Heart disease and heart attack are much more treatable, manageable, and preventable today than they were 40 or 50 years ago. For American Heart Month, cardiologist Dr. Peter Schulman joins Dr. Anthony Alessi on his UConn Health podcast “Healthy Rounds” to discuss the evolution of cardiovascular disease care and prevention, from medications to procedures to lifestyle changes.
Still, some things haven’t changed, including the crucial difference early intervention, defibrillation, CPR, and getting to the hospital as soon as possible can make with a suspected heart attack.
They also discussed the evolving recommendations on baby aspirin, the current and future state of statins, the difference between the sexes when it comes to heart disease, and the continued trajectory of cardiology care in the future.
Listen now:
Submit questions for “Healthy Rounds” to HealthyRounds@uchc.edu.
Support comes from UConn Health Orthopedics and Sports Medicine and Coverys.
Transcript
Dr. Alessi: Welcome to the Healthy Rounds podcast, where we provide you with up-to-date, timely medical information from national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopedic Surgery and a grant from Coverys. It is not designed to direct your personal health care, which should only be done by your physician.
I’m your host, Dr. Anthony Alessi, and it gives me great pleasure to welcome my guest today, Dr. Peter Schulman. Dr. Schulman is a professor of medicine here at the University of Connecticut, where he is also a cardiologist and has worked in the Department of Cardiology for the past 44 years. Peter, welcome to the show.
Dr. Schulman: Thank you very much. I’m happy to be here.
Dr. Alessi: So, this is American Heart Month and it’s kind of interesting ’cause it’s one of those concepts that’s developed over time where we make people a little bit more aware of heart disease. But I’d like to take a step back a little bit, since you’ve been here 44 years and you and I are relatively of the same generation.
Can you talk a little bit about kind of the evolution of cardiology and the things you’ve found over the past 44 years?
Dr. Schulman: Well, that’s a very good question. I think I would almost call it a revolution, but evolution is pretty good. So, I was just thinking back on this, when I started cardiology practice more than 45 years ago at one other institution, if you had a heart attack and you survived the heart attack, you would probably have your second heart attack within 5 or 10 years, almost for sure. Because there was such a high risk of recurrent heart attacks, we didn’t have ways to prevent the second heart attack once you had one.
Actually, we didn’t even have ways to reduce your risk of your first heart attack. Now, 45 years later, in 2026, we not only have ways to dramatically reduce your risk of your first heart attack, but should you be unfortunate enough to have one, we can substantially reduce your risk of a second heart attack.
So, people who have a heart attack, that may be the end of it. They may have no further heart problems for the rest of their lives, and that’s what we’re striving for. Now, the same thing happened in heart failure. If you had severe heart failure back 50 years ago, if your heart was weak, well, sorry about that, but you probably would not live another 5 or 10 years. Your heart function, it’s like a motor of a car, would just lose horsepower over the years and decades and you’d be possibly gasping for breath in 5 or 7 years. Heart function would decline inexorably, just keep on going down.
Nowadays, we have ways to reduce the risk of heart failure, and we have ways to actually improve heart function if you already have a weakened heart. We have whole host of medications and many are very new within the last 5 years and we have devices that can strengthen the heart. So really, it’s major advances in heart disease prevention, heart disease treatment, and patient wellbeing that I’ve seen over the past 50 years. Those are just two examples.
Dr. Alessi: You know, that’s interesting because you talked about, you know, this revolution in medication as opposed to the more sexy things, right? The angioplasties, bypass surgery, so many of them, replacing valves through a catheter. I mean, those are the things you hear about and yet, I’m impressed that we’re hearing about the medical things, in terms of treating with drugs, as opposed to those. Have those things changed things a lot? I mean, it used to be an angioplasty was a big deal. And now it’s kind of routine, isn’t it?
Dr. Schulman: That’s correct. If you have a blocked artery, let’s say from, you have a heart attack and that’s usually due to a blocked artery, you can have an angioplasty. What that does is they put a little tube in the coronary artery. That’s the artery that supplies the heart with blood and oxygen, like the fuel line to our car. If that gets clogged, you can go in there with a little tiny balloon at the end of this long tube, open up the balloon, open up the blockage, and then put a stent in there, like the spring from a ballpoint pen.
It expands, it stays open, and it keeps the vessel open sometimes permanently. That’s all you’ll need. The stents never come out, they stay in the heart, and the heart tissue grows over the stent so that it almost becomes a new artery again with no blockage whatsoever. So yes, that’s a sexier way of treating heart disease.
But if we can prevent heart disease from the beginning, that would be a better way. Now, you brought up the sort of sexy way to treat heart disease. Now we’re realizing now that you can make lifestyle changes and a lot of them are very helpful, like getting more exercise, keeping an ideal weight, not smoking cigarettes, making sure your diabetes is controlled, keeping your weight controlled, diet, et cetera.
We realize now that that can be helpful. The lifestyle changes are important, but the newer medications really sort of outrun the lifestyle changes, so you should be doing both, in many cases.
Dr. Alessi: And that brings up, I had a listener question to bring in, and Bob had asked me this question, and the question was about a baby aspirin.
Now, you know, we’ve gone through these changes where, you know, when I was in training, we all knew that well, most doctors are taking a baby aspirin every day. We know it reduces heart attack and stroke. And then we start hearing that aspirin can also reduce colon cancer. And then all of a sudden more data says it’s not that useful.
Where are we on the use of a baby aspirin? ’Cause it, it seems like such a benign way of causing such a catastrophe.
Dr. Schulman: So, that’s very interesting, baby aspirin. It has gone both ways about 81 milligrams. Some countries actually use 75 milligrams, some use 100 milligrams. Well, it turns out that aspirin does reduce the risk of heart attack and stroke in just about everybody.
However, in many people, and if your risk is very low, that is taken into consideration. The other side of the coin with aspirin is that it slightly increases your risk of bleeding, so you can have a bleed into your brain. So, every recommendation is based on trying to balance the risk of taking aspirin, causing bleeding, versus the benefit of aspirin reducing the risk of a stroke or a heart attack.
So, in general, the long story short is that for people who’ve never had a heart problem and don’t have a ton of risk factors, we generally do not recommend aspirin because even though it does reduce the risk, your risk is already so low, and your risk of a bleed into the brain is not very big, but it’s a little bit higher with aspirin.
So balancing risk/benefit. Most people with no heart disease, no stroke in the past, we would not recommend aspirin.
Dr. Alessi: Okay. Alright. Thank you for that. Bob, you got your answer now. And in talking about American Heart Month, I wanted to talk a little bit about something probably less sexy than even medication, and that is, we’ve had this revolution of using CPR and defibrillators and making them more available.
How has that impacted cardiac disease and cardiac death in the field? I mean, are we wasting our time or has this been, do we have real data to support putting money behind that and training people?
Dr. Schulman: Well, we do have data to support that. It turns out that the quicker that if someone has a cardiac arrest, out of a hospital, in the hospital it’s different, but if someone has a cardiac arrest outside of the hospital, their recovery, their neurologic recovery, in other words, how well they can function, and their probability of survival depends on how quickly the CPR is given and how quickly the patient is defibrillated, if there is a portable defibrillator on site. It’s called an AED, “automatic external defibrillator”.
So, yes, there are data that shows that the quicker you get those treatments, the greater the survival. Unfortunately, the overall survival in out-of-hospital cardiac arrest is not great.
If you have a cardiac arrest, a true cardiac arrest, it’s probably in the neighborhood of 25, 30, 35%, something like that. So, there’s a pretty high chance you’re not going to make it. But, if someone, if a man has a heart attack and the wife knows CPR and can get EMS to the house, to the patient very quickly, then there’s a much greater chance of survival.
And one thing that brings up, if someone is having a heart attack, the chance of a cardiac arrest is higher. So, it’s important to realize that 90% of deaths from a heart attack occur before the patient reaches the hospital. So, the best thing to do if you’re having a heart attack or you think you even might have a heart attack, is get to the hospital very quickly.
If you end up in the emergency department, you have already jumped over 90% of the risk of dying from that heart attack. So, we cardiologists would rather see a few false alarms. You know, people have crushing chest pain and maybe it’s heartburn, but we don’t know at that time.
Better to get to the hospital, let the ED figure that out, because if you do have a heart attack, we could provide treatment immediately and it’s dramatic in improving the chance of your surviving and improving your long-term health.
Dr. Alessi: Wow, I didn’t realize it was that big a hurdle. That’s so important for us to know. What’s the most common thing you see in your practice? Over the years, has that changed? Is it mostly coronary artery disease? Is it valvular disease? What do you usually see?
Dr. Schulman: So, the most common, basically the most common disease is coronary artery disease, heart attack, and stroke to a lesser extent. But stroke is still important. So, heart attacks and coronary artery disease - that’s blocked arteries that supply the heart muscle with blood and oxygen - that’s still the most common.
But now that people are living longer and healthier, we’re seeing a lot of other conditions. We’re seeing heart failure, and that means that the heart, it’s not failing completely, but it’s failing to do its job properly. Heart failure comes in two different shades, one of which is a weak pumping heart, that’s called systolic heart failure.
And the other is a not-well-relaxing heart. It’s too stiff, and that’s diastolic heart failure. Both of those are becoming more important. And the other condition that’s very common, more in the senior population over the age of 70 and 80 is atrial fibrillation. And that’s a condition where the heart rhythm is, the upper chamber is beating very fast and irregular, and the main issue, the main risk of atrial fibrillation, is you know, is stroke.
Dr. Alessi: Yeah, it’s interesting that you say heart attack and stroke, because I guess the old saying is “if it’s happening in your heart, it’s happening in your brain at the same time” when it comes to cerebral vascular disease and cardiovascular disease.
Dr. Schulman: That’s exactly right.
And we tell patients that coronary artery disease means cholesterol buildup, atherosclerotic cholesterol buildup, sludge in the arteries. That can be arteries in any place in the body. It could be arteries in the heart that cause a heart attack, arteries in the brain cause a stroke, arteries in the leg that cause peripheral vascular disease, and many other places too.
Dr. Alessi: I’m going to shift gears a little bit since we’re moving into that topic a little bit, and something I didn’t anticipate us chatting about is the use of statins. In a neuromuscular practice I see people who try to shun the use of a statin, they’ve heard it makes you weak, things such as this.
Can you talk a little bit about the benefit of being on a statin medication?
Dr. Schulman: Yes, and we get that question every week in our clinic. Statin medication, what it does is it lowers the level of your bad cholesterol. And that is very helpful. Yes, every medicine we take can cause side effects.
Statin side effects that are significant are maybe 5%, and if you stop the statin, the side effects go away. So, it’s basically a very safe drug. Some people think there may be a teeny, very, very small incidence of diabetes that’s triggered by that, but that is infinitesimal. It’s so tiny.
But the benefit of risk reduction for heart attack is dramatic. You can reduce your chance of a heart attack by 25 or 30% or even more by taking a statin. So, patients ask me, “well, what are the side effects of statins?” So I tell ’em, “Yeah, a few percent of muscle aches, is very rare. You stop it, it goes away. What are the side effects from not taking the statin is a heart attack and a stroke. So take your pick.”
Dr. Alessi: Yeah, it’s a good way to put it. And I think about that because, I mean, when we started practice we didn’t have these drugs, really. Lipitor, Crestor, things like that, you know. It has made a big difference.
The other thing in American Heart Month, recently, we’ve emphasized heart disease in women. And is that because they’ve been kind of an ignored population? I think have they thought that in the past that women didn’t get heart attacks. What has happened there? Why the need for more awareness now?
Dr. Schulman: Yes, many of the things you mentioned are correct. So, women were felt initially to have a lower risk of heart attack. Partly in the past, because there were fewer women who were smokers. The women were less likely to have more of the risk factors, hypertension, et cetera. Now we see that men and women are more alike from a physiologic standpoint.
Women are more commonly in the workforce. The instance of smoking is closer to the same, the instance of diabetes. So, all the risk factors for developing heart disease are the same. And then on top of, so women for initially underrepresented or non-represented in major clinical trials. For example, the first major trial of heart disease was the Framingham study that was started in the late 1940s.
And there were no women included. There were about 4, 5,000 men from Framingham, Massachusetts who were studied to see who would develop heart disease and what risk factors they had. So now we recognize that more frequently women are getting heart disease. But, the other side of the coin is their symptoms can be atypical.
So, women in heart disease, it’s in part an effort to assure that physicians and cardiologists and primary care providers are recognizing that A) women can have heart disease just like men, and B) the way that their symptoms could be somewhat atypical. So instead of, for example, a heart attack, instead of chest pain, like an elephant on the chest or a squeezing in the chest, women may have just shortness of breath, or weakness, or fatigue.
So, we have to remember that those could be symptoms of heart problems, and we need to take those seriously.
Dr. Alessi: If we were to have this conversation, I don’t know, 40 years from now, what do you think is developing in the field? What’s the future in terms of heart disease and treating heart disease?
Is it in mechanics? Is it in medication? Is it genetics? What do you think we’re going to be? Or are we going to be dealing with routine heart replacements? What do you think?
Dr. Schulman: That’s a difficult question. You know, I see patients coming into the office every day and I’m just trying to treat them for heart failure or atrial fibrillation.
I think, number one, we will have major strategies to prevent heart attacks. For example, right now, if you don’t get your cholesterol lower enough to prevent a heart attack with a statin, there are now injectable drugs. There are a class of drugs called long name PCSK9 inhibitors. They inject under the skin.
They substantially reduce the cholesterol levels to less than 40, let’s say.
Dr. Alessi: Really?
Dr. Schulman: And these drugs will be available in pill form in the next 2 to 5 years. So, we’ll start to get fewer heart attacks down the road. Heart failure will be treated with even more medication. Now we can, in most people, stabilize the weakened function of the heart. Few people, we can make it stronger. But, down the road we’ll have more medications that will clearly get the heart stronger.
We may be able to infuse cells, stem cells that are targeted for the heart. They implant themselves in the heart muscle and they regenerate normal heart muscle so any weakened heart will be strengthened again.
Dr. Alessi: Wow.
Dr. Schulman: We’ll have devices. There probably won’t be heart transplants, there’ll be little battery powered, AA-powered mechanical hearts that we could just slip in maybe through the leg instead of by open heart surgery. I’m just speculating, I don’t know, but I see things going in that general direction.
Dr. Alessi: Wow. Well, Peter, I want to thank you for your time today. But more importantly, I understand you’re going to be retiring this year, so I really want to thank you for everything you’ve done for our patients over the years and the care you’ve given them. So many patients speak so highly of you and the personalized care they’ve gotten from you, and I want to thank you for that publicly.
Dr. Schulman: Thank you very much.
Dr. Alessi: Many thanks to our guest today, Dr. Peter Schulman. If you have any questions or ideas for future programs, you can reach out to me at healthyrounds@uchc.edu.
Jennifer Walker is Executive Producer of the Healthy Rounds podcast.
Chris DeFrancesco is the Studio Producer for the Healthy Rounds podcast.
Until next time, this is Dr. Anthony Alessi. Please stay healthy.
