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 Warrick Bishop and welcome to my podcast and videocast station. And today I have a special guest, Dr. Ashtush Hardika, who's a cardiothoracic surgeon, who's a friend and a colleague from Hobart, Tasmania. Hi, Ash, how are you? Hey, good morning, Warrick. Nice to be on your podcast. Thank you for the invite. No, well, thank you for making some time. Look, Ash, we've spoken about cardiac rehab and we've shared many patients together now over the years. But before we talk about rehab, which is what really is the driver of this, just share with me and our listeners a little bit about your background. How did you come to cardiothoracic surgery? Was it a calling from childhood? It sort of was what it came and people like to hear. a story how you got led into. But I, as a kid, had read something in Reader's Digest about a famous cardiac surgeon in the UK and got very inspired. I used to... My father was a schoolteacher. He had a lot of doctor students go through and I looked up to them as someone who could contribute in a different way to society. But that particular... series on that cardiac surgeon, Magdi Akub, Sir Magdi Akub. It kind of inspired me. And right from my childhood days, I was pretty sure what I wanted to be and lucky to be here. Well, that's fantastic. Actually, knowing you, Ash, and working with you, I'm pretty sure you've inspired some others as well. So what I would like to do, though, is tap into your experience and knowledge about rehabilitation. Tell me just from a surgical perspective, what's important for you for cardiac rehab? And I know you even set up a rehab unit in India before you moved the family out to Australia. What are the main factors for you, Ash? I think we both share a common belief that any intervention that you do as a cardiologist or me as a cardiac surgeon is just a... It's a major, but it's just a step in a whole disease process which is unfolding. So I genuinely believe that there has to be some kind of rehabilitation program where a person can adapt to a healthy lifestyle, which can change the cardiovascular risk profile for that person. And I think that's what got me into the cardiac rehab program. I just thought that any intervention we do as physicians is a temporary... I call that a glorified plumbing job, Warrick, and it is what it is. It fixes the problem for the time being, but unless cardiac rehab in a long, sustained way gets to the patient's lifestyle, I don't think that is translated into a long-term meaningful change. So I genuinely believe that. So for the people listening to this, I'm going to use some terminology that we've used before, which is, stopping people having a second event, and the terminology with you, that is secondary prevention. So really, and I'm completely with you on this, Ash, I strongly believe that if someone has a first event, our whole obligation, our focus is to try and reduce the chance of them having a second event. So secondary prevention is really a huge component. of rehabilitation. What are some of the factors within that provision of a rehab service that you think are most important? Yeah, I think one thing people need to understand that it is an outpatient-based program and I kind of used to tell my patients it's three E's. It's easy to remember that way. I thought one was E standing for education. It's quite vital that people get A complete knowledge. A lot of patients these days turn out to Google and other kind of search engines to find information. And that might not necessarily lead you to the precise and the most scientifically accurate information, as you know. But people need to have the right education about what the disease process is, what does primary and secondary prevention mean, and what can they do in particularly their own context about it. The second part, as we all know, is exercise. And that's all people think of rehabilitation is some kind of exercise training. But it's a gradual program of, more importantly, what not to do as well as much as to. It's not for everybody that cardiac rehab can just. Everyone can have a set program and just start doing it from the internet. You know, in the current times of Zoom and video meetings, I don't think it's, it is a personalized exercise program. So that's the second E stand for. And third E, I would say, is emotional support or counseling. And that's the third E that I try to remember. And Warrick, I genuinely believe that the mental trauma that the cardiac surgery causes a patient. maybe subconsciously, is much more than the physical morbidity I kind of inflict on the patient. I think it's a scar on their mind, and it's up to each individual if they can translate this to say, oh, this is a game changer in my life. This is a signal that I need to change my lifestyle and get back into some healthy habits so that this does not happen again, and I improve my cardiovascular health. So those are the three E's. Yeah, yeah. To be honest, Ash, I completely agree with you, and particularly the emotional component. I often use a car analogy in talking to people about their hearts and their heart function, but when it comes to an event like a stent or bypass grafting, I often say it's a bit like a car crash, and we get to fix up the car pretty well, but sometimes we don't fix up the driver, and the driver is that mental state. And it is. It's a huge impost on people. And in my own interpretation, I think it's really part of a grieving process. And the more we can recognize that and help people through it, I think the smoother we can make that journey for them, because they're going to make that journey anyway. Very nicely put, Warrick. I mean, I think that those are the essential components of it. And that individualized planning, as you said, each person is different. There are some people who are very well motivated and they know exactly. And some people need a lot of coaxing. So we get a broad spectrum of patients and we need to have a team of people involved to deliver this kind of program. The emotional component I think is particularly interesting in that from my perspective, I see a good number of patients who go through a near-death experience and have a small wire cage. an architecture to hold the artery open. And they do that through the leg or through the wrist. And literally these people are out of hospital two days later and barely missed a day in their lives. And yet cardiothoracic surgery, there's a substantial scar to remind them of what's happening. True, I entirely agree. What do you think about the emotional impact between... um getting a stent or bypass graft except separate to the fact that of course we recognize you would go to one or the other based on appropriate clinical grounds what would you think about the emotional impact there i think i think i've been i did my first cardiac surgery in 94 so i can say that over the years i've seen a lot of people go through both stents and surgery um both in india in the uk and in australia and i feel genuinely that um Nine times out of 10, people would choose a stent just for this emotional apprehension. Besides the physical trauma that surgery has, no one likes themselves to be cut open, as they put it. People have some gruesome concepts because they also watch some videos on famous television programs about cardiac surgeries. And it might not necessarily be the best thing for a lot of people because that keeps more emotional and mental images and scars. rather than educating them about what the process is. And look, when I get old, the first thing even I'm going to ask is, is this fixable by a stent? And that's a natural question for people to come in. It's not just the physical part of it. I think there's a lot of mental scarring which goes with it. So the emotional reaction to it is what creates a lot of trauma. I'm going to offer a mirror. um image or comment to that and that is that although going into a stender or bypass people obviously would choose the easier path if they possibly could and we would try and facilitate that sure on the other side i think the the impact to change is greater in the patients who have gone through the harder journey and so Part of the reason for me raising is I see these people who just breeze in, have a stent, don't realize they've nearly died, and don't really embrace the change that they should because they think, oh, that was so easy, I won't worry about it. Sure, sure. No, no, no, that's a very well-made point, and I am with you on that. I think the way the morbidity of surgery, just the pain and the scars, probably reminds people more. As you know, the surgical wounds take time to heal. usually four to six weeks before the breastbone heals and people can start driving back. And a lot of people take a few weeks to get back into independent activities of daily living. So it is a reminder, I think for all of us, that the more time we have to spend with the ailment, it reinforces those brain circuits which tell us, hey, you need to change this. Otherwise, this is what you have to go through. It comes to like when people come for surgery, they are looking for longevity as well because they don't want to go through this again. So they just keep asking that's a very important question. And as you know, that's the only place where probably surgery scores over stents in multivessel coronary artery disease is that surgery promises to offer a better long-term result at a bit more pain. So, you know. No gain without pain, that's true, and especially more true in our field. So it's an interesting thought. Perhaps we should bind up our stent patients with a constricting thoracic bandage for a couple of weeks just so they get the impression of the significance of it all. Jokes aside, one of the things that we've spoken about in the past, which I found interesting, was that you talked of your own experience setting up a rehabilitation unit in India. There were some aspects of that which you really thought were valuable and we weren't really replicating out here in Australia. Would you like to speak to that? I started a unit in India in 2001 when I went back after formal training in Adelaide at the Royal Adelaide Hospital. I saw the Australian program, but what I was most impressed by a friend of mine in Singapore at the Singapore University Hospital. So I went there to see, I think they have one of the... very dedicated cardiac rehabilitation units. And as you know, it's a team approach. And the team there involved, they had a medical doctor and he was not just, he was a cardiologist with special interest in rehabilitation. There was a nursing coordinator. There was an educator. Again, it was a nurse. There's a dietician. There was a physiotherapist. There were occupational therapists. There were psychologists and there were exercise specialists. So It was like a separate building they had, and it was, I mean, they had large volumes of numbers, but I was just impressed by the way they could effect a change. I mean, people were catered for a variety of problems, might be psychosocial, might be how to get back to work, might be some people had some physical ailments which didn't allow them certain exercises, and there was an exercise consultant. But more importantly, I thought there was a cardiologist involved who had... who had a very clear idea of secondary prevention goals. He knew that particular patient's targets and could take it. I feel the difference in Australia, one, because everything is Medicare funded, I can tell you what's happening at the Royal Hobart, for say, or in Tasmania, that the funding for the programs never matches the kind of need. I mean, I keep saying this, that we cannot stress enough cardiovascular disease like heart and stroke events are responsible for more than one-third of the deaths happening in adult Australian population. And yet the kind of importance we give on this program is not the same. Not all cardiologists would be dedicated in having a long-term secondary prevention because that might not be their primary interest, you see. So we need to have a special... are significantly there where to have a mechanism and a team of people to reiterate to these 25,000 people before or after their intervention that, guys, watch out. This is what you need to do. This is the healthy lifestyle for you. I think we would lose that top ranking in the country that we have as a capital for cardiovascular disease, and we would definitely be able to improve. So I think this lack of having a complete team, trying to get the team together and the facility, possibly as an expert team in one place somewhere, that would help. And more importantly, the role of a clinician is at the wide limit. Certainly, you answered one of the questions I was going to ask you there, which is around how often should we be re-engaging? with these people in their journey ongoing. So once they've gone through rehab, do we see them six monthly, 12 monthly, two yearly, five yearly? Because there's no question we're all humans and we all drift back to our initial habits. So you mentioned 12 months there. Would that be sort of your preference interval between visits for following up for these sort of post-intervention rehabilitation cases? I would say that would be the minimum. And as you know, there would be some people who might need more support because they're isolated in the community or because they have got some kind of, let's say some people find it really hard to give up smoking. And it's a genuine psychological intervention that has to be done gently. And they might not get over it straight away, but they might need more frequent visits. And you might need a smoking physician nurse as a part of that program. But those kind of things, I would say at least an early approach. And you keep the original cardiologist in the loop and aware. But if there's a dedicated rehab team, I think we can bring about a change in Tasmanian numbers there. Look, I think rehab is incredibly important. And in fact, I'm, as you're aware, incredibly interested in prevention in the very first place. Prohab, if you like. Prohab. Prevention in the very first instance. And part of my own area of interest is in the rehab space, looking at the other family members who might be at risk before they have an event. So that's almost another story of its own. But we've covered some really important stuff. What I thought I might do is wrap up by inviting you to share a story with me if you've got a rehab story. And then... A couple of final points and we'll call it a day. How does that sound? Oh, yeah, absolutely. Look, I can share a story about a lovely guy and his wife. And they're from the eastern shore of Tasmania. They came for a second time valve surgery. And as you know, each surgery can be with complications. And unfortunately, his heart did not respond the same way. So this guy had to go on an artificial heartland machine support like what we call ECMO or extracorporeal membrane oxygenation for a period of seven to eight days. Just for the people listening who don't know what ECMO and extracorporeal means, it means basically the blood from the body leaves the body and gets treated. in a machine that acts as the heart and lung outside of the body, and then the blood gets pumped in, which is just an extraordinary bit of technology. Extraordinary, life-saving. It is. It is life-saving in those kind of situations. But luckily, and his angels were looking after him, and he responded well. On the eighth day, he was off that artificial life support. It took him kind of two weeks to get out of ICU and all. another week on the ward, and he was into a rehabilitation program. But what most helped him, because there was a side effect of a drug which caused Parkinson-like symptoms for a time, and he was mentally really, really down. And he had an extremely supportive wife. They kind of moved into a part on the eastern shore of Hobart, like somewhere in Lindisfarne, they rented a place. tried to go to the rehab program. But eight weeks down the line, when I meet that person, he's a changed person, Warrick. It not only had taken out the negativity which all this had created in his mind, but he was able to get over the scars. He was able to get over that feeling and say, this is a new lease to my life. And he said the rehabilitation part really helped him to start. It is like... making a child learn to walk again. Because these people are veterans for days together. And he, whom I thought might be, you know, a cripple, and maybe he got over those Parkinson's symptoms once the drugs were stopped. His heart was looking a lot better. So like when I get a call from him on Easter time that saying that he's out in the garden and the wife says they all really are thankful for the team. And that's where I thought if that rehab team was not there, My plumbing job has no meaning, you see. It has to be a complete thing which delivers. And it was not just the exercise specialist. It was the psychologist who got through, the occupational therapist who made small changes at his home place so that he could gently get back into walking and doing things. So it was really, really, very good. Yeah, that's a good story. And how satisfying to see someone in such a physical... It is. difficult situation to actually get a life back and have quality. Absolutely. Absolutely. Thank you for sharing the story, but congratulations to you and the team for giving that man some real quality and some life back. Absolutely. Absolutely. Look, I'm going to wrap up. I was going to ask if you had any final words, but I suspect you're going to end up on the three E's and then we'll wrap it up. I was going to say that, but I was just going to say it because a lot of people and your listeners. Everyone is getting more evidence-based and people talk about this. And there's a famous review system called the Cochrane Reviews. In 2011, they came up with what we call a meta-analysis or they looked at thousands of published articles in this field and they very clearly show that cardiac rehabilitation will have a mortality benefit as well. And that mortality benefit... is very clear across the studies, across different continents. So I just wanted to say that a program like this with the three E's that we talked, the exercise, the education, and the emotional support, will not only help regain strength, it prevents worsening or recurrences and improves both the quality and quantity of a patient's life. So I think that would be my... summarizing statements. Look, I think we talked about funding and there's no question that if we do those three as well, we're actually investing a small amount to save a lot down the line. Absolutely. Plus we're getting amazing dividends at the end. Look, I'm going to wrap it up there, Ash. It's been an absolute pleasure speaking with you. I've learned, as I always do, when I have the chance to speak with leaders in their field. I'm going to... Thank you once more for joining us. So thank you. And yeah, I'm going to say goodbye. For those who are listening, I hope we've educated and informed you. If you have any queries or questions, drop me a note at info at drWarrickbishop.online. Until next time, I wish you all the very best. Take care. Bye for now. 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.
