Qualy #82 - What is the most common first presentation of heart disease？
Episode Stats
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Summary
In this episode of the Qualies, Dr. Peter M. D. Schiller, a cardiologist at the American Heart Association, joins Dr. Kelly to discuss heart disease and the silent killer, atherosclerosis. Dr. Diller is a professor of cardiology at Rush University Medical Center and a cardiology professor at the University of Toronto, specializing in coronary artery disease. He is the author of several books on heart disease, including The Silent Killer: The Untold Story of the Silent Killer, and he is a frequent contributor to the Journal of Heart Disease.
Transcript
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welcome to the qualies a subscriber exclusive podcast qualies is just a shorthand slang for
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a qualification round which is something you do prior to the race just a little bit quicker
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subscribe so without further delay i hope you enjoy today's quali now when i was in medical school i
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remember in first year pathology lecture the pathologist said let's see a show of hands what
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is the most common first presentation of heart disease and you know everybody puts up their hands
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sentences a chest pain left shoulder pain shortness of breath and he said no no no no no it's sudden
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death yeah that was a little over 20 years ago is that still true today the estimates i've heard and
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i and i think this this is arguable because these are really rough rule of thumb calculations somewhere
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in the range of 30 percent possibly upwards of 30 percent which is still a huge number it's staggering
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it means that one third of people's first brush with the knowledge that they have atherosclerosis
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is death and i have patients and i'm sure you do as well who have died and come back and so there is
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this process where there's an acute event that causes an irreversible change but for some people
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fortunately we can bring them back but together that represents really the basis for calling this
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disease the silent killer because as you were saying we don't in those patients have
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premonitory symptoms sometimes in retrospect they are there and i think that's the important reason
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for educating the public as organizations like the american heart association does as to the first
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signs of heart disease because it may be and it probably is true that a significant component of that
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30 percent right upon further querying there was some exercise intolerance didn't recognize it yeah and
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it's very hard sometimes one of the things that we'll be talking about is ways of assessing
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risk and those are still imperfect and we can't with 100 certainty use any kind of risk predictor to
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know if somebody's destined to have a heart attack with certainty yeah you said something at the outset
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which is this is a disease that begins in infancy and i i one of the i have very few textbooks and or
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papers that are i refer to so frequently that they actually sit on my desk in my office so that every
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time i'm with a patient i can pull them out but one of them was a book that was given to me by one of
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my mentors i consider you a great mentor tom dayspring a great mentor alan snyderman a great
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mentor and alan gave me this textbook of pathology i think believe it's starry is the uh the author
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and while i believe the data uh represented there are somewhat dated because it was largely based on
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the vietnam cohort and and koreans yes where obviously smoking would have been a higher prevalence
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than today right the fact remains that when you look at autopsies of young people who died of
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unrelated reasons homicides accidents etc and you look at the histologic sections of their coronary
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arteries it's amazing how many of them have lesions that are type 3 or beyond type 3 meaning
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obviously a type of pathological region where you go beyond fatty street yes indeed that's right so a
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subset of these youths will have more advanced lesions and the studies that have been done have
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linked all of the usual risk factors uh smoking uh certainly diabetes hypertension uh and and
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dyslipidemia all of and a lipid disorder all of those uh have been associated with the more advanced
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uh lesions in in those individuals so as you're pointing out even even a more significant plaque
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development can occur in childhood i think the thing that's hard for people to understand uh and i think
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it's true of most chronic diseases but i don't think any disease in any disease it is as clear
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as it is with atherosclerosis which is the compounding nature of the disease you know another
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great example of one of those questions that the professor asks that gets everybody stumped which
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is what's the greatest risk for heart disease you know is it smoking nope is it high blood pressure
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nope is it dyslipidemia nope it's age that's right it's age i mean and why is it age because it's
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exposure it's time it's area under the curve yeah that's exactly true you know age regrettably is
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a risk factor that cuts across uh many of the diseases chronic diseases that we have to deal with
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cancer for example uh and yeah that's right it's a cumulative process that can progress at various
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rates depending uh the condition so people as you know when we talk about who have genetically
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elevated severely elevated cholesterol levels will have that process accelerate and have the disease
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who are clinically early on sometimes with these severe genetic disorders and the teens whereas
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others most of the population fortunately who do have risk factors show a gradual increase in the
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manifestation of disease as a result of those risk factors as a function of their age you know at
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last check and i can't remember if it was jama or another journal but it was about a year ago and they
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looked at some actuarial data for people out through being past centenarians and the only disease
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once you normalized for a few things the only disease that increased monotonically by decade
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in risk was atherosclerosis from childhood yeah even cancer actually you know i think by the ninth
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decade it started to come down i see yeah yeah yeah you know it's right no it's definitely different
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the latency period for cancer also uh is a factor there as well so there's this sort of latency period
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where nothing happens and all of a sudden in the older age it pops up i hope you enjoyed today's
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