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Salt, sugar, and fat, what's not to like? Well, there is such a thing as too much of a good thing, and salt may be one of them.

We evolved as humans in a low-sodium environment, the inlands of Africa. We have taste buds specifically for salt, sodium chloride, and most of us like salty things. We may be the sweatiest animal on the planet, and we lose salt when we sweat from heat and vigorous exercise. So we do have dietary needs for a little bit of sodium chloride, the chemical we usually mean when we use the word "salt" in terms of food. But is there such a thing as too much salt?

We know that drinking seawater is remarkably unpleasant because it's too salty, and you can't survive by getting your water needs from seawater. You'll die.

And when we eat a lot of salt in our food, potato chips followed by boxed macaroni and cheese for lunch and a store-bought pizza with cheese and pepperoni for dinner, we get thirsty. We drink a lot of water, and we wake up all puffy. And who wants to wake up puffy? And all that puff shows up on the bathroom scales. Well, being puffy means that your body has held on to water to help dilute all the salt in your blood that you ate yesterday, and holding on to extra water means that your blood pressure can go up. And when your blood pressure goes up, it puts you at risk for heart disease and strokes and kidney failure.

America's high-salt diet, on average 3,000 to 6,000 milligrams a day, has been linked to high blood pressure, a leading risk of heart attacks, strokes, and kidney failure. More than 4 in 10 American adults have high blood pressure, and among black adults the number is 6 in 10.

The issue of salt in food is a complicated one. Of course, some people are sensitive to increased amounts of salt in their diet. Research studies have defined this salt sensitivity as people for whom an increase of 1,000 milligrams of sodium, about half a teaspoon of table salt, increases their blood pressure by 5%. Now, that doesn't sound like very much, but it's a significant difference when it comes to health outcomes. Some people are genetically salt sensitive, and some people are salt sensitive because they already have a chronic medical condition that gets worse on a high-salt diet.

Of course, there are studies that suggest that people who eat sodium at the 3,000 to 6,000 milligrams per day and say they don't necessarily have bad health outcomes. An international study of more than 100,000 people suggests that while there's a relationship between salt intake and high blood pressure, if you don't already have high blood pressure and you're not over 60 or eating way too much salt, salt won't have much impact on your blood pressure. However, most research suggests that a lower sodium diet is good for people who are older, over 50, who are African American descent, who have high blood pressure or diabetes, or whose blood pressure is gradually creeping up.

The Institute of Medicine, the Dietary Guidelines for Americans, and the American Heart Association recommend limiting your sodium intake to no more than 2,300 milligrams a day. That's about a teaspoon. People with heart failure and kidney disease are advised to keep their sodium at about 1,200 milligrams a day or about half a teaspoon. And for the very significant percent of Americans who have kidney stones, including yours truly, excess salt in the diet contributes to the formation of the most common kinds of kidney stones. Ouch. I had to have that explained to me by my urologist.

Now, low-sodium diet, that's easy, you say. You wouldn't put half a teaspoon from your saltshaker on your food each day. It turns out that the major source of sodium in our diet comes from prepared foods from the store, that boxed macaroni and cheese, prepared soup, bread, prepared salad dressings. About 70% of the sodium people consume comes from premade or packaged foods according to the FDA.

With that in mind, the FDA recently issued voluntary guidelines for the food industry to lower the amount of sodium in prepared foods, manufacturers, restaurants, and food service operators. These guidelines are voluntary and temporary to seek to decrease average sodium intake from approximately 3,400 milligrams to 3,000 milligrams per day, about a 12% reduction over the next 2.5 years. Now, that isn't very much, but it can make a difference in a population of people.

A recent study published in "The New England Journal of Medicine," done in China in 600 rural villages, randomized households to using regular salt in their cooking to a salt substitute, which switched out about 25% of the sodium chloride in their saltshaker with potassium chloride. This isn't enough for most people to taste the difference. They were encouraged to use a little less salt in their cooking, but could use other sources of sodium, like soy sauce, in the usual way. This is a very small dietary change. The control villages did their regular cooking. There were about 21,000 people in the study, with an average follow-up of about 5 years. The average age of the participants was 65 years. Half of them were women. About 72% had a history of stroke, and 88% had hypertension. That's a pretty high risk group. There was about a 15% decrease in strokes and major cardiovascular events and deaths in the salt substitute group over this 5 years, which would be quite significant if you're talking about a billion people or talking about 10 years. So it was kind of a big deal.

Other studies have shown similar effects in the U.S. in people who adhere to the DASH diet, which stands for dietary approaches to stop hypertension, sort of a Mediterranean diet with lower sodium. They have lower blood pressures.

So how much sodium in your diet if you're mostly healthy? About 2,300 milligrams or one teaspoon of table salt. If you have genetic or medical conditions that predispose you to greater risks with salt, even less. If you're like the average American and get 70% of your sodium intake from prepared and packaged foods, read the label.

Americans consume a lot more salt in their diet today than they did 50 years ago. Largely this is a change in how we cook or rather how we don't cook. Many more meals are pre-prepared from the store, and many more meals are eaten out with a lot of salt. Women are often in charge of the food shopping and food prep in the house. Clearly this isn't always the case, and there are many days many people just don't cook. They eat out and they eat foods in restaurants that are often very high in sodium and few actually will give you the amount, but sometimes you can look it up online. Or they eat in prepared or prepackaged foods.

Sodium is important enough for your health that the FDA food labels on the back of the package let you know how much sodium there is per serving. Your local pizza place with high sodium crust, high sodium cheese, and high sodium pepperoni, yum, won't have the sodium content. You can make choices in the food you buy. Many prepared food companies, like Campbell Soup, have offered lower sodium soup options in their canned soups. Even the chip aisle in the grocery store has chips with lower sodium.

So what do the labels on the front of the box mean? Sodium free or salt free, each serving in this product contains less than five milligrams of sodium, very low sodium. Each serving contains 35 milligrams of sodium or less, low sodium. Each serving contains 140 milligrams of sodium or less, reduced or less sodium. The product contains at least 25% less sodium than the regular version, but in the case of some soups that may mean going from 700 milligrams of sodium per serving to 500 per serving, and that is still a lot. Unsalted or no salt added, no salt added during processing of food that normally contains salt. So this could still be salty.

So make a commitment to cook more food at home from scratch and more whole foods, whole grains, veggies and beans, and don't add salt when you cook. Let people add the salt at the table if they need. Adding spices, pepper, or lemon can increase the flavor in your home foods without adding extra sodium. Do you like sea salt on your chocolate chip cookies? Forget adding salt to the dough and sparingly grind a few flakes, a very few flakes on the top of the cookies.

Even though you and your family might not be salt sensitive or have risk factors that would make a low-sodium diet important, some of you will someday. Getting out of the salt habit, eating more food cooked at home by somebody is good for you and the people you love. Have everyone become involve in food shopping choices and cooking at least some of the time and guide these choices, and that will help everyone be more independent in their sodium, sugar, and calorie choices and maybe your face won't be so puffy after pizza night.

Interviewer: We are here with Dr. Jared Bunch, Professor of Medicine and Section Chief for Electrophysiology at University of Utah Health. Now, Dr. Bunch, when it comes to atrial fibrillation or AFib, what exactly is happening with the patient, and what are they experiencing?

Dr. Bunch: That's a great question. Atrial fibrillation is the most common abnormal heart rhythm that's sustained or maintained that we see in practice. I suspect most people who are listening to this know somebody that has atrial fibrillation. One in three of us to one in four of us will develop it. In fact, we live long enough, we live over 80, 40% of us will develop atrial fibrillation. And what it is is it's an abnormal electrical rhythm in the upper heart chambers, and these upper heart chambers normally beat in a really ordinary synchronized manner at 60 to 70 beats per minute. Atrial fibrillation replaces that maybe to 300, 350 beats a minute, the upper heart chambers. And that can cause stroke, it can cause heart failure, and it can cause a lot of symptoms such as chest pains, shortness of breath, dizziness, exercise intolerance, anxiety, fatigue. You may know somebody that has atrial fibrillation that called 911 the first time they developed it. In some people, the symptoms are more mild. So it's a symptomatic abnormal rhythm that's quite common amongst us.

Interviewer: And the potential for stroke, that sounds pretty serious.

Dr. Bunch: That's our biggest worry is stroke, because these upper heart chambers aren't squeezing and pushing the blood forward. So the clots that form can be larger than other sources of stroke and cause more disability and higher risk of death. So we really focus on trying to prevent stroke as an upfront treatment strategy.

Interviewer: Now, you said that some people live with AFib their whole life, and maybe it shows up at a physical or another kind of doctor visit. And other people, they feel it, and then they call 911, and they come in. Once a patient knows that they have some sort of AFib, what is the next step, and what are some of the treatments that can help kind of alleviate those symptoms or treat the disorder?

Dr. Bunch: So we look at this in three primary pillars, three primary treatment approaches. First, we want to prevent stroke, and our best way of doing that is early use and appropriate use of anticoagulants. They're often sometimes called blood thinners, but really they don't thin the blood. They make it slower to form a clot. So they're less likely to form a clot in the heart. And they can reduce the risk of stroke less than 1% a year, or it can be as high as 5% to 10% a year.

Our second concern is the heart is just a muscle. If the heart's going too fast or too long, it can begin to dilate, weaken, just like any of our muscles. And so we use medications to slow the heart down if needed. We want the average heart rate less than 100 beats per minute on average at rest. Sometimes we need to control it with exercise as well.

And then, finally, we focus on symptoms. Some people aren't aware that the symptoms they're experiencing is related to atrial fibrillation. They don't put that correlation together till we make the diagnosis. Other people know right away. So then we begin treatments to restore the heart rhythm really to help you feel better and do better and enjoy your quality of life at a higher degree.

Interviewer: Are there any kind of treatments that could potentially fix the kind of problems that they might be seeing that goes beyond, say, medications or some of these other things you've talked about?

Dr. Bunch: There's three primary ways that we treat this. First, we work on risk factor modification. What causes atrial fibrillation? The most common causes in the community, the most common we can't do anything about, we get older. It's a disorder of aging. But the other things we can do a lot about and that is high blood pressure, getting our blood pressure well-controlled, screening for sleep apnea when we hold our breath at night and treating that, decreasing alcohol intake, treating diabetes better, losing weight, and being more active. We want people to be active 30 to 60 minutes a day, that's the dedicated time towards activity, whether that's walking, jogging, running, swimming, yoga, whichever you like. It's important to have that time where we exercise our bodies.

So that is one part that we do to help lower the risk of atrial fibrillation. In fact, if we do those things really well, it will lower atrial fibrillation by 30%. We have medications that help force the heart to beat normal, what we call antiarrhythmic drugs. And there's a number that are currently available, and we can use them depending on the health of your heart. So sometimes we can use a lot if your heart's healthy. If your heart's weak or you've had heart attacks or surgeries, then there's only a few we can use.

Then, finally, there's approaches to do this without medication. So the most common is called catheter ablation, and that's a procedure where . . . it's a minimally invasive procedure where we advance little specialized tools that are flexible and move in your heart called catheters through the veins in your leg up into your heart and cauterize around the sources of fibrillation and block them. These electrical sources are like throwing a rock into a pond. The waves carry from outside from where the rock enters throughout the whole leg. We want to block these signals at their origin. And then sometimes also, if needed, the same procedure can be done by our surgical colleagues through open-heart surgery in patients with really advanced heart disease or disease that we can't get to from within the vessels.

Interviewer: So what kind of patient is best served by the cardiac ablation procedure? Is it the sickest of the sick or anyone with atrial fibrillation?

Dr. Bunch: Well, we've learned a lot just over this past year. A large trial came out that said, "When should we do it? Should we do it early?" And they took patients that developed atrial fibrillation within one year of diagnosis. We found that if we're going to get the most bang for your buck, the most efficacy for the procedure, we really should start looking at either using a medicine that helps the heart beat normal or an ablation within that first year. But that doesn't mean if you had atrial fibrillation longer that you wouldn't benefit from something like an ablation. Ablation is twice as effective as our medications.

And our patients that are the most sick really need their heart to be very efficient and those upper chambers to contract and squeeze just like the lower chambers. Sometimes they benefit from ablation as well and more so than medicines. And the best example of that is our patients with atrial fibrillation and heart failure. Ablation clearly is a better approach and actually can impact how long you live. If we can restore the rhythm effectively and get you off these medicines, it helps you live longer.

Interviewer: Now, one of the things I think we really need to talk about is that cardiac ablation is not necessarily a cure-all for AFib. Is that correct?

Dr. Bunch: Yeah, very much so. And it goes right back to that first thing I said regarding risk factors. If you still have risk factors that aren't treated at all, then our treatment approaches decrease in their efficacy and their success rates by as much as 50%. If you have sleep apnea that's untreated, then our success rates go down by 50%. So that's why when you see specialists, like myself, they will ask you about sleeping even though you came in with a heart problem. So you have to be diligent about the risk factors that you can control.

And then, also, atrial fibrillation, just like other chronic diseases, it can progress beyond the initial focal sources that we treat. And as it progresses, new areas can develop, and you could need a repeat ablation, or you could need a medication with the ablation to control it long term. But the good news with that is, if I am a patient that has atrial fibrillation, there's a lot I can do personally to help myself have a better outcome and to help the physician who is ultimately performing the procedure have a better outcome as well with the procedure.

Interviewer: For a patient that has been dealing with AFib for a while or maybe they just barely got their diagnosis, what advice would you give them for the treatment options available to treat their condition?

Dr. Bunch: Again, we need to work and minimize risk of stroke first. We're going to focus on that, and we're going to minimize risk of any potential injury or weakening to the heart. And then my approach has changed in the past year. I say, if we're going to do something about this rhythm, we should do it earlier, within the first year if possible, to keep the heart normal. The heart rhythm is a lot like kids. I have teenagers, and one teenager learns from the other. And the heart rhythm learns from the beat before it. So the more it's in fibrillation, the more it wants to be in atrial fibrillation. So we want to set the heart on a trajectory to want to beat normal. And so that's what we aggressively do in patients that have symptoms and want to pursue that route. People that don't have any symptoms at all, they said, "I came in for a test, and you found atrial fibrillation. I don't know why I'm here." In those people, we spend more of our time just making sure we lower stroke rates and making sure that that heart rate is well controlled, and so the muscle isn't in jeopardy of weakening.

Interviewer: Perhaps you're a patient that has been suffering in one way or another from atrial fibrillation, otherwise known as a-fib, and you've been working with a specialist and perhaps the medications aren't quite working, or your symptoms don't seem to be getting better. A potential option for treatment is called cardiac ablation, a non-invasive surgical procedure.

We're here with Dr. Jared Bunch, Professor of Medicine and Section Chief for Electrophysiology at University of Utah Health. Now, Dr. Bunch, what does a patient need to know about the cardiac ablation procedure itself? What's going to be happening, and what can they expect?

Dr. Bunch: There's a number of different aspects to consider if you're at the point that you want to pursue a catheter ablation for atrial fibrillation. First, it's that you go to a center that has experience. Centers should at least do 100 atrial fibrillations a year and should do more. Second, the operator that has done it. Have they done over 100 ablations? Have they seen different complications and managed them well? So picking the center and having someone with expertise is critical. It changes the outcomes.

And feel comfortable asking whoever is recommending ablation, how many of these have you done, how many does your center do, have you seen any complications and how did you manage those and did the people do okay? So that's an important foundation in choosing where to go.

The second is understanding what the procedure is. Most centers do ablation under general anesthesia. Some do it under what we call conscious sedation, where you're asleep but you don't need a tube to help you breathe. And the reason mainly this is done is not necessarily because the procedure is overly painful. It's that you'll have to lie flat on a table, what we call a catheterization table, from anywhere from two and a half to four hours, and that's a long time to lay still, and if you shift even a few millimeters, our maps that guide us in the heart have to be redone.

So the way we get to the heart is we put catheters or what we call IVs or intravenous accesses into the big veins, and we thread these long, flexible tools called catheters into the heart. And we go from the vein side to the artery side. The artery side is the oxygenated blood side, the bright red blood side, by making a small hole in the middle of the heart method. That heals up in about two to four weeks. And then fibrillation actually begins in sources outside of the heart, what we call the pulmonary veins, and these are the veins that drain, or bring oxygenated blood from the lungs to the heart. And they can trigger at 300 beats a minute and cause the heart to become unstable and create this rhythm called fibrillation.

So we identify the veins, and then we cauterize around where the veins enter the heart. We can't work in a heart, in the veins directly because they're fragile and they collapse and stenose. So we have to work around them.

Many people ask me, well, how do you choose which vein to treat? And I was part of those studies years ago. We would find the vein that was active and just treat that. And then, we would find that the patients all came back and one vein had replaced the other. So now we find all the veins that you have and treat around all of them. And then, we pull the catheters out and these IV accesses out of the legs, there's not stitches, usually before you wake up, some centers right as you wake up, and then you lie flat from anywhere from two to four hours after. It's a same-day procedure, and if you come off anesthesia well and you're relatively healthy, some centers will send you home that day. Other centers will watch you overnight just to see how you're feeling and how you're doing with the treatment.

Interviewer: Now, when we're talking about a procedure like this, what are some of the potential complications that a patient should keep in mind for a procedure like this?

Dr. Bunch: That's a great question, and it's really important to understand the complications and understand how those are influenced by operator experience and center experience and skill and centers that have dedicated time to be an atrial fibrillation center of excellence. So the most common complication is we access these veins in your leg, and there can be bleeding around them, bruising. Bleeding is what we call a hematoma. We may see that in 1% to 2% of people.

Our tools are designed to work in the heart, move with the heart that's beating, and they're flexible, so they can do that, but occasionally, there can be a small hole in the heart or a tear in the heart that can cause bleeding around the heart. That happens in about 1 in 500 to 1 in 1,000. Typically, we can treat this conservatively, meaning you don't need a surgeon to repair the entry, but about 1 in 10 of the people with these bleeds will need surgical help. There's a risk of stroke or clot formation on our tools. Our tools irrigate themselves. They have fluid bathing around them, so clot is less likely to occur, and that occurs about 1 in 1,000 to 1 in 3,000.

And then, the part that concerns me the most is the, not necessarily the heart at all, it's the structure behind the heart, the esophagus. So we have to identify where the esophagus is and make sure we avoid it, because if you heat two tissues or you freeze two tissues, they can grow together and form a communication. And we perform ablation either with heat injury or with extreme cooling or freezing, and both of those can cause injury to the esophagus. We have to know where that is to avoid.

But those are the most common things that we worry about. There's some other minor things. Major risk RE less than a percent, anywhere from less than a percent to 1 in 1,000. Success rates of the procedures for what we call paroxysmal atrial fibrillation that comes and goes, in most centers is 70% to 80%, and for atrial fibrillation that's persistent, meaning that it lasts longer than a week or we need to shock the heart to restore it, procedures' success rates will fall by about 10% to 20%.

Interviewer: So it sounds like the procedure has a decent success rate, but there are still things that we've got to look out for and what better reason to really be sure that you're going to a good center and have a good surgeon. So, after the procedure, on the same day they're put under general anesthesia, you're saying that some people have to stay overnight?

Dr. Bunch: And it varies a lot from person to person. So, again, once you wake up at our center, all the IVs are out, there's just bandages on the legs. We put little closure devices in the veins so they heal more quickly. So most people are up walking in two to four hours. I would say right now, approximately 50% to 2/3 of our patients go home the same day after being observed in recovery for 3 to 4 hours. We want people up and walking that day, in that evening. We don't want people lifting over anywhere from 10 to 20 pounds for about a week after, not necessarily because of the heart but the veins that we go in through, they have to heal as well. And typically, veins heal a little bit quicker than our skin. So, if there's no evidence that we were in the vein from the skin, you can rest assured that the vein is also healed at that time as well.

But what we have learned after to encourage exercise and activity. A lot of people with fast heart rates worry that they're going to exercise and their heart's going to go fast and it's going to cause fibrillation. But studies have shown that those that engage in exercise, yoga for like 30 to 60 minutes a day, they can influence the risk of recurrence by about 30%. And so we want our patients active right after.

But what I tell most people is follow their body. These procedures, they make people nervous. If it's your first one, you're nervous, you're anxious, you're under anesthesia, and some people just feel tired after it. And so, if you have a few days where you're fatigued, that's your body saying that you need time to recover. But most people can expect to be up and active and walking the day of their procedure with minimal to no pain.

Interviewer: What is recovery like for a procedure like this? It seems like a pretty major procedure to me as a lay person. But how long until a person heals, when can they get back to work, you know? What does the aftercare look like?

Dr. Bunch: That's a great question as well. So we want them up and active, but one of the things our heart doesn't like is to be touched. So our heart's surrounded by sacs. It's surrounded by ribs and muscles, so you can't touch it. And so, when we work in the heart, sometimes it actually gets more irritable for the first few weeks to months. So, if you have abnormal rhythms in the first three months, those really don't mean that this, the procedure has failed. That's part of the heart healing. So about one-third of people will notice some abnormal heart rhythms in that first three months. We want to know about those. We treat them. We'll use medications while the heart's healing. About two-thirds, their heart will be really quiet. And then, anything that happens after three to six months, then there's more significant long term, but it's just important to remember the heart has to heal.

It's easy when we have open heart surgery and there's stitches and our ribs hurt and our sternum hurts to know that the heart was worked on. When there's just some small dots near your veins in your legs, you kind of forget after a week or so that the heart still has to heal. So it is important to realize that our heart is beating 100,000 to 120,000 beats per day. So it's really healing on the run. So it takes time to heal. Even if we don't feel pain or anything, it's still undergoing this reparative or this healing process.

Interviewer: Now, say we're a couple of months after the ablation procedure, and a patient's heart is starting to heal, what are some of the quality of life improvements that we can expect? Keeping in mind that as we've talked about on an earlier interview, this procedure, the cardiac ablation is not a cure for a-fib. After all, there are still medications and other risk factors and other treatments.

Dr. Bunch: Some are intuitive that most people, when we study people and ask them specifically, people have more energy, they don't feel their heart symptoms as much, they want to do more, they're more engaged, they're more active, and those are all what we call physical measures of quality of life improvement. People also tend to have quality of life improvement in mental scores, how often do they feel depressed or a depressed mood. Those tend to improve as well. We can see that as early as three months, and those quality of life scores continue to be higher in patients that have an ablation compared to those that don't upwards to three to five years.

A lot of my research is on the cognitive component of atrial fibrillation and brain health, and we also see that the cognitive scores go up after an ablation as well, particularly in the regions of memory and memory storage. So people do also report a little bit better memory and cognitive function after ablation as well, which I think is exciting, because years ago we found that atrial fibrillation was associated with multiple forms of dementia, and these scores teach us that if we apply aggressive treatment, we improve the rhythm, we lower risk factors, that we can really help the general brain health, and a disease that really is terrifying to all of us or to lose our memory and our brain function and develop severe cognitive impairment or dementia.

In medicine, we were taught that women were protected against heart attacks until they went through menopause, and then our risks caught up with men's risks. But what if we weren't really protected that well?

For many years, our research into the heart attacks has been focused on men. Even on TV and the movies, something awful happens, and a man clutches his chest and keels over. And we find if it's a police or a medical show, that he died of a heart attack. Most of us could have figured that out before the forensic pathologist told us on the TV show because we know what men's heart attacks look like.

In fact, we understood men's heart attacks and the causes, high blood pressure, smoking, eating red meat and fatty foods, and high cholesterol. Doctors really got on men's cases, and since 1960, men have decreased their smoking. And if their cholesterol or blood pressure is high, and their wives drag them into the doctor, the men were on blood pressure medications and cholesterol-lowering drugs. And meat and fatty foods, they're still Super Bowl yummies and fast food, and they're doing better.

Men's rates of heart attacks dropped dramatically. And then we noticed that postmenopausal women caught up with men in the rates of heart attacks at about 60. So we sort of got on it and started a national campaign, like the red dress for heart health, to help women understand their risks and the signs of heart attacks. But we were still thinking about women over 50, at least OB/GYNs were. And now comes a troubling study that shows that the rate of heart attacks in young people, people under 50 are increasing and are increasing more for women. This is worrisome. And it's important to look at the communities where this work was done and see what we can learn.

From 1995 to 2014, the ARIC, A-R-I-C, Community Surveillance Study gathered information on almost 29,000 heart attacks. ARIC stands for Atherosclerosis Risk in Communities. And atherosclerosis is the clogging up of the arteries in the heart that can lead to heart attacks.

The communities that were involved in this study were in four geographic areas in the U.S. -- counties in North Carolina, Maryland, Mississippi, and suburbs of Minneapolis. Some of these counties have Americans at risk for heart attacks based on increased rates of diabetes, smoking, hypertension, obesity, and poverty in African American race. Of those 29,000 heart attacks, over the 20 years, one-third in what they called young people, people 35 to 54. Over those 20 years, the annual rate of young men's heart attacks went down some. But women's rates went up to the point that young women, pre-menopausal women had the same rate of heart attacks as young men. These data are alarming, and they mirror similar data from Canada, suggesting that the incidence of heart attacks in young women is rising.

Well, what are some of the risk factors for these young women? Smoking, high blood pressure, and diabetes very substantially increase the risk in women. And black women had very significantly more heart attacks than white women. Seventy-five percent of the young women with heart attacks had high blood pressure, 36 percent had diabetes. And women who had heart attacks were more likely to have multiple risk factors than men.

Young women who had heart attacks were less likely than young men who had heart attacks to have their cholesterol treated or their blood pressure treated. Young men and young women who had heart attacks had a 10% chance of dying the following year. Young women have some extra risk factors for heart attacks compared to men. They're more likely to have demonstrated risk for diabetes by being diabetic in pregnancy. They're more likely to demonstrate risk of hypertension and vascular disease by having preeclampsia when they were pregnant. And they are more likely to suffer the psychosocial stressors of poverty than men.

This information hurts my heart. These young women were mothers of young children and teens. They were at the most productive times of their lives, and they were also at the most stressful times of their lives. So what do we do with this information as women and as physicians? The risk factors in this study are ones that we all know about, risk for heart health, such as smoking, diabetes, and hypertension. But diabetes and hypertension often don't have physical symptoms.

Unless women are getting regular checkups, getting their blood pressure measured, their cholesterol measured, and their blood sugar checked, they may not know. Women used to go to their OB/GYN or their family doctor, get a Pap smear every year, but now they don't. Many women who used to go regularly for their checkups when they were having babies, don't go anymore. All clinic visits, for one reason or another, will have a blood pressure check, but cholesterol or diabetes checks aren't done so often in young women.

Of course, the big risk of smoking cigarettes in an unbelievable 48 percent of the young women who had heart attacks were cigarette smokers, would be addressed by the clinician, if women admitted to it. See our podcast on lying to your doctor.

So all women and men need access to health care. All the women and men need regular checkups at this very busy time of their lives, 35 to 54. All women and men need to have their blood pressure, high sugar, and high cholesterol managed according to national guidelines. And women need to take their medication.

How we manage the stressors of poverty, the stresses of being a minority are issues that we all need to address as a community and as a state and as a national level. So, ladies, please take care of your heart. And thanks for joining us on "The Seven Domains of Women's Health" on The Scope.

updated: September 5, 2019

originally published: February 7, 2014

Announcer: Health information from experts, supported by research. From University of Utah Health, this is thescoperadio.com.

Scot: Many people take fish oil for a lot of different reasons. Some of the benefits, well, there's a lot of mays in front of these benefits. May support heart health, may help treat certain medical conditions, may aid in weight loss and the list goes on and on. However, we might be able to take the may off of one of those. Dr. Tom Miller is an internal medicine doctor here at University of Utah Health.

What might we possibly be able to remove the may from, as to what fish oil helps with?

Dr. Miller: Well, it's interesting. Let's start with a little bit of history. Some time ago, probably back in the '60s, maybe '50s, we understood that the native population up above the Arctic Circle, Innuits had low rates of heart disease, and it was postulated that perhaps their high diet in fish contributed to this.

Now, Arctic fish have high levels of omega-3. The idea was that if you took omega-3s, you might have less heart disease, lower incidents of stroke. This went on for a number of years, in fact a couple of decades, and it was never really very clear whether omega-3 supplements actually made a difference.

But in the last year there have been a couple of landmark studies that have employed the large number of patients required to sort this out. And it does appear for people who have high triglyceride levels and have some type of event, like heart attacks or they have coronary artery disease or they might have had a stroke, that omega-3s supplemented to their diet will prevent and lower the risk of a second event.

The exact number that they came out with in this trial is 25% reduction if you were to take four grams a day. Now that's a higher dose than most people take. Most people take one to two grams a day as a supplement. I think what needs to be determined going forward is what would be the adequate dose for those who have had an event versus those who've never had that event. Should they just take a one gram, standard daily dose, or should it be more? We don't quite know that yet.

And then, secondly, there seems to be less evidence that's it beneficial in people who have never had an event.

So it does appear for the first time that we have some pretty reliable evidence, especially in people who have had cardiovascular events and high triglycerides, that the addition of omega-3 to the diet can lower the risk of a second event.

Scot: If they take a four gram dose. Dosage is important. That was the question.

Dr. Miller: That was the study that was done on four grams. Is that the optimal dose? I don't think we know just yet, but at least we have signposts that tell us that this is going to be beneficial.

Scot: Is this something you should talk to your physician about, or if you know that you fall into this category, should you just go ahead and start taking a four gram dose?

Dr. Miller: I think it would be wise to talk to your physician, because you also want to have the rest of your metabolic profile tuned up. So you want to make sure your other cholesterol subgroups are taken care of. And that's why people are on statins for preventing secondary events of coronary disease. And then, if you high triglycerides, which statins don't treat, then it might be wise for you to start omega-3.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Interviewer: Do you have chest discomfort, or are you short of breath when you're walking from the parking lot to the grocery store or maybe taking a flight of stairs? Dr. Steven Lofgren, what could be causing that?

Dr. Lofgren: One of the potential causes of these symptoms would be coronary disease or heart disease. That can be caused by a restricted amount of blood flow to the heart muscle itself.

Interviewer: And if somebody's suffering from these symptoms, what do you recommend that they do?

Dr. Lofgren: We would absolutely want to have a patient with these symptoms have what's called a stress test done. A stress test is nothing more than putting the body under some degree of stress and seeing how the heart performs. Benefits of doing this test is you can have an immediate diagnosis of a potential blockage in one of these coronaries, which then can be fixed very simply with a process called angioplasty. If you find that you have these symptoms, it is absolutely critical that you go in and see your doctor for further testing.

updated: March 23, 2021
originally published: April 1, 2019

Interviewer: All right. It's time for ER or Not. You get to play along and decide whether or not something that's happened is worth going to the emergency room or not. With Dr. Troy Madsen, he's an emergency room physician at University of Utah Health. Sitting around kind of minding your own business and all of a sudden you noticed like your heart's beating really fast, it's racing. ER or not?

Dr. Madsen: Yeah. Well, this is a good question because we see this quite often in the ER. And the medical term for it is palpitations when you just have that feeling like your heart's racing or maybe it's skipping a beat. So I'd say it kind of depends on the other symptoms you're having with it and how long this lasts.

If it's something that lasts for a few seconds, it goes away, you could probably just follow up with your doctor. But if it's something where it just will not go away, let's say you feel down and you feel your pulse and it's going really fast, if you're having other symptoms like you're light-headed, passing out, absolutely I'd get right into the ER.

Interviewer: All right. In the instance where you just see your doctor where if it's just for a quick moment, what could possibly be going on there?

Dr. Madsen: So one of the most common things we see when people say they have palpitations or they just have this feeling like it's skipping a beat or speeding up, we'll often see what are called premature ventricular complexes or PVC's. All that means is the lower part of the heart that squeezes the blood out, can beat a little bit early. Typically, it's not a problem.

If that happens, a lot of people have that especially when they exercise. If it's bothersome, a cardiologist can do an oblation where they find the spot that's causing that premature beat and get rid of it. But usually, it's not a serious thing where you need to rush right into the ER and get that diagnosed.

Interviewer: And it's usually something that just kind of happens once in a while?

Dr. Madsen: For some people, it happens more frequently. Others, may never even notice it when it's happening, you know. In some cases, people do feel it. They may notice it more when they exercise or they're walking, so it varies from person to person.

Interviewer: All right. And in the case of where you would go to the ER if it was continual and it lasted for a while, what could that be an indication of?

Dr. Madsen: Yes. So that could sometimes be an indication of more serious things. The most serious thing being ventricular tachycardia where your heart is just racing. And that can be a life-threatening thing. Some people may have heart conditions that set them up for that that make them more likely to have that happen. That's something where sometimes we even need to shock the heart to get it back into a normal rhythm.

Another thing we commonly see especially in older people is atrial fibrillation. Now, this is where the top of the heart, the atria, goes really, really fast. And in the bottom of the heart then senses some of those fast beats from the top and then conducts that at also a very fast rate. It also sometimes can be life-threatening because it will drop your blood pressure but in most cases, people come into the ER. Their blood pressure's okay. We can give them medications to slow their heart down or we can also, if we have to, give them a little bit of sedation and shock the heart back into a normal rhythm.

So if your heart's racing and it just lasts a short period of time, otherwise, you feel okay, I think you're okay just to see your doctor. If it's something that's going on for longer than a minute or two or it keeps coming back or you're having other symptoms with it, absolutely, you have reason to get to the ER.

updated: January 13, 2021
originally published: September 15, 2017

Interviewer: It's time for Seven Questions. It's time, seven questions for a cardiologist. We've got Dr. John Ryan here and I'm going to ask you seven questions. Just want your answers just as they come to you, okay?

Dr. Ryan: Sure thing.

Interviewer: Don't think about it too much, as quick as you can. What's the best thing that I can do for my heart to make sure it stays healthy?

Dr. Ryan: Probably exercise 30 minutes every day, something that gets your heart rate up, and just get it into your routine as something that is part of your daily schedule.

Interviewer: All right. What's the worst thing I can do for my heart?

Dr. Ryan: Probably not exercise at all.

Interviewer: Really?

Dr. Ryan: Yes.

Interviewer: Even worse than like smoking or something like that?

Dr. Ryan: It is. Yes. Well, that's fair. I mean, you're going to assume that folks know that they shouldn't smoke, but even when you have people who have a normal weight and who don't exercise, they actually are at a higher risk of having heart disease and a higher rate of mortality than people who are overweight who do exercise. The sedentary lifestyle is really hurting us.

Interviewer: What do you know about the heart that everybody else should know?

Dr. Ryan: You really can make a positive change to your risk of having a heart attack. Really, it is not something that you need to give up on. And even if you've had a historical lifestyle of smoking, not exercising, eating fatty foods, your destiny is not to have a heart attack. You can actually change your destiny and really reduce your risk of having a heart attack by stopping smoking, actively exercising, losing weight, etc. So I think that's really just key to be aware of.

Interviewer: Can you scare somebody to the extent that they have a heart attack?

Dr. Ryan: There's definitely a stress component to having a heart attack. There are people who, at football games have heart attacks, at roller coasters have heart attacks, downhill skiers occasionally have heart attacks.

Interviewer: What about, like a victim of an April Fools joke?

Dr. Ryan: I think that would be really unfortunate and would kind of make you have to rethink the whole tradition of April Fools' Day in general if mortality from cardiovascular disease goes up on April Fools' Day, I think we need to rethink why we have this holiday.

Interviewer: What is your favorite song that has the word "heart" in it?

Dr. Ryan: The favorite, probably "Total Eclipse of the Heart."

Interviewer: Okay.

Dr. Ryan: It's an incredible song.

Interviewer: Why did you specialize in cardiology?

Dr. Ryan: I think you can really do a lot in cardiology because you can take care of the individual person across the way from you, but there's also a large public health component to it, in so far as trying to get your community to be more active. And that's just a fascinating part in America because we're so heavily dependent on our cars and we don't walk, we don't cycle around our neighborhoods anymore, stuff like that.

And then there is also the nutritional components. So, as well as having that one-on-one relationship, you also have this public health issue from cardiovascular disease, which I think is really important for cardiologists to be at the forefront of.

And then also the basic science in cardiology is just fascinating and has really made a significant impact in cardiovascular disease over the last 30, 40 years. And when you look at how we have cared for people and the advances we've made in terms of reducing the rate of heart attack, reducing the mortality from heart attack and stroke over the last 40 years, those impacts have been made because we have done significant basic science advancements and because we've also made community awareness about heart disease and how to lower your heart risk.

Interviewer: What advancement in your field has you the most excited?

Dr. Ryan: I think we're getting at a point where the technology is becoming really personalized. It is really exciting that people come to us with the data that they've generated, either from their phones, from their smart phones, from what people have collected from wearables, and that their health literally is in their hands, and they are coming to us with what they've found.

Whereas traditionally, we do tests and we would say, "Well this is what we've found." Now they're coming to us with what they've found, and that's a really exciting thing because that really shifts the responsibility of cardiovascular care and risk reduction to where it should be, which is to the individual.

updated: January 27, 2021
originally published: June 14, 2017

Interviewer: You go to your doctor, they say your cholesterol is too high. Why should you care and what does that mean for your health? And what can you do about it? That's next on The Scope.

Interviewer: All right, Dr. Tom Miller, you know every year you go get you physical. One of the numbers you're going to get back is your cholesterol numbers. There are two or three of those numbers, and my doctor my tells me, "Oh, your cholesterol doesn't look good." What's going on?

Dr. Miller: Well, we've known for many years that high cholesterol can generally imply poor outcomes in the long term. It's related to vascular disease over many, many years, and it's associated with other risk factors for vascular disease, such as high blood pressure.

Interviewer: And which all can lead to heart attack or stroke?

Dr. Miller: Exactly.

Interviewer: Yes. So that's why if you see those high numbers they're predictor score, that this person is more likely to have those outcomes.

Dr. Miller: That's exactly right. So there's several things when people talk about cholesterol. Let me break those down real quick for you. First, is total cholesterol. And generally, if your cholesterol is over 200, that's too high, but you can break it down further from there. You break it down into triglycerides, you break it down into HDL, that's the good cholesterol, and then you break it down into LDL, the bad cholesterol. The way I kind of think about, Scott, is when you have a high HDL, that's the good stuff, it reminds me of a taxi that's ferrying sort of cholesterol and bad stuff away from the arteries and takes that back to the liver where it's chewed up and metabolized, and you don't have to worry about it anymore.

Interviewer: So you want lots of that HDL to help your body dispose off that stuff.

Dr. Miller: Yes, high HDL is better. High HDL is better.

Interviewer: Okay.

Dr. Miller: And you know how you get high HDL? Exercise.

Interviewer: Oatmeal. No, exercise.

Dr. Miller: Well, not so much oatmeal but exercise and weight loss and stopping smoking actually raises HDL as well. So really, what you do when you do those three things is you increase the number of taxis that are delivering bad cholesterol away from the arteries into the liver where it's chewed up. LDL, you think about that as a taxi taking cholesterol down to the arteries and depositing it into the sides of the arteries into the lumen or the walls of the arteries. And so that's where it sits, and over long periods of time, you get these plaque build-ups, and if those plaques rupture, then you can have bad things like a heart attack or a stroke.

Interviewer: So is the total cholesterol a sum of your HDL/LDL in the triglycerides? Is that where that number comes from?

Dr. Miller: Yes, basically, there's a little equation of that, but not to trouble ourselves too much about it. But the higher the HDL, the higher the total cholesterol. The higher LDL, the higher the total cholesterol. So if you actually have a nice high HDL and a low LDL, that's okay if your total cholesterol is just a little elevated.

Interviewer: Okay.

Dr. Miller: So total tells you kind of, is a sign post about you need to look at this more closely.

Interviewer: Okay. So you get that big number. Well, if the number is not big then you're probably fine. But if it's a big number then you need to look at how does that break down; the good versus the bad. If you got more good, fine.

Dr. Miller: Well, sometimes you can look at that ratio too. So you can look at that ratio total cholesterol and HDL. And there are calculators now that are put out by the American Heart Association in conjunction with the American College Cardiology that look at not only the total cholesterol and HDL, but they mix in your blood pressure and your other risk factors, whether you smoke, whether you have diabetes, and if you're on blood pressure medication. And it gives you score, and that score kind of tells you what your 10-year risk is.

Now, no calculator is perfect, Scott, but it's a pretty good indication of, "Wow, I'm doing really well. I'm eating right. I have low blood pressure and I don't have other risk factors," or, "Warning, I've got to do some other things to improve my health." Now, one of these things might be that you need to take a medication to lower your cholesterol while you're waiting for the lifestyle things to catch up.

Interviewer: Let's go back to the original question. Your doctor is concerned about your cholesterol numbers, so odds are at the point what he's going to say is you have high LDL, which is bad.

Dr. Miller: That could be one thing he says . . .

Interviewer: Exercise. I need you to exercise more. I need you to quit smoking.

Dr. Miller: Right, and you would say those things anyway, right?

Interviewer: Okay.

Dr. Miller: I mean, generally, those are great ideas, but we stress them more if your cholesterol and blood pressure are elevated.

Interviewer: What else would you doctor tell you to do to try to get that under control then?

Dr. Miller: So you want to follow a low cholesterol based diet, and there are ways to do that. You can Google a step one cholesterol diet and it will tell you. And basically, it's common sense. Don't eat a lot of animal products because animal foods have cholesterol, plants don't, they don't have cholesterol. So you're not going to get cholesterol from plants, so the more vegetarian based your diet is, the more leafy green vegetables you eat, the chances are you will help lower your LDL cholesterol.

And so you want to stay away from high cholesterol meats, fatty meats. You want to trim fat off of any kind of meat that you are eating chicken or steak, and some common sense things. And most of us have heard these over and over on the news and on the media but we have to pay attention to it on the cholesterol side. But at some point it might be high enough, you actually need to be treated for it.

Interviewer: You could do all the right things and still . . .

Dr. Miller: Yes, there are some folks that have a genetic predisposition to have high LDL cholesterol and they are predisposed to really heart disease. And so we do get after them with drugs and we have good drugs now to treat high cholesterol.

Interviewer: And nothing you can do if you're genetically disposition, if you do all the other stuff right.

Dr. Miller: Yes. First step in this treatment basically, and this is true for high blood pressure as well, is to get after your lifestyle improvements. So getting your body mass index down between 18.5 and 25 and exercising on a daily basis. And I'm not talking about on Schwarzenegger type weight room stuff, I'm just talking about going out and getting to walk for 30 to 60 minutes a day.

Interviewer: Elevating that heart rate.

Dr. Miller: Yes, getting your heart rate up to a moderately elevated level. We're not talking about Olympian athlete type redlining heart rates, we're just talking about getting out and doing a brisk walk or a swim or cycling.

Interviewer: Do you find that patients when you give them this information that they tend to think, "Well, really how much is that going to make a difference?" Are they skeptical?

Dr. Miller: I don't think patients are skeptical. I think we all want to do the right thing. And I think the vast majority of us believe that exercise is healthy. It makes us feel better and losing weight makes us feel better. There's a body image piece there. It's just hard to do. We don't have a pill to help you lose weight effectively.

Interviewer: And for cholesterol. . .

Dr. Miller: And we don't have a pill to make you exercise. So it's a lot of coaching. It's like you can do this, go out and do it. So you build your patient's will power up by suggestion.

Interviewer: And doing that will noticeably decrease cholesterol numbers?

Dr. Miller: Yes, it will definitely help reduce cholesterol in the vast majority of people, but not always to a level that would be necessary.

Interviewer: Got you. But it does make a difference?

Dr. Miller: It does make a difference, and it a makes difference for reasons other than just lowering cholesterol and lowering blood pressure. So there's many different reasons to stay healthy with lifestyle interventions.

updated: March 10, 2023
originally published: May 27, 2017

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

Interviewer: Heart failure is devastating no matter how you look at it. But it turns out that physicians can reverse the course of disease in a small fraction of patients. What makes these people different? I'm talking to Dr. Sarah Franklin who's researching ways to find out. So heart failure, what makes this a particularly interesting problem for you?

Dr. Franklin: So heart failure is the number one leading cause of death in the United States, and it has a significant burden on human health as well as a financial burden. And I think that one of the most exciting parts about studying the heart is that in recent years, we have started to realize that this organ which we typically have thought in the past was not able to regenerate itself or have regenerative capacity, actually is much more intricate than we thought. And we are starting to understand and realize that the heart actually is able to, in some circumstances, regenerate or essentially jump back after disease.

Interviewer: I mean this is just with a certain fraction of patients, is that right?

Dr. Franklin: Yes. So most individuals that experience heart failure or heart disease have two options. Unfortunately, these options aren't very exciting. But if you have a failing heart, you either can have a heart transplant, so have a new heart implanted, or you can have a left ventricular assist device, or essentially a mechanical pump implanted in your chest that pumps for your heart. And as you can imagine, both of these are life changing experiences and neither of them are really something that you want to look forward to.

However, there is a very small fraction of individuals that experience heart failure. But when a pump is implanted in their chest, as opposed to just maintaining function or prolonging life temporarily, their heart is actually able to regenerate itself or recover because there's stress that's actually taken off the heart from the pump. And this is the population that, as you mentioned, is quite small, but it's a really incredible phenomenon.

We didn't use to know that this occurred. And now that we know that actually a heart that's failing that we use to believe could never recover from that, actually some hearts do have this capacity. And if we can identify why and how this happens, then we can potentially understand how we can get more hearts to do this or go through this process. Or potentially just intervene at an earlier stage where maybe a lot more hearts have this capacity.

Interviewer: And so how are you looking at that?

Dr. Franklin: We are very excited to be involved in research to understand this phenomenon. Our lab is primarily using proteomics, a mass spectrometry. And as an LVAD device is implanted in someone's chest, naturally a piece of the heart tissue must be removed for that pump to be placed. And so we are able to take a piece of that tissue and to look at all the proteins that are expressed in the heart. And we look at thousands of phosphorylated proteins, we identify what the protein is. We identify how abundant it is. And then we actually compare between samples, and so this gives us thousands of data points that we can use to create a very unique signature for someone's heart.

Interviewer: So it's that molecular signature that possibly could become the basis of some sort of test to decide who might get this special treatment and who may not, possibly?

Dr. Franklin: Yes. So this molecular signature has a number of advantages. So at this point, the most exciting use of it is that we actually can predict at this point, and we've done this to 10 patients so far, we can predict whether or not they will actually recover from having an LVAD implanted in their chest. And so initially, just having a unique signature, we can kind of think of something similar like a fingerprint. So a fingerprint is made up of many different lines and curves that altogether make a very unique signature that is unique for one individual.

But we can take this molecular signature at the protein level and really identify who will respond and how to these therapies. So initially, there's a predictive power here. But the other advantages of this signature is that by looking at the individual proteins, we can try to understand at a knowledge level what is happening in these hearts. How are they failing? What's the difference between those that can recover and not recover? And how are those specifically involved in the function of physiology of the heart?

So on a knowledge level, we get to understand much more about heart disease and that can allow us to even create better therapies, by targeting maybe specific proteins or pathways.

Interviewer: So when you compare the molecular signatures of those who will just recover and those who won't, how large are these differences? Are there subtle differences, or is it really a striking difference between the two?

Dr. Franklin: So we initially look at thousands of phosphorylated proteins. But our goal has been to create the smallest panel possible that still allows us or gives us predictive power. And so we've reduced this panel down to about 24 phosphorylated proteins that allow us to distinguish between patients who will recover and those that won't.

Interviewer: One thing I wanted to bring out is something that we talked about earlier that instead of you going in with a preconceived notion of what might be different between these patients, you're letting the heart tell you what's different, so it's an unbiased study. Why is that important?

Dr. Franklin: We love mass spectrometry. It's one of the things that we get giddy about in the lab. We have lots of experience with mass spectrometry and proteomics, but we love the fact that it is an unbiased technique. We don't say beforehand we're only interested in this protein or only interested in this pathway, which in some areas can be helpful or in some labs is useful.

But we are really excited about the fact that we can go in unbiasedly and say we have no preconceived notions about what we may find. But we are going to apply this technique that will allow us to just sit back and have the heart tell us what's happening, tell us what proteins are being involved in this disease process. Have the list of proteins that are likely involved, identified through this technique as opposed to us picking or choosing what might be involved beforehand.

One of the things that I get really excited about is how impactful this study could be. As I mentioned, we're in the early stages but I can only imagine if you were in a patient's shoes, if you were the one that was having to make the choice of whether or not to have the LVAD surgery or to try and hold that longer for heart transplant, or where you might actually be listed on that heart transplant list. I can only imagine that that could be really stressful time in your life having to make those decisions.

And our hope is that we'll be able to provide more information or alternatives to actually helping us figure out who would benefit from an LVAD implantation or maybe provide additional information to influence where someone may be on a heart transplant list. And so really the idea of personalized medicine or helping the individual person and having information that would directly impact their specific situation is really what we're striving to do.

Announcer: Discover how the research of today will affect you tomorrow. The Science and Research Show is on The Scope.

Interviewer: Treating chronic thromboembolic pulmonary hypertension, also known as CTEPH. We're going to find out more about that surgery next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: You've been diagnosed with CTEPH and we've already learned about the condition, its symptoms, and stuff like that in our earlier podcast. But today, we want to talk about the surgery that treats it. Dr. Craig Selzman is a heart surgeon and one of the directors of the Chronic Thromboembolic Pulmonary Hypertension Program at University of Utah Health Care. So in case somebody didn't hear the first podcast, just briefly sum up what's going in the heart that causes this disease?

Dr. Selzman: It's actually, believe it or not, it's in the lungs and so the lungs are sandwiched between the right side of the heart and the left side of the heart. And so what CTEPH is, we'll just call it CTEPH, it is a form of what we call pulmonary artery hypertension. So pulmonary artery hypertension is high blood pressure in the pulmonary circulation. And there are a number of causes for it for which CTEPH is one of them.

This particular situation is a form of PAH, pulmonary artery hypertension, that is related to having blood clots that come from your legs or the lower extremities usually and get lodged into the lungs. We call that a pulmonary embolism. It's very highly morbid, causes a lot of problems, and it's lethal. It's one of several leading causes of cardiopulmonary death that can happen acutely.

And so what happens also inside the lungs is that the lungs actually start to remodel. You could almost imagine like you have some stuff in your sink and it gets into drains and it's kind of there, but you could imagine that a year or two later, it kind of forms and becomes part of the wall of the pipes. And that's what's happening inside your lungs and it becomes very hard for them to do their job, which is to take in oxygen and get rid of carbon dioxide.

Interviewer: So then over time, is it the stiffness that's causing that problem, that build-up of stuff in there that's causing the stiffness?

Dr. Selzman: That's right. We want our lungs, you know, you want your lungs to look like the sponge that you just bought out of the store. You open it up, it's this very light, airy, and it's just . . . you could kick it and it would maybe go up in the air, but it's not this heavy wet sponge that you've just finished cleaning the dishes with. That's what you want your lungs to look like. And you want all those little holes because all those little holes allow oxygen to go back and forth. But if you don't have good blood vessels that go to all those little holes, all of the ability of your lungs to do that work become compromised.

Interviewer: So during this surgery, what do you do to fix it when you go in there?

Dr. Selzman: So believe it or not, this is a roto-rooter operation. What we do is we have to do this, it's a major heart operation in the sense that we have to open up your breastbone. We do have to open up the pulmonary arteries. And then what we do is we open up the pulmonary artery and we actually peel out the inner layer of the blood vessel wall.

And so, sometimes, there's actual blood clot that you remove, but it's not really just the blood clot. It's you have this really thick rind that's layering out along the blood vessel wall and you have to remove this whole rind in order to allow the blood flow to get out to the periphery of the lung where it does all of its work. In order to do this, it's a major operation, you have to go on the heart-lung machine.

We actually have to take the body temperature very low because there's a lot of blood that gets in the way when you're doing this and so you need to be able to see. And so, sometimes, we actually have to even turn the circulation of the patient off and the only way to do that is to take the blood temperature very, very low to protect the brain and other organs. So it's not something that we take lightly. It's a very relatively conceptually, straightforward operation but has some pitfalls if you don't do a lot.

Interviewer: How long does it take for an average for you to do the procedure?

Dr. Selzman: Probably three to six hours.

Interviewer: Okay.

Dr. Selzman: And a lot of that time, the nitty-gritty work is actually only maybe less than an hour, but the prep time to get ready and to take the temperature down and then to bring it back up, it does take some time.

Interviewer: And you're able to go in and get most of that, if not all of that, usually cleared out?

Dr. Selzman: We are fortunate because we have really good preoperative testing so it might be that all of the lung is affected, but sometimes, it'll be just half the lung or, you know, three-quarters of the right lung and two-thirds of the left lung. And so we can kind of target that.

There are some disease processes with these pulmonary embolisms and the CTEPH that is stuff that we cannot fix. And that is the stuff that gets way, way deep out into the periphery of the lung and we just physically can't do it. When people have pulmonary hypertension related to that kind of disease, there' really only one out outside of medical therapy and that would the lung transplantation.

Interviewer: Got you. So I think you just answered who makes a good surgery candidate. If it's affecting the outside part of your lungs not so much, but if it's more in the main part.

Dr. Selzman: Yeah, I think that's a good way of thinking about it, you know, from a technical aspect. The more proximal or the less further out into the periphery defines some of the patients that we would just not even think about doing.

Interviewer: Got you. What kind of preparation does the patient go through leading up to it? Is it just typical surgery preparation, you just want to be healthy?

Dr. Selzman: Yeah. Unfortunately, you know, some of these patients aren't so healthy.

Interviewer: Because they have a hard time breathing, right? Which makes it hard to exercise and move.

Dr. Selzman: Exactly. And, you know, and also risk factors, which led them to have developed blood clots in their legs. You know, it's sometimes the blood clot is the classic traveler across country on an airplane and they're not moving their legs and they get the blood clot in the leg and then they later that day they walk around and then they get acutely short of breath and they might not even know that they had something happen.

As a matter of fact, about 40% of patients that have pulmonary embolism don't even know that they have it and a lot of CTEPH comes without an antecedent diagnosis of pulmonary embolism. And it's just something that happened that nobody . . . you just didn't know you had it. It's kind of like the silent heart attack. "Oh, I didn't know I had a heart attack, doc." It's the same kind of thing. "I didn't know I had a pulmonary embolism, doc." And so that can happen and it can be kind of very sublime, if you will, the development of the disease.

Interviewer: Got you. And then what's the recovery time look like after the procedure normally?

Dr. Selzman: Usually, in the intensive care unit for two or three days and then up on the floor for several days. Everybody is a little bit different how they do this. In the more severe cases, you can actually be in the hospital for several weeks because there's part of the lungs that aren't used to having seen blood flow and we acutely remove this stuff and then we get what's called reperfusion injury, which means of the lungs which hadn't had a lot of blood flow all of a sudden gets this rush of blood that comes to it. And that's called reperfusion and sometimes that can be very troublesome to deal with.

And so, yeah, this is not an easy physiologic process for the patient. I mean, the lungs are going through a lot of stuff. Obviously, it's very central and core, you know, heart and lungs. And so, you know, if the lungs are working good, then the heart works good. But if the lungs aren't working good, then it affects the heart and it can be a problem.

Interviewer: So you're taking a little bit of time off from work?

Dr. Selzman: Oh, yeah.

Interviewer: Probably.

Dr. Selzman: This is a major heart operation, but the cool thing about this as, you know, as big as of a procedure as it is, we just have some great stories that come back. I mean, you see these people that are on oxygen at home and then two weeks after surgery, they come and see you in clinic and they're off of oxygen and they say that, "Wow. I haven't been able to take a deep breath like this in years." And then you see them a year later and they're just so thankful because they can breathe because we see this in lung transplant.

You know, at the University of Utah, we're kind of lucky because we're one of the, we're really the only lung transplant center in the entire region. You know, you have to go to Denver or Phoenix or in California. And so we see great stories and when you see people that can't breathe, you know, just imagine you're down swimming and you're underwater. I mean, that's what these people are. And so when you allow the folks to actually take a deep breath and also the plastic hose of the oxygen just gets really old. And so it can be an incredibly gratifying thing to do for a patient.

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Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: The current medical guidelines for systolic blood pressure are between 140 to 150 but new research indicates that reducing that to 120 can drastically reduce the chance of heart disease and death for adults 75 or older even if they are considered frail elderly. Dr. Mark Supiano is a geriatrician and the executive director of the University of Utah Center on Aging. This study, is this a new revelation that lower could be better with systolic blood pressure especially for elderly adults?

Dr. Supiano: Yes, Scott. This is exciting new information that came out of the systolic blood pressure intervention trial otherwise known as SPRINT. The trial ended late in 2015, earlier than anticipated because of these very dramatic benefits.

Interviewer: When it initially ended early, a lot of people speculated that that meant bad news but it actually meant quite the opposite.

Dr. Supiano: Yes and particularly for the 28% of the SPRINT subjects who are over the age of 75 there were some concerns, myself and other geriatricians, that the very intensive systolic blood pressure target of 120 might not be safe for older people. When we first got news of the trial ending early I first thought that it was possible that older people had more side effects or more injurious falls or other complications of the very low blood pressure and that was why the data safety monitoring board might have ended the study early. In fact, the results were just the opposite.

Interviewer: Like a revelation almost it seems like.

Dr. Supiano: It really was a surprise to be honest. Not so much as a surprise that the benefit but the surprise that the benefit was of this magnitude and that this occurred this early on on the trial.

Interviewer: So the current guidelines are between 140-150. This study points out that 120 can drastically reduce the chance of heart disease and death. How drastic are we talking?

Dr. Supiano: I'll focus on the population 75 and older as I said, this is 28% of the SPRINT cohort and in that group there was a 33% reduction in the cardiovascular outcomes. This is primarily a myocardial infarction or heart attack or congestive heart failure and stroke and then in addition overall reduction of 32% in mortality.

Interviewer: That's pretty substantial.

Dr. Supiano: It is. To be honest there are very few treatments I can recommend for people over the age 75 that can have this dramatic impact on those outcomes.

Interviewer: So if you're going to do one thing, according to the study so far, it would be try to get that blood pressure down to 120. Now, does that mean taking medication? Does that mean lifestyle changes?

Dr. Supiano: All of the above. On average, the people in the intensive group who are managed to a blood pressure of 120 or taking one additional anti-hyperintensive medication relative to people on the standard arm.

Interviewer: Of course your eyes looking at the risk benefits and something like this. So the benefits are tremendous. Are there risks?

Dr. Supiano: Absolutely. The good news was, and again focusing on those 75 and older population, our major concern would have been there were higher rates of injurious falls or what's called orthostatic blood pressure - a reduction of blood pressure when the people first stand up and get light headed or dizzy. First, there was no increase in serious adverse events between the intensive and the standard arm. Second, and again very reassuring, there was no high rate injurious falls in the intensive group, nor were there serious rates in the intensive group. The intensive group did have higher rates of low blood pressure, of electrolyte abnormalities, largely low sodium levels which was to be expected because of the medications that were used and some other adverse events. But when we weigh though over the benefit of preventing heart attack, stroke, heart failure and death, most believe that those benefits outweigh those risks.

Interviewer: That number of 120, can you go lower than that and get more benefits or is there a point where no?

Dr. Supiano: That would be another study. And it's important to point out the one on average for 75 and older group achieve of systolic blood pressure of just under 122. That meant that half the people had a systolic blood pressure above 122. So 120 maybe recommended as a target blood pressure. That doesn't mean everyone is going to get there. Nor does it mean that the benefit won't accrue if you don't get exactly to that target. I think the take home message is, it seems to be that the lower, the better.

Interviewer: So is this something that if somebody does fall under this group or somebody has a grandparent or parent that's in this group that you would recommend that they go to their doctor and say, "I would like to try for a blood pressure of 120"? Because this isn't the guideline yet.

Dr. Supiano: So important point, the guidelines are being written down or likely incorporate this new information but those guidelines won't be out until later this summer. Even with that guideline, like everything we do in medicine and particularly in geriatric medicine we have to be patient-centric. So we need to weigh someone's benefits and risk of their elevated blood pressure and incorporate that those at greater risk are likely to have greater benefit. So it needs to be an informed decision with patient who discussed the pros and cons and determine their level of interest in trying to achieve this lower target and recognize those benefits.

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Interviewer: You have chest pain, but you don't think it's probably a heart issue, what could that be? Well, we're going to examine that next on The Scope.

Announcer: This is "From the Frontlines with Emergency Room Physician Dr. Troy Madsen" on The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health, and Dr. Madsen, sometimes I get this thing on my left side of my chest. I don't think it ever happens on the right, but it feels like there's a lot of pressure in there. It feels like a bubble, like an air bubble maybe. It's difficult for me to take a deep breath. And it'll either just go away, or if I can take a deep enough breath, it feels like it pops. What could that possibly be? I hope I haven't been having heart attacks this whole time.

Dr. Madsen: I hope you haven't. This is a very common question I get in the ER, and I may see over the course of the shift maybe even a couple of people, like yourself, who have this exact same question. So in my mind, of course, I'm thinking, "Okay. I've got to make sure it's nothing serious." So I would ask you about, do you have any risk factors for heart disease, any risk factors for blood clots in your lungs? So those are number one and two I'm thinking about. Have you had any recent surgery or anytime you just haven't been moving a lot where you could have formed a clot that went to your lungs?

But what you're describing doesn't sound much like either of those things. I might do some basic tests to make sure things are okay there. But once we rule out the more serious things, and I start to think about other things that often cause chest pain. And probably one of the most common things is acid reflux. People get acid reflux, acid that's working it's way up from the stomach through the esophagus into that food tube that runs down your chest, and that can oftentimes cause a feeling like maybe a bubble in your chest. Most people describe it as a burning sensation there, maybe a bitter taste in the back of their mouth.

Another thing we see often is something called costochondritis. And that's an inflammation in the cartilage where the ribs come and they meet the sternum. So the breast bone there, where they come together there, that that can get inflamed either from sometimes a viral infection, or just from maybe overuse, or maybe even you've been twisting wrong, and that causes some inflammation that can cause some pain.

Sometimes, you can get what we call pleuritis, where you get inflammation along the lining of the lungs. And that can cause, again, some chest pain in there that sometimes worse when you take a deep breath. But with your symptoms, if I had to say it's anything, I would lean more toward maybe some reflux, that feeling like a bubble in there.

Interviewer: I was thinking that's about as close, but it's not in the center. It's always off to the side, like up in this area. And it tends to be pretty consistent to where it will develop when it develops.

Dr. Madsen: Yeah interesting.

Interviewer: And it freaks my wife out a little bit when I'm like, "Oh, oh." And I try to take that deep breath and I can't, because there's that catch or something there.

Dr. Madsen: And sometimes you can, in your back, you can have some muscle spasm. You've got muscles between your ribs. Sometimes you could get maybe some muscles spasm or some inflammation between the ribs. That could cause, possibly, something that comes and goes like that, especially where it's worse when you take a deep breath. The reality with chest pain is, I tell patients, "Hey, once we've ruled out the bad stuff, it could be any of a number of things. It could be reflux. It could be the costochondritis. It could be some muscle thing, some inflammation there.

There's not a lot I'm going to do differently for these things. Maybe try some acid medications, some stomach medication for the reflux. Try some ibuprofen for some of these other things. And so I wouldn't worry about it. I don't want to tell you that now, I know you are going to have a heart attack just [Inaudible 00:03:36]

Interviewer: Well, I was going to say, this could point probably at this point two things. One, I'm going to pay attention next time and see maybe if I feel that it is acid reflux. Because sometimes just realizing what it could be makes you visualize it differently.

Dr. Madsen: Exactly.

Interviewer: Maybe that is indeed what it is. And then the second thing that I want to do right now is the importance of if you do feel like you are having a heart attack that you should go to the ER. And are there some very specific symptoms of that?

Dr. Madsen: Absolutely, yeah, and that becomes the challenging thing because the reality is if I were to see you in the ER, I'd probably at least do a couple tests. I'd probably do a chest X-ray just to look at your lungs, look at your heart size, make sure everything is normal there. I would do an EKG, just a basic test on your heart, to make sure the electrical activity looks normal, make sure I'm not seeing anything unusual there.

But the biggest things with heart attacks are people describe it as a crushing chest pain, like someone sitting on their chest. They say when they go upstairs or they try to walk, the chest pain is much worse, or they get short of breath. And they feel pain up their neck or down their arm. They feel sweaty, nausea, but it's challenging, because certain groups of patients like women, people with diabetes, sometimes older patients have really unusual symptoms. Some of them may just have some abdominal pain or just shortness of breath.

So it is a little bit of a challenge. If you have risk factors for heart disease, like high blood pressure, or high cholesterol, smoking, family history, these are all things where even just some kind of unusual chest pain like you're describing might be a reason to, if nothing else, at least see your doctor and get things checked out there.

Interviewer: Especially if it doesn't go away right away?

Dr. Madsen: Absolutely, yeah.

Interviewer: What about the pulse? Does the pulse increase if you are having a heart attack, or could the pulse stay at a resting heart rate?

Dr. Madsen: I've seen both. I've seen people come in with heart attacks who do have a high heart rate. I've certainly seen other people who come in and say, "Yeah, I'm having this crushing chest pain." But you look at their heart rate and it's normal.

Interviewer: So just it doesn't really manifest itself in any one way for any certain person, it sounds like? It's very unique. At least it could be.

Dr. Madsen: Yeah, and some people with heart attacks are on medication that slows their heart down so that affects it too when I see those patients.

Interviewer: So when in doubt, go see somebody.

Dr. Madsen: Yeah, chest pain is one of those things . . . it's tough. You want to take it seriously. Ninety-five percent of the time, people we see with chest pain, all the testing is normal, at least 90 percent of the time it is. But that 10 percent or 5 percent, you don't want to mess around with those things.

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updated: June 12, 2018
originally published: May 27, 2016