Nimeet K 00:11
Hello, Welcome to Adventist HealthCare & You podcast. I'm Nimeet.

Shanna M 00:14
I'm Shanna.

Nimeet K 00:15
And we're excited to have our new expert today. We have Dr. Bobby Ghosh, who is an interventional cardiologist at Advanced Healthcare through Cardiac Associates. And he's also the Director of Cardiac Research at White Oak Medical Center. Welcome Dr. Ghosh.

Bobby Ghosh, MD 00:29
Thank you.

Shanna M 00:29
Thank you for coming back.

Nimeet K 00:30
So as we're getting started, you know, I think many people are looking for healthcare providers, and at times, they're looking for a cardiac provider. So when should they start looking for a cardiologist? And what should they look for in a cardiac team?

Bobby Ghosh, MD 00:45
They should look for a cardiac team that has me on it. No, I'm just kidding. Well, it's a good question, I guess, you know, there's various ways to choose your, your team, your doctors, and so on. I think from a cardiology perspective, you know, my thought is one, you want someone who is going to spend some time to listen to you, and to listen to what your concerns are, but also bring forward what they think you should be worried about or thinking about. And then in cardiology, as many people know, there's a lot of, there are a lot of kind of sub specialties. And so a lot of groups have members of various sub specialties within their group. And so it's nice, I think, generally, too, if you go to a cardiology doctor that has an electrophysiologist, as a another partner, and a structural heart specialist as another partner, or, you know, all the different subspecialties available, then it's great. If those things are needed, you can be able to see somebody else.

Nimeet K 01:50
Navigate the healthcare system, which is already so complicated.

Shanna M 01:53
So complicated anyways,

Bobby Ghosh, MD 01:54
right.

Shanna M 01:54
So if you have a heart condition, either heart disease or you know something else going on with your heart, you may need to see more than one type of cardiologist,

Bobby Ghosh, MD 02:07
You may, you may, or maybe you specifically need one special particular specialist, I would say the majority of people generally would need to just see a general cardiologist or someone at least who's doing general cardiology, but in certain situations, so interventional cardiology, which is what I do is putting in stents and balloon angioplasty and some other procedures like that, as well as some structural cardiology, which is like replacing, you know, aortic valves or something, a procedure called transcatheter aortic valve replacement. And then there's electrophysiology, which is the electrical side of things and their their people may require a pacemaker, for instance, that would be the most common thing or management of heart rhythm abnormalities like atrial fibrillation, and then there's advanced heart failure. So you know, that obviously, as it sounds like it's something that you would go through the management through a general cardiologist, and at the point where you would need more advanced heart failure, management, and even talking about heart transplants and things. That's an entire specialty on its own. And then there are some other like kind of newer, smaller groups of specialties, like even cardio-oncology, which is kind of a mix between cancer issues and heart issues. And preventative cardiology, I wouldn't call that one small, actually it's a little bit newer, in a sense, but it's kind of a specialist in thinking about prevention for not necessarily younger, but basically people who don't have a known active heart issue.

Nimeet K 03:42
I think that's great. Because having preventing something and changing your lifestyle a little bit may, you know, go, may go a long ways and having that dedicated person who is an expert at it, is usually beneficial.

Shanna M 03:54
So you're an interventional cardiologist, which means, if someone is having chest pain, and they end up at the hospital, they might see you, is that right?

Bobby Ghosh, MD 03:54
Yeah.

Bobby Ghosh, MD 04:02
Yeah, it certainly, you know, the initial process and workup would be typically by an emergency room doctor, or an urgent care doctor to kind of look and see if you're having evidences, you know, chest pain, of course, is taken very seriously but,

Shanna M 04:17
it can be evaluated

Bobby Ghosh, MD 04:19
come from non-cardiac causes. But once that's kind of, you know, heading towards the direction of, well, hey, this may be a heart, artery blockage or coronary blockage, that's when they would call someone like myself to basically take a look with a procedure called an angiogram and then if needed, then open up such a blockage with a balloon and a stent, typically.

Shanna M 04:40
So what are some of the symptoms someone should look for if they think they might be having a heart attack? What are, what are the symptoms to watch for?

Bobby Ghosh, MD 04:48
So chest pain is definitely the first one, the most common one, but it's not certainly not by any means the only potential symptom. You know sometimes people will feel little bit more like shortness of breath, sometimes a little sweaty, sometimes the pain can be in the chest, but it can also radiate towards the arm, especially the left arm, or the jaw, or the back even, and sometimes even abdominal sort of pain or nausea associated with it too.

Shanna M 05:18
Can women experience different symptoms than men?

Bobby Ghosh, MD 05:22
Yeah, I mean, I would say, on average, probably chest pain is still the most common, but women, for some reason are more likely to experience some of the less typical symptoms, which is why sometimes it's missed by the patient and maybe even the physicians initially.

Shanna M 05:37
I've heard lately, many heart attacks, small heart attack, major heart attack, what are the differences?

Bobby Ghosh, MD 05:44
That's a great question. I mean, I think the, you know, sometimes these, these are colloquial terms, if you will. And sometimes they get passed around. And they don't exactly correlate directly to a medical description. But I think what it kind of boils down to is plaque builds up in the arteries. Over time, that's a slow and continuous process, hopefully a process that we should try to stop. But if and when one day, that plaque could break off or rupture, and in that area, then a blood clot starts to form essentially, because the body starts reacting to this broken plaque that's kind of hanging in the artery and the wall underneath that plaque kind of triggers a blood clot to form. And that blood clot basically can potentially close off the artery completely. Now, when it closes off the artery, completely 100%. And there's no blood flow getting through, it causes a change on our EKG, that we, we call it a STEMI or ST elevation myocardial infarction, that's the long term for it. But STEMI basically is the quote unquote, big heart attack. And then if it's an incomplete process of completely including, the artery which, you know, happens a lot of the time, maybe there's a clot and it's kind of like 90%, 95%, there's a little bit of blood flow getting through than the EKG doesn't show, typically doesn't show that chain what the 100% blockage does. And usually the blood test, there's another blood test that people are probably getting very familiar with, nowadays, because it's checked every time someone has chest pain in the emergency room, and that's called troponin. And that blood test may still be a little bit elevated, because it's starting to show some lack of blood flow, but not that 100% lack of blood flow. And, and so that maybe is what a lot of times is considered a minor heart minor.

Shanna M 07:39
Okay, thank you for that explanation. That's helpful. Then, to take it one step further, what is the difference between a heart attack and a stroke? Because it's your arteries, your veins, you may have heart disease if you have a stroke, too. So what's what are the differences?

Bobby Ghosh, MD 07:56
Right? Well, a stroke essentially, is, is a blockage of a brain artery. While a heart attack is a blockage of a heart artery or the coronary arteries. The underlying buildup of plaque process, we call it atherosclerosis is basically the same, the same type of buildup of plaque on the walls of the arteries, and inflammation and cholesterol kind of all coming together to create these plaques that build up over time. Now, strokes are not always caused by the same exact process, there are some other things that can cause a stroke, one of the most common of which is atrial fibrillation, which is the irregular heart rhythm where clots can actually form in the heart, and then exit the heart and go to the brain. And there are other types of strokes as well.

Shanna M 08:43
Okay, thank you for that.

Nimeet K 08:45
Sounds like there's some similarities between the two as well, maybe the risk factors may be similar, not the same, obviously, will be similar for a stroke or heart disease or heart attack?

Bobby Ghosh, MD 08:55
Yeah, no, they are, I think, especially for that atherosclerosis process, which is the plaque, it's essentially the same process happening in two different areas of arteries. And, by the way, it if it's happening there, in the heart, or in the brain, or both, it's probably also happening in kidney arteries in leg arteries. And so, you know, all the activity that we can do to try to prevent that is helpful for every essentially every artery in the body.

Shanna M 09:24
Okay, so, don't ignore signs or symptoms, know your, your risk factors.

Nimeet K 09:30
Absolutely. So you mentioned what happens, you know, during a heart attack, or what are some of the signs of heart attack? What happens after the heart attack? Like what happens after you've done the procedure? And what are the next steps after that?

Bobby Ghosh, MD 09:41
Well, first of all, the procedure, basically, the sort of timing of it has some to do with what you were talking about this minor and major, big and small. So that STEMI that we were talking about is something where basically as the healthcare team, we drop everything we're doing. Typically, that's the most important patient that the emergency room will then focus on for the next 10 minutes. Interventional cardiologists will come in from home a Cath Lab is where we do the procedure, the Cath Lab team will come in from home, if it's the middle of the night, or, you know, if it's during the day, they're already there. But we try to get that artery open within 90 minutes of the patient coming in through the door, we call it door to balloon time.

Nimeet K 10:27
That's very fast.

Bobby Ghosh, MD 10:28
Yeah, and that includes all of those steps,

Bobby Ghosh, MD 10:31
seen initially by someone in triage. And then, you know, getting an EKG, being seen by the nurse, the doctor, and then activating this system. And so that's the goal. And that's a nice nationwide goal. Now, the other type, if you're not actively having chest pain, if basically, if there's, we don't know yet, but if there's a 90% blockage, say, a little bit of blood flow getting through and you're not having active chest pain, then we put you in plan for a procedure, which could be done sometime, you know, generally in the next 24 hours or so. And we put you on some blood thinners to kind of keep things open as much as possible. And then you're asking about afterwards. So yeah, so basically, we, you know, we go and put in the stent, usually it's a stent. Sometimes, occasionally, somebody may require bypass surgery, but most of the time for a heart attack, we do stents, and going through either the wrist or through the leg artery and then are able to place this. And afterwards, you know, usually the recovery is very good from the procedure, because it's a relatively minimally invasive procedure. From the perspective of having a heart attack, we usually keep people in the hospital about two to three days, mostly for monitoring and a little bit more testing and understanding a little more about their heart, and then hopefully home after that. And then beyond that, of course, there's outpatient, definitely more follow up, you pretty much need to see a cardiologist regularly for

Shanna M 10:50
yeah

Bobby Ghosh, MD 10:59
Or as long as you would like to, I guess, but and, and then there's something also called cardiac rehab, which can be very helpful, which is an exercise program that helps people kind of get over the heart attack, get back into exercise, and it's medically monitored.

Shanna M 11:58
awhile.

Nimeet K 12:19
That's great. It's nothing, so there's obviously different pathways depending on the patient condition, you know, whether it be quote, unquote, meaning your major heart attack, there will be different pathway in different sorts of recovery. So I'm glad you shared both aspects of you know, which way you could go and what does that recovery look like for a quote unquote, major heart attack?

Shanna M 12:35
So Dr. Ghosh, you've talked a little bit about prevention, and you know how the atherosclerosis kind of builds up over time, it's a continuous process, when should someone start thinking about their heart health?

Bobby Ghosh, MD 12:47
It really starts with healthy living choices and eating choices and exercise all of that, which really is in childhood, I don't know that there's an actual age. But I do think any adult person who wants to start thinking about you know how to maintain a healthy life, kind of lifestyle, and part of that may be being evaluated by like a cardiologist, or maybe just a primary care doctor. So I don't think it's even out of the question for someone in their 20s. And certainly, you know, atherosclerosis is generally silent, it doesn't, it doesn't give you symptoms until you have severe blockages, you know, at least 70% blockage, we think is what causes symptoms. And so, you know, the steps leading up to atherosclerosis are having high cholesterol, certainly having diabetes, you know, being overweight, and certain genetic factors. I mean, there, there are many factors, high blood, you know, high blood pressure, so,

Shanna M 13:48
so there may be something that could kind of indicate that you might need a little extra care for your heart.

Bobby Ghosh, MD 13:53
Yeah, and I think a lot of those things are also silent, right? Yeah, having high cholesterol or diabetes or high blood pressure, you may not know those things either, unless you go get checked out,

Shanna M 14:04
which underscores the importance of continuing to get your regular checkups from your primary care provider.

Bobby Ghosh, MD 14:11
There are some tests that theoretically, can be done to kind of help a otherwise asymptomatic meaning having no no chest pain, or shortness of breath or anything like that. But taking a look to see if there's something that they should be being proactive about. Probably the one that comes most to mind is the what's called a calcium score. This is actually a CAT scan, that essentially just looks at the area of your heart where your coronary arteries are to see if there's any evidence of calcified plaque, which is basically on a CT scan, on a CAT scan looks bright, like a bone because it's has calcium in it. And so that we can get a score and that score could be zero, which is great news or it can be anything from you know, zero on up and so sometimes in younger people will use that because it helps to risk stratify, that doesn't necessarily mean that they have a severe blockage, it just means there's plaque starting to build up. And it's an indication that maybe we should take your cholesterol and be a little more aggressive. Maybe we should look more aggressively for or more frequently for diabetes, maybe we should think about whether you want to take an aspirin just to help as a preventative measure. These are all kind of considerations. If you have a positive calcium score.

Shanna M 15:29
Is that recommended for people that meet certain criteria? Or could that be open to?

Bobby Ghosh, MD 15:35
I think it could really be, frankly, could be done for anyone. It is frequently used in the position where, you know, cholesterol management has been a very, ever changing process. For the last number of decades, the goals have not been the same. At one point, we aimed for an LDL of 160, then we said 130, that it was more like well maybe actually shoot for 100. And then hey, actually, if you have coronary disease, or diabetes, we shoot for 70. So you can see how wide this range is? And what's the right and wrong answer. And so sometimes you'll get someone who doesn't have any symptoms, feels well, maybe they have a cholesterol of 130, an LDL of 130. And they're perhaps not too interested to be on a daily medication for the rest of their life. Maybe they're 35 years old, so here's a good place where we can potentially use, there are some risk calculators that we can use to try to determine what what's your risk. And then there's also this calcium score, where you can say, okay, the same 35 year old with the same LDL, but one of them has a calcium score of zero, and other has a calcium score of 50. And then another has a calcium score of 1000. We know generally, from studies that the person with 1000 is a little more likely to have a heart attack, or some sort of progression of coronary disease going forward. And the person at 50 is going to be more likely the person of zero. So we can kind of use that and say, well, now I might recommend this person to be aggressive about exercise and diet, this person may be a little more, you know, aggressive, and this person maybe should start taking a medication, because it's starting to build up a lot more aggressive.

Shanna M 17:15
So it's actually getting to the point where you can be a little more personalized and unique in the approach for each individual person. It's not a one size fits all.

Bobby Ghosh, MD 17:24
Yeah, yeah, I do. I do think so.

Nimeet K 17:27
And then you mentioned, you mentioned, talked about a little bit the risk factors. You know, if I had a family history of heart attacks, or there some other cardiac history, it is kind of guaranteed that I would have some of those concerns as well, or I would have a cardiac issue going forward? What are some of the things that I should look forward to?

Bobby Ghosh, MD 17:44
Yeah, I mean, we definitely utilize the family history to basically another feeder into the kind of equation or the model that we use to try to say, is this person higher or lower likelihood of having something, it's never a one to one correlation? Obviously, when somebody has a heart attack, if they are under the age of 50? Actually, we use 50 for men and usually 60 for women. We consider that kind of premature, meaning it's early in their life to have had a heart attack. Okay. So if you have a family member who had a heart attack, you know, below the age of 50, then we consider that to be a more strong family history. Versus if you know, and we get this a lot and right people say, you know, do you have any family history, and someone says, yes, my grandfather died of a heart attack when he was 92. It's not irrelevant. However, if you had a grandfather who died of a heart attack at 42, that's a very different condition, because you've now had 92 years of life style and environmental factors that are affecting your likelihood of having a heart attack.

Shanna M 18:48
It's still again, that more personalization of somebody's risk factors and life as a cardiologist, and as we, you know, think about heart care and into the future, what, what excites you about what you do and what may be coming in the future?

Bobby Ghosh, MD 19:05
You know, lots of things. I would say, you know, we're definitely moving very aggressively into the space of minimally invasive therapies. Balloon angioplasty and stents have been around for a very long time now. And a lot of heart attacks, as we were talking about are treated that way. We're also treating a lot of valve heart disease, valve related heart disease, as well with, you know, open heart surgery, of course, that's always going to be there and has been there for a long time. But a lot of minimally invasive therapies as well for that, probably the biggest example right now is transcatheter aortic valve replacement, which I mentioned earlier, aortic valves can start to get stiffer and not open well, usually a condition of patients age 60 are mostly like 70 onwards. And as that starts to happen, sometimes you need to replace the valve and we can do that. Now with a catheter-based procedure, basically where we deliver a large stent that has a functioning valve on the inside through a big artery through the leg. And it's a quick, less than an hour usually procedure and people stay in the hospital one night. So it's a, it's a big, dramatic change in how somebody might get their valve replaced.

Shanna M 20:17
Okay

Nimeet K 20:18
So we're not like going back to like, open the chest and replace valves that way anymore?

Bobby Ghosh, MD 20:23
Well, we definitely are

Shanna M 20:25
that's still an option

Bobby Ghosh, MD 20:27
I want to be clear about that. Because, as with anything using more finesse, and trying to snake through arteries and deliver a valve, you have to have the right anatomy for it, you have to be the right patient for it in general. And, you know, there are also considerations of your age. And you know, sometimes we may think about a younger patient and say, we should do a full open heart operation where we replace the valve. And certain types of aortic valves, for instance, would maybe be better for surgery. So we actually work is we call it a heart team. And so we have meetings every single week, where we meet with heart surgeon, interventional cardiologists and sometimes imaging experts if needed. And we go through and discuss cases and try to come up with the best plan.

Nimeet K 21:15
That's great. staying up to date and making sure that the evidence is really guiding the treatment. Exactly words.

Shanna M 21:20
Right? Well, thank you for coming today. We really appreciate all of this wonderful information, you've given our listeners, anything that you want to add any tips or anything like that for, for people to take better care of their hearts.

Bobby Ghosh, MD 21:34
I guess awareness is probably the way to put it. You know, we live in a world of tech, I think these days, that has helped to increase awareness, if you use it in the right, those tools, just like anything else, use the tools in the right way can really be helpful. So I think a lot of the watches and heart rate data and steps and you know, can be a lot of good self feedback for trying to remain active, you know, trying to make goals for yourself every day, or, you know, being aware of if something seems to be off, you know, something happening with your heart rate, are you going into an irregular heart rhythm, you know, those types of things are very helpful. And obviously, I'm sure everyone you know, talks about diet and exercise. And those are, those are always going to be the pillars of, of maintaining heart health.

Shanna M 22:19
I like that though, what you said you know, just aware and, and use technology or other things to just kind of help you along to you don't have to do it all on your own.

Nimeet K 22:29
You could actually measure 10,000 steps now. I'm gonna do my 10,000 steps today.

Shanna M 22:34
Yeah, maybe it just makes it a little easier to achieve any goals that you set, if you've got a little something to help you track it.

Bobby Ghosh, MD 22:41
I actually think it's a great tool. Because even if you see a cardiologist as regular as you need to like six months or something, and they say, Hey, please do you know exercise? That's very different than something on your wrist telling you every day stood up in the last 55 minutes.

Nimeet K 22:58
My watch does that. Still it gives you some perspective.

Bobby Ghosh, MD 23:03
It's very helpful, actually, to keep active, you know, physically and mentally both. And I think those tools are here to stay.

Shanna M 23:03
It does

Shanna M 23:11
Yeah,

Bobby Ghosh, MD 23:11
Not just get better.

Shanna M 23:12
Well, speaking of awareness, Adventist Health Care offers a free and fast health risk assessment online. So it's a simple little quiz that you put in some information and it helps you become more aware about your risk and your risk factors for heart disease. So we have that resource available that we'll put in today's show notes, too.

Nimeet K 23:30
That's great.

Shanna M 23:31
Well, thank you, Dr. Ghosh. We appreciate your time today.

Bobby Ghosh, MD 23:34
Yeah.

Shanna M 23:34
We hope you'll come back again.

Bobby Ghosh, MD 23:36
Absolutely.

Shanna M 23:37
Thank you to find more information about Dr. Ghosh visit AdventistHealthcare.com. You can also go there as well and learn more about the Adventist HealthCare Heart and Vascular Institute. And as always, we'd love to hear from our listeners. You can let us know if you like the podcast by leaving a review or you can email podcast at AdventistHealthCare.com, let us know about healthcare topics you want to know more about. Don't forget to subscribe to get all our new episodes. Thank you to our listeners and be well!