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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

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

Interviewer: CTEPH is a hard to diagnose disease that about one in 1,000 people will develop. And because it is relatively rare, many patients and even doctors haven't heard of it. The symptoms can easily be confused with other diseases and what makes it even harder to detect is many people don't have any symptoms or the symptoms that they do have are mistaken for other illnesses. Dr. John Ryan is a cardiologist, one of the directors of the Chronic Thromboembolic Pulmonary Hypertension Program at University of Utah Healthcare. So it's so hard to diagnose, how do people even find out they have the disease.

Dr. Ryan: No, it's really tough. So it is, as you describe, Chronic Thromboembolic Pulmonary Hypertension so it is a cause of pulmonary hypertension. Pulmonary hypertension is elevated pressures in the lungs. So, oftentimes, if people are short of breath, if they're fatigue, if they have some leg swelling, they might get an ultrasound of their heart, and then that might show that they have high pressures in their lungs. And that's where the pulmonary hypertension is.

So then, when you look at the causes of pulmonary hypertension, a lot of pulmonary hypertension is caused by problems with the heart, a lot of it is caused by problems with the airways, such as emphysema, COPD. Some of it is caused by exposures to things such as methamphetamines. And rarely, within pulmonary hypertension, you can have it caused by chronic thromboembolic disease or chronic pulmonary embolisms.

The reason this is complicated is because some people won't know that they've had a previous pulmonary embolism. So if we want to talk about pulmonary embolisms, because I think that will be the first thing to talk about and then we can go into the chronic pulmonary embolism or chronic thromboembolic pulmonary hypertension, the abbreviation for this is CTEPH. So pulmonary emboli are common and pulmonary embolism is common, you have a clot in the lungs.

A lot of folks will have family members who have this, sometimes they themselves have had it. It can happen after a hip replacement, it can happen after a long-haul flight, which is something that you've come across before, and that's where you have a clot in your lungs. In 97% of people who have clots in their lungs, that's a classical way they head back to their regular everyday life.

In 3% of people, that's not the case. In 3% of people, they end up with this chronic pulmonary embolism, which can either be recurrent pulmonary embolisms, so they have one and they have another and another. Or it can be that the clot doesn't actually go away. Whereas, 97% of the time, the clot dissolves. In 3% of people who have pulmonary embolisms, the clot may not dissolve and therefore, they're left with this blockage in their pulmonary vasculature.

The analogy I kind of give among other analogies, which at least people humor me and tell that my analogies are very good, but the analogy that I give here is that a clot in your lung is like a car crash on the freeway. All the blood flow stops. And then, eventually, the crash gets cleared. In chronic thromboembolic pulmonary hypertension, that crash does not fully get cleared, you're instead of having four lanes, you're now down to one lane. So you end up with just this one trickle amount of blood going through because the clot has never gone away. Or the vessel has changed in response to that clot and folks get short of breath.

However, what makes it hard, and the thing you've asked me in the beginning about, you know, why is this so hard to pick up, what makes this hard is, first of all, it is in . . . of all the causes of pulmonary hypertension, it's least common. Fifty percent of people who have it don't know that they had a blot clot sometime in their life. They think this was never picked up or it was missed clinically.

But the importance of it is that it is a curable form of pulmonary hypertension so you can get treatment. And that's what our program specializes in here. We specialize in the management, the surgical and medical management of chronic thromboembolic pulmonary hypertension. We're the only program to do that in the [Inaudible 00:04:03], one of the few programs in the country. And you can, again, cure people of their disease by medically managing this or surgically managing this, most particularly. And that's a pretty positive thing.

Interviewer: I'm still confused as to how I would know that I had it. I guess the first thing is . . .

Dr. Ryan: The first thing you'd be short of breath. You'd be short of breath with fatigues.

Interviewer: Those symptoms, yeah.

Dr. Ryan: So you'd have symptoms similar to heart failure. The symptoms themselves are not that dissimilar to heart failure. And then at some [inaudible 00:04:29] along the line, someone will do an ultrasound of your heart and they would do an echocardiogram. And on the echocardiogram, you would see that the pressures in your lungs are high.

Interviewer: Okay.

Dr. Ryan: So then you have pulmonary hypertension. And then, as a workup for pulmonary hypertension, people look to see, did you ever have any blood clots, either by asking you specifically or there are some scans that you can do on the lungs to see if there are any signs of old blood clots.

Interviewer: So you can actually see those also?

Dr. Ryan: Yeah.

Interviewer: So it's a little bit of a detective game that you've got going on.

Dr. Ryan: It is, yeah. I mean when you have the diagnosis, first of all, when you have a diagnosis of shortness of breath or when you have a diagnosis of fatigue, that's obviously, as you alluded to, when the detective game starts. And then, once you get diagnosed with pulmonary hypertension, then you start looking into the different cause of pulmonary hypertension. So a lot of these are going on all at the same time.

When you have pulmonary hypertension, people start looking, it is caused by the heart, it is caused by the lungs, it is caused by the airways, it is caused by the vessels in the lungs, it is caused by clots. So all of these things are being looked at, at the same time. And then, if you find that there are clots in the lungs that have never gone away, in some regards it's almost kind of a eureka moment. You've found the cause of this pulmonary hypertension and now you can treat it.

Interviewer: So if you continue to have these symptoms and they're not just going away and you've received treatments for other forms of pulmonary hypertension, then that's when you consider, "I could be in this 3%."

Dr. Ryan: Yeah. Hopefully, before you get treatment of your pulmonary hypertension, people have figured out what type of pulmonary hypertension you have. The analogy that we use for this is pulmonary hypertension, in many regards, is similar to cancer. There are lots of different types of cancer. There are lots of different types of pulmonary hypertension. We don't treat all cancer types the same. Bowel cancer is very different to leukemia, say, and so on. So that's the same idea that we do with pulmonary hypertension. You find the cause of pulmonary hypertension, then you treat it.

Now that being said, of the people who have pulmonary hypertension, 1% of them will have chronic thromboembolic pulmonary hypertension so it's the least common form of pulmonary hypertension. That being said, it's the most curable form or pulmonary hypertension. So in some programs, in some practices, we'll guess and you can be . . . you're right, 90% of the time or 99% of the time, you might be right. But if you or me are that 1% who don't have these other forms of diseases, then you're getting the wrong treatment.

Interviewer: Got you. And you said surgery is the treatment?

Dr. Ryan: Yeah.

Interviewer: How effective is it?

Dr. Ryan: Surgery is the cure. Yeah, so it's really rewarding that you can go from being very debilitated, very short of breath, very fatigued, not able to do the things you want to do, and you undergo a major surgery. It's an open heart or open lung surgery where the clots in the lungs are removed and you're on bypass. Your chest is opened and the clots in the lungs removed and that changes the blood vessels are fixed. And then you come to the ICU afterward, you come to the floor after being in the ICU, you enter into a rehab program. But down the road, you'd then do very, very well and you go from being very, very sick to essentially having a normal life expectancy and doing very well.

Interviewer: Are there consequences for not treating?

Dr. Ryan: The disease progresses without treating so you got sicker. The strain on your heart gets worse and, ultimately, the heart can go into heart failure, which is what drives a lot of the symptoms. And then, of course, you can have future PEs as well, or future pulmonary embolisms on top of it. So you can have your disease and then have another pulmonary embolism. So those are kind of the consequences of not treating it.

Interviewer: Any final thoughts for somebody that's experiencing these symptoms and thinks they might have it?

Dr. Ryan: Yeah, so two things. One, surgery isn't actually for everyone. There are some people who, even in 2017, still have inoperable forms of chronic thromboembolic disease. That doesn't mean you're out of options, it just means surgery, right now, is not an option for you. But there are other medicines available that can help you do better. They're not a cure, but they can help you do better.

And so I think the main thing is to ask your doctors, "Do you need to look to see if this is blood clots?" Again, oftentimes, as I said, people don't look fresh. It's rare, it's uncommon, there are much more common causes and people don't know that they have blood clots. I think people also assume that they would know if they had blood clots, that you and I would know if we have blood clots. So I think it's worth asking your doctor, "Did you check for blood clots." And this is an easy, straightforward, low-cost test.

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Interviewer: The Super Bowl and heart attacks: is there really a risk? We are going to find out from cardiologist Dr. John Ryan, next on The Scope.

Dr. Ryan, I've seen news stories, I'm sure our listeners have seen news stories, I even did a Google search because the thought of somebody having a heart attack during the Super Bowl seems kind of crazy to me. Really, does this happen? Is it a common thing or a rare thing? But there's some research out there that says that it really is possible. Is that true?

Dr. Ryan: Yeah, so it is a recognized risk, namely that's the Super Bowl and this has been shown in several studies the time of the Super Bowl is a high-risk time for heart attacks or a higher risk time for heart attacks. It's also been shown in the World Cup, in the soccer World Cup, there has also been shown that there is a higher risk of heart attacks around this time. It seems, in particular, in cities hosting the Super Bowl and in the cities whose teams are playing in the Super Bowl it seems to be higher. So when there's an investment in the game, it does seem to be higher as opposed to other cities that either aren't hosting or don't actually actively have a team in the Super Bowl. And this is, again, the same with the World Cup.

However, when you look at the people who have heart attacks during the Super Bowl, they're already at higher risk of having heart attacks. So they are typically folks who have high blood pressure, maybe a history of heart disease, a history of smoking, a history of high cholesterol, and then the stress and circumstances surrounding the Super Bowl event can be a trigger towards that cardiac event.

Interviewer: So if you've been told by your doctor that you are at a high risk of a heart attack and your lifestyle kind of reflects that, would it be the equivalent of going out and trying to run a marathon?

Dr. Ryan: Yeah. That's a good analogy, yeah, that's a good analogy.

Interviewer: Because I don't think that people watching the Super Bowl and having some wings and beer would be like running a long-distance race.

Dr. Ryan: Yeah, that's a good analogy. Again, it's all about you're introducing more stress onto your cardiovascular system and into your life and what are the consequences of that stress. One of those consequences of that stress is an increased risk of having a heart attack. So, a lot of times, it's just about stress management and how you deal with stress as well as you've rightly pointed out, it's risk factor modification.

When you look at heart disease in general, it's all about risk factor modification, eating better, not smoking, not drinking as much alcohol, and not getting dehydrated. And these are all things that happen in or around the time of Super Bowl or college game day or workups. When folks bring this up, I talk about my father, during Ireland rugby games, will sit outside in the garden and then when the game is over, he will come in and ask what the result of the game was. And that's his way of modifying his risk. So it's a matter of modifying your risk. Thanks, Dad.

Interviewer: And, as a result, he's been there for you all these years.

Dr. Ryan: Exactly. Exactly.

Interviewer: So if you're worried that you're going to have a heart attack leading into the Super Bowl, you probably need to take a bigger look at . . .

Dr. Ryan: Figure out your coping mechanisms, figure out your stress, what you do for stress and what you're doing for your risk factor modification with your heart disease.

updated: February 9, 2022
originally published: February 3, 2016

Interviewer: How e-cigarettes affect your heart and it's not in a good way, and it might not be better than smoking after all. We're going to find out more about that next with cardiologist, Dr. John Ryan on The Scope.

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

Before we get into the conversation about e-cigarettes and how they affect your heart health, I think it's important that we say that cigarettes and e-cigarettes are linked to many different health problems. But today, we're just focusing on one particular and that's issues related to the heart. So, Dr. Ryan, how do e-cigarettes affect a person's heart health and are the threats real?

Dr. Ryan: I think the threats are real. I think the concerns are legitimate. One particular concern with e-cigarettes is that it's really re-normalizing cigarette smoking, nicotine consumption, and tobacco use within North America. Some of it, the science is uncertain. We are not sure of the long-term effects of e-cigarettes, either on heart or lung disease. And then legitimate concerns get raised because of this chronic exposure to nicotine, chronic and also varying exposure to nicotine. One of the particular issues there seems to be marked variation in how much nicotine is being consumed with each vape.

Interviewer: Because when you get the little vapor things, it tells you how many milligrams per whatever, but that's not regulated so we don't know if that's accurate or not.

Dr. Ryan: Exactly. And the anticipated is .05 is what's often quoted. It can really range up to 15 whereas where your cigarettes would be about two to three. So in that regard, there's variation there that's concerning. Also, some of the physiologic effects that e-cigarettes and nicotine consumption, in general, are concerning, in particular, high blood pressure, fast heart rate, endothelial dysfunction, which is the lining of the blood vessels of the heart, in particular, which can be a trigger for atherosclerosis and coronary artery disease.

And all of these things are affected by the nicotine consumption and, in particular, by the e-cigarette nicotine consumption as well as other chemicals that are in the e-cigarettes. And as you rightly pointed out, the regulation of this is difficult and not as robust as many physicians and scientists would like. And that just raises further concerns.

Interviewer: So you mentioned a lot of different bad things that can happen from e-cigarettes, and it's related to nicotine primarily, the raising your heart rate, the blood pressure, your blood vessels narrowing, high risk of hardening of the arteries. What does that do, then, that causes heart failure or heart attack or stroke?

Dr. Ryan: So a lot of it we don't know, first of all. That specifically raises concerns, but the issues, in particular, that are raised with high blood pressure, with fast heart rates, with narrowing of the blood vessels of the heart, the coronary arteries, as you mentioned, this puts extra strain on the heart. The heart obviously depends on blood flow in order to get oxygen, and in the setting of high blood pressure, fast heart rate, decreased vessel size, you do raise the risk of having a heart attack.

So the essential concern, in particular, is for heart attacks, that the use of nicotine, e-cigarettes, and cigarettes raises your risk of having a heart attack. And also, it's not necessary, and that's where I got back to the normalization of tobacco consumption and nicotine consumption within North America. This is not a necessary thing that we need to do. This distinguishes it from . . . and there's controversy of this as well, but diet consumption, fat consumption, etc. However, we do need to eat. We don't need to smoke and we don't need to vape.

Interviewer: So for sure, we know nicotine causes these negative effects to the heart.

Dr. Ryan: Exactly.

Interviewer: What about the other chemicals, like . . . I've heard the flavoring chemicals. Even if you're getting the dose without the nicotine, they've found that it can cause other diseases.

Dr. Ryan: Yeah, so the flavoring has recently been associated with what's called popcorn lung or bronchiolitis obliterans, which is a form of inflammatory and fibrotic lung disease. The reason this raises concerns is, first of all, lung disease, therefore, puts a strain on your heart. And secondly, if there's chronic inflammation, which we see in the setting of poor air quality and stress, it can result in triggering heart attacks or heart disease. So I think there are two main concerns with the chemicals that you bring up in terms of e-cigarettes.

Interviewer: If you've got a patient that's right in front of you now that smoked e-cigarettes, how would you convince them that they shouldn't? Because a lot of people get enjoyment out of it, or it's an addictive habit that they can't stop. It takes a lot of willpower to quit.

Dr. Ryan: Being sensitive enough in terms of convincing people to do things. Ultimately, I think you have to introduce the risks associated with the disease, the risks associated with the risk factors, and hope that they make an informed, educated decision about their habits. And so I try and present to them the uncertainty about e-cigarettes. I try to present them with some of the concerns that I have about e-cigarettes and nicotine consumption in general. And then, hopefully, when they leave the clinic and when they go home, they're able to access resources themselves and make good decisions themselves and be comfortable with the decisions they're making.

Interviewer: And I think, essentially, it comes down to this is something that you don't have to do to your heart.

Dr. Ryan: Exactly, yeah. You don't have to do it to your heart. You don't have to do it to your lungs.

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.

updated: January 8, 2019
originally published: January 26, 2016

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

Interviewer: If you have chronic shortness of breath while exerting yourself or exercising, it could be a condition called dyspnea. Dr. John Ryan is the director of the new dyspnea clinic here at the University of Utah Division of Cardiology. It's one of the first clinics of its kind and currently the only one here in the Mountain West region. Tell me, dyspnea; what causes it?

Dr. Ryan: Dyspnea is, as you described, a shortness of breath on exertion. It can be driven by a lot of things. A lot of the time it's due to stiff hearts or diastolic dysfunction. Other times it's due to chronic lung disease; asthma, emphysema, bronchitis, etc. Obesity in particular can also contribute to it. Then sometimes, of course, it can be due to deconditioning.

However, most of the time that we see is a combination. People have problems with their heart and problems with their lungs and then become deconditioned, and then their shortness of breath begets more shortness of breath and begets more dyspnea. The analogy we give when people come in is that if your work life isn't going well, your home life likely won't be going well either, because everything just has a knock-on effect. Therefore, in dyspnea when you have the chronic shortness of breath in the setting with exertion, there will be knock-on effects on your heart, on your lungs, on your waist, and also, incidentally actually, on your mood as well.

So all of these things tie together and we really wanted to break down the traditional barriers in medicine which are organ-based barriers, which are incredibly artificial and evolve into a more patient-centered approach in order to figure out what it is that's going on with you and what we can do to help you.

Interviewer: And what's causing your problem.

Dr. Ryan: And what's causing your problem, specific to you rather than saying, "It's not this organ, it's not that organ," but actually say, "Listen, this is what's going on."

Interviewer: So is dyspnea hard to diagnose for a regular physician? If I went in to my physician and said, "I exercise and I get really short of breath," are they going to miss that a lot of times, or no?

Dr. Ryan: Yeah. Dyspnea is more of a symptom. It's what people describe or what they complain of. Ironing it out is not difficult, but it just takes time or takes testing to figure out what the cause is.

Interviewer: It takes an expert that knows, because there are a lot of different things that can cause it, right?

Dr. Ryan: Yeah, and it really takes an involved program as well, and a protocol. We have a protocol in terms of when people come in, what testing we recommend.

Interviewer: Who are some of the common patients that come in? Are they people that are athletes or like to exercise? You mentioned some of these rural areas. I suppose you get a lot of farmer ranchers?

Dr. Ryan: The patients that we get really vary considerably. We get a lot of young ladies in their 20s who really are thin and have previously been quite active and find themselves getting fatigued very easily. Then we get a lot of folks in their 50s and 60s who, again, similar to the farmers that you described who are just becoming very, very fatigued and aren't able to do the full days of work or are just very tired by the end of the full days of work.

I think the main thing that we're trying to move away from is a 60-year-old person who isn't able to exercise as much as they used to and telling them, "It's just because you've gotten older." So I think that shouldn't happen and that's not exactly very rewarding, either.

Interviewer: You said you can't help everybody, but for the most part do you find that people live better lives after they come to you?

Dr. Ryan: I think so, and that's our goal, that their quality of life improves. A lot of the times we try and rule out the things that will shorten their length of life, so coronary artery disease, valvular disease, pulmonary hypertension, and then once we've ruled out the things that will shorten their length of life, then we re-focus on improving their quality of life so that they are able to do more.

Most people have realistic expectations. Even your 60-year-old farmer from Idaho knows that they're not going to be able to do as much as when they were 20 or 30. So most people's expectations are realistic, it's just they want a better quality of life. I think we're doing that.

Interviewer: Are you somebody that a patient can come directly to or do they have to go to their primary care physician first?

Dr. Ryan: Folks can come to us directly. Most of the time, 90% of our patients are coming through their primary care doctor probably because dyspnea is a medical term for shortness of breath and most folks, patients themselves, don't describe dyspnea but their doctors would. So the moniker of the clinic is kind of designed that way. We do have 10% of patients self-refer or come in through other patients who've been through our clinic and liked what we did.

Interviewer: Where can somebody go to get some more info on this condition and the clinic?

Dr. Ryan: Through the University of Utah Heart website, which is heart.uofuhealth.org, and then find our dyspnea clinic through there.

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

updated: September 19, 2018
originally published: February 24, 2015