Cardiologist Dr. Fawad Virk Discusses Coronary Artery Disease

Paige Heitman, director of marketing at Phelps Health, talks with Fawad Virk, MD, FACC, a board-certified cardiologist and interventional cardiologist at Phelps Health, on The Scope at Night podcast.

Paige Heitman: Before we begin today, I want to introduce tonight's expert. Dr. Fawad Virk is a cardiologist and interventional cardiologist at Phelps Health.

Dr. Fawad Virk: Hi everyone. Thank you for having me. I'm really happy to be here to talk about coronary artery disease.

Paige: Yes, we're so excited to have you. [Let’s] dive into tonight's topic. What is coronary artery disease?

Dr. Virk: Coronary arteries are the arteries that supply blood to your heart muscles, and they are an essential part of your heart because your heart cannot function without coronary arteries. The average human being has multiple coronary arteries. And coronary artery disease is when one of the major arteries of your heart get diseased or damaged.

How does this happen? Basically, all of the cholesterol and calcium starts depositing in your coronary arteries. On top of that, there's inflammation going on in there that eventually causes narrowing of your heart arteries that can lead to heart attacks or essentially what we call coronary artery disease.

Paige: How prevalent is coronary artery disease in the United States?

Dr. Virk: In the United States and all over the world, one of the leading causes of death is coronary artery disease. More than 600 million people have gotten this disease in one way or another, either a mild or moderate or severe form, and either they have been treated with stents or bypass or medication. It [coronary artery disease] is really prevalent. Every other household has one of its members -- either mom, dad or some other family member -- who has coronary artery disease.

Paige: Yeah, absolutely. It's one of the top causes of death in the United States, too. What role does genetics play in coronary artery disease?

Dr. Virk: Genetics play a big role. If you have a significant family history of heart disease -- and if you have a family history of high blood pressure or diabetes -- that actually puts you at higher risk for having any future cardiovascular events compared to someone who does not have a family history. You also have environmental factors that include your personal habits, your diet, if you smoke and your management of your blood pressure and obesity.

Paige: What are some of the symptoms of coronary artery disease that you see in patients?

Dr. Virk: The typical thinking is that only the word "chest pain" is important, and people think that only chest pain is a sign of coronary artery disease, which is not true. Chest pain is one of the most common symptoms of heart disease and coronary artery disease. On top of that, patients can have chest tightness. People can have shortness of breath.

Some people, especially females, can present with different symptoms. They can present with nausea and abdominal pain. Some people have shoulder pain. Sometimes they have jaw pain and think that is because of a dental problem. People sometimes feel palpitations. They feel their heart beating fast and sometimes they have sweating.

There are different ways people can actually present with coronary artery disease. I think it's very important for all of the general public to know all of these symptoms. It’s not just chest pain and chest tightness.

Paige: Dr. Virk, what do you mean whenever you say "palpitations?"

Dr. Virk: Everybody has different ways to explain when they feel like their heart is beating fast. Normally, when you and I are sitting, we don't feel our heart beating. But if you suddenly feel that your heart is beating fast or you feel that there is a skipped beat -- sometimes you feel a flip-flop sensation -- we usually call it "palpitations."

Paige: Can you tell us about the risk factors for coronary artery disease?

Dr. Virk: Some of the risk factors you can modify, and some of the risk factors you cannot modify. For example, men have a higher risk of having a heart attack, and you can’t change that. Females have less risk, but these days, we've been seeing a lot of females with that, too. Age is one of the biggest risk factors. There's more prevalence of coronary artery disease in older patients, especially people who are about 60 to 65 years of age. You obviously cannot stop aging, so that's something you cannot modify.

If you have a strong family history – if your mom, dad, brothers, sisters or your first-degree family relative has premature heart disease (if they have a heart attack at a young age, under 55) -- then that can be a risk factor for heart disease. You cannot change your family history. Race is one of the biggest factors. The African American, Native American and Asian populations are at higher risk for coronary artery disease.

There are modifiable risk factors that include high blood pressure and diabetes. If you're obese, if you're a smoker, if you have high cholesterol and if you have bad dietary habits, those all lead to other risk factors which essentially, you can modify with your lifestyle changes and medications.

Paige: Dr. Virk, we often talk about diet and exercise and how important those are. What are some good diets?

Dr. Virk: The Mediterranean diet usually includes more vegetables in your diet, a lot of fruits in your diet as well as legumes and nuts. You can have some red meat, but not a lot of red meat. Red meat is actually not really good for you. So, try to avoid red meat and excessive alcohol. Once in a while, wine is good for your heart health.

Try to avoid having any deep-fried food and any canned foods full of salt. Pizzas and burgers have fat and extra salt in them. Fat and salt can affect your risk for coronary artery disease, high blood pressure, diabetes and high cholesterol, and can lead to heart problems. Diet is a very important thing. We all should modify our diet.

Paige: That's great advice. Now that we know diet is one of the important tools that we can change ourselves, what tools do Phelps Health cardiologists, like yourself, have at your disposal to help diagnose and treat coronary artery disease?

Dr. Virk: I think we are pretty blessed at Phelps Health. We have all of the advanced, state-of-the-art modalities to diagnose and treat coronary artery disease. For example, if somebody's having chest pain or they come into the ER or they are seeing us in the clinic, we have different modalities that we can do.

We can perform an echocardiogram, which is essentially an ultrasound of your heart to look for the heart muscles and heart valves. We can do a stress test on those patients to diagnose any coronary artery disease. We have CAT scans here. We can actually do a CT coronary angiogram that can help us look at the coronary arteries for blockages. We have "Holter monitors" or event monitors to look for any rhythm problems. We can do an ultrasound, MRI or a CAT scan of your neck arteries, too.

We have two state-of-the-art cardiac catheterization labs with all of the advanced modalities and imaging available, where we can diagnose and treat coronary artery disease. If we find any obstruction in there, we can put in a stent.

Paige: I love hearing you say that, Dr. Virk, because I think sometimes there's a misconception that we are just a small, rural hospital, and we don't have the availability or even the tools at our disposal that you just talked about to care for patients. They can stay here, and they don’t have to travel hundreds of miles, right?

Dr. Virk: Absolutely. If somebody’s heart is really weak, we have mechanical pumps we can use to stabilize them. We have a good relationship with other hospitals, so that if patients do need a bypass surgery, we can always refer them for bypass surgery. But for all the other modalities, here in Rolla, we have state-of-the-art facilities.

Paige: Dr. Virk, how do you determine what testing somebody gets?

Dr. Virk: It usually depends upon your risk factors. We assess your risk, and we assess your symptoms, and then we decide which way to go. Depending upon your age, if you're a young patient or if you don't have many risk factors, we have different modalities. We can do a CT scan to rule out any obstructive heart disease. If you are a little bit older, if you have more risk factors, or if you have a family history, then we would likely perform a stress test or an echocardiogram.

Paige: How do cardiologists, like yourself, work with patients to determine medication for coronary artery disease or if medication is needed?

Dr. Virk: Once you have coronary artery disease, as I mentioned, that essentially means you have cholesterol plaque inside your artery. You have to be on certain good medications to prevent any future cardiovascular events. These include baby aspirin and medications we call "beta blockers" and ACE inhibitors. Sometimes if you get a stent, you may be prescribed a blood thinner called Plavix or Brilinta. Not every patient can tolerate all of these medications.

Paige: What are some of the health problems that can arise from coronary artery disease?

Dr. Virk: Once you are diagnosed with coronary artery disease, if you don't take care of yourself, the biggest health problem you can end up with is a heart attack. That blockage or that plaque buildup can actually break and suddenly close your artery, and patients can end up having a heart attack. If you have a big heart attack, you can have a weakening of your heart muscles, and you can end up having congestive heart failure.

If you have congestive heart failure and if your heart function is not improving, then eventually you can have abnormal rhythm problems. Patients can have cardiac arrest because of those rhythm problems, and then usually those patients end up needing a defibrillator. If you have a weak heart, you are at a higher risk of having a stroke. You also can have blood clots that can develop inside the heart cavity. A lot of health implications can happen if you do not take care of yourself, especially if you are diagnosed with coronary artery disease.

Paige: Can you explain the difference between primary and secondary prevention of coronary artery disease?

Dr. Virk: Primary prevention essentially means that you do not have a heart disease diagnosed yet. You do not have coronary artery disease, but we take some measures to prevent coronary artery disease. That's why we usually call it "primary prevention," which essentially means taking care of your risk factors. You may have high blood pressure, diabetes, a cholesterol problem, and we can treat those things before you actually have a coronary artery event.

Secondary prevention essentially means that once you are diagnosed with coronary artery disease, we have to be more aggressive in taking care of all those risk factors that can actually lead to another event of coronary artery disease. Once you have a heart attack, you're at high risk of having more heart attacks.

Paige: You talked about smoking. Why is smoking one of the worst things that somebody can do for their body in the long term, not just for their heart health?

Dr. Virk: Smoking is one of the biggest risk factors for heart disease, but smoking also can affect your lungs. You can end up having COPD (chronic obstructive pulmonary disease), you may end up having lung cancer, and at the same time, you are at a high risk for stroke.

There are a lot of toxins -- we usually call them "free radicals" -- in nicotine that promote inflammation in your heart arteries and in other parts of your body. The toxins can lead to heart attack and stroke. If you are a secondhand smoker -- if your spouse or another family member are smoking extensively inside -- you're also exposed to that.

Paige: Let's say somebody doesn't want to follow the Mediterranean diet. Maybe they really love red meat. What are recommended diets or lifestyle changes for them?

Dr. Virk: I love red meat, too. I like steak, too. I usually try to pick that part of the steak where there's not much of fat. I'm not saying that you stop eating everything. My goal is to keep everything manageable, so find a balanced diet, which is different for each individual. If you're young, your needs are different as compared to an older person who has been diagnosed with coronary artery disease.

Paige: How does chewing tobacco affect coronary artery disease?

Dr. Virk: Chewing tobacco has all of those chemicals in it that can actually damage the lining of your artery walls. Once you have that damage in your lining, which we call "endothelium," it can speed up the process of developing plaque, cholesterol and calcium. Eventually, your artery gets really narrow, and you start having symptoms, which increases your risk for heart attack and stroke down the road.

Paige: If somebody has plaque in their heart, is that reversible, or is that something that builds up and just never goes away, even if you change your diet and lifestyle?

Dr. Virk: There's a lot of good medications, but essentially, that plaque itself is not really reversible. Once the plaque is there, our goal is to stabilize that plaque and prevent the progression of that plaque. All those medications work, especially the cholesterol medications. They reduce inflammation, and they stabilize your plaque.

Paige: Should someone who's been diagnosed with coronary artery disease check their blood pressure?

Dr. Virk: Blood pressure is one of the biggest risk factors. As you mentioned with primary prevention, even if you don't have a heart disease, you still check your blood pressure. But once you have heart disease, that's actually where secondary prevention comes in. You really have to watch your blood pressure and check your blood pressure. When your doctor is changing your medication or adding new medication, you check more frequently.

Once your blood pressure gets stabilized at the goal, you don't really have to check every day, but you can check usually once or twice in a week and make a log of your blood pressure. Your blood pressure can change according to your stress level and your day. I usually tell patients to make a log a week before their next visit with me or with their primary care physician, so that we can get an idea of their average blood pressure. Most of the time when patients show up in the clinic, their blood pressure is high. They are anxious in the cardiology clinic or in their doctor's clinic.

Paige: Why is it important for people to establish care with a PCP (primary care physician or provider) before they go to a cardiologist?

Dr. Virk: They (PCPs) are the ones who actually diagnose and establish that their patients have these diseases. They send a referral to us. A primary care and family physician is focusing on every aspect of your problems and diseases.

Paige: What are the current recommended blood pressure targets for males and females?

Dr. Virk: For males and females, blood pressure goals are almost same. The difference usually comes based on your age and any conditions you have. Usually the saying is the lower, the better. Less than 120/80 is perfect. But obviously, we're not in the perfect world, and people can have different problems.

For somebody who has established coronary artery disease, diabetes or a history of stroke, I usually tell them to try to achieve a goal of 120/80, but if they can bring it down to 130/80, that would still be good and reasonable as long as the patient is not feeling any symptoms, including dizziness or lightheadedness when their blood pressure goes down.

Paige: How can we correctly track our blood pressure at home? Walk us through that process.

Dr. Virk: Sometimes it's hard for patients to check their blood pressure manually, and they cannot do that at home. There are a lot of automated machines available, and some are recommended by the American College of Cardiology and American Heart Association. The important thing is that we have to make sure that their machines are calibrated correctly. Whenever they are going to their doctor, they can bring their machine, so that we can calibrate it. Many pharmacies have machines to check blood pressure, too.

Paige: If somebody has coronary artery disease, are they at a greater risk for additional heart events in the future?

Dr. Virk: Yes. Once you have coronary artery disease, that's where control of the risk factors comes in and that's where the importance of taking your medication comes in. All of those medications which we prescribe to a patient with coronary artery disease are to prevent any future cardiovascular events. These patients are at high risk for having future events, including another heart attack or stroke.

Because the plaque is still there, what we are trying to do by controlling diabetes, high blood pressure and cholesterol is to actually stabilize that plaque. If you get a stent, we want to prevent any blockage within the stent. Your risk is higher than someone who has not had coronary artery disease, and you really have to watch your risk factors and your diet.

Paige: What are some other common cardiovascular problems that you see in our community? What are some of the common things that you see people come in for?

Dr. Virk: Because of the pandemic, we've been seeing delayed presentations of patients who had a heart attack. They had some event, and because of the COVID-19 concern, they didn't want to go to the hospital. Then, they ended up having heart failure, which essentially means a weakening of your heart muscles.

Congestive heart failure is a common concern in our community. Many patients are coming in with a lot of blockages in the heart and needing bypasses. High blood pressure also is actually a big issue in our community. Most of our patients do not have adequate control of their blood pressure. Either they don't want to take medications or they are on too many medications that are causing side effects. Also, the same cholesterol that can build up in your arteries can build up in your neck, too. We’ve seen heart attacks and heart failures.

Patients also can have a blockage or a plaque buildup in the arteries in their legs. Patients may start having cramps and pain in their legs, and sometimes they end up having gangrene or an ulcer. Diabetic patients may bump their foot one day. After a month, they notice that there's a big wound that's developing because they have blockages in the heart arteries and in their legs, and they're not getting enough blood supplied to their legs. Peripheral artery disease, which we usually call "PAD," is very common. Unfortunately, if patients don't take care of themselves, they can end up with an amputation of their legs, and that changes their lives.

Paige: What should someone do if they have symptoms of coronary artery disease?

Dr. Virk: Especially if you fall in those bad risk factors or you’re a certain age, talk to your primary care physician or provider. If you feel like you're having some symptoms -- chest pain, palpitations, nausea, vomiting -- and you have a family history and you have all of those risk factors, please do not ignore it. Please seek help. If it's bad, severe chest pain -- if you feel like you’re having a heart attack, -- call 911 or go to the ER.

Paige: Should I bring my medications with me if I have a heart event or if I need to see a cardiologist?

Dr. Virk: We have patients…they're seeing multiple healthcare providers. They're on multiple medications, and these medications have side effects; they have interactions. Sometimes I can't even memorize all of those medications. How can I expect patients to memorize all those medications? So please bring your medication with you and show us, so that we can see what actual medication you are on as a patient. A lot of complications can happen, and especially if you're older, you can end up having a lot more problems with drug interactions.

Dr. Virk: I also want to add…anxiety and depression are also bad for your heart. Get help if you think that you're depressed, or if you think you have some problem with that. Psychosocial issues are also a part of our society, and everybody has different issues. It's very important that we take care of each other. Watch your neighbors, watch each other, watch your family and be happy.

Also, if you feel like you have a sleep apnea issue -- that essentially means that patients have some or a lot of snoring, or they just stop breathing -- ask your primary care physician or provider about that. Sleep apnea is a risk factor, too.

Paige: Dr. Virk, I love that. As we wrap up here today, thanks so much to everybody for tuning into The Scope at Night. A huge thank you to Dr. Virk for joining us today and sharing his experience and expertise. We appreciate all of the insight that you've been able to share with us and share with our community.