Speaker 1: 0:09
Welcome back to the Armor Men’s Health Hour with Dr. Mistry and Donna Lee.

Donna Lee: 0:13
Welcome back to the Armor Men’s Health Hour, this Donald Lee. Dr. Mistry stepped away. I think he likes to go visit with the KLBJ radio guys and talk about stuff that he doesn’t want to talk about on the air. So I brought in a couple of special guests today. So, I wanted to introduce everybody. We have Dr. Vamsi Krishna with Seton. He’s got several locations, we’re going to ask him about 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.

Dr. Yang: 0:43
Hey Donna Lee, glad to be back.

Donna Lee: 0:44
And Dr. Krishna, thank you for coming. We appreciate your time.

Dr. Krishna: 0:46
Thank you for having me.

Donna Lee: 0:47
Of course. So, I wanted to ask Dr. Krishna a few questions. He is a cardiologist, an interventional cardiologist. So first, let me tell you, he’s with Seton and we’ll talk about his locations and how to get in touch with him, and he’s accepting new patients and you all are going to 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–conventional and interventional.

Dr. Krishna: 1:06
General 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, able to suck out clot from people’s legs, hearts, and lungs. Kind of treat patients both in the office and in the hospital.

Donna Lee: 1:27
Okay, awesome. And how long have you been with Seton?

Dr. Krishna: 1:29
I’ve been with Seton for 5 years now.

Donna Lee: 1:30
Gosh, I bet you’ve seen a thing or two.

Dr. Krishna: 1:32
Yes. Yeah, yeah, exactly.

Dr. Yang: 1:35
And let’s just leave it at that.

Donna Lee: 1:37
Yeah, let’s not talk about any patient issues. I know that you’ve got, you’re located in West Lake, Kyle, and Luling through Seton, so we’ll talk a little bit more about that. But I’d like to turn over the discussions to you and Dr. Yang. We get a lot of questions about people having heart attacks or cardiovascular issues and testosterone. Why don’t you guys talk about is it safe to be on testosterone with cardiac issues, and to what extent?

Dr. Yang: 1:58
You know, and that’s definitely a lot of a good part of, you know, my conversation with patients when we start testosterone is there had been some studies out in 2013, 2014 range suggesting that maybe taking testosterone increases the risk of heart attack and stroke. The American neurological guidelines, the American Neurological Association, that’s the overall 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 I wanted to get kind of your thoughts on that being on the other side.

Dr. Krishna: 2:39
You know, you raise 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, etcetera. 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 2 years, there’s a slight increased risk of stroke based on the FINRISK study, which showed that about 15,000 patients who were getting testosterone replacement over the age of 45, there was a slight increased risk of stroke in the first 2 years. And then after that the stroke risk is actually mitigated. They actually had a decrease in all cause mortality. The data’s still kind of out there as mixed. 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.

Dr. Yang: 3:57
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 to replace the testosterone to help some of your symptoms.

Dr. Krishna: 4:10
Absolutely. I think TRT has a role and I think, you know, under urological care and you know, in partnership with cardiology in your more complicated patients, I think it can safely be done.

Dr. Yang: 4:20
Okay. Sounds good. You know, I guess we had a question a couple of weeks ago from a patient who said that he had had a heart attack–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, what type of tests would you do to say that patient’s okay to use testosterone?

Dr. Krishna: 4:41
You know, that’s a great, first a 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 them there’s actually 5 different types of heart attack, and without boring the audiences 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 2 heart–I mean a type 1 heart attack, and that’s one where people like me would come in, suck out the clot and put a stent in. In those type of patients where you actually had a stent and are on dual antiplatelet therapies, typically if you have no symptoms 6 weeks after this procedure, it’s safe to resume therapy under your guidance of urology.

Dr. Yang: 5:17
Okay.

Dr. Krishna: 5:17
If you had a heart attack where you were just treated in the hospital, did not need any real procedures, typically it’s a type 2 heart attack and in those cases, you know you’re able to safely resume the therapy at any point, at your urologist’s discretion.

Donna Lee: 5:31
Does that change though with age? Like do you do the same testing for a 30 year old that had a heart issue versus a 60 or 65 year old who had a heart attack?

Dr. Krishna: 5:40
The testing, you know right now a lot of people get stress test 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 the test irrespective of age. 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. That’s what it’s guessing. But it does 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 and [inaudible] 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 this, I’m concerned about this patients 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.

Donna Lee: 6:30
Gotcha.

Dr. Yang: 6:31
Okay. Now, what about patients who are taking aspirin? You’re taking other types of blood thinners, who want to do testosterone injections. Are there any issues as far as them performing injections, doing the needles, things like that?

Dr. Krishna: 6:46
Hopefully they’re coordinated, but no, there is no issues with the intramuscular subcutaneous injection.

Dr. Yang: 6:55
Okay. Um, anything you want to tell them about being coordinated enough to put it in?

Dr. Krishna: 7:00
Well, you know, we have a few friends, who I will not name, who I probably would not recommend getting injections from.

Dr. Yang: 7:08
Yeah. Okay. Now, um, some of the other patients that we see and 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, you know, they might be a little bit overweight, you know, they might actually have diabetes, high blood pressure, other types of issues. You know, when we first see them, what we typically do is get, you know, some of their blood tests as far as testosterone and other hormones. But we typically try to get them hooked up with primary docs or cardiologists. 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.

Donna Lee: 7:59
Right. Gets them in the door.

Dr. Yang: 8:02
Yeah, exactly. Tell us kinda what your thoughts are as far as, you know, men who 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.

Dr. Krishna: 8:14
Yeah. So that’s a fantastic question and one that is actually growing because you know, erectile dysfunction definitely creates, you know, a conundrum for patients. And usually that’s the presenting sign. And most of these patients with erectile dysfunction, as you said, if there’s an arterial issue going on thats decreasing flow, hence why medications like Viagra and Cialis work. And usually if you have artery issues in the microvascular system near the penis, you’re also going to have microvascular issues in the heart and brain and other areas.

Dr. Yang: 8:46
Yeah. That’s kind of exactly what I tell them when I see them in the office, I tell him that the blood vessels in the penis are just as small as the blood vessels, the heart. So if you have problems with one, you probably have problem with the other.

Donna Lee: 8:59
Good point.

Dr. Krishna: 8:59
And so it usually causes a polivascular disease. The way I kind of put this is that, 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 increased risk of having cardiovascular events. And basically if you’re over the age of 55, you’ve had ED for less than 7 years, smoker, and diabetes, you have significant increased risk of cardiovascular mortality, and that if you treat your ED and treat those symptoms, you will definitely decrease your mortality.

Donna Lee: 9:34
Gotcha. 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 going to do is go take a commercial break. We are Urology Specialists and armormenshealth.com is our website. You can send us any questions to armormenshealth@gmail.com. That’s armormenshealth@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 3: 10:32
Welcome back to the Armor Men’s Health Hour with Dr. Mistry and Donna Lee.

Donna Lee: 10:41
Dr. Mistry has stepped out, but I wanted to continue the discussion we were having with our urologist, Dr. Yang, Christopher Yang. Welcome back. And Dr. Krishna, the cardiologist from Seton. So you guys continue that discussion. It’s fascinating. And then we want to keep talking about more testosterone and cardio.

Dr. Yang: 10:57
Yeah. So basically what we were talking about was the link between erectile dysfunction and cardiovascular disease. A lot of men who have heart disease have erectile dysfunction? A lot of men that have ED have heart diseases as well.

Dr. Krishna: 11:11
A lot of the patients present with erectile dysfunction as their first sign. And so this gives a multi-specialty way of being able to, you know, help prevent what’s the number 1 leading cause of death in our country, which is cardiovascular death.

Dr. Yang: 11:23
It’s not because of the penis.

Dr. Krishna: 11:24
It’s not because of the penis, but the penis brings you there, you know? So…

Donna Lee: 11:28
It does have a mind of it’s own, gets you to the doctor’s.

Dr. Yang: 11:28
It’s kind of up in the air, which one is more important, right?

Donna Lee: 11:35
Right.

Dr. Krishna: 11:35
And you help them get up in the air. So you know, there was a wonderful study performed in 2019, a meta-analysis of multiple trials put together. 154,000 patients. So, you know, a small study. Jokes aside, it basically looked if you had erectile dysfunction versus not erectile dysfunction, what is your risk of death, 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 heart end point cardiovascular event. Hence it’s important to treat these risk factors as well as treat erectile dysfunction. I think it’s important as a multi-modality approach that we screen these patients. And screening would typically include in a coronary artery calcium scoring, EKGs, and just a basic panel which most primary physicians can do as well as cardiologists.

Dr. Yang: 12:39
Basically what you’re saying is that patients who have bad erections shouldn’t be mad if we send you to a cardiologist or a primary doc to look for diabetes, to look for high blood pressure, to look for high cholesterol. Right?

Dr. Krishna: 12:52
Absolutely.

Dr. Yang: 12:53
And then also patients who have had heart attacks and strokes, they might have other things going on, but you know, a lot of them probably have poor erections that need to be treated, that can be treated.

Dr. Krishna: 13:04
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 2 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 the next question is like, “Go ahead, if you’re not having any symptoms.” And the American Heart Association, they recommend like six weeks doing a submaximal stress test. You know, I currently state if a patient is able to do cardiac rehab or participate in 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.” And then this is where we have the conversation. So I’m going to throw it back to you, Dr. Yang. What is your algorithm for treating erectile dysfunction?

Dr. Yang: 13:43
I wanted to comment first on what you just said. From what I’m hearing, if they did attempt to have intercourse, that’s a pretty good stress test right there.

Dr. Krishna: 13:50
Right?

Dr. Yang: 13:51
Okay. Probably not as good as the stress test that you order.

Dr. Krishna: 13:54
Right.

Donna Lee: 13:55
But not more fun.

Dr. Yang: 13:56
Yeah. But having intercourse, it is a stress test.

Dr. Krishna: 13:58
It’s not one that I can prescribe, which many men probably would want me to. But a…

Dr. Yang: 14:02
A note from their doctor to prove to their wife that it’s okay. But men do 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 thing we look at hormones, you know, including testosterone, 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 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.

Dr. Krishna: 14:41
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?

Dr. Yang: 14:48
Sure, yeah, yeah. You know, it 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 want to 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. So it’s basically a discussion as well as patient preference.

Donna Lee: 15:21
And it’s really inexpensive now.

Dr. Krishna: 15:23
Right. And from a cardiology standpoint, I typically go with Viagra. Only because a lot of my patients are on multiple medications that may drop their blood pressure. And we know that being one of the side effects of this class of drugs is that this in conjunction with other smooth muscle relaxers can really drop someone’s blood pressure. So I typically go with a lower dose and use a shorter acting agent, as most of my patients are elderly and on other combinations of therapies that may affect their blood pressure. So 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 all your medications put together. And this is why you come see specialists like Dr. Yang and myself.

Dr. Yang: 16:06
Yeah. Now, 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. It actually fills up 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 because he does a procedure, where he actually can put a stent in there. Is that correct?

Dr. Krishna: 16:36
That’s correct, yeah. Pudendal artery stenting, a topic that has been hot for the last 7, 8 years. And 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 2 to 4 millimeters and they get, they can get diseased 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 I’m able to put a stent that is metallic…

Donna Lee: 17:09
And tell the listeners what a stent is, so if they don’t know.

Dr. Krishna: 17:13
Yeah, most of the stents that we use currently for this would be a cobalt chromium metal stent. And they typically…

Donna Lee: 17:20
It’s fancy. It sounds fast.

Dr. Krishna: 17:24
It is very fast. It’s mounted on…it’s crimped on a balloon, and when you expand the balloon, the stent goes onto the wall and becomes part of the artery within 45 days.

Donna Lee: 17:33
Wow.

Dr. Krishna: 17:33
And then it has a drug coating on it so that it prevents new tissue from regrowing inside the stent.

Dr. Yang: 17:40
Now, after they get a stent like that, do they set off the x-ray detectors when they go into airports?

Dr. Krishna: 17:44
No. No. As much as guys like to say that, you know, they have a metal rod….

Donna Lee: 17:49
“I have a giant stent in my penis!”

Dr. Krishna: 17:49
Right. Exactly. Unfortunately they will not, or fortunately, they will not be setting off any metal detectors.

Dr. Yang: 17:59
Now, you know, 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.

Dr. Krishna: 18:14
Right.

Dr. Yang: 18:14
Not the older patients who’s had a heart attack and things like that.

Dr. Krishna: 18:18
Absolutely. So, the premise of this is that typically, if you wait later in life, you 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…

Dr. Yang: 18:33
That’s too bad.

Dr. Krishna: 18:34
Yeah, it becomes a problem. Right? So your point is when you have trauma, you’re typically having a focal spot where 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 want to see specialists who are endovascularly trained and partner with a urologists on this topic, not one that is just performed on everyday basis.

Dr. Yang: 19:10
Okay. And that sounds good. I think we’re almost done with this segment here.

Donna Lee: 19:16
Yeah, almost done. I wanted to take a minute to reintroduce Dr. Krishna and let you guys know where he’s at. He’s accepting new patients. Yes. Seton.net is the website where you can find Dr. Vamsi…am I saying that correctly?

Dr. Krishna: 19:30
Vamsi Krishna.

Donna Lee: 19:31
You can see his handsome face on the website there. So just search for him. The number is (512) 504-0860. He again is at Westlake, Kyle, and Luling at the Seton location. Thank you so much for coming in today.

Dr. Krishna: 19:45
Thank you guys for having me.

Donna Lee: 19:46
That was awesome. Thanks Dr. Yang for popping in and saving the day because Dr. Mistry disappeared.

Dr. Yang: 19:50
Yeah, yeah. I’ll gladly take over the co-host role from him.

: 19:51
Awesome. You can send us your questions at armormenshealth@gmail.com. Armormenshealth.com is our website. We’re located in Austin, North Austin, Round Rock, South Austin, and in Dripping Springs. But we want to hear your questions. So if you have a question for Dr. Krishna, send it over to me. Is it okay if I reach out to you and say, “Hey, this patient had a question?”

Dr. Krishna: 20:13
Absolutely.

Donna Lee: 20:14
Awesome. Well, we appreciate your time and thank you guys so much again, and we’ll be right back after this commercial.

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