Transcript: Dr Paul Oh - Healthy Heart - Part 2 | Dec 10, 2003

(music plays)

A slate reads “The advice given in Mini-Med School is of a general nature only. Viewers should consult their own medical professional for medical advice specific to their circumstances.”

Against a blurry background of blue and pink pills, a video reel displays pictures of medical gear such as a needle, a scan of a human body and heart rate monitors.

The title of the show slides in: “Mini-Med School.”

Then, Paul Oh stands on a stage in a university auditorium giving a lecture. He’s in his mid-thirties, with short black hair and clean-shaven. He’s wearing glasses, a blue shirt and a red spotted tie.

Behind him, a computer screen is projected on a tall white wall.

Paul says IF YOU'RE GOING TO
EMBARK UPON AN EXERCISE PROGRAM,
THIS IS WHAT WE DO, DAY IN AND
DAY OUT AT TORONTO REHAB, HERE'S
THE GENERAL ELEMENTS THAT YOU
CAN ADAPT TO YOUR OWN
ENVIRONMENT.

A caption appears on screen. It reads “Paul Oh. University of Toronto. A Blueprint for a Healthy Heart Part 2.”

He continues YOU GO THROUGH SOME KIND OF
INITIAL CONDITIONING PHASE.
YOU'RE NOT GOING TO GO VERY FAR
IF YOU SAY, “TOMORROW I'M GOING
TO START MY 3 MILE PROGRAM,” AND
OFF WE GO.
YOU'RE SHINS WILL HURT, YOU'LL
GET INJURED, AND YOU'RE NOT
GOING TO DO IT THE NEXT DAY
AFTERWARDS.
REMEMBER THAT THERE'S GOING TO
BE AN INITIAL CONDITIONING
PHASE, AND GO SLOW, BUT GO
STEADY WITH IT.
EVEN IF YOU KNOW I CAN DO 2
MILES TOMORROW, IF I HAVEN'T
WALKED BEFORE, LET'S JUST GO
WITH HALF TO START WITH, BECAUSE
IF YOU GO THE 2, YOU'RE PROBABLY
NOT GOING TO GO WITH THAT FOR
MORE THAN 2 OR 3 DAYS AT A TIME.
SO, WE'RE GOING TO GO THROUGH AN
INITIAL CONDITIONING PHASE OVER
4 OR 5 WEEKS, GENERALLY LOWER
THAN WHAT OUR TARGET IS GOING TO
BE.

He runs a PowerPoint presentation.

He continues MAKE SURE THAT WE DO SOME
WARMUPS, THE STRETCH IS REAL,
REAL IMPORTANT.
IT MAKES YOUR BODY READY TO
ADAPT TO THE EXERCISE.
AND ANYBODY WHO HAS HEART
DISEASE, IT'S REALLY QUITE A
PROTECTIVE THING.
IF YOU JUST GO FULL GUNS RIGHT
FROM THE START, YOU'RE GOING TO
INVITE SOME TROUBLE.
YOU GO THROUGH THE WARMUP, YOU
GO THROUGH AN ENDURANCE PHASE.
INITIALLY THE DURATION OF THE
EXERCISE SHOULD BE RELATIVELY
SHORT -- 15 MINUTES.
SO WE'RE GOING TO TALK ABOUT
GOING HALF A MILE IN 15 MINUTES,
WITH A WARMUP AND THEN COOL DOWN
5 TO 10 MINUTES.
AND THEN BUILD THAT UP BY ABOUT
5 MINUTES PER WEEK UNTIL WE HIT
A TARGET OF ABOUT 45 TO 60
MINUTES.
DO THAT 3 TO 5 SESSIONS PER
WEEK, NOT EVERY DAY.
YOUR BODY NEEDS A COUPLE OF DAYS
PER WEEK JUST TO HEAL, JUST TO
REST, AND THAT'S A GOOD THING.
IF WE'RE GOING TO GET REALLY
PRESCRIPTIVE ABOUT THESE THINGS,
WE CAN PUT YOU THROUGH STRESS
TESTS, SET TARGET HEART RATES
FOR YOU...
ONE SIMPLE GUIDE COULD BE, TAKE
220, SUBTRACT OFF YOUR AGE, TAKE
ABOUT 80 PER CENT OF THAT, FOR
MOST PEOPLE THAT'S ABOUT 120,
130.
THAT WILL BECOME YOUR TRAINING
TARGET LATER ON DOWN THE ROAD IN
ABOUT 4 TO 5 WEEKS WHEN YOU'RE
READY TO GO FULL GUNS, OKAY?
AEROBIC EXERCISE IS GOOD.
DO YOU NEED TO RUN, DO YOU NEED
TO WALK, IT DOESN'T MATTER.
WHAT I TOLD THE LAST CLASS, THE
LAST GRADUATING CLASS WAS, IT
DOESN'T MATTER, AS LONG AS YOU
DO IT SLOW, AND STEADY AND YOU
SWEAT, AND THEN LOTS OF PEOPLE
IN THIS AUDIENCE SMIRKED AT ME
AND HAD ALL THESE DIRTY THOUGHT
ROLLING THROUGH THEIR HEADS.
I'M NOT GOING THERE, I'M NOT
SAYING ANYTHING ABOUT THE TYPE
OF EXERCISE, SLOW, STEADY AND
YOU HAVE TO SWEAT, AND THEN
THAT'S GOOD.
OKAY, AS WE SAID, YOU GO THROUGH
AN INITIAL CONDITIONING PHASE,
YOU PROGRESS YOUR PROGRAM, AND
THEN YOU MAINTAIN IT FOREVER
MORE.
ISN'T THAT SIMPLE?
IN 5 MINUTES, WE'VE SOLVED THE
PROBLEM WITH EXERCISE.
LOTS OF--
WHO HAS A TREADMILL AT HOME?
WHO USES THEIR TREADMILL AT
HOME?
THE MOST OF THE EXERCISE YOU DO
WITH YOUR TREADMILL IS MOVING IT
FROM ROOM TO ROOM.
CERTAINLY THAT'S THE CASE IN OUR
HOUSE.
TREADMILLS ARE GREAT, YOU KNOW,
LET'S MAKE A SMALL COMMITMENT TO
USING IT TOMORROW, 5 MINUTES,
SAY HELLO TO YOUR TREADMILL,
HELLO, TREADMILL, AND I'M GOING
TO WALK ON YOU FOR 5 MINUTES.
IT WILL BE GREAT, OKAY?
SO THAT'S THE KIND OF THING YOU
DO WITH YOUR PATIENTS.
IS TO SEE, WHERE ARE THEY?
ARE THEY READY FOR CHANGE, IF
THEY ARE READY FOR CHANGE, LET'S
DO SOMETHING SMALL IN TERMS OF
COMMITMENT, AND GET THAT
SUCCESS, AND THEN BUILD ON THAT
SUCCESS.
5 MINUTES THIS WEEK, WE'RE GOING
TO GO TO 10 NEXT WEEK.
GREAT.
SO WHAT, DOES IT MATTER?
THE ANSWER IS, YEAH, I THINK IT
DOES MATTER.
IF WE THINK OF SIMPLE WAYS TO
AFFECT SOME OF OUR RISK FACTORS
LIKE CHOLESTEROL, THERE HAVE
BEEN STUDIES THAT HAVE LOOKED AT
FOLLOWING THIS KIND OF HEART
HEALTHY SORT OF DIET AND DOING
SOME REGULAR AEROBIC EXERCISE
AND YOU CAN LOWER YOUR
CHOLESTEROL BY ABOUT 10 PER
CENT, THE TRIGLYCERIDES BY ABOUT
A QUARTER, THESE ARE RELATIVE
NUMBERS.

A slide displays a table under the title “Diet and Exercise-Efficacy?”

He continues ANOTHER WAY OF LOOKING AT THIS,
IF WE FOCUS IN ON BAD
CHOLESTEROL OR GOOD CHOLESTEROL,
THE RED BARS ARE OUR CONTROL
GROUPS, SO IF WE DID NOTHING
WITH OUR LIVES BUT CONTINUE TO
EAT THE WAY WE DO AND NOT
EXERCISE THE WAY THAT WE DO,
OVER A PERIOD OF ABOUT 3 MONTHS,
THIS STUDY SHOWED THAT THE LDL
CHOLESTEROL, THE BAD STUFF, WILL
TEND TO INCREASE FURTHER BY
ABOUT 5 PER CENT.

A new slide hat shows a bar graph appears.

He continues OUR HDL CHOLESTEROLS DON'T
CHANGE VERY MUCH.
IF WE THROW ON AEROBIC EXERCISE,
AND A WEIGHT LOSS PROGRAM
INSTEAD, WE CAN LOWER OUR BAD
CHOLESTEROL SIGNIFICANTLY, 5 TO
10 PER CENT, AND MORE
IMPORTANTLY, BOOST UP OUR GOOD
CHOLESTEROL BY ABOUT 10 PER
CENT.
GOOD CHOLESTEROL IS HARD TO
BOOST, BUT THIS IS ONE SIMPLE
WAY TO DO SO.
AND YOU KNOW FROM YOUR RISK
CALCULATIONS, THAT THIS WILL
HAVE A PROFOUND EFFECT ON YOUR
CHANCES FOR HAVING SOMETHING BAD
HAPPEN TO YOU, OKAY?
TO PICK UP ON THE SLIDES THAT
WERE SHOWN AT THE BEGINNING OF
THIS ABOUT THE RELATIONSHIP OF
ACTIVITY AND LONG TERM OUTCOMES,
HERE INSTEAD, WAS A STUDY ON
WOMEN, TO SHOW THAT WE ARE BEING
GENDER INCLUSIVE, AND THIS WAS A
LARGE STUDY OF ABOUT 18,000
WOMEN.

He uses a laser pointer to point at a new bar graph.

He continues THE REFERENCE GROUP IN THIS CASE
WAS THOSE WHO RARELY EXERCISED.
THIS AXIS TELLS US ABOUT WHAT'S
YOUR CHANCES OF HAVING A HEART
EVENT OVER A PERIOD OF THE
FOLLOW UP, WHICH WAS ABOUT 20
YEARS.
THIS AXIS TELLS US ABOUT WALKING
PACE.
SO IF WE COMPARED THOSE WHO DID
NOT EXERCISE, TO THOSE WHO
WALKED JUST A LITTLE BIT, KIND
OF THE 0 TO 1 MILE GROUP, THEY
REALLY HAD NOT MUCH OF A
BENEFIT.
BUT IF WE CROSS OVER THAT
THRESHOLD OF 2 TO 3 MILES PER
HOUR IN TERMS OF INTENSITY, SO
NOT ONLY DISTANCE BUT INTENSITY,
THEN WE START TO DERIVE A
SIGNIFICANT BENEFIT EVEN FOR THE
UBER-PEOPLE, SO EVEN FOR THE
JOGGERS, MIKE, THAT SOME OF
THESE FOLKS ACTUALLY DO BENEFIT.
NOW YOU DON'T HAVE TO RUN 20
MILES PER DAY, BUT IF YOU DO IT
AT A BRISK PACE, SO WHAT I TAKE
FROM THIS, IS IF YOU CAN SWEAT
WHILE YOU DO YOUR ACTIVITY,
WHICH IS WHAT THIS KIND OF
MEANS, THEN YOU WILL DERIVE SOME
BENEFIT, OKAY.
DON'T SWEAT, AND YOU'RE PROBABLY
NOT DOING ENOUGH.
IF YOU CAN EAT A BAG OF CHIPS
WHILE YOU'RE WALKING, PROBABLY
NOT DOING ENOUGH THERE, OKAY?
IF YOU CAN SWEAT WHILE EATING A
BAG OF CHIPS, NOW THAT'S AN
INTERESTING EXPERIMENT, OKAY.
ALL RIGHT, SO DOES IT ALL
MATTER?
WE LOOKED AT THIS FELLA'S DIET
AND SAY, YOU'RE EATING TOO MANY
CALORIES, LET'S DROP THAT DOWN.
AND WE DROP THAT DOWN, NOT A
LOT, BY ABOUT 20 PER CENT OR SO.
WE, MORE IMPORTANTLY CHANGE THE
COMPOSITION, AND HAD HIM EATING
HEALTHY CALORIES, LESS FAT, LESS
SATURATED FAT, LESS CHOLESTEROL,
SUCCESSFULLY, DRAMATICALLY LOST
A LOT OF WEIGHT.
NOW YOUR INDIVIDUAL RESULTS WILL
VARY.
A LOT OF PEOPLE DON'T LOSE
WEIGHT OFF THE BAT FROM
EXERCISING.
WHAT YOU DO DO, A LOT OF
CONVERSION OF, IS FAT TO MUSCLE,
AND YOU DON'T LOSE A LOT OF
WEIGHT.
YOU MAY LOSE A KILOGRAM OR 2
OVER THE FIRST FEW MONTHS, AND
THAT'S TREMENDOUS.
SO YOU MAY NOT DERIVE THAT BIG
WEIGHT LOSS AT THE BEGINNING,
BUT YOU'RE STILL BEING QUITE
SUCCESSFUL.
THE CHOLESTEROL NUMBERS, IF WE
THINK OF 1,2,3,4,5...
1, FOR HDL, WE GOT TO WHERE WE
WANT TO BE.
2, FOR TRIGLYCERIDES, WE'RE
BELOW THE THRESHOLD.
3, LOOKING AT AN LDL, THAT'S
GREAT.
4, FOR THE LDL, CERTAINLY WE'RE
BELOW THERE.
AND 5, THE RATIO OF TOTAL
CHOLESTEROL TO HDL, WE'RE
DEFINITELY UNDER THERE AS WELL.
WE'RE VERY HAPPY LOOKING AT OUR
CHOLESTEROL PROFILE QUICKLY NOW.
AND THE PROGRAM, THE CORNERSTONE
FOR THIS INDIVIDUAL REAL STORY,
WAS WALKING 3 MILES IN 45
MINUTES 5 DAYS PER WEEK,
CONDITIONED, BUILD UP TO THIS,
AND THIS WAS THE CORNERSTONE FOR
IT.
SO IT REALLY DOES WORK, IT
REALLY DOES WORK.
TAKE AWAY FROM THIS CASE STUDY
IS THAT...

A slide reads “Diet and exercise can significantly improve lipid and risk profiles. The effects in most is modest.”

He continues BUT TANGIBLE AND REAL IMPORTANT.
OKAY, SOMETIMES DIET AND
EXERCISE AREN'T ENOUGH, AND WE
WANT TO GO A LITTLE BIT FURTHER,
ESPECIALLY FOR OUR HIGH RISK
INDIVIDUAL.
SO THIS IS SOMEBODY ELSE THAT I
LOOKED AFTER, A MAN WHO HAD
BYPASS SURGERY, AND WE THING,
WOW, HE HAD BYPASS SURGERY, IT'S
ALL FIXED, ISN'T IT, I DON'T
NEED TO WORRY ABOUT IT.
AND THE ANSWER, OF COURSE, IS
NO.
THAT IF YOU DON'T CHANGE
ANYTHING, THOSE BYPASSES WILL BE
BLOCKED UP OVER THE NEXT 5 TO 10
YEARS.
IT'S THE BODY, IT'S NOT THE
VESSEL THAT WE'RE TREATING.
SO, SOMEBODY WHO HAS...

A table reads “Case 4, Treating Risks. 56 year old man post CABG: family history, smoker-35 years, BMI 29, stressed, BP 150/90, TC 5.49, LDL 3.85, HDL 0.83, TG 1.78. Fasting glucose 8.4. Meds: ASA, multivitamin + E, ACE-inhibitor, beta blocker.”

He continues 1,2,3,4,5 APPROACH TO THE
CHOLESTEROLS TELLS US THAT
PRETTY MUCH EVERYTHING IS
ABNORMAL, AND THE SUGAR IS A BIT
ON THE HIGH SIDE AS WELL.
THERE ARE A NUMBER OF
MEDICATIONS THAT WE ALSO PROMOTE
AS PRACTITIONERS, THINGS WITH A
GOOD EVIDENCE BASE, AND LET'S
REVIEW SOME OF THAT IN TURN.
WE CAN START WITH THE DIET AND
SAY, YES, THERE'S PROBABLY TOO
MANY CALORIES.
THE FAT INTAKES AND THE
SATURATED FATS AND CHOLESTEROLS
ACTUALLY AREN'T TOO BAD.
SO WHAT ARE WE GOING TO DO NOW?
AND THAT'S WHEN WE'RE GOING TO
TALK ABOUT EMBARKING ON FURTHER.
SO ONE APPROACH THAT I TOOK WAS
LOOKING AT, WHAT'S THE EVIDENCE
BASE IN LITERATURE.
DR. EVANS CAUTIONED US TO BE
CRITICAL WHEN WE LOOK AT THE
LITERATURE, VERY IMPORTANT.
SO THE ONE ARTICLE WE PULL OUT
SAYS, YOU SHOULD MAINTAIN GOOD
HEALTH HABITS, AND WE'VE ALREADY
BEEN THROUGH THIS PART OF THE
CURRICULUM, THAT SAYS, YES, YES,
YES, WE UNDERSTAND THIS.
EXERCISE TILL YOU SWEAT, FOLLOW
A GOOD DIET, LESS FAT, THAT ALL
MAKES SENSE TO ME.
MAKE THE LIFESTYLE CHANGES, YES.
COMMIT TODAY, MAKE A SMALL
CHANGE, BUILD ON IT TOMORROW,
OUTSTANDING.
AND IF YOU CONSIDER DRUG THERAPY
FOR THE CHOLESTEROL IN
PARTICULAR, “STATINS ARE USUALLY
THE BEST CHOICE,” IS WHAT THIS
ARTICLE TELLS US.
AND I WANT TO LOOK FOR THE
PROOF, AND SOMETIMES WHEN YOU
LOOK FOR THE PROOF, YOU LOOK FOR
THE SOURCE, OKAY?
AND HERE'S THE SOURCE FOR THIS,
NO JOKING, CONSUMERS REPORT,
OCTOBER 1998.
IN THIS ISSUE, THEY TOLD YOU
ABOUT WHAT WAS THE LATEST IN DVD
TECHNOLOGY, WHAT WAS THE BEST
SNOW TIRE, AND THEY ALSO TOLD
YOU WHAT THE BEST DRUG THERAPY
FOR YOUR CHOLESTEROL WAS -- NO
JOKE.
AND INTERESTINGLY, THIS WAS
CORRECT POSSIBLY.
LET'S GO LOOK AT THIS.
IF YOU LOOK AT THE EVIDENCE BASE
FOR CHOLESTEROL THERAPY WITH
DRUGS, ALTHOUGH WE'RE A LITTLE
BIT CONCERNED THERE MAY BE A
CONSPIRACY ABOUT JUST USING MORE
MEDICATIONS OUT THERE, THERE
ACTUALLY IS A PRETTY GOOD
EVIDENCE BASE.
AND IF WE DON'T GET FAR ENOUGH
WITH DIET AND EXERCISE, PEOPLE
WITH VARIOUS LEVELS OF HEART
DISEASE AND CHOLESTEROL, DO
BENEFIT FROM DRUG THERAPY.

A slide under the title “The Pyramid of Recent times” appears.

He continues AT THE TOP OF THE PYRAMID ARE
THOSE WITH REALLY, REALLY HIGH
CHOLESTEROLS, WHO HAVE HAD A
HEART ATTACK, AND OVER HERE, A
STUDY CALLED THE SCANDINAVIAN
SURVIVAL STUDY, 4
Ss, SO THE 4S ACRONYM, TOLD US
THAT LOWERING THEIR CHOLESTEROL
USING DRUGS WAS A GOOD THING,
AND THE MAGNITUDE OF BENEFIT WAS
ABOUT 30 PER CENT LOWERING OF
HEART ATTACKS.

He uses a laser pointer to point at the slide and continues MOVING DOWN TO THOSE WITH MORE
AVERAGE CHOLESTEROLS WITH HEART
ATTACKS TO THOSE WITHOUT HEART
DISEASE, WITH NORMAL
CHOLESTEROLS, SO A LARGE SEGMENT
OF THE POPULATION MAY BENEFIT,
AND THERE IS A FAIR SIZED
EVIDENCE BASE DENOTED BY THESE
ACRONYMS.
WE COULD SUMMARISE THESE STUDIES
IN THIS SIMPLE FASHION, SO IF WE
LOOK AT THESE VARIOUS STUDIES
LOOKING AT THESE KINDS OF DRUG
THERAPIES, THE RELATIVE RISK
REDUCTION IN EVERY ONE OF THESE
STUDIES WAS FAIRLY UNIFORM.

A slide shows a table with the information he mentions.

He continues THAT IS, IF YOU HAD A
CHOLESTEROL PROBLEM, IF YOU TOOK
A CHOLESTEROL LOWERING AGENT,
YOUR CHANCE OF HAVING A FURTHER
HEART ATTACK WAS LOWERED BY
ABOUT 30 PER CENT BY TAKING A
DRUG.
THE ABSOLUTE RISK REDUCTION, OR
THE NUMBER OF PEOPLE WHO NEED TO
RECEIVE A THERAPY TO DERIVE A
BENEFIT, RELATES TO HOW MUCH
RISK THERE IS IN THE POPULATION.
YOU CAN IMAGINE THAT THOSE WHO
HAVE HAD A HEART ATTACK WITH
REALLY, REALLY HIGH
CHOLESTEROLS, THOSE PEOPLE ARE
AT THE HIGHEST RISK, THEREFORE
THEIR ABSOLUTE RISK REDUCTIONS
ARE THE GREATEST, VERSUSTHOSE WHO
DIDN'T HAVE ANY HEART DISEASE.
BUT THE RELATIVE BENEFITS IN
EACH OF THE GROUPS IS ABOUT THE
SAME.
AND THE RELATIONSHIP THAT YOU
CAN PULL OUT FROM THERE, IS
LOWER YOUR CHOLESTEROL BY ABOUT
1 PER CENT, LOWER YOUR CHANCE OF
HAVING SOMETHING BAD HAPPEN TO
YOUR HEART, BY ABOUT 1 PER CENT
AS WELL.
OKAY, 1 PER CENT FOR 1 PER CENT.
SO IF WE LOOK AT THIS PERSON'S
PROFILE, AND KEY ON THAT LDL
CHOLESTEROL, REMEMBER IN OUR
1,2,3,4,5 SCHEMA, 3 IS THE LDL
CHOLESTEROL, WE'D LIKE IT BELOW
3, AND PREFERABLY BELOW 2 AND A HALF,
SO IF WE TAKE SOME KIND OF
STATIN MEDICATION, AS CONSUMERS
REPORT WOULD SUGGEST THAT WE DO,
THEN WE WILL DO PRETTY WELL, AND
OUR LDL CHOLESTEROL COMES NOW
DOWN TO 1.94 OR SO, AFTER WE
MODIFY DIET FURTHER AND LOWER
OUR BODY MASS FURTHER, AND WALK
THE MILES THAT WE'RE SUPPOSED TO
BE WALKING.
OKAY, NEXT PIECE FOR THIS ONE IS
THAT THIS PERSON WAS A SMOKER.
AND WHY IS THAT SUCH A BAD THING
IF YOU'VE HAD HEART DISEASE IN
PARTICULAR.
WELL THIS STUDY THAT WAS
PUBLISHED IN THE ANNALS OF
INTERNAL MEDICINE A FEW MONTHS
AGO, LOOKED AT THOSE WHO WERE
NON SMOKERS, WHO QUIT JUST
BEFORE THEIR HEART ATTACK, THOSE
WHO QUIT AFTER THEIR HEART
ATTACK AND COMPARED TO THOSE WHO
ELECTED TO CONTINUE SMOKING.

He turns to point at a slide displaying a bar graph.

He continues LOOK, I HAD A HEART ATTACK,
WHAT'S THE BIG DEAL, I'LL JUST
KEEP SMOKING, IT HELPS KEEP ME
SANE.
AND IF WE LOOK AT THE CHANCE OF
HAVING A SECOND HEART ATTACK
OVER TIME, CLEARLY THERE'S A
GRADATION IN EXPOSURE HERE.
THE MORE YOU SMOKE, THE MORE
YOUR CHANCES OF HAVING SOMETHING
BAD HAPPEN TO YOU.
THE POSITIVE THING I TAKE FROM
THIS ANALYSIS WAS, IF YOU LOOK
AT THIS GROUP WHO QUIT AFTER
THEIR HEART ATTACK, AND FOLLOW
THEM OVER TIME, OVER A TIME OF
ABOUT 3 YEARS, TO SEE THAT THEIR
RISK WASHED OUT.
AND THAT THEY STARTED TO
APPROACH THE RISK OF NON
SMOKERS.
SO AGAIN, MY FELLOW THAT TELLS
ME, “I QUIT THIS MORNING, I QUIT
EVERY MORNING.”
I SAY, “GOOD FOR YOU,” BECAUSE
IF YOU CAN STRING A FEW DAYS
TOGETHER, HOPEFULLY THAT RISK OF
SMOKING IS GOING TO WASH OUT OF
YOUR SYSTEM, SO LET'S KEEP GOING
WITH THAT.
THIS MAN'S BLOOD SUGAR WAS A BIG
HIGH.
HE WAS TOLD HE HAS DIABETES.
HE TELLS ME, “I HAVE DIABETES,
MY SUGAR IS HIGH, WHAT ARE YOU
GOING TO EXPECT?”
AND I SAY BACK TO HIM, “YOU GOT
DIABETES, OUR GOAL IS TO GET
YOUR SUGAR NORMAL.”
AND HERE'S ONE OF THE REASONS WE
WANT YOUR SUGAR TO BE NORMAL.
ON THIS AXIS, WE'RE LOOKING AT A
MEASURE CALLED HEMOGLOBIN A1C,
WHICH IS KIND OF A 3 MONTH
AVERAGE BLOOD SUGAR.
A NORMAL NUMBER IS ABOUT 6 PER
CENT, OR ABOUT .O6.
MANY PEOPLE WITH DIABETES LIVE
UP HERE, 8, 9, 10 PER CENT.
AND THEY'RE TOLD, THAT'S JUST
THE FACT THAT YOU HAVE DIABETES.
WELL WHAT THIS STUDY SHOWED US,
AGAIN ON THIS AXIS, WAS THE
CHANCE OF SOMETHING BAD
HAPPENING TO YOU.
THE HIGHER YOUR BLOOD SUGAR, THE
HIGHER THE CHANCE OF SOMETHING
BAD HAPPENING TO YOU.
THE LOWER YOUR BLOOD SUGAR, YOU
START TO APPROACH NORMALITY.
WHAT'S THE GOAL OF THERAPY?
IT'S NOT ROCKET SCIENCE HERE,
RIGHT?
THAT'S WHY I CAN DO MEDICINE,
IT'S SIMPLE.
WE LOOK FOR WHATEVER'S NORMAL,
WE TRY TO GET THERE AS HARD AS
WE CAN PUSH.
NOW, GETTING THERE IS SOMETIMES
DIFFICULT, AND AGAIN, THE SINGLE
STRONGEST THINGS FOR OUR TYPE 2
DIABETIC POPULATION IS, CAN YOU
FOLLOW THAT SENSIBLE DIET, AND
CAN YOU WALK.
STRONGER THAN MOST OTHER THINGS
THAT WE CAN DO, AND THEY ARE NOT
SO EASY, AND IT TAKES US BACK TO
THAT FOUNDATION OF LET'S MAKE
THE SMALL COMMITMENT, LET'S
BUILD IT IN PHASES, AND WE WILL
HAVE SOME TANGIBLE BENEFITS.
OTHER PROVEN THERAPIES, JUST
QUICKLY, BECAUSE SOME PEOPLE
SAY, IF I DO THE DIET AND
EXERCISE THING, DO I REALLY NEED
TO TAKE THOSE PILLS AS WELL?
DEPENDING ON WHAT YOUR SITUATION
IS, THE ANSWER IS PROBABLY YES.
AND SIMPLE THINGS, AND WHAT WE
CAN STRESS ARE REALLY SIMPLE
THINGS, LIKE TAKING AN ASPIRIN A
DAY.
YOU CAN LOWER YOUR CHANCE, IF
YOU'VE HAD HEART DISEASE, LOWER
YOUR CHANCE OF HAVING A SECOND
HEART ATTACK, SAY BY ABOUT A QUARTER,
BIG EFFECTS.
TAKING STUFF LIKE BETA BLOCKERS
AFTER YOU'VE HAD A HEART ATTACK,
ANOTHER 30 PER CENT.
TAKING BLOOD PRESSURE PILLS, HAS
POSITIVE EFFECTS NOT ONLY ON
HEART DISEASE, BUT MORE
IMPORTANTLY ON STROKE.
AND LOTS OF BIG STUDIES THAT
HAVE BEEN POPULARISED IN THE
PRESS RECENTLY TALK ABOUT THAT.
THE BENEFITS OF STAYING ON SOME
OF THESE THERAPIES.
OKAY, AND OTHER INTERESTING
PROTECTIVE THERAPIES.
SO BEYOND TREATING SPECIFIC
CONDITIONS, BUT ACTUALLY USING
SOME OF THESE MEDICATIONS TO
CHANGE HOW THE ARTERIES BEHAVE.
AND THIS STUDY REALLY CHANGED
HOW DRUGS ARE USED IN PATIENTS
WITH CORONARY DISEASE AND WITH
DIABETES RECENTLY.
A STUDY CALLED HOPE, AND ANY
PATIENT THAT I'VE TREATED OVER
THE PAST FEW YEARS WHO SEARCHED
THE INTERNET WOULD BRING IN
SOMETHING ABOUT THIS.
SO LOOKING AT DRUGS LIKE
RAMIPRIL OR THINGS LIKE THAT,
THESE DRUGS CALLED ACE
INHIBITORS AS PREVENTATIVE
MEDICATIONS, AND THERE ARE
PROBABLY OTHER THINGS ALONG THE
HORIZON.

Different slides show more tables and graphs.

He continues SOMETIMES VITAMIN THERAPIES MAY
HAVE SOME POSITIVE EFFECT IN
THIS WAY, OF POSSIBLY CHANGING
THE COURSE OF ATHRO-SCLEROSIS,
WHICH IS TERRIBLY EXCITING.
SOMETIMES WE GET MIXED MESSAGES
THOUGH.
AND IN THE WORLD OF ANTI-OXIDANT
VITAMINS THAT HAVE HAD SOME
POPULARITY IN MEDICINE AND LAY
PRESS, THIS TORNADO DIAGRAM
TELLS US ABOUT THE POTENTIAL
BENEFITS OF VITAMIN E IN
DIFFERENT STUDIES.

A slide under the title “Anti-oxidants: Vitamin E” appears. It shows a slide bar graph.

He continues IF THE ORANGE BOX LIES ON THIS
SIDE, IT MEANS THAT THERE WAS
SOME BENEFIT TO THE THERAPY, IF
THE ORANGE BOX LIES ON THIS
SIDE, IT LOOKS LIKE THERE MIGHT
HAVE BEEN SOME HARM ASSOCIATED
WITH THAT THERAPY.
IF THE BOX LIES RIGHT ON THIS
LINE, IT LOOKS LIKE THE THERAPY
IS REALLY OF NO BENEFIT.
AND A COUPLE OF THE BIG STUDIES
RECENTLY WOULD SUGGEST THAT
DESPITE THE HYPE ABOUT ANTI-
OXIDANTS, AND THE
ATTRACTIVENESS, AND THE SUPPORT
OF BRIGHT PEOPLE LIKE LINUS
PAULING, AND THE VITAMIN C
THEORISTS, IT MIGHT NOT ACTUALLY
PAN OUT TO BE ALL THAT
BENEFICIAL.
SO I TELL PEOPLE IF YOU WANT TO
TAKE VITAMIN E, GREAT.
I'M NOT SURE IT'S REALLY HELPING
YOU, BUT I DON'T THINK IT'S
HURTING YOU.
BUT IF I HAVE TO PRIORITISE,
TAKE AN ASPIRIN OR TAKE A
VITAMIN E, I'LL SAY TAKE YOUR
ASPIRIN, OKAY?
I'M PRETTY SURE THAT'S GOING TO
HELP YOU.
OKAY, SO BY DOING ALL THESE GOOD
THINGS, WE GOT THE DIETS FIXED,
WE DROPPED SOME WEIGHT, WE
STOPPED SMOKING, WE GOT THE
CHOLESTEROLS IN ORDER, WE GOT
THE SUGARS IN ORDER AND WE'RE
WALKING THE WAY THAT WE'RE
WALKING AND WE'RE FEELING PRETTY
GOOD.
OKAY, SO SOME OF THE TAKE AWAYS
HERE...

The slide changes to “Diet and exercise can significantly improve lipid and risk profiles.”

He continues WE LEARNED THAT FROM OUR
FIRST CASE.

The slide continues “‘Average’ LDL values are too high in CAD, respond well to drug therapy. Smoking cessation is important at any time. Preventative medications with proven benefit should be used and continued.”

He continues THERE IS A PLACE FOR THAT.

The slide continues “Smoking cessation is important at any time. Preventative medications with proven benefit should be used and continued.”

He continues SO WHAT HAVE WE DONE IN THE LAST
NUMBER OF MINUTES?
WE'VE REVIEWED WHAT THE RISK
FACTORS ARE.
YOU'VE GOT A GOOD HANDLE ON
THAT.
YOU CAN TAKE THEM AND
NUMERICALLY TAKE AN APPROACH TO
THEM TO CONDUCT SOME RISK
CALCULATIONS.
FROM THERE, YOU CAN SAY, IF I'VE
GOT SOME RISKS, I CAN DO
SOMETHING ABOUT IT, AND HERE'S
AN EVIDENCE BASE THAT I CAN TURN
TO, TO SAY I'VE GOT GOOD SUPPORT
FOR DOING THIS.
AND FROM THIS, FOR ANY
INDIVIDUAL, YOU CAN BUILD A
TREATMENT PLAN, TO HOPEFULLY,
POSITIVELY IMPACT ON THEM.
OKAY, WE ARE NOW INTO OUR
QUESTION PHASE, THANK YOU FOR
YOUR ATTENTION.

Mike Evans stands next to Paul. Mike is in his mid-thirties, clean-shaven with receding blond hair. He’s wearing glasses and a light open-necked shirt.

Mike says THERE'S LOTS OF
QUESTIONS PAUL ABOUT STATINS,
ACE INHIBITORS, LIKE WHAT ARE
THESE THINGS, BETA BLOCKERS.
SO I'M NOT SURE HOW TO HANDLE
THAT, BUT DO YOU WANT TO TRY?

Paul says THE PHARMACOLOGY IN
30 SECONDS

GO!
UM, SO WE TOOK MOR OF A
LIFESTYLE APPROACH TO THIS, BUT
THERE ARE LOTS OF MEDICATIONS
OUT THERE.
IF WE DO A QUICK THING, SAY ON
THE STATINS, BECAUSE I TALKED
ABOUT THEM A LOT, IN THE
CHOLESTEROL TREATMENT ARENA,
THERE ARE A NUMBER OF DIFFERENT
MEDICATIONS THAT MAY BE USED.
STATINS, IS, I GUESS A NICKNAME
FOR THE CHOLESTEROL LOWERING
DRUGS THAT AFFECT MAINLY THAT
LOUSY CHOLESTEROL, THE LDL
CHOLESTEROL, AND THESE ARE
PROBABLY THE MOST POPULAR DRUGS.
INDEED, IT IS THE NUMBER 1
PRESCRIBED DRUG IN OUR PROVINCE
ON A DOLLAR BASIS, SOMETHING
CALLED TORVASTATIN.
THERE ARE OTHER DRUGS CALLED
PRAVASTATIN AND SYMVASTATIN AND
LOVASTATIN, YOU KNOW WHY THESE
THINGS ARE CALLED NOW STATINS.
THESE DRUGS, MOST OF THE
CHOLESTEROL DRUGS WORK AT THE
LEVEL OF THE LIVER.
THE LIVER IS THE MAIN FACTORY
FOR CHOLESTEROL.
THESE THINGS GO TO THE FACTORY
IN THE LIVER AND BLOCK THE
SYNTHESIS OF CHOLESTEROL.
AND BY DOING THAT, THE BODY THEN
STARTS TO SCAVENGE CHOLESTEROL
OUT OF THE BLOOD STREAM AND OUT
OF YOUR ARTERIES.
SO THOSE ARE WHAT THE STATIN
DRUGS ARE.

Mike says ALCOHOL, PEOPLE WANT TO
KNOW HOW MUCH.

[laughing]

Paul says FEEL FREE TO DRINK
AND BE MERRY.
THERE ACTUALLY WERE SOME
INTERESTING MORTALITY STUDIES.
WE CHOSE NOT TO SHARE THOSE WITH
YOU.
BUT THERE PROBABLY IS A ROLE FOR
ALCOHOL IN HEALTH.
AND THERE ACTUALLY WAS ONE OF
THESE MORTALITY CURVES THAT WAS
GENERATED FOR VARIOUS
POPULATIONS, IN TERMS OF THE
AMOUNT OF ALCOHOL YOU DRANK.
PROBABLY THE OPTIMAL AMOUNT IN
TERMS OF LONGEVITY, IS TO HAVE 1
OR 2 DRINKS PER DAY.
A DRINK IS THIS MUCH, RIGHT, NOT
THIS MUCH.
THAT ALCOHOL MAY HAVE SOME
BENEFICIAL EFFECTS WITH RESPECT
TO THE HEART, BY IMPROVING
THINGS LIKE HDL CHOLESTEROL, THE
HEALTHY CHOLESTEROL.
SOMETHING KNOWN AS THE FRENCH
PARADOX, RIGHT?
THE FRENCH EAT HIGH FAT DIETS,
LOTS OF CREAMY THINGS, THEY
SMOKE TOO MUCH, THEY'VE GOT
STRANGE PERSONALITIES -- OH, WHO
HAVE I OFFENDED?
BUT THEY ALSO HAVE VERY GOOD
WINES.
AND SOME OF THE THOUGHT IS THAT
YOU CAN NEGATE SOME OF THE BAD
DIETARY THINGS, AND SMOKING BY
HAVING WINE IN YOUR DIET.
SO 1 TO 2 PER DAY.
SO WHAT SHOULD WE TELL OUR
PATIENTS?
WHAT DO I TELL MY PATIENTS?
IF YOU DON'T DRINK, I DON'T TELL
YOU TO START, IF YOU DO DRINK,
HAVE A GLASS OF GOOD RED WINE
PER DAY, IF THAT'S WHAT YOU'RE
INTO, AND THAT'S PROBABLY A
HEALTHY THING.
THE DOWN SIDES OF ALCOHOL ARE OF
COURSE GOING TOO FAR, FOR PEOPLE
WITH TRIGLYCERIDE PROBLEMS, YOU
GET A SUGAR LOAD WITH THE
ALCOHOL, WHICH CAN BE A BAD
THING, OR IF YOU'VE GOT
DIABETES, SOMETIMES THAT CAN BE
CHALLENGING AS WELL.

Mike says WHAT DO YOU THINK OF
THE ROLE OF MINDFULLNESS BASED
STRESS REDUCTION AND OTHER KINDS
OF STRESS MANAGEMENT?

Paul says STRESS REDUCTION IS
CERTAINLY IMPORTANT IN DEALING
WITH DEPRESSION, ANXIETY,
HOSTILITY.
AGAIN, IN OUR PROGRAM WE
ACTUALLY HAVE PSYCHOLOGISTS AND
SOCIAL WORKERS ON STAFF
SCREENING FOR THESE THINGS AND
DEALING WITH THEM.
DEPRESSION AND ANXIETY HAVE
EMERGED AS FURTHER INDEPENDENT
RISK FACTORS FOR BAD HEART
THINGS.
IMPORTANT TO DEAL WITH, NOT SO
EASY TO DEAL WITH, THOUGH.
BUT VERY IMPORTANT.

Mike says YEAH, AND ON THAT NOTE,
WE LOOKED AT IT AND I GUESS THE
NUMBERS ARE THAT DEPRESSION
TRIPLES YOUR RISK OF HEART
DISEASE, OBVIOUSLY DEPENDENT ON
YOUR AGE AND OTHER RISK FACTORS,
AND HAVING A HEART EVENT TRIPLES
YOUR RISK OF DEPRESSION.
DO YOU KNOW WHAT I MEAN?
AND SO THAT'S PROBABLY THE MORE
FOR STROKES SO THINGS THAT HAVE
A PHYSICAL CONSEQUENCE.
SO THERE IS A CLEAR MIND BODY
CONNECTION THERE.
A LOT OF QUESTIONS ABOUT
HYPERTROPHY, CONGESTIVE HEART
FAILURE, THE CONNECTION WITH
BLOOD PRESSURE MANAGEMENT.

Paul says SO WE INTRODUCED THE
NOTION OF LEFT VENTRICLE
HYPERTROPHY, THE THICKENING OF
YOUR MUSCLES, SO THE EFFECTS OF
BLOOD PRESSURE OR STRESS OR
THINGS ON THE HEART OVER TIME,
INITIALLY, JUST LIKE IF YOU PUT
A WEIGHT ON THE ARM, INITIALLY
THE MUSCLE TURNS NICE AND BIG
AND LOOKS NICE.
FOR THE HEART, WHEN IT STARTS TO
THICKEN UP, IT ACTUALLY STARTS
TO PERFORM LESS WELL.
THAT LEADS TO FURTHER
DECOMPENSATION OVER TIME, SO
YOUR HEART TURNS FROM A THICK
MUSCLE INTO A BIG BAGGY MUSCLE
OVER TIME.
HYPERTROPHY LATER ON, FAILURE,
SO A BIG BAGGY HEART.
HEART ATTACKS WILL ALSO
ACCELERATE THAT PROCESS BY
TURNING A NICE SMOOTH MUSCLE
INTO A SCARRED DISTENDED MUSCLE
THAT FUNCTIONS MORE LIKE A BAG
THAN A LEAN MEAN MACHINE.

Mike says I'M JUST GOING TO
ANSWER 2 MORE.
OR PAUL'S GOING TO ANSWER 2
MORE.
A LOT OF QUESTIONS ABOUT, IF
YOU'RE HEALTHY ALREADY SORT OF
PRIMARY PREVENTION QUESTIONS,
SHOULD YOU BE TAKING A STATIN,
SHOULD YOU BE TAKING AN ASPIRIN?

Paul says SHOULD YOU BE TAKING
CHOLESTEROL MEDICINES IF YOU ARE
OTHERWISE LOW RISK?
YOU CAN GO THROUGH THE PROCESS
YOURSELF AND ACTUALLY THE
PROCESS OF THE SCORING IS THE
PROCESS WE WOULD DO WITH A
PATIENT IN THE CLINIC IN
DECIDING ABOUT CHOLESTEROL
THERAPY.
PROBABLY IF YOU ARE PERFECTLY
HEALTHY IN EVERY WAY, THE
BENEFITS OF TAKING CHOLESTEROL
MEDICATION ARE PROBABLY SMALL
FOR YOU ON AN INDIVIDUAL BASIS.
ASPIRIN IS ANOTHER TOUGH ONE,
AND FOR A YOUNG, HEALTHY
POPULATION, THERE'S A TRADE OFF
BETWEEN PROTECTION AGAINST HEART
DISEASE, WHICH IS PROBABLY
THERE, VS. A SLIGHT EXCESS RISK
OF BLEEDING.
AND THE INFORMATION BASE THAT
MIKE AND I WOULD LOOK TO IS THE
U.S. PHYSICIANS HEALTH STUDY
WHERE THEY TOOK A BUNCH OF
MIDDLE AGED AMERICAN DOCTORS.
HALF TOOK ASPIRIN, HALF DIDN'T.
FEWER HEART ATTACKS BUT MORE
BLOODY STROKES IN THE BRAIN, SO
YOU KIND OF HAVE TO CHOOSE WHAT
YOU WANT.

[laughing]

Mike says CONFIDENCE IS THE
FEELING YOU HAVE BEFORE YOU
FULLY UNDERSTAND THE SITUATION.
SYMPTOMS OF A HEART ATTACK SO
I'M JUST GOING TO GO OVER THOSE
QUICKLY.
THERE ARE 3 SYMPTOMS THAT WE
TEACH OUR MEDICAL STUDENTS IN
RESIDENCE.
ONE IS, LOCATION, SO IT'S IN
WHAT WE CALL THE SUB STERNAL
AREA, SO UNDERNEATH YOUR BREAST
BONE.
YEAH, AND IT'S SORT OF PRESSURE
AS OPPOSED TO PAIN.
PEOPLE ARE OFTEN COMING IN WITH
PAIN HERE, AND IT'S OFTEN A
PRESSURE.
IT COMES ON WITH ACTIVITY.
ANGINA IS A SUPPLY DEMAND THING,
SO THEY WALK A BLOCK, THEY'RE
FINE, THEY WALK 2 BLOCKS, THEY
GET THE PRESSURE.
AND THEN IT'S RELIEVED BY REST,
OR IF THEY'RE ON MEDICATIONS
NITROGLYCERINE, BUT USUALLY THEY
SIT DOWN, IT GOES AWAY.
THAT'S ALL VERY PREDICTIVE OF
SOMEBODY HAVING ANGINA.
AND THE QUESTION IS, IS THERE A
DIFFERENCE BETWEEN THE
PRESENTATION OF MEN AND WOMEN.

Paul says THE ANSWER IS YES.
SO THE TRIAD, THE CLASSIC TRIAD
THAT'S BEEN PRESENTED TO YOU,
MAYBE ABOUT HALF THE PEOPLE WILL
COME IN WITH THAT.
LOTS OF ATYPICAL PRESENTATIONS
PERHAPS, JUST ARM DISCOMFORT,
THROAT DISCOMFORT, JAW
DISCOMFORT, BACK DISCOMFORT, AND
PROBABLY MORE SO IN WOMEN THAN
IN MEN WITH THESE ATYPICAL
PRESENTATIONS.
SOME PEOPLE WITH DIABETES MAY
HAVE NO PAIN AT ALL, BUT JUST
SHORTNESS OF BREATH.
SO IF WE ARE OF THAT AGE AND
RISK FACTOR PROFILE WHERE HEART
DISEASE MAY BE PRESENT, IT'S
IMPORTANT TO THINK ABOUT.
AND I THINK THAT'S THE BIG PUSH
ON, FOR WOMEN IN PARTICULAR THAT
THIS MAY BE HEART DISEASE,
PLEASE GET CHECKED OUT IF YOU'RE
CONCERNED.

(music plays)

A slate pops up. It reads “For more information about Mini-Med School at the University of Toronto visit us on the web at: www.tvo.org.”

The end credits roll.

Mini-Med School Producer, Wodek Szemberg.

Executive Producer, Rudy Buttignol.

Logos: CEP Local 72 M and Canadian Media Gold.

A Production of TVO Ontario.

Copyright The Ontario Educational Communications Authority 2003.

Watch: Dr Paul Oh - Healthy Heart - Part 2