people boost I just sleep for 4 hours your body needs that rest longer run makes a lot of difference do you think lack of sleep causes heart [Music] attack as the Dal Lama says sleep is the best form of meditation why because it allows your body to reboot from inside is stress is related to hypertension directly related especially in city like Mumbai where I practice reason for blood pressure stress higher the blood pressure pressure over a long time will lead to higher corat disease will lead to higher incidence of strokes and kidney diseases so I want you to explain to us in terms of why high blood pressure can cause heart attack diet lifestyle has changed economic growth is there but at the cost of everything you are saying that people are not taking blood pressure medications on daily basis only 30% come why why why is the hesitancy education because if we just control the blood pressure diagnos sit on maskin properly treat it adequately I'm sure 30% of your cardiac heart failure epidemic will go down what is the one thing that you wish your diabetic patient and listen and change prevention pay attention to the diet from the 30s early 40s if you're having blood pressure for a long time and taking blood pressure medications if you are experiencing exertional shortness of breath or when you are lying down at night and you gasping for breath all this a sign of heart failure that's Advanced heart failure easiest thing you can do if you feel discomfort even if it is to get an EKG done that the easiest way to diagnose things I think even though it is a very bold statement I think we can summarize this as any patient with diabetes imagine that you have some kind of heart disease already welcome to another episode of our podcast series G feeling with Dr pal in this episode we have a very good friend of mine Dr ano tande a popular cardiologist in Mumbai I brought him specifically to talk about how to diagnose heart disease what are all the symptoms of heart attack before having acute heart attack what are all the symptoms that you can actually diagnose at a earlier stage how can you listen to your body to make an early diagnosis and what are all the treatment options we went deep into what is angioplasty what is cardiac bypass why is it indicated is it safe not safe what are all the risk factors we talked about diabetes management hypertension management family history of heart disease we also talked in detail about cholesterol and lipid particles as well this is one of the most comprehensive discussion that I ever had in terms of managing heart disease if you or your family member has hypertension has diabetes or has high cholesterol this episode would actually help you to understand what is the pathophysiology behind all these diseases so that you can make changes accordingly in your daily lifestyle so the goal is you don't meet him in the hospital we had a wonderful discussion let's dive deep into it Dr anop so happy to have you here thank you so much so Dr ano is a popular cardiologist here in Mumbai very busy very busy Interventional cardiologist and uh I'm so glad that your brother is my colleague and he's a nephologist back in Chicago so I'm going to extract as much knowledge out of you yeah sure so that I can learn and I also teach my audience as well so right off the bat straight into the discussion I'm going to give you a patient scenario okay and I'm going to say what will you do in this situation okay I saw this patient in my clinic uh this was before an endoscopy okay so what happened was a 52y Old Gentleman he had diabetes hypertension and everything and uh uh the endoscopy was for epigastric pain pain here in the upper part of the stomach so then I uh was talking to him and then I said that okay so tell me when the pain is getting worse and he says the pain gets worse whenever I climb stairs huh and then I said um that doesn't sound like a stomach problem so what happens the pain gets worse after eating no no no no no problem at all whenever I climb the pain gets worse and does it radiate anywhere it radiates to the chest left chest and then it radiates down the arm and then does it happen when you are at rest he says no only on exertion okay so as you know exertional chest pain or chest discomfort I was so concerned okay so then I referred him to Cardiology and then uh you know they figured out that he has uh coronary artery disease uh so if this patient comes to you so I am a gastrologist I refer to you um he has hypertension he diabetes what is the test that you would do to diagnose uh any blockage in the heart I think so it's an uh excellent scenario excellent pickup uh by you Dr Paul uh whenever an elderly or middle-aged with risk factors like hypertension diabetes maybe D lipidemia and family history and especially if he's a smoker uh this upper epigastric pain may not be castric or the GI trouble as you said and as you rightly took on the history and the exertional component and the pain pain pain more than the pain it's at times the just the heaviness or a discomfort which exacerbates which worsens by activity by physical activity is mostly anginal pain or related to the heart so decreased blood supply to the heart yeah during activity what happens your blood flow is not commerate to the requirement and that's what precipitates uh anginal pain so during exertion like climbing up the stairs walking running uh you need more blood supply to the heart yes sir to support the activity support the activity and because there is a blood clot stenos H decreasing the blood Supply that's where the pain is at rest the blood flow may just be adequate to perfuse and you don't have any symptoms but during activity uh the blood flow the demand is increased the demand is increased the FL flow doesn't increase that much that's the reason you get pain it's a very classical symptom exertional component of that pain is a very classical discomfort in in us the most common presentation of chest pain is a person in the east coast like Detroit Michigan New York New Jersey where it is cold and you know they are snowing in the morning outside the house the front yard will be filled with snow so what they have to do they need to moow the lawn or Pluff the snow out so while they are doing they'll get CH I think it's a very classical scenario Winters visoc constriction physical activity demanding physical activity exer in your practice what is the most common situation over here the situation here I think so uh the classical chest pin we obviously don't have the scenario as you described no snow that's good the no snow but in Mumbai I'm talking about the local city one of the commonest pickup is usually when they have to change the platforms you never know where the train comes whether it is a platform two or four and they have to run the bridge run over the bridge to catch or change the platform and that's where they actually feel discomfort they have to climb at least two or three flights of stair fast very common scenario I used to do it very normally that's what the people see now it's becoming difficult I have to stop in between very interesting that's a pickup that's something wrong so someone who was well vered with do with a flight of stair doing it fast not doing it so I think so in Mumbai I think so everything is correlated with trains and traffic so I think this thing you know climbing the flight of stairs is important yeah I think and uh as a GI person again uh talking to you the gut uh one point very important point someone with a significant corat disease significant blockage if they have an heavy meal and post prandial if they walk try to walk and get lot of discomfort minimal exertion leading to heavy pain after a heavy meal can be a sign sign symptom of significant coronary disease it's a classical post prandial enina which we call it signifies extensive triple whistle or a left mean which is the most important AR wow I'm going to summarize what you said so post pralis after eting minimal discount minimal exertion to so the scenario that you are explaining is let's say you go to a restaurant called a Tob yeah yeah all you can eat all you can eat yes and then you eat everything like a full-blown lunch buffet and then you are walking from minimal from your hotel from the restaurant to the car in the parking lot and you had pain yeah or even chest disc I mean stomach discomfort a little bit it could be and if it's repetitive means uh that is actually repeated again and again I think so first thing go and consult cons because that may reveal something nasty any age group that we should be concerned about or doesn't matter in India H I think so I have treated uh as young as 18 and 20 years here in 20 years I had been in primary anoplasty to open up the choked vessels so no ages bar so no ages bar no ages bar usually was an elderly disease 55 60 but uh in India in India uh as I would say Indian Community Indian Community Indian Southeast Asians you can you can just mentioned the Southeast Asian Community we as a community uh have early onset of coronat disease what the classic literature would say is like 10 years earlier I think so more ner more diffus more extensive lot of things so the Indian genetics are such that uh we are more prone for cornea disease we already have the dubious distinction of being the diabetes Capal of the world now so so you'll be seeing a lot I see a lot of so when a patient comes to OPD okay and then says hey you know I have chest pain um people say think that okay you know uh people know about stress testing okay stress testing um can you explain how a stress testing is done right so I think uh for patients who come to the OPD with the classical or ATP presentations obviously when they come with an atypical or some chest pain or some discomfort we need to work it out so the certain battery of tests are advised uh for an we look at the probability before ordering a treadmill it's all about probability we look at the probability whether he's in low risk for corat disease intermediate or high risk and accordingly our treadmill is as well advised but it is advised for apart from the ECG 2D e we actually try to do a 2d Eco or 2D Eco cardiogram to assess the heart functioning the valves okay anything so so you get an EKG ECG ECG EKG okay ECG is the electrodes that they keep on the heart and then you can look at the arthia and I remember with whatever cardi you know there are some signs that you can pick up Pi up that there is decreased blood supply to the heart the second is the echo cardiogram is what is you have a gel applied on the heart heart and looking into you have a small probe goes there and then you can actually see the heart beating heart beating yeah and uh look at it's very important you know you should not miss out on valvular diseases you should not miss on obvious uh you know at rest if there is some problem we don't order a treadmill so when uh the ECG and 2D go is fine let's say third test we usually do is a treadmill test treadmill test CST or computerized tress what is called so when people say stress and everything you are stressing Your Heart by giving more more work to your heart how are you giving them more work by running on a treadmill running on a treadmill yeah exactly if you don't run on your treadmill every day you'll run on this treadmill on this treadmill exactly so running on that treadmill gives us an idea about uh any ECG changes which are happening number one we look at the physical uh you know parameters like how the blood pressure is rising ideally it should rise it should not drop and number three uh the symptoms whether you are experiencing the same symptoms on the treadmill that you are experiencing before so three important things the technician along with the doctor is always there to look for any kind of an abnormal ECG sign ECG sign and and they run fast they run fast there are stages obviously with stage one with minimal inclination minimal speed and then the stage two and then stage three and stage four we usually try to look at the metabolic equivalents we try to look at the targeted heart rate so there's a formula set for it so if you achieve a target heart rate without any changes without any discomfort and able to complete uh the test metabolic equivalence required I think so you are good yeah but there are easy changes and the same pain that you experienced is experienced while doing the doing the treadmill along with the changes it calls for an angiographic angiographic okay let I'm going to summarize that okay so patient had chest pain it comes to you uh there ECG relatively normal echo cardiogram which is a pict of the heart normal you do a strest where the patient runs on treadmill on the treadmill you slowly increase the difficulty by inclination speed while you're doing that if you experience the same chest pain what you had to that you came with which means that it is a decrease blood supply to the heart so we need to find out where the blood supply is being blocked blocked so for that we do something called angio graphy graphy Ang coronary angiography coronary angiography okay that would be the next test that would be advised uh however at times again as I told it's more of in probability testing yes right so what we find in clinical practice it's important there are false positives it's a screening test again it's a probability test so you can have false positives you can have false negatives you can true positives and true negatives so in Indian especially females the tread Bill gives a very posi positive impression lot of V changes that's what I've have like seen over last 17 18 years lot of the females especially 50s 55s HSE positives meaning there are a lot of V changes evening on the treadmill when do an angiogram it's clean it's clean so then again they are false positives but since the E changes are there uh which beyond the arteries are the capillaries and then there's an endo so we actually look at the capillary level and the endothelial dysfunction in this patient so possibly normal epicardial arteries so the angiogram is clean but we don't know what happens at the capillary level the perfusion is less the relaxation is not so great easy changes are there but yes so we'll track back a little bit coming back to the angioplastic so I'm going to tell you what I understand and so that in a layman term so the idea is to see how many blocks ages or in the heart so there are three major blood vessels yes correct what are they left left system we have the left main left Main and it bifurcates into the left anterior descending artery yes we call that as L A is is the terminology is like the Widow's artery because it's so big and IT Supplies almost 50% of the blood vessel thankfully you yeah you brought the important point it's called Widow Maker widower Widow Maker because this is the only main artery that supplies the entire heart and it can get blocked and if it gets blocked the entire heart circulation can be compromised so leading to a death of the person then uh that is why it's called Widow Maker video maker so left mean LED then you have the small Branch coming after the LED is like the circumflex left circumflex again it's a main artery uh then the right side we have single artery which is called the right corner artery most of the blood supply to the electrical system is through the right yes yes and and then posterior yes it goes right goes in the back back side just groes around okay so there are four chambers two on the top two in the bottom and there are three major blood vessel that people should remember left right and the posterior so while you're doing the angiogram is through the gro area Gro or the radial or the radial radial brist through the AR so through the arm of the groin you go all the way into the heart you inject a dye and you see these three blood vessels it's absolutely amazing absolutely amazing you inject a dye and it will fill up the blood vessel and it will tell you which of the blood vessels are blocked and how many percentage exactly so again uh when you arise an angiogram uh it's done on a daycare base is mostly dayare so through the wrist it's pretty comfortable for the patient so they can walk out if it's fine maybe after 3 to four hours like in a radial launch or in nicely in the cafeteria have a cup of coffee and they're off they can they can go back on the same day yeah after 3 to four hours so angiography typically is very very minimally invasive extremely low risk in good hands and uh it reveals and the most important thing is it reveals exact nature of the disease exact percentage and it gives you a plan what would you be advising whether it's so people should not be afraid of angiogram absolutely not right uh when it is advised in a proper scientific evidencebased way I think so they should not be and if it's advised most of the card would be advising to know the anatomy will and obviously if it's what you can say very difficult to gauge it but uh maybe around 50% 60% something which can be managed with medical management lifestyle dietry I think so aggressive management is advised it's not necessarily that you find something 4050 you just tent it or sent for no unless it's significant obstruction which causes pressure drop and it's correlating with the ECG territory nobody would actually advise anoplasty putting in a St or B yes of course of course of course so in when you inject the D you look into all the blood vessels um you can see how many percentage of the blood vessel is blocked blocked usually when you do urgently 100% is blocked then you put a small stin right so that procedure is called as uh primary angioplastic myocard infection it's called as py so it's offered for patients who have a major heart attack what is a major heart attack when the arter is 100% chopped off no blood flow no blood flow no blood flow the M muscles or the heart muscles are deprived of the blood flow oxygenation and they are dying every second every minute here time is muscle earlier you open up the artery put in a stent ensure that the flow is well established the better the functioning of the heart in the longer run right so the terminology time is muscle it stands true for major heart attacks extremely important uh here is green Corridor is established in the hospital any hospital has a program like a Cordes are announced if you have a major heart attack they are straight away wielded into the cath lab angiography is done to determine where the block is wire is crossed maybe there's a blood clot we try to retract the blood clot to a balloon and possibly if needed we put in a stent which is there most of the cases put in a stent it will ensure that the blood supply is back yeah so it will ensure that the life is saved let me just rephrase what you said so like a summary so the patient that I told you is an out patient right so he had chest pain and then we had time at that time right it's we're not talking about in hours we're talking about in weeks so came stress test we did angio there's a small block 70% 80% then you put a stent in and then you go the situation that you are explaining is a patient comes with severe chest pain ah severe chest pain that the patient cannot wait come to the hospital time is muscle muscle is the heart muscle if you delay the timing to the stenting every second you're losing the muscle heart muscle heart muscle which is and once lost they they don't once lost they don't come back yeah so golden hour is something like 60 to 90 minutes 60 to 90 minutes is the golden hour once the patient have chest pain they need to open up within 90 minutes open up which means the patient gets transferred to the from the home to the hospital cat lab that's why all the cardiologist cannot stay Beyond 15 minutes from the hospital yes they have to be rushing in rushing in yeah and someone has to stay in there hospital to do it as urgently as possible but that's for an urgent situation and the kind of situation that we had we have time do an Ango decide what we need to do and then decide yes yes yes beautiful beautiful while we are in that situation I also want to touch base upon bypass surgery people confuse between angioplasty and bypass angioplasty is when one blood vessel is block you put a stent good but bypass is when all the three blood vessels are blocked right so I think so again uh goes on to say uh when on angiogram you determine yes all the three vessels are there they're diffused at times very calcific they're very calcific hard long segment which may possibly not be yielding well with balloons and STS then obviously you should always think about whenever the left m is blocked or at the bipoc or a previous stent has blocked then again calls for bypass very important point is if you have placed a stent if you don't correct your lifestyle the stent can be blocked again yes it can instant thrombosis instant we call restenosis restenosis so it's like development of that blockage or aortic PL within the St isqu so then it calls for more aggressive action at times Byers Byers involves opening up the chest using the internal memory arteries the natural arteries to bypass the Block it's very important I want your opinion on this so I'm just summarizing so audience can understand um so the case that we're discussing is we have multiple blockage so you put a St it's not going to work yeah multiple I think so there are different scoring system again it necessarily doesn't uh we have patients with five six tents also but uh there's something called as a syntax scoring so we look at the probability again what will be better at the five years whether multivessel anoplasty or and bypass would be better that's a scientific scoring which is called as syntax scoring syta so basically bypass is similar to bypass road Bypass Road what does it mean you are traveling in a straight road if it is blocked you bypass right so this is a blood vessel right here there is a block you cannot put a stand because it's pretty severe and calcified so you are taking another blood vessel and putting it as a bypass so that the blood is coming over here will not go over here it bypasses and comes yeah it is is fantastic surgery life saving life saving yeah it's a open heart surgery open heart yeah it is called I have a sisted one wow only then I dearly said I will not do Cardiology cardiac surgery maybe C for people who like you you know who are really into it uh for me stomach colon and it's a long surgery right 6 hours 8 hours uh bypass surgery would involve approximately maybe from opening of the stonum doing the grafts closing it back I think so 4 hours approximately four hours yeah yeah um so that's what they call bypass surgery and it's a good uh prognosis right yeah so especially for diabetic patients especially for cor disease which is defuse extensive multiv I think bypass would be better in the longer run yeah we are not looking at very short term in the longer Run 10 years 15 years down the line how our grafts are working reserv the strengths then maybe certain subset they do well with bypass I had a 40-year-old guy uh patient I was involved as a gastro standpoint because he has started having some ulcers in the stomach uh cardiologist recommended bypass because of triple vessel disease yes triple vessel is you have disease in all the three major blood vessels and he's from uh band Bangalore bang but he he's living in Bay Area so he said he he called me and then he said Dr pal can I ask you a question I'm so scared I don't want to do the surgery what the option I have I said you don't have an option right what are the options you have you don't have an option this is a very safe surgery uh you know with good hands this is a wonderful prognosis you're only 40 years old yeah you should not don't take a second opinion he has asking me can if I drink turmeric water it will go away I said no turmeric water if you drink only the water will go away no I think uh like people are scared that's first thing to be realized realization is not there that I have so much of life-threatening problems so a positive approach uh making them understand that this would be beneficial in the longer run is very very important it's good for you your uh uh life lifestyle as well that's important longevity is a part but lifestyle also because what possibly is restricting you from doing things which you can uh will be possible after a bypass surgery so people run marathons after doing wow people run marathon I will tell you an exactly opposite scenario this was 48 years old and uh they recommended stenting okay this was an India actually in I think in mad okay so they called me for a second opinion in California okay so I said I looked up the report I sent it to my Cardiology friend and he said dude it's pretty Advanced and we have to uh get either Bypass or stting he was even concerned about angop plasy true story you will not believe it by the time I conveyed the message to him he had a massive heart attack he had to be operated urgently operated urgently urgently operate urgently so urgent bypass also the people do at times yes need it but at that time the it always better to do it on elective basis elective basis is always good yeah everything in place I think so that is comfortable for the patient the relations and the doctor as well you know bypass is something elective is better urgent anoplasty guys like me at the middle of the night middle of the night yeah but uh bypass surgery I think so elective is better but that is so rewarding for you that you you save a patient life yeah I think so right than there your wife might not like you yes because you have to go up in the middle of the night middle of the night but patient coming with chest pain you do the angio 100% blockage you put a St blood flows in you know you save the patient if not the patient is going to die yeah yesterday we did two of them and both are doing well have you seen patient die on the table yes yes extensive disease so that you cannot no matter how the senting is done like what they say is anatomy we are looking at Anatomy here arter is blocked we open up the artery put in extent but if the patient comes in a cardiogenic shock pulmon edema pulse BP is almost I mean no blood no blood pressure at all no blood pressure at all we put in whatever life saving measures we put in intra Artic balloon at times impella ECMO at times but still patients have refractory shock and happens so I always say this you know even how Advan medically there are so many technological advances in multiple medical Fields still prevention is always the Golden Rule it's always the Golden Rule there's always this percentage of patients we can't do anything we can do anything and we have seen people die on the table it is it is a true story true so the reason that we spend so much time in explaining all this is to explain to the audience that we don't want to be in a situation because treatment options even though it's good there could be situations where it might not work so it is absolutely critical to prevent for this complete blood clot to happen so coming back to my patient know he has hypertension and diabetes and you you said a very important risk factor I don't think many people understood family history correct cor right can you explain that about wow so family history is such an important determinant you know how uh aggressively you should be treating the patient from the doctor point of view and as a patient how aggressively you should control your lifestyle diet physical activity including and how aggressively you should be keeping a tab on your health status important family history one or both the parents having disease your genetics are at a at risk so if you have heart disease or heart attack history or heart disease in your father early early early heart so maybe 70s 80s it's still you know okay it's not okay in the sense fine but early early means you'll say around 45 50 so if your father had a heart attack or heart disease around 45 then you are at an increased risk yes you are so the genetics are there if your mother also had the risk doubles so the family history is there uh I think so genetics have a role how about uh grandfather not that much right it's only first degree I think so because I think so our grandfathers and the grandparents were blessed Lord because corat disease was somehow you know why because they slept very well a peaceful life yeah they slept well ate well more Rel relaxed lesser what you can say lesser means to do things but lesser expectations correct so they were more peaceful more peaceful more peaceful yeah so family history wow wow so the take-home point is if you have a family history of heart disease in your mother or father you better consider that as a wakeup call if you are from an Indian Community or South Asian Community that's even more important extremely important in southeast Asians the whole community the dietary patterns the family history apart you know we have that I think so we can't talk about it but the the Indian Paradox you know the thin Indian Paradox yes of course of course we will we'll talk about that in detail though so coming back to the patient where we had uh we talked about hypertension diabetes and family history so this patient had hypertension okay this patient I I vividly remember because uh he moved from a gastroenterology speciality to card ology because he was supposed to get gasty work so I figured out that okay this is not gasty go to so um he had hypertension he has he was taking uh um metoprolol beta blocker beta blocker for hypertension and some diuretic for hypertension um his blood pressure was around 135 36 even at home on normally okay um at that time it was very high so I want you to explain to us Educators in terms of why high blood pressure can cause heart attack I think so high blood pressure uh there would be certain now the guidelines keep on changing and there lot of confusion everywhere what is a high blood pressure yes so let me take the question back I'm going to say what is high blood pressure what are the numbers right so it's it's again first of all the blood pressure is a very Dynamic thing yeah so off in the office if I recorded blood pressure would be different completely from what you recorded at home so it's the white coat hypertension so how much to rely I as a cardiologist when I have to label it becomes in Indian setting it's like in or you know it's a final statement so I better be sure he has proper blood pressure so so the thing that you're talking about white cat hypertension is just for the audience is that um your blood pressure will be one 20 or 80 normal at home right you come you see Dr ano blood pressure goes up up so that's white cat possibly so you don't treat it based on one reading of that important uh so I advise for youngsters especially uh something like an ambulatory blood pressure I do advise it quite often 24 hours charting of your blood pressure to know the Peaks and troughs through throughout the day during activity at night time very important right so that activity uh sorry the blood pressure measurement at night the dropping the dipping of blood pressure at night is extremely important young patients especially stressed out type eight for San kinds the non- dipping parameter in blood pressure is extremely important so you're saying that ideally normally blood pressure should fall at night because you know things are like uh it's extremely important things are Tak but you saying that in non dipping non- dipping means if it is still high at night High yeah that it's it's one of the earliest catch that you should treat very important so early morning surge you can U maybe you have heard stories of patients having heart disease more in the early morning so that early morning search of blood pressure is extremely important again so that's the reason nowadays most of the scholarly papers are coming up that you should Target you know take your pill at night to maintain that lowering of the nocturnal pressures and prevent that morning surge important first thing first so I think so when we talk about the first office reading it could be white cat to an ambulatory I do it for young patients before labeling them as Hy so I'm just asking some questions to re reassure this um a patient comes to your office blood pressure is 140 over 90 you don't label hypertension because it is only one time reading so you ask the patient to go back home get a blood pressure monitor I think so we can from a phy store yeah and then measure blood pressure you can do the home blood pressure that's the home blood pressure monitoring so you can do it with your own instrument maybe 6: to 10:00 a.m. in the morning 6 to 8 fix set times whatever you can do two two readings or you have a device 24hours ambulatory BP it's called it's a device which is given at out patient from the hospital and that will continuously record your blood pressure is it right yeah so the blood pressure cuff will be attached attached and you have a machine which you carry you have a machine that you carry for 24 hours yes and then we look at the pixs and troughs so that gives you a better idea yeah so now once we are sure that the blood pressure is there right yes so once we know the blood pressure is say 140 by 90 the mean blood pressure is high the nocturnal blood pressure doesn't dip much you have an early morning Surge and you think this patient will benefit so how does it translate into heart attack is higher the blood pressure all the studies over last 30 40 years and there have been like lot of multiple studies higher the blood pressure over a long time uh will lead to higher cornat disease will lead to higher incidence of strokes and kidney diseases and peripheral vascular disease why because the strus and the strain of the high blood pressure the sheer stress and the force of the high blood pressure inside the vessels causes lot of wear and tear in the endothelium yeah that injury will lead to plug buildup slowly gradually so it leads apart from the other factors obviously diabetes wonderful point I'm just going to re summarize it so there's a blood vessel and the lining of the blood vessel is called endothelium okay a small cells that is lining inside this endothelium is extremely important to make sure there is no cloths of being formed inside the blood vessel when there when we say high blood pressure what is actually happening is this blood vessel wall is getting thicken continuous hammering inside and it will become thicken over a period of time and then the endothelium will also become more dysfunctional it won't relax it becomes more stiff and it will develop PLU and endothelium stops working starts forming SL small clots that's that starting that is the whole thing so uh the higher uh the pressures and the longer the duration of the blood pressure higher your chances of having stenosis narrowing of the blood vessels in the longer run you know this patient 52y old he got diagnosed with blood pressure at 43 so the longer 9 years it's very imperative that you control your blood pressure in fact there have been studies beautiful studies in the literature the well the blood pressure is controlled less than 130 by 80 your chances of having all the strings the end organ damage is what you call is less less uh so if you if you can decrease your blood pressure um the likelihood of blood clot formation everything is low which in turn there is no there is decrease in heart attack so in Indian setting you know I think so this is very interesting statistics what we see I'm talking about Indian because Indian patients I see what we see hypens is such an I think so very common common in the sense very very enigmatic I will say why first of all it is a silent killer it's called as a silent killer for reason I will tell you what we see in the OPD practice or in the clinical practice is really the tip of the Ice book in Indian mentality is such so maybe out of 100 patients who are hypertensive in the community only probably 30% are diagnosed m the remaining 70 are undiagnosed 30% are diagnosed they are prescribed medications approximately only 30% take medications out of the 30% because they don't want the taboo of taking medications so that's it's a wrong notion if there's something myth that you want to burst you take medications for good long-term benefit so out of the 30% only 30% take medications and out of the 30% are taking medications only 30% have adequate control control so if you calculate the numbers out of 100 patients only three patients have adequate control probability the whole Community it's such a vivid number and that's the reason you know we focus a lot on uh so many things like diabetes is I guess uh high cholesterol there's lot of noise lot of noise about yeah but blood pressure is somehow not being talked about that much not talked about and I think so it's it's an important you know almost the silent killer is the right right term and uh we have to be as a clinician our job is not only diagnos but to educate so you're telling me that high blood pressure can actually kill you 100% 100% And that is such an important thing because if we just control the blood pressure I will tell you and diagnose it on a mass scale properly and treat it adequately I'm sure 30% of your cardiac heart failure epidemic will go down it's it's it's actually Mass scale programs are needed so as a clinician as a doctor diagnosing is important educating is equally important equally important in in your practice you are saying that people are not taking blood pressure medications and daily basis few come only 30% only few people and why why why is the hesitancy education education I think so because it doesn't produce important is like there are two things first of all high blood pressure they don't produce symptoms number one 180 190 oh I'm okay with that doesn't no symptoms silent number two they don't want to be labeled as hypertensive oh they don't want to be labeled as you are hypertensive they want to be don't want to be as someone with high blood pressure number three I said like bravado nothing happens to me so three things education false bravado and maybe misconceptions yeah everything plays a role so I think so that needs to be focused and if you actually do something on a m scale the epidemic of both heart diseases corat disease and the heart failure will go down drastically we don't care about blood pressure as much as the diabetes and cholesterol a lot of noise lot of noise uh you know you said that you had a patient with 20year old yes heart attack right yeah I have seen multiple people like that as well uh in I mean very common in Indian Community no matter where they live in India or outside India doesn't matter um so in that situation people say that you know stress is one of the main thing correct is stress is related to hypertension wow I think so it's something that I focus on a lot yeah it's directly directly related directly related directly related especially in city like Mumbai where I practice number one killer is a stress number one killer for reason for blood pressure stress commuting meeting targets the kind of lifestyle that we have the kind of food that that we have maintaining life professional life personal life balance work life balance everything adds to the stress less sleep everything and uh again a forgotten cousin you say stress relief comes when you talk about prevention of heart disease that's something in the subtext is written Stress Management at the bottom at up the bottom would be Stress Management it has to be at the top I think so lifestyle should include Stress Management going back just wanted to uh put everything together okay so a 20y old 25 year old software engineer or any other professional very busy wanting to get Advan in the career you because he stressed out there's increased cortisol increase adrenaline sympathetic stimulation sympathetic stimulation and your blood pressure your your blood vessel needs to support you with increase blood supply so slowly blood pressure kicks in and then after that it gives a strain to the heart clots form so for young patient it's mostly multiple factors stress is one important thing if it's smoking is most important in young patients not only in males but I think so it has taken up in females in a big way so smoking can cause heart attack in women early earlier earlier so smoking I think so if there's one risk factor you to take away from Young patients quit smoking quit passive smoking as well tell me more about passive smoking so passive smoking when you are in actually a group and you are actually wanted to be part of the group obviously the peer pressure lot of smoking lot of intoxicants so the sympathetic surge happens The Vessel becomes more sticky and more vulnerable and especially if you have a genetic predisposition you should stay away because that smoking genetics diet not a good good combination so passive smoking is somebody smoking in the house house or in a group in a group but if you in that crowded place enclosed Place inclosed space a lot of smoking you I I uh flew into Mumbai in Mumbai airport there's a smoking Lounge there wonderful beautiful it was written smoking lounge and people were inside smoking and other people were outside the only problem was the door was open so I think that that call for a strict attention yeah so that's exactly we're talking about enclosed space but it's not like one time thing right you it continues chronic but if you're a chronic smoker I think so one risk factor that you should always always stress up on quit smoking that's the number one young patients yes you manage your blood pressure stress everything but smoking is something that you should and there's no qualms about it there are no second thoughts about it just quit it the best day is today to quit smoking I think so limit your alcohol I know it's definitely difficult to so alcohol can cause heart attack not directly not directly but again as a part it's advisable now the recent guidelines would say as a gastrologist also no alcohol I think so that is the Indian guidelines right now previously it was something was previously it was 12 O of beer 5 oz of wine and then 1.5 o of hard liquor hard liquor which translated to maybe around 60 ml or something of yes yes yes 1.5 is 45 ml 45 of U whiskey bka or anything like that and then 5 O 15 mL of wine and then 12 O it's a one can beer um the I'll tell you how that came out in Western literature there was a study that just say Okay Beyond this limit the there is no major outcome within this limit there's no major outcome but what they are missing is within this limit on everyday basis yeah and nobody stops at that correct that's what I told my patient was you know you can drink only 45 mL of watka and then for that I will drink water he say that nothing I'll stop drinking that's what happens like nobody stops at that single drink so the Indian guidelines have stringently said this time I think so the Indian guidelines no alcohol is safe so let stop squid smoking is important but yes whatever it is you either stop it completely at the alcohol part or limit it in your practice we talk we talking hypertension multiple Studies have shown that physical activity exercise decreases of blood pressure and everything right you see a lot of patients hypertension of course you recommend physical activity how many people actually do oh now that's interesting uh how it's very difficult to put it in percentage but uh yes the youngsters maybe up to up to the early 50s as well you know they take up pretty seriously the physical activity at least in any form that they want brisk walking uh to reduce their uh weight the BMI uh uh I think so it's percentage wise maybe I say three out of 10 would be a good number who actually not who who who actually will complaint will be complaint with they will be motivated ultimately it's self motivation no matter how much you educate them it has to come from inside so the remaining 70% they're happy taking drugs medications see that's the key that is that is what I was getting at I went to my native Village and uh I met my pera pera is an uncle um and then he said pal come here look at all these medications I mean taking it right and then I said the uncle you know this dosage is 20 migam if you walk every day the dosage will decrease maybe to 50 Mig and then he says whole walk man huh I'll take 25 Mig taking it is easy right but uh yes reducing weight physical activity whatever the ACC guidelines the American colge of Cardiology or the wh guidelines would say at least five to seven times a week or five to seven uh days a week you should have 20 minutes of correct 20 to 30 minutes per day yes yes yes that's the basic basic minimum minimum so you can do more than that so that's known to be helpful it's not only reducing the weight but physical conditioning both mental uh condition as well you know they get motivated to do more I think so it's equally important they start following their diet well so I think so that's part in parcel yeah one more thing I wanted to touch upon while we are in the subject of hypertension is you talked about high blood pressure endothelial dysfunction and blood clot formation okay and we talked about the angioplastic tending everything the other complication of high blood pressure is chronic stress to the blood vessel right and the blood vessel is coming from the heart right so the heart keeps on pumping pumping pumping to a point that the heart gets thickened the hypertrophy hypertrophy right and eventually it'll give up give up yeah and is that what heart failure is yeah heart failure again encompasses a lot of lot of things but uh yes any chronic stress over a long period of time it's like flogging your horse you know at some point of time it's bound to stop stop and fall so the heart also has a huge capacity to work continuously continuously work continues to take up the stress it has its own mechanism where by the heart muscles gets thickened hypertrophied to help it pump more yeah but after a certain period of time obviously the energy Dynamics or the muscle Dynamics won't allow it to pump as much as is needed against the increased pressure pressure so it starts failing it starts failing that's important again that would be again like missing the boat you want to act even much before that but that would be the earliest signs and symptoms when the patient comes from the clinic what is what is the most common symptom of a heart failure breathlessness called as dnia breathless shortness of breath breathlessness so breathlessness on there are different classification but yes whatever you are able to do before like I give you the example of walking up the flight of stairs for catching the train you are able to do it well and you are feeling breathless now so anything which is limiting you I think so that needs to be uh the first trigger which you should be taking to the clinic when you actually experience breathlessness even during normal activities I think so you have missed the board by long margin so I think so earliest detection earliest realization is very important and I think so paying attention to the symptoms and your own body hearing to your own body is very important so tell me whe the statement is right if you're having blood pressure for a long time and taking blood pressure medications if you are experiencing exertional shortness of breath uh or when you are lying down at night and you g gasping for breath I think so yeah all this a sign of heart failure yes that's Advanced heart failure yeah you don't want to act that time you to act much before that much before that yes Advanced heart failure it's probably if you're getting symptoms at rest while sleeping getting up in the middle of the night going to the window gasping for breath that's the classical scenario so that's I think so pretty much Advanced so we need to catch much early if you have a patient with hypertension how often that patient should come and see you uh if it's well controlled maybe 6 months 6 months visit is okay with the blood test whatever the battery of test which are advised apart from the blood pressure obviously we would be advising for the diabetes or the lipids and inflammatory markers and so many things and hopefully so once every six months every six months is fine how about salt rest wow I think so salt again is uh uh such a difficult uh uh thing to explain to my patient so Indian mentality is of extremes let me repas a question I'm going to say that we know that salt increases the blood pressure blood pressure yes how do we control it right so that's what ours is a mentality of extremes Indian mentality I advise someone to restrict what happens next two weeks later the elderly gentleman comes in an almost falling State because because the family starts cooking without any salt right that's that's very fun but common scenario we do extreme if want to do salt we do pickles poppers everything with full salt salt restriction no salt they actually go bland diet for a long time I don't know sodium level drops and along with the medications like diuretics and all it tends to fall even more fall more and they come with hypon so I think so salt restriction I think so the golden rule is something 1.5 yeah 1500 mg to 2,000 Mig per day that translates to an what you can say teaspoon of total salt per day that's approximately for a person approximately so so it's not only the salt that they are using it's the sodium content of the other food as well more important I'll tell you the most common mistake that patients do in any patient with blood pressure is they think that salt restriction means only the table salt they are adding to the foot that is not the case the french fries that you're eating the packet chips that you're get ah everything has sodium so if you have blood pressure turn the back of the packet look at how much sodium it is it should be less than 2,000 Mig for the whole day any package stuff any processed stuff any fermented stuff lot of salt simple Indian pickle poppers everything one of the most common item that is very rich in sodium is fried rice it is the the the Chinese Chinese right lot of it's added high in msgs and lot of salt I had a patient while I was in medical rotation in the morning he came in with shortness of breath and then pedal Eda swelling of the legs and I know that he has hard hypertension you know he went into heart failure I just saw him like a month ago I said dude I told you not to take anything more than 2,000 Mig of sodium and he said uh I didn't take anything and then I saw a small polyan bag right next to him you know what it says Asian Chinese restaurant yeah and he has the remaining fried rice to go box inside that's what so I think so rather than uh look at uh so many things I can call for a dash what you can say dash dash what is DASH diet the dietry uh for salt restriction exactly it's a it's a dash diet for hypertension DASH diet so I think so that's incult not only restricting your salt content but there is a lot of emphasis on fresh vegetables whole legumes fresh fruit the dietary source needs to be properly verified and taken mindfully I think so again mindfulness in eating is extremely important and be very sure what you are putting inside to be peaceful so I think it incult takes legumes nuts and so many things to be sure about what you're eating DASH diet included yeah super beautiful so we talked a lot about high blood pressure the same patient also had diabetes diabetes okay and uh if you look at my channel I'm not sure whether you know I have a social media Chanel I know everyone is you're so popular so my mom still thinks that uh he's asking me you still practicing right that's a typically Indian mom's question you leave the doctor you can't so that patient has diabetes uh in my channel what we talk about lots of diabetes and everything but one thing I'm not talked about is why are we really focused upon decreasing glucose all the things diabetes can kill you by causing heart attack how does diabetes cause heart disease yeah so diabetes is um such an uh you can say multif factorial again illness which uh impacts right from head to toe every system it's considered as an corne artery disease risk equivalent once you you have been labeled as a diabetes your parameters your set goals are different from n diabetics your level of ldal cholesterol blood pressure everything the targets are different that's the reason diabetes is called as corat disease risk equivalent so if you have diabetes yes it is almost equal to having heart disease almost heart disease almost so it's positively considered as in corat disease risk equivalent so that we better manage your blood pressure better manage your liid CH glucose everything so that the outcomes are better in the longer run diabetes we know this in cular terms is like high glucose the seat of diabetes is insulin resistance that's at the core of it so the high insulin property is not acting the sugar is up and that causes a lot of glucotoxicity everywhere what happens in the endothelium we talked about endothelium the innermost lining there is lot of endothelial dysfunction that's where it all starts the inner lining of the blood vessel is a very sacred Place For Us cardiologist it has to be healthy so endothelium when it is exposed to high sugar over a long period of time again it becomes more dysfunctional means it's not able to relax as well as it it should number one it becomes very inflammatory it becomes very sticky or prothrombotic right it becomes more vulnerable there are a lot of reactive oxygen species in there so lot of things all these multifactorial things can lead to early onset of atherosclerosis or plug deposition I usually tell my patients that the more the number of sugar in the blood the longer the sugar in the blood the endothelium the lining of the blood vessels acts as a magnet it just attracts all the blood clots slowly the longer the larger the clot the more the heart attack so diabetics in Indian population again as I said we have last from the 80s from 1980s we have that we have surpassed everyone and we have become the diabetes Capital very very you can say scary situation uh diet has changed from 80s lifestyle has changed stress level has increased economic growth is there but at the cost of everything so I think so before ' 80s we didn't have much data for the indan diabetics but now it's hum us diabetes usually have multivessel we actually talk about it so more arteries are involved if you talked about three arteries the possibility of all the arteries being affected are are very high let me just add a point so based on what we discussed before based on how much blockage is there in how many blood vessels the treatment option differ we said that if the blockage is in only one blood vessel you put a stent in if it is in multiple blood vessels we do bypass surgery what you're telling me is diabetes is for multiple multiple multiv vessel involvement so most likely bypass very common common and it actually gives better result as well in the longer run so it's extensive disease very small diffuse nature of disease calcification is more in diabetic patients and the outcomes I think so with angop plasties would be slightly slightly inferior in the given subset as compared to vipers so whenever it's multivessel calcific bifurcating diffuse longness segment we do a vipers so diabetes usually as I said affects everything it affects the nerves also it affects your pen sensative receptors as well so the typical symptoms of pain may not be present always in diabetic patients this is what they call silent silent attack so what do we experience like the kind of exertional discomfort pain left arm jaw pain in otherwise non diabetic patients diabetes since it's mutes your spin pain sensation reduces your pain sensation they not experience they don't experience the classical pain and what they are left with this just at times fatigability slight breathlessness not able to do activities that they were possibly able to do properly so these are soft signs that you should be aware of as a clinician you should dig it out and you should ask from the patients because not everyone will experience it most of my diabetic patients especially the inferior the basil W myocard infections goes to a surgeon or an gastr first because the pain is in the epigastrium as you said upper part of stomach severe pain rather than the so they just come with epigastric discomfort and ECG is EST elevations and the inferior lats so that's a learning point so so that's the whole thing about silent and usually you realize it after couple of days or after 12 hours when the patient comes in a lot of breathlessness congestion in the lungs the pp going down ECG shows that already the attacks are settled in for quite some time the Eco also shows the same so learning point over here is diabetic patients should understand their body better exactly understand any change in symptoms symptoms the things that you're doing before if you're not able to do it now please get it checked I had a patient has been going on for a while for a week he was not feeling well that much but he was just pushing along in his work and everything in the evening he told his family members that you know I'm not feeling well I don't want to eat anything and then he just went to bed in the morning massive heart attack they don't wake up also at they don't wake up sometimes so that's uh it's listening to your body listening intently carefully to any signs of symptoms especially important diabetic patients because they don't have that classical classical what your teaching is learning is you know chest pain heaviness I think even though it is a very bold statement I think we can summarize this as any patient with diabetes imagine that you have some kind of heart disease already you have to be treated aggressively and listen carefully yeah and listen to the sign small niggles sign symptoms and be careful the easiest thing you can do if you feel discomfort even if it is e get an EKG done that's the easiest way to noos things I think so I I tell most of my patients right you have any discomfort the best thing is to get an ECG and be sleep well if it's normal yeah and uh if there's any symptom don't wait too long yeah get it evaluated um yes it is a bold statement but the rational behind that statement is to make an awareness awareness that there is increased risk of heart disease among patient with diab yes 100% I agree does it matter about the A1C level if it is more than 89 yeah the higher the A1C level the higher high the risk of heart disase disease burden higher the disease burden disease burden so it's very diffus diffus poly atherosclerosis not necessarily heart but the brain kidneys the peripheral vascular disease you can see you know a lot of problems so everything every body system is involved so it's poly atherosclerosis so higher the see Direct correl higher aeny higher number of vascular beds involved well controlled aeny you can live normally I think so better outcomes in the longer run is that very aggressive in women diabetes especially heart disease in females we don't have data per which says uh diabetes in females behaves differently than males but uh till the time menopause set females are usually uh protected with the estrogen yes but after monopus the RIS Esten goes down the risk is SE so that's something the risk of diabetes if it's diabetes your risk is higher than a non-diabetic irrespective of the sex irrespective of gender yes in respect of the gender yeah so diabetics be careful be attentive do your blood test regularly get yourselves evaluated annually and pay attention let me ask you this you have you see a patient with heart disease not acute heart attack patient outpatient having heart disease you say diabetes you say you know you better control your diabetes two months 3 months later they come back is the blood sugar controlled by that time I mean what up like uh patient having diabetes and uh no no the question let me add me rephrase it so you see a diabetic patient and then you have some kind of heart disease and you are saying that you know it is absolutely important to control the blood sugar levels how um how serious they take that suggestion and work on the blood sugar I think so they take it pretty seriously after diagnosing I think so they are pretty uh as compared to I told you the blood pressure blood pressure which is like a sideline cousin people are slightly more aware and serious once they are not serious about getting diabetes per se you know till that time diabetes sets in they are not but once the diabetes sets in I think so irrespective of the huge you know communities and across India they're pretty serious about controlling their sugars and maintaining them they're pretty sure they know what to do uh the diet the again the Indian diet is in different talk with all together but they particular about the diet at times most of the Times They Are particular the medications and they try to control I think so most of them I would say 70 80% of the times they actually do well in the followup what is the one thing that you wish your diabetic patient and listen and change I think so prevention is most important preventing to get diabetic to start with most important most important maintain that ideal body mass index or ideal weight very important pay attention to the diet pay attention to the diet from the you know 30s early 40s you start paying that's the time when most of the harir start so start paying attention more and more so prevention is very important after say unfortunately because of the genetics or whatever you get it uh still not everything is lost you can reverse it if you have high body weight if your AV is like marginally high like around seven 7 and a half I have seen patients reducing their weight and getting that AMC normal yes so that's that's a positive thing so they do that stick to medication follow the physical activity do that steps which are necessary lose that weight at least don't allow it to go out of bound wants eat well eat mindfully very important that mindfulness in eating and like repeat it again is very very important what is mindful eating I think so paying attention close attention to whatever goes inside your mouth inside your mouth is extremely important and whatever you eat do it with the absolute peace of mind that's what I say m choosing and enjoying it but paying 100 % attention nowadays the culture is like you sit in front of the sofa and you gulp down whatever you want look into the phone phone here and eating here so I think so mindful eating is very very important to be honest I think that one little thing is something that everybody can do rather than thinking about okay you know is it vegetarian diet non-vegetarian diet but more importantly just with a regular simple thing that can reduce pretty much like I would say 10 to 20% of the problems because when when you're mindful you appreciate the taste better yes you appreciate the flavors flavors and the likelihood of you being hungry is going to be low yes so that's extremely important so we talked about diet choosing the proper diet eating well mindfully eating your diet in peace taking time out for physical activities reducing your weight quitting smoking obviously that goes without saying that weight reduction that diet that physical activity alone for someone who was non- compliant before will reduce your aeny at least by 1.5 at least at least 1.5% yes that's what I feel in the clinical practi maybe guidelines would say around 0.5 or something but in your practice but I think so because see our subset is like non-compliant one so either the the even reduction would be much better in a non-c complant patient in already as compared to someone who's already slightly more understanding and compliant with this diet so if you get a subset which is casual about eating no physical activity sleep and everything I think so we reinforce the lifestyle modification dietary modifications in them the results are I think so almost 1.5% a reduction possible just to follow lifestyle you think lack of sleep causes heart attack wow I think so very very very very important I think so as the Dal Lama says sleep is the best form of meditation sleep is the best form of meditation why because it allows your body to reboot from inside that's the like the period when you are actually the entire systems are at rest the entire systems go a reboot and you get reenergized and without adequate sleep so less of talk on again stress and sleep again a neglected Factor people boast I just sleep for 4 hours longer run I think so makes a lot of difference take that time out stay from the gadgets after a set limit maybe after 10 or whatever is needed if you can for someone like me who is always bound to phone is a different story but uh take out that time if you can be a from gadgets try to sleep calmly peacefully for at least minimum 6 to 7even hours longer run because your body needs that rest and needs that Rebo so the next segment is the cholesterol okay based on the ah recommendation they say that we need to check the cholesterol levels starting from age 20 and then repeat every 5 years if it is normal age 20 it was like 20 30 before 25 now it is 20 so in your practice let's say you check cholesterol levels like it's say normal patient approximately 30 years is like the time most of the patients do come for a regular check regular check after they set in career and all correct so 20 students usually usually don't come to outp so I won't be recommending but yes obese childhood obesity is a big topic again I think so again an epidemic which is brewing up it's it's actually Brewing up huge numbers the Next Generation we will be focusing on a lot of childhood obesity so I happen to check uh cholesterol a1c's American Association of Pediatrics is recommending lipid profile evaluation starting from Age Two If there is history of childood obesity and also family history of any obesity and they also recommend to check between 9 to 11 years of age again based on and uh people are actually IM one very good thing about Indian communities we are very family oriented we're extremely family oriented to a point that a very drastic difference between the west and Indian Community is there are two patients both are in ICU both are heart attack both are in you know ventilators because of respiratory failure and everything this patient we go around and we want to update about this white patient to a family member you know how he's doing I come out I say hey you know family member of this patient is there anybody there uh nobody nobody is there okay I go there and then there's an Indian patient I riew I come back I say family member of this Indian patient huge huge crowd which assem that's that's a truth that happens every day every day to me it's a wonderful thing it's a wonderful thing social connect family connect is is strong but that translates into feeding the kids a lot more than what they need yeah the Love Goes to the The Love Goes to the food love goes to one more idly now yeah one more Dosa one more serving of rice one more serving that leads so the parents should understand that okay so you know my kid on the growth chart or compared to other kids or slightly on the chier side please go and check lipid profile and cholesterol levels as recommend pediatrician because that is what is going to give you increased risk of heart disease at the age of 20 and 20 and 23 so that's an epidemic huge epidemic Brewing up because we didn't find so much of childhood obesity yeah doing our like 20 years back back now I think so I have a few patients in teenage who are on statins and met for men so on so wow that brings the next question so you know of course we know the good cholesterol bad cholesterol everybody knows about LDL LDL yeah and everybody knows about HDL HDL uh and it's always the opposite LDL is high HDL is low it should be the other way around LDL is low HDL is high so how people always get confused about about this I say l DL L should be low low HDL H should be high H should be high exactly exactly now there is this little thing again that they're talking about called appol lipoprotein little a yeah Appo APO a right is that something that you use practically over here in India so when we ask for a lipid profile you know it's it's an not to be taken in isolation again so our lipid profile will have uh the import factors that I focus on the primary target secondary tertiary and so on so we looked at the LDL we look at the total cholesterol triglycerides we look at the triglycerides we look at the HDL we look at the ratios LDL HDL ratios trig glycer HDL ratio tric HDL ratios we look at the Appo I think so the Appo B we look at the Appo B which is composite of all your bad particles together it's like a gang so all the LDL triglyceride kyom microns will have that epob so epob is a composite of all that so higher epob is again a Target uh which we want to minimize Appo a on the other side represents the we can say the good yes up a should be high up a should be it represents the good cholesterol so that is involved in the process of getting the bad cholesterol back from the blood vessel exactly to the liver wonderful yeah so wonderful the uppo B is something we target so we targeting that because the moment you lower your LDL triglyceride kyom Micron the epob tends to go down okay then then there ratios as well EPO B and EPO a But ultimately most of the thing diet canol control up to a certain extent definitely but if your cardiologist or a physician recommends then maybe statins would be the best and there are so many uh yeah statins as well as no path breaking uh achievements in the lipids nowadays we have monoclonal antibodies coming up the RNA base therapy is coming up which is like an vaccine you know taken twice a year to control your LDL so the era is going to be very the coming era is going to be very interesting very Dynamic but looking at the lipid profile uh the Indian I will talk about the Indian dis idemia is different from the Western so in Western counterparts if you actually have a composite of maybe 100 reports here and 100 reports this side the Indian dist epidemic we will have a slightly lower LDL as compared to the the Western that is the only good thing our ldr don't tend to be like 200 plus or 180 plus around 160 170 but our dis lipidemia the Indian subcontinent dis lipidemia is characterized by very low HDL yeah our HDL is very low so normal is around 40 50 the for females it should be more than around 45 plus 45 plus and males it should be more than 40 plus ideally what do you usually see uh in in HDL numbers HDL number 45 40 what do when you say low how low it is usually yeah yeah so indan dis limia I say moderately high LDL very low HD I have seen 19 20 15 15 yeah lack of physical activity no proper diet we can come about like therapies to how to improve your HDL but apart from moderately high LDL and very low HDL our triglycerides are Sky High Sky High It's Not Unusual It's Not Unusual to find triglycerides in the range of 1, 1,200 1,400 as it's bad you know in my I have been practicing for 8 years now 1,200 tries I've seen only like once in two years here we find it 800 700 very common very common 800 triglides again Focus as you said no the Chinese bask so ordering from all these portals and the kind of diet is it's it's causes huge problem our this is our typical dislipidemia moderate to moderate high LDL as compared to Western counterparts our LDL is not as high but that is you know I I'll tell you a very important point I think there a wonderful discussion over here where people in West West over there they keep on focusing on the LDL where they say should be less than 100 less than 70 if you keep on doing that they'll say LDL should be zero yeah right right right but in Indian Community I think the one thing that we should really look at is exactly what you said is trig glycerate HDL ratio very high triglyceride is very high HDL is low which means ratio is high very spite very spite if it is more than four increase risk of heart disease it should be less than two our triglycerides are Sky High Sky mainly the carb based diet excellent so much of carbs 80 to 90% of the Indian diet will have cars food portions less protein and fats so I think so somehow that ratio is total is C for spiking the triglycerides will you agree that high carb diet increases the triglycerides increases the atherosclerotic burden leading to heart disease right I think so we in India uh especially the lipid Association of India we have a different body focuses a lot on trial States as compared to Western counterparts who feel the primary target is LDL second is probably HDL tricide is again a forgotten cousin nobody bothers about tricide they say it's an innocent bystander yeah but we don't agree here because our triglyceride is very inflammatory it leads to a lot of atherosclerotic burden and higher the triglycerides remain say I'm not very concerned about something like 180 200 types but this 700 800 you have to treat aggressively if you can't you're obviously inflammation and the atherosclerosis woring what are you talking about usually we get to see triglycerides of 800,000 only in the case of pantis here this is normal you're talking about see you take a serum sample if you happen to collect a vile of blood let the blood settle in a patient with hyperglycemia we usually have been taught the sample the serum is not clear at all milky cloudy milky yeah so that's the kind of trigly we are dealing with I mean this is so fascinating but I'm just going to summarize it for the audience is that what what Dr anop is talking about is when you take a blood sample you look at the test tube usually triger is very pale you know you can C see through a little bit but when the triger is very high it looks milky white almost milky and that's that calls for attention that calls for attention so in West it might be a tertiary Target in Indian it's our primary target that is the reason tride lowering therapies are important I think so are important to prevent atherosclerosis burden in the future and we target it I know that I know exactly what triglyceride lowering therapy is decreasing the amount of Cups exactly that's the focus the first thing I tell my patient you will reduce the carbo the question is like in Hindi says that's the way in which question is always framed you have to give them options right you have to tell them there are many things you have to go beyond you have it as a small portion you have the first course or whatever it is you start with salad or some protein or Dal or Sprout have inculate and then we are left with something you have that portion of reduce the portion of chapati and rice I guess but I guess our rice are like huge in heaps of rice and that creates a huge Spike and it's important because everything is going to reflect in the atherosclerosis so that's why I say you know in South India you know we always have this Banana Leaf uh wedding where you know they keep on serving rice on the side right so I said we should turn it it's called reverse Banana Leaf where you make all the vegetables on this side and you keep rice on the other side so that first you eat the vegetables vegetables you feel full full yeah the second thing is it is too difficult to take the reach out that's a good plan no I think so we all need to work and we need to educate and that's very very important that is what you're doing right now yes we doing exactly right now you know hopefully people watching this you talking to one patient in your office it's exactly you're talking to like thousands of people over here yeah again that concept of so in India hardcore vegetarian hardcore nonvegetarian it's a very different ball game one fields we are doing the uh excellent Thing by being a vegetarian one felds we are also doing the good thing by just eating protein But ultimately balance is important in Indian unfortunately despite it being like almost 60% 50% vegetarian country uh it's very different from the Western vegetarian option it's actually I know the Indian vegetarian okay many few people are very good but most of them Indian vegetarians L J but they keep on then barking on that it's not good someone actually coined that term it's I don't know whether it's right but contaminated vegetarianism I think so I don't know but I may not agree but when I looked into it and then we tend to agree for the sake of being a totally vegetarian they actually inculate lot of other stuff which may not be uh yeah yeah part ofet of course of course the problem is people think I'm a vegetarian so I'm healthy yeah that's misconception misc consumption because Indian vegetarian diet predominantly contains a lot of ultr processed food Ultra processed foods that's a lot so need the balance right oh I'm not eating chicken I'm not eating beef I'm not eating you better eat that rather than avoiding chips eating chips and Cooks cookies or whatever bars for the sake of corre corre not so that actually is in I try to balance it balance balance is important and I think so once you reduce the carb load your trigly will get better your HDL HDL is again a different Beast all all together you know the dietary yes therapy is you know very difficult one thing people can do usually exercise is the only thing that increases HDL or you are genetically gifted where HDL is more than 50 but uh sometimes omega3 fatty acids again the fishes fishes salmon tilapia avocado is is there walnuts are there indan patient most of times we do AOC avocado I think so again Tire one cities only uh not still penetrated in the but flax seed I tell them at least try flax seeds you think flax seed helps in heart disease yeah I think so slightly whatever the data is it increases the HDL walnuts are there some almonds oily fishes yeah AOS I think so it's but apart from that I think so physical activity very important and HDL at times is very resistant despite doing this you don't have Therapies so when you do all this you increase the denominator of the trigly htl ratio which means the ratio will come down come down but if you can't despite everything despite modifying the diet physical activity most of times it's genetic as well not genetically blessed and HDL tends to be resistant low what you can do is to try to string the numerator as much as you can when the LDL HDL ratio is there though you have therapies to reduce LDL when when you have the triglyceride HDL ratio try to reduce the trigly so the ratio has to be do you hear this often that uh doctor this is familial you know it's hereditary my cholesterol level is not for me it's from my family I always say the joke that you know it is it is not that cholesterol runs in your family the problem is no one runs the family that's so true that's a running joke in my in my practice um how important is heredity how can you say is it true that they can say hey cholesterol is due to my family problems at times it's uh we have definitely the genetic variants of high cholesterol the familial variety wherein The receptors the LDL receptors are absent leads to familial hypercholesteremia and xanthomas and xanthas something below the eyes what is zanoma zanoma is like the cholesterol or the lipid deposition which you actually see below the eyes Cally or on the small bumps yeah bumps the cholesterol bums the elow elbows below the eyes around eyes I've seen a patient over here uh I will not it's wonderful example I never forget a patient comes in fit like a beast you know it was completely he has a small little bump and he was thought he he has been there since for a long time cholesterol levels trig glycerate 500 hyperr hyperr you need to treat it so Zan the point I was trying to make was the percentage of patients whose cholesterol level is high truly because of genetic reasons is very low it's low it's low but it's there is there correct is there some um no risk factors no dietary lifestyle good still they have high LDL then we have to think about genetic or the LDL receptors on the liver not being very uh what again inadequate numbers to take up that LDL from periphery so your LDL will be high in such patients If You observe it and regularly um what you can say follow up and if the LDL tends to be high despite whatever you do lifestyle modification I think so uh we prescribe statins for such patients yeah that's a beautiful question uh beautiful segue to the last segment about Statin so when we prescribe Statin the first response that I get especially from a patient from Indian Community is I don't want to take it yeah yeah I don't want to take it I am going to try lifestyle uh and uh I don't be on any medications at all question to you is in your practice what is the percentage of patients who are able to decrease their cholesterol levels with Lifestyle Changes in 3 months just a percentage probably less 25% 20% 25 so you see 100 people 25 people will be able to do remaining 75 people either they fall off the wagon they're not able to do they forget about it I think so it's important as I said if you have a diabetic patient your ldlb know has to below 100 ideally below 70 that absolute number non-diabetic again with some family history we want it to be less than 130 ideally the whole purpose of having the LDL in control is to prevent end organ damage and better cardiovascular outcomes in the longer run so we are not giving statins to prevent heart attack tomorrow or day after but in the longer run we are looking at this so this is something that needs to be fed into the minds educated I would say many of my close friends also don't take it despite so it's there is a resistance to take statins two or three things again silent doesn't bother number two is statins cause diabetes that's something which was so much on the uh high do at times would lead to small Spike small spike in aenc levels but uh the benefit of LDL reduction is much much much higher as compared to whatever the smallest mic so it's not again very proven but yes it could be with hyr statins the kind of Statin do that we use uh we see a lot of patients 80 migrastatin or rosu in 40 milligrams a spike is small but it's there at times but we not everyone gets it but that's again a uh slot of an deterant for them to start taking it silent and something is like yeah they find so less it causes diabetes let it be so third is like again I don't want to be labeled as take so a taboo Factor two or three things always are there in the picture which um inertia causes lot of inertia to the whatever I would say patients but OPD guys to take up status wonderful but we have to educate education is at the heart again we look at and so many data and like over metaanalysis 30 us of Saturn is like it's beaten to death yeah I think so that is beneficial I think so everyone who needs it should take it properly so I'm just going to summarize the key takeaways from our conversation so number one people should not be concerned about angioplasty uh bypass surgery uh yes it is sounds aggressive sounds invasive but if you need it it is absolutely needed okay it is okay to proceed further because the benefits outweighs risk and number two we have talked about all the treatment options for heart disease and it is very clear that it is better that you don't get the heart disease to start with yes prevention is always always you told me that third one is hypertension is a silent killer and as much as we are ATT focusing attention on Diabetes we are not focusing on hypertension and you are talked about the 24-hour ambulatory blood pressure and everything and it is absolutely critical to decrease the blood pressure and we talked beautifully about the pathophysiology of how hypertension endothelia dysfunction causing heart disease on Diabetes we went deep we make sure that A1C level comes down and a silent heart attack very critical because the nerve Supply is impaired so you will not feel the pain and the last one we talked about the lipids and Statin if some somebody prescribes you please take it please take it please take it maybe if you really don't want to take it you can try for 3 months if you're not able to decrease in 3 months better take it better take it better take it whatever it is the number should be correct you should Target the numbers as in the corporate word the numbers should be reached you mean the demand so that I told them do whatever you want make sure it goes below this if it's not going below that I will give you medications and you take it you don't have a choice choice wonderful it was a wonderful wonderful discussion it was absolutely amazing I'm sure my audience must have learned a lot from you thank you again so much for your time thank you so much pleasure being here I had so much fun in this episode discussing with Dr ano dande I'm sure you learned a lot as well again I don't want you to just move on think about what you learned during the podcast I want you to write down in the comment section so that the writing actually registers the fact in your mind so that you will actually implement it and not just use this as a bystanding video and just a scrolling thing I don't want you to do that okay so I want you to learn at least one or two points and hopefully you'll be implementing that not only to yourself but also to your family members so that together we can grow better both physically and also mentally thank you for your continued support please consider subscrib to my channel gut feeling with Dr pal clips and feeling with Dr pal shots two separate Channels with condensed clips from 8 to 10 minutes and sometimes one minute shots and reels of this clip from the longer 1 Hour podcast highlighting the San Futures so if you're a person who wants to listen to the audio format maybe while you're commuting or while you're driving we are available in Spotify as well please check out the link gut feeling with Dr pal and Spotify as well as usual thank you so much for your continued support remember one belly at a time it is absolutely important I'll see you in the next video