[00:00:00] Speaker A: Welcome to the Heart Rate Variability podcast. Each week we talk about heart rate variability and how it can be used to improve your overall health and wellness. Please consider the information in this podcast for your informational use and not medical advice. Please see your medical provider to apply any of the strategies outlined in this episode. Heart Rate Variability Podcast is a production of Optimal LLC and optimal HRV. Check us
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Welcome, friends to the Heart Rate variability podcast. I'm really excited to be here with and Doctor Desai. I love the subtitle of your website, the Heart mind Doctor Doctor Aseem Desai, welcome to the show. I'm really excited to explore your expertise on the heart and the rhythms of the heart. I've been like we were talking before, been nerding out on your website all afternoon watching videos and reading about your work. So welcome to the Heart Rate Variability podcast and I love just to give a quick introduction of yourself and your work to our audience.
[00:01:16] Speaker B: Absolutely. Well, Matt, thank you for having me today and hello to all the listeners out there. I think we're going to have a great conversation. My name is Aseem Desai and I grew up in Chicago and did most of my training in Chicago and at Stanford. I am a first generation asian Indian. My parents emigrated from India in the late 1960s and boy, to describe myself, the heart mind doc is a pretty good description. I'm massively interested in mental health and how it ties to neuroscience. And then of course, with regards to the heart, I was exposed to it actually. Unfortunately, early on when I was about three, my dad had a heart attack and then had sudden death when I was in the middle of medical school. And that, I think, definitely inspired me to pursue this career in cardiology. And in particular, I'm what's called an electrophysiologist or heart rhythm specialist or EP. And so I specialize in the rhythms of the heart and actually the autonomic nervous system and how that ties into heart rate variability is part of our wheelhouse in many different ways. And some of the data on heart rate variability actually originated from ultra monitors and things like that. In terms of else about me, I love yoga, I love playing guitar. I joke that I wish I was the fifth band member in U two. I think I have had an obsession with Bono since I was 16. So if he is listening, I'll say a quick hi to him.
And then I would say that mindfulness has probably been a big game changer for me. I am married, I have three sons, actually, and I live in southern California, in Orange County, California, and, yeah, just excited to be here. And I would say that if you were to sum up what I'm about and who I am, it's all about balance. All about balance and equanimity and just sort of living a mindful life as you sort of try to surf through the stresses that we have. So that's all about me in a nutshell.
[00:03:24] Speaker A: So I love it. So I got a sort of a just personal interest question to kind of kick us off here as we dive into your expertise and work.
When I talk to cardiologists sometimes about heart rate variability, I find a range of knowledge.
We still come across some cardiologists who may have heard of heart rate variability in their education, but have no sort of practical experience with it, where there's others that are as excited as we are about getting heart rate variability on there. As a monitor of both heart health, but also a range of other issues as well, how do you see being in the field and swimming in the waters of cardiology day in and day out? I'm just curious, and I'm sure our listeners are, too.
What are you all talking about at your conferences and other things about heart rate variability?
[00:04:24] Speaker B: Yeah, that's a great question. So, yeah, in the heart rhythm disorder world, in electrophysiology, as I said, heart rate variability, some of that data, some of that coming out with the sort of even idea of heart rate variability, was rarely born from heart rhythm type monitors and started with the holter. And we have a patch now that goes on the skin, and we actually have an implantable monitor that can do those kinds of assessments. Well, but I would say that in the realm of electrophysiology, we find that cardiac arrhythmias, whether they originate from the top of the chamber, like atrial fibrillation, that'll get one in four of us over age 40 at some point, big cause of stroke, or whether it's sudden death due to ventricular fibrillation or ventricular tachycardia, which is what my dad and mom both died of. That in particular, I think, has really been an area of focus with HRV in my field is changes in HRV and how it predicts risk of sudden cardiac death, changes in HRV, and how it relates to atrial fibrillation as a trigger. And then I would say in the realm of.
I would say with regards to just the beat to beat variation. I mean, in electrophysiology, we see it literally during our procedures, like ablations, and we can touch on this, but some of the rhythm issues that we deal with really impact the measurement of HRV for people and can actually throw things way off in terms of interpreting some of those data. And atrial fibrillation is a really good example. And then the last piece I'll say about HIV is a lot of our technology that originates from some industry partners, such as Medtronic, Boston Scientific. These are companies people may have heard about. They actually have in many of their devices, and in particular their icDs, their implantable defibrillators, and in their heart failure devices, which are called CRT, cardiac resynchronization therapy. It's a pacing therapy for congestive heart failure. That HRV is a core measurement in many of those algorithms because of the data that shows that in the setting of congestive heart failure, in particular systolic heart failure, where the heart muscle pump is weakened, and even diastolic, where it's a normal heart function, but the heart is stiff, that's the two kinds of heart failure. In those cases, heart rate variability changes dramatically, leading to a hospitalization. So we use it quite a bit in the realm of, you have a drop in heart rate variability that can act as an indicator of someone who may be going into a high autonomic sympathetic state. And that definitely is seen in the realm of congestive heart failure, cardiac arrhythmias, because it is showing, I mean, in a way, and tying back to that thing I said about me being all about balance, if you think of that autonomic nervous system and the balance of the autonomic nervous system, like a seesaw, with regards to my field and cardiac arrhythmias, kind of circling back to your question, that seesaw is extremely important, not only in risk stratifying people, but I think, and I think this is a good point you're making. We are not seeing it used in real time in clinical practice with patients, and we should. I mean, that's really my feeling on it. I have patients literally just recently, within the last week, that on their Apple Watch, they'll bring in their report of their heart rate variability, and they have Afib. And I don't understand why there's this one guy who actually said, I notice every time I get HIV or I get Afib, my HRV goes up. And so I was kind of explained to him, I was like, well, actually, that's a little bit of the opposite of what you would think when the heart's under stress. And then I kind of explained to him. The irregularity in the HRV in the heart rhythm can really impact the sort of accuracy of the HRV. So that's a lot of information I just threw at you, and I'm kind of known to do that, so please help me along the way.
[00:08:21] Speaker A: But there are so many big things. I wonder if we can just follow up on what you said last, because one of the things that we often get asked, and I'd love to kind of pick your brain about this, is when you have your regular heartbeats. I know my mom does. And so would you treat that as a kind of artifact when you think about heart rate variability? Because you're right, that can really, that can really mess up your heart rate variability reading. You know, if you do three minute readings and you've got, you know, the rhythm gets skewed, that that can show you something that may not be true. So do you kind of see that as an artifact or how. I think that's a great.
[00:09:04] Speaker B: That's a great question. That's an excellent question. I would say, you know, for people, again, who listen, who I'm sure very well educated on HIV with your podcast, but it's that beat to beat variation in heart rate that occurs to, uh, naturally, even in a normal rhythm, that is measured in milliseconds in. In many cases. And in the past, when I first started learning about it, I always thought it was all about a sympathetic overdrive stress state, and that's when your heart rate variability dropped. But it turns out, actually, and you can speak to this better than me, I'm sure, that parasympathetic nervous system, the vagus nerve, that's a big part of the determination of what's happening to the heart rate variability. So, interestingly, with regards to some irregular rhythms, they are actually triggered, believe it or not, by the vagus nerve. So we have a whole group of athletes now, and high endurance individuals who have low resting heart rates. This includes major sports figures, lots of different people you hear about who get a fib, and it has to do with that low heart rate. So there's less variability, even with bradycardia, even with low heart rate. And the vagus nerve is, like, overactive, but that actually acts as a trigger for acid, because the longer the distance between two heartbeats, or the longer the time, I should say, between two heartbeats, the easier it is for the heart's electrical system, especially the abnormal cells, to actually kick in and cause what we call a premature atrial beat. And if you have enough of those extra beats or irregular beats, that'll trigger a full blown episode of arrhythmia. So if you think of this continuum of irregular beats or sometimes what we call palpitations, which is just sort of a nondescript term for a feeling that something is off in your heart rate or rhythm, whether it's the heart rate's going fast or whether the rhythm is actually irregular, that's an important distinction, rate and rhythm. But with regards to that artifact question that you asked, I would say, and I'd have to look at this and circle back to you on it, how much is actually published or even presented on the connection between Afib and HRV? But I will say that trends are what matter. It's really the trends. It's not the individual numbers. So this patient, even though he was saying, my HR, and even as I think about it, I'm talking to, he said, I noticed my HRV goes up before my Afib episode. So my mind goes to, well, I would normally think with a drop in HRV, that's what causes. That's what triggers heart failure event or not triggers, but indicates the heart failure event could happen, whatever. And I was like, well, you know, a jump in your hiv doesn't make any sense, except, you know, if you think about it, right? When you have a higher hrV, your vagus nerve is active. So when in that particular episode, even the vagus nerve may have been involved. And I'll shut up after this one last statement, that when we do catheter ablation of atrial fibrillation, which is where we put a catheter in the heart and a beating heart through a minimally invasive approach, kind of like an angiogram or stent, and we identify the spots around what are called the pulmonary veins in the top left chamber of the heart that's the source of Afib. Think of it as almost like the sparks in these irregular beets are like the sparks, and then Afib is like the fire, okay? And you have enough sparks triggering the fire, and then what sustains the fire is the wood. And the wood are risk factors that are out of control, like obesity and diabetes and high blood pressure and sleep apnea. It's kind of a good way to think of it all. But in those ablation procedures, what we noticed, and this was, like, decades ago now, that people noticed. Electrophysiologists out of Oklahoma actually found that when you ablate the ganglionic plexi that surround the left atrium on the outside surface or the epicardial surface of the heart, the GPS the ganglion plexi, that's where the vagus nerve has input into the heart in a bi directional fashion with the central nervous system, that when you ablate those areas, you will get a massive vagus response. And the way that shows up with the heart is a long pause. And I'm talking a heartbeat of like ten beats a minute for a second or two. But so we're essentially talking about, like, 22nd pause, like really profound pauses. And in the electrophysiology lab, we're very comfortable with craziness like that, whether it's, you know, rhythms like ventricular fibrillation. Believe it or not, we're comfortable with. And I'm sort of, you know, tongue in cheek about that. We're not comfortable with it, but we're used to dealing with it and prepared for it. But when we do these ablations and we see these vagus nerve responses, where the blood pressure, the heart rate, either one of them or both drop.
And then after the procedure, the patient, like the athlete who had a low resting heart rate that was contributing to their Afib beforehand, and now it's 20 points higher after the procedure for the first several months. And that even once you ablate that GP during the ablation, you see the resting heart rate go up. That increase in resting heart rate is a withdrawal, or what we call a vagalytic effect, like you're withdrawing some of the vagus nerve tone, and the arrhythmia is getting under better control. So I know I'm kind of going all over the place with these sort of high level kinds of discussions, and I'm really nerding out, like you were.
[00:14:25] Speaker A: Talking about, this is great. This is great.
[00:14:27] Speaker B: But honestly, I hope you don't mind. This is sort of selfish of me. I take conversations like this as opportunities to even think through my evaluation of what's going on and hope that I am reaching not only, I mean, you obviously, who's very knowledgeable about this, but your listeners and the public of, you know, HRV is such a powerful measure. And I've just been talking about the heart and the rhythm. We know HRV has a huge impact with regards to your emotional health and your mental health and changes in HRV. You know, we use heart math accompany heartmath quite a bit with our patients. We can talk about that. But anyway, I'll stop. I thought I was going to shut up, like, five minutes ago, but I'll stop and say one other thing, which is that when you do those ablations and you see that vagus nerve response, and we get the heart. Basically, we cure the heart rhythm, this heart rhythm problem, this irregular rhythm. So it's an irregular rhythm. And then we ablate the vagus nerve area and the heart rate slows, indicates we're hitting the vagus nerve. And then after the procedure, the rhythm is regular and faster. That tells you that we're impacting the autonomic nervous system and the heart rate variability, because we're restoring that seesaw, that autonomic balance between sympathetic and parasympathetic. So I really hope I didn't come across just now is massively confusing.
[00:15:53] Speaker A: I just. I just gotta ask my follow up question.
[00:15:56] Speaker B: Yeah, yeah. So I'm gonna shut up. I'm gonna shut up.
[00:15:59] Speaker A: I'm dying to ask it. Because the vagal nerve is like, if. If this show has a best friend, a best buddy, it would be the vagal nerve. Like.
So I'm curious about, because everything I've read about it over the years, like, we want to strengthen vagal tone with all these great things. So why the heck is our best friend starting? Why is it turning on us? What is going on there? I mean, respiratory sinus arrhythmia is in my mind, like, why? Why is our best friend turning on us in this way? It's been such, it's our. It's our friend, and now it's possible it could turn on us.
[00:16:49] Speaker B: Matt, you need to be an electrophysiologist. It's not too late. I mean, it. I mean, it. That is a huge unanswered question. But there are some partial answers. Okay? In life, in the human body, we have this phenomenon of homeostasis that everything wants to return back to sort of a stable state. You know, even in the polyvagal theory that, you know, you hear Stephen porch talk about, I mean, the vagus nerve is our friend. So is the sympathetic nervous system when we're running away from a dinosaur. Right?
[00:17:20] Speaker A: Yeah.
[00:17:21] Speaker B: But when the sympathetic nervous system gets activated, when you're, like, stressed out at home because you're dealing with, you know, a meltdown from your child, like we often do, or you're in a conflict at work, then it's not your friend, because then you have this sort of emotional release. Right? Well, let's look at the vagus nerve. The vagus nerve is the rest and digest. It's the rest and relaxed response of the parasympathetic nervous system. So, yes, it is our friend when the need arises.
But if you have an over activation of the vagus nerve, or an under activation of the vagus nerve. If the vagus nerve, or let's put it a different way, if there's higher vagal tone, if there's literally higher impact to the vagus nerve, it can act as a trigger for issues and problems. So it's almost, I mean, rather than think of the Vegas as a friend, I think of that seesaw, I think of that homeostasis. I think of really the balance between sympathetic and parasympathetic nervous systems, like everything else in life. What do they say about diet?
Some people are atkins, some people are vegan, et cetera, et cetera. Well, why do they say the mediterranean diet is kind of one of the best? Well, it is a diet of moderation. What do we see about physical exercise? Extreme, high intensity exercise. Yeah, great. But then there's some disadvantages. Same thing with, like, being a couch potato, but there's something in between. So it's all about balance. So in the same regards, if we go back to the vagus nerve, the vagus nerve in the sympathetic nervous system, there needs to be a balance, and that balance is dynamic. And, you know, with the vagus nerve, and people may have heard of us, we do what's called a valsalva maneuver during cardiac arrhythmias. So people who have one called SV that has a rhythm called SVT or supraventricular tachycardia, this is where the heart rate just beats really fast, like 100, 8200 beats a minute. And it has to do with a short circuit in the heart. And we can see babies get it, and we can see people who are 100 get it. You can see a whole gamut of ages, and it can happen to healthy people with that SVT. We actually use the vagus nerve as our friend. We do the maneuver called valsalva, where you activate the vagus nerve, whether it's coughing, whether it's bearing down, whether it's throwing your face in a bucket of ice water, whether it's lacking, even though it activates the vagus. That tends not to have an effect on the arrhythmia. But what the vagus does is it affects the sinus and av node of the heart, the central electrical parts of the heart. And by doing that, you're transiently increasing, or you're using that friend more than you should. I mean, however you want to put it. But it actually stops the arrhythmia. So it's all about, again, it's all about moderation. Because the thing is, with our athletes, this is the cruelest aspect of nature. Why do high endurance athletes get cardiac arrhythmias? Like sudden death or like atrial fibrillation? Well, again, some of it is thought to be due to an imbalance of the autonomic nervous system and too much of a good friend.
[00:20:40] Speaker A: Fascinating. So I just gotta. This will probably, hopefully allow a lot of us to sleep tonight, because one of the things I'm sure I'm not the only one thinking is we spend this, all this time getting our residents frequency, breathing rate, and doing hrv biofeedback and all this stuff, I'm going to assume, but I want you to. I got the expert on the line here, so to speak, is I'm assuming we're not putting ourselves at risk of do, because I feel like so much of my day now, because I'm a huge nerd about this stuff, is like, whether it's splashing cold water on my face in the morning, whether it's gargling, whether it's doing my residence frequency breathing practice, I would term that of strengthening bagel tone, really regulating, I would say in my term, even though I think we get lost with this in some corners, really, that balance, I'm really. Because the sympathetic, there's so much stress in life that I'm just giving that balance back. Am I thinking about that correctly? There's a few people out there of us, HRV nerds that are like, but I spend all my time during the day strengthening this vagal nerve thing.
[00:21:58] Speaker B: Yeah, no, it's a great question because, again, it's kind of like, how do we really think about the nervous system and how do we think about our stress response, and how do we think about ways in which we can maintain that homeostasis or come back to that homeostasis when we're under stress? And then it's, yeah, the question is always like, what should I do with my diet or exercise or even this vagus nerve? Like, you know, can I over activate it? You know, can I? And that's an example of the high endurance athletes where if there's genetic components of arrhythmias there, those high endurance athletes with high vagal tone, that that perfect combination can trigger an arrhythmia. Does that mean someone shouldn't be a high endurance athlete? Absolutely not. I mean, if you look at the percentage of high endurance athletes that have cardiac arrhythmias related to elevated vagal tone, you can't blame everything on the Vegas. And so I would say the Vegas is protective, the sympathetic nervous system is protective. All of this stuff is meant to keep us surviving, thriving, populating the planet. All of these things are built into our nervous system, in our bodies. And so I think of, like, exercise as a great example of how you're activating your sympathetic and you're activating your parasympathetic because of all the shift. And that's why exercise is good for you. But if you're getting your blood drawn and you have a very painful needle, and then you feel dizzy and you pass out, called syncope, you have vasovagal syncope, where the vagus nerve gets activated or overactivated or hyper response, you will have a drop in blood pressure and heart rate that's profound, and it reduces blood flow to the brain, and you pass out. And so I hope I'm kind of getting a little bit to the answer to your question of, like, should we be afraid of the Vegas? Should we be afraid of these practices that we do and things like that? Absolutely not. These are great things. And as you and I know, the stuff that I'm talking about in this podcast interview is a combination of knowledge, experience, and perception, okay? And I have a very limited view of HRV. And if you were to ask our colleagues in sports medicine, where a lot of the HRV data also comes from, it's used in a very different way. So I think balance is a great word. You and I have been throwing it back and forth, and that's where I think heartmath. And I'm sure you've had episodes talking about heartmath or other products.
The idea that if you have a biometric like HRV, that is an indicator of your state of stress. If you were to just summarize it right, HIV is an indicator of your state of emotional, mental, physiologic stress. Okay? If you use that concept, then how can you use wearable devices or just practices, you know, that date back to the buddha like meditation, how do you use those practices? How do you get the feedback that you're doing it right? And that's where something like heart math, you know, there's. There's some criticisms in the western medical community about some products, sort of what we call pseudoscience. And you have to be careful about, you know, there are products out there that'll claim do a lot of things, but actually haven't even been necessarily gone through the FDA or large randomized trials. I'm not saying it doesn't work. I mean, my family's from India, and there's a lot of data about ayurvedic medicine, but it's not integrated a lot into western medicine, et cetera, et cetera. So I think with regards to HRV and using devices like the Apple Watch, for example, or in the case of heart math, they have a whole slew of products, and one that I love that interfaces with the app that you just put a clip on your ear and a clip on your chest, and you do deep breathing. What I love about that technology is it's not just you're looking at your HRV changes in real time as you're meditating, or I should say breathing, but you're also, and correct me if I'm wrong with that product, I know there's a focus on. I forget what they call it. Like it's coherent. You know, you're sort of right, but it's something. Isn't compassion part of the process? Like, I know breathing is, but there's something about, like, focusing on your heart, focusing on compassion. Right. And what I love about. And if I'm right on that, I think that's the important part, because the breathing brings in the physiologic aspect of HRV, right. But the focus on compassion, and we know this in science now, there's a lot of connection between biologically, physiologically, electrically, what's happening in your body and the health of your mental, emotional system and mind body connection. So if you're focusing like self compassion works from a scientific standpoint, it lowers your blood pressure and heart rate because you're taking everything down a notch. And so we see it all the time in electrophysiology, where someone is at a funeral for their loved one who dropped dead. And they dropped dead. Okay. We have something called takatsubocardiomyopathy, or broken heart syndrome, where mental stress, emotional stress triggers heart failure or a heart attack. And so I think in the same way, with regards to how we look at, how do we use HRV, I think this concept that heart mass has, and I don't know, you probably know better than me. I don't know if they're the originators of this. I did have a great opportunity to talk to, I think his first name is Roland, one of the scientists in that company. And we use heart math a lot within our health system in some of the integrated models. But I do think it's great, it's convenient, and it brings in that whole idea of mind body connection. I mean, I think that's what I really love about it. And last piece, I'll just kind of say on this is, I try to walk the walk on this. Okay. Do I use HRV in my day to day practice? No. But do I know a lot about it, and do I listen to my patients, and do I learn from them when they bring in information? Absolutely. And the gentleman I saw recently, really smart guy, and he pointed something out to me about this jump in his HRV prior to his Afib episode, and that was fascinating. And I have to do a lit search on this, but it's that two way communication between healthcare provider and person receiving care is the reality is, and we'll get a little philosophical for a second, but, you know, you have had a lot of great guests on the show that had different levels of background and experience in different aspects of the human body. And I think, for example, I'm fascinated with the brain, as I mentioned. But if you look at the real learning and the progress that occurs in healthcare, it's team based, and there has to be a partnership. And I would say I learned more probably day to day, about HRV because I was listening to one of your episodes in the past, the pulse code, which I found fascinating. And the.
I think it's true. I mean, just like many other things in medicine, you're seeing this movement. Like, more doctors are teaching mindfulness in their office to their patients. Okay? Like, we're seeing that. I think we're seeing more of this stuff on HRV. We just need more data. We just need to highlight this more at conferences, I think. And I'd have to look, the heart rhythm society, there's probably a lot of people that have presented stuff on this. But the data they use in the office of HRV, you know, whether it's in the office, in the hospital, you know, with data that patients are bringing to us through apple watches, et cetera, can make a huge difference because we see the value of the apple Watch in checking the heart's rhythm. I mean, people have made their own diagnoses of atrial fibrillation and other arrhythmias by sending me their Apple Watch tracings. They've come to me that way. And so I think HRV is just another metric. I think the challenge with HRV and medicine is we're not quite sure how to use it because it's part of the big picture. And we learned this with the device companies like Medtronic and Boston Scientific, they were incorporating this HRV metric, all right, in their devices, like defibrillators in heart failure therapy, is to predict who's going to have heart failure? Or are your lungs filling up with fluid? What change in HRV? And they then threw it with a bunch of other metrics, like measuring patient activity. Patient activity and measuring low resting heart rate. And they would come up with one thing called cardiac compass. That is an algorithm in one of the devices. And it puts together all of these different metrics that. That the devices have the ability to measure. These devices can measure heart rate variability. I mean, that's one of the most accurate ways to measuring it. These implantable devices measure it. You know, it's. It's unclear what combination of metrics is optimal for predicting something like heart failure admission. Right? But HRV is definitely, definitely a huge part of it and underused and an under recognized part of this aspect of medicine. And I would make the argument that to jump to the mental emotional health of people, and I speak to myself, I went through burnout. I've had mental health challenges, depression, anxiety after loss of my dad. I've had a lot of mental emotional health challenges in a field that's involving very high risk procedures, which we need to be balanced and we need to be able to have it all together. And I definitely see that while we may be teaching things like mindfulness in the office and compassion to our patients, and there's a growing movement in that in western medicine, and using those tools, just like you would use an antibiotic in some regards. Right. That, you know, HRV is part of that. And it's sort of like. And you may have even mentioned that on the pulse code episode that I listened to. But I. It's kind of like we have this metric. Why haven't we been using it for all this time? Right? And I think the reason why, at least from my perspective, I can speak to this is electrophysiologists who implant defibrillators, for example, where these HRV metrics have been available for a long time. Okay. A long time.
Even with the science, they weren't quite sure how to incorporate it. So I think that's the piece that, you know, needs to be kind of ironed out, is, okay, well, what, you know, what technology for measuring HRV is the best? And then what's the best way it gets incorporated into, like, a wearable device for someone, you know, and then, you know, how, like, how Apple, for example, you know, partnered with Stanford. So how do you get companies to partner with academic institutions to kind of figure this stuff out? Right?
[00:33:12] Speaker A: Yeah. And it would, to me, it's like. And this comes from, like, you know, my mental health background, not the medical background? I don't have the medical background. I got an MBA in healthcare administration, but they won't let me prescribe meds, which is probably a good thing. So it was just like, to me, such a vital sign. That's how I, like, looked at. My frustration was, is somebody, you know, working with an individual with trauma or addiction, you know, we're not going to do the implantable things unless there's other issues going on. But we couldn't get that data on a regular basis either, because that's where I think, like, heart rate variability nowadays can have power to track progress, treatment, or, you know, give you warning signs. In my world, it might be like a relapse or a self harm attempt. Your world, it might be a heart attack, but it gives us, if we can get daily readings, which if you got an implant, that's pretty easy to get. If you, you know, but now, you know, our device costs $40, so it's not that expensive nowadays to get that tracking and then look at that. But it's integrating that into, I think, like you said, educating providers on what that might look like. And in the medical profession, how do you give alerts if you've got a few hundred patients you're working with, how do you get alert that Matt's had a two day drop or a 50% drop overnight to get that sort of warning up to the physician or to me as a mental health therapist, so we can take action, which might just be a phone call. They may have started training for a marathon yesterday, and that would explain a lot. But to me, it's just like that vital sign, because I think when I go to the physician's office, my blood pressure is telling you the stress I've had on the commute over the doctor's office, my day, and sitting in the waiting room, it may give you a little bit more information, but it's such a one off kind of metric, and that's where I think a lot of our technology can start to give more everyday sort of data that could be really useful as well.
[00:35:19] Speaker B: I'm really glad you pointed that out, Matt, because, like, I have an oura ring on, right? And I had an apple watch on before.
The reason why I like the oura ring, I had an apple watch, but I'm a watch guy. I inherited that idea from my dad. So it's like, I don't want to wear an apple watch, so I want to wear, like, a watch my wife gave me for my 50th day.
[00:35:37] Speaker A: It's a very nice watch.
[00:35:38] Speaker B: Right. So I got an aura ring that kind of matches my wedding ring.
[00:35:41] Speaker A: Right.
[00:35:43] Speaker B: But I agree with you. There's, when you think about health, you know, whether it's emotional, mental, whether it's addiction medicine, whether it's cardiac stuff, you think about prevention and you think about intervention. And so prevention would be like a relapse, or prevention would be a heart failure, hospitalization, and then you think about intervention. So intervention. Let's start with prevention. What changes? I love the idea of a vital sign of. Yeah, people, I've heard people talk about that with HRV. You know, what changes in HRV? And let's get granular. Like, what changes in HRV have been shown scientifically in studies to predict x. Okay, whatever it is you want to say. And the challenge is a lot of that stuff. The literature right now is focused on physical health, not on a mental emotional health, and focused on areas outside of psychiatry and psychology and neurology. And I think that's the piece that really needs to move forward. And I think in the sense that we're in a place now, since the pandemic, where mental health has gotten significantly worse, where people are interested, people like companies are interested, Medtronic's interested, physicians are interested. Why? Because we're beginning to see that whether it's a behavioral intervention, like a twelve step program, all of those things that have shown scientific benefit, now we have a vital sign, a metric that has a dynamic, like you said, dynamic versus static vital sign. Most of the vital signs we have in the office don't reflect at all what's happening in the person. That's why amblyotor, ambulatory blood pressure measurement with the patient doing it at home multiple times a day, much more accurate than the office one. Right. And so it's the same thing.
[00:37:36] Speaker A: And.
[00:37:37] Speaker B: But I think the challenge is this.
We right now, are not at a place in the healthcare system from the standpoint of how to pay for it and the legality, the legalities of it and the ethics of it, of how to have a person and then the healthcare provider have data go between them. That's privacy protected.
All of those factors need to come into play because, for example, with Apple, the ability to record an electrocardiogram in EKG and send it to your physician, like, we're still in an unclear stage. I mean, there's some law that governs that, but a lot of it's like, consensus statements from society, and certainly whatever gets sent back and forth in the patient's electronic health record, that's protected but the challenge for physicians and providers is if a patient's sending me graphs on their HRV, and then I'm trying to make a decision about whether they need to be admitted, hospitalization, whether it's for their mind, their heart, or their body. Right.
There's a lot hanging on a physician. And I'm not just talking about medical legal. I know that's everyone talks about. But also just from an ethical and a scientific standpoint, we want to be very careful. We want people to be empowered. I always say it this way. I am knowledgeable about the human body. I have experience with the human body. But a person that I help take care of and partner with, they're knowledgeable and experienced with their mind and body.
And the interchange of information, like words are one thing, okay. Where there's, like, a back and forth and conversation that's been going on for millennia in terms of healthcare. But once you start exchanging information, that is more than just a message to your doctor of, I'm having chest pain. What should I do? Okay, sending it through. Once you start doing it with patients who.
Someone's wearing a garment, someone's wearing an Apple Watch, someone, you're having all these technologies, none of which have been, like, FDA approved. So where I'm going with this is obvious, right, that those are the hurdles at kind of a macro level we need to look at is getting the validation, the scientific validation for using HRV in healthcare in the day to day, on the front lines, in the office, in the emergency room, whatever. How do you incorporate it into a larger metric or a score? We do that a lot with heart failure scoring systems to predict stroke risk, any of those things, you can incorporate that easily into a scoring system. Right now, a lot of our scoring systems for risk, like for Afib, for example, the risk of forming a blood clot in your heart with this rhythm and it breaking off to the brain, causing a stroke.
[00:40:44] Speaker A: Yeah.
[00:40:45] Speaker B: It's called an embolism.
The risk of that is governed by different medical risk factors, including a history of congestive heart failure, high blood pressure, age over 65, diabetes, and prior stroke. That's called chads. Okay? B h a d s a. So that is a scoring system that's well validated. Why can't we do the same with HRV? Right. And it's not like we won't. But the problem, right, is that that pandemic, I mean, it forces. It woke up a lot of stuff, which I think is great on mental, emotional health. But I think the challenge is now, where do where does healthcare put its investment? Okay, so there's a. There's a finance piece to it, but I think just in the day to day practice, I think this is where I would say, empower people to talk with their providers about HRV that they're measuring. Now, my colleagues may get a little upset at me about that. Why? Because doctors and nurse practitioners, we have such a limited time, and we need to go through, like, a 20 point problem list with someone, and we need to triage, and we don't want to ignore what our patients are saying, and we want to support what they're saying. And the challenge is just that communication piece of how do we have enough time to. If I was a concierge physician and I can spend the entire day with my patient, we can talk, all. We can do lit searches together about HRV. There can be a lot of back and forth. But the challenge, I think, in the practice of medicine, where it is right now, and so. But this isn't. I mean, we don't need to reinvent the wheel. Right. I mean, there's a ton of stuff in medical history that had to go through, you know, groaning pains to figure out how to incorporate it in real time, day to day healthcare. That's really what we're talking about, you know? And I think it's going to require both patients and healthcare providers. And I think the big difference, I think what the pain like, just like the autonomic nervous system, and at.
I think, like, parasympathetic sympathetic in Vegas, I think healthcare with regards to physicians, allied health on one side of the seesaw and patients on the other. I think it used to be where we were at the pinnacle and everyone listened to us, and there's very sort of this very, like, authoritative way of telling people what to do. Right. And I don't think hippocrates did that, by the way. I think. I think that. I think it was a bit different back then. I don't think it's kind of. I think we need to circle back a bit philosophically. I was a philosophy major in college.
[00:43:24] Speaker A: Awesome.
[00:43:26] Speaker B: But I think. And patients were put at the bottom, and I'm using kind of extreme words, but what I'm really trying to say is, like, people were kind of talked down to or to right now, there's an empowerment. Right. And the challenge is that the CSA is getting back to where it always should have been, which is a balanced healthcare, where there's partnership amongst healthcare providers and patients. Again, people know about their bodies and experience their bodies and we know about the human body, all that. We need to figure out a way to have HRV, you know, as. As sort of part of that discussion so that when people bring in that information, we can use it.
[00:44:13] Speaker A: Yes.
[00:44:14] Speaker B: And we can. We can use it in the office visit or maybe just to quickly discuss it and then we can immediately put it into practice. The problem right now is how do you do that in a 15 minutes, 20 minutes office?
[00:44:25] Speaker A: Yeah. Yeah. I am with you on that 100%. I don't know how you do anything. I just feel, because I do a lot of work in resiliency and staff wellness and healthcare, and I just don't know how you do much of anything of meaning. And you do. You figure out ways to do it. But I. 15 minutes is just, how do you get to any of the emotional responses? How do you help create motivation for adherence? Like all this stuff that goes in that some people, 15 minutes is enough. But I know a lot of our population, it's not, you know, it's so hard. And I just feel. I feel for you that you try to accomplish so much in such a small period of time with that.
[00:45:12] Speaker B: I can appreciate that. I mean, I think I feel for people who are in the office visit who are going to see their doctor. Like they're sort of getting gypped of a lot of time, especially if the doctor's running late. Why do I say that? Because I have been a patient since the mid twenties. My mid twenties, I developed anxiety and depression after my dad's death. And I've had to see all sorts of doctors and practitioners over the years, therapists and different doctors. And I've been on the other side of the equation, I like to think. And I talk about this on my website, Doctor christinebasai.com, where I talk about being a physician, a patient and a family member with someone who had health issues. That triangle, that triad, it's given me a perspective of.
I remember recently sitting with my doctor and I had questions like these sort of scientific questions, and I did a little lit searching. My wife looked at some stuff and I went in and wanted to talk about it. You know, it wasn't like, mainly done, but very quickly kind of dismissed. And it's sort of like, you know, and I'm a doctor, for heaven's sake, you know, why can't we have that discussion?
[00:46:17] Speaker A: Right?
[00:46:18] Speaker B: It's a timepiece, but that's why people went into concierge medicine. The reason why the burnout rate is so high is that doctors and we can't spend the time with our patients the way we want. It's a healing profession. It's one of the greatest privileges that people give us, that trust in what we do. And everyone's gypped with regards to that time you take. So I know I'm getting a bit on the philosophical end of HRV, but I thought you're having me as a guest.
[00:46:47] Speaker A: Oh, no, I love it. I feel like I can talk about every sentence for, like, 20 minutes, but I know already, somehow, like, 47 minutes into this conversation, which just blows my mind, it's gone this fast. I do have to ask, because I'm afraid I'm probably opening up another three episodes if I do. But I got to ask, because being the heart mind doctor, one of the fascinating things in my learning curve around heart rate variability, especially when you bring the biofeedback piece of it. But just looking at all now, the meta studies on HRV and mental health is that connection between the heart and the mind, or the heart and the brain, however you want to look at it, I just love to get your perception.
How do you bring those two together in your thinking? Obviously, most, I imagine a lot of your day job is on the physical heart itself. But I know just by hearing, listening to you talk and knowing your work a little bit, that mental piece comes in heavy as well. So I wonder kind of from your perspective, how, like, I came to the heart through mental health and polyvagal theory.
[00:48:04] Speaker B: Yeah.
[00:48:05] Speaker A: Yeah. How'd you come to the mind? Coming from more of the physical aspect of healing the heart trauma.
[00:48:14] Speaker B: I mean, it was the loss of my parents. It was various traumas that took me down a dark path. Right. And for God's sakes, you know, while there's absolutely a role for pharmaceuticals and psychiatry and psycho, you know, in mental health, there's a lot of downsides to them. And once I discovered mindfulness in particular.
So it was trauma in my younger years that resulted in a cycle of anxiety and depression. And then it was burnout as a physician, being overworked, pre pandemic, in ungodly ways, that led me to take time off. I've had to take multiple times off over time, and I saw the value for myself. I saw the value of the mind. And if you take care of the mind, one of my books that's out there, restart your heart, is really all about looking at the heart physically and connecting it to the brain physically. And I talk about the bidirectional connection that when someone has stress, it can trigger heart rhythm problems. Or opposite. When someone has heart rhythm problems, like their heart rate's going 180, it'll make them feel really anxious. So I see it in practice. To answer your question, I have my 20 year old young woman who has supraventricular tachycardia, a short circuit in her heart she was born with. And she goes into it at home, and she feels like she had a panic attack. Right. She doesn't immediately think of her heart, shows us the ER, and she's flipped back into normal rhythm by the time the doctor sees her. So she gets diagnosed as a panic attack. And so I see that all the time. And so this bi directional aspect of heart and mind and heart and brain, there's a physical component. I mean, we've been spending all of this time talking about the autonomic nervous system in HRV, but there's a philosophical component, there's a spiritual component. And so I kind of came up with that idea because the heart is what I treat physically and what my family died of. The mind is what I experienced personally as a patient. And I needed to empower myself through getting informed and educated about how the brain works and how the two are interconnected. I would argue the heart saved my mind and the mind saving my heart. You know, my dad's cardiac arrest actually led to my career and gave me an empathy for people. My mental health challenges directly impacted not just my patients through empathy and compassion, but opened my heart.
And so the tagline on my website talking about, you know, empowering hearts and opening minds, you know, heart, mind, the book I'm working on, restart your mind. So the first one is restart your heart. Now it's restart your mind is that notion of the brain heart connection. And I have, you know, people are interested on psychology today's website, I have a column that's called Mindful Beats. So I actually talk. I talk about. There's a lot of articles in there about that connection between mind and heart, because we see it with, like, people who had bypass surgery, they got clinically depressed. We see that connection. So the way I got significantly interested in, though, what really shifted my career from being a guy who just did surgeries and sort of, like, getting burned out to someone who is seeing the connection between heart and mind was the personal experience of going through mental health challenges and starting to see that, you know, there's a. And seeing my patients, I mean, I think that's the last piece is, like, when I sit in the office, the way I integrate it in a quick visit is to say, hey, you know what? Let's start with just our breath. Okay? Let's just take a minute. Let's take a breath together. All right? Let's do a 1 minute. You know, whether it's alternate nostril breathing or whether it's box breathing. Let's just do that for a minute together. Let's start, and then, bang. Then we go into. Okay, what's going on? You know, let's go through the top three problems that you're, you know, on your problem list. So there's ways to integrate it.
[00:52:34] Speaker A: Yes.
[00:52:35] Speaker B: You can be a mindful heart doctor in the office very quickly. Very quickly. So that's. That's kind of how I integrate it.
[00:52:43] Speaker A: So you open to a door to a question I'm dying to ask you. So we'll. We'll start to wrap up on this. Even though I, like, said, I feel like we could talk for another 3 hours, easy.
I had a.
Because I believe you mentioned this, but it's enough of a door cracked that I'm going to walk through it.
I didn't know I knew this person through my parents, so they passed away before I was able to interview them because I was so fascinated. But I'm sure you probably have expertise in this. I don't even know what to call the condition, but he had a, I believe, a pacemaker implanted to keep his heart at a steady beat. So, as you and I know, the heart is not a metrodome. His heart became a metrodome. And I just. I was dying to interview the individual because what he told my parents and Barry Layman's is he didn't feel like himself anymore. And I just. I was fascinated by that because we know so much of ventral vagal activation, that sympathetic a balance and beautiful dance that it does and how that connects to the brain. I just kind of wonder, as you may work, and I'm assuming pacemakers aren't foreign to your work in any way, shape, or form. As you adjust the heartbeats and these things, do you see that often? Do you see personality change? You mentioned depression in your previous statement as well.
[00:54:14] Speaker B: Yeah, that's a great question. I talk about it. I talk about a case vignette about that in my book, restart your heart. The gentleman had afib. Afib results in reduced blood flow everywhere, including to your brain, including to the emotional centers and the mental centers and the cognitive, your prefrontal cortex, all of that reduced blood flow. Your brain is not working as well when you're in atrial fibrillation. When we did an ablation and normalized his rhythm. When you went from this chaotic, irregular rhythm to a steady heartbeat, in this case, without a pacemaker. But I've also done cases with pacemakers. When that rhythm normalized, when it became a metronome, there's this gentleman. His depression went away. Why? Fascinating, because with Afib in particular, one of the most common symptoms is fatigue, and sometimes depression is a part of that.
I would say that's where I see it, is that regularization of the heart rhythm, okay, improves blood flow to every part of your body, okay, including your brain. So that heart, mind, heart, brain connection in your patient, in that case where a person had an irregular rhythm, and then they got a pacemaker, which regularized it. So we went from irregular to regular, okay, restarted. That's kind of the idea that we think about, or we can do it. In the case of shocking someone's heart, irregular to regular is you've improved blood flow. You've made the heart, the heart's an engine. You've made it a more efficient pump. And so I would say, by and large, on the positive side, people will feel better and more fatigued, more energy, et cetera, et cetera, and mentally and emotionally and cognitively. And there's a lot of data on this. There's data on ablation and reducing the risk of dementia in patients with AFIB. There's a lot of information. Blood flow is probably the biggest piece and the efficiency of your heart as a pump to your brain. But then the other big piece of it is that you're not having this stress response in your body. We all know that depression, for example, causes very physical symptoms. Anxiety does the same thing. When you normalize the physical irregular to a regular metronome heartbeat, you're going to impact in a good, most of the time good way. But I will say there are times, of course, where medicine and some of our intervention make things worse. Okay. Can have a change, but I don't know if that's answering your question, but, yeah, I guess.
[00:56:47] Speaker A: I guess the layman's question is if I'm assuming when you turn the heart into a metrodome, are you overriding the venta, the vagal tone, and creating your own with that?
[00:57:05] Speaker B: Yeah, that's a great question. I think what you're in, I would think of it more this way. When you're irregular and fast and the heart's not doing well, and then you're changing it to a metronome, you're normalizing, you're bringing the body back to a state of homeostasis. Like, let's take HRV out of the equation. You're lowering cortisol, you're lowering the stress response state, okay? Because the stress response state is high when the heart is out of rhythm. And when you make it a metronome, it drops. Now, if you take someone who's so with pacemakers in the way they work, they don't stay fixed at 60. They work with your heart's rhythm and weight. So you know, the heart rate go up. And if a patient's heart rate gets variable, et cetera, you know, the pacemaker is not going to kick in. And you can adjust that rate on the pacemaker from 60 to 80 to 40. And so you can. You can adjust. That's a. Think of the rate on a pacemaker or the person you're talking about. That's sort of like a safety net, so it doesn't override the different aspects of the vagus nerve. It is meant to work with it. But if it's not programmed correctly, or if a pacemaker is put in for the wrong indication, or maybe not the. I shouldn't say for the wrong indication, but maybe a patient, their health has progressed too far or whatever it is, normalizing the heartbeat again, if it's way out of sync and irregular, normalizing it to metrum is much better than being way out of sync. Would it be ideal? But the only scenario really, where a pacemaker fully takes over is someone who's called pacer dependent, which is mean they have no underlying heartbeat. And there are some patients with atrial fibrillation, people who. There are conditions called av block, where you have to fully take over with the pacemaker, but that's much better than having a heart rate of 20 or a heart rate 180. So I don't know if you do zero. Yeah, yeah, yeah. Am I. I'm not sure if I'm answering your question.
[00:59:10] Speaker A: It just is fascinating research to me. So I appreciate you, my friend. I feel like. Like I said, I feel like I could talk to you for another three to 4 hours, just with everything we've opened up. So I'll just throw an open invitation to come back at some point, especially since you're writing a second book that definitely, I hope, will be a trigger to have another conversation. But Doctor Desai, I just appreciate you, appreciate your work and sharing it with our audience.
[00:59:45] Speaker B: Thank you, Matt. It's been an honor to be on the show. I really enjoyed our conversation. I really hope in the end, your listeners didn't get too distracted by all the weird paths that I was taking. But I'm a cardiologist and my mind's going all over the place right now. So heart mind docked. But I would say the three things I want to leave people with is with regards to the heart and HRV is number one.
Definitely you need to think about HRV from the standpoint, and not just physically, your heart, but also your emotional mental health. And really incorporating HRV, if you can, in the form of some kind of wearable, you know, into your daily practice and do experiments on yourself. Like, see, does my HRV change? Do I actually feel better? You know, that kind of thing? So that's number one. And then number two is, I would definitely encourage people, you know, if you want to learn more, I have a lot of videos, I have a lot of content on my website, drastimdesci.com comma. It's a
[email protected]. dot and then with regards to some of the stuff I've written about in my book and some of the stuff I'm working on, you really can improve your overall health and find balance in a chaotic world when you focus on both your mind and your heart. And there's tools, there's ways you can do it. And yeah, people can feel free to reach out to me on social media and stuff like that. But it's been an honor being with you and I appreciate your time and letting me kind of go all over the place with what we talked about.
[01:01:16] Speaker A: I hope you come back and do it again. I think you gave us HRV nerds a lot to chew on. So I will put links to the book, the website, everything in the show notes as well so people can get that information. But Doctor Desai, thank you so much. Thank you for your work. And as always, you can find show notes and everything
[email protected]. dot we'll see you next week.
