When looking at a patient, what are the signifiers of cardiovascular health and what do they mean?
Dr. Robert Eckart, electrophysiologist/cardiologist, Heart Specialists of Sarasota: That definition is changing all the time and the routine answers of cholesterol profile, of hypertension, of obesity and of athleticism have all come under significant question within the past 2-5 years. A lot of conventional thought has changed and it’s becoming harder to pigeonhole someone as having risk for cardiovascular disease; but at the same time, given our limited data set, that’s all we do have to go off unfortunately. The challenge that a lot of us face is that patients who are very athletic, don’t smoke and eat right also have cardiovascular disease. It’s easy to identify those individuals who may be at elevated risk using conventional markers, but at the same time we miss a large portion of them by ignoring immeasurable things. Dr. Stephen Culp, cardiology and internal medicine, Culp Private Medicine: We’re more and more looking at lifestyle assessment guidelines. We’re looking at multiple risk factors and trying to come up with an assessment of risk rather than saying that a patient does or doesn’t have coronary disease or must or must not be treated. Those guidelines are fairly simple to implement but they look at a broad number of things such as age, sex, gender, race, cholesterol levels, good cholesterol versus bad cholesterol, diabetes, blood pressure and things of that sort. We look at their weekly exercise amounts, body mass index; there are a lot of things that we didn’t really put into practice and bring together 5-6 years ago and that is a rapidly changing area of our assessment.

When it comes to heart health, what are the most common problems you see in our population today?
Dr. Jay Mathews, interventional cardiology, Bradenton Cardiology Center: For me, coming from the Northeast originally and then being in the Midwest for a long time, I’m shocked at the amount of vascular disease that’s down here. A lot of people, even younger patients, are coming in with peripheral vascular disease and a lot of times we catch it when it’s far too late, when something bad has happened. A lot of this is related to the amount of tobacco use going on–smoking is an extremely strong risk factor for developing these kinds of conditions. Dr. Gene E. Myers, interventional cardiologist, Gene E. Myers Cardiac and Vascular Consultants: The other thing that’s astounding is the fact that all the gains made in the past 25 years with tobacco cessation in the United States have been overcome by obesity. Ten years ago I went to visit my wife, coaching at one of the high schools, and I saw Coke machines in the gym. Cardinal Mooney, Booker and Sarasota High all have them, and that level of obesity is now an epidemic. Culp: Our demographics in Sarasota give us a slightly older patient age, so congestive heart failure and valvular heart disease are things that we see with a frequency here that may be higher than other places. David Patterson, executive director, Cardiovascular Services and Business Development, Sarasota Memorial Hospital: It’s amazing. We are partners with Sarasota Memorial and with Columbia University and everyone talks about the older population. No matter where you go, no matter what hospital you go to, they say, ‘We have older and sicker patients.’ When Columbia came in and reviewed our data, they said, ‘You do have older, sicker patients in Sarasota County.’ It was amazing to get that clarification and that justification. If you look at our demographics it is a much older population and we have to deal with that as healthcare providers. About 66 percent of our market is over 65. Culp: One of the remarkable things in Sarasota is the ability of our medical community to achieve many of the same outcomes or exceed the quality outcomes of other institutions despite those demographics.

How have you been able to achieve such results?
Culp: We’ve got a well-trained medical community. We have physicians who work in concert with the hospitals; hospitals work very carefully on quality guidelines and trying to meet and exceed national goals. There’s a lot of teamwork. Dr. Jeffrey Sell, chief of cardiovascular surgery, Sarasota Memorial Hospital: We work very hard to practice evidence-based medicine and look at what we do. Also, we have more patients with valvular heart disease in the surgery side than with coronary disease, which is unusual. Ten years ago it was 75-80 percent coronary disease, now it’s less than 50 percent. What we see is a lot of aortic valve disease, and the thing about aortic valve disease that’s interesting is, if you look at the survival of aortic stenosis, it’s at 5 years worse than most forms of cancer and yet it’s completely treatable.

What is aortic stenosis?
Sell: Degeneration of the valve in the heart that leads out to the aorta, which is the largest vessel. Over time if you take a little piece of tissue that’s less than a millimeter thick and bend it back and forth 60 times a minute for 80 years, it wears out. And when it wears out, it tries to repair itself by thickening and calcium gets deposited and it becomes very hard and it doesn’t open anymore. That leads to fluid backing into the lungs and a lot of bad things that will kill you.

What type of warning signs should people look for? At what age should they seriously be monitoring their heart health?
Eckart: The leading causes of sudden death in people over age 40 are atherosclerotic coronary artery disease, myocardial infarction and sudden cardiac death, representing around 70 percent of cases in people aged 40. We used to talk about screening for risk factors or looking for these things in people age 55 or 60, but we’re seeing it at much younger ages. There’s been an underappreciating of the impact of a lot of these risk factors in younger individuals. Unfortunately, a lot of the warning signs, for example for myocardial infarction – the classic chest pain and whatnot – may be when they end up having a near-fatal myocardial infarction. My specialty is sudden cardiac death, which is an electrical disturbance in the heart, a heart rhythm abnormality where the manifestation may be a loss of consciousness without an identifiable cause. And sudden cardiac death is responsible for nearly half a million deaths every year in the United States, more people than lung cancer, HIV and breast cancer combined, so unexplained loss of consciousness is a significant concern. Sell: It may be that for as many as 50 percent of people with coronary disease, sudden death is their first symptom. Culp: In terms of what the public should look for, it may not be the classic chest pain, heaviness and squeezing symptomology that most people think of when they’re having coronary problems. Changes in someone’s ability to exercise that don’t make sense–getting breathless going up stairs when previously stairs were comfortable, being unable to finish a workout, breaking out in a sweat inappropriately– are very often subtle things people report in retrospect, after they’ve come in with a heart attack. The classic signs–chest pain, heaviness, squeezing–should never be ignored. But some of the more subtle changes in how one feels should really prompt a visit to a primary care doctor. Indigestion is often the most misleading source symptom that people have. If people have indigestion discomfort that doesn’t make sense, that warrants investigation to make sure it’s not actually heart pain. Myers: Probably the simplest, safest, cheapest screening test is a coronary calcium score, because the disease we’re talking about is atherosclerosis. It just so happens that 94 percent of people who have atherosclerosis, who have had angioplasty or stent surgery, don’t know they had a disease. They think the blockage occurred with aging, but that’s not true. Atherosclerosis is not part of the aging process. If you have it, it does get worse as you get older, but of the billions of people in the world, many countries don’t see this. Both of our communities have very good quality CT scans for $100 and almost no radiation. So sudden death should never be sudden if people have $100 in their pocket. Mathews: The fact of the matter is, as people become increasingly sedentary and don’t exercise, a lot of the time symptoms are not going to be present or people are not going to recognize that they are having symptoms. They’ll ignore them or chalk them up to simply being out of shape. One of the largest populations at risk are women, because a lot of times women do not have typical symptoms.

How much of heart health is genetic and how much is a result of lifestyle?
Mathews: The reality is we don’t know. Ultimately at the end of the day you could come up with some type of association to a particular genetic profile, but the answer is that it’s always going to be some sort of combination of the environment and your genetic profile. We really cannot tell people to what degree particular genetic polymorphisms have an effect. They are associated with it and perhaps it may guide you to be more aggressive in terms of risk factor modification, but to say that this is 90 percent or 50 percent associated, it’s not that simple. The simplest example would be the marathon runner that has horrendous coronary disease. Why does this person have this significant disease when [he/she] is the pinnacle of cardiovascular health? Patterson: If there’s significant coronary disease in your family, you should get a CT scan early on and pay attention to it. I had a patient who was female, 40 years old, vegetarian, an avid rower with a fat level probably lower than five percent body fat, and she had a heart attack. We looked at her family history and both her brothers had heart attacks and her dad had a heart attack. If they have significant family history, that’s a good indicator that they will probably have it. Eckart: And a little separate from the coronary disease aspect is sudden cardiac death in the young. There is very strong genetic predisposition to those scenarios, so certainly anybody that has a family member who’s dropped dead before the age of 35 without an identifiable explanation should be evaluated by a cardiologist. Myers: Dr. Sell was talking about aortic stenosis and we know the locus where LPA, a kind of cholesterol, is associated with the aortic valve stenosis and calcification of the mitral ring. Now that those genetics have been identified, there’s a company that is building a drug to treat LPA disease, which is very hard to treat. That might make a difference in preventing it if you have bad genetics. The thing is though, if you have bad genetics, you can’t get rid of your past, so if anything, you can make your environment better. Culp: I want to emphasize that. I’ve seen many patients who have inherited a bad set of genes but didn’t take on the bad lifestyle that went along with their parents’ disease. So instead of having their heart attack at 40, they began to have coronary symptoms in their 60s and 70s, and that disease was recognized and modifiable and they’re alive and well at an older age without actually having a cardiac event. The worst thing that someone can do if they’ve inherited a bad set of genes is to ignore their lifestyle. And a smoker who inherits a bad set of genes is many-fold more likely to have a heart attack and die at an early age. You inherit your genes, but we can either inherit the lifestyle or we can change the lifestyle. Sell: In a way, the best sign of heart health is five generations of longevity. Everybody is fighting their genes; we’re all to some degree destined by our genetic makeup and certainly doing your best to minimize the effects of those genes is a multifactorial problem.

Before turning to surgery, what options do we have at our disposal for the treatment of cardiovascular disease?
Mathews: The big [treatment] in question right now is statin therapy. Statins are cholesterol-lowering medications and have been shown to reduce inflammation in the arteries and potentially stabilize plaque or even arrest plaque. Patients with any number of vascular conditions including coronary disease and peripheral vascular disease would be eligible for a statin. Eckart: Statin-based therapy has been proven and is still the only drug that’s been demonstrated to regress coronary artery disease or carotid artery disease. We use statin therapy to treat coronary disease and we use statin therapy to treat vascular disease, not just people that have cholesterol problems. The issue that has come into play currently is the cost-effectiveness. If you’ve got a 41-year-old who smokes, who’s obese, but wants to take Zocor, is that the right decision for society? Sell: The interesting thing about statins is that everybody talks about statins for cholesterol lowering, but we in the surgical side have evidence that if you start statins maybe as little as hours before open heart surgery, you lower the mortality rate. There are other effects of these drugs–primarily anti-inflammatory but probably some that we don’t even know. We look at a lot of these medicines and see different effects over time and change our usage based on that. Patterson: If you look at the impact changing outcomes in the cardiovascular world, it was drug-eluting stents, which came out in 2003, and statins. A drug-eluting stent is a stent that they put in after you have heart disease to open up the vessel again and it’s coated with a drug on it that prevents the platelet aggregation that would cause another clot. Those two things kind of came simultaneously and really changed the outcomes of cardiovascular disease, really lowered those incidents of sudden death and had a strong impact in changing the world. Culp: The reason why we virtually all jumped to statins is that it is the only medication that gives you a benefit for the primary prevention of a cardiac event or vascular event, as well as secondary prevention if you’ve had an event. We’ve got a lot of cardiac medication, but just about everything else treats symptoms. The statin drugs prevent disease, and even though most of us are trained to treat disease once it occurs, we get the biggest satisfaction out of people not getting diseases in the first place.

With the advent of new technologies and devices, how has cardiac surgery changed?
Sell: One of the biggest things is looking at cardiac replacement therapies–a machine to be implanted that can take over the function of a part of your heart. Right now it requires a small line to come out through the skin, but two years down the road those devices will be completely implantable. Our population down here, because of their age, is less a transplant population, but they will be candidates for implanting a device to support their heart. Eckart: From heart rhythm standpoint, the role of defibrillators, which is like a pacemaker that’s implanted in the chest wall for those patients who are identified as being at elevated risk for sudden cardiac death, can reduce their incidence of having a fatal event by around 95 percent. A defibrillator is like an insurance policy–it doesn’t make your heart any healthier, it doesn’t mean you shouldn’t take your medications or anything else, but it means if something catastrophic occurs it’s going to be there for you. It’s a procedure that takes less than an hour and resuscitates the heart within 2-5 seconds and has had one of the highest benefits for mortality reduction for a select group of patients. Mathews: Another big advance is structural heart technologies that are available for patients who are not surgical candidates for traditional valve therapy. We now have a transcatheter aortic valve, which has been very successful. These are valve implantations that are done either directly through a small hole in the chest or through the groin. These are for patients who have been deemed non-operable, who previously wouldn’t have anything offered to them. There’s also now a transcatheter-based mitral therapy, for patients with severe mitral leakiness or regurgitation. The big focus now in cardiology is structural heart disease and advancing valvular therapies with minimally invasive techniques in a partnership between cardiac surgeons and cardiac interventionalists. Culp: As cardiologists and cardiovascular surgeons we need to look at all the options on the table and whether or not medical therapy is sufficient and safer than microsurgery versus full surgery. That’s really our task. We need to look at the patient and make an assessment in terms of where they are going to be best placed down the road by the decisions we make today. Myers: You can look at surgery as failed early detection and prevention. There’s an 82 percent chance that you can prevent progression or get regression (reverse atherosclerosis) if you treat it aggressively and consistently for the rest of your life. That means that of all the people we’re seeing now, maybe as much as 80 percent didn’t need to get there. Eckart: In the world of heart rhythm care, I’ve got about 3,000 patients that, through their devices, we’re actively monitoring from home. They’ve got bedside units where basically I will know if they have a heart rhythm problem before they know. The same thing with implantable pressure monitors, so that way we can continuously tell exactly what their pressures are in their heart. This is technology that’s with them all the time, that will continuously send data to us so we can work to constantly tailor it to that patient’s needs. It’s about trying to stay in front of the problem instead of waiting for the patient to come in with symptoms.

Dr. Stephen Culp, MD; Cardiology and Internal Medicine; Culp Private Medicine Culp received his medical degree from University of Vermont College of Medicine before receiving advanced training in fellowship, residency and then intern programs at Duke University Medical Center. An interventional cardiologist, Culp specializes in diagnosing and treating patients upon the outset of cardiovascular disease.
Dr. Jay Mathews, MD, MS, FACC; Interventional Cardiology; Bradenton Cardiology Center Mathews attended Tufts University for medical and graduate school, receiving a medical degree in addition to a master’s in health communication. He earned board certifications in internal medicine, cardiovascular disease, nuclear cardiology and interventional cardiology.
David Patterson, RN, BSN, MBA; Executive Director, Cardiovascular Services and Business Development, Sarasota Memorial Hospital Patterson received his master’s in business administration with a focus on health care administration and management from the University of Phoenix. Patterson is current executive director of the Sarasota Memorial Health Care System alongside his position within SMH’s cardiovascular program.
Dr. Jeffrey Sell, MD; Chief of Cardiovascular Surgery; Sarasota Memorial Hospital A Harvard Medical School graduate, Sell went on to Brigham Womens Hospital for his internship and residency. Sell specializes in thoracic surgery.
Dr. Robert Eckart, DO, FACC, FHRS; Electrophysiologist/Cardiologist; Heart Specialists of Sarasota Eckart received his medical degree from the Philadelphia College of Osteopathic Medicine and completed his internship and residency a Tripler Army Medical Center.
Dr. Gene E. Myers, MD, FACC; Interventional Cardiologist; Gene E. Myers Cardiac and Vascular Consultants Myers attended medical school at the University of Pennsylvania Medical School before completing his internship at the University of Pittsburg. Myers received additional training in adult and pediatric invasive cardiology at Georgetown University and Children’s Hospital National Medical Center.