A Healthier You: A cardiologist's guide to protecting your heart

0:06This is TED Health, a podcast from the TED Audio Collective, and I'm your host Dr. Shoshana Ungerleider. Welcome back to our special series called A Healthier You. In today's episode, I want to start by sharing a bit of my own personal health journey. Over the past five years, I noticed that my LDL, or the bad cholesterol, was creeping up slowly. Nothing too alarming, but enough to keep an eye on. The higher that number is, the greater the risk for things like heart attacks, strokes, and other diseases later in life. This past spring, I went in for a routine checkup and saw that my bad cholesterol had jumped by 25 points.

0:46This was surprising because I've worked hard to develop positive habits in my life. I eat pretty healthy, I exercise every day, and I'm proactive about my health. So naturally, I started digging into the research and reached out to a preventive cardiologist to get her expert opinion. She first ordered a test to check for inherited genetic mutations, which thankfully came back negative. Then she recommended I try a high-fiber, low-saturated-fat diet for a few months. We did give it two and a half months, and honestly, I didn't know what to expect. But I was shocked when my LDL levels dropped by nearly 30 points, now close to the normal range.

1:30I learned things that completely surprise me, like how powerful simple dietary changes can be, even when you think you're already doing everything right. It's easy to assume that if you're eating relatively healthy and staying active, that you've done all you can. But sometimes the smallest tweaks can have the biggest impact. This experience reminded me how crucial it is to stay curious and keep asking questions, especially when it comes to something as important as your heart health. And that's why I asked Dr. Danielle Bilardo to join us today. Dr. Bilardo is a preventive cardiologist. She's also my doctor.

2:12We're going to talk about why heart health is something that you should be thinking about well before any symptoms or problems arise. Like me, this discussion just might surprise you too. But before we dive in, a quick break to hear from our sponsors.

2:33Hi, Dr. Bilardo. Thank you so much for joining us today. Hi, thank you so much for having me. It's such an honor to join you today. Danielle, what are common misconceptions people have about heart disease and age? Oh, that's a great question. I think that oftentimes what we see is that people think of heart disease as something that happens to people who are older. And older is, of course, relative to what our age is at the moment. But what's really fascinating that we know from the research studies is that actually heart disease does not just develop when we're older. It actually takes a lifetime to develop.

3:10We actually have research that shows that there was a really fascinating study called the P-Day study. In this study, they did autopsies in individuals who had died of non-cardiac causes. So they've died of things like trauma, things like drownings, non-health related causes. And they found that even in children, super young people that we would consider patients in pediatrics, they found the beginning of atherosclerotic plaque development. And so developing cholesterol in our arteries and heart disease is a lifelong process. You know, it is the number one cause of death for men and women. And so changing that mindset that, you know, it's only something that affects older people will really change the trajectory of prevention in general.

3:54So it seems like it's important to start thinking about heart disease prevention in your 20s and 30s. Can you tell us a little bit about why that is and maybe why it's too late to start considering all this in your 50s? So it's never too late. We always say, if you're listening in your 50s and you're like, oh man, I haven't been to the doctor, I haven't had my cholesterol checked, it's okay. It's never too late. But we actually emphasize, even younger than 20s, we actually are now emphasizing in cardiology what we call primordial prevention. So prevention starting in childhood. You know, all the same atherosclerotic cardiovascular disease risk factors.

4:28So this is like elevated cholesterol, high blood sugar, like diabetes, high blood pressure, called hypertension. prevention, various different risk factors for cardiovascular disease. We want those worked on as soon as they pop up, you know, throughout life and even in childhood, starting with healthy lifestyle and things like that. Prevention is the best intervention. But just to reiterate the point that even if you are in your 50s or your 60s, you know, we always say that cardiovascular disease prevention has evolved so drastically. We've really narrowed down the cause of atherosclerosis for both what's called primary prevention and secondary prevention.

5:08So preventing for someone before they have a heart attack or preventing for someone who has developed plaque later on, preventing them from having a further event. So it's never too late and it's also never too early to get in with your doctor and start talking about those risk factors. Can you tell us what happens inside the body when heart disease develops? Like, for example, explain how plaque buildup starts in the arteries. Yeah. The same way plaque develops in the arteries of the heart, which we call coronary artery disease, is the same way cholesterol builds up in the arteries in the legs, the arteries in the brain, the arteries in the genitals.

5:47And that's why we see that people with coronary artery disease also have a higher percentage of peripheral artery disease, a higher percentage of dementia, a higher percentage of erectile dysfunction, because our body's all connected. And so the way it works is that the only thing required to develop coronary artery disease, so plaque buildup in the heart arteries, is an elevated LDL cholesterol, which is the kind of cholesterol that deposits itself in the artery wall. Now, that being said, there's other things that can make it more likely to happen. And I think one thing that's really interesting that when I show patients this little cartoon cross section and I show them that we have what's in between the vessel wall and where the blood's flowing, which we call the lumen.

6:35The only thing that's separating it is this single cell layer. It's very small called the endothelium. And this endothelium, certain things can make it even weaker. So something like smoking. Smoking certainly weakens that endothelial wall, meaning that the cholesterol is more likely to get in the vessel wall if someone is smoking. Another risk factor is high blood pressure. So when high blood pressure is not controlled, and keep in mind that an elevated blood pressure is over 120 on the top or over 80 on the bottom. When someone has elevated blood pressure, it really puts pressure on that endothelial wall and allows cholesterol in the vessel wall a little easier.

7:14Similarly, with diabetes and elevated blood sugar, it's another risk factor because that elevated blood sugar puts more tension and stress and pressure on the endothelial wall, causes some dysfunction, and lets the cholesterol get in. Now, one misconception people have is they think, well, if I have high cholesterol and none of those other risk factors, I'm good. And the truth is, it's not the case either because the only thing required to get in the vessel wall is high LDL cholesterol. And so in reality, it doesn't mean that everyone with high cholesterol is going to develop heart disease, but it's so important to talk to your doctor about all of your risk factors, including for women, pregnancy history, things like preeclampsia are really important, and family history.

7:57These are all important components. And then we really individualize everyone's next steps in treatment based on the totality of their picture. So that brings me to my next question. we often hear about, quote, normal levels for things like cholesterol, blood pressure, blood sugar. Why might these normal levels still pose a risk for heart disease? And how can we recognize when, quote, normal isn't good enough? So remember, when we have target levels for anything, it's based on population data. And there's, of course, going to be some individualization that may differ. But essentially, for blood pressure, it's pretty straightforward, what's called stage one hypertension is if your top number is greater than 130 or your bottom number is greater than 80.

8:43And then stage two hypertension is if your top number is greater than 140 or your bottom number is greater than 90. And so that's pretty standard across the board. Now for cholesterol, we have different markers depending on different factors. So if someone's in primary prevention, so this means someone has not developed any plaque yet and they haven't had a heart attack or stroke or any cardiovascular event. Our goal is that their LDL be ideally less than 100, but we always say the lower the better, and so we want to reduce the exposure of the vessel walls to elevated LDL cholesterol over time.

9:19Now, that risk factor is one risk factor, but even in primary prevention, that target may change depending on someone else's other risks. The secondary prevention, it used to be categorized as some of the previous heart attack or stroke. That's changed. And that's changed because we have amazing early detection things. I always say, we don't need to wait for someone to have a heart attack or stroke to find out they have coronary disease. I'm a firm believer that absolutely no one should have a heart attack or stroke because we can catch it and detect it early. Now we have imaging, something called a calcium score, which is a CAT scan that is no IV contrast.

9:57It's low radiation. And this is a test that looks at, is there calcified plaque in the arteries? And this puts people in a new category we have called subclinical atherosclerosis. So what this means is that for this category of people, we know they've started to develop coronary artery disease, but they thankfully, thank God, haven't had a cardiovascular event yet. So for those individuals, depending on various risk factors and what their calcium score is, that may change their lipid lowering recommendation. It may be less than 70, or it may be even more aggressive. Now, for someone who's had a heart attack or stroke, or someone with severe coronary disease, someone with triple vessel disease, or someone with significant plaque burden and a high calcium score, we're now aiming for a target even lower for some individuals who are super high risk, even an LDL less than 40.

10:46The thing is, is that this is a little complex and nuanced. And so it really is individualized. As much as we have these phenomenal guidelines based on robust evidence that give us this algorithm, no two patients are going to be identical. And I always say the principle of evidence-based medicine, which I live by, is we can know all the research and the guidelines in the world, but it has to apply to the patients sitting in front of you with their preferences and goals in mind. Yeah, I think the tricky thing with heart disease or early stages is that there are no symptoms. So most people assume, oh, well, I don't feel any different.

11:23I'm fine. And so what makes it dangerous, even if there are no symptoms? That is such a great question. So 50 % of people at their first heart attack, that's the first time they find out they have heart disease. The reason why we're so aggressive with prevention now is because we know that depending on how much plaque someone has in their arteries, which we can see with the non-invasive tests like the calcium score, we know how much lipid lowering therapy we need and guideline-directed medical therapy we need to get there at risk as low as possible. We actually know that even these lesions, meaning this is plaque buildup, that are even small and not super thick, these can still break off and cause a heart attack and a stroke.

12:03So it's not a problem until it becomes a problem. Our goal is to intervene beforehand. And we call ourselves in prevention early interventionalists. And I always joke with my interventional colleagues, our goal is to put them out of business. And then eventually cardiologists will be out of business because it's so preventable, which is amazing. We have so many tools in the toolbox to help patients from both lifestyle, nutrition, exercise, and also guideline-directed medical therapy. There's an enormous plethora of options.

12:37so danielle what questions should someone ask their doctor if they get a blood pressure reading that's up over time or this elevated ldl or even fasting blood sugar numbers that are a little bit high to really make sure that their heart disease risk is being properly managed one thing i recommend to patients the first step would be you can always ask it's never too early to ask for a referral if you're concerned about your cholesterol or your blood pressure, just ask, I need to see a preventive cardiologist, a cardiologist that focuses in prevention, and that can help. But even if you just want to kind of look up and see what the recommendations are, one of the biggest cheat sheets that I recommend patients look at is going to our national websites and looking at the guidelines.

13:23So the American College of Cardiology has all of the guidelines that have ever been published, available for free, open access on their website. And you can go for high blood pressure, cholesterol, primary prevention, and they're really nicely designed and readable. And that's a good tool. They actually outline things. They have nice infographics and things that can tell you whether or not you're getting the right care. For example, if you have high blood pressure, you can go to the blood pressure guidelines and it'll tell you if your blood pressure is this and this, what are the next steps? You'll see the next step will be, okay, you're going to start to monitor your blood pressure at home in a very particular way.

13:58And you bring those readings back to your doctor. And same for cholesterol. We have cholesterol guidelines that do the same. Just checking guidelines can help you to see like, is my doctor following the correct steps? And it seems really cumbersome. And it is. It's a little overwhelming. But I always want to present that as an option to people where if they feel like they have any concern that they're not getting the right care, they can do a double check and see. But, you know, always feel like you can ask. I think every primary care doctor I've ever known never feels offended if their patient says, is it okay if I just talk to a preventive cardiologist?

14:32Can you refer me to one? They're happy to. I have patients that'll see me and they say, you know, I felt bad saying that to my primary care doctor. And I say, your primary care doctor has to manage a zillion things. My brain couldn't fit dealing with an ankle exam and knowing the cholesterol things and all these things. And they have so much on their plate that it would be appreciated if you bring that up to them and you're concerned. And I think that's a good next step. Well, I can tell you this primary care doctor right here agrees with that. Yeah. So you mentioned this a little bit earlier, Danielle, but when it comes to lifestyle, what are some surprising or maybe lesser known factors that might be affecting our heart health that people maybe often overlook?

15:17Generally, there's a whole, my goodness. If I have so much empathy for patients right now, because the amount of confusion that is out there in the press and the media about especially diet, you know, one week people are finding out, oh, there's a news article, you should be fasting. And then the next week, there's an article saying, oh, you shouldn't be eating fruit. And there's all these crazy ideas. And so I think the biggest misconception is that, you know, in one extreme, diet doesn't matter at all and that you just need to be on medications and it doesn't matter what you eat. And that's not correct.

15:47And then on the other extreme, there's this idea that, well, diet can fix everything, and you just need to be on X, Y, or Z diet, and that's all you need. And that's also not correct. The truth is somewhere in between, which is that all of our guidelines recommend making dietary changes that are based on the totality of evidence. And I always say for nutrition research specifically, there's no placebo. We all eat. So when you see on the news one headline that says X, Y, or Z food is going to cure X, Y, or you see one study that this is the miracle. We never look at that in just isolation. You look at the totality of the evidence.

16:26And the truth is that it's been quite consistent over time. So eating more plant foods that are higher in fiber, fruits, vegetables, whole grains, if you like them, legumes, lean protein, fatty fish is great. So a balanced diet, but also being active. So getting exercise, these things are incredibly important and valuable, and they actually are listed in every single guidelines. And that's why there's such a focus in cardiology now in primordial prevention, so starting in childhood. But it's never too late to start to make those changes. Now, making those dietary changes is not easy for everyone.

17:02And actually, the way metabolism research has changed over the last 10 years, now, thankfully, we do have for some patients who've struggled with their weight and struggled with what they've eaten. That is not their fault. I always say it has nothing to do with willpower. Zero to do with willpower. A lot of it has to do with the way these hormones work in our brain. And now we have new medications called GLP-1 receptor agonists that can help. And so some patients can make those dietary changes with no medications and do great. Some patients will require some medications to make those changes. And some patients will still require cholesterol medications, even if they make all the diet changes.

17:39But regardless, there's the dietary changes and the lifestyle changes like exercise can make a huge, enormous impact whether you don't have heart disease or whether you already have it. Now, I have a sort of a different question here. In medicine, risk calculators are often used to predict heart attack risk over the course of, say, 10 years. But how accurate are these tools? And Are there better tests or assessments that can give a clearer picture of early heart disease? Yeah, so the risk calculators are a great start. And actually, everyone listening to this can Google prevent risk calculator, and you can go in and you can type in your numbers, your cholesterol, your blood pressure, and various different risk factors.

18:22And it'll populate up for you, depending on your age, a 10-year risk for cardiovascular disease. Now, these are based on what we call pooled cohorts. So these are large population data. they don't take into account everything, right? So I always say it's a good starting point, but it's not an ending point. There's lots of other factors, right? So like family history. So if you've had multiple family members or even just one family member who had a heart attack or stroke at a younger age or your pregnancy history, that's not calculated into our calculators either. If someone's had preeclampsia or gestational diabetes, or if someone has other risk factors like autoimmune disease, like lupus or various different things, also depending on, you know, there are other risk factors that aren't calculated and now like lipoprotein A and certain things.

19:08It's a good starting point for a conversation with your doctor and to kind of get you in the door. But now we do have other tests. So for people of a certain age, we sometimes use that test I mentioned called a calcium score. The reason why we don't check it in everyone, especially people under 40, is because you may not develop calcified plaque yet. It may just still be soft plaque and then we're missing it, getting a false sense of security. We have genetic tests. So if someone has a kind of high cholesterol that we're not sure whether it's genetic or whether it could be mediated with diet. We have special genetic tests that look at that as well.

19:40What's one piece of advice that you wish everyone knew about heart disease prevention that most people don't know or maybe don't hear from their doctors? I would say that it's so preventable that the most important thing is knowing your numbers and where you're at. The earlier we can prevent, the better. And it's never too late to see your doctor and get involved with prevention. And so we recommend for people in their 20s, getting their lipids checked, their hemoglobin A1C, that diabetes test, their blood pressure, of course, knowing their family history if possible. And then as we get older to continue those same checks.

20:21And if there's any change, keep an eye on it and get referred to a preventive cardiologists earlier. We can treat and mitigate all of those different risk factors with a variety of tools in the toolbox. As you so brilliantly mentioned, so much of it doesn't have symptoms early on. And so it's a great idea to just get in with your primary care doctor just to get those first steps in. And if someone is interested in finding a preventative cardiologist, how do they go about doing that? That's a great question. And I actually, I get asked that and I wish I had a perfect answer to that. And unfortunately, so cardiologists, we're not a monolith.

21:03And so sometimes it can be a little tricky because someone could be a cardiologist that focuses on electrophysiology, which is the heart rhythm. Someone could be a cardiologist that focuses on interventions. So they're doing stents and procedures in the cathode. You could have a cardiologist that focuses on just cardiac imaging, doing echo, and then you have preventive cardiologists like me. One good step is looking for what's called a non-invasive cardiologist. So a general cardiologist. They're often ones that do focus more on prevention. I'm a non-invasive preventive cardiologist. We're not in the cath lab doing procedures.

21:34We're just focusing on prevention and lipids. And so when you look for a general cardiologist, that can be a helpful step. And that's usually a good foot to get in the door because often if they're a non-invasive cardiologists, prevention is a huge part of their practice. Thank you so much, Dr. Danielle Velardo. You are not only my doctor and have been such a phenomenal help to me, but you are out there just doing so much to help people prevent this set of issues. So I really appreciate you. Well, thank you so much for having me. And you are a testament to how incredible prevention works and you're phenomenal.

22:14And it's been my honor to get to know you. Thank you so much.

22:22And that's it for today. TED Health is part of the TED Audio Collective. This episode was produced by me, Shoshana Ungerleiter, and Costanza Gallardo, edited by Alejandra Salazar, and fact-checked by Vanessa Garcia-Woodworth. Special thanks to Maria Lagis, Farrah Degrunge, Tali Emlin, Daniela Balarezo, and Roxanne High Lash. If you enjoyed today's episode, rate and review the show on your favorite platform. It helps other people find us. And I'd really love to hear your feedback. Send me a DM at ShoshanaMD on Instagram. I'm Dr. Shoshana Ungerleiter, and thanks for listening.