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Episode 9 : Happy New Year 2007, A Discussion of the Key Messages About Vascular Disease from 2006

Release Date: January 1, 2007

Dr. David Meyerson: Hi, I'm Dr. David Meyerson, cardiologist at Johns Hopkins and your host for this edition of Vascular Disease Foundation's HealthCast. We are very excited to be able to bring excellent, easy to understand science to you on all topics relating to heart and blood vessel diseases as a public service. As a public education forum, the Vascular Disease Foundation is made up of representatives of the premiere medical and scientific advisory groups in the country that relate to vascular diseases. These are groups that use peer-reviewed science to verify that the information you are getting is nationally recognized as the very best and most reliable data available. Prior episodes in this series have dealt with exactly who the parent organizations of the Vascular Disease Foundation are, the spectrum of vascular diseases and how the non-invasive laboratory, those tests that are without needles, catheters or discomfort can be used to screen for such problems as coronary artery disease. Those are the narrowings of the arteries that nourish the heart muscle that can cause angina, the chest pain you get when too little blood supply and oxygen gets to your heart muscle and causes heart attacks. Carotid artery disease, that's a narrowing of the arteries of the neck that nourish the brain. These can cause strokes, threatened strokes we call transient ischemic attacks or TIA's and also abdominal aortic aneurysm, this is a bulging and weakening of the major blood vessels of the abdomen which can cause life threatening blood loss and finally peripheral arterial disease. Perhaps the main focus of this series of broadcasts. Narrowings or blockages in the arteries that nourish the legs which can limit your ability to walk, cause pain and cause ulcers in the legs and in extreme situations, can even cause one to risk amputations. These are largely preventable diseases. Once developed, they are very treatable diseases and the early recognition and treatment can prevent your disability, promote your physical well being and help you maintain the healthiest and most active lifestyle you possibly can. We've also spoken about the critical need to stop smoking and we had two outstanding programs on smoking cessation, methods and ideas. And finally we've spoken about exercise physiology and how those folks with peripheral arterial disease can actually do an enormous amount to help themselves. That is in essence what these VDF PodCasts are all about, giving you solid, reliable information and public education to allow you to maximally help yourself to prevent disease and to live more effectively with the medical problems you do have.

With me today is my good friend and colleague, Dr. Kerry Stewart, without whose imagination and hard work, these PodCasts would never have been possible. He's the Director of Clinical and Research Exercise Physiology at Johns Hopkins. I'm proud to call him my friend. Kerry welcome back to the HealthCast microphones.

Dr. Kerry Stewart: Well, thank you David and have a Happy New Year.

Dr. David Meyerson: A Happy New Year to you as well, Kerry. We're going to dispense with the formalities of the Dr. Meyerson and the Dr. Stewart and this will be our first 2007 broadcast of these PodCasts and this is the ninth of our series Kerry, can you believe that?

Dr. Kerry Stewart: That's correct. We've accomplished a lot in the last couple of months. This is, as you said, number nine and we have many more planned.

Dr. David Meyerson: Wonderful. We've hit so many wonderful topics, before we go any further I want the listeners that there is enormous amount of information always available to them at the Vascular Disease Foundation website and I'll just give the website right now, it's www.vdf -- the vdf again stands for Vascular Disease Foundation and be careful because the suffix, the ending is -- it's www.vdf.org, dot org. It's not dot com, it's www.vdf.org, org and there is an enormous amount of information available, plus you can access all of our previous PodCasts and listen to them at any time you want.

Dr. Kerry Stewart: Well, the PodCasts are posted on the vdf's website. There's a section called PodCasts and you can find all of our episodes. You can also sign up for the PodCasts through the iTunes music store.

Dr. David Meyerson: And if you want to see the faces to the voices that you're hearing right now and a little bio sketch about each of us, I doubt if you probably want to do that, but if you're so moved --

Dr. Kerry Stewart: I think that's the highlight of the website actually.

Dr. David Meyerson: This is going to be like car talk only for body part, is that right.

Dr. Kerry Stewart: I think so.

Dr. David Meyerson: Kerry, I'm so excited. We did a two-segment program on smoking cessation and one of the things that we decided was that people who try to stop smoking -- now this is our first program after the new year. People who have stopped smoking, we want to encourage them to continue to resist. You must resist. Smoking cessation is one of the best things that you can do to prolong your life, to prevent the aging process, to prevent hardening of the arteries, prevent stroke, prevent heart attack, prevent peripheral vascular disease. Don't you agree?

Dr. Kerry Stewart: I agree absolutely and I guess I -- since it's the time of the year that many people make resolutions, this should probably be the number one resolution on every smoker's list.

Dr. David Meyerson: And you know, it's a gift. It's a gift to people who live with a smoker get sick more, second hand smoke does cause cancer, that is absolutely critically understood now and it's a gift to your children or to your grandchildren if they're in the house. Children that around people that smoke get sick more frequently, they get more asthma. You can be giving a gift not only to yourself, and it's an enormous gift to yourself, but also to the people around you.

Dr. Kerry Stewart: That's exactly right. It's a major gift to everyone.

Dr. David Meyerson: And remember, cutting down while a good thought, is just like saying I only drive a hundred and thirty-five miles an hour two days a week, so you're going to kill yourself on a Tuesday or Saturday. It's worth it. I want you to look at yourself in the mirror and say, "Who am I kidding. Stop smoking." It is so worthwhile and it's less expensive if you stop. Kerry, let's talk a little bit about, there's a commercial out there that makes people believe that if they have peripheral arterial disease, that they are at increased risk for heart attack and stroke and I think we'd like to emphasize that while that is technically true, it's that the same set of risk factors are causing all those same diseases. We talked about the plumbing in a sixty-year-old house and if you have a problem with a blockage in a pipe in the basement or on the first floor, it wouldn't be surprising to find it elsewhere. And so I think what we take away from this commercial is that when you find out that you're having symptoms of peripheral arterial disease, and I might ask you what those are in just a minute, but if you're having symptoms, that's just a marker to say have the doctor also check you out for coronary artery disease and for carotid artery disease as they can all coexist in the same person. Is that about the way you'd put it?

Dr. Kerry Stewart: That's exactly how I would put it and as you said, peripheral arterial disease is one of the atherosclerotic diseases and why it occurs in the legs in some people first or in the head in some people first or in the heart in some people first, we really don't know. But when you have it in one area, you're likely to get it, develop the disease in another area.

Dr. David Meyerson: And once you have the earliest, wherever the earliest warning is, if the earliest warning is in the legs, take that as the warning and say I'm at risk for developing it elsewhere. Let's really get on the money and make sure that we prevent this disease from going any further.

Dr. Kerry Stewart: That's exactly right and technically we call these -- we would refer to that as a marker so P.A.D. would be a marker.

Dr. David Meyerson: So before we go any further, what's the symptoms of P.A.D. again for our listeners?

Dr. Kerry Stewart: Well, about -- only about half the people who have P.A.D. actually will develop the classical symptoms. The classical symptoms are that leg aching, cramping that occurs when somebody walks, what we call claudication which comes from the term to limp. I think it's believed that the Emperor Claudius actually had that symptom because he limped and that's where the word claudication comes from.

Dr. David Meyerson: He never consulted me about that.

Dr. Kerry Stewart: No, I don't know where he -- yeah, he -- maybe it was Hippocrates he was talking about. I'm not quite sure.

Dr. David Meyerson: Okay.

Dr. Kerry Stewart: But --

Dr. David Meyerson: Maybe Mommometies [phonetic].

Dr. Kerry Stewart: Mommometies too. We kind of have a bias in that direction.

Dr. David Meyerson: That's right.

Dr. Kerry Stewart: But in any case, only about half the patients, in fact, will have claudication.

Dr. David Meyerson: So I have patients that say, "Doctor, I have a long walk, I have a very long driveway and I have to walk up a hill either to my mailbox or where the newspapers are and every time I get to a certain point, I have to stop because I get this cramping in one of my legs." That's consistent with peripheral arterial disease, right?

Dr. Kerry Stewart: That should definitely put peripheral arterial disease on the radar screen and if you're getting that symptom, it's critically important to consult with a physician who can, in fact, do some simple testing. We've heard about some of the testing on a previous PodCast. The testing can be noninvasive, in other words, it doesn't require needles or anything to be put inside.

Dr. David Meyerson: Sound waves.

Dr. Kerry Stewart: Sound waves, ultrasound, device can be used to detect whether or not it's P.A.D. or perhaps some other problem. People also get pain sometimes if they have lower back problems.

Dr. David Meyerson: Absolutely. But I guess the idea is let the doctor help you decide what it is. If it's a lower back problem, there are things that you can do to lessen the effects of that lower back issue. Lots of people have that. But if it's peripheral vascular disease, if it's a marker, then you begin to look at all the risk factors and say, once it's developed, is it progression preventable and we believe that you can stop it right in its tracks and if you get it early, you can keep your blood vessels from ever getting any worse and there are lots of things that people can do, right Ker?

Dr. Kerry Stewart: There are many things that people can do. First of all, as we've said repeatedly, quit smoking, exercise and to modify the cardiac risk factors. In other words, make sure that the blood pressure, the cholesterol levels, body fat, are at the most ideal levels for you.

Dr. David Meyerson: One of the things that came out of our discussions, we talked about peripheral vascular disease, we talked a little bit about carotid disease, we talked about coronary artery disease and one of the interesting things is that whenever you have vascular disease of any sort and these are -- this is another plumbing problem. What you do to benefit one area of the vasculatiry, benefits it all.

Dr. Kerry Stewart: It helps the entire system.

Dr. David Meyerson: So if you were treating peripheral arterial disease with diet, with exercise, with medications, you're also doing yourself a world of good in preventing carotid artery disease from getting any worse and causing transient ischemic attacks and strokes and you're also doing your heart a world of good by preventing coronary artery disease from becoming narrow enough to cause angina and heart attacks.

Dr. Kerry Stewart: Absolutely. Let me just finish one last point about -- because you raised the question about getting this leg cramping and as I started to say, only about half the patients will actually have claudication which is the classical symptom. But half won't, but people who are at risk for atherosclerotic disease, those with diabetes, those with high risk factors, again should see their doctor and suggest the possibility that simple testing be done to see, in fact, if the blood flow to the legs is diminished. And that can be done through simple blood pressure measures of the legs or again some of these other ultrasound devices that we've discussed previously.

Dr. David Meyerson: There was that ankle- brachial index that you brought up previously.

Dr. Kerry Stewart: Ankle-brachial index, the primary noninvasive test that is very easy to do.

Dr. David Meyerson: It's simple. It can be done in the doctor's office with blood pressure cuffs.

Dr. Kerry Stewart: Most doctors would have the capability of doing that and it takes about ten minutes and it is very sensitive and very specific.

Dr. David Meyerson: And for our diabetic patients, they should be examining their feet and legs regularly. A non-healing sore or an ulcer or a bluishness of a toe or something like that should not be ignored and our diabetic patients, they often have less sensation in their -- they have what's called a stocking glove neuropathy which means that they may not feel, they may not have sensation in their lower extremities and that's why a sore or a small ulcer or a vascular problem which causes that in the lower extremities can go unrecognized for a while so we urge all of our diabetics, get good foot care and anytime you see any of those signs that we talked about, a small non-healing ulcer or discoloration or something like that, you should be looked at. And again, our diabetic patients or those people who -- what about if somebody doesn't have a claudication. They're able to walk a reasonable distance, but they have already had a coronary artery disease, let's say they've had a bypass or let's say they've had a carotid artery procedure like a stent or what they call the carotid endarterectomy which is the taking away of the plaque from inside that artery. Those people are still at risk for peripheral arterial disease and you mention that only half of the patients have symptoms so for those that don't have those symptoms, they should specifically ask their doctors for a P.A.D. evaluation.

Dr. Kerry Stewart: They should get a P.A.D. evaluation, but at the same time, if they're being treated appropriately for their carotid disease or their heart disease, in fact, they will be being treated appropriately for their P.A.D. because the treatments are almost identical.

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

Dr. Kerry Stewart: It's diet, it's exercise, it's smoking cessation and getting those risk factors under control.

Dr. David Meyerson: Now I just want to mention that for those patients that have pain in their leg at rest or have an ulcer that's not healing at rest, for example, it's always there, it doesn't heal or if they have pain at rest or discoloration or blueness or dysfunction, you can't use the leg as well as you did before, that could be a sign of critical limb ischemia and that's not something that we sit on. That's something that you get evaluated for right away.

Dr. Kerry Stewart: Oh absolutely because that's, as you said, a more advanced stage of the disease and if treatment isn't undertaken quickly, there's the threat of losing the limb.

Dr. David Meyerson: Right. Ulcers can get worse, they can get infected and that could cause terrible problems, but those are the ones that are also treatable, imminently treatable. Sometimes with just vascular procedures, not necessarily what you might call -- we call it an interventional procedure, not necessarily a surgery, no cutting. It could be a needle and catheter procedure.

Dr. Kerry Stewart: Right and we heard on one of the previous PodCasts from Dr. Drooz who's an interventional radiologist whose among the specialist that do these endovascular therapies. They're also done by surgeons and in some cases they're done by cardiologist. They're done by a variety of people.

Dr. David Meyerson: We don't care who you end up being treated by --

Dr. Kerry Stewart: Right.

Dr. David Meyerson: We want you to get your treatment because this will improve your activity and prolong your life.

Dr. Kerry Stewart: Right. And between to Dr. Drooz and also myself having heard several lectures now into vascular therapies. There are many, many wonderful techniques available in which a blood flow can be restored without necessarily a very extensive surgery. You know, usually you cut in the groin or in the leg an inch or two long as opposed to opening up the leg from groin to toe, so there's many advances --

Dr. David Meyerson: We try to get away with not doing a fillet of patient if you will.

Dr. Kerry Stewart: You know, that's exactly right. I was trying to avoid using that word because -

Dr. David Meyerson: That's what it is sometimes.

Dr. Kerry Stewart: But that's, in fact, what some people feel like they've been through is being filleted.

Dr. David Meyerson: But let me get you back to exercise, a little bit about exercise physiology and things -- one of the magic things that I think we've uncovered in our first nine episodes is that the patient really can do so much to help themselves. It's really, it's very heartening, no pun intended --

Dr. Kerry Stewart: Yes it was.

Dr. David Meyerson: As a cardiologist, of course.

Dr. Kerry Stewart: That part was. I know you better, David. That pun was definitely intended.

Dr. David Meyerson: It's very hard – but it's -- there are so many things, again smoking cessation, I could not say -- if I could drop on my knees before our listening audience who are smokers and tell you that I have seen so many people's lives ruined both with cancers, with oral cancers, with heart disease, with stroke, with peripheral arterial disease, with amputations. If you are a smoker, I bet of you, I beg of you. It will come back to you in enormous benefits to stop smoking, no matter how long you've smoked. But in terms of, Kerry -- you're Director of Clinical and Research Exercise Physiology at Johns Hopkins – people with claudication can actually improve their function by exercise, can't they?

Dr. Kerry Stewart: Absolutely and we've had instances of people doubling and tripling and even more increasing their ability to walk without getting pain. We have a patient now at our program who when they first came to us, couldn't walk more than a block without getting severe pain and just recently, returned from a trip through Europe --

Dr. David Meyerson: If you say the Marine Corp. marathon, I'm not going to believe you.

Dr. Kerry Stewart: Not the Marine Corp. marathon, but walking blocks and even miles during -- through cities of Europe without having to stop once where previously couldn't walk one block. That is not necessarily the most common outcome of exercise, but that is at least a possibility.

Dr. David Meyerson: But that's what we, I think are all about. Me as a cardiologist, you as an exercise physiologist and the Vascular Disease Foundation and the P.A.D. coalition. We want to be able to maximize the functional capacity for our patients for as long as they possibly want to do what they want to do. George Burns had a contract to play the Palladium when he was a hundred. He only missed by a couple of months. We would like you to have a high level of function for as long as you want to do what you want to do and I think that's what this is really all about.

Dr. Kerry Stewart: That's what it's all about, but it also requires work on the patient's part. The basis of an exercise program is to actually walk and develop some degree of pain because the pain becomes the stimulus for improvement, so it does take an effort.

Dr. David Meyerson: That's different from what we do with people with angina, with heart disease.

Dr. Kerry Stewart: That's exactly right.

Dr. David Meyerson: When they get in pain, e don't like them to go too much further and if they et pain with limited activity or any pain at all, we like them to be evaluated so that we can assess their risk. But in people with peripheral arterial disease, Kerry, you are saying that you take them to a certain - - after a medical evaluation --

Dr. Kerry Stewart: Medical evaluation and then go to a moderate degree of pain for a few minutes, stop, rest, let the pain go away and then start again.

Dr. David Meyerson: And this actually improves the blood supply or allows the muscles to function better with that diminished blood supply or maybe both.

Dr. Kerry Stewart: Maybe both. We think that at least from what we know today, most of the benefit seems to come from the muscles being able to better use the available oxygen. There have been some studies in animals which have suggested that there's an improvement in blood flow. This hasn't quite been the most consistent finding when you study human beings, so we believe it's the change in what we call the muscle metabolism that accounts for most of the benefit, but there is the possibility that blood flow will increase as well, probably in very small blood vessels that are very hard to measure.

Dr. David Meyerson: I want you to try to promise to explain this to us sometime in 2007. There was some research recently that showed that if you did upper body exercise, if you exercise with your arms and your torso and not necessarily your legs, you could still go further walking after that exercise if you had peripheral arterial disease, or claudication and that, to me, so that means something's going around. Something's circulating and making something better.

Dr. Kerry Stewart: Yeah, when you exercise, you get what we call two types of effects. You get what's called a local effect, so what happens particularly in the muscle group that you're using during the exercise so that when you walk, you use your legs and we believe there's improvements in the muscle of the legs.

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

Dr. Kerry Stewart: But you also get what's called a systemic effect, something that happens throughout the entire body and this could be an improvement in the way the blood vessels relax and contract related to endothelium function. We believe that --

Dr. David Meyerson: Endothelium is the inner lining of the blood vessel walls.

Dr. Kerry Stewart: Is the inner lining of the blood vessels and it helps --

Dr. David Meyerson: We believe this to be almost an organ in and of itself, --

Dr. Kerry Stewart: It is an organ in itself.

Dr. David Meyerson: -- it's an active metabolic lining of the blood vessels that has a lot to do with why people get vascular disease.

Dr. Kerry Stewart: That's one of the mechanisms. There's also the possibility – not possibility, we know that exercise will reduce another problem that occurs in people with atherosclerosis which is inflammation where the blood vessels throughout the body and other organs are somewhat irritated.  Almost as though they had a minor little infection going on and we know that exercise helps reduce inflammation, so it could be the reduction of inflammation throughout the body that can also be contributing to the improved symptoms in the legs. So there are lots of things that exercise does. We don't quite understand all of them, but we know there's a lot of benefit, no matter what the specific reason is.

Dr. David Meyerson: So Kerry in the couple of minutes that we have left of this first 2007 PodCast and for the Vascular Disease Foundation and P.A.D. coalition, again we want our patients to maintain as high a level of activity as possible. With regard to their diet, what would you say?

Dr. Kerry Stewart: Well, the diet should be focused on weight control if that's a problem.

Dr. David Meyerson: And you know exercise is absolutely integrally related to maintaining a normal body weight.

Dr. Kerry Stewart: It certainly contributes and particularly helps to contribute to reducing the fat around the waist and then if people have high blood pressure, they may need to be on a diet that's low in salt. If they have high cholesterol, they need to certainly avoid the trans fatty acids and other forms of fat, but primarily if most people reduced their calories, they'll benefit a lot.

Dr. David Meyerson: And then, with regard to careful medical follow-up, we urge see your doctor, follow the medications, make sure you know what the medications are for, make sure you know that the doctor measures that they're having their desired effect and if there's a side affect or something you don't like about it, don't just stop the medicine, talk to your doctor first because if you communicate this, then your doctor should help you find a medicine that works well and works well for you. And Kerry, again, I just want to thank the Vascular Disease Foundation and again if you want to see their website, it's www.vdf.org.

Dr. Kerry Stewart: Yes and on the website, let me just emphasize that we have information about the broad category or the multiple categories of vascular disease including abdominal aortic aneurysms, aortic dissections, burgers disease, carotid disease, congenital vascular malformation -- this was the condition suffered recently by the Senator --

Dr. David Meyerson: Right.

Dr. Kerry Stewart: Senator Johnson, I believe.

Dr. David Meyerson: And we'll be doing programs on a lot of these issues in 2007.

Dr. Kerry Stewart: Absolutely. Another one that I think we have planned for late January or early February is a discussion of deep vein thrombosis or venous disease, Raynaud's disease, renal vascular hypertension and varicose veins, so these are among the many topics that are covered by the Vascular Disease Foundation and on our website, we have pamphlet information that can be either requested through the mail or you can simply download it in a PDF file.

Dr. David Meyerson: And you can always listen again to all of our Vascular Disease Foundation PodCasts that are all archived right there on the website, www.vdf.org. For Dr. Kerry Stewart, Chief of Exercise and Clinical Research Exercise Physiology at Johns Hopkins, for me Dr. David Meyerson, I'm a cardiologist at Johns Hopkins as well, and for the Vascular Disease Foundation, thank you so much. We wish you good health and happiness in 2007. Thanks so much for listening, till next time.

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