The Armor Men's Health Show

Bonus Episode: Happy Heart, Happy Penis: Interventional Cardiologist Dr. Krishna Discusses How Heart Disease Can Hit Below the Belt

• Dr. Sandeep Mistry and Donna Lee

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In this segment, Donna Lee is joined by NAU Specialists' own Dr. Christopher Yang and special guest, Dr. Vamsi Krishna. Dr. Krishna is an interventional cardiologist who has been with the Seton Healthcare system for the last 5 years. Today, he answers questions about the relationship between cardiovascular and sexual health. Many of our urology patients are worried that hormone therapy to treat the symptoms of erectile dysfunction might increase their risk for heart disease. Dr. Krishna addresses this concern as well as the importance of weight management, smoking cessation, and blood sugar management in the role of both sexual and cardiovascular health. To learn more about Dr. Krishna or interventional cardiology, call Ascension Seton at 512-504-0860 or visit them online today!

Voted top Men's Health Podcast, Sex Therapy Podcast, and Prostate Cancer Podcast by FeedSpot

Dr. Mistry is a board-certified urologist and has been treating patients in the Austin and Greater Williamson County area since he started his private practice in 2007.

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Speaker 1

<silence>

Speaker 2

Welcome back to the Armor Men's Health Show with Dr. Mystery and Donna Lee.

Speaker 3

Back to the Armor Men's Health Hour. This is Donna Lee. Dr. Mystery stepped away. I think he likes to go visit with the K L B J radio guys and , um, talk about stuff that he doesn't wanna talk about on the air. So I brought in a couple of special guests today. So , um, I wanted to introduce everybody. We have Dr. Krishna with Seton. He's got several locations. We're gonna ask him a whole bunch of questions, but I also wanted to let everybody know that we have our special partner, Dr. Yang, back today. Hey, Dr. Yang. Hey

Speaker 4

Donna. Glad to be back.

Speaker 3

And Dr. Krishna, thank you for coming. We appreciate your time. Thank

Speaker 5

You for having me.

Speaker 3

Of course. So , um, I wanted to ask Dr. Krishna a few questions. Um, he is a cardiologist, an interventional cardiologist. So , uh, first lemme tell you, he's with Seton and we'll talk about his locations and how to get in touch with him . He's accepting new patients and you all are gonna be blown away by how awesome he is. But Dr. Krishna , why don't you explain to the listeners what's the difference between a cardiologist , uh, conventional and interventional general.

Speaker 5

Cardiologists see patients and are able to do basic non-invasive testing. Interventional cardiologists are able to then see the patient and able to do procedures such as heart attacks, strokes , uh, able to suck out, clot from people's legs, har hearts, and , uh, lungs, kind of treat patients both in the office and in the hospital.

Speaker 3

Okay, awesome. And how long have you been with Seton?

Speaker 5

I've been with Seton for five years now.

Speaker 3

Gosh, I bet you've seen a few a thing or two. Yes. Yeah , yeah. <laugh> scared. Yeah , exactly.

Speaker 4

Let's just leave it at that . Yeah .

Speaker 3

Let's not talk about any patient issues. I know that you've got, you're located in Westlake, Kyle, and Luling mm-hmm . Through Seton . So we'll talk a little bit more about that, but I'd like to turn over the , uh, discussions to you and Dr. Yang. Uh, we get a lot of questions about people having heart attacks or cardiovascular issues and testosterone. Why don't you guys talk about , um, is it safe to be on testosterone with cardiac issues and to what extent?

Speaker 4

You know, that's definitely a lot of a good part of, you know, my conversation with patients when we start testosterone is mm-hmm . <affirmative> had been some studies out in, you know , 2013, 2014 range, suggesting that maybe taking testosterone increases the risk of heart attack and stroke. American Neurological Association. That's the overall, you know, association for urologists have actually guidelines that say, you know, for patients who you know, well , it says specifically clinicians should inform testosterone deficient patients that low testosterone is a risk factor for cardiovascular disease. So wanted to get kind of your , uh, your thoughts on that. Being , uh, on the other side,

Speaker 5

You know, you raised a great point. If people have low testosterone, what is their risk? And is there risk being able to be mitigated with testosterone replacement? I would say the way I address low testosterone is typically it's a multifactorial things . Do patients that have low testosterone also have other risk factors that play a role that may also increase their risk of cardiovascular issues? And the answer is typically yes. Most of those patients may be obese, low physical activity, diabetes, smokers, et cetera. So I think when it comes to cardiovascular risk, I think low testosterone may play a factor, but I think risk factor modification probably plays a bigger role overall. When we talk about risk, mainly what we've seen in the studies is the first two years , um, there's a slight increased risk of stroke based on the fin risk study, which showed that about a 15,000 patients who were getting testosterone replacement over the age of 45, there was a slight increased risk of stroke in the first two years. And then after that, that stroke risk is actually mitigated. They actually had a decrease in all cause mortality. The data is still kind of out there as mixed. And the way I counsel my patients is really, if you're symptomatic and you're modifying your other risk factors, decreasing alcohol, removing tobacco, improving your diabetes, and you're still symptomatic, you know, and under the right professional care, it should be treated for your symptoms and not necessarily to decrease your cardiovascular mortality.

Speaker 4

Bottom line, you know, from what I'm hearing is studies are still mixed, but it is safe, you know, to take testosterone for, you know, e to replace a testosterone to , to help some of your symptoms.

Speaker 5

Absolutely. I think T R T has a role and I think , uh, you know, under urological care and, you know, in partnership with cardiology and the more complicated patients, I think it could safely be done.

Speaker 4

I guess we had a question a couple of weeks ago from a patient mm-hmm. <affirmative> , who said that he had had a heart attack mm-hmm. <affirmative> , is it still safe to do testosterone? And kind of what we answered at that time was, as long as his cardiologist was okay with it, then it's fine from your standpoint. Yeah. What type of test would you do to, to say that patient's okay to use testosterone?

Speaker 5

You know, that's a great, first great question you asked is, what is a heart attack? People come around and tell us they've had a heart attack. You know, I tell 'em there's actually five different types of heart attack and without boring, the audience is out there. The premise really everyone wants to know is the heart attack where you're clenching your chest acutely going to die, that is what we call a type one heart attack. And that's one where people like me would come in, suck out the clot and put a stent in those type of patients where you actually had a stent and are on dual PL therapies, typically, if you have no symptoms six weeks after this procedure, it's safe to resume therapy under your guidance of urology. Okay. If you had a heart attack where you were just treated in the hospital, did not need any real procedures, typically that's a type two heart attack. And in those cases, you know, you're able to safely resume the therapy at any point that the, your urologist , uh, urologist discretion, does

Speaker 3

That change though , uh, with age? Like, do you do the same testing for a 30 year old that had a heart issue versus a 60, 65 year old who had a heart

Speaker 5

Attack? The testing, you know, right now a lot of people get stress tests and various different types of stress tests . We typically base it on symptoms. So if someone comes and tells me they have a heart attack, but then they're not having any symptoms, we typically don't order test irrespective age. Mm-hmm. <affirmative> , if someone comes in and they say, Hey, I have a family history and there's multiple other issues, we typically order , you know, a stress test. A stress test again, only indicates if there's an obstruction of 70% or more. Mm-hmm. <affirmative> , that's what it's guessing, but does it not tell you it's not predictive if you're going to have a heart attack? So I tell everyone, again, back to that risk factor modification mm-hmm . <affirmative> and being connection. So Dr. Yang and I share patients together, if there's any concern, pick up the phone and say, Hey, Dr. Yang, I had these, I'm concerned about this patient's X, y, and Z issues. Can we optimize them before starting something? And I think that's the most collaborative way of going around this type of field. Gotcha.

Speaker 4

Okay. And now what about patients who are taking aspirin, who are taking other types of blood thins who want to do testosterone injections. Is there any issues as far as the performing injections, doing the needles, things like that?

Speaker 5

Hopefully they're coordinated , uh, <laugh> , uh, uh, but no, there , there is no issues with the intramuscular subcutaneous injection.

Speaker 4

Anything you want to tell them about being coordinated enough to put it in <laugh> ? Yeah .

Speaker 5

Well, you know, we , we , we have a few friends , uh, who I'll not name who I probably would not recommend getting injections from. Yeah . <laugh> .

Speaker 4

Um, okay. Some of the other patients that we see, you know , who come in to us initially as a urologist, they come in because they have erectile dysfunction. You know, they probably hadn't seen a doctor for 10, 15, 20 years. Mm-hmm. <affirmative> , you know, they might be a little bit overweight, you know, they might actually have diabetes , uh, high blood pressure oth other types of , uh, issues. You know, when we first see them, what we typically, we , what we typically do is get, you know, some of their blood tests as far as testosterone and other hormones mm-hmm. <affirmative>. Um , but we typically try to get them hooked up with primary docs or cardiologists. Um, you know, and you know, for most, for a lot of men out there, the first thing that they ever, you know, the first symptoms they ever have that they actually want to get treated is erectile dysfunction. Right. So, you know, gets them in the door. Yeah, exactly. Tell us kind of what your thoughts are thus far as, you know, men who have erectile dysfunction and the risk with, with heart disease. Now, we probably don't have too much time. We might need to go into the next segment. Mm-hmm . <affirmative> .

Speaker 5

Yeah. So that , that , that's a fantastic question. Um, and one that is actually growing because, you know, erectile dysfunction definitely creates , uh, you know, a conundrum for, for patients. And usually that's the presenting sign. And most of these patients with erectile dysfunction, a a as you said , uh, it's , there's an arterial issue going on that's di decreasing flow, hence why medications like Viagra and Cialis work and usually if you have artery issues in the microvascular system in near the penis, you're also gonna have microvascular issues in the heart and brain and other areas.

Speaker 4

Yeah. And that's kind of exactly what I tell them when I see 'em in the , in the office. <laugh> , I tell 'em the , the blood vessels and the penis mm-hmm . <affirmative> are just as small as the blood vessels in the heart. So if you have problems with one, you probably have problems, problems with the other . Good

Speaker 5

Point. And so point , and so it usually causes a poly disease. It way I kind of put this is that , um, you know, there's a lot of data, including this wonderful meta-analysis published this year, 154,000 patients being evaluated. And they basically looked , if you had erectile dysfunction, there's a significant increase risk of , uh, having cardiovascular events mm-hmm . <affirmative> . And basically if you're over the age of 55 , uh, you've had ED for less than seven years, smoker and diabetes, you have significant increased risk of cardiovascular mortality. And that if you treat your ED and treat those symptoms, you'll definitely decrease your mortality. Gotcha.

Speaker 3

Well, we definitely need to continue this discussion with the next segment. Wrapping up for this segment though, Dr. Yang, I wanted to make sure everybody remembered he's our urologist. He's one of our partners with urology specialists, and we have Dr. Krishna here. So what we're gonna do is go take a commercial break. Uh , we are urology specialists and armor men's health.com is our website. You can send us any questions to Armor men's health@gmail.com. That's Armor Men's health@gmail.com . If you have a question for Dr. Krishna or Dr. Yang in the future, we will answer those questions and we will be right back.

Speaker 2

The Armor Men's Health Show will be right back to submit a question for Dr. Mystery , visit armor men's health.com.

Speaker 1

Welcome

Speaker 2

Back to the Armor Men's Health Show with Dr. Mystery and Donna Lee.

Speaker 1

Donna Lee .

Speaker 3

Again, Dr. Mystery has stepped out, but I wanted to continue the discussion we were having with our urologist, Dr. Yang. Christopher Yang. Welcome back . Hey,

Speaker 4

Thanks again.

Speaker 3

Um, and Dr. Krishna, the cardiologist from Seton. So you guys continue that discussion. It's fascinating. Then we wanna keep talking about more , um, testosterone and cardio.

Speaker 4

Yeah, yeah. So basically we were , what we were talking about was the link between erectile dysfunction and cardiovascular disease. Mm-hmm. <affirmative> , you know , a lot of men who have heart disease have erectile dysfunction. A lot of men that have ed have heart disease as well.

Speaker 5

A lot of the patients present with erectile dysfunction as their first sign. And so this gives a , a multi-specialty way of being able to, you know, help prevent what's the number one leading cause of death in our country, which is cardiovascular death.

Speaker 4

It's not because of the penis, is it? It's

Speaker 5

Not because the penis, but the penis brings you there, you know, <laugh> . So , uh,

Speaker 3

It does have a mind of its own does its you to the doctor .

Speaker 4

It's kind of up in the air. Which one is more important. Right.

Speaker 3

<laugh> . Right.

Speaker 5

And you help them get up in the air. <laugh> . Uh , so, you know, <laugh> , there was a wonderful study performed , uh, in 2019 and meta-analysis of multiple trials put together 154,000 patients. So , uh, you know, a small study , uh, joke , jokes , jokes aside, it basically looked at <laugh> . If you had erectile dysfunction versus not erectile dysfunction, what is your risk of, of death , uh, stroke and overall coronary heart disease? And overall it's around a 30 to 60% increased risk if you have erectile dysfunction and if you have erectile dysfunction and you're over the age of 55 or smoker diabetic and have a shorter duration of ed, typically those are the most severe risk factors for having a hard endpoint , uh, cardiovascular event. Hence, it's important to treat these risk factors as well as treat erectile dysfunction. I think it's, it's important as a, a multimodality approach that we, we screen these patients and screening would typically include, you know, coronary coronary artery, calcium scoring, EKGs, and just a basic panel with most , uh, primary physicians can do as well as cardiologists.

Speaker 4

Basically what you're saying is that patients who have bad erections shouldn't be mad if we send you to the cardiologist or a primary doc to look for diabetes, to look for high blood pressure, to look for high cholesterol. Right.

Speaker 5

Absolutely.

Speaker 4

And then also patients who have had heart attacks and strokes, they might have other things going on. Mm-hmm . <affirmative> , but you know, a lot of them probably have , uh, poor erections that need to be treated mm-hmm . <affirmative> that can be treated.

Speaker 5

And that's usually my number one question. I get 62 year old, I fixed their heart, they came up with a heart attack, they're in for their two week appointment, they feel great. And then when the wife or partner leaves the room, they say, doc, when can I have sex? And then, and then the next question is like, go ahead, <laugh> . Uh , if you're not having any symptoms in the American Heart Association, they recommend like six weeks doing a sub maximal stress test. You know, I currently state if a patient's able to do cardiac rehab or participate and walk one mile, you're good enough in cardiovascular condition to have sex. But then they come back and say, well doc, I can't get it up. Mm-hmm. <affirmative> , and then this is where we have the conversation, so I'm gonna throw it back to you, Dr. Yang, what is your algorithm for treating erectile dysfunction?

Speaker 4

I wanted to comment first on what you just said. From what I'm hearing, if they attempt to have intercourse, that's a pretty good stress test right there. Right. Okay. <laugh> . So probably not as good as the stress test that you order. Right. But , but more fun. Yeah. But having other courses is a , is a stress test.

Speaker 5

It's not one that I can prescribe. Okay . Which many men probably would want me to. Yeah . But , uh,

Speaker 4

A note from their doctor, no , that would be be good to prove to their wife that it's okay. Alright . For men who come in with erectile dysfunction, I think we've talked about it before on this show, there's kind of a lot of different potential causes. You know, one, one thing, we look at hormones, you know, including testosterone and estrogen, some others, we look at the vascular disease to basically look at if there's any diabetes, any high blood pressure, high cholesterol that can be, you know, contributing to erectile dysfunction. We also look at structural issues of the penis and then we look at kind of psychological social issues as well treatment wise . You know, typically I look at medications like Viagra, Cialis, things like that.

Speaker 5

How do you decide, like, so let's say , what would be a typical starting dose and how do you decide between Viagra and Cialis now that both are generic, right ? Sure.

Speaker 4

Yeah. Yeah. You know, and kind of depends on the patient's preference. Some they work a little bit differently in that Cialis is in your bloodstream for a little bit longer. So patients who are younger who might want to have multiple, you know, multiple episodes of intercourse over the course of a weekend. Sometimes Cialis works better. People who don't really wanna think about it too much, you know, we can prescribe a low dose Cialis that you take every day , but you know, some people, since Viagra is the one that's been around the longest, some people prefer that. Mm-hmm . <affirmative> . So it's, it's basically a discussion as well as patient preference mm-hmm.

Speaker 3

<affirmative> and it's really inexpensive now. Right.

Speaker 5

Yeah. And from a cardiology standpoint, I , I typically go with Viagra only because , uh, a lot of my patients are on multiple medications that may drop their blood pressure mm-hmm. <affirmative> . And we know that being one of the side effects of , uh, this class of drugs is that this in conjunction with other smooth muscle relaxers can really drop someone's blood pressure. Mm-hmm. <affirmative> . So I typically go with a lower dose and use a shorter acting agent , um, as my , most of my patients are, you know , elderly and on other combinations of therapies that may affect their blood pressure. So you , you know, I get the question all the time where, you know, is it safe for me to take these drugs? And I tell them, these are safe, well-studied drugs, it just matters the pharmacology of , uh, of , of all your medications put together and this is why you come see specialists like Dr. Yang and myself. Yeah. Now,

Speaker 4

One of the other things that we had talked about before is one of the other tests that we do here in the office is a penile duplex ultrasound where we're looking at the actual blood flow into the penis. There's an artery on each side called the cavernosal artery that actually fills out the penis with blood when you get an erection. So one of the tests that we do is called a penile duplex ultrasound. Basically we're looking at the blood flow in, and that ties in with Dr. Krishna here 'cause he does a procedure , uh, where he actually can put a stent in there. Is that

Speaker 5

Correct? That's correct. Yeah. Pudendal artery stenting topic that has been hot for the last seven, eight years. And , uh, the, the how it works is you have iliac arteries and you have an internal iliac artery that gives off the arteries to the penis. And so, like we were talking about before, they typically range anywhere from two to four millimeters and they get, they can get disease depending on the risk factors that you have, there's approaches that you can engage the internal iliac artery and then put a wire and able to put a stent that is metallic and tell the

Speaker 3

Listeners what a stent is. Yeah . Because

Speaker 5

You don't know, most of the stents that we use currently for this would be a cobalt chromium metal stent. And they typically sounds fancy. Yeah . It's painful.

Speaker 3

It sounds fast. <laugh> ,

Speaker 5

Uh , it is very fast. It's mounted on a , it's crimped on a balloon mm-hmm . <affirmative> . And when you expand the balloon, the stent goes onto the wall and becomes part of the artery within 45 days. Wow. And the DR and then it has a drug coating on it so that it prevents new tissue from regrowing inside the stent.

Speaker 4

Now , uh, after they get a stent like that, do they set off the x-ray detectors when they go to the , the Air Force

Speaker 5

<laugh> ? No. No. As much as guys like to say that, you know, they have a metal rod, I have a giant stent . Right . Exactly. <laugh> , um, unfortunately they, they, they will not, or fortunately they will not be , uh, setting off any metal detectors. Mm-hmm .

Speaker 4

<affirmative> . Okay. Now, you know, from, from what I've seen as far as, you know, the times to do this stent, it seems like it works better with younger patients. It works better with patients who had this issue because of trauma. Right. Not the older patients who's had a heart attack and things

Speaker 5

Like that. Absolutely. So the, the premise of this is that typically if you wait later in life, you don't generally have more diffuse disease. And so when you have diffuse disease, you can't put stents throughout the entire penis artery. And so that becomes a, that's too bad <laugh> . Yeah. It becomes a , it becomes a problem. Right. So your point is, when you have trauma, you're typically having a focal spot where there is , uh, there's a change in flow and that's typically where stents work best anywhere in the body. And when you're dealing with diffused diabetes or elderly age and the arteries really become narrowed, stenting is not the optimal option. And again, this is still not something that's, you know, I would say everyday practice. It's, this is one where, you know , you'd wanna see , uh, specialists who are endovascularly trained and , and partner with a urologist on this topic, not one that , uh, is just performed on an everyday basis.

Speaker 3

Um , I wanted to take a minute too to reintroduce Dr. Krishna and let you guys know where he's at. He's accepting new patients. Yes. Uh, seton.net is the website where you can find , um, Dr. Vasey Krishna . Mm-hmm. <affirmative> , um, you can see his handsome face on the website there. Mm-hmm . <affirmative> . So just search for him. The number's 5 1 2 5 0 4 0 8 6 0. Uh, he again, is at Westlake, Kyle and Luling at the Seton locations. Thank you so much for coming in today. Thank

Speaker 5

You guys for having me. That

Speaker 3

Was awesome. Thanks Dr. Yang for popping in and saving the day. 'cause Dr. Mr. Disappeared. Yeah. Yeah.

Speaker 4

I'll , I'll gladly take over the co-host roll from him . <laugh> .

Speaker 3

Awesome. You can send us your questions at Armor men's health@gmail.com. Um , armor men's health.com is our website. We're located in Austin, north Austin, round Rock, south Austin, and in Dripping Springs. Um , but we wanna hear your questions, so if you have a question for Dr. Krisna , um, send it over to me. Is it okay if I reach out to you and say, Hey, this patient had a question?

Speaker 5

Absolutely. Awesome.

Speaker 3

Well, we appreciate your time and thank you guys so much again, and we'll be right back after this commercial.

Speaker 2

The Armor Men's Health Show is brought to you by N a U Urology specialist. For questions or to schedule an appointment, please call 5 1 2 2 3 8 0 7 6 2 or online at armor men's health.com.