Host: This is the best health podcast brought to you by wake forest Baptist health in partnership with med costs. Good day everyone. Welcome back to the latest episode of the best health podcast brought to you by wake forest Baptist health. Um, we're here on a beautiful late fall, early winter day here at, uh, the Winston Salem campus wake forest Baptist medical center. And, um, you know, [00:00:30] uh, we're, the holidays will be upon us any minute now and then the new year will be upon us. And, um, with that, people start maybe thinking about their health a little bit more during the new year and what can they do to maybe take some positive steps. And, um, we have a really special guest with us today at Dr. Michael Shapiro and, uh, dr Shapiro is part of our cardiology team here at wake forest Baptist health. I'm so welcome, dr Shapira. How's it going? Thank you so [00:01:00] much, Justin. It's wonderful to be here. Well, thanks for joining us. Um, I know you're, you're pretty busy. Um, and we're going to get into some really interesting tidbits, I think, uh, specifically with dr Shapiro about, um, preventative cardiology and what that means. Um, but before we do that, doctor Shapiro, maybe just take a minute and tell us about yourself and, um, how you become a doctor and how long you've been at wake forest Baptist health and all that fun stuff.
Dr. Shapiro: Certainly. So, um, well I'm delighted to be here. I'm originally [00:01:30] from the Northeast, uh, was born and raised in New York and New Jersey. Um, and actually, uh, as a child I don't have any strong memories of actually aspiring to be a doctor. Uh, in fact my major interest growing up was in music. And by all accounts I was, uh, on the trajectory to go to music school. Um, but, uh, fortunately for me, uh, I had the insight as the time got closer to it, probably not take that direction. And I went to a traditional [00:02:00] liberal arts college, really undeclared as to what I wanted to pursue. But, uh, it's so happened that my early friends in college were all premed, so I sort of kind of caught the bug and went on that trajectory. Uh, though it wasn't entirely clear to me that, uh, I was going to pursue that, but I had the opportunity, uh, one summer to, um, pursue, um, a really great program called the health scholars opportunity program [00:02:30] that was taking place at New York university where I had the opportunity to shadow some physicians and see what it's like to be a doctor.
Dr. Shapiro: I got an opportunity to do some research, was a couple of months and from then I really caught the bug and became very motivated and, uh, really focused my attention to going into medical school. And that's exactly what I did. Um, when I finished my, uh, medical school training, uh, did most of my, um, post med school training residency and cardiology fellowship [00:03:00] in New York city and then, uh, finished up, uh, in Boston after having completed a cardiovascular imaging fellowship and then went out West to Portland, Oregon, uh, with my first faculty position at Oregon health science university and spent 12 years there. And then, uh, my wife and I and kids were very happy to return back to the East coast where the rest of the family is. Uh, and uh, came here to Winston Salem, North Carolina over the summer. So I've been here since August.
Host: Okay. Well that's a well welcome. Thank you. I think you're still getting settled in here. Maybe have you found a favorite coffee shop or restaurant to hang out at you? A few. Nice.
Dr. Shapiro: Funny that you say coffee because you know, having spent the last 12 years in Portland, Oregon where coffee is extremely important, uh, I kind of, uh, became very enthusiastic and I'm delighted that a counterculture coffee, which is one of the main roasters, uh, is based in North Carolina. So I can get their beans anytime I want. And locally [00:04:00] I enjoy going to Camino. I think their coffee is great.
Host: Yes, absolutely. I mean it was one of my favorites. Um, so of all the different, um, body systems and organ systems you could have focused on, what would your ear to the heart to cardiology? Yeah, that, that's a great question. Um, you know, as I mentioned
Dr. Shapiro: and, um, it took me a little while to, um, uh, really find out within myself [00:04:30] that I wanted to pursue medicine and had something similar happen to me when I was, you know, in medical training, trying to understand what I wanted to pursue. And I had done a number of electives, um, and a variety of different medical specialties. And it wasn't until really I did a cardiology elective and, uh, saw, uh, kind of the breadth and scope of what cardiologists did that, uh, that I really became interested in that and decided to pursue a, a cardiology fellowship, but of course the hardest and the most important organ in the body. So [00:05:00] I think that's ultimately what drew it to me.
Host: It's pretty central, I would say. Yes, indeed. Um, so, um, you've been practicing, um, medicine in that field for the last several years and, um, here at wake forest Baptist health, if I'm not mistaken, um, you're, you're focusing on pre preventative cardiology. So tell us a little bit about that for the people listening to the podcast, um, how that kind of breaks out as a South specialty and what you're really trying to hone [00:05:30] in on.
Dr. Shapiro: Yeah, so preventive cardiology, um, is really just emerging now as a, uh, dedicated sub specialty of cardiovascular medicine. I mean, the notion of prevention of cardiovascular disease is not new. It really emanates from the landmark, uh, population based study called the Framingham heart study, which began in 1948 funded by the national institutes of health where investigators asked the question, uh, what are the factors that are associated with cardiovascular [00:06:00] disease. You have to understand that in the early 19 hundreds, we were still struggling with a lot of infectious diseases, but with major advantage, uh, major advances in public health measures like sanitation. And then of course, development of vaccines and antibiotics. We largely overcame infectious disease as the number one killer, uh, in the United States and abroad. Uh, but as people were living longer, they were developing cardiovascular disease. So by, [00:06:30] uh, you know, the 1940s and fifties cardiovascular disease really was the number one threat health threat, um, in the United States.
Dr. Shapiro: Um, as a consequence of the Framingham heart study, we learned that there were four major risk factors that predicted cardiovascular disease, high cholesterol, high blood pressure, diabetes and smoking. Um, and that really, that's the first time, uh, cardiovascular risk factors. A term was defined and it really motivated [00:07:00] investigators around the world to start studies to say, well, if all of those factors are involved in cardiovascular disease, what happens if we modify them? We lower cholesterol, we lower blood pressure, we stopped smoking, we prevent diabetes, would we be able to improve cardiovascular disease? And as we know now, certainly the answer is a resounding yes. And the first successes really were in, um, lowering cholesterol. And in 1994, the first of the landmark stat and mega trials [00:07:30] , uh, was published. The forest study, which enrolled 4,444, uh, men and women, uh, in Scandinavia. And they were randomly assigned to either simvastatin.
Dr. Shapiro: The Staten is a cholesterol lowering drug or placebo. And they noted during the study period of about five years, there was a 25% reduction in heart attack and all cause mortality. So it was really a stunning result. And in just five years, in just five years, and it was really the first proof that lowering [00:08:00] LDL, so-called bad cholesterol, sure resulted in improved cardiovascular outcomes. And then there was a litany of other Statens. And Stanton trials that followed. And that really has made Stanton's one of the most important preventive medical therapies. Of course the foundation of prevention of cardiovascular disease is in healthy lifestyle, but when that's inadequate, sometimes we have to add medications of which Statens may be one of the most important.
Host: Okay. Well I'm glad you mentioned that. So, you know, I [00:08:30] think for myself is true and maybe some of our listeners, I'll take an educated guess and say it's probably true. So when we go to our primary care doctor and hopefully everyone out there listening does have a primary care doctor. If you don't, you should go on our website and find one. Uh, but so when you go, you know, it's, most of the time I, I will, uh, it'll ha be suggested to me to maybe, you know, do my best to exercise routinely and, um, you, maybe you lose a couple of pounds and, and watch what I'm eating. And, um, [00:09:00] maybe some other people when they go to the doctor, they hear that. So, you know, fast forward to 2019 from, from that study, we, um, I think a fair amount of the public kind of says, yeah, I know I shouldn't smoke.
Host: I know I shouldn't eat that many pieces of pizza or all the deep fried food I eat or I should get to the gym or at least walk around my neighborhood. And so I think there's some knowledge about that. But then, you know, when we talk about, uh, like when we talk with our American heart [00:09:30] association friends for the heart and stroke walk that we participate in, like kind of the same subject comes up. So what can you as a print of preventive cardiologist, how can you come alongside us and, and what, what do you, do you come alongside and help provide information and data to, to, to primary care or to patients and say, look, this really could have a factor. I mean, how do we, how do we, I guess take action on that. What would be your magic wand that you could wave and say, this is what I would do?
Dr. Shapiro: That's [00:10:00] a very insightful and um, deep question, probably a proper answer would take a little bit more time than we have. But yeah, that gets to really the crux of preventive cardiology and it's a little bit different than maybe going to other specialists even within cardiovascular medicine. Sure. In that we take a multidisciplinary approach is some, when somebody comes to see us within the center for preventive cardiology, [00:10:30] they see a number of folks including a clinical pharmacist, one of our physicians and a dietician. Every new patient will touch at least three of those individuals. Gotcha. There's a huge amount of motivational interviewing and lifestyle counseling tailored of course to the needs of an individual patient. And if a single office visit isn't enough, we have providers who are specifically focused on lifestyle counseling, sometimes longitudinally [00:11:00] , um, and that might be, um, counseling on, you know, diet weight management, uh, exercise, prescription smoking cessation, stress reduction, and some individuals, it's more than one of those things.
Dr. Shapiro: And so we try to meet patients where they are and provide practical recommendations, um, that they'll be able to put into, into practice. I really love that team approach. So it's really interesting. It's really the only way to effectively, um, effect behavior [00:11:30] change because largely what we're trying to do, and I can't emphasize enough that while there's a lot of exciting developments both within diagnostics and medications that are coming out to prevent heart disease, truly the foundation of prevention and for most people what's required is um, lifestyle modifications. So the counseling becomes an extremely important part of preventive cardiology. That's really cool.
Host: So, um, if a patient is listening or a listener is checking out this episode [00:12:00] and, um, perhaps they have a primary care physician, perhaps they don't, is there is, how does one, um, become a part of the preventive cardiology, um, treatment options? Are they referred from their primary care or how does that work?
Dr. Shapiro: Yeah, yeah, thanks for that question. I would say that most individuals are probably being referred from their primary care provider. Though we do see quite a few self-referred patients, [00:12:30] maybe 30 to 40% of the individuals who ultimately wind up coming to see us, um, heard about us somehow or quite frequently they're worried about their cardiovascular health because there's a family history of cardiovascular disease sometimes at an early age. So they seek us out. Um, in some instances, even my colleagues in cardiology, uh, will send patients to me because of a specific situations where preventive cardiologist really focus their attention.
Host: Okay. So maybe [00:13:00] it's, it's someone who goes to their doctor, their primary care and one of the risk factors has it been identified and they'll say, Hey, you should maybe check out the preventive cardiology team over here. Um, that's really interesting. So I'm, and I'm glad you mentioned family history that we can touch on that. Um, you know, I think it probably behooves people to, to find that information out. Um, and, and if they do maybe have a family history of their parents or grandparents or uncles or aunts [00:13:30] having cardiovascular disease or issues, um, they should be aware of that. Um, you know, that that definitely plays a role into, into their health. Do you want to speak to that? How kind of family history plays a role?
Dr. Shapiro: Absolutely. And since cardiovascular disease is so prevalent, um, it's quite frequent that when individuals explore their family history, they will find it. Um, now family history can be from, you know, maybe [00:14:00] suboptimal behaviors, you know, a grandfather had a heart attack in the 60s because he smoked three packs of cigarettes per day. That will lead to heart disease in many, many people. Um, and if you're not smoking and you're eating right and managing your weight and, um, you know, exercising, it doesn't necessarily mean that you're actually at increased risk for developing heart disease. On the other hand, if there are multiple members of the family, uh, particularly if could have asked disease like heart attack stands, [00:14:30] bypass surgery, stroke happened in an earlier age, that really starts to make us think of an inherited form of heart disease in which we do specific types of evaluation.
Dr. Shapiro: And the good news is today, first of all, we can perform those types of evaluations through blood tests and imaging. Um, and then we have good tools. So it doesn't, you know, decades ago that was probably your fate if it was inherited, unfortunately, but it's not at all, particularly [00:15:00] when it's uncovered early enough. Um, and people are, you know, coming to attention, um, when they're younger, there's a lot we can do to mitigate that risk. And so a preventive cardiology is really a very fulfilling, uh, sub specialty to be part of because we know that, um, in, in many patients, particularly if they're coming to us before they have heart disease, uh, we can likely do a lot of good things for them.
Host: Okay. I'm gonna maybe I'll, maybe I should ask this earlier. I'm going to take [00:15:30] a step back maybe to a more foundational level here. So, um, cardiovascular disease, you've mentioned several risk factors. So let's pick on one for a second. So let's pick on high blood pressure. So if I have high blood pressure, you know, maybe I'm kind of like, eh, it's, it's fine. It's not, you know, it's not going to kill me. It's not astronomical. It's just kind of, hi, I'll deal with it later. What, what does high blood pressure actually do, um, to adversely [00:16:00] affect the cardiovascular system?
Dr. Shapiro: Well, so I like that question, but I'm gonna start a little bit. Um, uh, what may seem tangential but we'll tie it into, um, the question you just asked me. Um, that happens frequently where, um, a single risk factor is explored. It's found to be maybe mildly abnormal. So your blood pressure isn't one 20 over 80, but it's like one 40 over 90 sort of like just at the borderline of normal and high blood pressure. [00:16:30] And then nobody's really impressed. And from month to month and year to year, it's sort of staying there. And then over time, maybe it's increasing and if you plug in that blood pressure into standard risk factor calculators, which look at your risk for heart attack or stroke over the next 10 years, it may not be that high. But what happens is that's a 10 year horizon. And if you're 40 or 50 or 60, you know, maybe that's not adequate.
Dr. Shapiro: So we have new tools that [00:17:00] look at lifetime risk, which when you start to look at those, it's the cumulative exposure over the years to high blood pressure and what it does to the orders or cholesterol or diabetes or combination of factors. And in fact, usually when there's a single risk factor that may be mildly or moderately abnormal, it's often accompanied by others. And, um, you know, I think providers are often struck when there's a single risk factor that's really [00:17:30] out of control. Super high cholesterol, super high blood pressure, nobody awaits, you know, they treat it, but people have a little bit more inertia when things are mildly abnormal, but that's more common. And the combination of mildly abnormal risk factors, two or three or four will get you to that same place as one really elevated or, you know, uh, abnormal risk factor. So I tend to, um, try to comprehensively evaluate [00:18:00] both the traditional risk factors we discussed and some novel risk factors that we now have the ability to, to test.
Dr. Shapiro: Sometimes we use in people who don't already have heart disease, some imaging tools that can screen for the earliest signs and say, Hey, no, we already see some injury as occurred and we need to act on this. And of course this is coupled with what the patient's priorities are, what their desires are, what they want out of their life. Um, and then we come up with a treatment [00:18:30] plan. But to get to your specific question, what does high blood pressure do? Well, it puts an extra load on the heart. The heart has to beat against this higher pressure so it can lead to thicker heart muscle and heart failure can lead to stroke. It can lead to kidney and eye problems. And actually hypertension as a risk factor is the most prevalent of the cardiovascular risk factors worldwide. So the guidelines over the years, um, recognizing, uh, [00:19:00] the morbidity associated with untreated high blood pressure, um, have gotten more and more aggressive, more and more strict about saying, Hey, don't wait too long and don't wait it for to be this high.
Dr. Shapiro: We have good lifestyle modifications to address this. And if that's not adequate, we have a lot of inexpensive, inexpensive, effective, uh, you know, medications that can be used. So, um, the other thing I would point out, especially as people are living longer, a lot of these [00:19:30] cardiovascular risk factors like blood pressure and cholesterol also turn out to be very important to cognitive health because cognition is very much related to the health of your blood vessels, your vasculature. So if I can impress you with a heart attack, I might be able to impress you by saying, do you want to avoid becoming, you know, cognitively impaired? Do you want to avoid dementia? Sure. That sometimes gets people's attention more. So we do need to treat these things 30 years in advance [00:20:00] to have the best outcome.
Host: Yeah, that's really, that's really interesting how it, I mean if you stop and think about it, it makes sense that it's all tied together. But I guess most of us are just kind of going on with our day to day get through life that we don't take a step back and take a step back there. Right.
Dr. Shapiro: And it's hard frequently to convince somebody who's feeling otherwise fine, that it's important to treat something now to avoid a problem 30 years from now. So that takes some time and some counseling, um, for [00:20:30] people to become more receptive to that. It's a silent condition and tell it's not
Host: until it's not and then it could be very drastically not correct. So to that point, you know, if you hear, um, clinically there's lots of different reasons, uh, or conditions by which someone, um, is having heart or vascular problems. So you hear someone most of the time just out in day to day, you hear all so-and-so had a heart attack so and so had a heart attack. What, what, when you, [00:21:00] when someone's having a heart attack, what is actually happening to the heart muscle?
Dr. Shapiro: Yeah. Great. So very important concept. So through exposure to, uh, some of the risk factors we talked about smoking, diabetes, cholesterol, blood pressure, and others. Over time, cholesterol, plaque can start to accumulate in the lining of the arteries, the heart arteries, the brain arteries, arteries, really everywhere. Um, in the case of a heart attack, [00:21:30] what happens is when that cholesterol plaque is accumulated and then becomes vulnerable to rupture one day, it can rupture. And when the blood elements in the artery are now exposed to the tissue elements that were previously protected by a cap, um, now they're not because of the rupture of the plaque, then a blood clot can form over that area because that plaque is very, very sticky. So all of the platelets in the artery start [00:22:00] to stick to that and they clump together and they occlude blood flow down the artery for a period of time.
Dr. Shapiro: So part of the heart muscle is not getting any oxygen and nutrition and starts dying off. And it's like if you've exercised really hard, you can sometimes feel that burn, that lactic acidosis in your calves, your thighs, the pain you're feeling in a heart attack is essentially the same thing. It's the lactic acidosis building up in the heart muscle because it's being deprived of oxygen, it's not being cleared out. Correct. [00:22:30] So, so what winds up happening is, at least in the setting of an acute heart attack, the most important imperative is to restore blood flow to open the artery sometimes, but we don't count on it. It can spontaneously open. But the most effective therapy for an acute heart attack is going to the cath lab and having an angioplasty stent procedure to open it up. That's very different from chronic blockages, chronic coronary disease. We're really the foundation of that management again is lifestyle and medication. [00:23:00] And in more selective instances, would we necessarily need to think about opening up an artery, um, either with a stent or with bypass surgery because all of the data now suggest that while that may improve symptoms, it doesn't necessarily prevent heart attacks and make you live longer. That's where the lifestyle and the meds are extremely important. That's where you get the prevention of events.
Host: Well, talking with Dr. Michael Shapiro with wake forest Baptist health preventive [00:23:30] cardiology. Um, we're gonna be wrapping up in a second doctor before we wrap up, tell us, you know, if someone is listening and you know, they're like, Oh, I've been, I've been to my doctor and he said, yeah, should lose a few pounds or my blood pressure maybe is borderline. You should, I should, I should work on my cholesterol. If someone's interested in learning more about your program and maybe wanting to participate, what can they do to find you? How can they get in contact with you?
Dr. Shapiro: Yeah, so we're so new that, uh, we're still [00:24:00] working on some of that material, like a brochure and a website that's all in process. But for the meantime, uh, for interested individuals, they can certainly call our cardiology department and, uh, say they've heard about preventive cardiology or dr Shapiro and they'd like to come and make an appointment and we'll be happy. We'll have to be happy to do that.
Host: Great. And, um, so, uh, if people, um, maybe just want to find out more information, they can go to wake health.edu and they can search dr Shapiro or [00:24:30] preventive cardiology, um, or if you just call seven one six week, um, our main number, um, they can get you lined up with the correct people as well. Um, so dr Spira is, as we wrap up here, what's, um, one nugget you can pass along? One tip for, uh, for us to have a healthier hearts here.
Dr. Shapiro: Yeah. And as you started the program, I couldn't agree more. Now during the kind of the holiday season, it's a perfect time to reflect on health and cardiovascular health in particular. If I were to make [00:25:00] only one recommendation for folks to keep healthy, I would say exercise is literally the best medicine. Exercise is a cholesterol lowering medicine exercises, a blood pressure lowering medicine exercises is a diabetes medic medicine, uh, exercise elevates your mood, increases your energy. I mean, has myriad beneficial effects of, there was only one change that you could make. I would say start some form of exercise. Any form that you like that you can do most days of the week [00:25:30] walking program is just as good as anything else. Start slow, slowly build and that will take you a long way.
Host: Yeah, there's, I mean, of course there's people that join, um, uh, uh, uh, gym or fitness club, but you don't have to, you can find, you know, some good exercise videos on YouTube or walk around the neighborhood. Exactly right. Yeah. Alright, well this has been great, dr Shipra. I really appreciate you taking the time and my pleasure, Justin. Um, hopefully the listeners out there, um, got some really good information about this and, [00:26:00] um, this new emerging field of, of heading off the issue at the past before, before it becomes an issue. Um, so, uh, like I said, if you have any questions when I found out more at visit a website, www.wakehealth.edu and you can search, um, cardiology and preventive cardiology. Um, and, um, we'll be back here pretty soon with another episode, but until then, be well,
Speaker 3: thanks for listening to this episode of the best health podcast brought to you by [00:26:30] wake forest Baptist health. For more wellness info, check out wake help.edu and follow us on social media, wake forest Baptist health, the gold standard of health care.