Shireen: Join us in this episode as we welcome Dr. Amgad Makaryus, a renowned cardiologist to explain the compelling link between diabetes and heart health. Learn about the often overlooked phenomenon of silent heart attacks, their early warning signs and the distinct considerations for individuals with diabetes. Stay tuned. 

Dr. Amgad Makaryus currently serves as the Chair of the Department of Cardiology at Nassau University Medical Center in East Meadow, New York and professor of cardiology at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. He has authored over 200 peer reviewed publications and book chapters in the field of cardiology. Welcome, Dr. Makaryus. 

Dr. Makaryus: Thank you so much for having me.

Shireen: An absolute pleasure. Dr. Makaryus, let’s start up with, just getting to know you a little bit better. Could you share a bit about your journey in the field of cardiology? What led you to it and what has really inspired you to specialize in heart health?

Dr. Makaryus: Well, thank you so much for the opportunity. And I really, this is an area as I sometimes joke, very dear and dear to my heart. So, cardiology is something that I’ve always sort of become interested in going through medical school aside from, you know, family members who would end up asking cardiac related questions, whether they be diet or other situations, I came to the realization that cardiology is really central to everything we do in medicine.

Aside from being one of the most common causes of death in the US, if not the most common cause of death in the US, it is something that we see a wide range of throughout the field of medicine. And that’s how I became interested in it as well as the fact that in cardiology, we actually have many ways of treating patients when they do become sick with cardiovascular disease. But on the flip side of that, I think prevention is key to everything we do when it comes to cardiology. So that’s another major component that really drew me to the field of cardiology.

Shireen: So thank you for sharing that. And just for everyone’s note here, we are talking about really trying to understand diabetes and silent heart attacks. We’ll get into here in just a second understanding this world of sort of this core morbidity between heart disease and diabetes. Can you lead us through that? And then I want to talk a little bit more about our topic at hand here today.

Dr. Makaryus: Sure, diabetes has been called a Heart Disease equivalent. And the reason for that is that people with diabetes are felt to almost be assumed to have cardiovascular disease. And the reason for that is many large trials, including what most of your listeners are familiar with the Framingham Heart study, which is a large study that followed people over many, many years in terms of development of cardiovascular disease, looking at risk factors.

It’s basically one of the biggest landmark studies that we have to determine risk factors for cardiovascular disease. What that study and what many more found is that people with diabetes, it’s almost as if you’ve had prior coronary disease in terms of your risk factors and your risk of developing heart attacks, strokes and other cardiovascular disease.

So when it comes to diabetes, when, when, people in the medical field see diabetics, they know that they really have to keep an eye out for cardiovascular complications and the things that go with it. So it’s almost like they go hand in hand when you have somebody with diabetes.

Shireen: And that is interesting, you know, according to the American Heart Association Association, excuse me, silent heart attacks are common and overlooked. What are the early stage signs and symptoms of a heart attack and how might they differ in individuals with diabetes?

Dr. Makaryus: Excellent question. So, classically, when we’re talking about any patient who presents with cardiovascular disease, whether it be a heart attack or something else for a heart attack, the usual symptoms that everybody is familiar with is the classic crushing chest pain. that radiates usually down the left arm, it can radiate up into the jaw.

Other associated symptoms might be things like palpitations, a racing heartbeat, dizziness or even fainting. When it comes to diabetics, on the other hand, they can have what’s called silent ischemia and silent ischemia can be as the name implies, not presenting with any symptoms or what. And, and this is something that I usually find in my patients is a lot of times when you look back, you might have some atypical symptoms.

Now, what do I mean by atypical symptoms? The classic ones are the ones I just explained. Some people will present with something like suddenly feeling tired. So the sensation of fatigue or another classic strange sensation that some people might feel is they might just feel shortness of breath. So what I find is even though we call it silent ischemia, when you actually look back and question a lot of these patients, they end up having some change in their symptomatology or some change in what they could or could not do and what I tell people to watch out for is that change, because that can be a signal or a harbinger for something that’s actually going on. 

So that’s something that’s very important, a change in your symptoms. So, for example, if you were able to run up a flight of stairs and suddenly you’re not able to do that without huffing and puffing because you’re short of breath, that is a change. So that’s something to really keep in mind and diabetics tend to, you know, that’s the kind of thing where people tend to minimize saying, oh, yeah, I’m out of shape, that’s why I’m short of breath or something like that. So, never minimize a change in your symptoms because that could really be a sign of something going on.

Shireen: You know, help us distinguish because we may go through a long day at work and feel tired at the end of that, help us distinguish how these symptoms are drastically different from just feeling tired from other, other things, for instance.

Dr. Makaryus: Exactly. So, again, I think a good rule of thumb is if there is a change. So, if you’re tired after work every day, that to me is not a change. And that’s likely related to the, you know, the, the standard fatigue that develops from, you know, from work. If on a particular day you come home and you’re feeling tired again, that might be just that day, you had an extra hard day.

But if you’re starting now, suddenly over a week period of time and every time you come home from work you’re tired and you, you can barely even eat dinner, you can barely do the other activities you do in the evening. That to me is a dramatic change. So it’s really, and it’s very interesting because people who have heart attacks, the classic ones and, and classically, some heart attacks happen early in the morning and we can talk about the the mechanisms of of why this happens.

But the people who come into the emergency room in the middle of the night or during sleeping hours, those are the people who really notice that something is different and something is going on and your body will send you signals. I know it it seems a little questionable because some people are chronically fatigued and there are other things that cause fatigue, but the body will give you a signal of a difference in the symptoms as opposed to something that’s been ongoing that might not have been different from what you have. And of course, in diabetics, they tend to be the more atypical symptoms again for different reasons. Because in diabetics, there are other issues that might mask the classic symptoms that you see. 

Shireen: I want to next get into insulin resistance. Insulin resistance is a critical factor in increasing the risk of heart attacks among people with diabetes. Can you delve into the mechanisms behind find this link and then just how exactly, it impacts heart health.

Dr. Makaryus: OK. So that’s a very good question because there’s a lot of confusion I find around insulin. So insulin is a natural product that the body produces. And it’s actually used to break down sugars that we either ingest or believe it or not, the body itself produces sugars and it can produce sugars from fats and things like that. Insulin resistance, which is the lack of response to the body’s produced insulin really goes hand in hand with obesity.

And there’s been a lot of studies that have looked at correlating obesity and higher cholesterol levels and insulin resistance. So when, when you think about insulin resistance, you’ll, you’ll classically hear the comments that the health care providers will say that if you do lose weight, and in fact, there, there are studies, there was one study that comes to mind where if you lose about 5% of your body weight, you can actually reduce a person’s risk of developing diabetes by more than half over a three year period of time. And this is a classic study that came out actually very recently in 2019. And there’s many more studies that show very similar findings so that insulin resistance has to do with fat storage and obesity. So all of those go hand in hand in, you know, the development of diabetes.

Shireen: Can you speak to how exactly medications used to treat diabetes can impact heart health. And are there any considerations individuals should be aware of?

Dr. Makaryus: Right. So, diabetics, aside from the medications that are given to diabetics to improve the insulin response, and some people even require insulin itself to be administered exogenously, there are other comorbidities that develop in diabetics. So this is where we can make a big difference. And one of those comorbidities that happens is hypertension, high blood pressure.

So people who have diabetes tend to have high blood pressure and it has to do with the pressure within the cardiovascular system, the arteries that supply the whole body. And we have medications that can help control the blood pressure, aside from diet, which I’m sure, you know, we’ll talk about that a little bit more also. But diet as well as medications. So controlling your blood pressure. 

The other big component that I sort of mentioned already is your cholesterol. So diet again, has a big impact on your cholesterol. And there are medications classically, a lot of people hear about statin medications, these are medications that not only decrease your cholesterol, believe it or not, they will actually affect your morbidity and mortality if you have diabetes as well as coronary, vascular disease. So these medications have a big impact. 

And of course, we have newer classes of medications that are now coming on the scene. You might have heard of the GLP one Agonist, the SGLT2 inhibitors most people know them because, classically, a lot of people are using them for weight loss, but believe it or not, they actually have positive impacts on the cardiovascular system as well. And the, and the weight loss part is almost a side effect, but obviously it’s a main effect for a lot of people, but they do have cardiovascular beneficial effects as well.

Shireen: Next, what I want to talk about is something that, you know, we talk about time and again, but it’s really hard to, to emphasize how important this consideration is, but, and I’m talking about stress. The stress itself of managing a condition like diabetes can really take a toll on mental health, right? Can you explain how the stress might contribute to the risk of a heart attack?

Dr. Makaryus: Excellent questions. Stress actually has a physiologic impact on our bodies and the mechanisms for this are still being further discovered. But one of the main causative agents that the stress causes, that causes an increase in cortisol levels and again, just like insulin and, and things like that, this is actually a hormone in the body that gets elevated. And it’s almost part of, we hear about the fight or flight response and things like that, so cortisol is meant to actually help us in that situation. So if you’re in a fight or flight situation, you want cortisol to be elevated because that allows you to respond. It allows it, bring, it brings up your blood pressure, it raises your heart rate. It has all of these effects that you actually want to work. 

If you are chronically stressed, your cortisol is also elevated. And because of that, you then will develop hypertension. You can develop palpitations from an abnormal heartbeat, all of the fight or flight responses that happen will then be chronically going on. And as you can imagine, if you chronically have a high blood pressure, that will damage the blood vessels that can cause heart attacks and strokes and things like that. That case is a negative thing.

Classically also, and I think I mentioned this before, a lot of people suffer heart attacks in the early morning hours. And the reason for that is the cortisol levels have a diurnal change where in the morning, the early morning, which all sort of helps us awake from sleep and and and start to become more awake. The cortisol levels are elevated. So that’s a classic time when people will actually have a heart attack because the cortisol level will slightly increase the blood pressure, it can increase the heart rate. It’s all part of the sympathetic nervous system where you can have an increase in these things. So chronic stress does the same exact thing, but it now does it over a prolonged period of time that causes actually the negative response to what you would expect during the fight or flight situation.

Shireen: It, you know, it’s so remarkable to see that while stress seems like such an intangible thing, it has such a physiological impact on us. You know, what, what would you or what do you tell someone who is trying to manage diabetes, you know, in their life and ideally not have a heart as a result? Are there mindfulness techniques, stress management strategies that benefit both diabetes management and the potentially heart health?

Dr. Makaryus: Yeah. So that’s an excellent question. You know, a lot of people just say, oh, just get over the stress and feel better. But you know, my wife tells me you’re not a good psychiatrist if you tell people that. So mindfulness is, my wife happens to be a psychiatrist, so mindfulness is actually one of those great techniques whereby and again, I’m not an expert in mindfulness or anything like that, but I think of mindfulness as being in the moment. 

In the US. We’re always thinking of what I need to do next. What happened yesterday? What’s coming up? What my next meeting is, what’s next on my you know, social media feed and this and that, we’re never in the moment. And I find myself, I have, you know, younger children and I always find myself, you know, checking my phone is somebody texting me, is somebody emailing me to the point where my kids will say daddy, I’m here Hello, get off that phone or they’ll start grabbing their, you know, ipad or whatever it is and, and then they’re gonna be fixated into it. 

So we have to remind ourselves, and this is what I tell my patients, aside from the, you know, yoga and the other classic mindfulness techniques, I just tell people to be in the moment and a term that I recently heard which actually I think is a phenomenal and a great term is mindful eating.

And what mindful eating is, is actually paying attention to what you’re eating. Again, classically, we will eat while watching TV. We’ll eat while doing 25 other things, we’ll scarf something down and before you know it, you’ve scarfed something something down and you weren’t even hungry at that point, you reach your, your, you know, you know, satiety level much earlier than what you had or this classically happens at night. You sit there in front of the TV, and you watch something and you’re scarfing down this, you go to the fridge for some ice cream, you go to here and, and, and you’re not doing it because you’re hungry, you’re doing it just to keep yourself busy because you’re not thinking about it. So mindful eating is actually paying attention to what you’re eating and paying attention to the signals that your body provides to tell you when you’ve been satiated and thereby stopping at that point instead of just continuing to consume more and more calories. 

And the other very helpful thing that I tell people is to pay attention to the, those nutrition labels. I’m amazed by the people who have no idea what those nutrition labels are, how they work, what’s on there. I tell them if you knew nothing more, at least look at the top for the serving size and the number of calories because they’ll always get you with the serving size. You’ll see, oh, low calories, 50 calories, but serving size, you know, is whatever a high, a high amount. So if you finish the bag, you’ve gotten six or seven times what the, you know, caloric intake is. So I always tell people take a look at that. So tho those are, you know, some of the ways that I tell people to sort of pay attention and sorry about the tangent of the mindful eating and it really helps you pay attention to things. 

Shireen: And, and very helpful indeed. You know, can you speak to us a little bit about, not only the importance but the significance that regular health checkups can really have for both monitoring and ideally delaying diabetes or heart disease, and what are the key metrics that individuals should, should track around it?

Dr. Makaryus: Yes. So it’s, it’s really essential that you have regular follow ups with physicians even if you’re healthy. A lot of people tell me I’m completely healthy, I don’t need to go to a doctor, well, that’s not true because as a doctor, my job is not just to treat you when I’m, when you’re sick or in the hospital, my job is to prevent you from getting sick in the future with all of the tools that I know how and part of that has to do with screening. 

So specifically for cardiovascular disease, some of the metrics that we look at involve blood pressure. So every physical that you have should include a blood pressure, measurement, the vital signs, we talk about blood pressure, heart rate, breathing rate, we check pulse oxy met sometimes which is the oxygenation. Some of you are familiar, they put that little you know that red light on your finger, a lot of phones will now do it for you and your smart watches obviously can do that as well. So these are the things that we want to look at. 

So vital signs is the most basic and then going further than that, there are guidelines that tell you what screening you should be doing based on your age and your gender and things like that. And the US preventive services task force is one of these big agencies that helps physicians or guides physicians in terms of which screenings should be done. Everybody knows about breast cancer screenings and colonoscopies and things like that, but the most basic of screenings has to do with the vital signs I just mentioned, but also things like cholesterol levels or measuring a basic panel of your chemistries to see how high your sugars are and things like that.

So all of these things, if you have regular follow-ups, usually at least once a year, if you’re healthy and relatively young as you get older, those screenings or those things might involve different things, but you have to make sure to follow that by seeing a physician.

Shireen: My next question is, is, my favorite question given the work that we do at Yumlish and just building nutrition literacy, what lifestyle changes can individuals with diabetes make to really reduce their risk of heart? 

Dr. Makaryus: Exactly. So as the patient, I, I tell patients, you are your own physician. So the things that they can do with my health obviously is key and those things include things like avoiding all the negative things. Most people know that smoking is bad for you these days. That’s not as much of a challenge. Although you’d be surprised and there was just a report that came out, some of the underserved population, smoking actually has not decreased in, in those individuals. But that’s, that’s for a whole other podcast. 

When we talk, when I tell people what to do, aside from avoiding smoking, illicit drugs and all of those things, activity is very important and a lot of people, you know, start to squirm when I tell them activity because they think they have to get a gym membership, they have to do this, they have, they have to buy a treadmill, which is thousands of dollars, I tell them, you know, what, walk around the block, as long as you do it consistently, you know, most people have a block or somewhere where they can walk or some kind of space outdoors or even indoors if you can’t do it outdoors and you want to do that for at least 30 minutes.

It used to be three times or four times a week. Now, the American Heart Association says do it at least every day. So if you can do that every day, even if it’s freezing cold outside, put your, you know, your jacket on, do whatever it is, and if you do that or if you can’t do it after work, work it into your work schedule. So sometimes I’ll take my team here in the hospital and we’ll walk up, we have a number of flights of stairs, we’ll do a number of flights of stairs and they’ll joke. Oh, there he is. Dr. Makaryus is walking up the stairs with his team. But you know what? Number one, it’s team building and number two, it’s good for your heart. 

The next part is your diet, dietary intake. Aside from what I mentioned before, the most basic is to pay attention to what you’re eating. And I think what most people realize is when they pay attention, they will realize that they can really affect and improve things. So avoid the sugary drinks. Avoid empty calories is what is what I call them. So, any of these sodas, any of the I even iced teas, people think, oh, iced tea is more healthy but it’s full of sugar if it’s the sugar one. And then there are different diets that you can actually follow, that can improve things as well. So, those we can talk about as well if, if you would like and we can look at those. 

Shireen: Yeah. Are, are there any specific dietary recommendations that can help? I know there’s, there’s some popular ones that we, we sort of hear about. are there quick ones that you can point us to or that you recommend?

Dr. Makaryus: Yeah. So definitely two of the ones that I recommend because they’ve been proven to actually improve cardiovascular outcomes are the DASH diet, which is really a hypertension type of diet. It’s, it’s dietary approaches to stopping hypertension. And what it is is it, it looks at your dietary intake of sodium. This was based on large studies that were sponsored by the NHLDI, which is you know, a big group that sponsors these big studies, and what it does is it really factors in your sodium intake, so you wanna at least have less than 2 g of sodium a day or less than 1.5 g. And to be honest with you, the American diet already is full of salt. So we should outlaw those salt shakers because honestly, you don’t need any extra salt than you already get in the diet. And our processed foods, it’s already full of it. 

The other part of it is this diet has a lot of the good cholesterol. So believe it or not, there’s good cholesterol. There’s omega three fatty acids that are in a lot of the foods. So, fish, decreasing red meat intake is another part of it, and the poultry. So chicken tends to be a little bit better for your lipid panel and things like that. And I don’t tell people to stop red meat altogether because those people who love steak will eat steak no matter what, but maybe decrease it for some of the other fish related products or poultry products like chicken and, and the white meat. So that tends to be a little bit better. And there’s also the Mediterranean diet, which is kind of similar to the DASH diet, but in that diet, you involves more olive oil, extra virgin olive oil, nuts are very good for you. So certain nuts have good fatty acids. All of these things play very nicely into controlling your diet. 

Shireen: That’s super useful. Before we round up this episode though, Dr. Makaryus, what advancements, I mean, just given all of your research and all the work that you’re doing on that site, what advancements or breakthroughs are you working on in terms of research, treatment and prevention of diabetes related heart complex patients? Can you give us a sneak peek on what some of the things are coming down the pipeline there?

Dr. Makaryus: Sure. One of my focus or, or the big focus is that I have is, again, prevention. And that’s why when you gave me this opportunity, I was more than happy to partake because it’s really something that’s very important to me and honestly should be important to all because you can really make a big difference with prevention. 

So, one of the big studies that I was fortunate to be a research site for along with the Feinstein Institutes of research at the Northwell Health System was a PCORI study. Now, PCORI is a Patient-Centered Outcomes Research Institute, which is a large conglomeration that sponsors a lot of studies for prevention. And what we did is we looked at telehealth in patients with diabetes and specifically in the Hispanic population, we, we serve a lot of Hispanic patients here and, and as you know, the Hispanic population is inordinately sometimes affected by diabetes and cardiovascular disease.

So what better way than to actually help these patients take care of themselves by employing telemedicine. And this telemedicine was not just the standard like what we’re doing, speaking over a computer system, what it does is it actually deploys a machine, sort of a machine or a computer or a smart computer, that allows them to check their own blood pressure at home. It allows them to check their pulse. It has a smart scale that allows them to weigh themselves. And all of these numbers are automatically uploaded on a weekly or even daily basis if you wanted to and believe it or not, they even have a stethoscope that the patient can take and put on their chest and you can remotely listen to their heartbeat, you can listen into their lungs and you can really evaluate these patients remotely. 

And this obviously was a big thing during COVID, now less so, thank God, we’re all seeing each other again, but it’s the kind of thing where this and we actually just finished the study, so we’re analyzing the data, but there has been prior research that has shown that telemedicine if nothing else actually engages patients more in the care and in the management of their chronic conditions. So that’s coming out, look for our publication hopefully soon.

Shireen: Lovely. Thank you so much for sharing that Dr. Makaryus. We are toward the end of the episode at this time and what we will also do, by the way, is link up to some of your previous research in the show notes as well for this podcast. But coming to the end of the episode, how can our listeners connect with you and just learn more about your work?

Dr. Makaryus: Sure. I do have some, you know, websites that, you know, of the hospital where I work. I am on Twitter, or I guess they call it X now. So, that I shared those with you and hopefully we can share it with the listeners. I’m always happy to, you know, see, comments or questions or whatever comes through and it’s really a pleasure and I thank you for the honor of joining your podcast and, and great work that you’re doing in, in helping patients manage their diabetes.

Shireen: Thank you so much, Dr. Makaryus. And again, we’ll link up your Twitter handle as well in the show notes below. So for everyone listening to this podcast, head over to our show notes right below this episode and you should be able to access all of that information with that Dr. Makaryus, thank you so very much. 

And for all of your listeners for joining us here today, you know, the drill head over to our Instagram or Facebook and go answer the super quick question: Have you or someone you know, experience symptoms that you now suspect may have been a silent heart attack? Share that experience with us what that process was like for you and we will continue the conversation again on Facebook, Instagram. Again, go to our respective pages, find this podcast post and comment below if you learn something new and you identified something here as a result of this podcast. Again, we will continue the conversation on social media, Dr. Makaryus. Thank you so much. 

Dr. Makaryus: Thank you very much. Take care.

Connect with Dr. Amgad Makaryus:

Zucker School of Medicine: Dr. Amgad Makaryus

Northwell Health: Dr. Amgad Makaryus

Facebook

Twitter

LinkedIn

Publications:

• Racial and Ethnic Differences in Awareness and Prevalence of Unidentified Cardiovascular Risk Factors Among Health System Employees
• COVID-19 stressors for Hispanic/Latino patients living with type 2 diabetes: a qualitative study
• Inclusion of Under-Represented Racial and Ethnic Groups in Cardiovascular Clinical Trials
• Home Telemonitoring of Patients With Type 2 Diabetes: A Meta-Analysis and Systematic Review.
• Perceived Social Support and its Effects on Treatment Compliance and Quality of Life in Cardiac Patients