications to get to that level?
[00:16:42] Dr. Shenkman: People who we are recommending an l d l of less of 50 or less are people who have indications for statin medications.
[00:16:49] So those are people that we have on high intensity statins, and we typically, we can get their, their cholesterol down that low more often than not.
[00:16:57] Dr. Sagar: That makes sense because the population that would need to worry about that [00:17:00] probably isn't going to need where beyond any medications for that to begin with.
[00:17:04] So let's dive in a little bit more about the medications that you're mentioning. We've talked about statins, but what are the other medicines that somebody with heart disease. May find themselves on. And how do those medications work? Okay,
[00:17:17] Dr. Shenkman: so somebody who has heart disease, often we, we've talked about statins.
[00:17:21] That's pretty much across the board. If you have heart disease, if you had a heart attack, if you've had a stroke, if you have plaque in your arteries, you should be on a statin medicine. Unless you have some sort of untoward. Reaction to it. But other medicines are antiplatelet medicines for. So for example, there's baby aspirin.
[00:17:37] Now the pendulum is swinging one way versus the other. With, with new data that we had. At one point it was thought, well, everybody should be on a baby aspirin after a certain age. But the dilemma is, a baby aspirin isn't necessarily a benign thing because baby aspirin is something that can't, it's an antiplatelet medicine, it can cause bleeding.
[00:17:56] So if you're somebody who's considered to be [00:18:00] higher risk of having a heart attack or stroke, you talk to your doctor about whether you should be on one. But if you've had, if you've had a heart attack or stroke, you definitely should be on one. Especially if you've had a recent coronary angioplasty or stent.
[00:18:14] There are other medicines that are anti-platelet medicines that keep platelets from clumping together, that work in a somewhat different mechanism from from aspirin. Those go by the names of Clopidogrel or Plavix Prasugrel or ticagrelor. Those are often prescribed after a coronary stent is placed. And they're important medications because they, at least for the short period of time after the stent is placed, whether it be, you know, three months to a year, they're important for reducing the risk of a clot developing within that stent and causing a whole other heart attack or, or issues.
[00:18:51] Other medicines for the heart. There's medications for blood pressure. There's a new class of medications called SGLT 2 inhibitors. [00:19:00] The brand names of those are Farxiga and, and Jardiance, and those are medicines that can help to reduce the risk of, of developing congestive heart failure. They can also help protect the kidneys as well as being medications that are are for diabetes.
[00:19:14] There's also beta blockers, which help to control heart rate and lower the blood pressure a bit. They're good for congestive heart failure. And then ACE inhibitors or angiotensin receptor block. Or a newer medication called Intresto, which are good for protecting kidneys and, and good for heart failure and controlling blood pressure.
[00:19:33] Dr. Sagar: What's risk first reward for these medications? Are there side effects that may make them something that a person wouldn't wanna be on, or are they
[00:19:41] Dr. Shenkman: Yeah, there's side effects to everything, unfortunately. There's the good with the bad. I was briefly, I was talking about aspirin. Yes. It's an anti-platelet medicine.
[00:19:48] It reduces the risk of heart attack and stroke, but it's an anti-platelet medicine, so it, so it increases the risk of, of bleeding, as do those other medications that I mentioned. Namely clopidogrel, prasugrel and [00:20:00] ticagrelor,
[00:20:01] Dr. Sagar: and just to chime in, a platelet for anyone that, May not know is something that's instrumental to making blood clots.
[00:20:06] Dr. Shenkman: Thank you for clarifying that. Medications for blood pressure, they can lower blood pressure, but there's always the risk that they blood lower the blood pressure too much, which is why you follow up with your doctor. The beta blocker medicines that helped relax the heart and lower blood pressure, reduce the risk of heart attack and stroke and help heart failure.
[00:20:25] They can lower the heart rate too much and then the medications for ACE inhibitors, angiotensin receptor blockers or the newer medicine intresto can also affect the kidneys and and the electrolytes, and those need to be monitored closely when on those medicines. Now,
[00:20:42] Dr. Sagar: I encounter a lot of people that will have been prescribed these medications and some of them take them and some of the people decide that they don't want to take them and so they stop them.
[00:20:52] Or what happens way too much is they lose their insurance and then they can't afford the medications, so they stop taking them. What happens [00:21:00] if someone is supposed to be on these medicines and then. They're not,
[00:21:03] Dr. Shenkman: that's a great question, and that's definitely a problem that I see in my, my day-to-day practice when it comes to the anti-platelet medicines in people who have just had a stent placed.
[00:21:14] If those medicines are stopped abruptly, we can see what we call thrombosis. We can see that the stents clot off and the patient ends up having a whole other heart attack because that stent is suddenly blocked and we need to open that back up. We can see that if, if a statin or cholesterol lowering medicine, if that's suddenly stopped, no, we can see the cholesterol levels suddenly, suddenly rise.
[00:21:37] Though most statin medications are generics at this point and don't require insurance coverage. With the blood pressure medications and heart failure medications, we can just see the blood pressure go up. Or we see our patients who just become decompensated with heart failure, they can't move as much, they're more short of breath, their legs are more swollen.
[00:21:57] So those are some of the consequences of suddenly [00:22:00] stopping medicines. All
[00:22:02] Dr. Sagar: the problems that they were trying to avoid come back. Yes. And cause the problems that they were trying to prevent with the medications. Besides medications, we've talked about it a little bit, the procedures that can be done to somebody that has heart disease, both for diagnosing and for treating.
[00:22:21] What else is there? Is there really just placing a stent or are there other procedures as well?
[00:22:26] Dr. Shenkman: Now when you say other procedures, are you talking about specifically for coronary artery disease or Yes. Yes. Coronary artery disease. Well, well, there is definitely a stent will open up an artery, but just to clarify, stents will save a life in the setting of a heart attack and somebody who is otherwise.
[00:22:43] Having what we call chronic stable angina. In other words, they have chest pain or shortness of breath with exertion that is due to a blocked artery. We really don't have the evidence to suggest that putting in a stent is going to save a life or prolong your life or reduce your risk of a heart attack.
[00:22:59] It's just [00:23:00] treating that one particular spot. And that's because coronary artery disease and plaque is, is a more diffuse process. And putting one little stent in one place just doesn't, doesn't cure the whole
[00:23:09] Dr. Sagar: issue. I'm, I'm glad you mentioned that, cuz I was gonna ask you about that as well, because people will look at stent placement as a cure Indeed.
[00:23:17] Or a preventive measure.
[00:23:19] Dr. Shenkman: Yeah. And there actually was a really interesting trial. It was done a couple of years ago, call, it was called the ORBITA trial. And it was done in England and it was, we call a sham control trial. So it, it took patients with coronary artery disease and randomized them to either having an angioplasty or an artery opened versus just undergoing a procedure and having catheters put in and out and nothing done.
[00:23:43] That's a great control group and the. Overall outcome showed that there was no statistical significance between the two groups. Now, that's not to say that there is the overall conclusion that stents do nothing, but it is a small study and [00:24:00] it's, it's certainly thought-provoking that there was no significant statistically significant difference between those who underwent the procedure and those
[00:24:08] Dr. Sagar: who did not.
[00:24:08] And just to give it another underline, these were not people that needed their life saved. These were people with stable. Yes. Yes, exactly. Stable chest pain. Exactly, yes. From blockage. And then what's the role for bypass surgery? Is it only going to be in people that wound up an emergency catheterization and couldn't get a stent?
[00:24:28] Or who else might be interested in a cabbage? Or coronary artery
[00:24:32] Dr. Shenkman: bypass graft. A coronary artery bypass graft is really used in people who have severe coronary artery disease, particularly in the settings of having had a heart attack or in somebody who has congestive heart failure as a consequence of their severe coronary artery disease.
[00:24:49] A bypass surgery can have benefit in prolonging life, in reducing risk of, of heart
[00:24:55] Dr. Sagar: failure. Is this a treatment? Is this a cure? And will it prevent future disease? [00:25:00] It
[00:25:01] Dr. Shenkman: is a treatment to reduce the risk of congestive heart failure, but just by putting bypasses in, it's not a rotor rooter. I have patients who undergo bypass surgery who come to me and say, I had bypass surgery.
[00:25:13] I had my arteries cleaned out, and no, you didn't have your arteries cleaned out. The blockages are still there. You just have. Bypasses around them, so you've got a little, a little route for blood to get past that blockage. Interestingly, in people who've had bypass surgery, those blockages actually tend to get more narrow, more quickly.
[00:25:34] Really? Yeah.
[00:25:36] Dr. Sagar: Why the heck would that
[00:25:37] Dr. Shenkman: be? Yeah, so you can actually have progression of coronary disease in the setting of having a bypass around that, that particular lesion or narrowing.
[00:25:47] Dr. Sagar: How long does the bypass graft last? Are these people able to say, Hey, I've got a bypass. I'm good to go forever now.
[00:25:56] Keep eating the way I'm eating and moving the way I'm moving.
[00:25:59] Dr. Shenkman: Right. [00:26:00] It, it depends on the bypass. So the left internal mam artery, when it's rerouted onto the heart, onto the left anterior descendant coronary artery, that's a pretty durable graft and the vast majority of people that's gonna last than the rest of their life, a radial artery graft tends to do pretty well, but those vein grafts from the leg.
[00:26:18] Those don't do so well. At about 10 years after a bypass surgery, about half of those are completely occluded or blocked. So those are not very durable. And what
[00:26:29] Dr. Sagar: about the arterial bypass? Will they stay free and open for a lot long? How long will they stay free and open for is my question?
[00:26:39] Dr. Shenkman: They tend to the the left internal memory artery, and that'll stay healthy for most people for the rest of their lives.
[00:26:45] It's, it's pretty uncommon to have an issue there. And the, the artery, the radial artery also does pretty
[00:26:51] Dr. Sagar: well. There's not really much risk of plaque development and rupture and what's happening in the rest of the coronary arteries, [00:27:00] typically? Yeah,
[00:27:00] Dr. Shenkman: typically
[00:27:00] Dr. Sagar: not. That's actually great to know.
[00:27:03] Yes, that is correct. Have you had a, had one of these wonderful people that come from the Unicorn Village and has taken on your optimal recommendations and how have they done with their heart disease?
[00:27:14] Dr. Shenkman: That's a great question. I, I do have, you know, a collection of patients who have, you know, had heart issues and have just really embraced lifestyle and they've are on medications because after a heart attack, medications are indicated.
[00:27:27] But these people have gone like full bore plant-based diet. Some have embraced the, the essin style of eating, which is, you know, beyond just plant-based. It's, you know, no oil, no seeds, no avocados, you know, and these people for the most part have, have done amazingly well off the top of my head of people who've really stuck with that diet.
[00:27:46] And again, it's, it's challenging, you know, to stick with eating in the, the Essen style. I really haven't seen anybody who's had a recurrent heart attack with that pattern of eating.
[00:27:57] Dr. Sagar: Wow, that's a potent statement. [00:28:00] Right.
[00:28:00] Dr. Shenkman: But that senate I have had, I have had plant eaters, you know, vegans who have had heart attacks, who have gone on to develop progression to coronary artery disease, even if they've been on their, their vegan diet.
[00:28:14] You know, more often than not, that's been in the setting of not necessarily taking the medications that they're supposed to be taking. But, you know, even eating, it's, it's a matter of reducing your risk. You know, I don't know that there's anything that can absolutely make your risk zero, but certainly eating whole food plant by diet is definitely gonna slash
[00:28:33] Dr. Sagar: risk.
[00:28:34] And so do you see value in people trying to adhere to that essel style where they cut out oils and they're being as whole with their plant foods as they can?
[00:28:43] Dr. Shenkman: It's a good question. I, I think that the, you know, essel data is, it's. Pretty compelling. He took some really sick people and with dietary intervention in the 1990s, he really helped 'em.
[00:28:56] And he repeated the study in a larger [00:29:00] population, and it was published in 2014. And, and similarly, very, very positive results. I, I think that at, at least from my experience as a cardiologist, an essel skin style diet is something that is very, very hard to stick to 100%. There's also some data that suggests that there is benefit from, from oil, so things like olive oil can provide some beneficial effects.
[00:29:27] I don't know that excluding nuts and seeds and avocados, 100% from the diet is something that needs to be done. We don't, we've got a small amount of data from Dr. Essel, but I. Don't think that there is overwhelming data that would make us say that everybody who has heart disease should exclude those things from their diet.
[00:29:49] Dr. Sagar: that is, that is a study of people that had very bad heart disease. Let me interrupt the conversation real quick because we're talking about Dr. Selten, like everyone knows who he is and what he did, so let me provide some [00:30:00] brief context. Dr. Selten took about 200 people with severe heart disease and placed them on a whole food plant-based diet that insisted on several servings of leafy greens per day and avoided added fats like oil, as well as avoiding avocados, nuts and caffeine.
[00:30:15] 177 people stuck with the diet and of them, 81% improved, and somewhere between one to 10% got worse depending on how you define that. Turns out that 21 people didn't stick with the intervention, and of them 62% got worse. Now back to the conversation.
[00:30:31] So there may be a difference there in who needs what kind of measures. Just like not everybody needs to be on a statin. There are certain people that need to get their LDL low enough. There are certain people that need one thing and not the other.
[00:30:42] Correct. I've talked to cardiologists that are kind of not convinced on plant-based diet being the way to go. They're more saying that there's only enough data to say that a Mediterranean diet or lots of veggie fruits and fish and olive oil is supported. [00:31:00] Where do you see the evidence being strongest?
[00:31:03] Dr. Shenkman: I, I think honestly, a Mediterranean diet and a whole food plant-based diet are closer to one another than they are to the standard American diet. So I think that. Following a Mediterranean diet, you're gonna get, you're definitely going to get some benefit following a whole food, plant-based diet diet.
[00:31:23] You're definitely going to get, get some benefit as, as well,
[00:31:27] Dr. Sagar: because the, the alternative is the regular things that people are eating with their pizzas and their cheeseburgers isn't there? Exactly, yes. Gigantic. Seven-eleven pops. Mm-hmm. Or sodas, if you're listening somewhere that is in Ohio and
[00:31:40] Dr. Shenkman: Right.
[00:31:40] It's pop. That may be Oh, from Michigan. It's pop. Right.
[00:31:44] Dr. Sagar: It's funny. That's just a fact. Yeah. What do they call it out there?
[00:31:48] Dr. Shenkman: It's soda out here in California.
[00:31:50] Dr. Sagar: Oh, that's boring. So this isn't directly related to heart patients, but for just anyone who's thinking about changing their diet, what do you, what [00:32:00] tips do you have for them and how fast should they try to do it?
[00:32:03] Dr. Shenkman: I think it's really person to person approach. I've talked to people who've like gone vegan overnight and like they've just stuck, stuck with it. For years, that certainly wasn't me. It took me a year and a half to, from contemplation, from being ATO of a vegetarian to being a, a vegan. So, you know, I take my own experience into into mind.
[00:32:23] I think for some people it's a matter of making changes, you know, slower, one thing at a time. Things that they can feel they can sustain, but also helping to find the motivation to do that, that it's not motivation. I think this is Dean Ornish who says this people aren't motivated by the fear of dying.
[00:32:40] They're motivated by the joy of living in the long term. So you make people see that they can enjoy eating this way, that they feel better eating in a way, and that's gonna help to make it sustainable.
[00:32:51] Dr. Sagar: Leave them with carrots. Yes. Figuratively and literally. Yes, there should be carrots. And what about for people with kids?
[00:32:58] Any tips for parents?
[00:32:59] Dr. Shenkman: You know, [00:33:00] I had my daughter after my book was written, so I didn't, I didn't have that perspective on a firsthand basis when I wrote my book. My daughter is three and a half years old. And we are, we're raising her with what I would describe as a vegan ish diet. We eat vegan within the home.
[00:33:17] Her, her tastes are not necessarily the healthiest. She loves tofu. She loves bananas, but, you know, she goes to birthday parties and she, she loves cake and she loves, she say she loves frosting cuz she'll want cake, but then she'll just eat the frosting often and leave, leave the cake. That sounds familiar.
[00:33:34] So I, I think a lot of it is, you know, at least from, from my learning of how you feed kids, it's like you don't push foods at them. You show them the foods, it's, you know, it's, it's up to you when and what it's up to the child if and how much. So like I'll give her one of those plates that's got like three spots on it.
[00:33:54] You know, I'll put something that I know she lo like two things that I know she loves and then something different. So like, for example, last night we, we [00:34:00] had tacos for dinner, so I put some guacamole on her plate cuz I know she likes guacamole. I gave her some of her day of vegan mac and cheese, which not the healthiest vegan thing, but she enjoys it.
[00:34:12] So I put some that on her plate as well. And then I put some of our like our beans on the plate. She's not a big, big fan of beans, so those didn't really get touched. She had a little bit of the guacamole and she had a lot of mac and cheeses, but at the very least, you know, I wanna expose her to those foods and let her see that the mom and dad are, are eating healthy things and give her the sense of curiosity and exposure to these healthy things.
[00:34:34] Dr. Sagar: You know, you say that as far as feeding a three-year-old, but I have to, I can just see how that translates over to people just setting an example for their own family members. You know? Yeah. Here's the stuff. I've switched my diet. I'm a heart patient, so now switch my diet and then this is the stuff I'm eating.
[00:34:50] It's gonna find its way onto your plate with your usual stuff. Once you get curious to decide, oh, well that's not so bad. Alright, I'll ask some of that too. Yeah. [00:35:00] Okay. And any final two things. One, tell people how they can find you and how they can learn more about your work, how they can find you, and what final words you would leave people with.
[00:35:12] Dr. Shenkman: Great. I have a website. It's my practices website, www.drheathershankman.com. That's dr. Heather shankman.com. Got a, it's got links to my Instagram and Twitter and my Facebook page. Twitter and Instagram handle are vegan hearts. Doc. I am definitely seeing new patients. If you're somebody who. Finds my approach to heart disease, something that resonates with you.
[00:35:37] I'm in Tarzana, California, call my office and make an appointment. I do telemedicine and I can see patients via telemedicine if they're anywhere within the state of California. All right.
[00:35:47] Dr. Sagar: That's several hundred million people or something like that. I don't know how big California is. That's probably not the entire United States though.
[00:35:53] That's great to hear. They can find email@example.com. Is that what I, yes, definitely. Check out the book. It's [00:36:00] comprehensive. It takes on diet, it takes on exercise, it gives examples, and then also talks about the other lifestyle factors like how important sleep and stress reduction and time in nature.
[00:36:09] And there's more than we've talked about and there's more than I've said. So go find the book again. It's the Vegan Heart Doctor's Guide to Reversing Heart Disease, losing Weight, and Reclaiming Your Life. Dr. Shankman, thank you very, very much for being on the show and sharing your knowledge with people.
[00:36:25] I think it's definitely gonna be helpful. Great.
[00:36:27] Dr. Shenkman: Thank you for having me.
[00:36:28] Dr. Sagar: You can find the information we talked about plus more in her book, the Vegan Heart Doctor's Guide to Reversing Heart Disease, losing Weight, and Reclaiming Your Life. Also, remember, the library is a great free place for books, and if they don't already carry it, they might buy it if you ask them.
[00:36:45] Additionally, thank you to everyone that is listening. The point of this podcast is to help you understand and intervene on your health problems. If this podcast is valuable to you and you think it deserves it, please give it a five star rating wherever you get your podcasts. It'll help others [00:37:00] discover this information and help me continue to bring you wonderful guests.
[00:37:04] The numbers show that way more people are listening than have left a review, so please do. As a quick recap, we discussed that most sudden heart attacks are chunks of quickly forming clot that end up stopping blood flow to your heart muscle, causing it to suffocate, and that 80% of the risk comes from your lifestyle, meaning what you eat, how you move, how you sleep, how you stress your relationships, and avoiding toxic substances like cigarettes.
[00:37:30] We also talked about the typical ways heart disease is diagnosed and treated, and some of the ways that you can drastically lower the chance of your first or next heart attack.
[00:37:39] Here's my personal takeaway. If you are someone who is quite healthy and not at risk for heart disease by your family history or a risk calculator, like the one American heart has, and that's in the show notes. Then you probably don't need meds. You might even be able to get away with a Mediterranean diet. And even though we didn't talk about it in this conversation, a true Mediterranean diet is [00:38:00] heavily plant-based and has some fish here and there and some real olive oil mixed in.
[00:38:05] The caveat overall, being that these days, most people have grown up eating the standard American diet that is heavy on the meat, sugar, salt, light on the fiber implants. And thus could easily have underlying hidden heart disease already. If you fall into the camp of being high risk by your current lifestyle or diagnoses that's when it's time to throw the car in reverse and put the pedal to the metal and a lifestyle overhaul with a medication assist.
[00:38:31] If you need help with the overhaul, make an firstname.lastname@example.org.
[00:38:37] Remember. The way you live. I can save your life