- 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 honoured for a five-star review. You can share it with your family and friends. It may well save you. Someone you love. *music* Hi, it's Dr. Warrick here, and thank you for joining my podcast and videocast station. I hope you find today's podcast interesting and hopefully relevant for you or someone you love. As always, I really appreciate the fact that you've tuned in. That means that your valuable time you're happy to give to this, well, 10, 15, 20 minutes, however long it runs. And I don't take that for granted. So thank you for that. If you have any friends, family, someone you'd like to share this with, please share it. I really value that. I do put a lot of work into these and I do... Well, I'd really like to see the information I'm producing get out there and make a difference for people. Today I'm going to talk about prevention. I had a paper come across my desk and I thought it was interesting so I'm going to share it and there's a slideshow with this. You can listen obviously on podcast but if you want to check it out on YouTube you'll see the slides as well. The um The basis for this particular presentation today is really in regard to a paper that was generated through the University of Chicago this year, so fairly recently. And what they looked at was prevention, which is obviously something very interesting for me because I'm very proactive about cardiovascular prevention, imaging arteries, treating cholesterol as appropriate and so forth. And a group out of the Chicago community. university really wanted to know what actually saves the most lives so let's have a look at that and um I think it's relevant for all of us because let's face it, we'd all like to have our life saved and, uh, If we're informed with the right knowledge, there's half a chance we might get there. So one of the really interesting things about this paper is that they actually came up with nearly 42 cases. different we could risk people and evaluate people to reduce mortality, morbidity. And of course, what the United States Prevention Services Task Force does recognized was that if you've got 42 things you can do to try and reduce people's future risk, that that's a heck of a lot to cover in a seven and a half to 15 minute or 20 minute or even half an hour consultation and That's really important to think about because we know that many people will present maybe once to their GP looking for a routine follow-up. Some will follow up a second time and a third time. But many you may only get one bite of the cherry. So... It turns out that with many different potential problems tests to help rank people that the average patient as they're getting a bit older could potentially be lining up for a huge battery of tests and there isn't any particular guidance on how to rank them what should be done and what the GP is. or the primary care physician should be doing. And this is important, as I said, because if you get one visit from an individual and you lose them to follow up, then you really have to make that first visit count. One of the authors of this paper, Dr. Porter, really just made the comment, you can't do all of these tests in one visit. And of course, that makes perfect sense. So where is the money and what are the top six tests? preventative strategies that can give the most years life gained per patient. Well, at the very top, is... primary prevention of exposure to Hi. risk patients in regard to HIV prevention. So this is really important to understand. So pre-exposure prevention of HIV in people who have high risk sexual activity is one of the most powerful Bye. interventions for gaining future years. Turns out Not all primary care physicians will engage in the conversations required to implement that strategy. But that's number one. And I bet that's a surprise for many of you. It was a surprise for me. We're talking about pre-exposure prevention. And we're specifically talking about HIV, in spite of there being good medications available for that particular virus these days. So the next on the list, the next most beneficial risk modifier was engaging with patients who are at high risk around the role of breast cancer reduction medication. Now, I hadn't even known about this, but there are. There is good research that tells us for high-risk individuals of breast cancer that there could be a role for anti-estrogen medications and anti-aromatase medications. Now, this is not my wheelhouse, but it's really important. because it's the second most valuable intervention for future risk production, and I didn't even realise it existed. So, It's something I understood from the paper that was presented that it's not regularly done by primary care physicians. So if you or someone you know is a high risk breast cancer individual, maybe have that conversation. So the next... most valuable intervention is pre-exposure prevention of intravenous drug use, and that carries with it its own risks, as you might imagine. So pre-exposure prevention of intravenous drug use might be counselling, it might be identifying high-risk individuals who may progress to drug use, but a really important space to be. And Again, one that really requires that primary care physician to be comfortable to engage in potentially difficult or sensitive conversations. At number four is the one that I thought might have been much higher, and that's the role of statins in primary prevention. above the 40 But also not in the paper, but in my own practice, people have been identified as high risk because they've got plaque significant plaque burden identified in their coronary arteries really important The next most important, and this probably isn't a surprise, is... alcohol counselling and altering those habits of hazardous drinking and looking at interventions. That's common sense. And the next one's not a surprise either. It's right up there and it's one that we've probably all been aware of for the last few decades, and that's weight loss counselling and dietician referral. So they're the top six. Pre-exposure prevention for HIV, talking about and maybe implementing as appropriate breast cancer reduction medication, pre-exposure prevention of intravenous drug use, statins in the right setting for primary prevention, weight loss. So doctors will often say that their time is a problem, and we do know we've got limited time. And even covering those six things in one consultation would assume that that patient has all those six things, which is highly unlikely, but each of those does require some time. And interestingly, I've just given you the ranking one to six of the most useful things to do for the patient's benefit. But let's turn that around and say, well, what's the most useful thing to do from a time period? based perspective, From the doctor's point of view. And interestingly, it's not exactly the same. It's very similar. So pre-exposure prevention for high-risk sexual activity and prevention of HIV still is the best use of doctor's time. Breast cancer medication conversation and implementation, if appropriate, is still the best. Second most valuable thing based on doctor's time, Pre-exposure prevention for IV drug use remains at number three. when we take into account the best use of the doctor's time, and number four still remains appropriate statin use, but number five, which in the previous slide, list which was patient-centric was alcohol counseling for the doctor's time it's hepatitis b screening and in number three Six, the sixth most useful thing to do in The patient-centric list, the most valuable thing for the patient at number six was weight loss. the for the doctor adjusted, doctor time adjusted list, sitting at number six is hypertension screening. And I have to say for me, hypertension screening is really a side box that I jump on. I think it's super important. But of course... I'm in the cardiovascular space. I'm not in the infectious disease space or the oncology space. But, you know, cardiovascular disease, super important, hypertension screening up there and good use of time for doctors. So what's a real world example look like? How does all this impact? Well, first of all, as a patient, you need to be thinking about it. Or as someone who's educating and getting better health literacy, this is something you share with people you know and care about who may be at risk. But a real world example, maybe a 65 year old woman who's overweight. What really would we be looking at about health? the GP, how would that GP prioritise the different risk stratification or risk stratification interventions? And this paper suggested that the first step would be to offer statins for primary prevention. Now, this would be assuming that this individual with obesity also had the other risk factors that would drive a high risk score on a risk factor calculator. But statins, number one. As you might guess, weight loss counselling, number two. Pleasingly, I believe the GLP-1As look to be offering a very, very, a very important support adjunct or intervention for people in this sort of situation. We're seeing significant impact by these agents and really seeing some significant changes in weight for people who've been targeted in that regard. Step three is to consider colorectal cancer screening. If that's not being done, it is ranked ninth overall in terms of the benefit that could be provided imparted by acting on it and number four reassess and follow up and that just makes sense because there is a process in going through this risk stratification and a bit of a journey and a requirement to touch on a number of tests as part of a process. So what would be your prevention priorities? Well, importantly, not all prevention is... created equally, some interventions return much more than others. And that's why the United States Prevention Services Task Force actually ranked these 42 interventions. different interventions so that you knew what was most powerful. Pre-exposure prevention is way at the top of the list, but it's underused, at least according to this paper. It is the single biggest winner for the individual, and it just doesn't appear to be discussed regularly in primary prevention settings. This particular paper also suggested that statins were underappreciated and underused. Now, this is a complex space. If you've listened to my podcast in the past, you'll know I've got a strong interest in lipids. And you'll probably also know that my good friend and colleague, Professor Karam Kostner and I have just released a book on cholesterol. really doesn't bring all the granularity and the detail to that situation. There's a lot of pushback in the community on statins. I see it every day in my... practice, and we've dealt with a lot of that in The book we've just released, it's on Amazon, but if you wanted a physical copy, you'd try and buy it in Australia through my website. it's not back from the point yet, but it's called Cholesterol Explained. And we really talk about what some of the barriers to individuals getting onto statins are about and try and explain, deconstruct and put together those arguments, some of those theories and that information. It's interesting that the paper, having rated and ranked those 42 different interventions, or made the comment that some screening is just not as good as you might have thought. emotionally thought. One example is that cervical screening ranks much lower than most expect, and that breast cancer medication discussion and implementation where appropriate actually ranks far higher. So most of us, and certainly I'm included, would not have known that. It's really important that patients come to their appointments prepared and know some of the priorities of the visit so they're ready to take advantage of it. And that's a really important place to stop and a really interesting space where we're thinking about a multitude of different things that could happen give rise to future risk. Of course, my focus over the years has been hearts, but it's much more than hearts. It's cancer, it's HIV, it's obesity, hypertension, hepatitis C. Alcohol. So all of us are slightly different. All of us will need an application of those risk assessments and risk interventions applied to us as appropriate. Well, I hope that makes a bit of sense. For me, I thought this was a really interesting bit of information, particularly since I'm so passionate about the preventative space, particularly in cardiology. But this takes it more broadly. And obviously, I have to thank the work of the United States. uh prevention services task force for pulling all that information together they do some amazing stuff Well, I'm going to wrap it up there. If you've got any queries or questions, drop us a note at info at drwaribishop.online. As always, if you've listened this far, I so appreciate your attention. I so appreciate your time. And I really do take it as a compliment that you've chosen to take your valuable time to listen to what I'm sharing. I hope it's been valuable. Until next time, I do wish you the very best. I hope you live as well as possible. for as long as possible. Take care and bye for now. Did you know that coronary artery disease kills one in four people? So most of us are likely to carry some risk or know someone who does.

If you're interested in finding out more about how to evaluate that risk, check out www.virtualheartcheck.com.au. It'll give you information about risk, And what else can be done to be even more precise?