Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name is Dr. Warrick Bishop and I would like to welcome you to my podcast station and of course to the Healthy Heart Network. Today I have an opportunity to speak with Dr. Alistair Begg, a specialist cardiologist with an interest in rehabilitation. Alistair is based in Adelaide and today we're going to be talking about a question that turns up frequently in our consulting rooms and that's patients asking Why me? But before I do that, I'd like to welcome Alistair and say, hi, how are you going? Thank you, Warrick. Thanks for having me on your show. And it's lovely to be here. Well, thank you again for joining me, Alistair. I think today's topic's a really interesting one. The number of times people are surprised when an event comes out of the blue and want to know what's going on. So, look, why don't... Why don't you just share with me off the top of your head, if you can, a couple of statistics just to remind us of how common cardiovascular disease is within the community. Sure, Warrick. Well, look, it's still the commonest cause of death in the community, unfortunately. About 50,000 people a year in Australia die of heart disease. And so it's a common problem in the community. It's still one of the most common causes for hospital visits. And about one Australian every 12 minutes dies from heart disease. It affects about one in six Australians. It affects two out of three families. And a lot of these deaths are largely preventable. So it's important that we understand the reasons why it happens. Those sort of statistics or those sort of numbers, Alistair, this is really a component of health that probably touches, either directly or indirectly, nearly every Australian, I would have thought. Yes, certainly. Most people in Australia either have a friend or a relative that's been affected by cardiovascular disease. So it's important that we all understand why it is that it happens in the first place. Look, I'm going to ask for a little bit of a definition here because this is a word that comes up a lot, and the word is heart attack. A lot of people talk about having a heart attack, but you and I both know that's sort of a layman term. Would you like to deconstruct that so that our listeners know really what's meant by a heart attack and how we think about it? Sure, Warrick. Well, look, the classic sort of concept that people have about heart attack is, you know, the one you see in the movies where the guy's clutching his chest and sort of flakes out and passes to the floor. And that's really your typical sort of heart attack when someone has chest pain and then they suffer a blockage in their arteries and then they have a cardiac rhythm disturbance that makes them pass out. So that's really your classic. heart attack description but there are heart attacks that are just purely due to problems with the heart rhythm where there's no actual pain and the heart goes out of rhythm and there's no actual blockage in the artery so that's another mechanism if you like for heart attack and sometimes that can be due to a sick heart pump and other times it can just be a primary problem with the heart rhythm so there's various sort of if you like categories of heart attack But the one that we all sort of more familiar one is the one of the blocked artery causing the chest pain. And that causes, if you will, a death of the heart muscle. And that's the classic one that we all sort of know and hear about in the media. Yeah, look, honestly, that's a great breakdown, Alastair. Not only can that blocked artery give rise to death of the heart muscle, it can give rise to death of the individual. that about one in six people who have a blocked artery out of the blue, a so-called heart attack, as you've just discussed, one in six will die. So this is a serious life-threatening condition. Look, if I could follow on from your description talking about the rhythm problems and the pump problems, one of the ways I like to break it down is to think of the heart as a car engine. And think about the coronary arteries as the fuel lines that supply blood or fuel to the pump. The electrical system of the heart, making sure the timing is right. And also think of the engine block or the pumping chamber of the heart as the same as the pumping chamber of the car. And if we think of it that way, then our heart attack can be a blocked fuel line or the electrical system playing up. or the pistons and valves being a problem. Nice way to think of it, Alistair? Sure. Well, I think if you use those sort of terms, everyone sort of understands what happens under the bonnet. And it's a similar sort of imagery, really, with the heart, because the heart is just a pump. It's a very sophisticated pump. When it breaks down, you know that it produces symptoms. But the actual reasons why it breaks down could be electrical. It could be plumbing or it could be just weakness of the heart. So let's jump on the fuel lines first, Alistair. We're really talking about coronary artery disease, the fuel lines that supply blood to the heart. The topic of this podcast is why me? Well, why do people tend to be at greater risk of developing rust in their pipes, blockages in their fuel lines or coronary artery disease? Well, look, they've done lots of studies looking at this, and at the end of the day, about 50% of the time, it's a hereditary reason for heart disease, and about 50% of the time, it's more of a lifestyle issue. So, obviously, the hereditary factors, things like family history, you've got a first-degree relative, that's your mum or your dad or your brother or sister. have got heart disease, particularly if it's early onset, sort of under 65 or even under 55 years of age, then that's a lot more significant than not having any family history of heart disease. So that's one of the first questions as a cardiologist I ask a new patient, do you have any family history of heart disease? And if everyone in the family has had heart disease, it obviously makes that individual much more at risk than if none of the other family members have had heart disease. So that's really the sort of the 50%. The other 50% is what we call lifestyle factors. So things like smoking, diet, exercise, stress, blood pressure and cholesterol and those sort of factors. And they're the ones that we can do something about. And that's why we often focus about in that group when we do cardiac rehabilitation after a heart attack or a stent. We put a lot of emphasis on those what we call reversible or modifiable risk factors and they're the ones that you can do something about and we know that the more risk of those modifiable risk factors that you can get under control the better your prognosis that means the more chance you have of surviving 10, 15, 20 years after a heart attack so we we know that just making sure you get attention to all those what we say modifiable risk factors will improve your prognosis. That's a great summary of some of the background to what might drive coronary artery disease or development of plaque in the arteries. I think one of the things that really turns up from time to time for me, and I'm sure you see it as well, are the patients who seem to have no clear-cut family history and tend to look after themselves. They're not overweight. They don't smoke. They exercise, perhaps. eat a healthy diet, have not developed diabetes, look after their blood pressure, and yet despite what would appear to be having done everything right, they're still struck by a block in the arteries. I'm sure you see that. How do you discuss that situation with individuals who are understandably wondering, what on earth happened to me? Sure. I think there's always that question mark. some people's minds as to why me. Because, I mean, as I said before, half the time it's genetics and half the time it's lifestyle. But then there's people that have done all the right things and don't have a family history. I mean, at a very much a sort of cellular level, we know that coronary artery disease is due to, if you like, a weakness in the body's ability to prevent rusting or plaque development inside the arteries. And that can often be as a result of some inflammation in an artery. So inflammation is when body's cells find a spot inside your artery that is a weak spot and provides sort of an area where cholesterol might build up and then it is prone to rupture and that can cause a heart attack. So we don't always understand the mechanisms for that, but we know that... underlying all this is a bit of inflammation in your arteries and there's a lot of research being done to try and work out why that is. I do come across this situation from time to time and obviously it's distressing for the patients who are looking for some reason or explanation. One of the things that I try and share with them is exactly what you say which is to talk about not just traditional risk factors and family history, but what's happening in the artery. And one of the examples I use is talking about people with arthritic knees. Some people have arthritic knees and some people don't. And it may be that the knee joint hinges slightly to one side or the other, which appears to cause no problem in younger years. But over many years in later life, causes wear and tear, and those occasional people with perfect alignment of their knee joint may never get arthritis, despite running, exercise, et cetera. And so what I often say to patients is that the wear and tear in the arteries may be related to the very specific twists and turns and path that the artery takes over the heart, particularly since the heart moves underneath it. And we haven't got any way of evaluating that. excuse me that wear and tear and so sometimes out of the blue wear and tear could be occurring in these arteries in otherwise people who look healthy and at low risk despite every effort to minimize that risk it's a complicated area and I think it just reminds us we don't fully understand it inside your arteries are more prone to this sort of wear and tear. There are certain spots like the start of the main artery down the front of the heart or the anterior descending is a very common spot for build up of plaque and we think it's probably related to perhaps as you say those wear and tear spots where there's high flow and shear stresses inside the arteries that make these certain spots in the arteries around the heart more prone for a build up of plaque. I'm going to move on to the electrical system next. But before I do, Alistair, about that situation where we just can't understand risk for everyone, I'm going to put a plug in there for cardiac CT imaging because I think if we don't fully understand the process, then to my mind, lifting up the bonnet and taking a picture and having a look at exactly what's going on is not a bad starting point. So for anyone interested, I've... I've produced a bit of information in that space, so check it out. But I'm going to move on to the electrical system. And from your experience, Alistair, I mean, I know some of the numbers and I know my own practice, but what do you see as the main electrical problem with the heart, giving rise to heart attacks and giving rise to the sort of symptoms and problems that come through your room? One of the most common conditions that cardiologists are seeing now is a condition called atrial fibrillation. I know you've done a lot of work in this area, but about 500,000 Australians have got atrial fibrillation. A good number of those don't even know that they've got it. And it's increasing every year. And it's probably the most common presentation to cardiologists now and also has overtaken heart attacks and heart failure as the most common presentations to hospital. So there's certainly... been described as a tsunami of the current decade in terms of cardiovascular disease. And there are more and more people with this abnormal electrical rhythm being discovered every day. So I know what atrial fibrillation is and you know what atrial fibrillation is and anyone who's got atrial fibrillation and being told they have atrial fibrillation knows what it is. But for those who don't... Have you got a simple description for what's going on that you share with your patients? So if any listeners want to be informed, how would you describe this condition? Sure. Look, that's a good question. The back chamber of the heart, the atria, have their own conduction system inside them. That means the electrical wires that form inside the back wall of your heart. And occasionally they can go out of rhythm and instead of producing a nice regular beat, produces scattered irregular, very fast and uncontrolled heartbeat. And those impulses get transmitted through to the front of the heart and then the front chamber gets irregular as well. So the actual beating of the heart becomes very irregular and that can lead to symptoms of lack of effort and lack of breath, dizziness, lack of blood flow to the brain. and chest tightness and other symptoms and it can even lead to other symptoms such as swelling of your ankles or a general feeling of poor appetite. So these sorts of vague symptoms can often be related to atrial fibrillation and in those people we see in the clinic it's a very common presentation. So I'll often say to people, it can drop your blood pressure and muck up with the pump. So they lose pump or they can have a pump failure for want of a better term. But the other thing is, and you were going to touch on this, I'm sure, is the possibility if a chamber of the heart's not pumping properly, blood can pool in that chamber. And if it pools in that chamber, a clot can form. And if a clot forms, that clot can break off. and gutter the brain and causes a stroke, which is just devastating. That's right. Well, I can certainly... One of the two common causes of stroke is actual fibrillation along with high blood pressure. And we know that fitting the blood down with the appropriate medication can reduce your risk for stroke back to that of the general community. So it's important that the... is detected and that it's properly treated. So we've used up a heap of time. I normally try and run to about 15 minutes as a max for these discussions. We've hit 16 minutes. I think what we might do is come back and talk about atrial fibrillation a little bit more and talk about cardiac failure. So talk about the rhythm problems. and talk about the pump problems of the heart. So I'm going to thank you so much for sharing today. I really would like to catch up with you and talk about a bit more on atrial fibrillation and why me and cardiac failure and why me, because I think there's a whole topic there. So thank you for joining me today, Alistair. Thanks, Roy. It's been great to be on the show. Look, for those listening, Really appreciate you tuning in. I hope you've learned something from this. If you have, then stay tuned for the second part of Why Me, covering atrial fibrillation in more detail and cardiac failure. As always, if you have any queries or questions, please drop us a note at members at drWarrickbishop.online. Any queries or questions, let us know. Any suggestions, let us know. As always, I wish you the very best until next time. Take care and bye for now. You have been listening to another podcast from Dr Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
