Ep. 44 | Arleen Ramirez, MD, General Cardiologist, SGMC Health

Transcript

---

- Welcome to another episode of What Brings You in Today?

- I'm Erika Bennett.

- And I'm Taylor Fisher.

- And we just wanna thank all of our listeners for tuning in today. If you haven't already, please like and subscribe so you can stay up to date with all of our new episodes.

- And if you have any topics or questions you would like us to discuss on future episodes, you can submit those at sgmc.org/podcast.

- Alright, well we are here today with Arleen Ramirez who is cardiologist with SGMC Health. So Dr. Ramirez, what brings you in today?

- I'm here today to talk about heart health.

- Alright, well tell us first a little bit about you 'cause you're relatively new to our health system, so give us a little background and what led you to a career in cardiology?

- So I'm originally from Cuba and when I was starting medicine there I had a lot of exposure to cardiac disease and I wanted to find a specialty that gave me the opportunity of helping people. And I found that in cardiology that is too much medications, technology that we could offer and that we could see results and that make me passionate and make me choose this career and this specialty. Did you always know you wanted to be a doctor or what kind of So I, when I was younger I thought that I wanted to be a journalist but then I didn't find like a lot of like purpose and satisfaction and I decided to choose something that will be more rewarding. And I think medicine is that

- And you still get to be a little bit of a journalist investigative, you get to figure out what's going on. Yeah, I love and not your

- Patience. Yeah, I also thought I wanted to be a journalist too and I did not end up going that way. So I, I feel like what we do is rewarding too. Yeah. Especially in the healthcare field. I really enjoy it for sure.

- So you've been here for how long? Not very long but a

- Month.

- Okay. Well what do you think it so far?

- I like it. Good. It's a very welcoming place. I enjoy a lot working with my team. I think we have an amazing team in the cardiology clinic and I love that this hospital is, is growing and is embracing new technology, new opportunities to take a better care of our community.

- Definitely. We're excited to have you on because you are the only female cardiologist that we have are the only female in that whole area and we really wanted to have you on, especially for the woman's perspective on heart health 'cause it can be a little bit different than you know, the male, the presentation as far as what the issues are and

- Everything. For sure.

- So I think we can just dive right in. What are some of the most common conditions you're seeing in your clinic for what patients come in with?

- I see a lot of people coming with like chest pain, coronary art disease with cardiac arrhythmias. Like there are a lot of people complaining of having palpitations, heart failure. I will say that these are the most common pathologists that so far I've seen,

- Well we had the opportunity to interview Dr. Hinkey just recently so it was nice to get his perspective on cardiac electrophysiology. How does general cardiology, we've interviewed interventional cardiologists now we've interviewed the cardiac AP and heart surgery but we haven't had just a general cardiologist. So tell us a little bit about what type, what you see here in our area. What's your typical I guess, patient population?

- I think most of the time we are the first phase on the face at the first encounter that patients have with a specialty. In general we are the doctors who listen first what is the main problem And we try to solve the puzzle once we find what is going on. For example, once we find that the patient has an electrical condition of the heart that requires an electrophysiologist, we are the ones who refer them to the electrophysiologist. Or when the coronary disease is C severe enough that has not been responding to medical therapy where the interventional will help us like with procedures like percutaneous coronary cutaneous intervention like stents or if they have a severe valvular disease we refer them to the cardiothoracic surgeon or our structural cardiologist for either, for example aortic stenosis for a TAVR versus like an open heart surgery. So we are the first one in line. We are the first ones who talk to the patient, get to know them, listen to their symptoms, their complaints and then make the diagnosis and route them to a more specialized help if needed.

- Are most pat, so if they, do you tend to provide more medication do you think for those that maybe don't need specialist, what kind of options are there for heart issues? I mean I know it probably goes for example, probably a loaded question but

- Patients who have chest pain and we diagnose them with coronary artery disease, which basically is like when you have plaques in your coronary art disease that are making your heart not to get a good blood supply according to the guidelines. The first thing that we should do is try medications unless like there are severe lesions in certain birth, but I will not enter on doce tails. But it's like you should treat them with medications and if that fails then for their quality of life you try other interventions. Gotcha. Yeah, but I will say in general I love prevention. I think that the best medicine is not the one that cures is the one that prevent the problem. So I usually pay a lot of attention even if they are coming for palpitations. I always check like what is your cholesterol? Are you diabetic? Are you are if you are diabetic, are you taking cholesterol medications? Because all diabetic patients, regardless of what is the cholesterol level, they should be on cholesterol medications to prevent coronary disease. Are you a smoker? What are we doing to make you to quit smoking? This type of things. Yeah.

- Well we also interviewed Norma Brown who's our diabetes education specialist. So it's interesting that you say the relationship between all the different specialties. Yeah. Is we, it's all interconnected, which I think is, which is good that we have all these different specialists that can work together to kind of help with the issue the patients be able to get the right care for their issues.

- And you just mentioned smoking, so that's kind of a lifestyle thing. Do you see that a lot of your patients, their lifestyle modifications that they need to make?

- Oh yes. Unfortunately we see a lot of patients in our clinic who are either like overweight or with different grades of obesity. And obesity is linked to multiple heart conditions. For example, electrical problems of the heart like having atrial fibrillation or having a lot of premature ventricular contractions or other type of arrhythmia. So it is wonderful that we have here a weight loss clinic that we can refer. Also obesity is linked to obstructive sleep apnea, which is another condition that it goes hand to hand with heart problems. So I try to refer a lot of patients to that clinic to make sure that they get diagnosed and get proper treatment to prevent further complications in the future.

- Right, yeah. Sleep being so important Again what, so tell us a little bit about the difference in women and male symptoms from heart issues. Do what? And you know I have heard that especially like I guess in a heart attack more so, but that women tend to have different symptoms than men. What kind of issues would a woman experience that she may need to seek guidance from her physician?

- So I don't know if it's because we are socially conditioned like that. Like we have to have, well we are the ones who have the blessing of having babies and like doing a lot. Sometimes we as women do not give the importance. We like try to like this, give importance to the symptoms compared to megs. Like Meg, sometimes I have a paper cut in their fingers and they react but we, we sometimes are kind of like tougher and kind of, and it is like I have a chest pressure but that is probably because I'm anxious. Women try to blame a lot symptoms to anxiety or panic attack or those type of things. And unfortunately because of this they can get undiagnosed or they can get complications. And I, I can tell you probably some of the worst cases that I'm seeing in my career are women who have neglected their symptoms and when they come they come already with, with a complication because they, they were having indigestion for a long time and it's like oh I just have gerd, I just have gerd. But they were having a heart attack, they were diabetic, they didn't know that they were diabetic and they came with with a rupture in in in the vent like in the ward. So I will say having any type of chest discomfort, the new guidelines, they are running away from the term chest pain because sometimes you ask do you have chest pain? And people say no I don't have pain but I'm having a discomfort. Right. And just having a discomfort it like a pressure maybe not a pain pressure or something squeezing or it requires evaluation because we always have to put things together and is in that, in that puzzle that we have to fix is what are your risk factors. Sometimes they have family history of premature coronary disease like relative who have been diagnosed with coronary disease in their fifties that is important or they have been smoking for so long or they are diabetic and then they come with just discomfort. You have to take that seriously. You cannot say that is a panic attack.

- That's really interesting the comparison you made about the men and the women's tolerance to pain. That is very true and I could see us just explaining it away because, but the other thing that we do is if our significant other is having issues we're like go to the er, you need to get care. It's such a role reversal. Yeah we'll make, we're the ones that make them go get care but we won't necessarily do it for we won't care about ourself. Exactly.

- Yeah. Well I experienced indigestion for the first time since being pregnant and it was kind of like that, that pressure and that uncomfortable and and I did ask several people, I was like am I dying? Am I having a heart attack? But no it's just indigestion which is,

- Which is something that you pregnancy expect when you are pregnant. Right. But it is, it's always good to to seek the opinion of a medical professional who can figure it out your symptoms.

- Yes, yes. And again I expressed the importance of having a primary care physician that's, I was having some issues where I felt like my chest was just getting just something didn't feel right and she said, you know it, I don't know what it is but, and we're gonna still get you checked out. So she referred me to Dr. Disser and we were able to run through all the test but it's again having that advocate that will kind of help push you to make that decision just to check it out just to make sure you're okay. And it was fine. I think I was just drinking too many energy drinks so I think that was causing the issue or maybe it was stress but either regardless it was nice to have someone to help me give you that little push to just check it out and have that. And I think that's one thing we don't think about if you're not in the medical career, if you're not around doctors is how doctors, people tend to be scared of doctors but they're really like your partner. I mean they're your, they're your advocate, right? They're there to help you be your support system and that's kind of one of the messages I always like try to share with people because I see get to meet so many awesome physicians and that are so friendly, so kind, so knowledgeable not to be scared to go to the doctor. Of course I know that's your support system. They're here to help you feel your best and be your best. So definitely that's my spiel for that.

- So when a patient in and they, you know, maybe say I've been having these heart pain, no chest pains or you know, whatever it is they're coming in with, what kind of tests would you start running? What would you start looking at?

- So first you have to perform a good interview 'cause as a cardiologist you should be able to classify, not all the chest pains are cardiac chest pain. So you should classify is my patient having a classic angina or is my patient having a possible cardiac chest pain? 'cause sometimes the not every description makes the the diagnostic criteria but still you have suspicion that they may have some disease or based off what you are telling me, this is non-cardiac, I'm I'm, I'm positive that this is non-cardiac. And when you make that classification then you determine what test you are going to do to confirm your suspicion. If I suspect that someone has coronary disease depends also what age the patient has. For young patients who are not like older than 65, I love to do a coronary CTA which is a CT of the heart where we inject contrast and we are able to see if they have plaques inside of their vessels and if they do, what is the grade of the stenosis if this is a mild, a moderate or a severe disease. And that tell us a lot because sometimes patients could have a problem, it's not severe yet and we could put them on the right medication to prevent that from becoming a severe problem in the future if patients who are older, for example, like older than 70, doing like a nuclear stress test where we could see if they have a good perfusion when we stress the heart, that also help us if they are young and it's kind of like you don't know, it may have, you can put them to run like in a treadmill. The guideline are running more and more away from that because this is like a less sensitive test. For example, if I do a coronary CTA and we see that you do not have any plaques there, we can give you like reassurance. It's like you do not have any disease.

- Yeah. Is there any kind of relation to birth taking birth control and heart problems? I feel like I heard that at some point in years past that maybe you, they were seeing heart issues in a younger female audience and that may just be a myth that we can boast if that's not what we're, what we're seeing. I was just curious if there was any, if you had seen any correlation with birth control and female cardiac problems.

- I don't think that there is like a strong correlation between birth control and heart disease estrogens. They are kind of protective to the heart and that's why when you look for what is the proportion in younger people of, or the prevalence of having coronary disease, men have a higher prevalence compared to women because we are kind of protected because of the estrogens. Once we become menopause we kind of lose that protection and that ratio gets inverted. In the past I think they did studies about hormonal replacement to try to see if there were any benefits from women taking hormonal replacement for prevention of coronary disease. But those studies were not Gotcha. Positive so. Gotcha. Yeah,

- That's interesting. I didn't know that about the estrogen. Is there, do you know why it, the estrogen is protective? I don't know. It's not special. I don't know why special, that's why I was just, I was just curious. I mean I think that's

- Very

- Interesting

- It but the body is a fascinating, I mean mothers, females being able to have children is just fascinating in itself and it's special. It's okay. Is there any particular patient story that you have where that you've treated anything that was like something that you'll, you were like, I'll never forget this experience or this situation maybe that was particularly impactful to you?

- I, I had one patient when I was doing my fellowship, she had history of seizures since she was a baby and she presented to the ER with tonic-clonic seizures, which basically is the generalized seizures when they are checking. And that was a new pattern from her because she used to have just like jerky movement in one arm. That was what she used to have. So this, this was a new pattern for her and when she came to the hospital she was not to have very elevated troponins and pretty much everyone was assuming that that was because of the seizures that she had, that she was having elevated troponins as a result of, of the seizures. So I evaluated that patient and something that caught my attention is first the change on the pattern of the seizures and on telemetry when she was having this seizures, she was having an arrhythmia that people were saying that is an artifact but it was ventricular arrhythmia. I immediately asked for an stat echo and she had what we call wall motion abnormalities on her echo, which means that some walls in the heart are not moving well and that happens when you have ischemia sometimes. So we took her to the cath lab and she had an occlusion on her left anterior descending artery and that was the cause

- Wow.

- Of her having seizures. She was having this different pattern because she was having a ventricular arrhythmia as a result from and acute fart wowing. So I interesting. I was glad to put things together because otherwise she would have going home thinking I, I had an elevated troponins because I had seizures and it was a really heart attack. Yeah,

- Wow. That that is, that's where you get to be a detective and I guess trying to figure out what exactly is going on.

- Yeah, that's difficult. And I'm sure that's something y'all have to juggle all the time is what's causing, you know, is this causing that or is that causing this? Yeah. And how do we treat the underlying issue to fix them both but exactly everything's related.

- What advice do you have for patient patients or just people out there on how to live a little bit of a healthier life so maybe they don't end up needing to come and see you?

- It is very simple. We need all to eat better, to move more and to be happier. Take less stress in our life, try to sleep like eight hours and take, take a good care of yourself. It's like we all can make good choices when we go to the cafeteria. We have many options but we have the, the power of like making good choices and good selections for our health and our future. That's, that's what I would say that's, that is I think is the core of all the prevention that we do. If you eat better, if you are size more, you're not gonna increase weight, you're gonna be healthy and if your stress level is low, that also will protect your heart. Food is

- Medicine. Exactly. Exactly. You know, if you're eating the right, the right kind. So,

- And the stress, I think we talk about that in a lot of podcasts is you know, trying to manage your stress levels because the stress and the sleep and that all kind of contributes to a lot of issues. I wonder if that is some another thing, men versus women, the stress levels.

- We had

- More city,

- You know, no digs to all the men out there, but we kind of do it all. Well we do take

- You, you do take a lot on yourself as a woman of taking care of other people and, and the, you know, the home and careers and that is very stressful. It

- Is.

- And then you put things off like we talked about so

- And put off the good, a lot of times we sacrifice the things that we need to be doing, like walking more or doing some of that self care because we feel like we should be doing something else instead for someone else. And I think all doctors agree that it's important to, to exercise that self-care. So we can't use that as an excuse anymore. We need to prioritize your health, your own health because if you don't do it, no one really will until you're at the, at the level where you're seeking professional help. And then of course they're your partner but you still have to ultimately make the decision yourself that you want to to lead a better healthy life. So it's a challenge though. It's hard. It is. It is hard.

- Do you see that the patient's family or support system is, is a very important part of them being able to do that and manage their conditions?

- 100%. When you have your family as a team supporting you, for example, someone who wants to quit smoking or someone who wants to lose weight having support from their families, like you can do it maybe sometimes like exercising with them, supporting the changes on the diet for people with heart failure for example, encouraging them to keep a good diet like low in salt, like washing the amount of fluid, measuring their weight, taking their medications and being with their medications. That's, that's important. We do not have like a transplant center because this is not a teary center. But something that they evaluate when they are considering someone for, for a heart transplant for example, is what good social family support do you have because it has been demonstrated that people who do not have family support, they will not do well.

- Yeah because you still have to make that transition and that lifestyle once you receive Yes. A new heart. Yeah that's, that's tough. But family support is, is key but again it's ma it's prioritizing that healthy

- Making - That putting it out more in the forefront and not on the back end. Which I think we've kind of as a society tend to glorify, you know, our career goals and our family goals and all these accomplishments. But the underneath all of that, you're still people, you're still a human so you gotta take care of yourself.

- Yes, definitely.

- But on that congestive heart failure topic, we did implement here, I guess it may be six months ago, outpatient case management for our hospitalized patients who leave with congestive heart failure for that purpose to kind of help guide them and help them make those transitions and make sure that they're weighing themselves every day and that there's not any changes that need to be looked into so that they can maintain that healthy lifestyle without adult end back up in the ER and back in a situation. Because I think, I mean it is challenging to someone end up here in the hospital, they figure out they have CHF and then they, their whole lives change 'cause they have to now live this new lifestyle that they're not used to. So that's one program that's been very successful. We've seen it's early in, its in its stages but it's been showing already that a lot of the patients that we are reaching out to and having those daily conversations with are, it's bene, it is beneficial to them to get that little extra support at home once they've gotten home. So we look forward to expanding that to other areas too.

- Do you have any final thoughts you'd like to leave us with? Any words of advice or anything for our listeners about heart care in general?

- I think we have been like talking in general. I will be just repeating myself, but I will say I would recommend to keep like a good and healthy lifestyle. Please take care of yourself whenever you have symptoms. Sick, medical attention. Don't, don't try to diagnose yourself or look for answers in Google because sometimes those answers are not the correct answer. And I think the early that we could diagnose a condition, the better, the less complications that patients will have in the future and just try to be to, to have a better and happy life. That's what I will say. Alright, keep it

- Light. That sounds good to me. So thank you so much Dr. Ramirez for joining us today. We've really enjoyed it. And thank you to all of our listeners for tuning in today. And if you have any topics or questions you'd like us to discuss on the next episode, so you can submit those at sgmc.org/podcast.