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December 03, 2021  

Dr. Barry Ramo

Dr. Barry Ramo: Making Strides in Cardiac Care

July 25, 2002

Dr. Ramo is a clinical cardiologist and his area of practice is electrophysiology, which means he takes care of people with heart rhythm disturbances.

Do you see most of your patients before or after a heart attack?

Electrophysiology encompasses a wide range of patients. Patients who have abnormal heart rhythms can have normal hearts or they could be people who have congenital heart problems that they were born with. There are also people who require a variety of different problems from coronary disease to hypertensive heart disease, and they can have problem with their lungs or certain metabolic problems that can cause disturbances in the heart rhythm.

When patients visit you, what is the most telling gap in their knowledge about heart attacks?

The vast majority of patients have a general idea about what cardiac risk factors are. They know that smoking, high blood pressure, and high cholesterol are bad, but they don’t have any specific information. For example, when you talk about their lipids, their cholesterols, they are not well aware of the fact that there is a happy cholesterol and a lousy cholesterol which are both important for them to know and also a triglyceride which is another fat in the blood that people need to worry about, They know about exercise, most of them don’t do it. Most of them are interested, but it’s like sex – they talk about it a lot but they don’t actually do it. But the fact is that some of them area afraid of exercise so they’ll come to a cardiologist for advice don how to get started and they don’t know how much to do or how long to do it or what intensity to do, so they’re confused about that. They often don’t understand about diet. A large number of people are overweight now. There is an epidemic of obesity along with diabetes and so people don’t understand the risks that that poses for them, and certainly don’t realize what their blood pressure is very often. And if they do, sometimes it’s not being treated, so a lot of the important risk factors for heart disease that various patients want to know about, they have a vague idea about it, but when it comes to the man how to implement them into their lives, they are totally clear.

Is an electrophysiologist considered a primary care doctor or would someone see you based on a referral?

An electrophysiologist is generally a referral physician. It’s rare for a patient to understand that they need that kind of problem dealt with. They’ll usually go to their primary care physician because they feel a fluttering in their chest or they’ll have a blackout spell or they’ll have difficulty breathing that they don’t understand. Those situations are initially evaluated by a primary care doctor.

What has been your greatest contribution to cardiac care?

I’ve spent most of my professional career with education at a variety of levels – medical student, health staff – and a lot of time doing public education and setting up programs to help people understand their bodies and what they can do to prolong their lives. One of the areas that we started in New Mexico is called project Heart Start, which was a program that we stared 20 years ago to train people in cardio pulmonary resuscitation (CPR) so every year during Memorial Day we’d have everybody bring their family out and we’d train about 2,000 people to do a short course in CPR. I’ve spent a lot of time on television educating people about heart disease, what they can do to prevent it, raising their awareness about the fact that it exists and that it’s a potential risks for them. We’ve also done a lot of work with trying to educate about women and heart disease.

There seems to be a large misunderstanding that women are not at risk for heart problems.

Heart disease is not for men only. It’s the number one reason why women over 50 die. But for several reason – one is that women don’t get diagnosed as early, their treatments are often less aggressive, and they tend to wait longer to get help, so there are a lot of reasons why women have a different outcome when they do get heart disease.

Typically aren’t men the one’s who wait longer to get help with a medical problem?

That’s a good point. Men do tend to not want to go to the doctor, but as far as heart disease is concerned, they seem to recognize that when they get chest discomfort they need to go to the doctor. Whereas very often, women who do develop symptoms of heart disease are ignored. Their symptoms are sometimes different – they are more short of breath, they have less chest pain, sometimes more fatigue, and so it’s harder to diagnose. Even when they get to the doctor a lot of times the doctor doesn’t pick up on it.

Is there any relationship between menopause and women getting heart disease?

Unless they have some kind of family predisposition, women rarely get heart disease until menopause. And it usually isn’t for five or 10 years after menopause. It’s a post-menopausal disease and unfortunately estrogen does not seem to protect women against heart disease.

What are your initial thoughts on the results of the MADIT II study?

Over the past 10 years, there have been clear indications that patients who have coronary artery disease who have major damage to their heart are at risk for sudden cardiac death. The first group that was evaluated were the groups who had 1 episode of sudden cardiac arrest and those people were at very high risk for having a second episode. And these people were treated with implantable defibrillators and they did well. They had a better prognosis than those who didn’t [get a defibrillator]. Subsequently, we continued to look at secondary prevention -- people who had life-threatening arrhythmias – and they were given defibrillators and the defibrillator seemed to be the important factor in determining whether they lived longer. Then there were several primary prevention trilas – primary prevention is like getting your cholesterol treated before you have a heart attack rather than getting it treated after you have a heart attack. And in primary prevention trials people had defibrillators placed because they were considered to be at high risk for SCD. And although cardiologists in general believe that the ejection fraction is probably the single most important determinant of a patient’s risk for sudden cardiac death, the trials were very carefully done to see if they could select out the highest risk patient. So at the beginning we had to do electrophysiologic tests to determine whether or not stimulating the heart in a certain way would elicit life-threatening rhythms. If a patient did not have such rhythms, they did not get defibrillators.

What the MADIT II trial showed was that it didn’t really seem to matter what you do other than the fact that if you have a reduced ejection fraction than your risk for sudden cardiac death, once you reach a certain level, goes way up. And those people benefit from having implantable defibrillators as compared to pretty much identical patients who were not treated with defibrillators. So the study is important in that it says that the marker doctors should be looking at is ejection fraction in terms of whether their patient should be treated with an implantable defibrillator.

What about the cost of the program?

I think everyone is concerned about the cost. The devices, by the time you get through with everything, are anywhere from $30,000 to $50,000 so it is a major expense. But in medicine we find very often that there are innovations that are very important and lifesaving, and certainly in the MADIT II trial they were lifesaving. So if there are appropriate indications, you worry about the money part as you go along. Not everybody who is a MADIT II candidate will get a defibrillator because some of them have very severe heart failure and are going die in a short time, and a defibrillator is not going to make any difference. I think that will have to be sorted out. But we’ll also have to see the cost-analysis -- they said the same thing about dialysis, which costs about $30,000 to keep someone alive. It may be that the defibrillator will fall into a group even less than that.

Is ejection fraction something survivors of heart attacks should be asking their doctor about when they visit the office?

What I tell patients and other doctors that we teach is that there are three things people have to worry about after their heart attack. Number one is that they want to prevent a second heart attack or a third heart attack, and they do that with modification of their lifestyle (quit smoking, exercise, diet), and taking medications which will stabilize the inside of the arteries and hopefully prevent a second heart attack. Secondly, they want to prevent heart failure which is the consequence of a damaged heart, and sometimes a patient will have a heart attack and go on to develop heart failure because the heart dilates, and we have medications to try to work on those factors. The third, which is probably the single greatest threat to the patient, is the risk for sudden cardiac death. And in that situation they have to understand that there are certain markers, and one important marker – which is ejection fraction -- that gives their doctor and indication that they are high or low risk. If they are at high risk, at least they ought to be apprised of that risk and have the discussion with their doc to determine whether or not they may be a candidate for therapy with a defibrillator. But certainly its very important, just as a patient knows their cholesterol and blood pressure, that they know their ejection fraction.

Is that a relatively simple test for the patient?

Yes. Ejection fraction can be measured in a doctor’s office using an echocardiogram.

Last updated: 25-Jul-02

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