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Ep. 103 - LiveWell Talk On...Know Your Numbers to Prevent Heart Disease (Dr. Richard Kettelkamp)

episode 103

Ep. 103 - LiveWell Talk On...Know Your Numbers to Prevent Heart Disease


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Host: Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital

Guest: Dr. Richard Kettelkampcardiologist, UnityPoint Health - St. Luke's Cardiology

Dr. Arnold:
This is LiveWell Talk On knowing your numbers to prevent heart disease. I'm Dr.Dustin Arnold, Chief Medical Officer at UnityPoint Health-St. Luke's Hospital. Heart disease is the leading cause of death in the United States. Yet many people have no symptoms. To prevent a cardiac event from affecting your life, it is essential to learn what puts you at risk of developing heart disease and how to keep it from occurring. Knowing your numbers and maintaining a healthy lifestyle can naturally help prevent heart disease. Today we are delving into what exactly those numbers are, how to maintain them naturally, and how to impact your heart health. Joining me to talk about this is cardiologist, Dr. Richard Kettelkamp from UnityPoint Health Cedar Rapids Heart and Vascular Institute as well as St. Luke's Cardiology. Thank you for taking the time to discuss this topic today.

Dr. Kettelkamp:
Glad to be here Dustin.

Dr. Arnold:
What do we mean by by the numbers? Need to know your numbers/by the numbers?

Dr. Kettelkamp:
Sure, so when you're thinking about cardiovascular health, you think about, well what is my blood pressure? What's my cholesterol level? What's my BMI? What's my weight? You know, those sorts of things are important because they impact your health overall. But it also impacts your heart health.

Dr. Arnold:
What should my blood pressure be?

Dr. Kettelkamp:
So blood pressure arguably should be at rest, when you're relaxed and you're not stressed about something. Should be about 120 or less. That's the big number, that systolic number and ideally your diastolic number, which is a small one. Should be less at 80 or less. We consider borderline blood pressure in the range of 120 to 129. That's when we start thinking about what to do about it at that point.

Dr. Arnold:
You know that borderline, that's like being half pregnant. I mean, either have high blood pressure or you don't. So how long can someone be borderline? I mean I don't think borderline diagnosis is something you want to carry it for like 10 years. In your opinion, when do you say well this is no longer borderline, we need to treat this?

Dr. Kettelkamp:
Right. So if I see a patient who has that sort of borderline blood pressure and we talk about it and we say, okay, here's the things we can do to try to affect that. And there are things that we can all do to try to lower our blood pressure and we give him a shot. Let's do that for six months and see how you do three to six months. And if we can impact it that way, fantastic. If not, then I think it's time to start thinking about maybe first line blood pressure meds.

Dr. Arnold:
So if a patient has exhausted the... Quit smoking and lost weight, but yet they're still having a high blood pressure, then it's time to treat with medication?

Dr. Kettelkamp:
I think so, yes.

Dr. Arnold:
Now is it still true that most patients take multiple medications at lower doses rather than one medication at a high dose? That was reported a couple of years ago. Is that still true?

Dr. Kettelkamp:
Tends to be, yeah. It tends to be easier and better tolerated.

Dr. Arnold:
Okay. One of the, probably the most important number that we need to talk about before we get to cholesterol and its influence on heart diseases is the number of cigarettes, you smoke a day. That's probably the most important number. And we want everybody to be zero.

Dr. Kettelkamp:
I think zero is a good one.

Dr. Arnold:
Yeah. People try to rationalize that a small dose or moderation of alcohol is beneficial to health. Then there's various studies that have proven that, but there's just nothing that indicates. People should not smoke, should they?

Dr. Kettelkamp:
That's right. There is no...it's unequivocal. Smoking is not good for you. And there are multiple things, you know, it's not cardiovascular alone, but obviously pulmonary. There's so many connections to smoking and in any kind of vascular disease, you name it. It's clearly an issue. So smoking is clearly a bad thing. Don't do it.

Dr. Arnold:
Yeah. I've always been kind of perplexed that who thought of I'm going to light something on fire and inhale the smoke into my lungs. The first guy that did it, that's kind of bold, if you ask me.

Dr. Kettelkamp:
Yeah, I imagine it's a cultural thing. It'd be interesting to know what the history of that is. It goes back to, you know prehistoric times, I'm sure.

Dr. Arnold:
Well, the first man to eat an oyster was hungry.

Dr. Kettelkamp:
That's a good point.

Dr. Arnold:
Well cholesterol, that's one good cholesterol, bad cholesterol. How does cholesterol influence heart disease and what should we know about it?

Dr. Kettelkamp:
Definitely. So cholesterol is one of those modifiable risk factors for coronary disease. And you know, there's several things that we have control of, but there's a lot of things we don't. And at least cholesterol was one of those. So knowing your cholesterol numbers is helpful because you can impact that. You know we talk about cholesterol as an aggregate of all the different good cholesterol, bad cholesterol, triglycerides and so forth. But a total cholesterol of 200 is considered to be kind of right there where you want to maintain 200 or less as a total cholesterol. And then we can get more specific about bad cholesterol, good cholesterol, triglycerides.

Dr. Arnold:
The good and bad cholesterol. I always remember the HDL is the helper cholesterol. The LDL is the loser cholesterol therefore it's the bad. So that's one way to keep it straight. Now I know Dr. Kettelkamp, up until a couple of years ago it was just get the LDL as low as possible, particularly people at high risk or who have had heart disease.

Dr. Kettelkamp:
Correct.

Dr. Arnold:
How has that changed? How are we managing cholesterol differently today than we were five, six years ago?

Dr. Kettelkamp:
Well, so it is a little bit different. You know when you have a patient who has coronary disease. And there are these expert panels all across the country that kind of get together occasionally and make recommendations. And the latest recommendation in patients who have diabetes, which is considered a coronary artery disease equivalent. Or people who have had a history of heart disease with stents or bypass surgery. Absolutely lower the better is considered to be the appropriate care. And it's not exactly the group of people we're talking about here in terms of, you want to be preventative. But if we're thinking about secondary prevention for those high risk populations, coming down from the experts is start a person on a high potency statin at the highest dose they can tolerate and never look back. That is the guideline. And so you start a high dose of Crestor say, and you never check it again. Because it really doesn't matter because you don't impact beyond that. There are rare exceptions, but that's the case. So it becomes a little less concrete when you're dealing with people who don't have a history of coronary disease and don't fit that high risk category and you're really just trying to reduce your risk. And then the numbers probably have some meaning and some pertinent. And so we start thinking about bad cholesterol, the loser cholesterol. We want the LDL cholesterol to be arguably 100 or less. We really don't start thinking about treatment until it's 140 or higher. We don't start thinking about medications. HDL cholesterol is a little bit harder number to move. Exercise, diet impacts it to some degree. Omega three fatty acids can help with HDL cholesterol, but you'd ideally like to get your HDL cholesterol above 40.

Dr. Arnold:
And that has a large genetic component to it, doesn't it? The HCL compared to the others, right?

Dr. Kettelkamp:
It does. You bet. There's these pockets of super healthy people all over the world in what they call blue zones. And one of the arguments that these people live so long is because they have this, fancy high HDL cholesterol level or the Milano cholesterol. They call it a HDL Milano. Is one example and it's interesting with these people, there's a higher number of centurions in these little communities and one of the things that points to that is their HDL levels. So it's genetic to some degree.

Dr. Arnold:
So they're not eating the Milano cookies from Hickory Farms?

Dr. Kettelkamp:
That's right. Unfortunately that doesn't work.

Dr. Arnold:
Okay, well that's too bad. Scratch that treatment plan. Yeah, I would always tell patients that heart disease and your family history is kind of like a firearm, a gun. And your family history is the gun itself, which is not dangerous if it's not loaded. And then then when you smoke, you put a bullet in the chamber, maybe two. You add type two diabetes, you add hypertension. Now you have a dangerous scenario. So I used to tell people that you can change it. It isn't a fait accompli that oh you have a family history of early death so therefore you will. It is modifiable.

Dr. Kettelkamp:
Absolutely. Yeah, that's a good point. I mean people feel frustrated and actually the proactive patients, I see them all the time. They come in because mom or dad had a heart stent in their forties and they want to be proactive and the thing that they will relate is that well, dad didn't take care of himself. You know, he was overweight, he smoked. And so that is extremely important. Diet, exercise, you know, managing your numbers.

Dr. Arnold:
So you want to diet and exercise enough so then if you do pass away, people go, wow, what happened? Rather than, oh yeah, I saw that coming. That's the goal, at least the one I have. So back to weight and exercise. How does weight influence coronary artery disease or heart disease? High blood pressure?

Dr. Kettelkamp:
Sure. Well weight is a complex issue. You know, it manifests in lots of ways, right? Or it has impact in multiple ways. There's clearly a connection between high blood pressure and weight, sugar/diabetes and weight, high cholesterol and weight. They all kind of go together. The other part of weight that's challenging is that it impacts joint health, physical health, the ability to get up and move around, get off the couch and do things. That has a sort of cyclical effect. As you can imagine, the more weight you gain, the harder it is to do things. The harder it is to do things the more weight you gain. And so it's a tough cycle to get out of.

Dr. Arnold:
Yeah. And it's been dispelled just recently, last six months, Annals of Internal Medicine. There's a couple of articles that there's no such thing as healthy fat, you know, or fit fat I think is the phrase they use. I think that was, I don't want to say a crutch, but some sort of solace for being overweight, but you're in shape and the insulin resistance and the possibility of obstructive sleep apnea. Which as you know, causes, it's kind of a silent killer in a lot of respects.You know that happens. The cholesterol medications you mentioned, the statins, the HMG CoA reductase inhibitors, they're expensive.

Dr. Kettelkamp:
Yes, well and statins, maybe not so much the statins anymore, you know, that's the good news. The potent statins that in particular Lipitor and Crestor would be the two name brand examples that, thankfully those are basically generics now. Which is great. So statins really are relatively inexpensive. You know, statins get kind of a bad rap in the press and there's a lot written about them. I will say that people do have some side effects with them. But generally speaking, statins are very well tolerated. They were very effective at lowering cholesterol and they truly do impact cardiovascular health. So there's a lot of data to support their use and that's why they're part of our guidelines.

Dr. Arnold:
How young would you start a statin?

Dr. Kettelkamp:
Well, again, it kind of depends on your family history. You know, there is some information in pediatrics that statins are appropriate. You know, these are people with familial hypercholesterolemia. So they have these HDL cholesterols of 400 and or higher and impacting that level early is important. So there is some data in exceptions where you start very young. Typically we think about statins in terms of your numbers again. So if your LDL cholesterol is above 140, then we start thinking about impacting statins. If you haven't been able to bring it down with diet and exercise. You also think about first degree relatives. So when did mom or dad start having problems?

Dr. Arnold:
Yeah, I think that young men, I used to call it life insurance, liver disease. Because they get about 25 years old. They get married, they have a mortgagee, they have a kid on the way. So then, they would need some life insurance and they get their blood drawn and their liver enzymes are a little elevated from fatty liver. And then they end up in the office for the first time ever. We talk about it at that time. And I always started the statin, but sometimes I thought, wow, I'm committing this 25 year old to taking this medication without any evidence of what is the longterm side effects stantins have been out for. Well, as long as you and I have been in practice so over 25 years, any longterm concerns that you know of?

Dr. Kettelkamp:
They used to really be concerned about liver issues and that really has been developed. We used to always, every time you check off cholesterol profile, you checked your trans amylases. And we don't do that anymore. You know, it's really the effect liver issues are almost a nonissue. And so they're very safe. The biggest issue with statins really are the muscle aches and pains that occasionally patients have. But aside from that, there really isn't a big downside to statins.

Dr. Arnold:
Okay. The other medications for you mentioned fish oil. Is all fish oil the same? Did I see something? You know, I try to manage most of my practice by watching television ads these days. You know, cause they're so informative. But isn't there a prescription fish oil now for like triglycerides? Did I see that the other day?

Dr. Kettelkamp:
There is. Yep. So there is a prescription strength triglycerides in essence that is a little bit more concentrated. So the pill is smaller. So that's the big difference. There was actually an interesting article. I bet it was over 10 years ago. There was published in the annals of internal medicine about fish oil. It was specifically looking at brands across the spectrum. So there were fish oil tablets from Walgreens, from Target, from Costco, and they looked at a few things. They looked to see does the fish oil, is it actually the in the concentration they claim it is? Were there any toxins in particular heavy metals? Because you're worried about that with fish. And there were a couple of other variables and they looked at cost. And the only variable that was at all pertinent was cost. Turns out that if they claim they have 1200 milligrams of fish oil in the concentrations, they claim it was. What they claim is true. There were no toxins. There were no heavy metals, which is interesting. Apparently the process by which they remove the oil from the fish also removes the heavy metals, which is interesting. So the only variable that had any impact was cost. So that's what I tell patients, buy the cheapest.

Dr. Arnold:
You know, I tell patients that just in general on all supplements. Don't buy the Shaklee mail order of vitamins. Just Walmart, Hy-Vee brand, just bottom row because vitamin C is vitamin C.

Dr. Kettelkamp:
Exactly, good point.

Dr. Arnold:
Speaking of vitamin C, does that have any influence on heart disease?

Dr. Kettelkamp:
I guess I'm not, you may more know more about that than I do. I haven't heard. There was a thought that that vitamin E had some impact on heart health and it doesn't. Patients used to take vitamin E for heart health, but that's sort of been debunked. There was some thought that vitamin E has some impact on for women for breast health. And that may be the case. I don't really know that that's the case. But vitamin E not so much. Vitamin C you hear about that for cold and flu and that kind of thing.

Dr. Arnold:
Well I think the vitamin C in the Wound Clinic is a very good supplement because it helps with the cross linkage of collagen as the wound heals. And we know that from case reports of scurvy in the Victorian Navy. That the sailors would become vitamin C deficient, of course, you know? And old scars from like 20 years previously would open up because of the collagen become deficient from the vitamin C deficiency. So vitamin C does have some benefit, but I always tell patients, don't spend tons of money on supplements. Dr. Kettelkamp, this is great spending time talking about this today. I think I feel a little bit more comfortable with knowing my numbers and talking about, and I really appreciate your time. Again, that was Dr. Richard Kettelkamp, a cardiologist from UnityPoint Health-St. Luke's Cardiology and Heart and Vascular Institute. If you have a topic you'd like to suggest for our TalkOn podcast, shoot us an email at stlukescr@unitypoint.org. Let me encourage you, tell your family, friends, neighbors, strangers about our podcast. Until next time, be well.