ZACH MOORE: Welcome to On Health with Houston Methodist. I'm Zach Moore. I'm a photographer and editor here, and I'm also a longtime podcaster.

KIM RIVERA HUSTON-WEBER:  I’m Kim Rivera Huston-Weber and I’m a copywriter here at Houston Methodist.

ZACH: And, Kim, today we’re talking about something, kind of, an under the hood health topic, coronary artery disease.

KIM: Yeah, we’re talking about coronary artery disease. You know, and it goes by a lot of different names too. I think people will interchangeably use cardiovascular disease, or they’ll, like…

ZACH: Mm-hmm.

KIM: Say heart disease. And CAD, coronary artery disease is the -- probably the most common form of heart disease when you think about it. And it’s extremely common here in the U.S., but even though it is so common, I think a lot of people don’t quite get the severity of the condition. I think the American Heart Association did a survey last year, and over half of the respondents were unaware that heart disease is the leading cause of death in the U.S., and it’s been that way for more than a hundred years.

ZACH: Wow.

KIM: I think both heart disease and stroke combined claim more lives each year than all forms of cancer and chronic lower respiratory infections, which is, kinda, crazy to think about.

ZACH: Yeah. I mean, obviously people are aware of, you know, heart attacks, heart conditions, you know, your arteries, cholesterol, that sort of thing. But, you know, if you go to the man on the street, I’d say probably six out of ten people would not guess that that’s the number one killer in America today.

KIM: Yeah, and I think it’s because coronary artery disease really is the -- what happens to you as your arteries build up that calcium plaque that can lead to both heart attack and stroke. So, it is really, kind of, a silent condition until you have an event like that. Unless, you know, you’re managing everything with your primary care doctor or your cardiologist.

ZACH: Yeah, so we’re going to be talking a lot about preventative care today. And who did we talk to about coronary artery disease today, Kim?

KIM: Sure. We spoke with Doctor Mahmoud Al Rifai. He’s a Preventive Cardiologist here at Houston Methodist.

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KIM: Thank you so much for being with us today, Doctor Al Rifai.

DR. MAHMOUD AL RIFAI: Oh, it’s my pleasure. Thank you for having me.

KIM: Of course. So, I read a surprising statistic that there are over 18 million people living with coronary artery disease here in the U.S., and I think it’s roughly the combined population of New York, Los Angeles, Chicago, and our beautiful, fair city of Houston. So, could you share with me what coronary artery disease is and why it’s so prevalent here in Americans.

DR. AL RIFAI: Right. So, coronary artery disease is still the number one cause of deaths and morbidity in this country and pretty much around the world. So, I’m not surprised it’s that many number of people that live with coronary artery disease or cardiovascular disease. And what cardiovascular disease is, it’s a disease that affects the heart and the vasculature. It starts with -- it’s a process that’s, kind of, what we refer to as atherosclerosis. You have some plaque development that really happens in pretty much everyone. You have soft plaque that happens in the arteries of the heart, and they can also happen in the arteries of the neck. Pretty much everywhere in the body. But specifically talking about the heart, you have these small, soft plaques that start early on, and they can develop progressively over time. And especially if you have risk factors like smoking, diabetes, high blood pressure, high cholesterol, the development of those plaques is really accelerated. And what’s even more scary is that if those plaques can rupture at some point in time causing a heart attack, or they can cause a stroke. And those are, like, one of the two major manifestations of cardiovascular disease. And so, that’s really what CVD or CAD is all about.

KIM: So, you kind of touched on some of the risk factors. Are those solely what causes the disease or is it simply just the accumulation of the plaque over time?

DR. AL RIFAI: So, you kinda wanna think about it as like these factors acting on the vasculature through the development of plaque. And it’s not only those risk factors per se, but the major -- we would think the major culprit is cholesterol. Influx of LDL particles into the vessel lining of the arteries, the coronary arteries, that’s really what triggers the atherosclerotic process. The LDL particles come in, they have some kind of inflammation there, and then slowly over time, there’s plaque buildup, and there’s what’s called soft plaque, that’s very likely to rupture. Especially you know, if you’re a smoker, if you’re diabetes, if you have blood pressure. All these factors can, kind of, all act on that plaque and then cause it to rupture over time. And at some point in time, as we said, it can cause a heart attack if it happens in the arteries of the heart, or it can cause a stroke if it happens in the arteries of the neck and the brain.

KIM: Is it mostly just almost like a perfect storm happening?

DR. AL RIFAI: Pretty much. If you have the right ingredients, it can cause these plaques with high risk features. Basically, when you have a cap -- think about a plaque that has, like, a very thin lining. That kind of plaque is more likely to rupture. And if you have risk factors like smoking and diabetes, high cholesterol, hypertension, they can cause that lining to rupture essentially.

KIM: In preparation for our conversation today, I came across a book by a preventative cardiologist and it, kind of, makes the case that patients should take a diagnosis of coronary artery disease as seriously as they might if they were told that they had cancer. So, the physician, kind of, lamented that the medical community has moved away from the term atheroma with that suffix “Oma” and its meaning for tumor to plaque, which may make it sound more benign. What are your thoughts on this and, you know, what screening tests exist for coronary artery disease? And how do most people find out that they have it?

DR. AL RIFAI: I think patients and physicians, especially patients, need to take the diagnosis of CAD very, very seriously. Because once you have that diagnosis, it makes it more likely that you’re gonna have a future event down the line. So, there’s four kinds of prevention. There’s tertiary prevention, which means that you’ve had an event in the past, and you’re trying to prevent the burden of that event. Whether you had or a stroke or a heart attack in the past, trying to lessen that burden of having that stroke or heart attack. There’s secondary prevention, which means that you have a disease, you’ve had the disease before, you’ve had a heart attack or stroke, and you’re trying to prevent a future heart attack or stroke from happening again. And then there’s primary prevention, which means that you don’t have the disease yet, but you have risk factors for the disease. And again, the high cholesterol, high blood pressure, diabetes, smoking. You’re trying to control these risk factors to prevent you from having the disease. And lastly, what we call is primordial prevention. So, you don’t have the risk factors yet, and you’re trying to prevent those risk factors from happening. That’s really -- the best way to prevent disease is to control the risk factors and prevent those risk factors from developing. But then again, once you have those risk factors, there’s also an opportunity to act there and then to prevent those risk factors from progressing, and then like I said earlier, having their effects on the vasculature and that causes an event. Even if you’ve had the disease before, you can also prevent that disease from happening again in the future. So, at each level of prevention from primordial all the way to tertiary, there’s opportunities where you can prevent the disease from happening again, or the risk factors from developing in the first place. Once the patient has had a diagnosis of coronary artery disease or stroke, and the combination of coronary artery disease or stroke is referred to as cardiovascular disease, it encompasses the two. Once they’ve had that diagnosis, I think it becomes instilled in them that they have the disease and they’re trying to prevent it from happening again. But when a patient does not yet have CAD or stroke, it may be a little bit difficult for them to try to prevent something from -- That something hasn’t happened yet. And so, the opportunity to discuss prevention, I think primary and primordial should be the focus of clinicians and patients. You know, whenever we have patients present to us for prevention visit, they usually recommend that initial visit to start around the age of 40 or 45 years. We do what’s called a comprehensive risk assessment. So, we assess, you know, what’s their cholesterol, what’s their sugar levels, what are their blood pressure? And then we also look at factors that they can’t control, their age, their sex, their race. These are factors that they have, and you can’t change someone’s age, you can’t change the fact that someone’s a male versus female. And so, we look at all these factors and then we plug them into calculators. And just basically what those calculators are, they use population-based studies, whether from cohort studies or from patients enrolled in health care systems, those patients are followed up over time, they assess what risk factors are based on, then they follow them up over time for events. And then based on that risk factors and disease, they come up with these risk calculators. And what those risk calculators give you is a number which is -- what is their estimated percentage of having an event over the next ten years, and that event is either a heart attack or a stroke. And so, let’s say I have a patient that comes to me, and I know their lab values, I measure their blood pressure, I know their age, sex, and race. I put those numbers into that equation, and it gives me a number. Let’s say that number is 8%. The way I explain that to patients is if I take a hundred people who look exactly just like you, same age, same sex, same risk factors. On average, eight of those patients will have a heart attack or stroke over the next ten years. And so, to a patient when they’re reading that statistic or they’re hearing that statistic, they’re gonna say, “Well, eight patients on average are gonna have a heart attack or stroke, but then on the flip side ninety-two patients will not have a heart attack or stroke on average. So, it may seem, kind of, abstract to them in that they don’t have that disease yet, so what are we doing here? What are we trying to prevent? Screening, really we don’t screen for heart disease or stroke, but we estimate someone’s absolute risk of having a heart attack or stroke over the next ten years. And risk calculators are currently standard of practice, but then there’s a better tool now, and it’s a very well-established tool that we’ve had data for a couple of decades now called the coronary arterial calcium score. It’s a non-contrast CT scan of the chest. So, it’s a CAT scan, no contrast, it’s timed appropriately in the cycle of the heart so that we can image the arteries of the heart. And really, what we’re looking for is calcium deposit within the plaques and the arteries. Based on the size of the plaque and how dense that calcified plaque is, we can calculate a score called the coronary artery calcium score. And that score ranges from zero, which is basically no calcified plaque. It doesn’t mean there’s no non-calcified plaque, it just tells us there’s no calcified plaque. And it can go up to the thousands. And what studies have shown is that the higher that calcium score is, the higher the risk of you having a heart attack or stroke over the next ten years. That test, I think, is useful for patients because seeing is believing. When I do a calcium score test and they see that their calcium score is 150 or 200 or 50, then they can see that there’s disease, right? That’s called subclinical disease, but it’s also disease. And subclinical atherosclerosis is basically the precursor of the atherosclerotic cardiovascular disease. And so, when they see that they have calcified plaque, subclinical atherosclerotic plaque, then they can, kind of, have an idea, “Alright, whatever risk factors I’ve had before seem to have caused some effect on the arteries of the heart, and then that puts me at risk of having a heart attack or a stroke in the future.” And that may make them more convinced to take a statin to lower their cholesterol and lower their risk of having a heart attack or stroke. Now, I’m not saying every patient should get a calcium score. Every patient should have their risk estimated with those risk calculators. And if they’re borderline, or intermediate risk, or high risk, they will benefit from having a statin to lower their LDL cholesterol and lower their risk, in addition to controlling their other risk factors like diabetes or high blood pressure or smoking. But if the patient is not convinced -- You know, I tell them that you risk score is 8%, which puts then in the borderline or intermediate risk score. But they’re not convinced that they’re gonna benefit from a statin and they need more evidence or more reason to believe, you know, that they would benefit, then I will order a calcium score. Not as a screening tool. Again, it’s not a screening tool, it’s more of a risk decision tool. A way to, kind of, help refine our risk estimates, and then support the decision to start someone on the statin or no.

KIM: Who is that calcium risk scan for? Like, what ages? When would you want to be talking to your doctor about that if you’re someone who “yeah, maybe my cholesterol’s a little high, maybe my blood pressure’s high.” How does that conversation go?

DR. AL RIFAI: That is an excellent question. So, calcium scan basically measures the amount of calcified plaque. So, it doesn’t measure non-calcified plaque. And so, younger people, younger patients, and young, usually less than 40 or less than 45, if they do have plaque, it’s more likely to be non-calcified. So, if I think a patient is at very high risk and they’re 30 years of age, if I do a calcium score on them, it’s most likely going to be zero. So, younger patients, usually I will not order them. Now, we do have a lot of refers for patients under the age of 40, and they end up having a calcium score, and it’s actually their calcium score in more than zero, and that’s actually a very high risk. Because most of the scores in that age group should be zero. So, if it’s not zero, even if it’s one, it’s high. But for a patient that’s 40 years or older, after doing a risk -- formal risk estimation and they’re borderline or intermediate, and the patient’s still reluctant about starting a statin, or the clinician’s unsure really what their risk status is, then the guidelines tell us it’s reasonable to order a calcium score as a risk arbiter. So, if it’s zero, your calcium score is zero, that puts you at a lower risk category of having a heart attack or stroke over the next ten years, such that you can the first statin therapy at this time, but continue to reinforce healthy lifestyle, continue to maintain good risk factor control of other risk factors, not just their cholesterol. But then, follow that up with another scan in the next three to five years, because we know from prior studies that measuring calcium score at baseline, and over time, we know that calcium score progresses. If it’s zero today, it’s probably gonna be a hundred or more if you have risk factors. But if your risk factors are controlled, that score zero may still be zero even in 20 or 30 years. So, measuring calcium score at baseline and then following up over five years is reasonable if your calcium score is zero. And what the guidelines tell us, if it’s one to ninety-nine or more than a hundred, it’s reasonable to start someone on a statin, and the higher your calcium score, the higher intensity of statin that we need to start you on. And so, for me, I really look at it as binary. Zero or more than zero. If it’s zero, reasonable again to withhold statin therapy if the patient is reluctant to take a statin, and if it’s more than zero, I think it’s a reason to start someone on a statin. And then once you’re started on a statin, you need to make sure that their LDL cholesterol is followed up to ensure the anticipation reduction LDL is achieved, and you just continue to monitor that over time. So, it’s really a risk arbiter rather than a screening tool per se.

KIM: Yeah. And so, when people find out, is it usually when someone has had an event like a heart attack or stroke, or so you see more people getting diagnosed in clinic?

DR. AL RIFAI: Right, so for a calcium score, it’s only recommended if you haven’t had a heart attack or stroke, or heart attack like a stent or any prior revascularization. It’s usually for people who are primary prevention or, kind of, like primordial, but more for primary prevention people. So, once you’ve had the disease, once you’ve had a heart attack or stroke, the utility of a calcium score is not really tested, especially if you’ve had a stent or a CABG, we really don’t order a calcium score for those patients. But once you’ve had a heart attack or stroke, that puts you in a different category. You’re not primary prevention anymore, you’re secondary prevention. And so, if you’re secondary prevention, you should be on aspirin and statin regardless. It’s -- a class one recommendation, someone with a prior MI, myocardial infarction or stroke, to be on a statin or aspirin. The calcium score doesn’t really have much of a utility in those patients because it’s not changing the decision. They have to be on it to prevent a future heart attack or stroke. But in someone with risk factors who haven’t yet developed a heart attack or stroke, it’s reasonable to get a calcium score just to get an idea of what their risk factor burden is. Because let’s say we measure someone’s blood pressure today, or we measure their cholesterol, or their blood glucose levels, we know that those risk factor levels change over time, even in the course of a day. Your blood pressure today, right now at 10 A.M. is not what it’s gonna be 6 P.M. So, that’s one of the limitations of these risk calculators that depend on risk factors. We measure them a .0, but it doesn’t tell us what it was before, it’s not gonna tell us what it is after. And those risk estimates really can change significantly based on what risk level you enter. And so, if we think about calcium score as the risk integrator, such that all the effects of risk factors, again, diabetes, hypertension, high cholesterol, they all act on the coronary artery and the vasculature. And by measuring how much calcification there is in the arteries of the heart, we can, kind of, have an idea of what’s been your cumulative burden of exposure to these risk factors over your lifetime. And so, it’s a much, I think, comprehensive risk assessment tool as opposed to a risk calculator integrating all your risk factors just by that one simple task. I think that’s why makes calcium score such a powerful tool for prediction and also it has been shown to affect reclassification. So, if we’re not sure what someone’s risk category is, having a calcium score really can make sure you’re in the right risk bucket so you can treat appropriately.

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ZACH: Heart disease, cardiovascular disease, coronary artery disease, they’re all the same, or are they? These terms are often used interchangeably but it’s important to understand the differences. Cardiovascular disease is the term used for every kind of disease that affects the heart including conditions such as heart attack, arrhythmia, stroke, coronary artery disease, heart failure, and heart valve disease. Cardiovascular disease also describes diseases that affect the blood vessels, including peripheral artery disease, deep vein thrombosis and more. Heart disease is a catch all term for conditions that affect the structure and function of the heart. That means that all heart diseases are cardiovascular diseases, but not all cardiovascular diseases are heart disease. The most common type of heart disease is coronary artery disease, also sometimes called coronary heart disease. In fact, when most people refer to heart disease, they often mean coronary artery disease. Since the condition can be a silent disease until it strikes, it’s important to work with your primary care provider or cardiologist to understand and control any risk factors you may have.

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KIM: After the break, more with Dr. Al Rifai about how can prevent coronary artery disease and how you can support a loved one with the condition.

ANNOUNCER: From annual checkups to managing chronic conditions, your health care should be personalized to you. At Houston Methodist, our primary care doctors provide customized care for you and your family with more than 40 convenient locations across greater Houston. We offer a variety of ways to get care, from in-person and virtual appointments to same day visits when you’re sick. Choose your doctor and schedule online at Houstonmethodist.org/stayhealthy. Houston Methodist, Leading Medicine. 

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KIM: So, is it possible to go into remission with the disease or is there a way for you reverse the effects?

DR. AL RIFAI: So, we get asked this by patients all the time. So, let’s say they’ve had a calcium score test and their score is a hundred. Can a score of a hundred go back to fifty? Not really. Clinical atherosclerosis it’s a progressive process and it increases over time. So, a score of 100 today is probably gonna be 200 or 110 depending on what other risk factors exist and how well controlled they are. So, it’s not possible as of today to “go into remission,” quote unquote, but you can definitely change that slope of progression over time from a steep slope or from a flat slope depending on how well your risk factors are, and not just cholesterol but other risk factors as well. But as far as having a heart attack or stroke, it is very possible to prevent you from having another heart attack or stroke by controlling your risk factors. So, it’s not inevitable that once you’ve had a heart attack, you’re gonna get another heart attack over the next ten years. And there was actually a recently published study just from Denmark showing that once you’ve had a myocardial infarction and you’ve had a stent, and you control your risk factors very well that really, your risk is not that much higher compared to the general population who hasn’t had a myocardial infarction. So, controlling the risk factors really goes a long way. And it’s not taken for granted that you are going to have a heart attack or stroke regardless. You can modify the course of the disease by controlling your risk factors. No remission per se, but more of preventing it from happening, controlling that change and progression.

KIM: Getting a diagnosis of coronary artery disease is not a diagnosis that you are going to have a heart attack or stroke down the road.

DR. AL RIFAI: Correct. So, we’re not talking about people who’ve already had a heart attack or stroke, that’s a different bucket. But for people who have not yet had a heart attack or stroke, talking to them about prevention is the opportune time to prevent it from happening in the future. And it doesn’t mean that it’s going to happen, but if we control your risk factors very well, we can almost be certain, or at least maximize your risk from happening in the first place.

KIM: Talk to me about managing those risk factors. You shared being on a statin to control your cholesterol, that sounds like it’s one. What are some of the other ways that we manage the disease?

DR. AL RIFAI: Right. So, the AHA has their Life’s Simple 8, which is a very elegant way of showing a patient what their overall risk factors that they can control. And there are things that are modifiable and things that are non-modifiable. For example, we -- major risk factors that we all know about: cholesterol. And that can be targeted with medication and lifestyle. Same as diabetes, that’s a second one. The third is blood pressure, and the fourth is smoking, and then you have other risk factors like your diet. You know, make sure that you’re on a healthy diet, and usually that means a Mediterranean diet, DASH diet. These are diets that are typically low in salt and low in saturated fats, low in cholesterol, high in vegetables, and whole grains, and white meat. The other is exercise and physical activity. Making sure that you walk 8,000 or 10,000 steps per day, going to the gym and doing moderate to vigorous activity at least three to five times per week. And I usually tell my patients anything that breaks a sweat can be classified as moderate to vigorous intensity activity. And then, something that we really don’t talk about much is sleep. Getting adequate sleep. Whatever that number means, there’s no ones -- Seven hours or eight number -- eight hours. Whatever works for you. But getting an adequate amount of sleep, making sure you don’t have sleep apnea that needs to be controlled with other -- with like a CPAP. So, these are collective risk factors that have to be controlled. And it’s not just one risk factor that needs to be controlled. If you control just one risk factor and you have other risk factors that are not well controlled, you’re kinda negating the treatment of that risk factor. So, all risk factors need to be well controlled. And studies have shown us that really, the minority of people have all eight risk factors well controlled. Most of us have at least one risk factor. But really, the higher the number of uncontrolled risk factors, it does corelate with how much calcified plaque you have and also what your risk of having a future heart attack or stroke is in the future.

KIM: Based on, kind of, everything we’ve discussed, prevention really is key. And if we can, trying to prevent coronary artery disease from ever developing if we can. So, if we want to prevent disease, what should we be doing? Is it the healthy eight?

DR. AL RIFAI: It’s the healthy eight. Trying to emphasize a healthy lifestyle in conjunction with medications as needed, and just follow up with your physician. Whether it’s your cardiologist, or your family doctor, or your primary care doctor. Whoever it is you’re following up with, making sure that all these risk factors are well controlled and, you know, having yearly follow up, and we check cholesterol at least once a year, blood pressure. Because that can change over time. And so, just making sure that these risk factors are seriously monitored and treated appropriately. And each one of these risk factors that I mentioned before, there’s clear guidance on what the optimal levels of those risk factors are. And so, trying to get to optimal levels of all those risk factors, I think that’s going to be the biggest chance that you have to prevent heart attack from happening in the first place, or stroke. And so, just -- at every visit, try to emphasize those eight factors. And then if you need a coronary calcium score to, kind of, help convince your patient that prevention is important because they already had subclinical disease and, you know, they can see it in their own eyes. That can help them as well be convinced about the importance of controlling their risk factors.

KIM: I’ve had the opportunity to have lots of conversations with different physicians across our system, and there’s always this kind of common theme where when you don’t prioritize some of the healthier habits, whether it’s, you know, working out or getting that healthy diet in. There’s a lot of barriers into doing those things. And I think perhaps with coronary artery disease, heart disease in general, there might be a perception of moral failing with it. Could you talk to me about that and how does someone, kind of, work through that?

DR. AL RIFAI: People who’ve had a heart attack or stroke may feel like they have -- They may feel disappointed. In the sense that, you know, they did something wrong. And they may feel that people are, maybe, judging them for it. You know, why couldn’t you have done a better job at controlling your risk factors? Why couldn’t you have done this? But regardless, once the disease has happened, it’s not a life sentence. There’s opportunities to prevent disease at any point in time. Whether it’s before it happens or after it happens. Prevention can happen at any level. And so, unfortunately it can be sometimes a wake-up call when someone comes into the hospital with a heart attack or stroke, it’s a wake-up call that, you know whatever you were doing before wasn’t working and probably needs to be changed. Patients need to feel empowered that the changes they make today will most certainly have an effect on changing the course of the disease in the future. And whether they’ve had the disease or just the risk factors, making those changes today will certainly help. And they shouldn’t feel like “it’s certainly going to happen, I can’t do anything about it.” There’s no remission per se, but there’s preventing and there’s changing the course of the disease. So, they do need to feel empowered. And I think we need to speak to that as well, just to empower patients to be able to make the changes today that can change tomorrow.

KIM: To follow up on that, when someone gets diagnosed with a serious disease like cancer, or maybe someone does have a heart attack or stroke, it’s usually that family and friends all, kind of, rally together to give support to someone. Before coronary artery disease is diagnosed, it’s more of an unseen condition. You have certain risk factors and, as you’ve mentioned, like, someone might not be able to contextualize it for themselves to take seriously. So, how are they going to communicate that to their friends and family. So, what advice would you give to a patient to get that support to make any lifestyle risk factor changes that they may need to and for anyone who has a partner, family member that is -- has those risk factors. What can they do to support?

DR. AL RIFAI: Old habits can be hard to break. So, you know, if someone’s a smoker their whole life or their partner’s a smoker, you know, the partner really has a very important role to play. If the partner doesn’t smoke, they can help their spouse who does smoke, kinda, quit smoking. Or if the patient themselves doesn’t smoke and their partner smokes, and that patient is trying to prevent heart disease from happening, their partner can see it as, you know, maybe a reason to stop smoking themselves. Or if a couple goes to start working out together or change their diet together. It's much easier to make changes when both parties are invested. And so, having that family member also, kinda, be involved in the new, healthy lifestyle just makes it more likely that the patient themselves will adhere to it as well. So, it does take a village. Whether is your spouse, your parents, your children. I feel like everyone should be involved in that care and trying to reinforce that new, healthy, lifestyle change that the patient’s trying to adopt. Because if it’s just them and they’re -- you know, it’s not really easy to stop smoking when everyone around you is smoking, right? Same goes with diet and other risk factors. So, kinda, everyone needs to be educated about the disease, and everyone needs to play a role as well.

KIM: Is there anything that we haven’t touched on that you would absolutely want someone to know about the condition?

DR. AL RIFAI: You know, I think something that we don’t talk about as much as well is mental health. And so, whether that’s stress, anxiety, depression, these are all factors that can not only have physiologic consequences, but also if you’re stressed, and you’re anxious, or you’re depressed, it may be a little bit harder to take your pill, or stop smoking, or have a good diet, or sleep as well. So, it does take the collective, both mental health and physical health. Both need to be well taken care of for the patient to, you know, give them the best chance possible. And so, I think also addressing mental health, even if we’re not experts at it, I do ask some of my patients to follow up with their primary care physician if I feel maybe they’re anxious or depressed or stressed, because there are some things that I’m not an expert at. But these are still risk factors that need to be controlled. And I think mental health is very important to stress as well.

KIM: What about that, sort of, low hanging, chronic stress that probably a lot of us deal with all the time where it’s just like this low --  yeah, yeah. Just that life stress that, kinda, comes into play. Does that, like, get the blood pressure up?

DR. AL RIFAI: It can. Especially blood pressure is very labile. It can go from 120 to 180 if you’re under stress. So, indolent, kinda, low or long-term exposure to stress may, not certainly, but may have an effect. And so, I think it still needs to be controlled. Especially when we consider that the cumulative burden of someone’s exposure to risk factors is what determines their likelihood of having an event in the future. So, all those risk factors combined, you know, can be potentiated by stress or other chronic mental health conditions. So, they may act synergistically at times. But there’s no clear data or evidence to say how much degree of stress or other mental health conditions has on someone’s likelihood or chance -- or risk of having a heart attack or stroke. But more likely or not, it does. And stress needs to be managed, again, with all the other risk factors that we talked about.

KIM: Well, thank you so much for talking with us today. I feel like I have a much better understanding of risk factors for coronary artery disease, and prevention, and -- So hopefully, for myself and for others, we can, kind of, help lessen our risk for heart attack and stroke.

DR. AL RIFAI: Absolutely. It was my pleasure being with you today. It’s some -- prevention is something that I’m very passionate about, and I do think an ounce of prevention is worth a pound of cure. And the risk factor discussion and prevention can happen anytime, but the earlier the better. And just know that you have the power to change the course of the disease. And what you do today will definitely have an effect. Even if you don’t see it today, it will have an effect in the future. But I encourage you to see your physician and talk about prevention, and kind of educate those around you about the importance of prevention.

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ZACH: So, Kim, something Dr. Al Rifai was very passionate about was preventative care, which is something we talk about all the time, but I feel like in this conversation, we probably talk about it more than anything, right?

KIM: Oh yeah. And I think one of the most powerful messages was, again, prevention. But once you have a heart attack or a stroke, you’re not destined to have another one because you had that first one as long as you take the necessary steps to control your risk factors or control coronary artery disease. And, you know, and I think when we think about preventative care, we don’t necessarily know what we’re preventing against. It’s like this big amorphous thing. But, you know, if you know that you’re more or less keeping a healthy diet and working out as much as you should, you know, you’re doing your best to help prevent heart disease.

ZACH: You know, he mentions a lot of things that we talk about all the time on this podcast. Either specific topics like sleep apnea. Alright make sure you get your sleep because sleep apnea can lead to this. Or, you know, exercising, right? And he mentions, like, three to five days a week, which is whew. But, as long as you’re, like, sweating like he said. As long as you’re sweating, which is great, that’s great news because I sweat all the time. So, that’s fantastic news. As long as I’m sweating.

KIM: You might be getting more exercise than you think you are.

ZACH: I know, that was great. But also, the Mediterranean diet. I mean, I feel like every expert does mention the Mediterranean diet. And so, all these other things, they all add up. Everything is all connected, right? And it kinda helps you understand what you are preventing like you said, Kim.

KIM: Yeah. And I think it’s great to know, especially younger folks. Because again, it is this -- the plaque building up in your arteries seems like this kind of amorphous threat. Everyone knows what a heart attack is, but really what you should be afraid of is that plaque.

ZACH: Mm-hmm.

KIM: And I loved what he said about, you know, it not necessarily being a sentence to have a heart attack or a stroke if you find out that you have plaque or that you have coronary artery disease. If you’re doing everything you can to manage your health, you know, managing your diabetes, managing your blood pressure, your cholesterol, all that. You know, there is a lot you can do to stop -- We know we can’t go into remission with it, but we can definitely stop it from progressing as much as it can.

ZACH: Yeah. I mean, that is -- it’s intimidating to know that one, it’s the number one killer in America, and two there’s no remission from it. But it’s encouraging, like you said, that there are all these avenues you can take to stabilize, maintain your condition, maintain your health. And by doing that, it’s gonna increase your health in all these other areas of your life too. So, you can look at the silver linings I guess.

KIM: Of course. And I think another thing that was really important is just going to the doctor when you can because you’re not really going to know if you’re at risk unless you really know your numbers about your cholesterol or your blood pressure. And these are all topics that I know that we’ve covered on either the blog, or the podcast, or both. And so, I would encourage everybody to check out those episodes. But knowing those numbers is really key to making sure that you’re doing everything you can to prevent heart disease.

ZACH: Absolutely. All right, that’s gonna do it for this episode of On Health with Houston Methodist. We drop episodes Tuesday mornings, so please be sure to share, like, and subscribe wherever you get your podcasts. And until next time, stay tuned and stay healthy.