AT&T Business Wireless Announcer (4:02)

Not every sale happens at the register. Before AT&T business Wireless checking out customers on our mobile POS systems took too long. Basically a staring contest where everyone loses. It's crazy what people say during an awkward silence. Now transactions are done before the silence takes hold. That means I can focus on the task at hand and make an extra sale or two. Sometimes I do miss the bonding time. Sometimes.

Capital One Bank Announcer (4:27)

AT&T business Wireless Connecting changes everything. With no fees or minimums on checking accounts, it's no wonder the Capital One bank guy is so passionate about banking with Capital One. If he were here, he wouldn't just tell you about no fees or minimums. He'd also talk about how most Capital One cafes are open seven days a week to assist with your banking needs. Yep, even on weekends, it's pretty much all he talks about. In a good way. What's in your wallet? Terms apply. See capitalone.com bank capital1NA member FDIC.

Dr. Shoshana Ungerleiter (5:05)

Hi, Dr. Volardo.

Podcast Host/Interviewer (5:06)

Thank you so much for joining us today. Hi.

Dr. Danielle Belardo (5:09)

Thank you so much for having me. It's such an honor to join you today.

Podcast Host/Interviewer (5:13)

Danielle, what are common misconceptions people have about heart disease and age?

Dr. Danielle Belardo (5:19)

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. We actually have research that Shows this. 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 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.

Podcast Host/Interviewer (6:25)

So 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?

Dr. Danielle Belardo (6:39)

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. So this is like elevated cholesterol, high blood sugar, like diabetes, high blood pressure, called hypertension, 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. So preventing for someone before. 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.

Podcast Host/Interviewer (7:56)

Can you tell us what happens inside the body when heart disease develops? Like, for example, explain how plaque buildup starts in the arteries?

Dr. Danielle Belardo (8:05)

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. And 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. 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, the only thing that's separating it is this single cell layer, it's very small, called the endothelium. And this end, 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. Similarly, 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, really important, and family history. These are all important components. And then we really individualize everyone's next steps in treatment based on the totality of their picture.

Podcast Host/Interviewer (10:37)

So that brings me to my next question. We often hear about, quote, normal levels for things like cholesterol, blood pressure, blood sugar, or why might these normal levels still pose a risk for heart disease. And how can we recognize when, quote, normal isn't good enough?

Dr. Danielle Belardo (10:56)

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, or your bottom number is greater than 80. And 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. Now, 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 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, it'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 start 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. The thing 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 do 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.

Podcast Host/Interviewer (13:44)

Yeah, I think the tricky thing with with heart disease or early stages is that there are no symptoms. So most people assume, oh well, I don't feel any different, I'm fine. And so what makes it dangerous even if there are no symptoms?

Dr. Danielle Belardo (14:01)

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 test like the calcium score, we know how much lipid lowering therapy we need and guideline directed medical therapy, we need to get their 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. So it's not a problem until it becomes a problem. Our goal is to intervene beforehand. 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.

Schwab and Siemens Announcer (15:12)

Want to turn challenges into chances? Go digital enterprise and adapt to every change by combining the the real and digital worlds. Transform the everyday.

Capital One Bank Announcer (15:25)

With Siemens with no fees or minimums on checking accounts, it's no wonder the Capital One bank guy is so passionate about banking with Capital One. If he were here, he wouldn't just tell you about no fees or minimums. He'd also talk about how most Capital One cafes are open seven days a week to assist with your banking needs. Yep, even on weekends it's pretty much all he talks about in a good way. What's in your wallet? Terms apply. See capitalone.com bank capital1na member fdic@schwab.

Schwab and Siemens Announcer (15:57)

How you invest is your choice, not theirs. That's why when it comes to managing your wealth, Schwab gives you more choices. You can invest and trade on your own. Plus get advice and more comprehensive wealth solutions to help meet your unique needs. With award winning service, low costs and transparent advice, you can manage your wealth your way at Schwab. Visit schwab.com to learn more.

Podcast Host/Interviewer (16:22)

So 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?

Dr. Danielle Belardo (16:40)

One thing I recommend to patients, first step would be you can always ask. It's never too early to ask for a referral. If you're concerned about your client 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. So 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, 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. 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 this 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. Can you refer me to one? They're happy to. I have patients that will see me and they say, you know, I felt bad saying, that's 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, a good next step.

Podcast Host/Interviewer (18:44)

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?

Dr. Danielle Belardo (19:02)

Generally, there's a. Oh, 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. And 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. 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, you know, there's no placebo. We all eat. So when we're looking, when you see on the news one headline that says X, Y or Z food is going to cure X, Y or Z, 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. So 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 in 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. And 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 GLP1 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. But 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.

Podcast Host/Interviewer (21:35)

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, these tools and are there better tests or assessments that can give a clearer picture of early heart disease?

Dr. Danielle Belardo (21:54)

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 and 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 every 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 a 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 but 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, it'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 in 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 plaque. 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.

Podcast Host/Interviewer (23:25)

What'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?

Dr. Danielle Belardo (23:34)

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 preventions. And so we recommend, you know, for people in their 20s, getting their lipids checked, their hemoglobin A1c, their, that diabetes test, their blood pressure, of course, knowing their family history, if possible, and then as we get older, to continue those, those same checks and if there's any change to keep an eye on it and get referred to a preventive cardiologist earlier. We can treat and mitigate all of those, 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.

Podcast Host/Interviewer (24:30)

And if someone is interested in finding a preventive cardiologist, how do they go about doing that?

Dr. Danielle Belardo (24:36)

Such a great question. And I actually, I get asked that and I wish I had a, a perfect answer to that. And unfortunately, so cardiologists, we're not a monolith. And 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 cath lab. 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 noninvasive preventive cardiologist. We're not in the CAP lab doing procedures, we'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 cardiologist, prevention is a huge part of their practice.

Podcast Host/Interviewer (25:34)

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 this set of issues. So I really appreciate you.

Dr. Danielle Belardo (25:50)

Well, thank you so much for having me. And you are a testament to how incredible prevention works. And you, you're phenomenal and it's been my honor to get to know you.

Podcast Host/Interviewer (26:02)

Thank you so much.

Dr. Shoshana Ungerleiter (26:08)

And that's it for today. TEDhealth 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 Lajas, Farrah de Grunge, Tally Emlen, Daniela Balarazo and Roxanne hi 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 hoshanamd on Instagram. I'm Dr. Shoshana Ungerleiter and thanks for listening.

Schwab and Siemens Announcer (26:53)

Imagine the merging of trusted intelligence into a unified experience. Imagine collaboration amongst teams and across continents. Imagine an empowered ecosystem designed to deliver actionable insights that inspire growth and sustainability. That's the power of the Connect Industrial Intelligence platform to help you see further innovate faster, accomplish more. That's the Connect effect. Learn more@thatsteconnecteffect.com with no fees or minimums.

Capital One Bank Announcer (27:24)

On checking accounts, it's no wonder the Capital One bank guy is so passionate about banking with Capital One. If he were here, he wouldn't just tell you about no fees or minimums. He'd also talk about how most Capital One cafes are open seven days a week to assist with your banking needs. Yep, even on weekends, it's pretty much all he talks about. In a good way. What's in your wallet? Terms apply. See capitalone.com bank capital1na member fdic@schwab how.

Schwab and Siemens Announcer (27:54)

You invest is your choice, not theirs. That's why when it comes to managing your wealth, Schwab gives you more choices. You can invest and trade on your own, plus get advice and more comprehensive wealth solutions to help meet your unique needs. With award winning service, low costs and transparent advice, you can manage your wealth your way at Schwab. Visit schwab.com to learn more.