Your Heart: Why It Works & Why It Fails with Dr. Steven Nissen

Podcast Transcript

Nada Youssef: Hi, thank you for joining us. I'm your host, Nada Youssef and today we are talking to Dr. Steven Nissan, Chairman of Cardiovascular Medicine here at Cleveland Clinic, talking about your heart, how it works, why it fails. Make sure you guys send us all your questions in the comments section below so we can read it off here to our expect. As always, please keep in mind, this is for informational purposes only and is not intended to replace your own physician's advice. Thank you so much for coming in today, Dr. Nissan.

Dr. Nissan: It's great to be with you and great to be with all of you.

Nada Youssef: Great. Well, do you want to take a few minutes to introduce yourself to our viewers?

Dr. Nissan: Just a little. As you mentioned, I'm the Chairman of the Department of Cardiovascular Medicine here at the Cleveland Clinic. We're a very, very large heart center. My interests are in prevention of heart disease and in the development of new, novel treatments, but also areas like diet, which of course is very important in preventing heart disease.

Nada Youssef: Great. Well, heart disease is the number one cause of death in the United States and all around the world. Cleveland Clinic did conduct a survey and we find that Americans are very confused about their heart. Many of us are confused about the key symptoms.

I wanted to talk about the results that we have. First one is 87% of Americans wrongly believe heart attack and cardiac arrest are the same thing. Can you talk a little bit about the difference between the two and what they are and what the symptoms are for those two?

Dr. Nissan: Well, I was very surprised by this survey. Here's a disease that's the number one killer of men and women, and people don't know very much about it. A heart attack is when there is a blockage due to a blood clot in an artery that supplies blood to the heart. Part of that heart muscle then begins to die and that will cause characteristic symptoms, chest pain, often in the center of the chest, often radiating to the left arm or to both arms or up to the jaw.

It's a medical emergency for sure because we have great treatments now for stopping a heart attack in its tracks. We can get a patient, particularly if we can get them within about 90 minutes, into a heart catheterization laboratory, where we take pictures of the arteries, and we can open up and put a stint in and we literally stop the heart attack.

Nada Youssef: Wow.

Dr. Nissan: When I was a young physician, all you could do is watch and wait and hope for the best for the heart attack. We don't do that anymore. You have to know about these symptoms and you have to understand it's critical to get treatment right away. We have a phrase. We say, "Time is muscle." What that means is time is wasting heart muscle. You don't want to lose that heart muscle. It's the only one you've got.

Nada Youssef: Tell me the difference between the cardiac arrest and a heart disease and what to do in both cases.

Dr. Nissan: Cardiac arrest is a very different problem. Cardiac arrest is usually an electrical disturbance of the heart. It may be actually caused by a heart attack, but the heart is either beats wildly or doesn't beat at all.

 This is a grave situation where death will occur within just a very few minutes. We know that if we don't get the heart restarted within about four minutes, if we get it started within four minutes, the outcomes are pretty good. People's brains recover. They do okay.

Between four and eight minutes is kind of a gray zone, and then after eight, and particularly after 12 minutes, usually the outcome's not so good. There's permanent brain injury. The brain cannot do without blood flow. When the heart stops working, there's no flow to the brain, and permanent injury occurs. Knowing what to do in a cardiac arrest is critical to saving lives.

Nada Youssef: Sure. Can we factor in the symptoms of a stroke, as well?

Dr. Nissan: Yes.

Nada Youssef: I think a lot of people are also confused. They think that the symptoms are very similar, and a stroke is different.

Dr. Nissan: We were surprised that people were not so clear. A stroke is not a blockage in the artery in the heart. It's a blockage in the artery that goes to the brain. What happens is people will have either numbness or weakness in, it can be an arm or a leg. Usually it's one side of the body, sometimes with difficulty speaking.

Again, it's changed how we treat this disorder. In the old days, you put a patient to bed. You gradually recovered over a period of days to weeks and you kind of hoped for the best. Now with a stroke, we do the same thing we do for a heart attack. We give clot-busting drugs to break up that clot in the artery in the brain or in fact, sometimes the neurosurgeons or neurologists will go in, radiologists, and they'll actually open up the artery. It's been shown now that if you intervene promptly in the case of a stroke, people's recovery of function is much, much better. If you have those symptoms, you obviously want to get treatment right away.

The biggest problem we have is people try to wish away these symptoms, and it's dangerous. If you've got chest pain that you think may be a heart attack, don't call your doctor. Don't call your friend. Don't drive yourself or have your family drive you to the hospital. Call 911, get an ambulance crew there so that you can be treated promptly.

Nada Youssef: Okay, and then with cardiac arrest, that's something, if let's say we see someone in front of us pass out or just fall to the ground, chest compressions.

Dr. Nissan: That's right. Well, there's a number of things you have to do. Obviously you want to feel for a pulse, because some people have passed out that really not, the heart hasn't really stopped. You have to know to do the right thing, and so you check for a pulse. If there is no pulse and you're pretty sure that the heart's not working, then you start chest compressions.

There's a big change in recent years. It's now recommended for bystanders who know CPR, that you just do the chest compressions. You don't have to do the mouth to mouth resuscitation. The evidence is that people do about as well just with the chest compressions and it takes away some of the concerns that people have about doing this.

There's one more fact. Many offices, buildings, public places have these defibrillators, these AEDs. You can see those signs up everywhere. A lot of people will walk by them every day and not really notice that they're there. You ought to check around your workplace, because you can save a life. If someone has a cardiac arrest, you can put on these paddles and the device is very smart. It looks at the heart rhythm and it will only deliver a shock if in fact it's the right thing to do, if it's needed.

These smart automatic external defibrillators, AEDs, look for where they are, know where there is one, if there's one at your workplace, and know how to use it. You can save somebody's life by promptly restarting the heart. Long before that ambulance crew has gotten there, you've got them back.

Nada Youssef: Right. I think that's very important, because the survey results also showed 46% of Americans don't know CPR and a whopping 85% of Americans aren't aware that CPR only requires chest compressions.

Dr. Nissan: That's right. Knowledge is power here and knowledge is life-saving.

Nada Youssef: Sure, sure. Now, I've actually been hearing a lot of our own Cleveland Clinic commercials, and it talks a lot about, did you know if you're having a heart attack or you're suspecting that you're having a heart attack, to actually chew on aspirin, not just take it orally. Why chew?

Dr. Nissan: Well, you want to get the aspirin into the bloodstream right away. If you chew it up, it facilitates its absorption. If you think about it, if you swallow a whole aspirin, that tablet's got to dissolve in the stomach and that takes time. You can get aspirin into the bloodstream more quickly.

Now, why aspirin? Well, aspirin has an anticoagulant, an anti-clotting effect. It breaks up something known as platelets and it can actually in a small percentage of patients, just a small percent, can actually cause the artery to reopen. In those in whom it doesn't reopen, having it onboard when you actually get to the hospital can also facilitate the other procedures that we do to open up the artery.

Get an aspirin in, so 325 milligram full size aspirin, not a baby aspirin and not a coated aspirin, because a coated aspirin takes too long to absorb. You want to get it in right away, one regular aspirin. Chew it up.

Nada Youssef: 325 milligrams and chew it up.

Dr. Nissan:  Chew it up and swallow it.

Nada Youssef: Then swallow it. Perfect. Now, can we talk about some of the biggest heart attack risk factors?

Dr. Nissan: Yes. Well, certainly the most important one is age. You don't see many heart attacks in 18 year olds. As you get into middle age years, your risk goes up. Men, at least at the younger ages, in the 40s and 50s, have a higher rate of heart attacks than women do, so gender is certainly an issue.

Smoking is an enormous risk factor. Smoking about doubles your risk of a heart attack at a given age. It's really remarkable. A lot of people know about smoking and lung cancer, but a lot of people don't necessarily know that smoking is a huge risk factor for heart disease.

High cholesterol, high levels of the bad cholesterol known as LDL cholesterol, that's another really, really important risk factor. High blood pressure. Lots of high blood pressure in our society now. We have new guidelines that just came out a few months back that recommend treating blood pressure to lower target levels than in the past, so if you have high blood pressure, get on medication. See your doctor regularly. Get it treated.

The other really big one is diabetes. Diabetes is increasing with great alarming speed in America. Diabetics have a very substantial increase in risk. If you're diabetic, it means you probably ought to be getting care to try to protect your heart, because it's a huge risk factor for heart disease. Those are the really, really big ones that we worry about.

Nada Youssef: What about the ones that we don't actually think about a lot? I read somewhere, I'm going to list a few here. Intense emotions, sudden excursion, extreme cold, heavy meals. Does that factor?

Dr. Nissan: What we're talking about here is mythology, right, that you go out and shovel snow and have a heart attack, but in general, exercise is very safe. If you have very severe heart disease, you probably aren't going to be wanting to be out shoveling snow, but for most people, it's good. I got my wife to do it, which is good, but I sometimes do it myself. In all seriousness, heavy exertion is not something you worry about. Getting exercise is actually generally a good thing.

Yes, intense emotions can put a little bit of stress on the heart, but it's not right up there at the forefront of our thinking. If you've controlled your cholesterol, diabetes, blood pressure, if you don't smoke, if you exercise regularly and if you avoid obesity, you're not going to have to worry so much about whether you're under a bit of stress.

Nada Youssef: Sure, sure. That makes sense. Great. Well, can we talk about the ideal diet for heart health?

Dr. Nissan: Yes. It's very controversial. What we recommend is, jokingly, we recommend the no fad diet. There are a lot of fad diets out there. Most of them have almost no scientific evidence. It's almost unbelievable how many there are. We've got people out there saying, "Don't eat any fat." We've got people out there saying, "Don't eat any carbs." Those extreme diets are not heart healthy.

There is one diet that has very good scientific evidence. It's known as the Mediterranean diet. It's the diet that people that live around the Mediterranean Sea eat in Italy and in Greece and in other places. It's very rich in olive oil, nuts, lots of fruits and vegetables. There is some meat and fish, but probably more fish. It's not heavy into the steak and potatoes kind of diet that Americans eat, but it's very healthy things. It's wonderfully tasty. You don't have to eat cardboard boxes for dinner in order to have a healthy diet. You can eat a really, really tasty diet. You just got to eat the right things.

You can go out and read about the Mediterranean diet, but it's got great evidence. 7,000 patient study done in Spain showed about a one third reduction in the risk of developing heart disease. This was a very well done study, people that eat the Mediterranean diet. All the other fad diets, they don't have that kind of evidence.

Nada Youssef: I know we talked a little bit about olive oil. Can we talk a little bit about coconut oil? I know I've heard a lot of different opinions.

Dr. Nissen:  Yes. Well, again, there are all these cults out there and mythologies. People will tell you coconut oil is somehow very healthy. There are other people that will tell you coconut oil is terrible. We have very little evidence.

Nada Youssef: Okay.

Dr. Nissan: There's quite a debate going on now because coconut oil is something known as a saturated fat. It's the type of fat that's in butter and other things. It's not entirely clear that all of the older conventional wisdom that said that saturated fats are bad is correct.

 We do know what kind of fat that is bad, and it's known as trans fat. These are fats that are made by bubbling hydrogen gas through vegetable oil. You sometimes see them on product labels as hydrogenated vegetable oil. There's pretty strong evidence that those trans fats increase the risk of heart disease. In fact, in some places, they've actually been banned. Look for that. Look for those key trans fat, hydrogenated vegetable oil on labels in foods. If you see that, you probably want to stay away.

Nada Youssef: Stay away from it. Okay, well, I'm going to go to some live questions. I have Lisa. "I'm more confused about how to eat. So many different thoughts to this, knowing inflammation is the main cause of problems. I have had two heart attacks, ER, CABG, Widowmaker, failed heart surgery, which caused CHF. I just need an idea on a diet."

Dr. Nissan: Yes. I'll reemphasize the Mediterranean diet. Yes, inflammation is important, but we don't have any evidence that there's a particular diet that reduces inflammation, maybe the Mediterranean diet. Get a book on the Mediterranean diet. It's wonderfully tasty. It's very evidence-based. It's also important how much you eat.

Nada Youssef: Of course. Portion control.

Dr. Nissan: Obesity is a major driver. You can go online and you can find a calculator that calculates your body mass index. You want your body mass index to be under 25. When you're under 25, you're at a healthy body weight. You get between 25 and 30, you're overweight. You get above 30, you're obese. It's not just about what you eat. It's also how much you eat. It's portion size.

The other issue that relates to all this, of course, is lack of exercise. If you eat a lot of food, you don't exercise, you gain weight. That does put the heart under a lot of stress, changes the metabolism, and is a major driver of heart disease that we're really struggling with in America.

Nada Youssef: Speaking of exercise, I have a question from Michael. "Is it true that swimming is the king exercise for heart health?"

Dr. Nissan: There's nothing special about swimming.

Nada Youssef: Okay.

Dr. Nissan:  In fact, walking is good. Cycling is good. Any aerobic exercise is great. I'll tell you something Michael may be a little surprised by. There's a little bit of evidence that swimming is less effective at weight loss than other types of exercise.

Nada Youssef: Really?

Dr. Nissan: There's a reason.

Nada Youssef: Yes. Tell me.

Dr. Nissan: When you're in water, usually in cold water, and the body interprets the cold as being a suggestion that it needs more insulation, it needs more fat, and so there's a bunch of things that happen. People's appetite may actually get increased a little bit more by swimming than it will be for other activities.

I personally advise patients, walking is great. You don't have to be a runner. Cycling is great, particularly if you have arthritis or joint disease because it doesn't put the joints through so much stress, so that's a big plus. Frankly, any aerobic exercise you do is better than none.

We put a little less priority on strength training because it does not appear to be as effective at prevention. It's not bad for you, but you want to at least mix it up with plenty of aerobic exercise.

Nada Youssef: Great. Let's see. Mary asks, "Can stomach problems mimic heart conditions?"

Dr. Nissan:  Yes, they can. Stomach problems can indeed. This is why heart disease is hard to diagnose. If you've got refluxive acid from the stomach into the esophagus, you get this burning sensation in the chest, and it's pretty hard for a patient, and sometimes it's very hard for a physician, to tell the difference between a GI problem and a heart problem.

That's why you want to talk to your doctor. Describe your symptoms very carefully. Clearly symptoms that occur that when you eat spicy foods, well, it's probably more than likely that it's GI, but it isn't always. We really struggle sometimes with interpreting the symptoms that patients have. The more you can tell your physician about your symptoms, the better job they can do, and you may need some diagnostic tests to figure it out.

Nada Youssef: There are no clear signs or factors between the two?

Dr. Nissan: Well, there are. The pain that people have in the chest that's heart related is often described, in fact people will actually take their hand and they'll go like this. They'll make a fist like they're squeezing, and this so called squeezing pain in the chest.

Doctors, when I have a patient that comes into my office and says, "Whenever I exercise, I get this pain," and they do this with their hand, you think that's very likely to be heart disease. If they say, "When I eat spicy meals, I regurgitate a little bit," we can figure it out a lot of the time from the description of the symptoms.

Particularly if the pain goes down the arm and also particularly if it goes up to the jaw, chest pain going up to the jaw tends to be much more related to the heart. These are some of the clues, but it really takes a professional to interpret those, and you want to make sure you get good professional advice.

Nada Youssef: Sure, great. Brenda's asking, "Is it bad to eat eggs?" We'll talk about yolk in particular.

Dr. Nissan: Yes. The US Dietary Guidelines, which I'm not necessarily a particularly big fan of, fortunately got it right finally after 25 years. Basically, eggs are no longer on the bad boy list.

Let me tell you why. Of the cholesterol in your blood, only about 10 to 15% of it comes from cholesterol that you eat. 85 to 90% of the cholesterol in your body you're making in your liver from nutrients. If you just took every speck of cholesterol out of the diet, you're only going to lower cholesterol a little bit.

Eating eggs, I wouldn't be on egg eating every day, but if you want to eat eggs a couple times a week, if you want to have an omelet, you want to have a boiled egg, it's pretty healthy. It's low calorie, fundamentally healthy. I wouldn't worry too much about eating eggs.

Nada Youssef: Can you talk a little bit about the cholesterol, the LDL, just the factors between the good and the bad?

Dr. Nissan:  Yes. Well, again, it's complicated but not all that complicated for people to understand. LDL cholesterol is the form of cholesterol that gets into the plaques in the arteries that cause coronary heart disease. The lower your LDL cholesterol, the better. We used to say, "You can't be too rich or too thin." We now say, "You can't be too rich, too thin, or have too low an LDL cholesterol."

We've recently done studies, some of which we did here, where we got people's LDL, the bad cholesterol, down to as low as 30. They had less progression of their heart disease. In a separate study done out of Boston, they had less heart attack and stroke. Clearly having a low LDL is good.

HDL is the so-called good cholesterol. It turns out that the higher the level the HDL, the lower the risk of heart disease. Now, what brings up HDL? Well, we tried to do it with drugs and it didn't work. Exercise, a little bit of alcohol, it turns out one and a half ounces of liquor a day actually raises HDL a little bit. Don't take up drinking to raise your HDL because there are other risks involved, but a little bit of alcohol, but primarily exercise and weight loss. People that are obese have higher body mass index and lower HDL. If they then get their body mass index down to normal, down below 25, their HDL goes up.

Nada Youssef: Can you increase your HDL by eating good fats?

Dr. Nissan: It's not entirely clear that you can make a big difference. There are small differences that occur. Fats where we feel most comfortable with are known as monounsaturated fats and polyunsaturated fats, and that's exactly what's in olive oil. They're also in things like canola oil and other very healthy fats, but the reality is the best evidence is for olive oil. People in the Mediterranean figured it out a long time ago. They planted those olive trees and they've been reaping the harvest ever since.

Nada Youssef: Well, let me ask you this. Butter, beef, and bacon. I know we have a Health Essentials post that you contributed to, so I'm going to put you on the spot and ask you to talk a little bit about those kind of foods.

Dr. Nissan: First of all, it's very controversial, okay? We certainly don't recommend that people go out of their way to eat butter and beef and these other things. It is unclear based upon recent evidence that they're as bad as we might have once thought that they were.

First of all, there are plenty of people that are healthy vegetarians. I'm not telling you that's not a good thing to do, but I'm also not telling you that you need to go to confession because you had a piece of lean beef last night.

What I do, I can tell you what I do personally, I try to eat more fish. I eat a little bit of chicken. I occasionally will have beef, usually lean cuts of beef, and I can't tell you we have ironclad evidence that it's a bad thing to do.

If you can increase your fish intake, great. Get your protein from fish when possible. Tofu is another great source for protein, but you don't have to be a vegetarian. Vegetarians are healthy. It's a good thing to do, but it isn't the only way to go.

Nada Youssef: Okay, great. Theresa, "Can you talk about vitamin K foods and taking blood thinners? I've read that you should try to keep the intake of vitamin K foods to a consistent level. Fact or fiction or any concerns?"

Dr. Nissan: Well, that's a great question. Okay, so it turns out, the traditional drug that we used as a blood thinner is known as warfarin, or by the brand name Coumadin. Coumadin antagonizes the effect of vitamin K, which is why it's a blood thinner. If you vary your intake of vitamin K containing foods, you can have wild swings in the degree to which your blood thinner is actually working.

Green leafy vegetables and certain other kinds of foods are very rich in vitamin K. If you're on a blood thinner, warfarin or Coumadin, you want to have a steady intake of vitamin K containing foods so you don't have these wild swings.

There's a new contemporary solution to this problem that's now becoming very, very popular. There are new drugs known as direct-acting oral coagulants, or novel oral anticoagulants. They're newer drugs. They're expensive, but they don't antagonize vitamin K and they don't even require monitoring. You don't have to actually have your blood checked for the anticoagulant level.

Increasing numbers of patients are now getting these NOACs or DOACs that are these very fancy new drugs. I wish they were less expensive, but the reality is they're a lot easier to take.

Nada Youssef: Perfect, great. Let's see. I have Nancy, "I recently moved to Salt Lake City. My blood pressure has went crazy, 200 over 100. I've tried a couple of medications. Do you think this could be altitude related?" When visiting out of state, her blood pressure does go down.

Dr. Nissan: Well, it's an interesting idea. I'm unaware of medical literature that says that living in a place like Salt Lake City is associated with higher blood pressure. In fact, some very healthy populations live up in the Andes and in the Himalayas. Think about the Sherpas. Of course, those people are exercising all day long and so on.

I think it is unlikely that the problem is directly related to altitude, but I'll also tell her that it is really important that you get your blood pressure down. You don't want to be up at 200 millimeters of mercury for the top number, the systolic blood pressure. Those are dangerous levels. Get in with a good physician that will stay with you, work on this.

We recommend to people, you can go out and for less than $100, you can get an electronic blood pressure cuff at the local pharmacy. They're pretty accurate. You can go to a place like Consumer Reports and you can get rating on them. They've been well-tested, and then you keep a chart.

I can't tell you how great it is when a patient comes in and hands me a chart and says, "Here, I've been checking my blood pressure twice a day. Here's my blood pressures for the last two weeks." I can see the pattern and I can make adjustments to their medication.

This is a general principle that we really think is important and why this kind of a chat is important. Take charge of your own health. Don't be passive. Be proactive. Get that blood pressure cuff. Measure your blood pressure. Show it to your physician. That will help them to help you.

Nada Youssef: Great, great. Well, we only have two minutes left and you've given us some great information, but is there anything you want to tell our viewers that maybe we have not touched on yet?

Dr. Nissan: It's really that last message. You want to know your risk factors. If you don't know what your blood pressure is, you may be at risk. If you don't know what your cholesterol is, and I'm not talking about total cholesterol, I'm talking about the LDL cholesterol, the bad cholesterol, you may be at risk.

If you smoke, you ought to be terrified. Honestly, in today's day and age, we know so much about this. It's going to take seven or eight years off your life. Don't do it. If you're overweight, find a way to get on a diet and exercise program. If you're a couch potato, get up off the couch. Get out and start to walk or bike or swim or whatever it is that you like to do.

That's the other thing about exercise. They're all good, so pick something you like to do. I happen to like to walk, and I also like to cycle. I cycle in the summer, not so much in Cleveland in the winter, but I like to cycle in the summer. Be your own advocate. Don't rely on your physician to be your conscience. You should be the one to take charge.

Nada Youssef: Thank you. It's been a pleasure. Thank you so much for coming in today.

Dr. Nissan: Pleasure for me, too.

Nada Youssef: Make sure you join us next week. We're actually having two Facebook Lives again dedicated to heart month. Thursday we'll be having Dr. Chode to talk specifically about women and heart disease, and on Friday we'll be having Dr. Surrell, a pediatric cardiologist to talk about congenital heart disease. For more health tips and information, please follow us on Facebook, Twitter, Instagram, and Snapchat @ClevelandClinic, one word. Thank you. We'll see you again soon.