Latest / Off the Chart: A Business of Medicine Podcast / S1 Ep199: Your patients want a quick fix for their heart, with two Mayo Clinic cardiologists
Transcript
- Speaker 1 0:00 I usually joke with patients whenever they, you know, a patient with high with history of high blood pressure. I will generally ask them, "Do you have?" I assume that you have a blood pressure machine at home. When they say no, my next question is, "Do you mind if I ask you how many TV sets do you have at home?" And they usually will say, "Well, like a four or five or six, and then I say, well, you know, I think you need to get a blood pressure machine as well. You know, if you have three TV sets, you should have at least one blood pressure machine at home. Speaker 2 0:48 Welcome to Off the Chart, a business and medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Luttrell. I'm the associate editor of Medical Economics, and I'd like to thank you for joining us today. Today's episode comes from earlier this year when Richard Payerton, senior editor of Medical Economics, sat down with Mayo Clinic preventive cardiologist Dr. Francisco Lopez Jimenez and Dr. Kyla Lara Breitinger, two of the authors behind the Mayo Clinic Guide to a Healthy, Happy Heart. So today, Richard and Dr. Lopez Jimenez and Dr. Laura Breitinger talk about how primary care physicians can steer patients toward small changes that actually last. They also explain why the best goals are behaviors that a patient can control, like cutting back on salt, instead of things like blood pressure numbers. Plus, they get into how to talk about weight when BMI doesn't tell the whole story, and how to make better use of patients' at-home blood pressure readings. And they close with what primary care physicians should actually know about prescribing GLP-1s to patients without specialists on hand. Needless to say, there's a lot to get to today. So, without further ado, thank you to our guests for joining us. Let's get into the episode. Speaker 3 2:03 Thank you for joining us today. Speaker 4 2:05 Thank you for having us. Speaker 1 2:07 Thank you, Richard. Speaker 3 2:08 And just to get us started, I would be remiss if I didn't mention that your co-author was the late Dr. Amir Lerman, and there are at least 30 other contributors to the book. Can you share your thoughts on Dr. Lerman's research and the work of those other contributors, Speaker 1 2:24 I kind of start with that, Richard. So, Dr. Lerman was really a pioneer in many things in cardiology, but perhaps one of the most relevant contributions was his discovery of how the inner layer of the arteries works, and how that is relevant for what we know as cardiovascular health. That portion of the arteries was basically unknown or ignored before, because a lot of those functions were not known, and he really pioneered that area, among many other things. But I would say that was his major contribution to science. Speaker 3 3:10 In regarding some of those other contributors, obviously this is a work that has had a lot of collaboration behind it. What was it like to manage everybody involved? Speaker 4 3:20 It was wonderful. Mayo Clinic is really a collaborative environment, and so we feel 100% that the more, not only the merrier, but the wealth of expertise across all of our campuses has been truly wonderful. And we wouldn't have been able to produce a book without them. And so we have CVOB, we have stress experts. We have meditative experts. We have even beyond cardiology, exercise physiologists, cardiologists across the board, Mayo, Arizona, and here. And so, you know, we wanted to give a special shout out to them in terms of their recognition, and then really having interviews with them throughout the process, recording them, and then having kind of digesting that into reader-friendly information that's easily actionable, biteable for the common audience. Speaker 1 4:11 And and I will just add that something unique about those contributors is that everybody sees patients in a regular basis, so at Mayo Clinic, our concept of being an expert is not just being known outside for what we do scientifically or publications, etc. But the the fundamental tenet of this is that we do see patients in a regular basis, because that's at the end of the day what gives us more and more experience. Speaker 3 4:48 You know what, doctor? It's a great segue to a point I wanted to ask about because the book opens by describing maybe a mindset that our audience will be familiar with. Patients go into. The exam room. They may want a quick fix, or as the book puts it, just one thing they can do for their heart or for overall health. To begin with, what's some good practical advice for primary care physicians for redirecting that conversation toward sustainable behavior change without losing patient engagement? Speaker 1 5:21 Okay, I'm gonna start with that because we we do this in a regular basis, and we emphasize that small changes are in many in many situations big big changes. So it sounds contradictory, but what is small in terms of a relatively modest goal actually represents a big thing for the body. Like, for example, for somebody who is completely sedentary, just moving around a few minutes every day means a lot, and actually, the greatest benefit people get is going from doing nothing to doing something in a regular basis. And when patients learn that, they recognize that health is not really so far in the horizon, or wellness shouldn't be something too difficult to achieve when they think about small goals one at a time. Speaker 4 6:31 Yeah, and I would just add that it could be overwhelming with social media and all of these longevity experts that are telling you 30 different things to do, and most people have to work. They have families, they have professional responsibilities, and it can really take and consume your whole day just to become healthier. And so, I totally agree with Dr. Lopez Jimenez. You know, meeting decreasing the activation energy or the threshold to change one or two things per week can add and kind of co-synergetically improve over the course of time, and really sticking to little habits that you feel that you can accomplish, and not feel like a failure. Where then you just kind of go from 100 to zero, as opposed to doing 20% of something right, eating 20% less ultra-processed foods in the week. Saying instead of you know having ice cream every day of the week and I love sweets maybe having it three times a week and over time seeing results right making these small changes that take time the problem is is with longevity and health health span it's delayed gratification so if you're not going to die from doing something tomorrow you're less likely to do it unless you're a very disciplined person, which most of us distracted in our world. It's very difficult to focus on that every day. Speaker 3 7:50 You know what, though, I think it's another great segue to a point that really struck me in early on in the book because you mentioned the importance of physicians asking patients to consider goals, and also that the goals such as "I want to be healthier" is too broad; it's too vague. What advice would you give to primary care physicians to guide that conversation about goal setting with patients? Speaker 1 8:16 Well, we we talk about goals because we recognize that if we don't measure something, we cannot. It gets more difficult to improve something that we don't measure or don't set a specific goal. So goal setting is key for behavioral change. But again, one of the basic principles is to to set realistic goals and not something that would be so difficult. But we talk about things that when we talk about goals, we need to be careful and setting up goals that are easy to track, easy to measure goals that patients can evaluate in a regular basis and not always depending on complex machines or wearables, etc. You know, some of those things will require something to measure, like steps, for example, which is a very common goal we set, but you know these days, just having a smartphone in your pocket will be enough to to measure that. Now, as we know, technology is advancing, and more and more things are coming up to measure pretty much everything we want from the sugar level in the blood every single minute to measuring your stress or measuring your sleep, etc. But all in all, we recommend primary care clinicians to focus on simple goals. Speaker 4 10:01 And I would just add that number one, I commend primary care physicians, healthcare professionals across the country. They have the most difficult job of trying to encompass the whole person in a single visit and having to see so many patients. And so, in addition to what Dr. Lopez Amendment mentioned, is you know just asking that patient in front of you how they're doing and what's their biggest cause of stress right now, and then understanding that you know reading our book, having the toolkit in the back of your head, you can identify something individual to that person in front of you and treat them like a human based on their individual circumstances, and then apply one of these small goals for them, and it I think it can over time, if you follow them on a continuous basis, improve that relationship and that trust to hey this physician, this NP, this PA, listen to me about the stress I have, and but they're giving me a goal that seems like very pragmatic, and it can fit my schedule without deterring too far. That makes it insurmountable for me. Speaker 1 11:07 Yeah, yeah. The other thing, Richard, is when we talk about goals, is we focus on goals that are really under the power and control of people, and this is important to clarify to patients because we can set up a goal of weight loss. Well, that is one type of goal, but truly, as as a clinician, my primary goal for my patients would be: let's start eating differently and and eating you know smaller portions, for example, that is more under the control of the person than the actual amount of weight loss. The same goes with blood pressure. We as clinicians focus on blood pressure numbers as goals. I mean, we are doctors. That's what we do every day, right? But, but for a patient, it's going to be a more realistic goal to to consume less salt, less sodium, and to eat more fruits and vegetables. That yes, ultimately will improve blood pressure, but the blood pressure itself is not necessarily under the total control of the patient, but but the behavior is, Speaker 3 12:25 you know what, doctor? I and I I I'm liking this personal connection here and the notion of empowering patients to to take some measure of control over their health, and and so this question might be a little off track from that because I wanted to ask about some of the science that is involved. The book does discuss emerging markers such as the lipoprotein A, LDL particle size, you know, alongside the standard lipid lipid panel. In a primary care practice setting, we know doctors are pressed for time. How should they think about some of those advanced markers? What does that add, you know, to clinical value? And how do they know when a standard panel is sufficient? Speaker 4 13:14 That's a difficult question for at least personally myself to answer as a preventive cardiologist because if the primary care professional has the bandwidth to go all the way, why not, right? And if it's easy to add a lipid panel, you could clearly add a high sensitivity CRP, which can detect low grade inflammation in the body, which we know is linked to cardiovascular disease and stroke. Lipoprotein little A, which we know is an independent risk marker for cardiovascular disease and calcific aortic stenosis, and Apo Lipoprotein B. And I feel that if they have the bandwidth, if they do a little bit of reading and they want to use that for more information to then provide to their patient, that based on all of these extra things that I've taken from you, I think we should have a very aggressive LDL goal for you, and we should really push to replace the five servings of animal meat you're eating per week to replacing it with three servings of fish or vegetables, vegetable protein, plant proteins, and that I think can help a patient who is focused on objective evidence to be like, "Oh my goodness, look at how high that is!" I don't know. What do you think, Dr. Lopez Menes? Speaker 1 14:32 I completely agree. You know, and heart disease is so prevalent, so common. Indeed, the number one cause of death, not only in the U.S. but in the world. Therefore, you know the more clinicians engage into the testing of risk factors, the better. And there will be still not enough clinicians to to see every single person. In the world to be tested and get what they need. So I have always said that truly the the main goal of us as clinicians should be that we eventually become more solid. And and you know one of the visions of Dr. Lerman was you know imagine a world without heart disease. Of course, if you are a cardiologist and the world has no more heart disease. We become obsolete, but that will be that will be a beautiful thing because then we can dedicate our times to something else, and and we don't worry about heart disease anymore, right? But but but the idea is that the easier the access patients might get to basic testing for heart disease risk and prevention, the better. I think that's something that should be promoted more and more. Speaker 4 15:48 And the one thing I'll add, because Dr. Lopez Amanis is very humble, we've done a lot of research under his leadership on even things such as muscle mass versus where we store our fat in terms of distribution, and so additionally, if a primary care physician could get a DEXA composition scan to determine where they distribute their fat versus their skeletal lean muscle mass, we know that there's a growing focus on looking at visceral adiposity or central adiposity. Adiposity, where you store your fat centrally, is associated with more disease, more inflammation, and we work in a space looking at normal weight obesity. Right, it's not the number on the scale. It's not your BMI. It's do you store most of that dangerous fat along your belly, which encases all of your organs like your pancreas, your heart, your liver, which we know is metabolically dysfunctional. Physicians Practice 16:52 Hey there, Keith Reynolds here, and welcome to the P2 Management Minute. In just 60 seconds, we deliver proven, real-world tactics you can plug into your practice today, whether that means speeding up check-in, lifting staff morale, or nudging patient satisfaction north, no theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom; they come from you. Got a clever workflow hack, an employee engagement win, or a lesson learned the hard way? I want to feature it. Shoot me an email at kreynolds@mjhlifesciences.com with your topic, a quick outline, or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next P2 Management Minute. Speaker 3 17:45 You know what? And and again, another great segue to a question that I wanted to ask about because when we get into patients' actual physical bodies, the book covers obesity as a disease and notes that body mass index or BMI is a diagnostic criterion. Let's face it. In our society, there's a lot of different conversations that take place about a person's size and weight. How should primary care physicians be updating how they communicate with weight about weight, I should say, with patients right now? Speaker 1 18:19 Well, I think that's a, you know, the conversation about weight needs to happen in every single individual. I mean, whether the weight is not healthy or is healthy, and and they need to have that reassurance. But it has to go beyond weight, particularly individuals who might not be very heavy, but they might still have a lot of fat, or something we call normal weight obesity, where a person might have a BMI, let's say 23, that is within normal limits, but might still have a lot of fat. That's a situation that we know relates to higher risk for heart attacks, higher risk for diabetes, and many conditions. And unfortunately, those cases go undetected because they feel happy because their BMI is normal. Now, those individuals will have to be tested for fat. You know how much fat they have, but but the reality is that in most of the cases, what primary care clinicians have to deal with is is the other side, right? The the excess weight, and I think that's a conversation that needs to happen every time. It has to be done with tact and and sensitivity because we recognize there is a lot of body shaming in the country and every place. So we have to emphasize the the importance of that is from the clinical standpoint, and and once patients. Recognizes that the interest of the doctor is about their health. Generally, people are more receptive. It's a conversation that might not lead immediately to trying to lose weight, but at least generates the interest on that. And and particularly nowadays with the different options that we have available, this is truly a conversation that should happen because there are ways for patients to control their weight that we didn't have 10 years ago. Speaker 4 20:36 And I would just add that I mean, obesity is a chronic, relapsing condition that's chronic, and even in our cardiometabolic clinic that we both chair and co-chair, and we save 60 minutes to destigmatize obesity, normalize that it's multifactorial. Some of it you can control; some of it is beyond our control. Genetics, different types of medications you take that can make it more difficult to lose weight that lower your basal metabolic rate, and then understanding that BMI came as a way to categorize large populations of people so we can identify those at highest risk, but then use our brains and individualize what's in front of us. If you have someone with a higher BMI who's metabolically healthy, and I'm talking about your hemoglobin A1C is normal, your high sensitivity high sensitivity CRP is normal, you have normal triglycerides, a good lipid panel, your blood pressure is great, and you're performing on an exercise treadmill test with a good functional aerobic capacity, or even more specific, if you can get a peak VO2, which is a measure of your cardiorespiratory fitness, then they're metabolically healthy. They have no end organ damage, no fatty liver, and we're very happy with that. And so, you know, it's difficult though. Does every primary care professional have time to, or the cost for the DEXA scan, or even accurately measuring someone's waist circumference. I wonder if we pulled the country of how many people actually accurately or have the time to measure your waist circumference, which would be free and cheap. But if the visits are 15 to 30 minutes, that could easily take 15 minutes. Speaker 3 22:18 You know what? One of the things, and I made a long career as a community journalist. I've been at medical economics for four years in February. And one of the things I find fascinating are sort of the interrelations about different factors and affecting people's health. And if I may, I'm going to kind of there's at least two more things, kind of whole list of questions here. But a couple of things I'd like to touch on because this has been something that has kind of come up lately, not least in the context of remote patient monitoring in a primary care setting for our audience. I think, and that involves blood pressure monitoring at home. The book goes into detail about home blood pressure monitoring, and you know mentions such as, for example, white coat hypertension. From a practice management standpoint and a patient health standpoint, what are some good ways for physicians to integrate patients' home data into care? Speaker 1 23:14 The reality is that we haven't done a good job integrating all this wealth of information that patients get at home using different devices into the electronic medical record or the you know the the medical chart. I think that's an area where we can do better, and I hope and I'm very optimistic that in the next few years that will happen, where we create seamless integration of patients' data that is obtained at home with what we can see in in in our electromedical record. Now, it is also relevant to underscore that that needs to happen in a way that is simple and summarized to clinicians because it happens these days. For example, that a patient might bring 250 pages of PDF records of electrocardiograms they obtained for the last two months using a particular point of care device or a wearable, right? So, so we don't have the bandwidth to review 250 pages in every patient, right? So, the information will have to be abstracted, summarized, and simplified. Now, it is also important to say that in the in the case of blood pressure, that the measurement of reliable blood pressure at home doesn't occur with all the devices that are claiming to do that. Okay, actually, the FDA has been very strict on that, and there are even some warnings that have been published. About this, because not every single device that claims to measure or monitor blood pressure actually does it in a reliable way. Nonetheless, the standard old-fashioned you know blood pressure cuff that these days even the grist versions are actually pretty pretty good. We give a lot of good information to clinicians, and we we totally believe that the future of blood pressure monitoring relies should rely on the patient's hands, and this should not be a doctor's office diagnosis. This should be really a home-based diagnosis, aided or confirmed by the doctor's office measurement. But this is really should be something that should be monitored at home. Kyle, any thoughts on that? Speaker 4 25:54 Yeah, I can't agree more. To save time, I will not repeat. That was very comprehensive. Other than to say that you know hypertension, we're probably very numb hearing high blood pressure. High blood pressure kills, but that's the easiest, most easy disease that we can actually control, monitor, and treat with lifestyle modifications. And there is an enormous amount of different classes of medications that can be tailored to a patient to get to these goals, because having these strict criteria of blood pressure goals less than 121 20 over 80, even in the elderly decades, is being associated with less strokes, better cognition, and less heart attacks. Because we know, based on Dr. Amir Lerman's legacy of research, right to the point where he talks about endothelial function, which is the type of elasticity that was already mentioned by Dr. Lopez Jimenez in terms of vascular health. Hypertension is much later in the disease course, where you're actually having high pressure hitting against these arteries, and over time, over decades, you can't reverse anything like that anymore. And so, it's really important for patients to feel like they can advocate for their own health, including their blood pressure. But it's super important for us who went through the training, the education, medical school, RN school, PA school, to really, if your physician, if your NP, if your PA does not say and sit down with a patient and say this is important, and just say, oh, you know, work on your blood pressure, the patient doesn't feel this like sense of oh, this is a big deal. Speaker 1 27:33 Yeah, and really, you know, blood pressure being one of the main killers in the world, and with technology that is rarely available, I usually joke with patients whenever they, you know, a patient with high with history of high blood pressure. I will generally ask them, "Do you have?" I assume that you have a blood pressure machine at home. When they say no, my next question is, "Do you mind if I ask you how many TV sets do you have at home? And they usually will say, well, like a four or five or six. And then I say, well, you know, I think you need to get a blood pressure machine as well. You know, if you have three TV sets, you should have at least one blood pressure machine at home. And they just, you know, it's basically jokingly saying this is so relevant, so important for you that you cannot not have one at home. Speaker 3 28:25 You know what, doctor? If I may, I'm going to make a little transition here because you both had touched on some points that caught my ear about a question I wanted to make sure I get in there. In the last few years, of course, and it's been a huge part of our coverage, really, with the GLP-1 receptor agonist drugs. There's been a lot of research, frankly, a lot of good news coming out about how those really can improve and help patient health. With primary care physicians who are increasingly being asked to prescribe and manage those drugs, they may not have the support of an endocrinologist or a cardiologist. What do you want them to understand about appropriate patient selection and long-term management? Speaker 4 29:08 Absolutely, this is probably the biggest focus. We could talk all year about this, but yes, in terms of the infrastructure, because we know these medications have really exploded and transformed how we treat obesity beyond diabetes, because let's remember these drugs have been studied originally to treat diabetes and reduce hemoglobin A1C, increase insulin sensitivity. This big side effect was transformational weight loss comparative to almost bariatric surgery, and so the the studies that were done in non-diabetic patients were for patients who had a BMI 30 or greater, or 27 with a concomitant obesity-related disease: sleep apnea, fatty liver disease, hyperlipidemia, high blood pressure. Those types of diseases that kind of go with obesity. Oftentimes, and so as a primary care physician, those are easy. Those are easy to get approved because the FDA has approved those certain indications. I think with the shift to you know thinking about people who are already healthy who want to lose some weight, get their inflammatory markers down because maybe they have some autoimmune disease. Maybe they had some gestational diabetes, and now they're trying to get the weight off. They've weaned off of breastfeeding. This is where it's very challenging for most of us, right? If their BMI is 2526, we can start to see pre diabetes. We can start to see small increases in that hyperlipidemia that are not quite high enough to say you're approved. Then it's the finesse and the art of how can we prescribe these? We know these have been proven to improve systemic inflammation, but then the socioeconomic status of that patient, right? If you have the means. We can help order it for you, and you're going to pay full price, which is unfair and unjust in our current healthcare system. From my personal opinion, I'm speaking on the record that this is only to do with my opinion, and so that's when it's more difficult. So having a conversation with that patient, understanding their SES socioeconomic status, and then determining like how can we make this work? How can I think about different ways? There are a lot of medical liaisons in industry that can help determine if there's extra support they can do to help these patients get these medications. Speaker 3 31:35 If you could change one thing about how primary care physicians approach cardiovascular prevention with their patients, what would that be? Speaker 1 31:45 I would recommend primary care clinicians to focus on on four things. Number one would be making people more active, and by more active, you know, exercise is one type of activity, but is not the only one. So, just moving will be goal number one. Goal number two will be small but meaningful changes in their nutrition or diet. I prefer not to use the word diet, but more about you know healthy nutrition. And those changes again should not be huge, but they will be important and meaningful. Number three will be avoiding tobacco in all ways and means and shapes and forms, even secondhand smoking, which is something that is usually under the control of people to avoid. Less of a problem these days, but still particularly among younger individuals with the smokeless nicotine use, etc. And number four would be to recommend their patients to keep track on their numbers. You know, watching the numbers, and the numbers would be BMI, cholesterol, blood sugar, and blood pressure; those are the four tenets of prevention. And people who follow those four basic principles will have a much lower risk for heart attacks and strokes in their lifetime. And all those four things gotta be relatively simple goals to achieve, Speaker 4 33:24 and I'll just add probably the most important thing I think for primary care physicians to know is asking their patient what brings them joy, and then kind of creating exactly what Dr. Lopez Jimenez mentioned around that particular response, and really focusing on all of these things that he just mentioned reduce inflammation, systemic inflammation in the body that we know is around us environmentally, in the food we eat, in you know nanoplastics, forever chemicals, pollution, being next to fires. All of these contribute to cardiovascular disease and strokes, and so having patients understand any small thing that can reduce your level of inflammation in the body is probably good. And I will have to put in with the new lipid guidelines: the lower your LDL cholesterol, the better over your lifetime. With the current evidence we have, I know there are others out there looking at different types of saturated fat and the quality of saturated fat that needs more investigation to for us to move the needle. But as it sits, the lower your LDL is in whatever format of lifestyle you can reduce that, the better you're off. And then the last thing I'll say is this book was an inspiration by Dr. Mayor Lerman. He took on Dr. Lopez Menez and I to co-author this book, co-edit this book, and all of the proceeds go back to the Mayo Clinic CV Research Department to further the research for cardiovascular health, disease, and longevity. So, Speaker 1 34:57 I cannot emphasize. Of what Dr. Lara Brittinger had said that heart disease prevention should be matched with joyful activities, joyful decisions. So it's it's not something that you know because sometimes people have this misunderstanding that everything that leads to health is boring, you know. I think quite the opposite, right? So to me, there is nothing more boring than be sitting in front of the computer the whole day, right? So I have to move around, greeting my my colleagues next door, and there are many joyful choices, decisions, foods that are delicious. That one of the things that we emphasize the most in that book is that keeping our heart happy many times means we stay happy. Speaker 3 35:57 I'm Richard Payerton reporting for Medical Economics. Today I've been speaking with two guests, Dr. Francisco Lopez Jimenez and Dr. Kyla Lara Breitinger, cardiologists and co-authors of the new Mayo Clinic guide to a healthy, happy heart. It's been a great conversation, and I think this book is going to be a helpful resource for physicians and patients. Thank you both for your time. Speaker 4 36:20 Thank you so much, Richard. Speaker 2 36:35 Once again, that was a conversation between Medical Economics senior editor Richard Payerton and Mayo Clinic preventive cardiologist Dr. Francisco Lopez Jimenez and Dr. Kyla Laura Breitinger. The Mayo Clinic guide to a healthy, happy heart is available through Mayo Clinic Press, and proceeds from book sales support the Mayo Clinic cardiovascular research development. With that said, my name is Austin Luttrell, and on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts sharing strategies, stories, and solutions for your practice. You can find us by searching "Off the Chart" wherever you get your podcasts. Also, if you'd like the best stories that Medical Economics and Physicians Practice published, delivered straight to your email six days of the week, subscribe to our newsletters at medicaleconomics.com and physicianspractice.com. Off the chart, a business and medicine podcast is executive produced by Chris Mazzolini and Keith Reynolds, and produced by Austin Latrell. Medical economics and physicians' practice are both members of the MJH Life Sciences panel. Thank Unknown Speaker 37:32 you.