Heart to Heart
conversation with a cardiologist
From childhood on an apple farm in upstate New York to medical school at LSU, Dr. Frank Wilklow has impressed teachers, mentors and colleagues. “In my 18 years of training cardiology fellows to do interventional procedures, Frank was the best. I found no faults. He is a hard worker, smart, likable, good with patients. People like him,” says Dr. O’Meallie. These sentiments are echoed by Dr. Edward St. Martin, another beloved and recently retired cardiologist: “Three things make a good doctor. Know your topic, know your patient, and show up in person to see them. Dr. Wilklow makes the trifecta. I recommend him most highly.”
This being National Heart Month, some questions and answers with Dr. Wilklow:
Q: Heart attacks seem on the downswing; true or false? It depends on who does the counting and how. We heard in November that the incidence of both heart disease and heart attack has decreased at least 20 percent over the last 20 years. Most think this is due the decline of smoking, healthier diets, more effective medications and promotion of an active lifestyle. The physician from Duke who presented the data summed it up: “Coronary disease was once the size of a large pizza, but now it’s a medium pizza.”
Q: Are we seeing fewer heart attacks locally? Interestingly, a paper presented at the American Heart meeting showed hospital admissions for heart attacks in the years after Hurricane Katrina increased threefold at the Tulane Hospital. Reasons given were stress, substance abuse, poor diet and lack of continuity of medical care. The study compared hospital admissions to the Tulane hospital for two years prior to Katrina to 10 years after the storm. Whether statistics are skewed, given that several hospitals did not re-open after Katrina, would take a city-wide study.
In my practice, Katrina certainly seemed to have an effect on health, but mostly psychological. Patients seemed to have higher levels of anxiety and depression, which can affect health. It became a milestone in people’s lives. Often patients are unclear about when medical procedures or diagnoses occurred. I often ask, “Was that before Katrina or after?” and they seem to immediately organize their time lines.
Q: New Orleans was Ground Zero for cardiologists from all over the world last November. What was going on? Some 18,000 professional attendees from more than 100 countries came to town to attend the annual meeting of the American Heart Association. It was dubbed the “premier cardiovascular research and instructional meeting in the world.”
Q: What impressed you most about the meeting? In addition to the research studies, meeting organizers took on contested topics in cardiology and presented evidence to help clinicians like me make decisions about common but controversial matters.
Q: What are some examples of those topics? Treatment recommendations for persons with peripheral arterial disease, the safety of arthritis medications like Celebrex and approaches to patients with both coronary artery disease and atrial fibrillation requiring multiple blood thinners. There was an interesting trial regarding whether controlling blood pressure and cholesterol translated to less dementia. This year an entire section was devoted to the use of technology in medicine and the pluses and pitfalls technology lends to the practice of medicine.
Q: What this thing called SPRINT that I read about? We know that high blood pressure is a risk factor for stroke, heart attack, heart failure and death, but how low is best and how low is too low? The National Institutes of Health sponsored the Systolic Blood Pressure Intervention Trial, nickname SPRINT, to answer this question: “Will lower blood pressure reduce the risk of heart and kidney diseases, stroke or age-related declines in memory and thinking?”
SPRINT researchers enrolled some 9,300 patients 50 years old and older with diagnosed hypertension across the United States. The subjects, none of whom had diabetes, were randomly divided into two groups. One group continued with standard care, which meant keeping the systolic or top blood pressure number at 140 or lower. The second group received a more intensive drug regime targeting a systolic blood pressure of 120 or lower.
The plan was to run the study five years or so, but researchers pulled the plug after just three years. Those subjects in the more intensely managed group with lower blood pressures had significantly fewer heart attacks, stroke, heart failure and cardiac deaths in general.
Q: Any new drugs of interest either on the market or soon to be there? Two new medications to treat congestive heart failure are Entresto and Corlanor. Entresto is a combination of an older heart medication with a new drug that reduces fluid overload in the body. Such fluid overload leads to shortness of breath, difficulty lying flat and difficulty with exertion.
Less fluid in the lungs and cardiovascular system leads to better breathing, better quality of life and ability to walk farther. An elevated heart rate can be a problem in patients with congestive heart failure. Corlanor can help in some of these difficult situations by reducing the heart rate and decreasing the work on the heart.
What is new in cholesterol reduction? Repatha and Praluent are monoclonal antibodies. They block a protein in the liver that slows down cholesterol metabolism. These antibodies rev up cholesterol metabolism causing an impressive drop in low density LDL cholesterol levels. Lower levels of LDL, aka as the bad cholesterol, lead to less plaque and blockages in the arteries of the brain, heart, and other vessels within the cardiovascular system. These medications can have dramatic results. We use them in our practice, and I’ve seen people come in with an LDL of 350, start on the new medication and in 2 to 3 months their LDL is less than 100. The downside to these medications is the cost of over $14,000 a year, and they must be injected like insulins.
Q: Why is there increased heart disease in “food deserts?” Food deserts are areas where people cannot obtain quality healthy food due to affordability, distance or availability.
Part of what has led to the decrease in the incidence of heart disease is the improvement in the diet that most of us have enjoyed; however, some people don’t have access to a healthy diet. Even in our city, poor neighborhoods may not have access to fresh fruits and vegetables because of cost or a lack of a large supermarket. Fresh fruits and vegetables have a short shelf life; unhealthy processed foods are cheaper and easier to stock. Inner cities have higher cardiovascular disease rates in part due poor diet. Public health initiatives such as farmers’ markets, neighborhood gardens and food preparation classes in schools are helping to alleviate this situation.
Q: Any new management tools for persons with atrial fibrillation and other irregular heart rates? Most of the new management tools for atrial fibrillation are device based. Most of the new pacemakers and implantable cardiac defibrillators are now MRI compatible. In the past, patients with pacemakers or defibrillators were unable to get MRIs because of the metal in the device. This is no longer the case with these newer devices; it makes it easier to get through airport security, too.
We also have devices that can be placed on your cell phone to monitor your heart rhythm if you feel episodes of palpitations or a racing heart. These devices can be used to document heart irregularities as they happen.
Dr. Lutz edited and condensed the interview for space and clarity.
"Part of what has led to the decrease in the incidence of heart disease is the improvement in the diet that most of us have enjoyed; however, some people don't have access to a healthy diet. Even in our city, poor neighborhoods may not have access to fresh fruits and vegetables because of cost or lack of a large supermarket."