4 - Heart Health and Heart Screenings (Dr. Richard Kettelkamp)

Dr. Richard Kettelkamp, cardiologist, joins Dr. Dustin Arnold, chief medical officer, to discuss heart health and heart screenings.

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Transcript

Dr. Arnold:        
This is LiveWell Talk On... Heart Health and Heart Screenings. I'm Dr. Dustin Arnold, chief medical officer at St. Luke's Cedar Rapids UnityPoint Health. Heart disease is the leading cause of death in the United States. Yet many people have no symptoms. To prevent a cardiac event from affecting your life. It's essential to learn what puts you at risk of developing heart disease and how to keep it from occurring. Heart screenings allow individuals with or without family heart disease to be proactive about their heart health and potential risk for heart disease. Today we are delving into what exactly the test screen for, who should have them, when they should have them and what value do they offer. Joining me to talk more about this, his cardiologist, Dr. Richard Kettlekamp from UnityPoint Health - Cedar Rapids Heart and Vascular Institute and St. Luke's Cardiology. Thanks for taking your time out of your busy schedule to talk about this today, Dr Kettlekamp.

Dr. Kettelkamp:     
Glad to be here.

Dr. Arnold:        
You know, we live in a capitalist society, and you know, we have a free market and so with heart disease being so important and large in our society. And you know, I remember one time you and I are about the same age, 50 percent of heart disease presented with sudden death.

Dr. Kettelkamp:     
Right. That's true.

Dr. Arnold:         
You know, and I know you, maybe you could comment on what that percentage is now, but I know it's significantly less.

Dr. Kettelkamp:     
Yeah, sudden cardiac death occur, it still occurs. And in fact heart attacks, roughly 25 percent of them present as death. Right? So that still a big proponent, it's the leading cause of death, heart disease is, here in the United States and anywhere else we're really living in a modern society. And so it is a important thing to get your arms around and assess your personal risk.

Dr. Arnold:        
Well, and as I started to say about the capitalistic and so you have these heart screenings, these health screening fairs, sometimes sponsored by perhaps a service organization, Knights of Columbus, Lions, other times it's something in the tidbits newspaper flyer, $99 all these screens. And I guess as a physician when I see that, I always worry that patients are gonna have something done and it's not going to be followed up on or it's, you know, we as you well know, we have accreditation and quality assurance with our diagnostic studies and our laboratory studies and our physicians' performance. And I worry that this someone in a white panel van is going to screen and it's not gonna be followed up on. What's been your experience? Have you seen that? Have you seen a patient come in or seen where the system broke down for that patient because of this rogue screening, if you will?

Dr. Kettelkamp:       
No, that happens all the time and I think that's the real advantage to the way things are done here with the heart check. That is the big issue. Patients will occasionally come in with their sheet with some numbers on the page and sometimes they're interested enough to ask about, you know, what do these things mean? But oftentimes it's by chance that I find that they had this done. And so you're right, it can reveal true problems in disease and if it's not followed up upon or discussed, you know, real time, that's an issue.

Dr. Arnold:        
You know, on the medical staff at St. Luke's we have a policy, it's nickname is 'you order it, you own it.' Meaning if you order a test, a laboratory diagnostic on a patient, you have the responsibility, if not the duty to follow up on that and make sure the patient first of all knew why they were getting it and the results of so, so that's, that's why I worry about, I had a patient once described where they had this done in the kind of the back room of a grocery store, you know, and the exam table was made from milk crates and they were screening these ultrasounds. And I just found that just...

Dr. Kettelkamp:     
Archaic.

Dr. Arnold:        
Yeah, archaic, if not third world almost. But so here, I think it's really a positive that St. Luke's and your colleagues have embraced this rather than ignore it. Because I think some physicians do kind of dispel the screening. It's there, it's not going away. And you know, I'd like to talk more about the structured response St. Luke's has had to that with the what is referred to as the heart check and the heart scan. What exactly do these tests measure? What are, what is the patient gonna expect?

Dr. Kettelkamp:     
So a lot of ways, there are some tests that are similar to the tests that you get at the, you know, Hy-Vee parking lot in a van. But there are things that go beyond that. So the basics include a carotid artery scan or duplex study, a abdominal AAA duplex and a peripheral arterial disease test, which would be called an ankle brachial index. And those look for, you know, basic issues with vascular disease. And these are fairly easily screenable problems that can be sort of surrogate markers of other bad things. Plus they can be the silent but deadly things like an abdominal AAA, you wouldn't know you had one unless you've screened for it potentially. And so those are included in that exam. And then beyond that, there is a limited echo, an ultrasound of the heart, looking at the heart structure function, and an EKG is done as well. So it adds a little bit more regarding, you know, heart health, conduction system, arrhythmia issues, that kind of thing. I think that the way that it steps things up a notch so to speak, is there is a person who speaks to you afterwards, here's your results. You have a nurse that goes through the results line by line, what does it mean, what should we do next?

Dr. Kettelkamp:     
And then in addition, you, I didn't bring this up there are some lab tests that can be done as well. So if you're interested.

Dr. Arnold:        
It's a thyroid and cholesterol check, correct?

Dr. Kettelkamp:    
Yeah, that's right.

Dr. Arnold:         
And then all those results are reviewed by a board certified cardiologist, correct?

Dr. Kettelkamp:    
Right. Real time. That's, I think one of the other advantages. You have the results in hand as you leave the heart check center up in the heart center. After you've had a discussion and sort of counseling with a nurse.

Dr. Arnold:         
What who should have these tests. You know, the whole statistics behind a screening test and it's positive predictive value, negative predictive value, you know, you want to direct them towards the appropriate population. Because as physicians, the last thing that we want to have happen is a false positive and expose that patient to greater testing. Whether it's invasive or noninvasive. So who would you direct to have these test?

Dr. Kettelkamp:    
So people with risk factors. So patients, you know, clearly people who have risk factors for cardiovascular disease, like diabetes, high cholesterol, a big one and one that seems to incentivize people mostly is a family history. So mom, dad had heart disease at a very young age a brother or sister had a heart attack and they're only two years older than you. Those are big triggers for testing. So it's really, it's based on risk factors.

Dr. Arnold:     
Is there a certain age that this should start? I mean, you know, I could have a family history of let's say colon cancer of a first degree relative late in life, but I wouldn't have my screening colonoscopy at 14 years of age. You know, there's, so at what age should someone say, you know, I need to start looking at this.

Dr. Kettelkamp:    
Sure. Usually they say, what age does your first degree relative have a problem?

Dr. Arnold:        
Okay.

Dr. Kettelkamp:     
So your dad died of a heart attack at 50. Well, maybe I'll get screened at that age.

Dr. Arnold:        
At that age?

Dr. Kettelkamp:     
Right. Assuming you're doing the right stuff. Now, if you were diagnosed with sugar diabetes at 45, you know, you, have other risk factors, you're on blood pressure medicine, you're on cholesterol meds, you may want to be screened earlier.

Dr. Arnold:         
Now let's talk a little bit about one that I know is within your realm of expertise, and that is the peripheral vascular disease, lack of blood flow in the lower extremities. I think when people think about heart and vascular health, they think about strokes, they think about their heart. Often they don't think about their lower extremities. They, and as you, and I know, cholesterol is not selective in what it deposits. So if it deposits and obstructs flow in the lower extremities, it's possibly elsewhere. So I, you know, I think that's a, that's a harbinger of underlying problems if you have bad blood flow to your lower extremities. Talk a little bit about peripheral vascular disease and what symptoms patients have because I'm going to throw out a percentage here and you correct me, but I think only about 15 to 30 percent of peripheral vascular disease is diagnosed. So the other 70 percent are, pardon the pun, are walking around with peripheral vascular disease. You want to comment on that?

Dr. Kettelkamp:     
Yeah, no, I agree with you. It's a very prevalent disease process. Interestingly, many times we'll see patients who have for years complained of leg pain and never really had this investigated as a possible cause. So, you know, you think about, boy, I have leg pain and have had it for a long time and it's easy to write it off. 'I'm getting older, like my joints hurt, I have muscle aches and pains,' that sort of thing. And they just sort of say, well, I just have to live with it when in fact it could be a process or a disease that could be treated. And so it's important to get checked for that, particularly in the setting of leg pain, typically pain that occurs with activity, with exertion, cramping in the calves and the thighs and the buttocks and the hips. The other issue with peripheral arterial disease, even if it's asymptomatic, which oftentimes people have, it's not an uncommon scenario to have peripheral arterial disease, maybe even obstructed peripheral arterial disease and have minimal symptoms. That's, that's the other, you know, the sort of the corollary to that. But peripheral arterial disease is a fairly important marker for other things. As you pointed out, cholesterol doesn't just hit the leg arteries, it goes everywhere. And so if you have leg artery blockage, you have a 50 percent coincidence for coronary artery disease. It's the strongest risk factor for obstructive coronary disease that there is. And so if you have peripheral arterial disease, it's a surrogate marker for coronary disease.

Dr. Arnold:         
You know, I'd like you to comment on, and just reinforce the significant impact or contribution that smoking contributes. And it's just not, I think sometimes patients, have a misbelief that it's the smoke from the cigarette when in fact it's the nicotine, whether it's nicotine gum, smokeless tobacco, these vaping devices that I'm not familiar with, but I hear about. Do you want to just comment on that factor, how nicotine plays into this and how, significant a threat it really is.

Dr. Kettelkamp:     
Sure. So I, you know, I don't know all the pathophysiology of nicotine on atherosclerotic disease, but I do know that nicotine causes actually vascular issues with accelerating atherosclerosis, but it also causes vasoconstriction. And so that's one of the big factors for nicotine and peripheral arterial disease, coronary disease as well. But there's a very strong connection between smoking and leg artery blockage.

Dr. Arnold:        
Yeah. We see that in the wound clinic with vascular disease, that how nicotine, you can look at a wound and tell whether or not the person smokes.

Dr. Kettelkamp:    
Wow.

Dr. Arnold:        
You know, you really can, you can look at it and say that has microvascular compromise and you're always right when you do look at that. You know, as we start to wrap this up, Dr. Kettlekamp, one thing I think patients are hearing, and even some physicians are confused on this, the old aspirin a day keeps the doctor away. Where are we at with aspirin right now? That's, you know, to be or not to be was a title of an article published recently in the Journal of American Medical Association, where are we at with aspirin?

Dr. Kettelkamp:     
Sure. So for years, as often happens, we believe that one thing be true based on data and you know, the best available evidence at the time. So the aspirin came out because of the Framingham study, which was a study of tens of thousands of physicians in fact, and well, other patients and other people looking at multiple drugs and risk factors for coronary disease. And it was probably the most extensive to date study looking at the natural progression of atherosclerotic disease. And aspirin was felt to be cheap, easy and very effective in preventing strokes and heart attacks. And I think to some degree for appropriate populations that is probably true but not necessarily for all comers, because more recently data's come out to say that aspirin actually potentially has an increased risk of bleeding complications, particularly in patients over the age of 70 who don't have documented or confirmed atherosclerotic disease. So there's no real rationale if you're a healthy 70-year-old or older that aspirin is probably effective for primary prevention.

Dr. Arnold:        
Primary Prevention.

Dr. Kettelkamp:     
Secondary prevention is a different story.

Dr. Arnold:        
Okay.

Dr. Kettelkamp:     
You have a history of atherosclerotic disease, aspirin is good. Low-dose. Baby.

Dr. Arnold:         
So a baby daily is the, is just as beneficial without the risk of bleeding as the full strength aspirin.

Dr. Kettelkamp:     
Correct. Exactly.

Dr. Arnold:         
That's good information and stay tuned it'll probably change in our recommendations. And you know, if you practice medicine long enough, the pendulum swings back to where you started and you, you become in vogue again, you know, so you just have to, the key is just to practice long enough.

Dr. Kettelkamp:     
Practice as long as possible. Sure, good point.

Dr. Arnold:         
Well this is great information, Dr. Kettlekamp and I want to, I'm very grateful for you taking time out of your busy schedule. Again, this was Dr. Richard Kettlekamp, one of the over 500 board-certified specialists that are on staff here at UnityPoint Health - St Luke's, Cedar Rapids. He is a leader in cardiology, as well as the heart and vascular institute. If you have a topic you'd like to suggest for our LiveWell Talk On... podcast, shoot us an email at stlukescr@unitypoint.org, and we encourage you to tell your family, friends, and neighbors about our podcast. Until next time, be well.