Did you know the human heart beats approximately 2.5 billion times over the course of your life? It’s a powerhouse! And one that needs to be taken care of.
Did you know the human heart beats approximately 2.5 billion times over the course of your life? It’s a powerhouse! And one that needs to be taken care of. We’re getting to the heart of the matter in the first episode of our 2-part series on dyslipidemia– talking about heart health, heart disease, high blood pressure, and more.
Our LISTEN WELL host Dr. Mo Alsuwaidan chats about all things cardiovascular with Dutch lipidologist Dr. Peter Lansberg and Katherine Wilemon, CEO of the FH (Familial Hypercholesterolemia) Foundation.
The opinions expressed are the opinions of the individuals recorded and not the opinions of Viatris.
https://thefhfoundation.org/
Disclaimer: This podcast is provided for educational purposes and is not intended to replace discussions with your healthcare provider. All decisions regarding your care must be made with a healthcare professional, considering the unique characteristics of your personal situation. The opinions expressed are the opinions of the individuals recorded and not the opinions of Viatris. Individuals featured in this podcast may have participated in the past as or may be current members of an advisory group for Viatris.
Welcome back to LISTEN WELL, where we connect you to the world of health and wellness. I’m Dr. Mo Alsuwaidan.
It’s a genuine wonder of engineering that our hearts can work so hard for so long. On average, the human heart will beat nearly 2.5 billion times, pumping blood across thousands of miles of vascular pathways over our lifetime. Yet, as a society, our hearts and bodies are suffering. An estimated 18 million people die worldwide from cardiovascular diseases – or diseases that affect the heart and blood vessels. In this two-part series, we will have a heart to heart with Dutch lipidologist Dr. Peter Lansberg about the risks of not taking proper care of our body’s powerhouse. We’ll also hear from Katherine Wilemon – founder and CEO of the FH foundation, to get her first-hand perspective and advice about living with high cardiovascular risk.
Now, I know a lot of you are probably saying, “But Dr. Mo…lipidologist? Dyslipidemia in the title? What does FH mean?” Good questions – we’ll get to that. First, we have to start with the basics. We’ll be dropping some jargon but we’ll make sure you know what it all means. By the end of this Part I, you’ll know what lipids are, what cholesterol is, even what atherosclerosis means, I promise. In Part II, we’ll talk more about risk, what lifestyle and genetic factors contribute to cardiovascular disease, and what steps we should take to protect our hearts in the long run.
I don’t know about you, but I’m pumped. It’s time to LISTEN WELL.
Mo Alsuwaidan: It's a pleasure to have Dr. Peter Lansberg with us.
Dr. Lansberg: I'm very happy to share some of my experiences and questions, insights. Let's see where this journey takes us.
PART 1: INTRODUCTION
Mo Alsuwaidan: So before we jump into some jargon, what can you tell us about the heart? Any interesting facts?
Dr. Peter Lansb...: Well, the heart is a very impressive organ. I mean, if you realize that the size is only about fist size in an adult, but its performance is astounding. It beats roughly 100,000 times per day. So, in perspective, that means over a lifetime it's three and a half billion beats it pushes away. 2,000 gallons of blood are pumped around our circulatory system every day. And although it's a simple type of pump, the complexity in the way that it performs in different circumstances and allows us to use its properties for such a prolonged amount of time, I think is impressive. And it's an organ that, it never falters, because if it falters you have a big problem. But it does need some care, it does need some tender, loving care. And I think over the last 30 to 40 years, we've learned a lot about what is really important to keep your heart healthy.
Mo Alsuwaidan: So what can listeners do at home to make sure that their heart is healthy?
Dr. Peter Lansb...: In these days we are so exposed to all kinds of electronic gadget, information, but just simply feeling your heartbeat, feeling your pulse, to see if it's regular, to make sure that you are counting the beats and see how many counts it is when you're exercising, or when you're in a rest state, already gives you some information. The amount of beats in a trained person are somewhat less than a less trained person. And with the electronic devices, the wearable devices that are so omnipresent.. watches, Fitbits, they give you a lot more information, telling you something about the chances of having heartbeat irregularities that need to be taken care of, or saying something when your heart actually stops and giving an alert to an emergency services. Those are things that are now more or less commonplace and not that difficult to obtain, and provide, especially for the people that are a little bit older or at risk, very attractive options to make sure that you live longer and you live with a healthy beating heart.
Narration: Fun fact. The Heart Foundation of Australia has a section on their website called the Heart Age Calculator that allows you to compare your heart’s age to your actual age. It’s a simple way to learn more about your heart disease risk and what contributes to it. You’ll find it on their home page at heartfoundation.org.au.
Mo Alsuwaidan: What about blood pressure? What does blood pressure tell us about the heart and how do we measure it?
Dr. Peter Lansb...: Yeah. So blood pressure is the amount of pressure generated by your heart when it starts to pump an amount of blood through the vasculature. And after that pump, there is sort of a relaxation phase, but still continues to add some pressure in the blood vessels. So when you measure your blood pressure, you usually get two numbers, the upper value and the lower value. And the upper value tells you something about the pressure of the heart that's pumping out the blood, and the lower value tells you something about the relaxation of the heart and the relaxation of your blood vessels. Now very simply, the optimal level is 120 millimeters of mercury. So when your heart is beating and the blood is coming out, it should be around that value. If it's less, you might be a little bit dizzy. If it's more, most people don't actually feel it, but it's associated with a higher risk particularly of strokes, but also of cardiovascular disease.
Dr. Peter Lansb...: The lower value is around 80. If it’s a little bit lower, it’s not a big thing, but if it's higher, especially if it's above 95 or 100, it reflects actually less flexibility of your vascular system. And as we age, the vascular system, the blood vessels tend to become a little bit less extendable and become harder. And that's reflected in the undervalue or the lower value of your blood pressure. So measuring those two values gives you a lot of information about the condition of your heart and your risk of cardiovascular problems, particularly stroke and heart disease.
Narration: Now for a not so fun fact. In November of 2017, American guidelines were published that changed the definition of hypertension, lowering it from 140 over 90 to 130 over 80. This change gave 14% of the population, literally tens of millions of Americans, high blood pressure overnight. It was done to empower earlier intervention in the disease process.
PART II: HEART DISEASE: ATHEROSCLEROSIS
Mo Alsuwaidan: So you mentioned heart disease, and I know people mean different things by that. Let's start with a common term, atherosclerosis. What does that mean?
Dr. Peter Lansb...: So there is two terms actually, and that might also contribute to the confusion. There's atherosclerosis and there's arteriosclerosis. Atherosclerosis is the buildup of fat, fatty mass, in the vascular wall. Sometimes also accompany accompanied by infiltration of inflammatory cells, of muscle cells. And that's what we call the classic atherosclerosis. Arteriosclerosis is a hardening of the blood vessels. And that's what you observe when people get older. And there are even calcific deposits. So when surgeons sometimes operate on a very old person and they cut the blood vessels, they hear the crisp ring of the calcium crystals that break when they go through the blood vessels. So, that's two different aspects of atherosclerosis.
Dr. Peter Lansb...: It's not like a sewage system where you have debris on the wall that can clog up things.
Mo Alsuwaidan: I think that's what a lot of people picture, right? A blocked pipe.
Dr. Peter Lansb...: Exactly. it's inside the wall where cholesterol and deposits of cholesterol crystals or calcifications take place. Now, once they expand, what happens is in most people, they expand centrifugal. So they go outwards. So they don't compromise the lumen of the blood vessel in the first stages.
Narration: And just to be clear, the lumen is the hollow inside of the blood vessel.
Dr. Peter Lansb...: But once the amount of plaque builds up and there's not enough space to go outward, it will also go inward. And that inward leads to a vasoconstriction or less lumen that's there to pass the blood. Up to 60, 75% of narrowing of that blood vessel usually doesn't give you that many complaints, but if it's more than 60 to 75%, then there's insufficient blood going through the cells that need the oxygen. Blood is used to transport oxygen to the hardworking cells, muscle cells in the heart, so that they can contract. So if there's insufficient blood, insufficient oxygen, the heart will protest. It will give a signal and usually that's pain, or in some people that's also reflected, because the pump function is not enough, by breathlessness or feeling heavy pressure on your chest, because there's not enough oxygen to supply the heart muscle for functioning.
Narration: Ok, so it up, the plumbing of your cardiovascular system can run into two common problems. One is arteriosclerosis, where the pipes lose their flexibility, and the other is atherosclerosis, where the pipe walls get thicker and thicker until the hollow part inside is too narrow.
Mo Alsuwaidan: What do people mean by a heart attack?
Dr. Peter Lansb...: Well, there's a myocardial infarction, and that usually termed a heart infarct. So what happens is that you have your blood vessel that's already compromised. So there's not a lot of blood that can pass through there. And then the layer that covers the blood vessel, we call that endothelium, can be damaged as well. And what happens then is that the body tries to restore that damage by putting their blood platelets to make sure that it's covered again. But sometimes that goes out of pace. And what you see is that the platelets gather together and you get a clot formation. And that creates a sudden complete closure of the blood vessel. And that's what we call an infarct. So that means no blood can pass through, and the cells that get the oxygen from that part of the system, the vascular system, behind the closure are deprived of oxygen. And if that takes a long time, they die. And then part of your heart muscle dies.
Narration: So a heart attack, or myocardial infarction, is caused by a lack of oxygen to the heart due to one or more narrowed coronary arteries limiting blood flow. In other words, the heart not being able to feed itself.
Mo Alsuwaidan: People often group strokes under heart disease. So what is a stroke exactly?
Dr. Peter Lansb...: Yeah. Well, there are many similarities. Also in strokes, there is the problem of a blood vessel and the buildup of plaques. Usually the vessels involved in the heart are the coronary arteries, so the arteries that are linked to the heart. For stroke, it's usually the carotid arteries, the arteries that are visible in your neck or in the brain itself. So when plaque builds up there, again you can get blood clots that stick to the wall, and these blood clots can completely occlude the vessel or they can be released and then end up as a blood clot in a much smaller blood vessel, but still the effect is the same. They close off the lumen. And that means that the brain cells, that desperately need oxygen, don't get that oxygen anymore.
Dr. Peter Lansb...: A second form of stroke is what we call a hemorrhagic or bleeding stroke, where the blood vessel is not obstructed, but it's torn. It's ripped because of the vessel wall, that is not as solid anymore. And once that ruptures, you get simply a bleeding in the brain, and that bleeding compresses the brain cells and also kills them off. So these are two types of stroke, and you have to be very careful in making that distinction, because the treatment for these two types of stroke is quite different. If there is a thrombotic stroke or ischemic stroke, you need to use anti-coagulants. And you can imagine if you have a bleeding stroke, you don't want to use drugs that inhibit blood coagulation, because that would increase the amount of blood released in the brain.
Narration: Well, we’ve certainly covered off on the major cardiovascular diseases of our times. Now it’s time to learn what we can do to help avoid them.
PART III: PREVENTION OF DISEASE
Mo Alsuwaidan: So let's talk a bit about prevention of all these diseases. Before the interview, you mentioned there was a Chinese proverb that fits well into discussing prevention.
Dr. Peter Lansb...: Yes, It's my favorite proverb. And you have to imagine this is four and a half thousand years old. This was in the first medical textbook ever written. It was called the Yellow Emperor Textbook of Medicine. And it simply states that inferior doctors treat the full-blown disease. Mediocre doctors treat disease before it's evident. And only the superior doctors prevent disease. Now that is very close to my heart, because I think prevention is really what we should aim for. Early intervention, early prevention, making sure you stay healthy instead of waiting for the damage that's already been done and trying to repair it, because that's a big challenge.
Dr. Peter Lansb...: So just imagine when we were still walking around with bear skins and trying to catch a bear and eat that, in Chinese culture they already had this really deep understanding of how medicine was important. And what's interesting as well, I'm not sure if that's completely true, but people told me that in those days, doctors were paid by the inhabitants of the village, as long as they stayed healthy. As soon as they got sick, payments stopped.
Mo Alsuwaidan: So they're on retainer.
Dr. Peter Lansb...: So that's a very more motivating way to make sure that you keep your patients well and healthy. Yeah.
Mo Alsuwaidan: That's fantastic. So when we apply it nowadays, can you expand on the idea of fighting disease versus nurturing health?
Dr. Peter Lansb...: Yes. In medicine, we have been very much focused in trying to minimize the danger or how should I say, the damage that has been done. We're very good to sort of limit the damage that has already been done. And maybe... Let me explain it in what I call the three major paradigm shifts in medicine. Right?
Mo Alsuwaidan: Okay.
Dr. Peter Lansb...: Medicine for centuries has been sort of like magic. It's like the magician who had tricks that he didn't tell anybody, and people came to a doctor because he had these secret ways that nobody else knew how to deal with disease. Now, these secret were kept personally, so you didn't share, you didn't publish it. No. These were passed on to your students who paid for it, and then would become a master or a doctor himself. Now in the late 1800s, 1900s, science started to take root and Furkov, who was one of the first scientific doctors you could say, he started to study and to describe what I call the late stages of the disease, the anatomy of the disease. He described what happened when the damage was done. And what he also did, and that's very characteristic of modern medicine, is that he shared that information in books so that other doctors could learn from it.
Dr. Peter Lansb...: Now, in the beginning of the 20th century, we come in the second paradigm, which I call the physiology of the disease. So what happened then, is that we not only started to understand the final stages, the anatomy, but we also learned the process of the disease, the different pre stages before the damage was done. And very pivotal in that concept was, for instance, the blots using markers that allowed us to check certain things. We had treatments that were focusing on blood-based delivery of drugs to organs that were diseased.
Dr. Peter Lansb...: We became very good at the infectious type of disease and the traumatic kind of diseases, to manage and treat that. And now in the beginning of the 21st century, we come in the biology of the disease. We have very sophisticated scientific methods, looking at the biochemistry, looking at the genetics, looking at the metabolomics that allows us to much earlier recognize who is at risk, what kind of risk and what would be best to prevent disease. So we're now actually entering the stage where the Chinese already said, "This is what we call superior doctors. This is superior medicine,” to recognize who is most likely to become sick. And then start trying to reduce that risk by focusing on the factors that we know are involved.
Mo Alsuwaidan: So it took us about 4,000 years to circle back to that original wisdom.
PART IV: Lipids and Risk
Mo Alsuwaidan: Now in the intro, we talked about your work in lipids. What are lipids exactly?
Dr. Peter Lansb...: So lipids, very simple, are transporters. Our blood is our transport system. It brings not only the oxygen, but it brings all kinds of important substances to organs and cells that need them. But blood by itself is a watery type of substance. Now, many of the molecules that are important are not water soluble, but are fat soluble. So to give you an example for nutrition, one of the best compounds to store energy is fat, because per gram it allows you to store a lot of energy. Now, fat and water don't really mix. And the best example I can give is if you wash your dishes, you need detergent to make sure that the fat is sort of soluble in the water and allows you to clean it. Now, lipids are packages, that on the outside are water soluble and on the inside are fat soluble. So they allow us to transport fatty like substances throughout the body, where they can deliver them, in terms of energy distribution, in terms of hormones, in terms of vitamins, in terms of all kinds of important substances that are needed in specific type of organs or cells.
Dr. Peter Lansb...: we can still use a very simple model, where we say there are particles that we call LDL particles. And sometimes they are referred to as the bad cholesterol particles. They're quite small, and they are circulating in the bloodstream containing, basically most of it is cholesterol and a little bit of protein, a little bit of triglycerides, or a little bit of fat. They are responsible, we think, for the process of atherosclerosis. Then we have a particle that looks a little bit similar. It's called HDL. And it also carries cholesterol, but the outer layer is slightly different. So instead of depositing its content in the vascular wall, it actually takes out the cholesterol content from the vascular wall and then returns it to the liver.
Narration: Not to oversimplify, but when it comes to heart disease, LDL is the bad one, and HDL the good one. I like to think of the H as standing for Helpful….
Mo Alsuwaidan: I think the way you explained it, most people have heard the term maybe good and bad cholesterol. What does that mean about normal cholesterol levels? Is there one number or there are several numbers?
Dr. Peter Lansb...: The way I try to explain it to colleagues and to patients is that I give the example of blood pressure. What is a normal blood pressure? And everybody on this planet agrees that a normal blood pressure, as I explained earlier, is the level of 120 versus 80 or versus 90 as the higher and the lower values. And why do we call that blood pressure normal? Very simply because we know that if it's not higher than those numbers, it's not associated with developing disease. It's not associated with myocardial infarctions or stroke. Now, we go to cholesterol, and what we did in the past is that we measured cholesterol, and then we measured it in a large number of people, and then we came to the conclusion that the total cholesterol, so that's everything combined, is roughly 200 milligrams per deciliter, or 5 millimoles. That was the median or the mean value in a population. And interestingly, that's observed in quite a few westernized populations, so we said that is probably what we should term normal.
Dr. Peter Lansb...: But if you use the same definition for cholesterol as we use for blood pressure, to be honest, I think that number is actually far too high. What we know from a lot of experimental studies, animal studies, looking at primitive populations, looking at other mammals, most likely a normal, and I mean a physiological or a non-harm-causing, cholesterol is somewhere between 70 to 100. So an LDL cholesterol, that's something that we usually refer to when we try to discern if we should treat or not treat, should be around 50, or maybe even a little bit less than 50, or 1.2 millimoles per liter, and that is quite a difference if we use this concept compared to the other concept, and it also puts a different scope on treating cholesterol where quite a few patients, and sometimes even doctors, say, "Oh, your cholesterol is normal," referring to the 200 or 5, "So we shouldn't really think about treatment," but if you think of it from a different perspective and say, "Yeah, but what's the harmful level?" you would initiate that actually much earlier.
Mo Alsuwaidan: So we have to take this risk preventative perspective.
Dr. Peter Lansb...: Yes, that's again coming back to my Chinese favorite saying.
Mo Alsuwaidan: So, to what degree do our genetics play a role in controlling our lipid levels?
Dr. Peter Lansb...: Genetics do play an important role, but I think predominantly where it becomes relevant for us are in the extremes. So there is a disease, and this disease has been a focus in my career for the last 30 years, called familial hypercholesterolemia. This is a problem where the cholesterol metabolism is broken to a certain extent. These individuals have a cholesterol that's much higher than what we would see normally in a population. To give an example, if you talk about milligrams per deciliter, on average, these patients have a level around 350, 400 milligrams per deciliter of LDL cholesterol, of bad cholesterol.
Narration: I think this is a good time to introduce Katherine Wilemon – founder and CEO of the Familial Hypercholesterolemia (or, FH) Foundation. If you can guess from the name, FH is a genetic disorder that causes a malfunction in how bad cholesterol, or LDL, is cleared from the body. The result is an abnormally high cholesterol concentration in the bloodstream, and we’ve already heard how big of a problem that is – like leading to relatively young people having heart disease and heart attacks. But I’ll let Katherine explain what her foundation and her condition is all about.
Mohammad: So can you tell our listeners a bit about the work of the FH foundation?
Katherine : Sure. So the FH foundation is a partnership of both clinician scientists and individuals like myself who live with familial hypercholesterolemia. And we're based out of the United States. It's really been our goal to quantify this problem that has remained really invisible and to innovate new solutions for how we get people diagnosed earlier and get them the care they need. Because what I really would love to share with your listeners is that FH is a story of hope.
Katherine: You can take an individual who was born at the highest risk of early heart disease and with appropriate diagnosis and treatment, you can normalize their risk and it can impact their whole family. You can help so many other people. And it's really been an exciting journey. The National Heart, Lung, and Blood Institute actually just recently designated FH as a prototype for precision medicine. And because if we find out that this is wrong, that people carry this mutation, we can help them so much. And so the work of the foundation is to do research, it's to support the community, it's to work on a policy level, to help the 34 million people in the world who have this condition and to see what we can learn, how we can help people with conditions beyond FH.
Mohammad : So Katherine, can you tell us a bit about your personal experience with familial hypercholesterolemia?
Katherine:Sure. I have familial hypercholesterolemia, but it actually took me a very long time to discover that. When I was 39 years old, I started to develop symptoms, shortness of breath when I was hiking with my husband, and it got so bad that even when I walked up the stairs I would have some pain in the center of my chest. So, I went to go see a cardiologist.
Katherine: He was really shocked that my cholesterol was above 300 and I told him that it had always been that high and that my genetic father had had a heart attack in his early thirties. My husband and I were trying to get pregnant at the time, so I couldn't take statins or other cholesterol lowering medications. The cardiologist told me not to worry, and suggested that perhaps I'd try heartburn medication. A few months later, I had a heart attack. I had actually 100% occlusion of the main artery that feeds your heart. It took me two additional years after my heart attack to actually find a doctor who was a lipidologist, like Dr. Landsberg, who gave me the diagnosis that changed my life. He told me that I was born with a genetic condition called familial hypercholesterolemia.
Mohammad: So with FH, you said you'd noticed when you were younger that your cholesterol was always high?
Katherine: You know what, when I was 15 years old my family physician discovered that my cholesterol, actually my LDL cholesterol was above 350. And as you know, this is three times what it normally should be for a teenager who's active. He was quite concerned, and my family went on really an extremely low-fat diet, and I adopted that for most of my life, but my cholesterol remained above 350, regardless of what I did.
Katherine: During the same period, cholesterol was just entering the cultural vernacular as a known risk factor for heart disease and statins became available right as I was graduating from high school and heading off to college. Certainly I had other priorities, but I did take my statins on and off, but I really never had a name for my condition, and I thought it was something singular to me.
Mohammad: So, Katherine, I guess it's quite shocking for a young person to have a heart attack. Along the journey, did you notice that it was a condition that most doctors don't know about?
Katherine: Yes. So what we know from surveys is that there is very low awareness amongst primary care physicians and even cardiologists of familial hypercholesterolemia. And there's a misconception that it's rare, but FH affects 1 in 250 people, so it's actually quite common, but as a culture, I think that everyone, physicians included, think of heart disease as a disease of the elderly, and individuals with FH actually show clinical signs of very aggressive heart disease as early as their twenties, thirties, forties, and fifties. So, there's a disconnect between this being a common condition that affects young adults with heart disease and our cultural perception of heart disease as a disease of people who are much older.
Mo Alsuwaidan: So, I guess the moral is: from infancy to old age, heart health is never NOT important. I think this is a good time to wrap things up for part one of this heart to heart. We've thrown a lot of terminology your way, and some of it may be new to you. For now, we hope you have a clearer picture of what's going on in our blood vessels that can make it hard for your heart to do its job. I’d like to sincerely thank Dr. Peter Lansberg and Katherine Wilemon for providing their expertise and personal experience in this topic – but the conversation is far from over. Tune in to part two to learn about cardiovascular risk: what it is, and how to measure it, and what we can do to reduce it.
Mo Alsuwaidan: If you're looking for more information or resources about the topics covered in this or other episodes, you can visit www.listenwellpodcast.com. I’m Dr. Mo Alsuwaidan. Thanks for listening.
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