Hello. I'm Dr. Steve compat,
scape preventive cardiologists at
Mayo Clinic in Rochester, Minnesota.
It's a great pleasure to
introduce my colleague and friend,
Dr. honest thought the Coba,
assistant professor at Mayo Clinic in
the Department of cardiovascular disease,
the Division of Preventive Cardiology.
So welcome and thank you so
much for having me.
Great day, great to have you here.
So To talk for a few minutes
about inflammation of the heart millage,
so important, It's really,
we're realizing how much more
important is almost every year.
And you'll can you just help tell us what
is inflammation and how do we define it?
Yeah. It's a very good question.
So inflammation in a nutshell for,
as it relates to higher disease,
is an important pathogenic component
of cardiac and vascular disease.
If we think about systemic inflammation,
V know that it's
simply our immune system at work,
so it should be good.
But I devote, we have a learn,
especially as it relates to the hard it,
it can cause trouble.
Especially it can cause trouble if
it's constantly turn on.
And that the turning of
the immune system an inflammatory responses
is due to a lot of bad risk factors and
bad habits, actual and salary.
And then so what are
the effects of inflammation
on our body and
specifically our cardiovascular system?
Yeah, So inflammation, first and foremost,
the whole process starts that when we have
too many cardiac risk factors and we
know that that high blood pressure,
high cholesterol,
diabetes,
smoking can lead to endothelial injury.
And was the endothelial injury starts,
it sets off a cascade,
all fun immune responses cascade
when inflammatory markers are aggregating,
then there's platelet aggregation
and ultimately
leads to propagation of
atherosclerosis and then black.
And what we have learned over the,
over the years or decades is
that most likely inflammation
stands behind a lot
of the plaque rupture that happens.
Fascinating. So it's R or lifestyle
or risk factors you're
pointing out that lead to the inflammation.
And then so something the inflammation
affects the endothelium
allows these other processes,
they atherosclerotic process or cholesterol
molecules leave in which
propagate more inflammation and injury.
You know, the, the,
how do we measure this?
So information can be measured by
multiple blood markers by the most
commonly used is the high sensitivity CRP.
And it's,
has a very nice sensitivity
to detect disease,
which defines even people at lower risk.
So we use commonly high sensitivity CRP.
It's an acute phase reactant.
So we have to understand that
the values of CRP can be very wide.
So for instance, if Somebody's in sepsis,
the CRP will be sky high.
However, when, when it relates
to kind of heart disease
or systemic diseases that
are kind of low grade and constant.
These levels can be, can be low.
So it's a wide variety of the CRP levels.
So the rate is not helpful.
We use that as well,
but higher sensitivity is the CRP levels.
There's other ones that we can,
or some studies use like
a fibrinogen or we can use ferritin levels,
so some other markers as well.
Okay, so then if the inflammation is
they're misleading to
this atherosclerotic process
and propagating it.
What do we do for it? How do we,
you mentioned risk factors and such?
Yes, there is that Mozart play a big role.
So risk factors on a play as
a super big role in it.
It's what starts of
the endothelial injury and
propagates the whole cascade.
So then we talk about life on or,
or lifestyle, then we talk about diet.
It's important to point out
that it's at obesity.
It has been shown that people that have
visceral obesity have a higher CRP levels.
A poor dietary habits.
So eating, eating diet
that is high in saturated fat,
that is high in process or
ultra processed foods is also detrimental and
sets off the inflammatory processes
and lack of exercise right now
VR sitting so much
that you think is considered a new smoking.
So these risk factors are very important.
So addressing these risk factors is,
I believe that the cornerstone
of kind of subsiding or
preventing the inflammatory processes.
And of course, there are also
medications that are out there
that have the potential
to reduce the inflammation.
So the lifestyle very important.
Unfortunately, during the pandemic we are,
You mentioned ultra processed foods.
I ultra processed food intake has gone from
about 56 percent of
our daily calories in this country up to 59%.
And for adolescence, two-thirds of
their calories are ultra processed food.
Do we find this inflammation even an
adolescent, she'll age absolutely.
So early on
the whole inflammatory process
starts early on,
even in childhood JVC,
so much obesity and actually a lot of
the inflammatory markers on
our central of Indie in the adipose tissue.
So certainly it starts at then at a,
at a young age.
Now the, you mentioned
the visceral adiposity,
which course plays a big role
in the inflammation.
Are you a believer in this concept that
the visceral adipose tissue actually is we
changed as we evolve to organisms
with a mouth and an **** that we started,
our visceral adiposity took over some of
the inflammatory role from a liver.
I mean, that's what I love.
So luckily, I I
I I believe in dad and I think there's a lot
of truth in it that the adipose tissues
becoming the endocrine organ
that sets off this whole process.
So, so it was, this,
is this part of the process that used to be
a good thing for us and
now is actually a bad thing.
Yeah. Almost like clogging
of the arteries arise.
Absolutely. That's that's a very good point.
And I think, like you said,
points out to the importance of,
of, of our dietary habits,
of our exercise and how do
we modify our lifestyle,
you know, keep up the good fat
and prevent a bad fat.
So in terms of dietary habits, you know,
there's a lot of studies that
show that the inflammation can be
reduced by Healthy Mediterranean
type of diet and
their components of
Mediterranean type of diet to
prevent can reuse the inflammatory responses,
especially extra virgin olive
oil, nuts, and seeds.
So these are some of
the kind of important factors,
how we can prevent
inflammatory process,
launch a wonderful trip.
So those things in the
military and actually will reduce
your CRP irritation, inflammation, right?
So we have known
for quite a while
now added and monitoring and
tie the healthy as in terms
of preventing cardiovascular events.
But a recent study
from the woman's health studies
showed that actually
the main driver for
reduction of cardiovascular events
is their importance in
anti inflammatory responses.
More so than their effect on,
on the glucose or lipids.
While Shall I tell them
the inflammatory potential?
The Mediterranean diet
reduces somebody's other things
like arthritic pain and
things like Right, Absolutely.
Then you bring a very important point,
the inflammation Vc.
A lot of patients in our clinic that
have systemic inflammation already
present because of having
rheumatoid arthritis, lupus psoriasis.
And these are important co-morbidities
that we have to pay attention
to because these patients,
especially that have systemic inflammation
present from
under conditions are especially at
higher risk of having heart disease.
Why is there a mechanism
that's understood that may lead to
that arrived so the
mechanism so we still feel that aids
the ongoing a low-grade inflammation
that happens in the body that cause
the atherosclerosis
are atherosclerotic process
and it's like
a pair picture that accelerates it.
There are some studies
recently that look at
bone marrow and the effect
of bone marrow activation that
would be activated even
before the process of inflammation starts.
And Dr. volunteer foster DC
or publish in the European Heart Journal.
This study showing that
we should not forget about the bone marrow.
The vomer are actually puts
out like Milo sites that are
pro-inflammatory or right,
perpetuate this process.
Yeah, so it's a systemic response.
Systemic response.
And what was interesting
in his study that they looked
about 1700 the patients that
were seemingly normal healthy people.
And they found that
the bone marrow activation is
triggered by presence
of cardiovascular risk factors.
So mostly those that are
composite components of metabolic syndrome.
So the factors like
obesity, high blood pressure,
abnormal abnormalities in triglycerides or
HDL and they trigger
cause activation of the bone marrow.
And interestingly,
it was founded deactivation is
present even in people they did not have
CRP elevation or did
not have the inflammation present yet.
So v should stay
tuned because the bone marrow, like you said,
the myeloid cells can kind of start
the process even before
Vr of air of the inflammation.
So this may be actually
involved in like the process of people
get influenza than their risk
for heart attack goes up.
People to get the flu shot annually.
Risk for our tech is down.
There was all this inflammatory processes.
Well, it's a fascinating the way
everything is connected to
the body, isn't it?
The year you mentioned of our lifestyle.
What about medications?
Do we have meds that worked for them?
Yeah. Very good point. Very good question.
So yes, we do have medications.
Are they use clinically?
It's still a work in progress.
I would say there are several clinical trials
and I will start with
their latest one that was on
call she'd seen and
the frequently used score sheets in for
pericarditis patients with
inflammatory cardiac diseases.
And to study showed on course it's aimed at
even a low dose on daily call
she'd say and reduce the CRP levels.
It did not reduce the costs,
they're all in these patients,
but it did have protective effect and
reduce the risk of cardiovascular events.
That's one of the latest one.
Before that, we have
the study contours trial
that looked at kinda Keno math,
which is a monoclonal antibody that
targets the inflammation upstream of CRP.
And that study also
showed that CRP is reduce.
It show that there is decreased number
of cardiovascular events with the medication.
However, the trial was
stopped earlier because it had
higher incidences of fatal infections.
And most likely by,
driven by driving the immune system too
much that people became
more prone to infections.
Then methotrexate trial is
also worth mentioning gum.
And the study was negative and did not show
reduction in cardiovascular,
cardiovascular events.
These are more of the novel of one's a bad.
Let's not forget about startings.
Does that stop things
across the board have been shown
to decrease the inflammation
and decrease CRP levels as well.
And this has been,
the work started to be like in 990s,
the doctor readchar that show that CRP is
elevated in patients that
have a lot of cardiovascular risk factors.
Now we are learning that
actually the startings of
a huge effect in reduction
of CRP along with reduction in LDL.
And so, oh, that's very interesting.
And so we assume that the newer agents,
the PCSK9 inhibitors probably
also will be involved in that and can reduce.
So please upload a right to ride.
I think it's still a work in progress.
We know that the patients that
have the residual kind of
a lipid lowering effect or need.
And that PCSK9 inhibitors are
very important option for them
by that how it effects inflammation.
We still have some to learn.
Yeah. Yeah.
They do we know anything about that?
We assume that your lifestyle
is important, some major important.
But most of our studies in
this country are usually medicine oriented.
Overly. You'll put minuss against lifestyle.
Dewey, we assume these things are
additive and we should do absolutely.
I am a strong believer in lifestyle.
So I think we can do a huge amount
and a huge percentage and by,
by modifying our lifestyle.
And certainly the medications,
especially if patients have
this systemic disease like
rheumatoid arthritis, lupus,
I think it's very important to get the
I'm treatment for these conditions.
But really a lifestyle can,
can bring down
the information very much down.
And then two other lifestyle
factors that we haven't
talked about, sleep, stress. Absolutely.
They involve, you think?
Yeah, absolutely. I'm talking about
sleeve working with Dr. Summers.
And early on, we
actually are our lab shown that
patients with obstructive sleep apnea have
actually elevated CRP levels.
So sleep apnea and
the repetitive episodes of hypoglycemia that
happens during sleep is a big trigger and not
only for oxidative stress
but also for inflammation.
So CRP levels in patients
that have sleep apnea is elevated.
Interestingly, there are also studies
the CBF
decreases the CRP levels
and decreases inflammation.
So there was a study that
ever even three month use of see
BAB reduce CRP levels
significantly. So that's one thing.
And now stress is the other point,
like now COVID, time and stressful lifestyle.
It's a combination and I think
that's also very important.
And using stress reduction techniques,
using physical activity,
increasing physical activity exercise.
It has been shown to be very
powerful in reducing inflammation.
In the Clinically.
How do you follow
the unfulfilled inflammatory
response and PR Yeah.
Very good question. Now, what do we have in
the 2018 ACC AHA guidelines
for risk assessment, ASCVD risk assessment.
Now we have the data
to incorporate inflammation also
into risk assessment as a,
as an extra risk factors
or kind of triggers for increase the risk.
So I am frequently measure
CRP levels in patients,
especially if they are at
the intermediate risk.
Where we are deciding
should this patient be on starting or not.
And I think it's a very powerful marker,
the CRP and knowing about inflammation.
So I, I measure that and
then we know that startings
decrease CRP and decrease inflammation.
So that intermediate or
a gray zone patient that has
a high CRP despite
having reasonable lipid levels.
I think we should look at that,
look at that patient carefully to
see whether studies would be of help.
Now, some of the therapies are
quite elevated or not.
Of course, due to the corner disease,
is there a number CRP range
where you say this is likely
something important?
We have that rule either.
Absolutely. So around three, some study.
So, so tell us more than three modes of
most commonly is kind of
in the zone of every tri or more than 2.5,
you know, to start
incorporating inflammation.
And then what do we have
learned is the higher the CRP,
There's a linear kind
of increase in cardiovascular events as well,
as, well as in inflammation.
So the values matter and like you said,
there can be the CRP levels
that are elevated for other reasons,
but they are super high.
Then we are looking for the beak
trigger little bit and be clear,
we're talking but a high sense?
Yeah. Erp. Yeah. And does it change quickly?
Do you?
Absolutely. So a high sensitivity
CRP is an acute phase reactant.
So any infection in the body can trigger CRP.
And high sensitivity.
Crp has such a good sensitivity
than pigs out the,
the inflammatory responses.
So I like to kind of
check it periodically
in those intermediate patients
or when I'm thinking that the risk reduction
is a further important VV tend to monitor it.
Was this is a fascinating discussion the
that as we learn more and more
about inflammation and in ****,
the, so many parts of the body are connected,
which I leave the stress
relieving the hero or bone marrow are
visceral fat and the poor heart and the
arteries for giving the brunt of all this.
So any, any other
things you want to discuss or any any final,
I think it's very important for us to
talk to patients about information.
Because people knowing information,
you bump your ankle,
you twist your ankle,
you cut your finger,
you know that there's inflammation,
you know, it's red, it's warm.
Day they feel the pain bad.
They don't know about inflammation in the
hard because it's so low grade
chronic that they are not aware or
the inflammatory processes going inside
and causing the whole process
of atherosclerosis down the road.
So I think it's very
important to talk to them about it. Yeah.
Avoid the sun all day.
Expect to get sunburn
theat if you're overweight,
don't exercise in animation
exactly what I've just tried to code.
This has been a fascinating
discussion and thank you
for enlightening all of this about
the role of inflammation in the heart,
how to approach it, how to improve
our patients, our patients outlooks.
Thank you, Dr. capacity.
My pleasure to be here.
So it's been great for you to join us.
We appreciate you listening to us today.
Thank you. Buh-bye.