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Interactive Learning : HealthCast Transcripts

Episode 2 : VDF Health- The Vascular Laboratory

Release Date: October 10, 2006

Dr. David Meyerson: Good afternoon and welcome to another edition of the Vascular Disease Foundation's HealthCast. I'm your host, Dr. David Meyerson. I'm a cardiologist at Johns Hopkins, and a national spokesperson for the American Heart Association. The Vascular Disease Foundation is made up of premiere health education groups known nationally and internationally. Our goal is to bring you the best quality public education for heart and blood vessel disease. Information that you can rely on, that you can trust that comes from some of the best sources of information that you all have heard at one point or another. The American College of Cardiovascular and Pulmonary Rehabilitation, the American College of Cardiology, the American Heart Association to name but a few.

With me today in studio is Dr. Kerry Stewart. Dr. Stewart is the Director of Cardiovascular Exercise Physiology and Research at Johns Hopkins and Dr. Stewart, just for a moment before we get to our very special guest who I'll introduce shortly, tell us a little bit more about the Vascular Disease Foundation.

Dr. Kerry Stewart: The VDF, David, is actually an organization of organizations. It has representatives from the fields of cardiology, vascular surgery, nursing, ultrasound, interventional radiology and rehabilitation. This organization was formed to provide public education about vascular diseases and to improve the awareness about vascular diseases. Through the VDF website, which is www.vdf.org, that's www.vdf.org, individuals can obtain for free, educational materials about specific topics related to vascular disease. VDF website, individuals can also subscribe to Keeping in Circulation which is a quarterly publication. It covers a variety of topics related to vascular disease. Of note David, these articles, old materials are all reviewed by experts in their field to assure that we're providing trusted information to the public.

Dr. David Meyerson: What you would call similar to peer-reviewed science, meaning that multiple experts across the country agree on this information and it's desolate of what the best science is to change public policy perhaps, correct?

Dr. Kerry Stewart: Absolutely.

Dr. David Meyerson: Great. And with me today, Dr. Stewart will be with us during the PodCast, but I want to bring to you, to the microphones, a very special guest, Dr. Heather Gornik. Heather Gornik is a Cardiologist and Vascular Disease Specialist at the Cleveland Clinic. She is Director of the non-invasive laboratory there and Dr. Gornik, thank you so much for joining us on VDF HealthCast.

Dr. Heather Gornik: Thank you for having me David and Kerry.

Dr. David Meyerson: It's a pleasure. One of the references that sometimes I use, Dr. Gornik, is if you had a sixty or seventy-year-old house and a plumber told you that there was a corroded pipe in the bathroom on the second floor, because the whole house is sixty or seventy-years-old, it wouldn't surprise you for a moment that there would be disease, if you will, blockage, if you will, corrosion, if you will in a pipe in the basement or on the first floor or anywhere in the house for that matter. So one of the things that I like to explain to our audience is that when we talk about blood vessel disease, this is a general plumbing problem of the entire body, so that if we have the arteries that nourish the brain called the carotid arteries, if there are narrowings there, there can be lessened blood supply to the brain, there could be little particles of material that go up to the brain that cause either small blood clots, or what sometimes we call transient ischemic attacks. And if we take the same problem with the blood vessels, and move it down a little bit to the heart, we have a problem where too little blood supply goes to the heart muscle, and we have something called angina, which is the temporary deprivation of blood supply to the arteries that nourish the heart muscle, and finally if the --

Dr. Heather Gornik: I think that's absolutely correct.

Dr. David Meyerson: -- and finally if we go downstairs just a little bit further to the lower extremities, when people walk they get all kinds of pain and discomfort and I guess what I'm wanting to tell our listeners is this is a generalized problem throughout the body and even thought we have different names for diseases in different areas of the body, we're dealing with something similar, aren't we?

Dr. Heather Gornik: I think that's absolutely correct. Atherosclerosis which is the plumbing problem, the corroding of the pump so to speak, is a process that really affects the arteries of the body head to toe and it causes coronary artery disease, carotid artery disease, atherosclerosis of the abdomen and even aneurysms of the abdomen and peripheral arterial disease, which is blockages of the arteries of the legs. I think what we're learning more and more through scientific research is that these problems are extremely common and in the case of vascular disease, many patients have vascular disease, but may not have symptoms at all. For example, you mentioned that people with blockages in the leg arteries may experience leg pain when they walk. What some scientific research has demonstrated is that among people with blockages in the leg arteries, only a small fraction have symptoms and many patients have blockages without even being aware of them.

Dr. David Meyerson: And Dr. Gornik, one of the things that we could and should talk about is that if you have been diagnosed as having a problem in any of these areas, would you think it would be appropriate then to return to your doctor whether it be your internal medicine physician, your cardiovascular specialist, your vascular surgeon, wherever you entered the healthcare system for this problem and say, "What are my risks for having this in other areas of my body?"

Dr. Heather Gornik: I think that is definitely the case and I think we've just launched -- actually the Vascular Disease Foundation has been participating in a national public awareness campaign for peripheral arterial disease and we've been encouraging patients to ask their physicians, "Am I at risk for having peripheral arterial disease or PAD?"

Dr. David Meyerson: Now interestingly most of the therapies that we offer medications and preventive therapies for many of these processes are pretty similar, aren't they?

Dr. Heather Gornik: Very true. The goal of therapy for patients with atherosclerosis is to prevent heart attacks or strokes because patients that have blockages in the carotid arteries, the coronary arteries or even in the arteries of the legs or arms are at an increased risk of having a heart attack or stroke, so we target our medical therapies at preventing heart attacks and strokes and that includes things such as aspirin or clopidegril which are therapies that prevent blood clots. Blood pressure lowering, aggressive lowering of the cholesterol, tight control of the blood sugar for diabetic patients and quitting smoking. And all of these treatments are the same. There are some different therapies that are targeted towards the specific blockages. For example, if someone had chest pain and had coronary blockages, they may be considered for certain medications or even a revascularization procedure such as a coronary stent or open heart surgery. And similar for blockages in the carotid arteries or legs if there are symptoms, we often do specific procedures for the blockages in those areas.

Dr. David Meyerson: Uh-huh [affirmative].And what we might mention that a stent, for example, the ones that go in one of the arteries that nourish the heart muscle, the coronary arteries, to our public, they might imagine a spring inside a ballpoint pen for example. It would be about that size, maybe just a tiny bit bigger, but really not much. We can use those same type of devices -- these are little metal, cylindrical devices that go inside the blocked artery and actually open them up and prevent them from closing down. That's often something we can do, but let me bring you back to something you just said, Dr. Gornik. You said that one of the goals of these prevention is to prevent stroke and heart attack and I agree so whole heartedly, but one of the other goals in the treatment and the prevention of peripheral vascular disease is to maintain someone's high level of function because I'm sure, you have seen with your patients as I have in mine, someone who then is limited in their physical activity by lower extremity, like claudication, lack of blood supply. They're not able to do the exercise they want to do, they gain weight, they become less functional in terms of their cardiovascular physiology and they're less able to keep the weight down, keep good cardiovascular health. The exercise effect on their lipids, their blood fats become limited and this is also very preventable disease and very worth while preventing and we want to see our older cross section of the population in their sixties and seventies and eighties. There's nothing that pleased me more than a ninety-year-old gentleman that still plays a round of golf. They don't carry their clubs or anything, but they're able to get out there, hit a ball and enjoy it and that's what you want for your patients as well, isn't that right?

Dr. Heather Gornik: Definitely. So I think it's very important to identify patients who have PAD causing their loss of function because there are treatments that we can offer these patients. Something as simple as supervised exercise training can greatly improve patients' abilities to walk further distances without having leg pains, but we can't give patients the appropriate therapy if we don't know what they have and that's why making a diagnosis of PAD is very important.

Dr. David Meyerson: And one of the biggest things that you mentioned a little while ago. You mentioned stopping smoking. How important is that?

Dr. Heather Gornik: Stopping smoking is vital. In fact, it's probably the most important thing a person with PAD can do to slow the progression of their disease.

Dr. David Meyerson: It is absolutely critical, I could not say that better and let me mention, Dr. Gornik, that when my patients tell me that they're cutting down, I respect that. I tell them that's very good, but I also tell them that cutting down is a little bit like saying I'm only going to drive a hundred and thirty-five miles an hour two days a week, so that something horrible is going to happen on a Tuesday or a Friday, but cutting down isn't good enough. It really is quitting smoking and we would both urge our patients to stop smoking and all of our listeners to stop smoking immediately. Isn't that the strongest message that we can give?

Dr. Heather Gornik: Yes.

Dr. David Meyerson: Now one of the things I'd like to bring over because you are the Director of a noninvasive laboratory at the Cleveland Clinic. One of the perhaps strongest places for cardiovascular medicine on the planet. Not to say that it's better or worse than Johns Hopkins --

Dr. Heather Gornik: Thank you David.

Dr. David Meyerson: -- we feel pretty good about that. But, certainly one of the strongest places in cardiovascular medicine on the planet, truthfully and can you tell us what is a noninvasive laboratory and what are some of the tests that you do and how does that work into our discussion today?

Dr. Heather Gornik: Sure, I'd be delighted. Well, noninvasive vascular laboratory is a place where patients come for investigation of their blood vessels. And in the laboratory, we have tools to study arteries and veins in the body and we have tools to actually detect atherosclerosis or blood clots using very simple noninvasive painless techniques.

Dr. David Meyerson: So by noninvasive, you don't use needles then do you?

Dr. Heather Gornik: Not at all.

Dr. David Meyerson: Okay.

Dr. Heather Gornik: What we use in general

Dr. David Meyerson: Needles per say.

Dr. Heather Gornik: Correct. We use, mainly we use variants of an ultrasound machine and we use the ultrasound machine to generate pictures of blood vessels and also to analyze flow within blood vessels to see if there are blockages.

Dr. David Meyerson: So let's start for a moment many of our listeners know. When a woman is going to have a baby, she often has an ultrasound. The ultrasound shows the doctor and the parents to be, the size of the baby, how the baby's forming, sometimes it even shows the sex and that's done without needles, without medications and if they're going to do it on an infant in utero, it's not going to be harmful, so you use similar techniques just designed for different areas of the body. Is that right?

Dr. Heather Gornik: That's right. Actually ultrasound is an amazing advance. Our current ultrasound machine probably came into development in the mid 1970's and what they allow us to do is use sound waves, just like the sound waves you and I, David, are generating, but they're at a higher frequency of sound that are not detected by the human ear. And the ultrasound transducer actually generates these sound waves which travel through the tissues in the path of the ultrasound transducer and they actually bounce off of structures in the body and then return to the transducer where there's a special crystal that listens for the returning sound waves and the information that returns from the body is actually used to generate pictures of the tissues that the sound waves have encountered as they've traveled.

Dr. David Meyerson: So the technology is such, it's a little bit like when you get stopped by the policemen and he's either used radar or laser where he throws a beam of light or radio waves at the car, they bounce back and then the device looks at the reflected waves, makes some analyses and says you were going too fast. You can actually measure the blood flow going through a certain area of a blood vessel, can't you?

Dr. Heather Gornik: That's right. Not only do we get beautiful pictures, for example, the pictures that we have in obstetrical ultrasound. We can take pictures of the arteries and veins. We can actually see clot or clot -- I'm sorry, we can see plaque or clot, but we can also use the ultrasound technology for something called doppler to measure the blood flow and the speed of blood flowing through the veins and arteries and that gives us information as to the presence of a blockage.

Dr. David Meyerson: Would you tell our listeners what the difference is between plaque and clot?

Dr. Heather Gornik: Sure, it's actually a very good question and it's easy to stumble upon. Plaque usually refers to atherosclerosis and that is the so-called hardening of the arteries where there's fat deposition in the wall of the arteries, often with some fibrous or scar tissue around the fat deposits. And sometimes there's even calcium or hardening of the plaque as well. A clot, also called thrombus is a material that's formed with platelets and clotting factors that usually form in veins, but can also happen in arteries, but typically causes occlusion or blockage of a vessel completely.

Dr. David Meyerson: Uh-huh [affirmative].

Dr. Heather Gornik: Usually plaque is something that forms over time and is slowly progressive in response to the risk factors for atherosclerosis.

Dr. David Meyerson: Kind of like the corrosion that we talked about --

Dr. Heather Gornik: Exactly.

Dr. David Meyerson: -- in the seventy-year- old house.

Dr. Heather Gornik: The plaque is the corrosion and that can worsen in people who continue to smoke and have high cholesterol and diabetes. Thrombosis is something or clot is something that tends to form abruptly, such as patients who have a DVT or clot in their legs or something --

Dr. David Meyerson: DVT means deep vein thrombosis and that's the blood clot that could break off and go to the lungs and that could be life threatening and that's why it's so important.

Dr. Heather Gornik: That's right. So a clot is something that usually forms more abruptly than plaque which is more chronic and slow to develop.

Dr. David Meyerson: And all clots are not bad. A blood clot sitting on a stomach ulcer, preventing it from bleeding is your friend.

Dr. Heather Gornik:  That's true. Or a clot when you cut yourself shaving is also a good thing.

Dr. David Meyerson: Absolutely, but those that form in the arteries that nourish the heart muscle can cause a heart attack. The ones that form in the carotid arteries can either break off and go to the brain and cause stroke and the ones that go to the lower extremities can cause terrible pain, ulcers that don't heal and they can also cause the need on rare occasions for amputation. Dr. Gornik, let's walk ourselves from head to toe briefly and talk about the vascular studies that you do. If somebody has had a mini stroke or threatened stroke, they are often sent to you to look at the carotid arteries, the arteries that nourish the brain. Is that right?

Dr. Heather Gornik: That's true. And we would do something called a carotid duplex examination which involves the patient coming to the noninvasive vascular laboratory and lying down on a stretcher and an ultrasound transducer or probe is actually put on the neck and we actually take very careful pictures of the arteries of the neck and then carefully measure blood flow in the arteries of the neck. What we are looking for is actually a blockage in the carotid arteries and we can diagnose a blockage if there is a high velocity or a very fast blood flow in the artery of the neck. We can also see plaque that is causing the corrosion that's leading to the blockages of these arteries.

Dr. David Meyerson: And again, this is painless and it's done in what twenty minutes or something like that?

Dr. Heather Gornik: A typical carotid duplex examination takes about, I would say, thirty minutes total to complete.

Dr. David Meyerson: And how about if we go into the abdomen? The major blood vessel called the aorta in some people can widen and in some people that can threaten to rupture, that would be called an abdominal aortic aneurysm. How do you diagnose and follow those?

Dr. Heather Gornik: Those are also detected by ultrasound routinely. And what we do is we use and ultrasound transducer that we place over the abdomen and we visualize the abdominal aorta which is located toward the back of the abdomen near the spinal column and we measure the size of the aorta and look for enlargement of the aorta to a certain size that is consistent with aneurysm. Aneurysm means enlargement of the aorta and a normal aorta should be less than three centimeters in diameter. If an aneurysm is greater than three centimeters in diameter, that's called an aneurysm.

Dr. David Meyerson: And then if they get to a very large size of if they grow very quickly, those are red flags.

Dr. Heather Gornik:  That's correct and usually patients who are diagnosed with an aneurysm should return regularly for another ultrasound for surveillance, to look for growth of the aneurysm to the extent that would warrant the repair of the aneurysm. And generally is indicated when the aneurysm reaches five and a half and in some cases, five centimeters in diameter.

Dr. David Meyerson: And especially if it gets there in a hurry.

Dr. Heather Gornik: That's correct. Or for women, sometimes there's a lower threshold for repairing the aneurysms.

Dr. David Meyerson: And so far, I'd just like to emphasize that none of the testing that you've mentioned is painful, there's no needles involved at this point and it's very easy to do. Let's take us to the lower extremities and the peripheral vascular disease that you look for as well.

Dr. Heather Gornik: Sure, well we actually have a lot to do in the lower extremities. There are a number of tests that we do in the lower extremities to evaluate for vascular disease. One of the tests we do is actually using ultrasound, but in this case not using ultrasound with pictures, but just the sound waves to measure the blood pressures in the legs and compare the blood pressures in the legs to the blood pressures in the arms. This is something called a simple ABI or ankle-brachial index test and this is a test that is done to diagnose peripheral arterial disease or PAD.

Dr. David Meyerson: And then you can also do testing to rule out blood clots in the veins of the legs too.

Dr. Heather Gornik: That's right. So in addition to measuring the blood pressures in the legs, we can also use the duplex ultrasound machine to image the blood vessels and measure the velocities of blood flow in the legs and we image both the veins and the arteries, so in the veins we use the ultrasound machine to look for blood clots and in the arteries, we are actually looking for plaque and blockages.

Dr. David Meyerson: In the about two minutes that we have left Dr. Gornik, I think you and I should sum up for our patients what they can do between today and tomorrow to reduce their risk. They should obviously see their doctor if they've had any problems with their blood vessels whether it be stroke or heart attack or any lower extremity problems, they should ask am I at risk, but not smoking is critical. Knowing your cholesterol.

Dr. Heather Gornik: Yes.

Dr. David Meyerson: And again blood pressure control would be important.

Dr. Heather Gornik: Blood pressure control. If you are a diabetic patient, getting your blood sugar to its target and having regular monitoring of your blood sugar levels.

Dr. David Meyerson: Exercising as much as you can, staying lean would be helpful.

Dr. Heather Gornik: Absolutely.

Dr. David Meyerson: And we would -- one last word from you about, what's the one thing that patients can do -- the most important thing between today and tomorrow?

Dr. Heather Gornik: I think knowing are they at risk for having vascular disease. Knowing their blood pressure. Knowing if they have high cholesterol. Do they have diabetes? And if patients do have risk factors for peripheral arterial disease or vascular disease in other areas, ask your doctor if you're at risk.

Dr. David Meyerson: And if we could end by saying stop smoking, stop smoking and Dr. Gornik together.

Dr. Heather Gornik: And I'll say it again stop smoking.

Dr. David Meyerson: Excellent. Thank you so much. This is Dr. David Meyerson for VDF HealthCast, you've been listening to our PodCast with our special guest Dr. Heather Gornik, Cardiologist and Vascular Specialist at the Cleveland Clinic. That's all for now. We'll see you next time on VDF HealthCast.

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