Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi there, hearties. It's Angela here from Healthy Hearties. I'm here with Australian cardiologist, Dr. Warrick Bishop, who's kindly given up his time to talk through some of our most common questions that we receive in our heart group. So good morning to you. Well, it's good evening to you. Thank you for joining us, Warrick. It's a pleasure, Angela. In fact, it's afternoon and it's Father's Day. Oh, happy Father's Day. I hope you've been spoiled today. I've seen my dad and my kids have seen me. It's been a great day. Thank you. Oh, fantastic. So you have written a few books all about the heart and preventing heart attacks. So I was very excited to meet you and talk through some of the key issues really with the heart. So can you just tell us a quick little bit about yourself and why you're so passionate about prevention? Well, look, I'm a cardiologist, as you said. About 10 or 15 years ago, I really had an impactful patient experience where I literally was involved in the roadside resuscitation of a man who dropped dead during a fun run. Now, the confronting thing for me was that I'd seen the very same man some 18 months earlier, and I'd reassured him after a treadmill test. You can imagine that that was just... incomprehensible. And it really set me on a path to try and understand better how we could predict risk. But during that journey, Angela, what I've also realised is that best educated patients get the best healthcare. And the more people understand, the more engaged they are in their own health. And so I've written a couple of books trying to help and empower people, one on atrial fibrillation, one on heart attack prevention. And as you know, you've already helped me with one that I'm writing about cardiac rehabilitation. Yes, looking forward to that one. So am I. So are you happy for us to get going with some questions? Absolutely. One of the common questions we have is about stenting, which I know you do a lot of in your practice. So just so we have a little bit more understanding about stenting, how blocked does an artery need to be before you decide to stent? And then after someone had those one or two or more stents put in, if they've still got leftover blockages, should they still be worried about those? So look, this is a fascinating space and there's a couple of trials that sort of guide us as well. But first of all, from a practical perspective, sometimes it's really, really hard for us to evaluate critically if a narrowing in an artery is actually hemodynamic or flow limiting. And so what I mean by that is you might imagine a... Your listeners or the people in your group might imagine a plastic tube that's been left out in the garden. It's got a lot of rubbish and dirt inside it. And you look at that plastic tube and it's clear and you think, oh, that looks like it's blocked. But if you run water through it, it actually lets water through really quite effectively. And the significance of that is to be really precise about whether something's flow limiting or not can be very hard. in a three-dimensional moving object, which is what an artery is. And so we have different techniques, but essentially when we do an invasive angiogram and look closely at the artery, we're thinking that a narrowed artery that may need a stent is probably gonna be 70% luminally narrowed compared to the normal artery. So we're thinking about 70% or greater. But we then have to prove that what we see, if it's close to that 70%, we then have to prove that it's actually causing flow limitation. So the way we prove that something is truly causing flow limitation is that we put people often through some sort of functional test. stress test may have led us to take someone to the invasive angiogram lab so we can get those very precise pictures. And our stress test would show abnormality that tells us that the heart's not getting enough blood during the time of exercise. So that's our functional proof. That's our hemodynamic proof that the narrowing is significant enough to limit blood flow. Would the same apply if they were having chest pain? Correct. So chest pain as part of the stress test is obviously some of the information that we collect and very important together with shortness of breath, of course, as well. Now, the really interesting thing is that there's been a lot of talk over the last five, five to 10 years about whether we should be stenting or comers. And there's been a large trial done last year. called the ischemia trial, which really looked at people who had one or two narrowings causing hemodynamic problems as evidenced by stress test abnormality. And they randomized those people to receiving a stent straight off the bat or just optimal medical therapy. And it turned out that after about the three or four years of follow-up, the lines, for outcome in terms of major mortality, morbidity and cardiac events was almost identical. And so we're starting to reframe how quickly we jump into putting stents in once we've proven an artery is a problem. And that ischemia trial sort of told us that if we're putting in stents to help angina, we're probably helping those patients in particular over and above. optimal medical therapy okay and so you've told someone i've you know put in a stent or two but there was a few other blockages that didn't need stenting should they be worried about those is there anything they could do to reverse them yeah so There's no question that if we found someone who needs stenting, they'd be on a group of drugs which are no-brainers, so they would be on aspirin. And then they'd be on a second sort of fancy aspirin after their stent, which might be called clopidogrel or prazogrel or ticragilor or bralintid. But if you've had a stent, you'll be taking a fancy aspirin and a normal aspirin. We call that dual antiplatelet therapy. You'd almost... You'd also be guaranteed to be on a cholesterol lowering agent because we have enough research to tell us if you've required a stent or you've had a heart attack or you've had a bypass or a stroke, that putting those people on cholesterol lowering agents reduces future events. Well, in the last year or two, we've had some major trials come out. The advent of these new lipid lowering agents, which can be injected. the, what we call the PCSK9 inhibitors. These agents have allowed us to get cholesterol levels down to very low levels. And with that, we've run trials to literally look at whether we can get plaque regression. And we can, if we can get that LDL cholesterol, that so-called bad cholesterol down under about 1.6 millimoles per liter, we give people a sporting chance of their plaque. getting less and less. Interesting. There's not so many people offered that here unless they are not responding to the stat. So these new agents, they're quite expensive. They run at about 10,000, 15,000 Australian dollars a year, which is probably 5,000 to 7,500 quid. So they're not cheap. So we have them for... a condition called familial hypercholesterolemia, where people have extraordinarily high cholesterol levels and will die prematurely without proper therapy. But we also have it for our very, very high risk people who have had perhaps subsequent events on maximal therapy. So they are restricted. I guess behind the question, people are just saying, you know, should I be worried? Am I a ticking time bomb if I've got a few 50%? ones that you didn't stent you know is that the stress behind the questions i guess so the answer to that is that there is absolutely no um there is no suggestion from the literature that we should be stenting those intermediate non-flow limiting lesions and the literature even questions whether we should be running in and stenting the clearly hemodynamically significant lesions so the answer is Don't fuss, but do take your tablets and do demand that your cholesterol is properly managed. But together with that, also get the blood pressure down because blood pressure has a role in driving further plaque formation. So blood pressure under control, cholesterol under control, good exercise and good eating. Of course. Yes, and crap. Yeah, all the lifestyle measures and live a healthy and active life. and do all the prevention stuff, which I know you're keyed on as well. Absolutely. Yeah, good. Okay, well, great. Thank you very much for that. I was going to say just before we wrap up on this particular topic, which is fascinating, I hope the hearties enjoy it, I'd just like to say to you, as we were saying before we commenced this interview, that I've got... a whole lot of resources that I've put together for my healthy heart network, which I'm very happy to extend to you and your hearties. We've got podcasts, newsletters, videos, a whole range of bits and pieces to help support and educate people with cardiac interest and to try and give them as I've said to you before, best educated patients get the best healthcare. So thank you for that. Yeah. Pleasure. I understand you're going to put a link for that below. Yes. Yes. If you share the link with me and then I'll pop up below. So all the hearties can take a look. And then as you say, a good thing that I would recommend is going for a walk while listening to a podcast. Perfect. Ties it all in together. Well, thank you for your time, Warrick, and have a fabulous Father's Day. Thank you so much, Angela. You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
