Taking heart health home: Cardiology experts on monitoring, medications and meaningful change

Body weight, blood pressure and cholesterol are familiar territory for primary care physicians.

But in medicine, the conversations surrounding all three may need updating, based on new tools and medications that are changing what is possible in cardiovascular prevention.

Francisco Lopez-Jimenez, M.D., M.S., and Kyla M. Lara-Breitinger, M.D., M.S., are Mayo Clinic cardiologists who co-edited the “Mayo Clinic Guide to a Healthy, Happy Heart” with the late Amir Lerman, M.D., a pioneer in endothelial function research whose vision of a world without heart disease continues to shape their work.

The physicians spoke with Medical Economics to address how to discuss weight with patients in a way that is clinically direct without being stigmatizing, how to integrate home blood pressure data into practice, the potential of GLP-1 medications, and why joy may be an underutilized asset in long-term prevention. This transcript has been edited for length and clarity.

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Medical Economics: The book discusses emerging markers alongside the standard lipid panel. In a primary care practice setting, we know doctors are pressed for time. How should they think about some of those advanced markers? What does that add to clinical value, and how do they know when a standard panel is sufficient?

Kyla M. Lara-Breitinger, M.D., M.S.: That's a difficult question for at least, personally, myself to answer as a preventive cardiologist, because if the primary care professional has the bandwidth to go all the way, why not? And if it's easy to add a lipid panel, you could clearly add a high sensitivity CRP (C-reactive protein), which can detect low grade inflammation in the body, which we know is linked to cardiovascular disease and stroke. Lipoprotein A, which we know is an independent risk marker for cardiovascular disease and calcific aortic stenosis and apolipoprotein B. And I feel that if they had the bandwidth, if they do a little bit of reading and they want to use that for more information, to then provide to their patient that, based on all of these extra things that I've taken from you, I think we should have a very aggressive LDL (low-density lipoprotein) goal for you, and we should really push to replace the five servings of animal meat you're eating per week to, replacing it with three servings of fish or vegetables, vegetable protein, plant proteins. And that, I think, can help a patient who is focused on objective evidence to be like, oh my goodness, look at how high that is.

Francisco Lopez-Jimenez, M.D., M.S.: I completely agree. And heart disease is so prevalent, so common, indeed, the number one cause of death not only in the U.S., but in the world, therefore, the more clinicians engage into the testing of risk factors, the better. And there will be still not enough clinicians to see every single person in the world to be tested and get what they need. So I have always said that truly, the main goal of us as clinicians should be that we eventually become obsolete. One of the visions of Dr. Lerman was: Imagine a world without heart disease. Of course, if you're a cardiologist and the world has no more heart disease, we become obsolete. But that will be a beautiful thing because then we can dedicate our times to something else, and we don't worry about heart disease anymore, right? But the idea is that the easier the access patients might get to basic testing for heart disease risk and prevention, the better. I think that's something that should be promoted more and more.

Kyla M. Lara-Breitinger, M.D., M.S.: And the one thing I'll add because Dr. Lopez-Jimenez is very humble. We've done a lot of research under his leadership on even things such as muscle mass versus where we store our fat in terms of distribution. And so additionally, if a primary care physician could get a DEXA (dual-energy X-ray absorptiometry) composition scan to determine where they distribute their fat versus their skeletal lean muscle mass, we know that there's a growing focus on looking at visceral adiposity, or central adiposity, where you store your fat centrally, is associated with more disease, more inflammation. And we work in a space looking at normal weight, obesity, right? It's not the number on the scale, it's not your BMI (body mass index), it's do you store most of that dangerous fat along your belly, which encases all of your organs, like your pancreas, your heart, your liver, which we know is metabolically dysfunctional.

Medical Economics: When we get into patients, actual physical bodies, the book covers obesity as a disease and notes that body mass index, or BMI, is a diagnostic criterion. In our society, there's a lot of different conversations that take place about a person's size and weight. How should primary care physicians be updating how they communicate about weight with patients right now?

Francisco Lopez-Jimenez, M.D., M.S.: The conversation about weight needs to happen in every single individual. I mean, whether the weight is not healthy, or is healthy and they need to have that reassurance. But it has to go beyond weight, particularly individuals who might not be very heavy, but they might still have a lot of fat, or something we call normal weight obesity, where a person might have a BMI, let's say 23 that is within normal limits, but might still have a lot of fat. That's a situation that we know relates to higher risk for heart attacks, high risk for diabetes and many conditions. And unfortunately, those cases go undetected because they feel happy, because their BMI is normal. Now, those individuals will have to be tested for fat, how much fat they have.

But the reality is that in most of the cases, what primary care clinicians have to deal with is the other side, the excess weight. And I think that's a conversation that needs to happen every time. It has to be done with tact and sensitivity, because we recognize there is a lot of body shaming in the country and every place. So we have to emphasize the importance of that is from the clinical standpoint. Once patients recognize that the interest of the doctor is about their health, generally, people are more receptive. It's a conversation that might not lead immediately to trying to lose weight, but at least generates the interest on that and particularly nowadays, with the different options that we have available, this is truly a conversation that should happen because there are ways for patients to control their weight that we didn't have 10 years ago.

Kyla M. Lara-Breitinger, M.D., M.S.: Obesity is a chronic, relapsing condition, and even in our cardiometabolic clinic that we both chair and co-chair, we save 60 minutes to destigmatize obesity, normalize that it's multifactorial. Some of it you can control. Some of it is beyond our control, genetics, different types of medications you take that can make it more difficult to lose weight, that lower your basal metabolic rate. And then understanding that BMI came as a way to categorize large populations of people so we can identify those at highest risk, but then use our brains and individualize what's in front of us. If you have someone with a higher BMI who's metabolically healthy, and I'm talking about your hemoglobin A1c is normal, your high sensitivity CRP is normal, you have normal triglycerides, a good lipid panel, your blood pressure is great, and you're performing on an exercise treadmill test with a good functional aerobic capacity, or even more specific, if you can get a peak Vo² (oxygen consumption per unit of time), which is a measure of your cardiorespiratory fitness, then they're metabolically healthy. They have no end organ damage, no fatty liver, and we're very happy with that. It's difficult, though. Does every primary care professional have time to or the cost for the DEXA scan or even accurately measuring someone's waist circumference? I wonder if we polled the country of how many people actually accurately, or have the time, to measure your waist circumference, which would be free and cheap, but if the visits are 15 to 30 minutes, that could easily take 15 minutes.

Medical Economics: The book goes into detail about home blood pressure monitoring. What are some good ways for physicians to integrate patients home data into care?

Francisco Lopez-Jimenez, M.D., M.S.: The reality is that we haven't done a good job integrating all this wealth of information that patients get at home using different devices into the electronic medical record, or the medical chart. That's an area where we can do better, and I hope, and I'm very optimistic, that in the next few years that will happen, where we create seamless integration of patients data that is obtained at home with what we can see in our electronic medical record. Now, it is also relevant to underscore that that needs to happen in a way that is simple and summarized to clinicians, because it happens these days, for example, that a patient might bring 250 pages of PDF records of electrocardiograms they obtained for the last two months using a particular point of care device or a wearable, right? We don't have the bandwidth to review 250 pages in every patient, so the information will have to be abstracted, summarize and simplify.

Now, it is also important to say that in the in the case of blood pressure, that the measurement of reliable blood pressure at home doesn't occur with all the devices that are claiming to do that. Actually, the FDA has been very strict on that, and there are even some warnings that have been published about this, because not every single device that claims to measure or monitor blood pressure actually does it in a reliable way. Nonetheless, the standard, old-fashioned blood pressure cuff that these days, even the wrist versions, are actually pretty good, will give a lot of good information to clinicians. And we totally believe that the future of blood pressure monitoring should rely on the patient's hands and this should not be a doctor's office diagnosis. This should be really a home-based diagnosis, aided or confirmed by the doctor's office measurement. But this is really should be something that should be monitored at home.

Kyla M. Lara-Breitinger, M.D., M.S.: I can't agree more. Hypertension — we're probably very numb hearing high blood pressure, high blood pressure kills. But that's the easiest disease that we can actually control, monitor and treat with lifestyle modifications, and there is an enormous amount of different classes of medications that can be tailored to a patient to get to these goals. Because having these strict criteria of blood pressure goals, less than 120 over 80, even in the elderly decades is being associated with less strokes, better cognition and less heart attacks. Because we know, based on Dr. Amir Lerman's legacy of research, to the point where he talks about endothelial function, which is the type of elasticity that was already mentioned by Dr. Lopez-Jimenez. In terms of vascular health, hypertension is much later in the disease course, where you're actually having high pressure hitting against these arteries. And over time, over decades, you can't reverse anything like that anymore. So it's really important for patients to feel like they can advocate for their own health, including their blood pressure. But it's super important for us who went through the training, the education, medical school, RN school, PA school, to really — if your physician, if your nurse practitioner, if your physician assistant does not sit down with a patient and say, this is important. And just say, oh, you know, work on your blood pressure. The patient doesn't feel this sense of, ‘Oh, this is a big deal.’

Francisco Lopez-Jimenez, M.D., M.S.: Blood pressure being one of the main killers in the world, and with technology that is readily available, I usually joke with patients. A patient with history of high blood pressure, I will generally ask them, I assume that you have a blood pressure machine at home. When they say, no, my next question is, do you mind if I ask you, how many TV sets do you have at home? And they usually will say, well, I’ve got four or five or six. And then I said, well, you know, I think you need to get a blood pressure machine as well. If you have three TV sets, you should have at least one blood pressure machine at home. It's basically jokingly saying, this is so relevant, so important for you, that you cannot not have one at home.

Medical Economics: Primary care physicians who are increasingly being asked to prescribe and manage GLP-1 drugs, but they may not have the support of an endocrinologist or a cardiologist. What do you want them to understand about appropriate patient selection and long-term management?

Kyla M. Lara-Breitinger, M.D., M.S.: This is probably the biggest focus, we could talk all year about this. But in terms of the infrastructure, because we know these medications have really exploded and transformed how we treat obesity beyond diabetes — because let's remember these drugs have been studied originally to treat diabetes and reduce hemoglobin A_1c increase insulin sensitivity. This big side effect was transformational weight loss comparative to almost bariatric surgery. And so the studies that were done in nondiabetic patients were for patients who had a BMI 30 or greater, or 27 with a concomitant obesity-related disease, sleep apnea, fatty liver disease, hyperlipidemia, high blood pressure, those types of diseases that kind of go with obesity, oftentimes. So as a primary care physician, those are easy to get approved, because the U.S. Food and Drug Administratin has approved those certain indications. With the shift to thinking about people who are already healthy, who want to lose some weight, get their inflammatory markers down, because maybe they have some autoimmune disease, maybe they had some gestational diabetes, and now they're trying to get the weight off. They've weaned off of breastfeeding. This is where it's very challenging for most of us, right? If their BMI is 25, 26 we can start seeing prediabetes, we can start to see small increases in that hyperlipidemia that are not quite high enough to say you're approved. Then it's finesse and the art of how can we prescribe these? We know these have been proven to improve systemic inflammation. But then the socioeconomic status of that patient, right? If you have the means, we can help order it for you, and you're going to pay full price, which is unfair and unjust in our current health care system. From my personal opinion, I'm speaking on the record that this is only to do with my opinion. And so that's when it's more difficult. So having a conversation with that patient, understanding their SES, socioeconomic status, and then determining, how can we make this work? How can I think about different ways? There are a lot of medical liaisons in industry that can help determine if there's extra support they can do to help these patients get these medications.

Medical Economics: If you could change one thing about how primary care physicians approach cardiovascular prevention with their patients, what would that be?

Francisco Lopez-Jimenez, M.D., M.S.: I would recommend primary care clinicians to focus on four things. Number one will be making people more active, and by more active, exercise is one type of activity, but it's not the only one. So just moving will be goal number one. Goal number two will be small but meaningful changes in their nutrition or diet. I prefer not to use the word diet, but more about healthy nutrition. And those changes, again, should not be huge, but they will be important and meaningful. Number three will be avoiding tobacco in all ways and means and shapes and forms, even secondhand smoking, which is something that is usually under the control of people to avoid. It’s less of a problem these days, but still, particularly among younger individuals with the smokeless nicotine use. And number four would be to recommend their patients to keep track on their numbers, watching the numbers. And the numbers will be BMI, cholesterol, blood sugar and blood pressure. Those are the four tenets of prevention, and people who follow those four basic principles will have a much lower risk for heart attacks and strokes in their lifetime. And all those four things got to be relatively simple goals to achieve.

Kyla M. Lara-Breitinger, M.D., M.S.: I'll just add: Probably the most important thing for primary care physicians know, is asking their patient what brings them joy, and then kind of creating exactly what Dr. Lopez-Jimenez mentioned around that particular response, and really focusing on all of these things that he just mentioned. Reduce inflammation, systemic inflammation in the body that we know is around us, environmentally, in the food we eat, in nanoplastics, forever chemicals, pollution, being next to fires — all of these contribute to cardiovascular disease and strokes. Having patients understand any small thing that can reduce your level of inflammation in the body is probably good. And I will have to put in with the new lipid guidelines, the lower your LDL cholesterol, the better over your lifetime. With the current evidence we have — I know there are others out there looking at different types of saturated fat and the quality of saturated fat that needs more investigation for us to move the needle. But as it sits, the lower your LDL is in whatever format of lifestyle you can reduce that, the better you're off. And then the last thing I'll say is, this book was an inspiration by Dr. Amir Lerman. He took on Dr. Lopez-Jimenez and I to coauthor this book, coedit this book, and all of the proceeds go back to the Mayo Clinic CV Research Department to further the research for cardiovascular health, disease and longevity.

Francisco Lopez-Jimenez, M.D., M.S.: I cannot emphasize enough what Dr. Lara-Breitinger had said that heart disease prevention should be matched with joyful activities, joyful decisions. Sometimes people have this misunderstanding that everything that leads to health is boring. I think quite the opposite, so to me, there is nothing more boring than be sitting in front of the computer the whole day, right? So I have to move around, greeting my colleagues next door. There are a lot of healthy nutritional choices we can make that are delicious, delicious, that once you try those things, you cannot live without them. Preventing heart disease should not be considered a boring task. Quite the opposite. There are many joyful choices, decisions, foods that are delicious. One of the things that we emphasize the most in that book is that keeping our heart happy many times means we stay happy, basically.