Welcome, my name is Dr Warrick Bishop. I'm a cardiologist, an author and a keynote speaker. I'm CEO of the Healthy Heart Network. I'm all about trying to help people live as well as possible for as long as possible. Heart disease is huge in Australia. Every 20 minutes someone suffers a heart attack. Most of these could probably have been avoided if only we knew what to do. This podcast is all about helping you understand blood pressure, weight, cholesterol for better health. If you enjoy this podcast, I would be honoured for a five-star review. You can share it with your family and friends. It may well save someone you love. Hi, my name is Dr. Eric Bishop and welcome to my podcast and videocast station. Today I'm really pleased to have the opportunity to speak with Angela Paris who's a cardiac nurse who I've known for years. She's an advocate for preventing heart disease, she's an advocate for good care and cardiac care, she's an author, she's a committed nurse, she's a fantastic individual and today she's going to share with us her own cardiac story. Now, I've got her permission. We are going to talk about some of her specifics, but we do have a permission to share. She's very happy to use herself as an example to help others. I'm so grateful, Angela, and welcome. How are you? Good. Thank you. Thank you, Warrick, for having me today. Yes, I'm well, thank you. Well, let's keep you well. That's pretty important and number one priority. What we're going to talk about today, Angela, is your own journey to a degree you've explored getting your heart screened. Would you like to tell us a little bit about why you've done that? Yes, so I'm 68 years old. My father passed away of a sudden heart attack at the age of 56. So I have been, that's been in the back of my mind all the time to make sure. that I stay healthy and not be subject to a fatal heart attack at a young age. And I've also been a coronary care nurse, intensive care nurse for many years. And I have seen people losing their loved ones due to a sudden heart attack. In fact, I was involved with saving somebody's life at the age of early 40s. He had a massive heart attack. And it was a matter of... minutes was going to be pronounced dead. So yes, I'm very much interested in preventative health for cardiac disease. There's no question, Angela, that being involved in the resuscitation of someone who was previously fit and well and then struck down by a heart attack is an incredibly confronting and vivid way to be reminded of the impact of heart disease. And both you and I know so well that we can now be proactive about it by looking and imaging the heart arteries to truly see the health of someone's arteries and understand what's going on. Exactly. One of the things I'd like to speak to, just for the people listening, and you would know this already, I'm sure, is that when we think about family history, we think about premature coronary artery disease in the context of men having an event at about 55 years of age or less, and women at an age of about 60 or less. So your dad was certainly borderline premature coronary artery disease. Angela, did he smoke or have any other risk factors that may have meant that he had that event at a relatively early age? He did smoke only on the weekends, wasn't a heavy smoker. He was a doctor, was under a bit of pressure from work because we had just been saved from cyclotrasy in Darwin. Wow. So he died. five years after that. Wow. I didn't realise you were from Darwin and I didn't realise your dad was a doctor. So obviously you've got that healing, caring, health professional gene that has been passed through. So that's lovely to hear, Angela. I didn't even realise. Let me also put in there for a bit of understanding again for the listeners. When we think about relating your father's event at about 55 to your risk, in general terms, what we see is that women follow men in terms of their risk by about 10 years. So the way to think about that, and vice versa, so men tend to be ahead of women. by about 10 years so if we were to try and put that into a simple example if i saw a male who had an event at about 55 56 years of age i'd be thinking that the the daughter or the sister of that male might have the event at about 65 so about a decade later that means we want to be screening five to ten years earlier to make sure we're way ahead of the game and conversely if I were looking after a woman who was a 60 who had an event then I'd want to be screening her male first degree relatives in anticipation of them having an event at 50 years of age yes they're screening them at 40 to 45 so I just Obviously, you understand this because you're in the space, but I want the listeners to get that that 10 year shift is really important in the difference of sexes. And it means if a female has had an event, we can't be complacent about following up the male. And it also means if a male has had an event, we've generally got a little bit of time. We don't have to be too panicky about following up the female. So I think that's a really important. Interesting. And also if we throw smoking in the mix, that brings people's sort of, if you like, risk zone forward about 10 years. So your dad smoking on the weekends probably had a small impact, not a huge one, but we know even a small amount of smoking can have an impact on cardiovascular disease. So this led to you getting some testing done. Angela, tell us what you got done and maybe we'll go through those results so the audience can have a listen and understand how we explain and interpret these results. Yes, so I have been having CT angiograms. I had one about seven years ago just for checking my heart arteries. So last year, this time, was it last year or this year that I had the angiogram? This year, I had a stress test and echocardiogram. They were within normal limits. And then I had a CT angiogram in February this year. Well, we've got the result of that CT from February, and I'm going to go through that because I think that's... central to us having a discussion about what we do for you next. Do you remember, by any chance, the results from your scan seven years ago, Angela? Yeah, there were similar blockages, narrowing in the arteries, but a little bit less at that time. So I'm just keeping an eye on it, how it's progressing. Yeah, okay. I'm just having a look at the report. Was it done through the same centre, do you know? No, it was a different place. Okay. First one at Monash. Okay, no worries. So for people listening, I do at times repeat CT imaging. And generally for people who have had a cholesterol-lowering medication like a statin, repeating calcium scoring which is a non-contrast set of images so we don't inject any dye or contrast at all checking calcium if someone's been on a cholesterol lowering agent doesn't normally help us because we know that if there's any fatty plaque there that the use of a cholesterol lowering agent tends to stabilize that plaque and turns it into a more calcific plaque so if we look at a baseline and then look at a follow-up and there's been treatment in between we don't get a lot of benefit by recognising that the calcium score has gone up because that is affected by the plaque actually potentially becoming more stable. So hard to interpret. When it comes to a CT coronary angiogram, that's where we inject contrast or dye. So we can have a really good look at the details of the artery. Then we can line those up side by side and look at the non-calcific or fatty plaque within the arteries. And the first set of images compared to the second set of images will tell us if the fatty plaque has got more or less. And that can be valuable. It's not a guideline recommendation. You do have to pay for it out of pocket. But I do tend to do that with many of my patients who are particularly high risk and particularly have a lot of fatty plaque so that we can get a good idea. potential change to reassure us that we've got good control of what's going on in their arteries what i also say to those people and i'll advise you the same actually angela if you get another scan down the line is to try and do those two scans at the same center just so that the so that you can actually request that the radiologist slash cardiologist who reports that has the chance to line those images up side by side and make that comparison it's really valuable yes so when um when we uh looked at that first scan you obviously realized that there was some plaque there uh did you go on cholesterol lowering therapy at that time angela no i haven't gone on any um cholesterol lowering therapy at all okay so one of the things that um so i don't have the benefit of your scan from uh seven years ago but i've got the scan from now and what i i've noticed because i had a quick look at it is that there's a number of points there that i'd um make comment about first of all is there's no calcium score um and often i think that's in my own practice quite a valuable uh test because a calcium score It's not perfect and it doesn't give us the same detail as a CT coronary angiogram, but it does give us a rough idea of someone's propensity to put plaque in the arteries. Now we can measure that. There's a lot of research around it, about 30 years. And that means that although it's not the gold standard, in my opinion, it's a really good starting point. So we look at that calcium score, we can look at it in... absolute terms is it a high number or a low number but I think the reason why I think it's so valuable Angela is if we can look at it in context of a percentile meaning how does your calcium score compared to other women your age then that gives us a real idea as to whether you're more likely to put plaque in your arteries compared to other women your age less likely or average and I think that's a valuable piece of information. Yes. Unfortunately, your recent CT doesn't have that. And I'd almost be inclined to invite you to just contact the service and say, look, is there any chance you can retrospectively look at the images and give me an idea? Because I may have done a screening set of images and just not reported it because it may not have been their practice. So I'd invite you to do that because that's pretty useful. Then when we look at the actual result of your CT scan, what we see is that there's some plaque that's calcific in the left main. And then as we look at the left anterior descending artery, there's a focal area of complex plaque. in the mid LAD with mild stenosis. Now, mixed plaque means that there's some fatty component to it. And then when we look at the right coronary artery, there appears to be nothing in the circumflex. It's a small artery, which is good to know. And there appears to be a distal stenosis, right? So how do I think about that when I'm thinking about trying to apportion risk? to your score well if um you've remembered from my book i've got this algorithm i sort of use and for anyone listening if you've had a look at um have you planned your heart attack i dedicate a whole chapter to how we can interpret risk and the way i tend to do it is recognize that risk relates to the weakest link in the chain And so when we're thinking about risk, we think about different aspects of the CT scan and we deal with the highest risk feature because that's the one where the chain may break. And the chain in this case is having a heart attack. So I think you might be aware of this, Angela, because I know you've read my book. You've even quoted it back to me. So I know you've read it. When I'm thinking about risk, I use what I call the C. plus algorithm or c plus approach c stands for calcium score and we don't have that but if that's super high then we know uh calcium score over 400 or even over a thousand goes from high to very high risk yours isn't that obviously they just haven't measured it but it doesn't look that high from what i can read so we use calcium score is that the weak link in the chain then i use calcium score percentile now it's hard to be sure where your calcium score percentile is because i don't have that measured now um we're thinking about you at 58 years of age if there was a fair bit of calcium there you might be in the higher quartiles yeah and that would be one of a a weakish sort of link it means you've got a greater propensity to put plaque in your arteries and that would embolden me to want to do um want to bring some focus to your cholesterol lowering so see plus P for percentile, L for low attenuated plaque. Well, that's mixed plaque or fatty plaque. And they allude to that in your mid LAD. I can't see the image and they don't mention how much there is, but we know if you have a low attenuation plaque that's larger than about eight centimeters in length, then its volume is greater than about 20 millimeters cubed. That's a high risk feature. We don't have that information. It doesn't sound like it is based on the description. But that's one of the things I bring to that understanding of risk. C plus, C for calcium, P for percentile, L for low attenuation plaque, U for unfavorable remodeling. They haven't spoken about that. So let's say it's not there. S for stenosis. Pleasingly, you have no tight blockages. The most they report is 25% or less than, which is good to know. And then the last S, because it's C plus with a double S, the last S is for sight. So where is the location? And therefore, is that a weak link in the chain? When I read your report, Angela, your calcium is in the left main coronary artery. This is a weak link in my opinion. And I would immediately be saying left main disease, we treat this without question, regardless of what the quality of the plaque is, we treat it full stop. That is the weak link. Now you have plaque mentioned in the circumflex artery, but that's a small artery and it's distal disease. That means if you had a heart attack at that tight narrowing, it really won't. It won't do much damage. It is, if you like, a small heart attack and it wouldn't cause a problem. But you have a problem with the left main, that's your day's over. That's what I'm worried about. Yeah, so my interpretation of that would be to say, look, I would be aiming to get the LDL cholesterol, the so-called bad cholesterol, down to the level that we currently use. for secondary prevention because i really want to make sure we stabilize that process so that means i'd be aiming at an ldl cholesterol level of 1.8 millimoles per liter or less i would also recommend aspirin i know there's a lot of stuff in the literature about aspirin and there is quite reasonably some data that tells us aspirin shouldn't be in the water but none of those trials The ARRIVE, the ASCEND and the ASPRE trials, which came out about two and a half years ago, none of those trials actually used imaging to sub-stratify and quantify risk in those individuals. In your situation, we have image gerardas. We know there's plaque in the left main. This is unacceptable to me in terms of risk. So we lower that cholesterol and we put you on aspirin. Does that make sense? Yes, makes sense. So when we then look at the other testing you had done, they put you through treadmill testing. Now, I'm going to be cautious what I say here, but that treadmill testing was done before the CT scan, which is good, but really it should have been done after the CT scan. And if it was going to be done after the CT scan, because there was no evidence of narrowing in the arteries, then in fact, it shouldn't have been done at all. So anyone who is doing that treadmill test with the results of the CT coronary angiogram that you have, I believe is taking advantage of the system and testing you inappropriately. If you have no suggestion of narrowing in there, there is absolutely no reason to have a treadmill test. Now, you could quite reasonably argue, you could. argue that that tight narrowing in the small circumflex could give us changes on the ECG and let's get a baseline so we know what they're like. So if there's ever a change in the future, we can compare with current day to the change in the future. And that would be reasonable as long as that was explained to you. No, that wasn't explained at all. Yeah, if that wasn't explained, then I think that's... Well, that's dodgy medicine. And to a large degree, Angela, you know that the very reason I create these podcasts, do the books, run the courses is to help people be educated so they can recognize if they're getting the best care or not, because it drives me nuts when people don't. We can also look at your echocardiogram report now. I've moved to getting echocardiograms done fairly regularly, at least as a baseline. And part of the reason is it was what turned up my own dilated ascending aorta. I didn't know it was there. I'd had an echo 25 years ago. Everything was normal at that stage, but it changed. And it was only through having another echocardiogram that I realized my aorta, which should be about 35 millimeters in diameter, was nearly 50 millimeters in diameter. And if that tears or that bursts, you don't get another symptom. So your echo was plumb normal, which was fantastic. I'm very reassured by that. I would be encouraging you to make sure your blood pressure is beautifully controlled as well. So if you have any question about your blood pressure, if clinic blood pressure is to say 130, 135, I'd recommend a 24 hour blood pressure monitor because that will give us great insight into exactly what your blood pressure does over a 24 hour period. And if you want to protect your arteries. You want to run your blood pressure as low as possible. Now, let's get on to your cholesterol. Where is your cholesterol, Angela? Because that's what we're going to fix up next to make sure you don't die from a heart attack. Yes. So total cholesterol was 6.2. Yep. HDL, 1.5. Yes. LDL was 3.9. Yes. And non-HDL cholesterol was 4.7. Did you get a triglyceride by any chance, Angela? Yeah, 1.7. Triglyceride was 1.7. Yeah. Okay. Well, look. You want the ratio HDL-LDL ratio was 2.6? I think we'll just run with the LDL. For those listening, a quick reminder, the low density lipoprotein is what we call figuratively the bad cholesterol. It's the one that all our research is about. It's the one that we know if we can lower, we can improve outcomes. There's no question that in secondary prevention, there is robust data that tells us we can reduce risk using these agents. It's not as clear cut in primary prevention. unless you've got very high cholesterols. But none of those primary prevention studies really represent the situation we've got with you, Angela, where we've got left main plaque plus plaque running down into the left anterior descending with mixed plaque and a modest increase in your cholesterol level with a family history. So it's very important that we deal with you as an individual. and make the best decisions for you, knowing what the research is in the background, but knowing that none of those research studies have actually studied 10,000 angioparises and divided them into two groups. So we're applying our knowledge from that 30 odd years of research to fit you as precisely as possible. Having said all that, we need to get your LDL cholesterol from nearly four. yeah down to 1.8 or below that's a 50 reduction yeah so that's quite significant how are we going to do that well we know the cholesterol lowering agents the statins in particular are very effective and at mid and high doses we'll see a 50 reduction in cholesterol 50 so that would take us at 3.9 down to about 1.95 and that's not quite even where we want to be so if we then said um for example we use 20 milligrams of rosuvastatin or 40 milligrams of atorvastatin which are mid-range doses for both of those very common statins both of those will get you close to where we want to be but in my world in my consulting room i'd be saying to you angela this left main plaque we don't want it to advance we want to we want to put you into a range where we know there's a possibility of plaque regression and stabilization well we know from our research that a plaque an ldl level of 1.6 millimoles per liter can actually lead to plaque regression in about 60 percent of people in a formal study setting so what i'd be doing is looking at a mid-range statin for you um 40 of october or 20 of resuvastatin as i mentioned but i would combine that with ezetimibe so rather than use the highest doses of statin i'm going to use an intermediate dose that's still very effective but it reduces risk of any side effect but i'm going to add in a second agent And that's azetamide. That's the one that binds cholesterol in the gut. And it adds an extra 20% relative reduction in LDL cholesterol. And because it's a different agent doesn't add to the side effect profile. And that's what I do. And then I'd invite you to maybe think about five or six years down the line, having a follow-up CT scan at the same location, ask them to line them up side by side and ask specifically about whether there's non-calcific plaque, because that's what we want to see as best as possible. Sounds good, yes. My blood pressure this morning was 1.30 on 74. Well, that's pretty good. I'd probably get a 24-hour BP monitor and just make sure that's fine. One of the things that I think is valuable is to add in something like an angiotensin. two receptor blocker just at a low dose these have fantastic sort of remodeling effects on the arteries they dampen down some of the enzymes within the artery wall which drive hypertension and wear and tear and the idea of running your blood pressure as low as possible is really beneficial in the long term for coronary disease stroke atrial fibrillation cardiac failure renal failure and dementia so I take my blood pressure tablet every night. Yes. Thank you so much for your time. And that is very valuable information, which I didn't get from my cardiologist here. He said, don't worry. I said, I'm a little bit worried about my left main. He said, no, no, it's okay. Don't worry about it. But, you know, being a cardiac nurse, I know the left main is once it's gone, I'm gone, right? It's a bit like my aorta, Angela. You only get one symptom. You only ever get one symptom from left main disease. You only ever get one symptom from a ruptured aorta. You've got to treat it as the weak link in the chain, in my opinion. That's what I would be doing. Do you have any other questions before we wrap up? It's been an absolute delight to share with you, and I hope I've given you all the information you need, and I hope I've been able to inform. the listeners into the thought processes we bring to this fantastic space of preventing heart attack. Do you have any questions? No, you have covered everything very well. Thank you so much. And this is very good information for everyone to know, you know, because most people are not aware how these cholesterol lowering tablets work. And you have explained that very well. So thank you very much. Angela, it's an absolute. pleasure again thank you so much for joining me thank you so much for sharing your personal information as well uh for those listening i really hope you got something from this my desire obviously is to raise awareness i don't believe We can accept people having heart attack in 2023. There are things we can do about it. Angela's been kind enough to share her experience. I can pretty well assure you if we put in place what we've discussed today, then Angela's risk of heart attack is going to be so low that I anticipate you'll never have a problem in that space. For those listening, I really hope this has been worthwhile for you. If you have any queries or questions, please drop me a note at info at drWarrickbishop.online, all as it sounds, or hit my webpage and engage with the AI bot and ask him a question. For now, I'm going to wrap up. Angela, thank you so much. Listeners, thank you for joining me. I really do appreciate it. For now I'm going to wish you the very best. Please live as well as possible for as long as possible. Take care and bye for now. Join the Healthy Heart Network and become part of our growing community. If you're interested in your heart health and risk of heart attack, then join the Healthy Heart Network for only $5 as a lifetime member. This represents $55 worth of value. We offer and help people understand their present state of heart health, what their current level of risk is and the positive steps they can take to improve their risk of heart attack in the future. Go to www.healthyheartnetwork.com.au and click the join the family button.
