The Peter Attia Drive - Qualy #82 - What is the most common first presentation of heart disease?

Episode Date: December 25, 2019

Today's episode of The Qualys is from podcast #03 – Ron Krauss, M.D.: a deep dive into heart disease. The Qualys is a subscriber-exclusive podcast, released Tuesday through Friday, and published exclusively on our private, subscriber-only podcast feed. Qualys is short-hand for “qualifying round,” which are typically the fastest laps driven in a race car—done before the race to determine starting position on the grid for race day. The Qualys are short (i.e., “fast”), typically less than ten minutes, and highlight the best questions, topics, and tactics discussed on The Drive. Occasionally, we will also release an episode on the main podcast feed for non-subscribers, which is what you are listening to now. Learn more: https://peterattiamd.com/podcast/qualys/   Subscribe to receive access to all episodes of The Qualys (and other exclusive subscriber-only content): https://peterattiamd.com/subscribe/  Connect with Peter on Facebook.com/PeterAttiaMD | Twitter.com/PeterAttiaMD | Instagram.com/PeterAttiaMD 

Welcome to the Qualies, a subscriber exclusive podcast. Qualies is just a shorthand slang for a qualification round, which is something you do prior to the race, just a little bit quicker. Qualies podcast features episodes that are short, and we're hoping for less than 10 minutes each, which highlight the best questions, topics, tactics, et cetera, discussed on previous episodes of the drive. We recognize many of you as new listeners to the podcast may not have the time to go back and listen to every episode, and those of you who have already listened may have forgotten. So the new episodes of the quality is going to be released Tuesday through Friday,

and they're going to be published exclusively on our private subscriber-only podcast feed. Now, occasionally, we're going to release quality episodes in the main feed, which is what you're about to hear now. If you enjoy these episodes and if you're interested in hearing more, as well as receiving all of the other subscriber exclusive content, which is growing by the month, you can visit us at pteratiamb.com forward slash subscribe. So without further delay, I hope you enjoy today's quality. So without further delay, I hope you enjoy today's quality. Now, when I was in medical school, I remember in first year pathology lecture, the pathologist said, let's see a show of hands. What is the most common first presentation of heart disease?

And you know, everybody puts up their hands and says, a chest pain, a left shoulder pain, shortness of breath. And he said, no, no, no, no, no, it's sudden death. That was a little over 20 years ago. Is that still true today? The estimates I've heard, and I think this is arguable because these are really rough rule of thumb calculations, somewhere in the range of 30%, possibly, possibly upwards of 30%, which is still a huge number.

It's staggering. It means that one third of people's first brush with the knowledge that they have atherosclerosis is death. And I have patients, and I'm sure you do as well, who have died and come back. And so there is this process where there's an acute event that causes an irreversible change. But for some people fortunately, we can bring them back. But together, that represents really the basis for calling this disease the silent killer. Because, as you were saying, we don't, in those patients, have primaticity symptoms. Sometimes in retrospect, they are there.

And I think that's the important reason for educating the public as organizations like the American Heart Association does, as to the first signs of heart disease, because it may be, and it probably is true, that a significant component of that 30%. Right, upon further querying, there was some exercise intolerance in real life. And recognize it, yeah, and it's very hard sometimes. One of the things that we'll be talking about

is ways of assessing risk. And those are still imperfect, and we can't, with 100% certainty, use any kind of risk predictor to know if somebody's destined to have a heart attack with certainty. Yeah, you said something at the outset, which is this is a disease that begins in infancy.

And I have very few textbooks and or papers that I refer to so frequently that they actually sit on my desk in my office so that every 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 my mentors. I consider you a great mentor, Tom Daye, spring a great mentor, Alan Snyder, I'm in a great mentor.

Alan gave me this textbook of pathology. I think, believe it's Stari, is the author. And while I believe the data represented there are somewhat dated because it was largely based on the Vietnam cohort. And Korean. Yes, where obviously smoking would have been a higher prevalence than today. The fact remains that when you look at autopsies of young people who died of unrelated reasons, homicides, accidents, etc. And you look at the histologic sections of their coronary arteries,

it's amazing how many of them have lesions that are type three or beyond type three meaning obviously a type of pathological region where you go beyond fatty street. Yes, indeed. That's right. So a subset of these youths will have more advanced lesions and the studies that have been done have linked all of the usual risk factors, smoking, certainly diabetes, hypertension, and this lipidemia all of, and in a lipid disorder, all of those have been associated with the more advanced lesions in those individuals. So is your point out even a more significant plaque development kind of current childhood? I think the thing that's hard for people to understand, and I think it's true of most chronic diseases, but I don't think any disease in any disease it is as clear as it is with atherosclerosis, which is the compounding nature of the disease. You know, another great example of one of those questions that the professor asks that

gets everybody stumped, which is what's the greatest risk for heart disease. You know, is it smoking? Nope. Is it high blood pressure? Nope. Is it dyslipidemia? Nope. It's age.

It's age. I mean, and why is it age because it's exposure? It's time. It's area under the curve. Yeah, that's exactly true. Age, regardless of a risk factor that cuts across many of the diseases, chronic diseases, that we have to deal with cancer, for example. And yeah, that's right. It's a cumulative process that can progress at various rates depending the condition. So people, as you know, when we talk about who have genetically elevated, severely elevated cholesterol levels, we'll have that process accelerated and have the disease so up clinically

early on. Sometimes with these subvergenetic disorders and the teens, whereas others, most of the population, fortunately, who do have risk factors, show a gradual increase in the manifestation of disease as a result of those risk factors as a function of their age. You know, at last check, and I can't remember if it was JAMA or another journal, but it was about a year ago, and they looked at some actuarial data for people out through being past centenarians. And the only disease, once you normalized for a few things,

the only disease that increased monotonically by decade and risk was atherosclerosis. From childhood, yeah. Even cancer, actually, you know, by think by the ninth decade, it started to come down. Yeah, I see, yeah, yeah. You know what, yeah, it's right, no, it's definitely the latency period. If we're cancer also is a factor there as well.

So there's this sort of latency period. There's nothing happens and then all of a sudden an older age pops up. I hope you enjoyed today's quality. Now sit tight for that legal disclaimer. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services,

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