'State Of The Heart' Cardiologist Assesses Breakthroughs In Heart Health

Jul 22, 2019
Originally published on July 23, 2019 2:43 pm

TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross. Breakthroughs in heart medicine, including surgical procedures, devices and medications, have changed how various forms of heart disease are treated and enabled many people to live longer lives. We're going to hear about some of those new developments from Haider Warraich, author of the new book "State Of The Heart: Exploring The History, Science, And Future Of Cardiac Disease." We're also going to talk about cholesterol and blood pressure.

Warraich previously joined us to talk about his book "Modern Death: How Medicine Changed The End Of Life." He's a cardiologist who began his medical training in Pakistan, where he's from, and continued his training in cardiology at Harvard Medical School and Duke University. In September, he joins the faculty of Brigham and Women's Hospital at Harvard Medical School and the Boston VA.

Doctor Haider Warraich, welcome back to FRESH AIR. You write that during the time that you were a medical student, you saw so many changes in heart medicine and technology. Tell us about one that you think is most significant.

HAIDER WARRAICH: When I was a medical resident up at the Beth Israel Deaconess Medical Center in Boston, this was around the time when a new device had just started to be used in clinical practice that I had really never heard about before. And this was a device called a left ventricular assist device. And really what it is, is it is a mechanical pump that can be sewn directly, right into a patient's heart, and basically takes over the pumping function of the heart. And I know when this program started, there was a specific row in the hospital, in the wards, where these patients would be taken care of. And at least initially, residents were not even allowed to take care of these patients. So they had this aura, this mystery to them.

But the interesting thing about this therapy is that it fundamentally changes so many of the things what we consider to be, you know, the key fundamental principles of being a human being. So, you know, these patients who had these mechanical pumps, you know, they didn't have a pulse. If you performed CPR on them, it could actually do more harm than good. And these patients were basically dependent on their batteries for their life.

So this was such a dramatic departure from really any type of other medical intervention that I'd ever even heard about, which is, you know, part of the reason why I actually pursued this and now I actually specialize in taking care of these patients.

GROSS: Yes, and you describe this device, which is an LVAD - which stands for left ventricular assist device - you describe it as representing the dawn of a new era in human life, the union of man and machine. Because you're totally dependent on the machine, I mean, every second of the day. But really, the idea of, like, no pulse. I can't - it's, like, hard for me to conceive of that.

WARRAICH: I mean, it's hard as a physician. I mean, checking someone's pulse is part of the - you know, one of the sort of purest and oldest rituals in medicine. When you come up to someone, you shake their hands, and you're examining them. And you almost always start by checking the pulse in their wrist. And the other thing that happens in these patients is that if you put a stethoscope to their chest, usually, you'll hear, you know, the gallop of the heart kind of, you know, running away as it has been since, you know, we were in our mothers' womb.

But you don't really hear the heart sounds. All you hear is this mechanical pump kind of whirring away, pushing blood to every part of the body. It really is a surreal experience the first time you experience a patient with an LVAD as a physician, and I can't even imagine what it must be like to have one.

GROSS: Why don't you have a pulse when your blood is being pumped by the LVAD device?

WARRAICH: So the reason we have a pulse is because the heart beats rhythmically, you know, beat by beat. And with every beat, it sends a pulsation through the body that can be felt as a pulse. But the VAD, the motor is just continuous. So because it's continuous, there's no pulsation to be felt in most patients.

GROSS: It's not pumping. It's a continuous flow?

WARRAICH: It's a continuous flow.

GROSS: Isn't it another strange thing about this device - and again, I found this really hard to imagine. You write about a patient whose device was still pumping blood even though the patient had died.

WARRAICH: So, you know, LVADs are really a great therapy. I've seen them really transform some patients' lives. It's allowed a lot of patients to, you know, live parts of their life that they may never have been able to - been able to attend grandchildren's graduations or bar mitzvahs, or do really, really important things that they would not have been able to were it not for the device. But it does in some ways represent a turning point in what it means to be human. You know, I think you look at TV and, you know, everyone is talking about this distant future in which we will be transhuman. But if you're a cardiologist, like me, and you take care of these patients with VADs, you know that transhumanism has arrived. And it affects us - and especially for these patients, who are dependent on these machines, it's a central part of their life. But not just to their life but also at the end of their life.

So one of the things that LVADs make a bit hard is that, you know, the LVAD separates the heart from the rest of the body. Because the rest of your body is still mortal while the LVAD, in some ways, has removed that feature from your heart because it'll keep pumping as long as it has power and has battery life. So when patients do in fact pass away, it may be that their LVAD is still functioning, and it has to be - it has to be turned off. Which is, again, something that is so foreign to really anything else that I'd ever done. But it is a really important part of taking care of these patients. A lot of patients who get LVADs, they get it, and those things will stay in them until they pass away.

GROSS: There's another breakthrough in heart medicine that happened while you were a medical student. In fact, you witnessed it. And I'm thinking of aortic valve surgery. You observed the first time a transcatheter aortic valve was placed in a patient in a minimally invasive procedure. So, like, what was - tell us about this procedure.

WARRAICH: So one of the things that is a disease that's fairly common is called aortic stenosis. The aortic valve is the last door that the blood has to leave before it leaves the heart and enters the rest of the body, starting with the aorta, which is the greatest vessel in your body. Over time, this valve can sometimes get thickened, and it can basically cause an obstruction of blood flow, basically raising the pressure that is needed for blood to leave the heart. And it can be a fatal diagnosis. And initially, and before, like, 1950s, we really didn't have any treatment for it. But then the sort of revolution in cardiac surgery meant that now people who had aortic stenosis, especially if it was severe, it could be repaired with surgery.

But then starting in Europe, physicians and researchers started to think about, you know, how can we do this better? How can we help patients with aortic stenosis without having to necessarily cut their chest open? You can replace the aortic valve, without doing surgery, through small catheters that are inserted through your leg or other blood vessel. And it's transformed the treatment of aortic valves surgery. And I was a researcher and up in Boston when one of the first few of these devices were ever implanted in the United States.

And I don't think anyone could have ever imagined at that point just how revolutionary this treatment might be. In fact, the most famous TAVR patient is actually Mick Jagger. He just had his - he had severe aortic stenosis, and he underwent TAVR - this TAVR procedure. And within days of this, he shared this video on Twitter in which he was back, you know, doing his act, dancing. And, in fact, he was back doing a concert just a few days ago. And this was unimaginable - unimaginable, I would say even, you know, a few years ago that we would be able to transform treatment in a way that no one could have really imagined.

And these - this is what's really one of the really interesting things about heart disease is that even though it doesn't get as much attention as so many other diseases, the advances that we have seen and the advances that we keep seeing in this area are just extremely fascinating and, to me, represent the pinnacle - one of the pinnacles of human achievement.

GROSS: There are several heart procedures now that used to be much more difficult and risky. And now they're minimally - they're like minimal invasive procedures. But bypass surgery, has that really come very far in the past decade or so? I mean, doctors still have to cut the chest open and saw through the breastbone and put the heart in a heart-lung machine. I mean, it still seems like such a really difficult procedure for the patient.

WARRAICH: I mean, it is a difficult procedure. It has gotten better over time. And - but again, I, you know, one of the patients that I spoke to who had had bypass surgery, I mean, he described to me what it felt like when he woke up. And it was - it, I mean, the amount of pain that he had for the - for even with, you know, adequate pain control, it's still not enough. It is a - it is still a - it is a big deal. And we haven't really seen - we've seen incremental progress in bypass surgery that has helped, you know, improve outcomes. But we haven't seen dramatic, you know, a dramatic shift in how the procedure is performed.

What we have seen is now a lot more patients who may have gotten bypass surgery a few decades ago, now they get coronary stents, which are really minimally invasive, and at least for many cases, have provide patients outcomes as good, if not at times better - better than bypass surgery.

GROSS: Well, I want to talk with you about stents a little later. Right now, we have to take a short break, so let me reintroduce you. If you're just joining us, my guest is Dr. Haider Warraich. He's a cardiologist and author of the new book "State Of The Heart: Exploring The History, Science, And Future Of Cardiac Disease." We'll be right back. This is FRESH AIR.

(SOUNDBITE OF WES MONTGOMERY'S "4 ON 6")

GROSS: This is FRESH AIR. And if you're just joining us, my guest is Dr. Haider Warraich. He's the author of the new book "State Of The Heart: Exploring The History, Science, And Future Of Cardiac Disease."

You write what constitutes a heart attack is different from what was a heart attack 10 or 20 years ago. How has our definition of a heart attack changed or a diagnosis of a heart attack?

WARRAICH: So, you know, a few decades ago, the only way that, you know, you could diagnose a heart attack was by looking at the electrocardiogram. This is, you know, also called the EKG, which is the squiggly lines that, you know, you see all the time on TV shows which go flat, which is bad. And the only way to really diagnose a heart attack was to look for a specific pattern on the EKG which suggested that there was some type of critical blockage in the blood vessels that supply the heart with oxygenated blood.

And what was going on, though, was that we were missing a lot of patients who were still having heart attacks but didn't really have that type of pattern on their EKG. Now - but then what changed was that we developed these new blood tests called troponins. And these troponins really can become elevated when people are having some type of damage to the heart. So they're much more sensitive than if you just get an EKG. And this allowed us to really pick up heart attacks that we were really missing, especially in women. Women have the heart attacks with this troponin elevations more commonly than men do.

But now what we're removing is that we have new technologies - new type of troponin called the high-sensitivity troponin, which is incredibly sensitive. In fact, though - that the level of troponin can be detected even in patients who are perfectly healthy and normal, so - which is one of the reasons why I think we need to be wary of newer technologies that are increasingly sensitive. You know, someone who may not have been labeled with having a heart attack now with, you know, a slight bump in their high-sensitivity troponin now gets labeled as having had a heart attack.

And we don't know - and for most cases, it's still the same. But really, I think what I worry about is that if we use these new extremely sensitive tests without being extremely thoughtful about which patients we draw them in that we might, in fact, start seeing what's been called diagnostic creep, in which, really, we start labeling people who are having, you know, some amount of damage to the heart - maybe not amounting to what we would, you know, call a heart attack or - as having had one. And I think we don't know what that will do to someone's sense of self, how they see themselves and if we - if treating that actually helps them in the long-term.

GROSS: The most low-tech version of diagnosing a heart attack is what is described as the eyeball test, which you say is really important in diagnosing a heart attack. What's the eyeball test?

WARRAICH: Well, the eyeball test is, you know, you walk into a patient's room, and you just eyeball them and get all the sort of information you need from them based on just a visual inspection. Are they - do they look gray? Are they sitting up breathing comfortably? Are they, you know, lurched over? It is inevitable that we use the test on really every patient. But it is - it fails a lot of people. It's really not a great substitute for all the additional information that we have. And the eyeball test is also one of the things that's - introduces a lot of bias.

So for example, the eyeball test fails a lot of women with heart disease because I think so many of us, both physicians, nurses, as well as patients themselves, have been trained to think of heart disease as purely a man's disease, as a disease of middle-aged or older men. And I think - which is why, if we just rely on visual inspection and, you know, we - that we're actually opening ourselves up to a bias in which we might, you know, incorrectly assume that a woman who is having difficult breathing or having chest pain probably doesn't have - is not having a heart attack or any type of heart disease. And this has been something that's been a - really a historic wrong that I hope that we can overcome.

GROSS: While we're on the subject of women and heart disease, how do women's symptoms present differently than men's sometimes?

WARRAICH: So this is a bit controversial. But, you know - but women are more likely to have what's called atypical symptoms, in which - which include symptoms other than your classic chest pain. This could include, you know, even nausea, vomiting, stomach pains, things that we don't usually necessarily associate with heart disease. I mean, some studies have shown that that - not to be the case, but I think that overall there is consensus that women are more likely to have these atypical symptoms.

And what that does is that not only does it throw off the physician or the nurse or the paramedic who's taking care of these patients, it can throw off the patient as well. And patients who don't have classic chest pain are less likely to come to the hospital in a timely way. They're more likely to delay care. And that can have really bad consequences downstream.

GROSS: Let's talk about blood pressure a little bit. It's a standard part of physicals, of, I think, most medical exams, especially if you're prone to high blood pressure. You can have your blood pressure tested more frequently. I think most of us don't really understand what blood pressure is and why there's two separate readings, the higher - you know, the upper number and the lower number and what they each indicate. So just give us a basic brief overview, if you would, about what blood pressure is.

WARRAICH: Sure. So every time the heart beats, blood is injected into the arteries of a human being, of - you know, like me and you. And that injection of blood basically sends a pulsation that travels throughout each and every artery in your body. You can feel it in your neck. This is the pulse that we feel in the wrist. It goes all the way down to your toes.

And so the higher number, which is called the systolic blood pressure, is the pressure recorded at the peak of this pulsation. And the diastolic blood pressure, which is the lower number, is the pressure in the blood vessels when there's no pulsation passing through it, which, you know, represents the resting blood pressure or tension in the arteries when there's no active pulsation passing through it. And as blood pressure goes up, it increases the pressure or the force that the heart needs to generate to push blood through the body.

And one of the things that we know increases blood pressure is salt intake. But there are many other factors as well. Being overweight can increase your blood pressure. But it is one of the most important things that we can do and one of the best ways to prevent heart disease if we control our blood pressure. And in fact, we're learning new things about blood pressure really every week. There was a study in The New England Journal (ph) just this week showing the relationship between increasing blood pressure and increasing mortality and other adverse outcomes.

GROSS: My guest is cardiologist Dr. Haider Warraich, author of the new book, "State Of The Heart: Exploring The History, Science, And Future Of Cardiac Disease." After a break, we'll talk about how stents are used in treating heart disease and heart attacks. And David Bianculli will review the new "Veronica Mars" sequel series, which is now streaming on Hulu. I'm Terry Gross, and this is FRESH AIR.

(SOUNDBITE OF MUSIC)

GROSS: This is FRESH AIR. I'm Terry Gross. Let's get back to our interview with cardiologist Haider Warraich, author of the new book "State of The Heart: Exploring The History, Science And Future Of Cardiac Disease." In September, he joins the faculty of Brigham and Women's Hospital at Harvard Medical School and the Boston VA. He began his medical training in Pakistan, where he's from, and continued his training in cardiology at Harvard Medical School and Duke University. We're talking about new developments in treating heart disease.

Let's talk about stents. There have been breakthroughs in stents. On the other hand, their value has been questioned in some situations. Let's start with, what is a stent? What is it supposed to accomplish?

WARRAICH: So the heart, even though it's full of blood - it's pumping blood to the rest of the body - it also has its own separate supply of blood that comes from these teeny tiny arteries called the coronary arteries. They basically wrap around the heart and supply it with oxygenated blood. And you can argue that this is some of the most important real estate in your entire body. Any blockage or obstruction of blood flowing to coronary arteries can result in a heart attack and, basically, result in a lack of oxygen to your heart, resulting in that basically becoming dead tissue within minutes.

And so what the stent does is that a stent is a small, metallic wireframe that can be introduced through plastic-based catheters that can be inserted either through the groin or through the wrist, preferably through the wrist because that procedure has fewer complications, and can be inserted all the way into the coronary arteries through a minimally invasive way and can help open up any blockages or lesions that might be in the coronary arteries, restoring blood flow.

I mean, coronary stents are one of the most dramatic advances that we, as a civilization, have achieved in the 20th century. And most listeners may know of people who have had stents. Many may have had stents themselves. Both my father and my father-in-law have stents in the coronary arteries in their blood vessels. And so there's no denying that this is one of the greatest advances that we've known. And over time, it's actually become more safe as well. At the same time, just like any other procedure, it is not a perfectly benign procedure. And there is always a risk, especially with how medicine is paid for in this country in which you basically get paid more for doing more. There is always the risk that people who may not necessarily benefit from a stent may end up getting it because of either - not just for a bad financial motive but because, you know, someone maybe just wants to help them - help a patient and think that this is the best way to do it.

So there's no controversy about stents in patients who are having heart attacks. There's - study after study has shown that if you're having a heart attack, if you have an unstable or worsening chest pain or if you're having a heart attack, the stent is a lifesaving procedure. But there is some controversy in patients who have stable chest pain, who have, you know, chest pain maybe, you know, once a week after they've walked for a couple of miles and which goes away kind of predictably if they rest. And there is some controversy in which, in these patients, it's not really clear if stents are any better than medical therapy which is very underused in this population. We just don't do a good enough job of getting the right meds for all these patients with stable chest pain. And so the question there is that in these patients, is a stent working more as a really powerful metaphor or as a powerful placebo rather than as something that's giving any additional benefit to these patients? And that science is still in flux.

GROSS: So the substance that mostly clogs arteries is plaque. When I think of plaque, I think of dental plaque. Is there any connection between dental plaque and the plaque that can clog arteries?

WARRAICH: So there is no direct connection, but bad dental hygiene actually is a risk factor for heart disease. But the plaques are totally different. The plaques that form in the blood vessels are basically - these are the - when - things that are kind of full of cholesterol and - but the plaques on your teeth are totally different.

GROSS: So the cholesterol creates the plaques, which clog the arteries. Let's talk a bit about cholesterol. There's two kinds of cholesterol now. There's the good guy cholesterol and the bad guy cholesterol. The LDL is the bad guy. The HDL is the good guy. It's relatively new that doctors have divided cholesterol on those two different parts. So can you explain what the difference is between the good HDL and the bad LDL cholesterol?

WARRAICH: Sure. So LDL cholesterol is basically a protein that transports cholesterol from your liver to the rest of the body. And if you have inflammation - if you're inflamed or if you have sites in the blood vessel that have inflamed, that protein starts depositing cholesterol into your blood vessels. And over time, those cholesterol-filled plaques can grow and grow and grow. And if they rupture, it can cause this really sort of chaotic inflammatory cascade that results in obstruction of the blood vessel. This is really how most heart attacks happen is when a plaque ruptures in one of the coronary blood vessels that has been deposited there over time by LDL cholesterol.

HDL cholesterol, which is a good cholesterol, is a protein that takes - actually does the opposite. It takes cholesterol from the blood vessels and back to the liver. And there are a lot of studies that show, quite definitively, that having a higher HDL cholesterol actually reduces your risk of heart attacks while the opposite is true for - in bad cholesterol, LDL cholesterol, in which if you have high levels of LDL cholesterol, that actually increases your risk of heart attacks. And even though treating LDL cholesterol has been shown to be effective, treating HDL cholesterol with medications has actually not been shown to be effective in reducing risk.

GROSS: So if you eat foods that are high in HDL cholesterol, it's not necessarily going to help you.

WARRAICH: Well, it is controversial. But certainly, taking medication that raise HDL cholesterol, so far, has not been helpful. But if you...

GROSS: I see.

WARRAICH: ...Do other things like if you exercise or if you watch your diet and if your HDL rises because of those lifestyle changes, that can actually result in meaningful benefit.

GROSS: Statins are drugs that are used to treat high cholesterol. You seem very enthusiastic about them in your book.

WARRAICH: Well, I am like anyone else. And I would strongly advise everyone listening is that, you know, we need to be very skeptical in general but especially of medications. There's very few things in life or especially that come out of, you know, a prescription closet that have no tradeoffs. But statins are one of the most well-studied drugs in human history. And they're one of the few things that have been proven to reduce the risk of heart disease in patients who are at high risk. And really, it's the strength of the data and the decades of data that we have around the world in patients who are at really across a spectrum of disease that has really convinced me that that we need to be very, very strong proponents of statins to reduce the risk of heart disease.

GROSS: Let me reintroduce you here. If you're just joining us, my guest is Dr. Haider Warraich. He's a cardiologist and author of the new book "State Of The Heart: Exploring The History, Science, And Future Of Cardiac Disease." We're going to take a short break. Then we'll be right back. This is FRESH AIR.

(SOUNDBITE OF MUSIC)

GROSS: This is FRESH AIR. And if you're just joining us, my guest is Dr. Haider Warraich. He's the author of the new book "State Of The Heart: Exploring The History, Science, And Future Of Cardiac Disease."

When we last spoke, in late January of 2017 - this was shortly after Donald Trump was inaugurated - your father couldn't get a visa to visit you in the U.S. And your mother, who had a visa, was denied entry to the U.S. during - and this was during the Obama administration. And she was told she had to get a new visa, and then she was rejected when she applied for it. Is - are their visa statuses still the same?

WARRAICH: Their visa statuses are still the same. My parents have applied multiple times and have been denied visas. But we're hoping that will change. In fact, just today, I'll be filling out the form to apply for U.S. citizenship. And my hope is that - and I will pray, and - that that application gets accepted and that we are able to sponsor our parents.

But there is a lot of uncertainty. There are a lot of things that we just can't take for granted. The only thing I can hope for and pray for is for my parents' health while we wait for this process. But, yes, it's been difficult. My parents can't visit. And - but we're hoping that that will change in the future.

GROSS: Were they ever given reasons for their visas being denied?

WARRAICH: They have never been given a reason, and it's not for lack of trying. And this is the - you know, we've - you know, they have talked to people. They have done multiple interviews. They have never been given a single reason. And that's part of the frustration that we face, is that we just don't know what we're up against. We don't know what we can do to rectify.

I mean, these are people whose - you know, their - all their children are in the United States, all, you know, green card holders, all of them, you know, serving this community, all of them - and good citizens. And yet, they, for, you know, reasons that we don't know, are not even allowed to come and see the homes that we have built here. It's a shame, and it's a real tragedy.

GROSS: So you're applying for citizenship. Your parents don't have visas. But you hope, after you become a citizen, you'll be able to sponsor them and bring them here. But your daughter was born here, so she is a citizen. So what's it like for you to have a daughter who is a citizen of the United States while you're trying to become one?

WARRAICH: America is more than just a country. It's an idea. And the idea is that you can come here, and you can succeed and become a part of this society and not only help yourself, but help everyone you touch and help this community grow. And I feel like, through my work, I've been able to do that in a very direct way.

And a lot of people get embarrassed when, you know, someone asks them, where are you from? And I wait for that question. I wait for someone to ask me where I'm from so I can tell them I'm from Pakistan so that they know that there is a Pakistani who's there amongst them who's there to help, who's there to love and who's here to help not just this country but this idea continue to grow, that this is a place where you can come from - doesn't matter how much money is in your pocket or who you know, you can succeed, and you can serve. And I hope that my daughter can be a part of this idea, and so can we.

GROSS: Meanwhile, I think a lot of us have heard President Trump at a campaign rally talking about four new women members of Congress, women of color, and - Alexandria Ocasio-Cortez, Ilhan Omar, Ayanna Pressley and Rashida Tlaib, three of them born in America. All are citizens. And he, during the rally, was saying things that many people have interpreted as racist about them. And the people in the audience were chanting, send her back, send her back. As an immigrant from Pakistan trying to become a citizen now, what goes through your mind when you hear that chant?

WARRAICH: It's gut-wrenching. And I have - when I saw that video, I didn't have the stomach to open it up. Also, because, you know, like so many others, I have heard that myself. My wife has heard that herself. She has heard that from people who are governmental officials, not just people that - on the street.

But, at the same time, I also know of people who lined up airports when the Muslim ban was first considered. I know of people who are rushing to the border to help immigrants. And this is the paradox of America, that, at the same time, you have so many people who care so deeply about what makes this country beautiful and who have welcomed us and are welcoming millions more to come to this society, to be a part of it and to grow here with them and help them grow as well. And this is one of the sort of fundamental schisms in what it means to be an immigrant, that you can succeed as much as you want professionally, but someone can come up and tell you to go home.

GROSS: Aren't you tempted to say when somebody says go back to where you came from, to explain to them that you're a cardiologist, and you're here saving lives?

WARRAICH: That's why I've always tried to focus on my work. That's why I always want people to know that I am from Pakistan, but that I am here in a capacity where I have this wonderful, great privilege, not just to help people who are in front of me, but to share their stories so that they'll inspire others. And that's why I don't shy away from telling people where I'm from. In fact, it is - it's really important for me for people to know that so that I might be the only Pakistani they might ever see in real life. Maybe the others, they just see on TV as caricatures in Hollywood films.

We can - but I can only do so much. You know, this burden of being this political as an immigrant in this country, it's not fair. I think that, you know, we want to come here and be human beings like everyone else. But an apolitical fate is not our destiny. Our destiny, until this politics continues, is that we will be politicized. We will be characterized - not just immigrants, but people who have - born here who are - who look different.

But my faith and my hope as I fill out this application is that the arc of history will continue to grow positively, and that the American idea that so many people have come to will continue to grow and shine and that this will be an aberrancy. But it will need us to work together. If you're complacent, then the forces that want to, you know, shatter this dream or shatter this vision of America will prevail.

GROSS: So the first time you were on FRESH AIR in late January, just a couple of weeks after Donald Trump's inauguration, you said to me, you know, that you'd only lived here since 2010, and you'd only really known the Obama presidency. And you said, I don't know what Trump's America will look like for me, but it does fill me with a great deal of trepidation. How does it look to you so far?

WARRAICH: In some ways, it looks better and worse than I would have thought. In some ways, I do think that the checks and balances that are present in our government, in the judiciary, in our media, in our public have kept some of the worst tendencies or some of the worst outcomes that we could have imagined at bay. But at the same time, as you've already referenced to the rally, those are things that one couldn't imagine would happen at a presidential rally.

But I hope that people will see the work that immigrants do in this country. I'm, you know, I'm going to be working at the Boston VA, where I hope to serve the veterans of this country. And I will - if asked, I will tell them I'm from Pakistan, so that they can - they will know and others will know that we're here, and we don't want to - we just want to be. We just want to have a good, happy life just like them. And we're not as different as they might be led to believe.

GROSS: Haider Warraich, thank you so much for joining us again. It was really good to talk with you.

WARRAICH: Thank you, Terry.

GROSS: Dr. Haider Warraich is the author of "State Of The Heart: Exploring The History, Science, And Future Of Cardiac Disease." After we take a short break, David Bianculli will review the new "Veronica Mars" sequel-series, which is now streaming on Hulu. I'm Terry Gross, and this is FRESH AIR.

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