Detect Silent Heart Disease Early

Joel Kahn, MD, FACC

I’m here. Thank you, fellow. Joel, actually, one of my favorite T-shirts somebody made was Dean Colin SC, and he has one more name and two Joel’s, which I’m not sure I get in that hallowed group, but it’s good to work with you. And that’s teach some people some great stuff about preventing heart disease today. All different aspects.

Joel Fuhrman, MD

Great. All right, let’s get right into it. So there’s something called silent heart disease because most people that have heart disease could be killed with the first symptom, could be a heart attack. So what are some of the symptoms of heart disease that people could suspect? That’s something they should be concerned about.

Joel Kahn, MD, FACC

Yeah, this may be one of the most important things that are presented in this really broad and educational summit that you and I are hosting in its second year because you can’t assume that you’re free of atherosclerosis, even in my opinion, as a cardiologist, even if you’re really adhering to an excellent a Nutritarian lifestyle and you’re working out. This is such a pervasive disease. There are many, many studies that talk about how frequent silent atherosclerosis is. Silent meaning you had a good day, you went to the gym, you worked, you were with your family, but your arteries are far from healthy. One of the most famous studies is in Spain, in Madrid, it’s an ongoing study for about the past six or seven years called PESA, PESA progression of early subclinical atherosclerosis studies. They are all experts.

But they took a little over 4000 people from age 40 to 54 working at a bank, a big bank in Madrid. And they’ve been putting them through a drill of the heart, calcium CT scans, ultrasounds of their arteries, of their brain, the carotids, ultrasounds of their leg arteries, and looking for silent atherosclerosis, and it’s found and these are relatively young people. They’re all under 55 years old. They’re all without symptoms. 71% of men, and 48% of women in this age group, you can find deterioration in their arteries. Now, that may be 10 years away from a heart attack, the bypass, the stroke, or the sudden death you mention. Might be three, four, or five years away from an erectile dysfunction problem developing in a man, which is common in other manifestations. But, you know, I just said that 50 to 70% of people thinking they’re doing okay have silent atherosclerosis. So it’s a big, big issue. It’s our Western lifestyle and, you know, you’ve got a great solution to it. I work on it, but you got to know you have it so you can really monitor it.

Joel Fuhrman, MD

Right. And of course, with the majority of the population being overweight and eating worse than ever, I’m sure it’s much greater than people that have atherosclerosis and heart attack risk. And even found that in the PESA study, you know, especially in this country.

Joel Kahn, MD, FACC

I agree. I agree. We’re probably in worse shape than some of these fitter European bank workers.

Joel Fuhrman, MD

Yeah. So go on. So what are the symptoms that people have to consider there if they don’t know they have heart disease? So is a no symptoms at all?

Joel Kahn, MD, FACC

Right. It can be none but you know, people still need to be clued in to the understood appreciated ones and never ignore them. So anything that feels bad on exertion and feels better quickly when you stop exerting and exerting could be going to the gym, could be walking through a parking lot or an airport, could be carrying heavy garbage bags or leaf bags to the curb, could be doing a treadmill test. But anything that feels bad really, we say between like the nose and the belly button, and if it feels better within a couple of minutes, be concerned. Now, the classic is pressure, tightness, and squeezing that for hundreds of years has been called angina pain or angina. You can tomato, tomato, say it either way. Dr. Heberden, I think is the one credited with ascribing to that. So if you start to feel a fullness, a burning, and a pressure. Patients correct doctors. Doc, I don’t have any pain but I have this pressure, this uncomfortable feeling, this distress, and it comes on when my heart rate and blood pressure go up with exertion and it goes away in about a minute or two. It could be hiking, or biking. Never ignore that. And that’s a horrible thing to wait for because that does mean if it’s accurate, you’re probably already 80, 90, 95% clogged up in some important blood vessels. And those are the classic angina symptoms. But there’s more.

Joel Fuhrman, MD

Yeah. There are the atypical symptoms, right? That people don’t generally feel like chest pressure.

Joel Kahn, MD, FACC

Right. And these are again, people really got to pay attention to this, particularly when we’re talking 50 to 70% of the population just randomly selected has atherosclerosis. Some of them are going to have it more severely not as many as 50 to 70. So anything you do on exertion and forget about the pressure in the angina. If you get very winded, if you get very weak and fatigued, if your fitness is starting to drop, there are many factors, but atherosclerosis could be one and that’s the one that could kill you. But then there’s the really crazy ones that are not stressed enough. I had the pleasure of interviewing Dr. Scott Stoll of physical medicine and rehab plant-based physician, and we talked about low back pain being more common in people with atherosclerosis because the blood vessels to your spinal column can get involved. And that’s a very rarely mentioned clue to atherosclerosis.

So there are many causes of back pain. Don’t jump to the conclusion you’re having a heart attack, but know your numbers for sure. We’re going to talk a lot about knowing your numbers on this summit. A pain in your calves. You’re walking up a hill and your calves cramp up. Could be your thighs, but the classic is your calves. You sit down on a park bench and in two minutes your calves feel better. That’s the engine equivalent in the chest when you have blockages in your legs. So don’t ignore that. Talk to your doctor about it. Get a Doppler study, have somebody put their hands on your legs, and feel your pulse. Maybe you’re losing some hair prematurely on your legs. That can be a subtle sign that’s called clotting. And then there is in the men’s erectile dysfunction and there’s been good data for way too long, at least 25 years that a man developing erectile dysfunction may have poor blood flow to the pelvis and many times also has poor blood flow to the heart that’s silent. So it’s often three to four years after the development of erectile dysfunction that men may start to show up in an emergency room, have a heart attack, are actually drop dead.

So never just get the blue pill and certainly change your diet and your lifestyle. Still, get your heart checked. Just a couple more, there is a little bit about premature graying. You’re in your forties and your hair is turning gray or you’re losing it on top in your forties. Premature gray is associated with atherosclerosis. It’s a sign of maybe your inflammation and your oxidative stress. You’re out of balance. And the last one is perhaps the strangest one but it’s so easy. I was sitting next to a gentleman yesterday and I noticed his ear lobe had a deep, deep, deep crease. About 50 years ago, a doctor in New York City was examining his patients every day, every day, and made an observation, when my patient had heart disease, maybe they had a heart attack or bypass. I see this deep crease and he called it a diagonal earlobe crease. And Dr. Frank was his name. He published that observation that was forgotten for a while. But in the last 15 years, there are a dozen or more scientific papers that say it’s not perfect. It’s about 70% predictive. But if you notice in yourself or a loved one, or if you’re a health care provider and a patient, a deep crease in your elbow, get checked, get your heart checked. It’s a strange one. DLC diagonal earlobe crease. Just go look up and a search engine Steven Spielberg and you’ll see really deep creases like the gentleman I was sitting next to yesterday, just casually talking. But you owe it to that person to tell him. Get your heart checked. You want every early warning system possible.

Joel Fuhrman, MD

And that could be high cholesterol that can cause earlobe creases, right?

Joel Kahn, MD, FACC

Yeah, we think so. You know, it’s debatable that we don’t think they go away and we don’t think you’re born with them. And some people have gone back and looked at, you know, pictures of themselves 15 years earlier. They didn’t see it. So and a strange one with real science.

Joel Fuhrman, MD

Also, women can sometimes get like abdominal pain, nausea, sweating, and could be an almost is like gallbladder disease, almost like gallbladder disease with a sweating, nausea, abdominal pain could be can’t tell the difference between that and heart disease, or a possibility of a heart disease or a heart attack.

Joel Kahn, MD, FACC

Yeah, that’s when it gets really tricky but it’s important what you brought up. You talk to people in the emergency room having a heart attack and they’ll tell you quite frequently, Boy, I’ve been having dyspepsia and burning, and right above my belly button, a lot of burning. I took some Maalox, I tried some Tums. And there’s particularly one of the three arteries, the heart called the right corner artery, it feeds blood to the bottom of the heart. The bottom of the heart and the top of your stomach are set right next to each other. So you can really make it challenging to suspect heart disease. So if you know you’ve had a scope and everything’s fine and you don’t have any known peptic ulcer disease and you’re having burning and you’re, you know, we call it your epigastrium but that spot between your belly button and your chest and then there are all the other subtle ones, particularly we talk about it, women just fatigue. I feel run down now. There are so many different causes, palpitations, and shortness of breath, for sure. Shortness of breath has many manifestations like lung disease, emphysema, and COPD. But particularly if you’re just on a daily level getting more and more short of breath, you need an urgent evaluation.

Joel Fuhrman, MD

Well, almost all Americans, you know, if people are overweight and they have to start to get their blood pressure going up, they’ve got heart disease, they’ve got high blood pressure and they’re overweight. They have heart disease. It’s an early form of heart disease and yet that’s why we want to make sure that they learn what we’re teaching them here so they can lower their blood pressure, lower their weight, eat super healthy, and not have to worry about these issues. You know, it’s like everybody’s going to want disease like other Americans. They’re all going to get it eventually. If they don’t if they eat that the way other Americans are reading, you know.

Joel Kahn, MD, FACC

Well, I think you, from your clinical experience, have seen that over and over. And that’s what my practice is all about, is an office full of people that I give them the news. Yeah, I suspected and we confirmed and now we’re going to work on it.

Joel Fuhrman, MD

Yeah. So, when you’re evaluating people, what role does the ultrasound like the CMT ultrasounds play versus let’s say something like calcium scoring? So go in the ultrasounds first. I use that.

Joel Kahn, MD, FACC

Yeah, ultrasound is such a great technique. You know, when it’s done of the heart, we call it an echocardiogram and we’re not talking about that right now. We are talking about ultrasound of blood vessels. So we usually call it an ultrasound because it’s no radiation. It’s generally less expensive and widely available. So, I tell people there’s kind of three options. Some people sign up and I’m not promoting anything. But your town will probably have a life screening event or you’ll pay some dollars and they’ll do a quick ultrasound of the arteries, the brain, the right carotid, and the left carotid. They usually do it of your around your belly button. It’s called your abdominal aorta looking for an aneurysm. And it’s a reasonable thing to choose. But they’re solely looking for this 70, 80, 90% blockage. And I don’t know about you and the listeners, but I want to find out when I’m five or 10% narrowed so I can intensify what I’m doing, what lifestyle or whatever else is needed. So I’m not against those programs. But I, you know, if you have limited dollars, they’re far from accurate, particularly for early screening. That’s not what they did in this Madrid, Spain study. 

Then you can go to the hospital, you can ask your primary care doctor. Can you write me a prescription for a crowded ultrasound? That’s where I’m really disappointed because they will charge a lot to the insurance company or maybe a self-pay. And it’s very common for the report to come back with no severe narrowing, but I don’t know what that means as a doctor, or might come back with less than 50% narrowing. Well, I don’t know if that’s 2% or 49%. It’s done by measuring something called velocity, and they may not actually comment on plaque or how much plaque. Then there’s really the state of the art but unfortunately a little hard to find it. So when I do at my clinic and you did in Fleming, New Jersey, I think it’s still available for years and years. The CIMT, four letters, Carotid Intima-Media Thickness ultrasound. It’s the same technique, but it’s the computer quantification. And then I can sit down with the patient and say, you know, you’re 11% narrowed here and you’re 17% narrowed here, and you got two spots on the right, three spots on the left, and there’s something called the T, the thickness, CIMT, and the thickness of your artery at age 60 is more like a 75-year-old patient and I’m worried about you or the thickness of your artery at age 60 is more like a 52-year-old patient. I’m really proud and pleased by what we’re finding.

And because it’s an ultrasound, you could choose to repeat it once a year, once every 18 months. The biggest downside to the CIMT is that insurance companies don’t recognize that despite about 2000 research studies and maybe 20 to 25 years of availability. But I still recommend people try and find a center that offers CIMT, and I’m going to tell you, it’s a challenge. We do it in my clinic, you do it in your clinic, but I think it’s the best available. And even in this Madrid study, that’s basically what they did in the carotid. They also used the leg arteries, the femoral artery kind of by the crease in your groin. That’s the least common to see done well in the United States. Maybe this Madrid experience will move that up because that’s actually where they found silent atherosclerosis, most commonly first in the legs then in the carotid arteries, and then it shows up a little later in the heart arteries, partly because heart arteries are hard to see.

Joel Fuhrman, MD

Right. And what’s interesting well, number one, I’ve used it to so people feel confident when they’re doing the diet. So a year later they see actually it got better and they say, oh, it worked, I’m getting a lot better. It’s almost gone. It’s like so it’s very encouraging. I had people call them consecutively every nine and a 12 months to see the improvement so they’d even know that they’re doing is working. And I think the bifurcation of the carotid artery, it correlates pretty well in scientific studies with the atherosclerotic burden in the heart that the burden when in the carotid there. So it’s a good pretty useful test.

Joel Kahn, MD, FACC

I agree completely but then there are people that say, okay, that’s my brain health and I do care about that, but what about my heart? So I’ll just dive in. You know, we’re talking in 2024. In 1990, a test was developed called a heart calcium CT scan. Some people call that coronary artery calcium score CACS. Some people call that a CACS study, but basically lie down, go in a CT scanner and you’re done in about 10 seconds. There’s no injection, no I.V., no pain, no claustrophobia. And during that brief period, a picture’s made of your heart arteries, because at some point, if you’re building up plaque it gets calcified. You should have no bone material in your heart arteries. You shouldn’t have bone material in your carotid arteries. And sometimes actually a dental x-ray. I get patients referred by dentists that dental X-rays showed calcification in the brain arteries. So they said to me, But we can look for it directly in the heart arteries with a CACS coronary artery calcium score. 1990, first arrived in Michigan, where I practiced in 1995 as a 1500 dollars cash study. Now it’s $50 to $100 out of pocket. The radiation dose is extreme, only low. It’s not zero, but it’s low. And you get a number.

And if you’re a zero, you don’t have obvious silent atherosclerosis in your heart arteries. If you come back 742 or 1496 or even 58, these numbers are a continuum, and it’s also very dependent on your age and your gender. There are all kinds of national databases with 6000 research studies. That’s the missing piece to me to the American medical system. When you’re 45 years old and you’re getting your first Cologuard, colonoscopy, mammogram, thermogram, and starting the screening prostate exam, cervical cancer exam, get a heart checkup. And when you’re a zero, you go do it again in 5 to 7 years like a colonoscopy. And it just is still 34 years after it was described in the scientific literature, a pretty rare test for a primary care doctor to order. You usually do need a prescription. So let’s eliminate silent atherosclerosis. I use a little hashtag test and do not guess because that’s how you find out. Unless you got the earlobe crease, or the angina, or claudication in the legs, or erectile dysfunction. If you’re asymptomatic, you still want confirmation that you’re in good shape. And this is now worked its way into the American Heart Association language. But in reality, I would estimate maybe less than 10% of people by age 50 have had any of these tests we just went through.

Joel Fuhrman, MD

Right. But there’s no way to look at juvenile plaque or vulnerable plaque that’s not calcified yet. Sometimes, you know, just having any person that’s living and eating unhealthily, they probably have those plaques even when the calcium score isn’t too bad. That could be, it could be the plaques maybe didn’t calcified yet. They could still have, you know, plaque and cholesterol laying plaque in there. Right?

Joel Kahn, MD, FACC

Absolutely. I had the pleasure of interviewing Dr. Jay Earls from a company called Cleerly Health it does advanced CT scans of the heart will show you a soft plaque when there is no calcium. And also a cardiologist in Detroit, Kavitha Chinnaiyan, who is a world expert also. Those tests can be as much as 1500 dollars and involve iodine injection. So you really got to work with somebody who is going to recommend that for you for the special patient. But with 90 plus percent of people not getting even the calcium score, we got a lot of work to do to get routine silent atherosclerosis screening going. There is a fascinating study about to kick off in New York in 2024 called Prev Cad. And I’ll be real quick Prev Cad. And they’re going to take people from age 20 to 39 and they’re going to do these screens with ultrasound of their carotid and their leg arteries. And then if they find a silent plaque, they’re going to put half of them on early treatment. Unfortunately, not early dietary and lifestyle treatment. Primarily it’s drug treatment. But will you, by age 50, have prevented strokes and heart attacks by finding disease? When you’re 28 or 34, a very provocative but well-done university-based study. So that may completely transform medicine, but we’ll have to wait four or five years to see that.

Joel Fuhrman, MD

Well, I’m still trying to get people to, you know, change the way they live and not what happens to them. What happens to other Americans is you are to write. All right. Let’s pause here for a minute. Thank you for joining us, everybody. And if those of you who signed up for the bonus section, stay tuned. We’re going to go into some more time here with Dr. Kahn. And if you’re not and you want to move on you could, of course, join us for that more advanced part of this summit. All right. Welcome back and thanks for joining us for being such a strong supporter of the summit. Dr. Kahn, another topic we continue on this subject for a little bit longer. So we’re talking here about, you know, just this idea of testing so people get finished this kind of like subject matter. What about just routine stress tests or what about these, like executive tests where people just like, do you go to the doctor, you pay a lot of money to do all these things? You know, they look at everything in your body with ultrasound and they put you on a stress test machine. What about that?

Joel Kahn, MD, FACC

Yeah. So sort of the executive physical stress test, that’s what we’re talking about because people are still offered that as part of perhaps a routine physical. Maybe their company pays for an executive physical, or maybe they pack up their suitcase and get over to the Mayo Clinic or the Cleveland Clinic if they don’t live in those areas and other places. And, you know, without any promotion. I wrote a book about four years ago called Dead Exact Don’t Get Bonuses, a short little book. Telling you which tests to get for this silent atherosclerosis topic and what to do about it. And I went through the literature and actually executive stress tests are not recommended by the American Heart Association. The American College of Cardiology. We are talking asymptomatic people.

If you’re having tightness in your chest, your doctor may recommend a treadmill test. That’s perfectly appropriate. Whether you’re 48 years old and you work for the Big Three automotive and the doctor says we’ll do a treadmill. There are a lot of places in my own community that will do that and somehow they get it either self-pay or through insurance. There are a lot of what are called false negatives. Your stress test comes back with good results and you’ve completely missed atherosclerosis and you’ll always miss it when it’s early because the stress test cannot identify it. You want to see arteries. The CIMT shows arteries and the calcium score shows arteries. The advanced C.T. tests of the heart called a C.T. angiogram directly show arteries. No stress tests in the world show arteries. So you will miss so many cases of early atherosclerosis. So this study in Madrid and the upcoming study in New York are not going to do a stress test. And then there’s something called false positives. Your doctor calls you very concerned and says, boy, your stress test didn’t come out as expected and you need to see the cardiologist. The next step could be even invasive evaluation because maybe up to 30% of stress tests are false negative and false positive. I mean, that’s not really ready for primetime. And there’s a small risk of a stress test just from the procedure. 

There is an expense either you’re paying for it or your company, or your insurance. But the real issue is the accuracy. So we need to eliminate executive stress tests and really a stress test, the most basic stress test might be a $300 or $400 examination. These coronary artery calcium C.T. scans in many communities are $50 to $75. So they’re more accurate, they’re more available, and they’re less expensive. You don’t do a merely. And so I have eliminated these routine stress tests for my practice long ago. The final word, I’ll stay on this topic because we’re both, you know, natural-oriented doctors. It’s still very common for primary care docs, but extremely common for cardiologists to order a stress test called a nuclear stress test, which involves an I.V. and injecting a clear liquid. But it’s a radioactive liquid even compared to the CT scan. The radiation dose of a nuclear stress test is horrendously high. I mean 10 times higher than these CT scans we’re talking about. So I have a history in the past of being a pretty well-known nuclear cardiologist. I published many papers. I had board certification. I don’t think I ordered two years usually now in people that can’t walk the treadmill and have to be evaluated for either symptoms or big upcoming surgery because I just don’t want to give my patients that radiation. And you might say, well, what about the CACS? The calcium score is very low dose radiation. So I asked that question. I’m glad we could get that topic covered.

Joel Fuhrman, MD

Great. All right. Well, thanks, everybody, for joining us today. And stay tuned for more interesting and informative episodes with Dr. Kahn.