Welcome, my name's 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 honored for a five-star review. You can share it with your family and friends. It may well save someone you love. Well, g'day, it's Warrick here, and I'd like to welcome you to my podcast and videocast station. And I've got a super important presentation and podcast. in video cast to do today and this is around coronary artery calcium scoring and an absolute journey I've had without none and I'm really appreciative that you're tuning in. I want to let you know that I'm going to speak to some slides so if you do get the chance to look at this on video it'll make a little more sense. You should still be able to follow it on audio though. So today's topic is coronary artery calcium. Prime time. Well, my story with cardiac CT began back in approximately 2010 when I had the chance to go and undertake the training. And really, I was so impressed by the opportunity to look into someone's arteries and have the chance to find problems before they presented with an event. I became quite an enthusiast around primary prevention and using cardiac CT for that opportunity to look ahead. I actually got really frustrated when the first book I wrote, which was Have You Planned Your Heart Attack, was written because I just couldn't get and didn't feel that cardiac CT was being taken up and used as broadly as it should be. And I couldn't understand it. As I sort of thought about it and how to make this particular sort of testing more available, I tried to think through where there might be levers to pull to really have cardiac CT used more. Well, it turned out, and I found this firsthand, that when I shared the role cardiac CT had with cardiologists to a large degree, I think they were slow to change or adapt and many of them were used to evaluating risk using treadmill testing. Personally, I don't think that's appropriate and that's really one of the reasons I wrote the book. The other thing is that if you're not doing treadmill tests and you're sending patients off to have an x-ray, you're sort of giving the patient away and I think most of us like to hold on to our patients. I thought about why GPs may or may not be using this technology. And to be fair, I think GPs have so much on their plate. I don't think they should be considered as the leaders for adopting a technology in this space. It's just unrealistic to think that they could be across all the other things that they need to be and across leading the charge using a new technology for cardiac prevention. I thought about whether patients could actually drive change in this space. And when you think about it, the patients I'm talking about imaging are people who are already well. They're not sick. They just don't know that they might have a problem down the line. So we don't have someone who's suffering, demanding to be recognised or requiring to be recognised. One example that really resonated with me was when Greg Page, the original yellow wiggle, had his cardiac event. He was saved by a defibrillator, and his subsequent focus was really empowering greater use of defibrillators around the country. Now, that's a fantastic thing to do because a defibrillator saved his life and really focused his attention to that. But he didn't ask the question, how could his problem have been identified five, 10 years earlier and potentially not had the heart attack in the first place? So patients can't drive this sort of prevention space because honestly, they're just not aware of that risk until that risk occurs and then they see it differently. Radiologists wouldn't drive cardiac CT because frankly, cardiac CT imaging. doesn't generate a lot of money. Radiologists can generate much more income from different sort of testing, think MRI scans or injecting joints. So as I was thinking of levers to try and move cardiac CT forward to get it more broadly used in the community, it occurred to me that if I could find the money, I might have a sporting chance of making a difference. And that led me to believe that payers The people who pay for the services, the people who pay for the consequence of heart attack could be the people to deal with. Well, with that as a backdrop, and there is a Shaggy Dog story before I actually get to the next bit, but with that as a backdrop, I was fortunate enough to connect with St Luke's Health, who are prominent as a not-for-profit health program. health insurance provider in Tasmania. I have to say the organisation and the individuals I've dealt with are beyond reproach and genuinely have the best interest of Tasmanians health at front of mind. It was a pleasure to deal with them. I was able to sit down with them and tell them how I really believed that cardiac CT imaging could make a difference. For their members primarily, but also for St. Luke's, because if we could save money for St. Luke's, that would go back into the membership. And you can see if you can improve the outcome for members, you can also improve the outcome for the organization if you're doing things that can save money, reduce morbidity and mortality. So I spoke to them about running a pilot using the virtual heart check platform. created and had run for a number of years now. A number of people listening to this may have already checked out that platform. And if you have, well, I've given it a name. I've called it Patient Resourced Initiation of Medical Engagement or Prime. And that allows individuals to use that platform without the need to see a GP, without the need to see a specialist. and basically book a coronary artery calcium score in any major centre in Australia, which I think is pretty damn good actually. As part of that though, with the pilot, we wanted to look at how individuals self-assess themselves, how a traditional risk factor assessment would assess them, and then look at their risk through the lens of coronary artery calcium scoring. So we were looking at risk, patient's perception, traditional risk scores, coronary calcium. We've used the platform, the prime health platform to save time and the potential, some of the blocks to getting therapy. St. Luke's was happy to cover the cost of 100 patients and their scans, which is approximately $300. per scan, and we look to do follow-ups of three, six, and nine months to track behavior. Looking to compare self-assessed to risk calculator to coronary calcium score risk, we wanted to highlight gaps in risk perception, traditional risk assessment versus coronary calcium scoring, evaluate the impact of coronary calcium scoring. on lifestyle, so when individuals are given their score, and assess the engagement in self-directed testing. So we took 100 individuals, and interestingly, these are all men 55 plus, female 65 plus, but St Luke's had to put out nearly 5,000 emails to get that 100. So from the get-go, really poor, engagement, lots of opening of the emails, but very poor engagement of the next step. There was a free heart check offered. And patients were then who went through, those 100 who went through were categorised as a zero score, very low risk. A score of 1 to 99 as a low risk. A score of 100 to 299 as an intermediate risk. A score of 300 to 999 is high risk and 1,000 and above, very high risk. We asked questions about lifestyle, diet, exercise, cholesterol, blood pressure, and we looked to those three, six, and nine-month behavioural follow-up surveys. The patient self-directed through that coronary artery calcium to order and organise that coronary artery calcium score through the online platform. And St Luke's had applied to the Department of Health for an appropriate permission to run the pilot with consent. And we also provided an opportunity for individuals who went through to tick off on a disclaimer and a consent for use of that information for research purposes. So people would go to that website, they would follow a number of questions and those questions were guided by some videos and then they would be given an answer to what their risk would be based on traditional risk factors. And because we selected males 55 and above and women 65 and above, they were all going to be intermediate risk or higher. I like going to intermediate risk or higher, but basically if we think of people at risk of heart attack, they could be low risk, high risk or in between. I haven't got the time to go into all of that in a great deal of detail. You can check out my TEDx talks. I cover that there. But basically we were looking for people who were predominantly intermediate, possibly intermediate to high risk. Those individuals then proceeded to get a scan. So out of the 100 people who got a scan, 31% had scores of over 100. Now, we know that a score of over 100 has been shown to be the cutoff point for the benefit of giving individuals cholesterol-lowering therapy and aspirin. So we found 30% of the individuals who... prior to the scanning, prior to the survey, prior to going through the process, had no idea that they were at any risk at all. And one third of those people were going to benefit from going on some sort of therapy. 20% had scores over 400. This is high risk. And the risk that these people have is as high as someone who's had a previous heart attack. So we found some really significant high-risk individuals in our cohort. We found there was significant inaccuracy between what the calcium score showed, which is really the plaque that's in the artery, and that is the final common denominator, compared to what people thought their own risk was and compared to what the traditional risk factors thought their risk was as well. And as far as we could tell, the high-risk individuals did show improvement in behaviour post-scan. Now, for those who are on the podcast, you can't see this, but I've got a series of graphs which show low perceived risk versus coronary artery calcium risk, average perceived risk and high perceived risk compared to coronary artery calcium risk. So three graphs in all. What I can tell you, even if you aren't looking at these graphs, is there is no correlation at all between what people thought their risk was and what it actually was based on what was going on in their arteries. So we had some amazing key insights. From this, we knew that coronary artery calcium scoring suggested much higher than expected when it came to risk. It really does bridge a gap between perceived risk and actual risk and allowed personalised assessment. We saw that the high risk participants had the chance to then potentially have appropriate interventions, but they also appeared to alter behaviour. Patient resourced initiation of medical engagement, Prime Health showed incredibly slow uptake, but for those that did uptake, it worked. And I think we're looking at the very beginnings of a potentially new way that we deliver healthcare. We believe, and more work will need to be done, that expanding this coronary calcium screening and impacting. A larger population in the same sort of way could certainly save lives and we believe reduce events. So what are the takeaways? We had 100 St Luke's members. The emails out to 5,000 odd people, we had a poor engagement. We need to come back and understand that. 5,000 emails, 100 people went through the process. We did have more men than women. But when we took those people who were all without any problems whatsoever at the time of entry into the pilot, 31% of them had a calcium score of 100 or more, and that's high enough to warrant treatment with aspirin and cholesterol-lowering therapy. 20% of those people were high risk, as high risk as someone who's had a stroke, had a heart attack, had a stent or a bypass. From that, we know that the number needed to scan to initiate therapy was only three. And the number needed to scan to avert a major cardiovascular event in the next five years was 25. And in the next 10 years, 12 to 13. In the next 20 years, we only needed to scan six and a half people to basically save a heart attack or prevent death. And you might be asked, well, but maybe this all costs too much. Well, when you boil it down, scanning those 100 people costs $30,000. One acute coronary care syndrome, one acute heart attack, one acute episode of angina will cost $30,000 or $40,000 for one episode. So scanning those 100 people, identifying those 30 people who could be better off on therapy only needs to prevent one event to be cost effective. I don't think you even need the back of an envelope to realise that that is a great way to save money, but more importantly, to make sure people stay well. So what are our conclusions? There was a wide discrepancy between self-assessed risk, traditional risk and coronary artery calcium risk. From what we saw, calcium scoring is a transformative tool for personalised risk assessment. It's precise and it gives actionable insights for risk management. Of the people who did respond, we saw those high-risk individuals did improve their lifestyle, but more data is required. We believe that we can... enhance and improve this through the St Luke's organisation and then on to other private health insurers. There's no question it's early days for prime health patient resource initiation of medical engagement, but I'm optimistic that this will be what we see more and more of in the future. And although this is an absolute tip of the tip of the iceberg, we recognise further research is needed. for the long-term health and economic impacts of using coronary artery calcium scouring in this intermediate and above-risk cohort. So what is it for you? What does it mean for you? Well, here's your call to action. If you have done the risk calculator through the virtual heart check but haven't gone on to purchase a scan, we've just given you the stats. There's a one in three chance. that you would benefit from appropriate therapy. There's a one in five chance that you're at high risk and just not aware of it. So males 45 and above, females 55 and above, please go to virtualheartcheck.com.au and see if it's something that you should be doing for yourself. In my perfect world, every male 45 and above, every woman 55 and above. should be having a heart scan to know what's going on, not wait until an event occurs. That 45 for men, 55 for women is for average people. If there is a really bad family history or really clear-cut other risk factors that might wish, that may indicate you could be at higher risk sooner, then those ages can be earlier. Men down to 40 if need be, women down to 50 if need be. Currently, St. Luke's, based on this pilot, have started to pay their members a rebate if they have a Koremachi calcium score, which is absolutely fantastic. And I believe that there will be a knock-on effect to other providers. Watch this space. I hope you found this informative. I'm super excited that I had the chance to work with St. Luke's Health and I can't thank them enough for the opportunity that they've given me. And I'm really focused on doing more to figure the next steps to make an even greater difference. If you've got any queries or questions, drop us a note. I'd love you to share this. I'd love you to like it. I'd love you to do all the things that you're meant to do on social media. But most of all, I hope you live as well as possible. For as long as possible, take care and bye for now. Hi. Ever wondered what your risk of heart attack is? You should. It's the single biggest killer in the Western world. We're talking one death less than every 30 minutes in Australia. One death less than every 60 seconds in the United States. Nine million deaths globally. per annum. Well how do you check your risk? Well you can go to www.virtualheartcheck.com.au. You'll find out about your risk and what can be done beyond that to be even more precise.
