Appointment Icon

St. Luke's Emergency Department

First Available Time :

Jones Regional Medical Center Urgent Care - Anamosa

1795 Highway 64 East
Anamosa, IA 52205

Closed Patients
Waiting Now

UnityPoint Clinic - Express (Lindale)

153 Collins Road Northeast
Cedar Rapids, IA 52402

Closed Patients
Waiting Now

UnityPoint Clinic - Express (Peck's Landing)

1940 Blairs Ferry Rd.
Hiawatha, IA 52233

Closed Patients
Waiting Now

UnityPoint Clinic Urgent Care - Marion

2992 7th Avenue
Marion, IA 52302

Closed Patients
Waiting Now

UnityPoint Clinic Urgent Care - Westside

2375 Edgewood Road Southwest
Cedar Rapids, IA 52404

Closed Patients
Waiting Now


Ep. 170 - LiveWell Talk On...Preventive Cardiology (Dr. Fahed Al Darazi)

episode 170

Ep. 170 - LiveWell Talk On...Preventive Cardiology

   Subscribe so you never miss an episode!

   Apple Podcasts | Google Podcasts | Spotify | Pandora | iHeart Radio |   
   Google Play Music | Stitcher TuneIn SoundCloud 


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

Guest: Dr. Fahed Al Darazi, cardiologist, St. Luke's Heart Care Clinic

Dr. Arnold:
This is LiveWell Talk On...Preventive Cardiology. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health - St. Luke's Hospital. The Centers for Disease Control and Prevention reports about 600,000 Americans die each year of heart disease. Annually, that's about 25% of all deaths. Now the CDC has certainly been in the news a lot with COVID, but there are other health conditions that continue on despite the pandemic. According to St. Luke's Heart Care Clinic, they are seeing more people for preventative heart care. Joining me today to discuss what that means, is Dr. Fahed Al Darazi, cardiologist with St. Luke's Heart Care Clinic. Welcome.

Dr. Al Darazi:
Thank you.

Dr. Arnold:
This is your first podcast, isn't it with us?

Dr. Al Darazi:
Yes.

Dr. Arnold:
Well, we're glad to have you. We're hoping you can outshine Wagdy, so the bar's set pretty low for you. I think you can do it. I'm confident. But you know, I've talked on my updates about COVID how some of the stuff that we're seeing in the hospital right now, this what I call the tsunami of just chronic medical disease, is a result that we suspended healthcare for six months in 2020. We just quit doing what we normally do, and I think it's coming in now because cancers kept going, heart disease kept going. And so, tell me what you guys are seeing in the clinic as far as heart care and preventative care, et cetera.

Dr. Al Darazi:
Well, I mean, initially at the beginning of the COVID we postponed everything. Diagnostics, screening, office visits. Even when we reopened, patients did not want to come forward. There was a lot of delay in care that patients initiated even after we opened. So I would say for the first six to 12 months, I mean, we've seen that trend. In the last six months, we're seeing exactly the opposite trend. We've seen a very high referral basis, very high self-referral basis. We're almost not able to accommodate new patients on a timely manner, the same way we used to do it in the past. For example, we used to see a new patient within two weeks. Now it's taking much, much longer to do that. And the reason is, I think with the vaccine and with the fear becoming less of going to the clinics, basically people are coming more forward. They want to get back to getting their screening done, getting their healthcare taken care of. Even the people with the heart disease, I mean, they delayed their care a lot.

Dr. Arnold:
Yeah.

Dr. Al Darazi:
When we start seeing them—I mean, I saw one of them today, I was like, where have you been for the last year and a half?

Dr. Arnold:
Right.

Dr. Al Darazi:
I mean, just today. But I believe the last six months has seen that shift where it's not happening as much. I mean, we are getting to those annual checks, six month checks. We're doing our screening, like the way we used to do it before. So I think it's opened up again.

Dr. Arnold:
Yeah. I went to a visitation recently and the person that passed away was in their nineties, but they just simply quit going to the doctor about two years ago. Now, they still might have passed away in their nineties, but I mean, they just quit participating in healthcare two years ago because of COVID and being afraid of that. So it's certainly real. And again, as I said at the beginning of the podcast, I think it's part of the tsunami that we're seeing now. I think that's why we're so busy. You know, yeah COVID, we might have 40-50 COVID patients, but you know, there's still 85 to 90 other patients in the hospital that are not COVID. They have some sort of chronic medical condition that's been exasperated, because we're not doing a lot of elective surgeries right now with the volume that we have. So it really puts in perspective what we're up against.

So preventative heart care, there's two patients that are going to come to you, in my assessment. There's going to be one patient, that's either self-referred or referred from another colleague that has a concern: chest pain, shortness of breath, etc., that they want investigated. And then there's preventative heart care. So let's start with that symptomatic patient. I'm referred to you, I was out shoveling the snow and got a little chest pain. I have a snow blower, so that's not a risk factor for me, but it's a real risk factor. So take me through what's going to happen to that patient in the clinic when they show up to see you.

Dr. Al Darazi:
So they come, I mean, of course they're screened by the nurses for their chest pain. We do that too, like the first time for their medications. They get their blood pressure checked. And then when we are introduced to them, I mean, we're going to go over a history taking. So history is the most important thing, including their past medical history, their current history of why they're coming, description of their condition. When did it start? What's making it better? What's making it worse? So if we're talking about chest pain, I mean, it's a good 5/10 minutes of history taking at first. We're going to ask about their family history to see if there's any predisposing factors, if they have any of these factors themselves. Have they ever been screened for anything, have they ever been tested for it, or for any heart condition before? We can lump all this information together and then come up with a plan. And the plan is going to focus on stratifying if this is a benign condition, or if this is an intermediate risk condition and then we need to do more investigation. Or say we have a diagnosis and we need to jump to a treatment plan. So this is basically, I mean, how we do it. It's usually anywhere between a 20 to 40 minute office visit when it's a first time person coming. I mean, a physical exam focuses on the heart mostly. Because it's a first visit, we also check the legs for swelling. We check the legs for circulation. We examine the carotid. So basically it's a full cardiovascular assessment, even if it's not related to the main symptoms. Of course, we're going to answer their questions, we're going to focus on why the person is coming to us. But just coming the first time, they're going get a full evaluation, like head to toe for their arteries, for their heart, and their medical history.

Dr. Arnold:
So depending on a scale one to ten, whether or not you're concerned—you know, ten being the most concerned, one less concern—that may influence whether or not you go and do a cardiac angiogram or just a stress test, etc. Because sometimes if the story's so convincing, you just go straight to the cath lab, don't you?

Dr. Al Darazi:
We do that, I mean, at least once a month. At least myself. If somebody comes and the story is like, that's it, slam dunk, I mean we cast them within the first 24-48 hours from seeing them. So if it's convincing chest pain history, that suggests there is an ongoing heart problem and then we think it's a high risk problem, then just go straight for the cath. That is where we basically check the arteries of the heart to see if it's clogged up or not. If it is like an intermediate history or like an intermediate suspicion, not kind of slammed dunked, we call it cardiac. And at the same time, it's not completely benign, like it's not a muscle in the chest. It's not as acid reflux, or any of this, then we'll investigate more. We might do an ultrasound of the heart. We might do a stress test. If we suspect arrhythmia that's causing it, if there's any other findings on the history that suggests this as a rhythm issue, especially nowadays a lot of people carry either a Fitbit or an apple watch or a sort of device around their wrist that tells them if their heart is going up during those symptoms. This might tilt us towards other investigations, for example, a heart monitor. A lot of people with chest pain, it's not necessarily coming from a blocked artery, it comes from AFib for example, or angio-tachycardia. So it depends on what the story is telling us. It's always the story.

Dr. Arnold:
Right.

Dr. Al Darazi:
We focus a lot on the story and then the exam of course is going to help us. When I first see patients for first time in the clinic, I do get an EKG. It's a screening tool that's going to tell me a lot if it's abnormal. If it's normal, of course, it's not going to rule out things. But it's abnormal, it's going to help me exactly to where things are going. So that's something else also we do on the first encounter.

Dr. Arnold:
Isn't it interesting, despite all the advances in technology that you have at your disposal—you know, my 25 years of medicine, how I've seen that technology presents—the good old fashioned 12-lead EKG still provides a lot of information.

Dr. Al Darazi:
Nothing beats that.

Dr. Arnold:
Yeah. Einthoven's triangle still, you know, it's still, it's practical. It really does accomplish quite a bit.

Dr. Al Darazi:
You what, nowadays it's almost available to people.

Dr. Arnold:
Yeah.

Dr. Al Darazi:
I don't know if you've ever heard about the KardiaMobile device.

Dr. Arnold:
Yeah, I've seen the commercials.

Dr. Al Darazi:
Yeah. I got it because my first encounter with that was a patient, I just saw her husband today. She reminded me of that today. She was the first patient I even learned about the KardiaMobile with. And on her device, I mean, I saw Vtach.

Dr. Arnold:
Wow.

Dr. Al Darazi:
And she actually got the advanced one, not the regular one. So there's this one that gives you one strip, and the one that gives you six leads. So the one that gives you six leads, basically it's all the limb leads, so it gives you a lot of information. And then on that, I mean, she had a Vtach. She ended up with an ablation. I mean, all these things, but guess what. People can get screening by themselves now. I mean, she was feeling those palpitations. She took things in her hands and then got this device, checked it, figured out it's not normal, and came to us. That's how it happens.

Dr. Arnold:
Yeah. Well okay, I'll tell you, I won't roll my eyes as much at those commercials as I have been, based on that story.

Dr. Al Darazi:
I keep telling people, the apple watch is real, especially if it can identify a good P wave. I tell them, get me a good baseline, get me a good standard strip, so we can compare when it's abnormal. Because if the baseline normal is not well seen on the device, that means otherwise it's not going to give us much information. They are real, I mean, we detect a lot of things on those devices. And it's cheap, much cheaper than doing monitors and then repeating those monitors. If the data is good, if we can interpret the data, nothing beats that. I mean, an EKG is an EKG.

Dr. Arnold:
But you know, I do think we should cover—patients will ask: what symptoms should I go to the doctor to find out if it's heart disease? And I'll get your opinion on this. I always tell them, I say, you just come when you have a symptom, I'll figure out whether or not it's something to worry about. That's not your job. That's my job.

Dr. Al Darazi:
I was going to say the same thing.

Dr. Arnold:
Yeah.

Dr. Al Darazi:
I mean, chest pain, heart racing, fluttering, problems breathing, even if you're dizzy, lightheaded, passing out. Just name it, anything. I mean, doesn't have to be chest pain. It could be jaw pain. It could be—my first patient in this practice was a pain between the shoulder blades. First patient, first day. And he ended up with a bypass because he had atypical symptoms. It wasn't like the slam dunk chest pain that comes with exertion. So anything that concerns you. Tell people from here to here (chin to pelvis), just let me know.

Dr. Arnold:
That's so true. I can honestly say over my years of medicine, I've seen more people show up with kind of fatigue and shortness of breath as their presenting symptom, because they curtail their activity over time. So they don't get crushing sub sternal, chest pain because they've curtailed it and not really noticed.

Dr. Al Darazi:
Most I remember are basically the highest risk, like somebody passing out for no reason. And then I mean, you do it like a regular workup and things are fine, but when you cast them, they have like a 99% left main, which is the main artery of the heart. And then they stop passing out once you fix it. So yeah, things can be atypical, I tell people. I mean, when I see patients and then I tell them about the warning signs about their heart, I tell them at the end: if you have any concerns, if you have any questions, don't hesitate. Don't just sleep on it and say, oh, that's just gas or something else. Just ask the question. I can tell you the difference.

Dr. Arnold:
So now let's take that other patient, because patients can self-refer, correct?

Dr. Al Darazi:
Yeah.

Dr. Arnold:
So I've self-referred to the office and I'm 55, I'm actually 52, and I have some risk factors. What should I do? So take me through that patient. How is that? I'm having no symptoms, from a baseline.

Dr. Al Darazi:
We do see that a lot. A lot of people, self-refer because either the way you're describing this scenario of, I have some risk factors, should I be concerned about my heart health or not. Or even, I have a family history of a heart condition. Like somebody died in my family suddenly. We don't know what from, or there is a family history of congenital heart disease, or valvular disease, or myopathies where the heart is weak and dilated. So we get all of this. So when people come, we go through the—I mean, this is not tailoring towards symptoms, but tailoring towards prevention. So based on the profile, we decide which type of testing they need for screening. So for example, somebody who is a diabetic, who smokes and they're feeling fine, they exercise, they don't have symptoms. They need to know whether they should be on a statin or not. They should be on aspirin or not. We do a CT calcium score. So that test tells us if there is calcium built up in the heart of the heart. It's a very cheap test, very low radiation. It takes about 10 minutes. It's a very vague picture of the heart that just counts the dots if there is calcium built up in parts of the heart. Now it has to be done on people above the age of 40, because below that, it's unlikely for people to build up calcium.

Dr. Arnold:
And women, right? Women will have softer plaques.

Dr. Al Darazi:
Women will have softer plaque, yeah. But still, between the ages of 40-79, basically 80, this test is used as a screening test for people that have risk factors. Now when we check the cholesterol for people, and then we assess the risk factors, if their risk is very high, we don't need to do that. We can just start a treatment with a statin. Let's say their risk is more than 20% of having heart disease in the coming 10 years, then we can just offer them treatment. If they're reluctant, we can do the calcium score to kind of prove it or not. But really the population that benefits from the calcium score, is a population that has low risk and a family history of heart disease at early age, or the intermediate risk population that has a 10% to 20% risk of heart disease. So you don't know, should we treat with the statin? Should we do any other testing? The calcium score is the best test to do. So this is how we evaluate coronary artery disease. This is not the population that has a family history of cardiomyopathies, or weak hearts, that's different. So people can come for screening for different reasons. So just to answer, based on the scenario you gave me, it's more focused on coronary artery disease.

Dr. Arnold:
Right.

Dr. Al Darazi:
Where we can see people coming for screening for lots of different other reasons.

Dr. Arnold:
That's interesting. The listeners are going to want to know this. Did you see any vaccine related cardiomyopathies or myocarditis?

Dr. Al Darazi:
Yes. I've seen it more in the hospital setting, than clinic. Because what happens is people get the vaccines, especially the second dose, and then within the first 24 to 48 hours, they come either with chest pain, syncope, and they come in and their troponin is up. Now, I can tell you we've cathed those people. So initially we did not know, but now we know that this was a focal myocarditis or an episode of myocarditis that led to this. So I haven't seen massive myocarditis with the vaccine. It's more in the younger population group. So I haven't encountered one myself. I mean, I know it exists. I mean, we read that. I mean, we've seen the reports. The lucky thing about it is recovery, so they all recover. That's the good thing about it.

Dr. Arnold:
That is good.

Dr. Al Darazi:
Yeah. But definitely I've seen the elderly or the older people with the vaccine getting focal myocarditis. I mean, I've encountered many of those people in the hospital.

Dr. Arnold:
Interesting. Yeah, I think over time it's going to be interesting in 10 to 20 years from now to look back on all this and kind of really being part of it, to look back on the pandemic and other things. You know, we like to talk here on the podcast that, you know, I always make the reference that family history is like a handgun. Okay. So here you have this handgun that's empty. It's not really a risk factor to anyone, right? But then you start putting bullets in the chamber. You put one in and it's high blood pressure, then you put diabetes in there, then you put smoking in. You know, and now pretty soon you have a very dangerous weapon in your hands, right. That you've made dangerous, you know? So in your clinic, you guys focus on cholesterol management, blood pressure management, smoking cessation. I know pulmonology has that as well, but you know, stopping the nicotine, right? Yeah, if people didn't smoke most of us physicians would need part-time jobs. You know, really. I mean, if everybody quit smoking, we'd be great.

Dr. Al Darazi:
I tell people there are five things they can do to minimize their risk of having heart issues: exercise a lot, watch their diet, avoid smoking, and if they have diabetes and high blood pressure, make sure they're under good control. If they have all this, they wouldn't need a doctor at all.

Dr. Arnold:
Right, that's so true. Is there anything else you wanted to cover regarding preventive heart disease?

Dr. Al Darazi:
I do want to say that we are under-screening people for heart disease. We have to be a little bit more aggressive. Now, unfortunately that's partly because insurance companies are not covering those screening tests. So there is less motivation from people. Although, I mean, there is a trend that people self-refer, but I think when you take the general community, there are not a lot of people coming forward to get screening for their heart, or for any heart condition. And again, I'm going to repeat something I just said earlier. CT coronary calcium score is one of the best screening tools for people if they have any underlying coronary artery disease. Because that's going to determine if they should benefit from aspirin, if they should benefit from statin, whether they have diabetes, whether they have hypertension. So anybody with a family history or anybody with an intermediate risk score should get that. Right now out of pocket, it's about a hundred dollars.

Dr. Arnold:
And they can just call the clinical and get one of those scheduled, or how does that happen?

Dr. Al Darazi:
It has to be ordered by a physician. It can be ordered by the primary care doctor. So it's ordered as a CT calcium score, coronary calcium score. And it's fast, I mean, you get the reading the same day. I mean, so if it's negative, you can repeat it after 5 to 10 years. If it's positive, meaning if the calcium score is more than 100—because zero to 100 is kind of like a vague area of what people should do with—more than 100 should be on aspirin, it should be on statin to prevent heart attack, to prevent strokes, to prevent any heart events. So this is one of the best tools. And the other thing I would say is people underestimate the bad outcome that they can get from alcohol. Excessive alcohol causes a lot of arrhythmias. This has been already established, this has been already put in the news and in the papers and everything. But that's something people should know. I mean, if they have, one of those old studies that one to two ounces of red wine is good for the heart, no more than that. No more than that. So social drinking is okay. Daily drinking is really bad for the heart, it can cause high blood pressure, can cause brain issues, myopathies, the heart can get weaker, can cause a lot of arrhythmias. A lot of arrhythmias, AFib, Vtach, SVTs. We see this all the time. So something we don't focus on a lot in the clinic, but once we see people we tell them, but it's not a common knowledge for everybody is that alcohol is as bad as smoking on the heart. People can get a lot of, I mean, heart issues from alcohol. So focus on exercise. Again, exercise, exercise, exercise, no smoking, cut down on alcohol, those are the most important things.

Dr. Arnold:
That's really great advice. Well, the final question to all the guests or almost all of them for sure, is why did you choose cardiology? Why not internal medicine or surgery, what drew you to cardiology?

Dr. Al Darazi:
I'm going to give you a background and I'll tell you the rest. When I got into medical school, I thought I'm going to be an orthopedic physician. The reason is I was so much into sports and varsity teams and national teams that I was like, okay, that it fits into this. But I have to say around my mid third year of medical school and my fourth year, is when all of a sudden I said, okay, it's internal medicine. I'm not into surgery. And I kind of loved it. I mean the physiology, the pathophysiology of the heart, it's kind of like all of a sudden, this is what attracted me. Just kind of like you fall in love with it. And then there was this doctor, it was a fresh fellow graduate from Emory who came to Lebanon. I did my medical school at the American University of Beruit and he moved there. I mean, he finished his studies at Emory as a cardiologist, interventional cardiologist, and I was lucky to train with him for a couple of months in the CCU. Lebanon, as medical students, we used to cover the CCU. That's how it was, so you get the bread and butter of everything right on.

Dr. Arnold:
Yeah.

Dr. Al Darazi:
And honestly, he had a lot of influence for me to decide to go for cardiology. I mean, he did such a great job. He did, terms of teaching, kind of made me love it even more than what I thought I did. And when I started cardiology, I mean, it's just a passion.

Dr. Arnold:
Yeah.

Dr. Al Darazi:
It's a passion. And now in practice even more, I mean, I do things right now I did not even learn in fellowship. I learned more cardiology in practice than I learned in training,

Dr. Arnold:
Yeah. I've said that to other people that I feel sorry for people that the first year you're in practice, you learn so much. And, you know, and I was lucky I had this partner. It was just me and another guy, but he was a good teacher, he liked to teach and he was smart and I learned so much. You know, you don't appreciate that at the time, because it's just survival days, right?

Dr. Al Darazi:
Yeah, yeah.

Dr. Arnold:
Then in the end you're like, wow.

Dr. Al Darazi:
Other than just building experience, cardiology is a very moving field. Literally, like five years back there were things that we have now that did not exist.

Dr. Arnold:
Yeah.

Dr. Al Darazi:
I'm doing things that I never thought I would do when I was in training. Skills, of course, experience, you keep reading and you have to catch up with all the studies and all this. But on a procedural level, I mean, we learn stuff that are fun. For example, I take fun in doing an imaging procedure and catching something. I like the diagnostic part of cardiology more than the treatment part. So doing those imaging procedures, like the TE, it's fun. Beyond just treating somebody, like establishing good health for people, there's fun in catching these things and then making a difference by changing the outcome. So I mean interventionist can probably tell you more because they are like right up front when people are all of a sudden dying and then the next day they're going home. That's even more rewarding. Like when I went on my vacation, it just happened that me and another doctor, we were on call over the weekend. And then we had three emergencies at the same time. He was in the cath lab putting an impella, a kind of a support device. And at the same time, we get two calls from the emergency room, two STEMIs, so we kind of start dividing. I mean, I go down and as I was talking to the person, he codes on me. He goes into VFib and was having a seizure, and then we shock him out of it. And I go home, and something happened that gave me goosebumps, like when he came back from it, he was like: guys, I saw God.

Dr. Arnold:
Wow.

Dr. Al Darazi:
Literally. I mean, you don't see this anywhere. I mean, I have to say, cardiology is self-satisfactory. And you have to like it. And I really like it a lot and I did get influenced, as I said by a lot of people in medical school probably, and especially this guy, the cardiologist, and I don't regret it.

Dr. Arnold:
Well, I think it's going to be really easy for listeners to understand why we're so glad that you're here. I love having you on medical staff. I've had family members that have seen you and mutual patients, and you're doing a great job. We're glad you're here.

Dr. Al Darazi:
Thank you very much.

Dr. Arnold:
Once again, that was Dr. Fahed Al Darazi, cardiologist with St. Luke's Heart Care Clinic. For more information about St. Luke's Heart Care or to consult a cardiologist, visit us online at www.UnityPoint.org/heart. Or you can simply call 319-364-7101.

Thank you for listening LiveWell Talk On. If you enjoyed this episode, don't forget to subscribe. And if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers about our podcasts. We're available on Apple Podcast, Spotify, Pandora, or wherever you get your podcasts. Until next time, be well.