PODCAST: What Cardiologists Do & When to See One

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, when was the last time you went to the cardiologist?

KIM: You know, I actually don’t have a cardiologist at this time, but heart issues do run in my family so that’s always a risk I might have that I might, one day, need one.

ZACH: I also do not have a cardiologist at this present time. And not something that had occurred to me to look into, at least right now, where I am. Fortunately, health-wise, I don’t have a history of heart conditions in my family, I haven’t experienced any myself. And that’s our human nature, right? You’re not gonna address it until a problem comes up. And that’s, kinda, where I am right now as far as cardiologists go.

KIM: Yeah, and what I think is very interesting is that cardiologists can help manage maybe some of the things that are risk factors for heart disease. So, they’re going to help manage cholesterol, they can help manage blood pressure. And those are things that you can work with a primary care doctor with as well. But I think maybe having that specialized care might help prevent heart disease from ever occurring.

ZACH: Yeah, we like to talk about preventative care here at Houston Methodist. And a cardiologist is, I feel, is on page one of that list, right?

KIM: Yeah. I think it was very interesting to hear our expert today talk about how -- I guess my perception always was if you need to see a cardiologist, you already have something, perhaps, serious happening with your heart health. But what I learned is that, really, a lot of cardiologists’ work is to prevent you from ever developing heart disease and so it was really illuminating. I was surprised how much I didn’t know.

ZACH: Yeah. And who did we talk to today about this, Kim?

KIM: We spoke with Dr. Joe Aoun. He’s an Interventional Cardiologist here at Houston Methodist.

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I think it’s safe to say that navigating healthcare can be challenging at times, knowing who to see and when. So, on the podcast, we’ve been exploring specialty care topics to help folks get a better sense of what they can expect when they’re working with a physician on their care. And today, we’ll be talking about all things cardiology. So, to start, what is a cardiologist and what do they do?

DR. JOE AOUN: So, a cardiologist is a medical doctor who actually specializes in diagnosing and treating heart disease and vessel or blood vessels disease. So basically, that’s what we call cardiovascular disease. Now, a cardiologist has to be an internal medicine specialist who specializes further into cardiovascular disease. And sometimes, we see subspecialists including interventional cardiology such as myself, electrophysiology, and others which we’ll probably talk about today.

KIM: What are some of the common and not so common conditions that cardiologists treat?

DR. AOUN: So, in general, some of the most common conditions that cardiologists treat include high blood pressure, for example, which is hypertension. Other diseases can include coronary artery disease, which are clogged arteries that give blood supply to the heart, and other diseases can include heart failure, when the heart is very weak, and then irregular heartbeats or rhythm problems such as atrial fibrillation for example. Less commonly, we treat with patients who have congenital heart diseases where they have defects when they’re born for example, or they have certain cardiomyopathies and valvular heart diseases. For example, I’m a specialist in valves, and I treat conditions, and I do transcatheter interventions on valves such as mitral valves and aortic valves. Those are not uncommon but sometimes we have to treat them with interventions or medications based on that.

KIM: What cardiology subspecialists support these various conditions?

DR. AOUN: So, we have a total of big four if you want. One is an interventional cardiology which are the plumbers of the heart in a way so they can open up clogged arteries. Sometimes we treat valves, as I mentioned, with transcatheter options without opening the chest. That means going through the groin or the wrist and fixing the valves. Other specialists include electrophysiologists, which are cardiologists who focus on the rhythm and problems in the rhythms of the heart such as irregular heartbeats, or patients who have some dizziness related to their heart issues. And then, the third category is heart failure specialists. Whenever the heart is very weak and they really need advanced therapies such as heart transplants and what we call LVADs, which are assisted ventricular devices. And then finally, we have cardiac imagers, who are subspecialized in looking and reading echocardiograms which are the ultrasounds of the heart, CT scans, or cardiac MRIs.

KIM: Can any of these big four be surgeons or are they their own specialty?

DR. AOUN: Cardiologists are usually not surgeons. We -- Interventional cardiologists and electrophysiologists, they do procedures but they’re usually not open-heart procedures. Cardiac surgeons are a different specialty in a way. They tend to do procedures such as open-heart surgery or sometimes robotic surgery. Those are not done by cardiologists.

KIM: Does someone need to work with a primary care doctor or a primary care provider in order to see a cardiologist? Or can someone make an appointment with a cardiologist directly?

DR. AOUN: I think that’s a very important question, and the answer, it will depend. It depends on several things. Sometimes the healthcare system, sometimes the insurance. And I would encourage any patient to contact their insurance before they have an appointment with their cardiologist. The main reason is, last thing you want is getting a huge bill to your place just because you did not get referred by your primary care physician. Sometimes it’s okay to just go to a cardiologist, and insurance companies and health care centers would allow that in certain situations, and that’s very important to check. I would encourage any patient to contact their primary care physician and tell them about their symptoms, because sometimes, it’s not the heart and they need to be referred to other medical specialties.

KIM: And I think that’s a great segway into what are some of the classic symptoms that would signal someone should see a cardiologist or maybe take that first step and talk to their primary care doctor?

DR. AOUN: The most common symptoms that we encounter patients having are chest pain or discomfort in the chest. Sometimes they say, “Oh, I have an elephant sitting on my chest,” for example. Other stuff includes shortness of breath. “So, whenever I’m starting to exercise, I’m having this shortness of breath. I cannot really breathe comfortably. This didn’t used to happen before, and this is new.” Palpitations, heart fluttering or heart racing, swelling in the legs, which can sometimes be related to heart disease, or sometimes to the kidneys, sometimes to the lungs or the liver, but it’s important for us to check the heart. And finally, dizziness, lightheadedness, fainting, all of those can be managed, or at least assessed by a cardiologist.

KIM: And are there any symptoms that we’re having that should prompt us to either call 911 or go to the emergency department, and which ones would be best suited for us to just see our primary care doctor or seek a cardiologist’s care?

DR. AOUN: Yeah. So, if someone is experiencing chest pain that lasts more than a few minutes, and especially let’s say they have some sweating, some nausea, some difficulty breathing, then definitely call 911. If they’re feeling that they have this elephant sitting on their chest and that chest pain is radiating to either their back, their left shoulder, or their jaw, those are signs that are typical of a heart attack. It’s not the pain that goes within a second, it’s the pain that lasts few minutes. Other things that are important and considered that are essential that we need to seek urgent or emergent medical care can include, like, sudden onset of shortness of breath, or fainting, or irregular heartbeat that are not going away and I’m having shortness of breath with. Some other conditions that are most commonly treated in the office would usually include, like, mild chest discomfort that went away, for example. Or I’ve had this irregular heartbeat for a few minutes, it hasn’t happened again and, you know, or it’s intermittent. Maybe every week, or every other week I have that, or every month. Those are conditions that can be evaluated just in a clinic setting anyway.

KIM: Yeah, you’re getting your notification on your watch that your irregular heartbeat’s happening. Yeah, that makes sense. We’ve talked a lot about symptoms, but are there risk factors that should make someone consider seeing a cardiologist, even if they’re not showing any of those symptoms yet?

DR. AOUN: Absolutely. I think it’s important to know that genetics play a role. So, number one factor is actually family history. So, if I have a history in my family of heart disease, or heart failure, or heart attacks, especially at a younger age, I think seeking the care of a cardiologist is very important. Other stuff includes risk factors such as smoking. “I’ve been smoking for a long time,” then it’s important. Uncontrolled high blood pressure, diabetes, and then obesity. And finally, with age. I mean, we know that heart disease commonly occurs in older patients. So, with age, some patients, they need to see their cardiologist in order to make sure that there’s no heart disease.

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KIM: After the break, we speak with Dr. Aoun about what you can expect during your first cardiology appointment.

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KIM: In general, what can you expect at that first appointment? Are we going to be getting any tests or are there any kind of standard questions that we should be ready and raring to answer?

DR. AOUN: Definitely. So, I think in general, whenever you meet your cardiologist for the first time, you’re gonna expect some of -- sort of a lot of questions. One, we really wanna listen from the patient what symptoms they’ve been having, how long they have been having these symptoms. So, medical history is very, very important. The second thing is family history. So, what’s been happening in your family? Did they have diseases at a young age? And then the third thing would be what has your lifestyle been? Have you been exercising? What diet have you been having? Do you smoke? Do you drink alcohol? And we really are interested in some of the details that are important. And we might tend to tell you, “Hey, please explain the symptoms in your own words and elaborate on that.” And that’s very important. Now, it’s not routine that we do testing on the first appointment, but in case that you need some tests, one of the most common tests that we do is called electrocardiogram. We use a machine that actually checks your heart rhythm, and it gives us a tracing, and it tells us the basics and the baseline of your heart rhythm at that moment when we do this test. Now, other things that we do in clinic are blood pressure checks, and we check the heart rate. Sometimes we order an echocardiogram, which is an ultrasound of the heart, in order to see if the heart function is normal, it’s not really enlarged, and if there are any congenital abnormalities or not. All those are very important. And lastly, we check some blood tests, for example high cholesterol. If you have diabetes, we might check your A1c, which is the reserve of the blood -- glucose in the blood, for example. And in certain situations, we might -- if somebody has been having chest pain, for example, we might tend to order a stress test. So, a stress test can be on a treadmill done or it can be using a machine where we inject some medication in the blood vein and then put them in that machine, which is close to a CT scan, but not pretty similar. But those are not done the same day of the visit, those can be done further down the road.

KIM: Are you gonna come out of your cardiologist appointment with some homework? Are we going to have to start tracking our blood pressure or, kind of, what are some of the follow up steps that you might encounter?

DR. AOUN: Yes, definitely. So, I think it will depend on the disease of the patient, or the condition, or the risk factors. But a lot of the time, our patients have more risk factors than the disease itself, and we would tell them that lifestyle changes are very important. And definitely, no matter what we can do as cardiologists, I think the patients are the leader here, right? So, whenever we advise them we would want them to exercise more, control their salt intake for example, be on a healthy diet, more vegetables, maybe less meat, stuff like that. But definitely, majority of the time, we recommend these things to our patients, and I think we cannot really improve their health without that decision and that lifestyle change that they will do.

KIM: That’s so interesting because in preparing for our conversation, I encountered an analogy from another cardiologist and it was that there’s a ship, a captain, and a first mate. And the patient is the captain, and the cardiologist is the first mate who gives information and counsel, but ultimately, it’s that patient, the captain, that has to make decisions and sail the ship. So, does this analogy resonate with you? And, you know, how would you describe the cardiologist/patient relationship?

DR. AOUN: I mean, I really love this analogy. It really captures the collaboration between the patient and the physician. And I think as a cardiologist here, my role is to provide the expertise and information, and guidance to help the patient understand what the disease is, what can they improve. But at the end of the day, the patient are the captain of their own ship. They are gonna make their own decision. They’re gonna manage their health care. We’re gonna provide them with options on how to treat their condition and they’re gonna be, sort of, choosing what is the best approach for them, right? I mean, sometimes we might recommend something that is a medication, and sometimes we might think that actually that procedure is the best option, but the second best option might be actually medication. But then the patient would decide, “Hey, I do not wanna have the procedure right now. Maybe I will just try the medication.” And that’s okay sometimes. In certain situations, our recommendations are really important, and we tell them, “Hey, this procedure is lifesaving." And that's when we tell the patient that, “Hey, you should proceed with that.” But at the end of the day, they decide if they really wanna go through this. Again, being a good captain means actively participating in the care, right? That doesn’t mean that, “Hey, if we do this procedure to the patient, that’s it.” No. Lifestyle changes are important. Taking the medications are important. Following up with a primary care and with a cardiologist is really important. And making sure that they track what they do. For example if -- let’s say somebody has really high blood pressure, and then we give them the medication. We wanna know if they’re taking the medication, it’s really important for us to know if they are on low-salt diet and they’re following that diet. And if they’re measuring it at home, is it really well controlled? And we cannot really know that without the patient, right? So, they have to be the captain, and once they start taking care of themselves, I think with our guidance, they will do a great job.

KIM: And so, it sounds like being a good steward or being a good captain is all about that engagement. And is it fair to say that if you’re not very engaged then perhaps, you know, you kind of get what you put in?

DR. AOUN: Yes. So, basically being a good captain involves being proactive, informed, and engaged. So, here are, like, some few tips. Number one, I would say be honest and detailed. So, we wanna hear about your symptoms. We wanna know when they started, what makes them better, what makes them worse. Just tell us everything. Second thing, ask questions. By asking questions, you’re gonna know what to do on a day-to-day basis and what to expect in the future. Three, is be open to making changes. Again, lifestyle changes are very important, and we might recommend that. And nobody wants to change what they’ve been doing for a long time, but if it helps you then why not? And finally, keep track on your health. So, monitor your blood pressure, monitor your diet intake, and give us all this information so we can help you in the future.

KIM: You bring up such an interesting point about honesty. Because I think anyone who goes to their doctor and, you know, the doctor’s asking them questions, you know doctors are very prestigious and they, kind of, hold places of power. And so, I mean, I’ll speak for myself. I don’t wanna let my doctor down by telling them how many glasses of wine I have in a week. Like, nobody wants to let their doctor down. But it’s very important that you are honest with them because they can’t help you if you’re not honest.

DR. AOUN: I agree. Well, I mean, it’s one thing that physicians tend to, you know, give advice. But trust me, it’s not easy for them to follow their own advice. So, we all know that we’re human beings, right? I mean, we recommend that you should do this, you should do that. That doesn’t mean that every physician is doing this and that. And by the end of the day, lifestyle changes is difficult. But what we say is what we have learned throughout experience, throughout studies, and all those recommendations are based on evidence-based medicine. And if we don’t really know what your lifestyle has been, we cannot really make recommendations to help you specifically. So, I would say honesty is number one no matter how hard it is. because after that, everything becomes easier.

KIM: Can you share what people may expect if your cardiologist refers you to a subspecialist such as an electrophysiologist?

DR. AOUN: So, cardiologists in general, despite that they’re very specialized, most of them can treat with basic bread and butter cardiology and heart diseases. Now, the most important is when you -- when your cardiologist wants to refer you to a subspecialist for a certain particular condition in the heart. That’s when it’s really important to find the specialist that you really need. In a way, if you’re dealing with a heart rhythm, a general cardiologist can treat majority of those. But let’s say if you need that to be ablated, they will have to refer you to a specialist such as an electrophysiologist. And the field of cardiology has been progressively, and over time, has been impacted by so many advances. We, at this point in time, are able to do so many interventions that we have never thought of that we can do through transcatheter options and transcatheter based therapies. And all of those, despite that they have been new, a lot of them have shown that, in certain situations, they can be as important or sometimes better than open heart procedures. That’s why cardiologists in general tend to do these meetings, what we call multidisciplinary meetings between cardiologists and surgeons, cardiovascular surgeons, and other subspecialties in order to determine what is the best for this specific patient. In other words, sometimes surgery is the best option and cardiologists wish for that. Sometimes putting a stent is the best option. Or sometimes doing a repair on a valve using an open-heart surgery is a better option maybe. And in certain situations, transcatheter based options by going through the groin or the wrist are the best options. And at the end of the day, despite that we would recommend the best options, again, the patient is the captain of the ship so they will decide what they want and what we will do for them.

KIM: Heart disease runs in my family, so I can imagine feeling some level of trepidation about needing heart care. But from what you’ve shared, it sounds like with improvements, and treatments, and procedures, you can work with a cardiologist and you may never see the inside of an operating room. Is that fair to say?

DR. AOUN: Yes. So, what we do, in general, for patients who do not have heart disease, we actually work on prevention. And the most important thing is actually prevention of having a heart disease more than fixing or managing the heart disease. A lot of our work is actually treating the risk factors for getting heart disease, such as high blood pressure, diabetes, other stuff. So, we actually are prevention specialists in a way to try to stop heart disease from happening. But in case it happens, we are able to diagnose and treat those conditions. And hopefully, we can get by without even needing an intervention, which is a procedure or a surgery. And again, prevention is very, very important.

KIM: When we’re thinking about potential treatments and interventions we might have when we’re working with a cardiologist, what do those look like?

DR. AOUN: So, first thing is actually lifestyle changes. This is the bread and butter. And majority of the time, that comes before the medical therapy. The second thing would be starting a medication. And sometimes, that does on cut it, or in certain situations, which are conditions that are life-threatening or not on the short term, maybe long term, sometimes interventions such as transcatheter based or surgical based are recommended. But again, we try to prevent as much as possible, but in case the disease is there and it can be fixed by lifestyle changes, or medication, or procedures, this is when a cardiologist would intervene.

KIM: So, this has been so enlightening. And I’d love to know, is there any last message you’d like to leave our listeners with before we wrap up today?

DR. AOUN: So, cardiology has been a growing field. Years ago, back in the 1990s and even before, medical therapy was the only option. And a lot of our patients, sometimes, did not make it to be elderly and that’s because heart disease is the first cause of high mortality in the United States. At this point in time, with the advances in technology and medication and prevention, our patients are currently living longer and living healthier. And basically, we want them to make a decision and have set goals that we can work on with the medications or sometimes with procedures to get them there.

KIM: Thanks so much for being with us today, Dr. Aoun.

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ZACH: So, cardiologists, Kim, not to fear.

KIM: No, no. I don’t think so, which helped ease some of my trepidation about potentially needing heart care down the line, or just even thinking about getting that referral from your doctor being a scary thing, and it’s not anything to fear.

ZACH: Mhm. And as usual, you know, our experts, the advice they give us, get your proper seven to eight hours of sleep, eat healthy...

KIM: Control your blood pressure, control your A1c or your blood glucose, yeah. I think the American Heart Association has their essential eight, I think it’s called, which are all of the heart healthy habits you can do. Quitting smoking, eating healthy. All the things we really, kind of, talk about here on the podcast are part of that healthy eight. So, you know, a lot of preventing seeing a cardiologist comes down to basic healthy habits.

ZACH: And of course, all that sounds like common sense, but there’s a reason we have to keep reminding people, and there’s a reason that these issues crop up and --

KIM: Yeah. And I thought what Dr. Aoun had to say about us all being human, and knowing that change is hard, but trying to be a good advocate for yourself to have the kind of outcomes you want and the kind of life you have…

ZACH: Mhm.

KIM: I found that very inspiring because, you know, I think when you’re starting on a health journey, it can seem very, very daunting.

ZACH: Right.

KIM: But you know kind of what your outcome, what you wanna have is. Like, you wanna be able to be healthy as you age, you wanna be able to see your grandkids graduate from high school, or college, or whatever. Taking steps to help you achieve those goals are really what doing all of these things that we don’t wanna do like eating healthy, that’s what it can do for us.

ZACH: Well, and I really like what you guys had mentioned about you need to be honest with your doctors, right? Because there is that -- there’s that guilt or shame or like, “Have you been doing this?” And you wanna say, “Oh, of course, I have.” And you haven’t, right? And they can’t help you unless they have all the proper information because it’s like, well, if you’re not doing steps one, two, three, getting to steps four, five, and six don’t even matter because your foundation is all messed up. You have to be honest about that. Get that solid foundation of health and then you can move on to the deeper steps, right?

KIM: Yeah, and you know, I think there is a certain amount of we don’t wanna let our doctors down…

ZACH: Right.

KIM: When we’re in there. And it can also, like you said, the shame can crop up. But if there is no one you can be honest with, you probably should be very honest with your doctor because otherwise, they’re working with incomplete information and you might not get the care that you need if you’re, you know, hiding how many glasses of wine you have in a week or if you’re hiding about, you know, “I go to steak night every week.” Or, like, whatever it is that you might be doing.

ZACH: Yeah. I mean, that’s the time for brutal honestly on both fronts, right? ‘Cause you wanna -- I mean, at least the way I think about it, you wanna hear it straight. Like, “Here’s what your issues are, where you need to be. And if you don’t do these things, you’re at risk,” whatever that risk may be.

KIM: Cardiologists really are intervention specialists, and I was so surprised to hear that because I thought if we’re going to have to see a cardiologist, we already have heart disease, right? We already have something serious happening. But I think so much of what they do is helping you from ever developing heart disease. You might not need to have a catheterization, or you might not need to have open heart surgery because you’ve been working with them for so long and you’re managing your heart health, and it’s not an issue.

ZACH: Right. So, don’t be intimidated that you’re going to the cardiologist. They are your friend.

KIM: Yeah, they are your friend, and they can help you live the best life that you can.

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