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's Dr. Warrick Bishop and I'd like to welcome you to my podcast station and of course to the Healthy Heart Network. Today I'm delighted to say I have a special guest, Dr. Alistair Begg, a cardiologist from Adelaide with a special interest in cardiac rehabilitation. Welcome Alistair to the show. Thank you Warrick, it's a pleasure to be here. Alistair, I'm... So excited to catch up again today. We've had the chance to catch up on a number of other occasions and we've talked about cardiac rehabilitation. As a brief overview, if I can steal some of your words, it's really an overarching holistic approach to try and define exactly where a patient is in terms of their heart events to try and understand what brought them to that event and then pave and find a path towards best health into the future by modifying what we can and engaging that patient through education and involvement in their own best healthcare. Would that sort of sum up your overarching definition of rehabilitation, Alistair? I think that sums it up, Warrick. I mean, it's really about the journey, the patient journey, and that's going to be different for every patient, but the cardiologist is really well placed. to supervise that journey and encourage and guide the patient through that journey? Well, it is a journey that many, many people will be undertaking. We know that coronary artery disease affects nearly 50% of the population in the Western world, so it's a huge burden on the community, on society and on individuals. So, we've talked about... in our first two podcasts on this, trying to get an inventory of where people are in terms of what we can observe that could be contributory to the situation they're in at the moment. So things like trying to figure out if they had a family history or a smoking history or they're overweight. So I'd like to continue in a similar line and ask you about blood pressure. Tell me, in your approach to patients in a rehab setting, how do you approach blood pressure? What are you thinking as you evaluate that for a patient? When I talk to patients in cardiac rehabilitation, I really impress on them that probably the single biggest risk factor for cardiovascular disease is blood pressure. And I also like to impress on them that it's a very treatable risk factor. It's a very important risk factor for both heart attack and stroke. And that even a modest reduction in blood pressure can have a profound effect on the risk of heart attack or stroke. I also like to give them some guidelines as to what sort of levels that we would expect your blood pressure to be to achieve an optimum risk factor control. So you mentioned about what sort of levels would I be happy with. I mean, the Australian guidelines and many of the world guidelines suggest that a blood pressure of 130 over 80 is a reasonable blood pressure to achieve. Although for those people that are younger and that don't have diabetes, there's also some evidence that perhaps 120 over 70 would be the ideal blood pressure. So somewhere in that range, depending on age and the presence or absence of diabetes, would be what we're trying to achieve. So one of the things that I... Sorry to interrupt, Alistair, but one of the things that I think is particularly complicated about blood pressure is getting good blood pressure measurements. Because my observation is that most of the time when patients come into my office... If I take their blood pressure, they've had trouble finding a car park and they're scared seeing their cardiologist and they wonder how much the consultation might cost. And almost invariably, their blood pressure's up through the roof. How do you deal with that? One of the things that we're looking towards now is getting more of a handle on out-of-office blood pressure measurements. So often I ask patients to go to the local pharmacy, have their blood pressure checked. And that's a good also way of monitoring them throughout the two months or so between visits to the doctor. So we're after a bigger picture rather than just isolated office measurements which may or may not reflect the patient's blood pressure control over the last couple of months. Getting a patient to write down their measurements in a diary, getting them to have some office measurements but also some out-of-office measurements. gives the treating medical practitioner a much better idea of their blood pressure control and a much better idea of what their requirements are for blood pressure tablets. So, Alistair, one of the things that I try and use as often as possible is a 24-hour blood pressure monitor where the patient literally wears a little machine that's attached to a blood pressure cuff that goes up. twice every hour during waking hours and then every hour overnight to make sure that when they're deeply asleep, it sets off and gives them a little bit of a disturbed sleep. But nonetheless, we get plenty of measurements from these monitors and they give us a fantastic profile and give us a good indication of effective therapy and fluctuations of blood pressure secondary to therapy. On a beautiful graph, do you use those 24-hour blood pressure monitors much? Thanks, Warrick. Yes, certainly I do organise a 24-hour blood pressure monitor when there's some uncertainty about how well the blood pressure is controlled and also can be very useful in deciding whether someone actually needs blood pressure treatment in the first instance. In fact, in Europe, the guidelines suggest that before initiating treatment... that a 24-hour blood pressure monitor should be done to really assess whether the patient truly has high blood pressure or not. And most people will have heard of what's called the white coat syndrome. So when the patient goes to the doctor, their blood pressure's up, and yet maybe when they're out of the clinic and at home in a more relaxed environment, blood pressure may be normal and they may not actually truly need that blood pressure that's been prescribed. So getting an out-of-office measurement can be very useful to assess blood pressure control. I completely agree that blood pressure is incredibly important in terms of risk of heart attack and risk of stroke, as you mentioned, but only because I've just finished writing a book about atrial fibrillation and I'm writing a book about cardiac failure, I'd love to add in there for those listening. The blood pressure is so closely linked to cardiac failure and so closely linked to atrial fibrillation, to conditions that we see more and more as people are ageing in the Western world, that blood pressure is a critical risk factor to keep a close eye on. So like Dr. Begg says, check it as often as you can with the pharmacy, with your local doctor. And if you've got a machine at home, knock yourself out without going silly. Did you want to throw anything in there, Dr Begg? Look, I think all I'd like to say is that certainly heart failure and atrial fibrillation are now the two most common cause of hospitalisations for people with cardiac problems and they have overtaken heart attack. And we know that the long-term effects of high blood pressure on the heart cause structural change to your heart. or make you more likely to get both atrial fibrillation and heart failure. So controlling the blood pressure long-term certainly is the key to preventing those hospital visits in the longer term. Yeah, look, I have many conversations with patients these days saying, look, it's not sexy, it doesn't have all the excitement of putting in a stent or a trip in the back of an ambulance, but... Sorting out blood pressure is probably the single most useful intervention we can medically do for people, for people's best long-term cardiovascular health. Look, I'm going to move on to diabetes. Dr. Begg, how do you think about diabetes in your patients in rehab? I think diabetes is a very important risk factor for heart disease. It's certainly people with diabetes have very difficult to treat heart disease. They have more complications from heart disease. They don't respond as well to the standard treatments for heart disease and their outcomes are worse than people that don't have diabetes. So we know that having diabetes is a red flag when it comes to heart disease. So certainly prevention is really important and preventing those factors that cause diabetes such as preventing being overweight, avoiding being sedentary and having a healthy diet are really, really important. So I just emphasise how important that preventing diabetes is and certainly is something that all people should have their... blood sugar checked regularly by the GP. And there is certainly a lot that can be done if someone's trending higher in their blood sugars to try and prevent the onset of diabetes. So that is a particularly important risk factor for heart disease. I completely, completely agree with you there, Alistair, and follow the same. principles myself I'm going to jump in there and say a couple of things though one is I really do appreciate you finding the time to speak with me today I know you're on call and I can hear that those needy patients are calling you from coronary care unit and seeking your advice so we'll let you go as soon as possible I'm also going to throw in there that some people during their rehab will have been found to have had a degree of cardiac failure now i don't want to get too caught on the idea of cardiac failure but cardiac failure and diabetes is being talked about a lot and i know you were recently at the european society of cardiology meeting in in paris where they talked about the dapper hf study now do you want to share a little bit of uh a little bit about that because it is quite an exciting frontier that we're on the verge of Certainly, Warrick. Well, look, there's a new class of drugs that have been developed in recent years that really have provided some really refreshing news about diabetes and heart disease. These drugs are becoming more and more available through the PBS in Australia and they certainly have been shown to be effective in preventing heart failure. And they tend to cause a degree of improvement in blood pressure control and the weight control as well. And in fact, one of the conferences I was at recently, they suggested that it really is potentially almost a cardiologist drug rather than a diabetes drug. It's that good. So we're looking forward to more studies coming out about this new class of drugs. And we know that the benefits seem to be real in terms of preventing hospital visits and improving patient survival. So we're really excited about that in the cardiology community. Look, if it's all right with you, for some of our listeners who are a bit more detail-minded, I might just add a little bit of extra granularity to that. The medications, the class of drugs that Dr. Begg is talking about are the sodium glucose transport inhibitors. And that simply means that these drugs stop reabsorption of sugar in the kidneys. So literally, by allowing sugar to pass into the urine so that the patient can urinate it out, the... Sugar in the blood is reduced. So it's like a leaky tap of glucose trickling out of the body, the sodium glucose transport inhibitors. And it turned out when these agents were being evaluated for their efficacy, for their effectiveness in diabetic patients in a trial called the EMPA-REG trial, they were trying to understand how well they worked at diabetes patients. When all of a sudden... they found quite to their surprise and beyond their explanation that this particular class of drug was helping patients with cardiac failure. And so this most recent trial released in Paris, the DAPA-HF trial, used the same class of drug, leading to loss of glucose in the urine in patients with established cardiac failure. And interestingly, not only took diabetic patients, but took non-diabetic patients and showed an equal benefit in both. So an amazing, interesting new class of drug, and it's going to open a whole new frontier for management. Watch this space. So did you want to add anything further on that, Dr. Beck? Because we're disappointed to say pretty close to time. All I can say, Warrick, on that front is that my personal experience with using these drugs is very favourable and I haven't had a number of people who've had frequent hospital visits who actually aren't coming into hospital now because of these drugs. So as well as the evidence, that base being very strong, the clinical experience that we're seeing with these drugs is very favourable as well. I think at the moment because of access through the Pharmaceutical Benefits Scheme here in Australia, These drugs are not available broadly for cardiac failure, but it's really raised my awareness and raised my antenna for trying to detect patients with diabetes who may have any degree of heart failure. And for these people, these agents may be a perfect dovetailing therapy to improve not only their sugar control, but their cardiac function as well. So a great opportunity. access to these agents becomes more broadly available. Alistair, I thank you so much for your time. I'm going to let you get back to those messages, I'm sure. Those patients will need you and you'll be able to help. Thank you so much for taking the time. Say goodbye to our audience and I so look forward to the chance to catch up again and continue this fascinating journey on cardiac rehabilitation. Thank you Warrick and once again thank you for the opportunity to have a chat today. Really appreciate it. Well again thank you Alistair. To my listeners I hope we've given you some really interesting information about blood pressure. Go and check your own blood pressure out. It's a cheap test. Anyone will check it for you. It's so important that to neglect it is just not worth doing. Diabetes, really important. We've touched on those new agents, which are really exciting in the future. I hope we've given you some good stuff to mull over. If you have any queries and questions, drop us a line on members at drWarrickbishop.online. If you've got any suggestions for future podcasts, of course, let us know. And as always... Until next time, I wish you the very best health and please don't die from a heart attack. Goodbye. 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.
