026 - Stress Tests, Stents & Bypass: The Expensive Illusion Of Heart Disease Care | ClearCardio

I, I think we really are on the verge of being able to eliminate heart disease.

Most people are defensive, like, oh, I'm, I'm fine.

But a heart cath is $20,000 MSRP, right? Doesn't fix anything, doesn't diagnose anything. It's a $20,000 diagnostic test. The only way we can see that is cardiac CT or Right. Or an autopsy. This changes everything. Hello everybody, this is Dr. John Osborne, the preventative cardiologist that is the Chief Medical Officer at Cleer Cardio. I am really excited today. We have a fantastic program. We have some wonderful people joining us. They just got their scan with Cleer Cardio, with our approach, If you have the disease, if you have plaque, if you have the most minuscule amount of plaque, we can both detect it, we can measure it, we can monitor it, but most importantly for you is we, we're really on the verge of helping to eliminate the disease, plaque, atherosclerosis, that still kills today about 45% of us. And many times the first symptom of heart disease is death. Sit back, relax, and we're going to take you on a beautiful ride through the hearts of Floyd and Claire today. So I was just pointing out, there's the sutures they use, the steel sutures they use to tie the breastbone back up. The breastbone itself, of course, is well healed here.

Yeah.

You can also see behind the breastbone Right here. There's an artery here, right behind the breastbone, and another artery here. Those are the arteries we use for bypass surgery. So we just kind of dissect those off the back of the, the breastbone and then just redirect that.

I thought they kind of came—

Well, we only have 2 of those, so we can do 2 grafts with those, but if we need more vessels, then we go for the veins.

Okay.

And generally, almost 100% of the time, this vessel right here on the left side, this is the right, the one on the left side, we plug into the LAD, the left anterior descending coronary artery, 'cause it's, you can see, it's located very conveniently. We just redirect that into this vessel right here. And so, Pretty much everybody who has bypass surgery, we always use this. In a lot of people, we'll also use that one and plug that into the right side of the heart, because it's closer to there. And then if we need more vessels, we need to do more bypasses, then we grab the veins from the leg.

Okay, got it.

So there's your aorta here, so all that looks good. I'll also show you right here. See this right here? This is what's called a granuloma. So usually when we're young, maybe teenage, you know, a lot of people get a little lung infection, okay? And they'll feel bad, get a cough, whatever, goes away. But that lung infection will cause some calcifications either sometimes in the lungs, sometimes in the lymph nodes here, sometimes even in the liver and spleen. It'll cause these calcifications.

Right.

And it's evidence that you had an infection years and years ago. years ago, it's of no clinical importance, whatever. But pretty common to find these. So you have a couple little granulomas. And again, this is the stuff I mentioned that's— it's not clinically important or relevant, but if they do imaging, right, you know, that way I just point it out so that if they ever find this again, you go, yeah, I know all about it. Hello everybody, and welcome. This is Dr. John Osborne, the Chief Medical Officer of Clear Cardio, and I have something really exciting I want to share with you. We now have a newsletter. So this newsletter is all of the great science that I look at every day and read and scour the medical literature for. Important studies, important outcome studies, new tools, new drugs, new data on nutrition, all of the different things that I commit my life and have committed my life to and am passionate about in helping me to further preventative cardiology. From new diagnostic tools, to new blood tests, to new medications, to the latest on intermittent fasting and dietary approaches to help people live longer and better. So it will all be in our newsletter. It is great reading. The price is right too, because it's free. So please subscribe to our newsletter. Go to clearcardio.com, or you can click down below and get access to our newsletter. Whether you're one of our patients or not, it's all good. I love reading, I am a voracious reader, I love medicine, and I love finding all the little charms, little treasures out there that make me a better doc, that better inform me, and ultimately help people along the way. So please, please support my habit of finding the greatest, newest, most important literature, and I'm delighted to share that with you. So please click below, subscribe, we'll get you on the newsletter list, And I think you'll really find it fascinating. So again, click below, join our newsletter, and we'll be really excited to help educate— or because we're in Texas, I like to say edumacate you— on preventative cardiology and what the latest and greatest tools, tricks, and treasures are. So thank you again. This is Dr. John Osborne, the Chief Medical Officer of Clear Cardio, and Click below and get on that newsletter. Okay, so we're gonna do the same thing. So there we are looking at— we call these the axial images. Here you can see that valve right here, and that looks good. There's the left ventricle, left atrium, right ventricle, right atrium. Aorta looks good. So did you have a bicuspid valve, or did they say what caused the valve to Basically go bad or?

Well, the way it was detected was, of course, when I'd go in for my physical, when he would listen to my heart, he kept saying for, I don't know, it went on for 10 years.

Oh, really?

Oh, that thing is rattling, you know. And then finally—

Did they ever do an echocardiogram?

This thing is really rattling.

I see, I see, got it.

So we went and had an echo and then they called me in and they said, you know, you're calcified and so your blood flow And says, we need to do, you know, surgery. And I said, well, what if we don't do surgery? And he says, well, you'll be dead within 2 years. And I said, well, let's schedule surgery. Yeah, got it. So that's kind of how that—

Got it.

Yeah.

Well.

And years ago, this Dr. Larry Brock, I don't know, this might have been 15 years ago, he had a CT scan down in the coast in Pensacola.

Oh, okay.

And I went down and we— it was, I guess, for calcium. And I was clear as a bell and there was one spot right here. And I always wondered now if that was the calcium that was detected. But of course, back then it was like, here's your information, good luck today.

Right.

There's a little here. No, what do we do about it? Right.

So they did the imaging but they didn't like And here's the plan.

No, there is no plan.

Yeah, we don't leave people on alerts like that.

Yeah, just keep sedated and hope.

Well, I suspect what you had was a calcium score.

Yeah.

Right?

Exactly.

Yep.

And it was when they were first starting.

Right, right.

You know what I mean?

Right.

Yeah.

So aorta here, ascending aorta, the descending aorta. There's your left atrial appendage where those blood clots like to form, which all looks good. And no fluid around the heart, no pericarditis, no holes in the heart. Mitral valve looks good. There's the anterior leaflet, posterior leaflet, so that all looks good. There's a little bit of calcification right here in that anterior leaflet, no big deal. And then there's just a tiny smidgen right here as well, but not a big deal.

There's some plaque somewhere in there, or was.

Yeah, well, we'll get to that. And then we're going to take a peek at the lungs here. So on these views, that's that little calcification I was mentioning that we saw earlier. So again, not anything of concern. There's the right lung, left lung. So all of that looks good. There's your liver, and we can measure the liver density. So a little bit low. So the magic number here is 60, okay? If it's below 60, you might have a little fatty liver, okay? Which is about 40% of us have fatty liver. So—

She's probably scotching one.

Several people.

Yeah, yeah. So little fatty liver, join the crowd. There's your spleen. So there's your spine. Little, little, little curve here, a little scoliosis, not a big deal. Here you can see some arthritic changes here. And here. So normal wear and tear. There's your trachea. All that looks good. And there's your breastbone. You can see those sutures.

Right.

They'll be there forever, huh?

They're not going anywhere. Yeah, we, we don't— I mean, we, we could take them out, but there's Hey. There's no reason to. So, but they've already done what they needed to do, which is just to make sure that bone grew back. But it's well fused at this point. But we never, never take those out again. And then you can see some of the arthritic changes here in the spine. We'll measure that bone density here. Yeah, so here you can see 270. So that's some good bone there. Yeah, so yeah, 300, 270, 266, 228. Almost wonder, maybe your bone metabolism is such that maybe that contributed to that calcification of the valve, right?

Right.

Because the bone is like Yeah, really great. So there's your esophagus here. So no tumors, masses, cancers, hiatal hernias, etc. Nice view of that aortic valve here. We'll look at that too as well later. But esophagus looks good. So all the extra cardiac stuff, nothing exciting there.

A little fatty liver.

Yeah. It's interesting. So our radiologists, they never call fatty liver Really? Yeah.

Wow.

I like to extract every little bit of data that we can, right? Because it's all here, right? So, and it's interesting, a lot of my colleagues in cardiac CT, they'll look at the heart, but they just don't look at all the other stuff, right? Because, you know, again, I mean, like David Ledbetter, I mean, we found out something really important.

Exactly.

You know, what happened, why he had the fracture, and all the blood in his lung, and all that stuff. So there's a lot of very useful, helpful information that we get out of this. All right, so now what we're going to do is we're going to look at your heart here. So there is your heart.

That's something.

It's a little jumpy there.

I remember that, yeah.

Label them.

And that's why I always say this is the virtual autopsy. If there's an issue, we'll see it. And if it's not here, it's not here.

Yeah.

That's what I told them last night at dinner. I said, you need to do this autopsy now before you're dead.

Exactly. Before you, before you get a real one. Virtual's always better. So as we did before, so the computer has done all of its processing, and I'm gonna go ahead and just peel away everything except the blood vessels here. So we'll start with the right coronary artery. And again, there's that one view, turn you, spin you, rotate you. Look at that vessel. And then here we're going to take that right coronary artery and then—

Straighten it out.

Straighten it out with the magic of computing. And then we'll grab our little arrows here. And let's fly through your right coronary artery. Please don't try this at home. And I would say it looks, looks pretty good to me. I'm sorry I haven't found any big nasty plaques to show you. Sorry about that. You probably don't feel too bad about that, but yeah, looks good to me. Again, we'll see what the AI does, but—

Yeah, right.

In the old days, up till 4 years ago, I would say that vessel looks Fine.

I would say I'd be walking over here.

But AI is better than I, than maybe my eyes.

False happiness.

So I always call the AI, that's the microscope. So this is the vessel going down the front part of the heart, the LED. I will show you there's a little plaque right there. See that little guy right there?

Yeah.

But again, this is in the wall of the vessel. So if you, when you had that, when was the valve done?

November of '20.

Of 20.

It'll be 5 years this November.

Got it. Did they give you the option for the— well, maybe not. Did they give you the option to have it done? Yes.

And that one—

Was it the mechanical versus the—

No, to do that, it would probably last, what, 5 to 7 years? Or they said you can crack your chest, longer recovery, but you might get Got it. 10 or 15 years.

Got it.

They said, you're healthy, there's really not a reason.

Yeah, you could do a redo.

Yeah, and I said, I'm kind of put off the redo.

Yeah, understood. So, and when they did the heart cath, I'm sure they said it looked fine, right?

Right.

Okay, but again, heart cath, I only see the doughnut hole, right? Here we can see the entire doughnut, right? The only way we can see that is cardiac CT.

Right.

Or an autopsy, right? So a heart cath can only see if there's any blockages in the lumen, in the channel itself.

Right.

Can't see what's happening in the wall. Right.

Okay. Because when I'd get my blood work back, you know, the doctor would say, you need to take a picture of this, it's very rare. We see all green, everything is green, you know, as far as your different levels of calcium and everything else. Well, that didn't tell me too much.

Well, exactly, right?

Something went awry.

Exactly, right? You know, it's interesting. There's— I mean, this has been an ongoing effort for decades, right? Looking, trying to get ideas from blood tests like cholesterol, right, in my world, you know, to understand if you have plaque. And I'm going to tell you, I don't think we'll ever have a blood test for heart disease because you got to look at it.

Yeah.

Right? It's imaging, right?

Yeah.

Because yours was always Yeah.

So, little baby plaque right here. You can see here that little plaque right there. But again, all this is in the wall of the vessel, so stuff that you can't see on a heart cath, right? So a little baby plaque right there, and it's got a little bit of calcification. So again, I, I will— we'll see what the AI shows. You can see a little bit of baby plaque right here. Okay, uh, we'll see what the AI shows. But I can show you a little bit of visible plaque, but I'd say much less than the average bear. And then the left circumflex, that's the big vessel going to the left side of the heart. By my eye, looks pretty good. So again, we'll defer to the AI here, but in the old days, pre-AI, I would say this looks pretty normal to me. So that's good. So, you know, with aortic valve stenosis, right, the calcification of that valve, it creates a load on the heart, right, because it has to pump it via a small hole. So that is another thing. High blood pressure is the most common cause, but that's another thing that can cause some thickening of the heart muscle. So you can see they're mostly green, which is good.

Yeah.

But there's a little bit of red. But with the aortic narrowing, I'm not surprised that you see a little bit of that.

Yeah, actually a little rubbery.

Yep, yep. And then here all the dimensions look good. And then I know you've been waiting for this. Here we are. That aortic valve here. So this is the surgeon's view of the aortic valve. You can see the 3 leaflets of the valve.

Right. So it's a cow valve.

I was going to say, I can't tell you whether it's cow or pig here. They both look the same. But there's the 3 leaflets of the valve. So that looks beautiful.

So how would I know when that valve is wearing out?

Oh, well, usually If you listen to it, you can hear the valve, right? It creates—

That's how they detect it.

Exactly, right. So you can detect it that way. Usually though, we follow up with an echocardiogram, right? And you probably are having those maybe every year or so, something like that. Yeah, every couple years. But echo is really the way that we really do that. I can see it. So if that valve were failing, if it were Damaged, torn, leaky, narrowed, we can see that, and we can measure the area of the valve, which is critical, right? 'Cause it's really the area that's critical to that. And when we do echo, we can also measure the area. CT is actually even better and more sensitive to measure the area of the valve, which is really the critical number. But we can use echo to get a pretty close idea of what that area is. CT is even better.

All right.

If we have that. So yeah, so those are the different kind of things. Basically, you know, we're gonna listen to the heart. If we hear a new murmur, then we go, hmm, time to get an echocardiogram. But the valve here looks beautiful. You can see this is the surgical, the sewing ring of the valve, which is the bright stuff. That's the metal part of the valve. And then the valve itself, the leaflets are here, and they look beautiful.

Yeah, I said, well, I'm anxious to see what my valve, new valve is doing. I said, well, I probably need to be more concerned about those that are 77 years old.

Right. Yeah, but it looks beautiful. All right, so good news is I did see a little plaque. We'll see what the, you know, we'll see what the AI shows. In you, I didn't see any, but again, we'll see what the AI shows. But everything else really looks, looks, looks good.

We like that.

Yeah, I, I think we really are on the verge of being able to eliminate heart disease, right? I mean, plaque stuff, right? Valve stuff, yeah, for the moment we're still going to have that, that issue. I think that's a further out issue. But what really kills the vast majority of people and causes the strokes and the heart attacks and people killing over dead and needing defibrillators, uh, is atherosclerosis. It's plaque. And I think we're really on the cusp of being able to basically eliminate it.

Now, on the electrical side, where do you see the AI that could, I guess, map the signs and codes and stuff like that?

Exactly.

Where do you see and how do you see all that?

Yeah, so I think on the electrical side, and this is where I throw in my joke, when people ask what I do, I say I'm just a general contractor. I do some plumbing, I do some electrical, right? So on the electrical side, we can, and again, I'm gonna say I'm Certainly not an expert on the electrical side. You know, those are the electrophysiologists, right? They're the electricians, right? I'm just a general contractor.

Sure.

But in their world, they can— they have these probes, sensors, leads that can electrically map all the electrical patterns in the heart. So just like we do that for the plumbing, with this we can also do that Oh yeah. We could also do that and look at all the electrical pathways as well.

Oh, I bet that's— I had a friend that he just had his mapping of his heart, so that's what they were mapping, the sinus nodes and the electrical.

And what we do now, it's, it's pretty cool, uh, for people having ablations like he probably had, uh, they usually do a CT, and the CT will map it structurally, anatomically, right?

Right.

The size, the dimensions, where the pulmonary veins are, and all those things, right? So we get a beautiful high-resolution image of the left atrial— left atrium, left atrial appendage, all that stuff. We then fuse that anatomical structural data with the data we get in the EP lab that gives us all the electrical data. So we literally fuse the electrical data image over the anatomical data, so we can see how all of that, both the anatomy and the electrical, all then get fused together.

So is that, like, insurance will pick that up for people that have the electrical, like Bobby?

Oh yeah, yeah, so we do just scads and scads of these AFib ablations.

But not yet, I mean.

I mean, so I will— yeah, yeah, I mean, I agree on the electrical side. Yeah, I mean, that's just— it's a routine bread-and-butter standard thing. This should be, but not yet. And I started doing this—

It will.

Oh, absolutely right. I started doing this 25 years ago. So, and you know, you can imagine sort of the pushback Back then, I mean, you know, they thought it was crazy, right? But I knew where all this was going, you know. And, you know, I think even people got the iPhone 1 could see, oh wow, yeah, this changes everything, right? Now we have the iPhone 16, right?

Right.

Um, so I, I got my first iPhone 1, if you will, for cardiac CT about 25 years ago. And, and back then it was crude, the resolution wasn't nearly as good. It was really hard to do, right? On the software side, on the hardware side, all of the processing I showed you didn't exist. You had to do it all manually. But I could see where this was gonna go, and I said, hey, this, this is the future.

Right.

Which now I can look back and go, yeah, it definitely is. I think the biggest problem right now and why this isn't just I like to call this the cardiac colonoscopy, right? Got a polyp? Don't have a polyp? Got a polyp? We take care of the polyp, you don't get the cancer, right?

That's right.

I mean, everybody gets that. And that's why colon cancer screening is for the entire population. In fact, now people are getting colon cancer younger, so it went from 50 a couple years ago, now down to 45, and they're probably going to drop it to 40. I know the GI docs are All in favor of that?

Yeah.

Right?

But it's crazy that we have all these ways to screen for and that are done universally for cancer, right? Breast cancer, colon cancer, prostate cancer, right? Cervical cancer, right? And everybody gets it. It's all covered by insurance and it's screening. We're not saying you have symptoms, right? We don't wait to have symptoms of colon cancer Breast cancer. Or breast cancer. We screen everybody, right? And it's paid for, and under the Affordable Care Act, right, all those deductibles are waived to enhance people, to make it more accessible, right, for all these cancer screenings.

The economics are going to catch up and make them want to do it. Oh, absolutely.

Oh yeah.

Start saving them billions of dollars.

Right. And, and, and I'll say this as a reformed cardiologist, right? I mean, up until cardiac CT, For me, we had stress tests, we had the heart cath, right?

Right.

Stress tests, really insensitive, right? Anything less than 70%, your stress test is normal. Plus 25 to 40% of the time, the stress test would look okay and you weren't. That's a big problem. And then the other flip side of that was 25 to 40%, the stress test would look funky, then we take those poor people to the cath lab, And they go, you look fine. Still $20,000, and hopefully you didn't have a stroke, heart attack, bleed out, an infection, damage your kidneys, or whatever, right? And that was it.

Yeah.

Now, we all knew, even back 25 years ago, that stress tests weren't terribly accurate. They were very insensitive, but we just didn't have an alternative to it, right? And we also knew, again, 25 years ago, that a heart cath could find blockages, but it wouldn't allow me to see where the plaque actually began and started. And even then, even if I saw—

It's in the wall.

Exactly.

If it's sitting out on the wall, it doesn't pick up.

Yeah, for literally from years to decades, all the activity is happening in the donut. Only late, late, late into the disease, there reaches a point where the vessel can't expand anymore, then it goes inward. But we will not have symptoms, chest pain, angina, flunk a stress test till we have a 70% blockage.

Okay.

Right? So that is way, way late.

Because you said that, my heart doctor doesn't do the stress test anymore.

Well, good. Yeah, he said, no, I mean, they're just—

when I went in, they checked. I did a quick CT, right? I mean, it wasn't anything like this, right?

Yeah.

And he said, I don't even He goes, I don't even do the stress test anymore unless I really—

And listening to Fred Funk's story, they almost killed him. You know what I mean? They revved him up to the point.

And it doesn't happen often, but people—

I think my mother was doing the stress test when she started having problems, and she had a triple bypass like the next day.

And what's amazing, think triple bypass, that means she had at least 3 of those vessels with 70-plus percent blockages, right? And the year before, did she have any problems? 6 months before? 3 months before, right? And I actually think this stress test wasn't because of problems.

I think it was just time to—

The old, you need your stress test, right? Well, in fact, we used to— thank goodness we've gotten away from that. We used to say, oh, you turn 60 or some age and you get a stress test, right? So using a stress test as a screening tool, okay, that was really never endorsed because we knew it's insensitive, high rates of false positives, high rates of false negatives. It's just not a very good tool.

Right.

So we in the cardiology world, you know, always wanted a tool to pick up disease early, and the only thing we had that was non-invasive was a stress test, but that was a really, really bad screening tool.

Right.

Inaccurate, non-sensitive, right? Not until we developed cardiac CT. Now, this is a screening tool.

Yeah.

Right?

This is.

And we can now take the population and go, you're fine, it's all good, and not, your stress test was normal. Well, right.

So what would they do on the stress test when they put the dye?

Yeah, so what we do, there's a variety of flavors of stress testing. We can do stress echo. So what we do is, you know, that involves basically running on a treadmill with EKGs. We take a set of pictures before the stress, and then a set of pictures after. So if there was a narrowed vessel, the part of the heart that that vessel's supplying will show up on the echo, right? So in other words, after the stress, the heart's beating more vigorously. If we see a section of the heart that is not beating as vigorously, and it's pretty subtle, that might suggest that that part of the heart muscle is not getting as much blood flow.

And they don't really know what the stress test is.

Right. Another— and that's a pretty commonly done stress test. The other kind of stress test that's very common, we do about 10 million a year in the US, is called a nuclear stress test. So that's where you get the injection. What the dye does is give us some idea of blood flow to the heart. So you have to have bad blood flow to the heart, but remember that doesn't start till you have a 70% blockage.

Right. So if you have 60% or 50%—

It'll be normal all day long. And here's another crazy thing, to get into the weeds of this and how bad stress tests are. Um, and, and I'm glad that your doctor doesn't do them anymore, right? They're just about useless, right? Um, and a lot of times too, if, if you have a zero calcium score, your near-term risk of any cardiac event is pretty low. However, 10 to 30% will have lipid-rich plaque, soft plaque that's invisible, and have a negative calcium score. With this—

Mm-hmm.

Any plaque of any kind, it'll show. It's going to show up. And this is even before we add the AI, which I'll show you. So, anyway, I think that's it as far as the pictures go. Oh, I was going to say, the other thing about stress testing is, you'd think, right, if you have 1 blocked vessel, 2 blocked vessels, 3 blocked vessels, the more blockages you have, the more likely the stress test would be positive.

Right.

It's exactly the opposite. The more blockages you have, the test becomes less and less sensitive to detect the disease.

Wow.

So it's— yeah, again, when that's all we had 25 years ago, then that's all we had, right? But nowadays with cardiac CT— so I stopped cathing people 20 years ago.

Right.

That's because I did about 5 years of cardiac CT with really, really crude equipment, really crude software. And pretty much everybody that I, that I did cardiac CT that I saw plaque on, I cathed them. So I had about 5 years, about 700 patients, where I had 100% CT and cath correlation. So when I went to the cath lab and go, okay, I missed that, or, or, okay, CT showed me this and I didn't see it on the cath lab, right? Um, in 20— in 2005, 20 years ago this year, The first of what we call the multi-slice scanners became commercially available. And the first, the iPhone 1, was a 64-slice scanner. Right.

Okay?

So that was the first. Now, when those arrived, that's when cardiac CT got serious. And the images were so good, and the software was so good, particularly with what I had before, that I gave up cathing people.

Right, right.

'Cause I could get more data, better data, more accurate data, 5% of the cost, non-invasively, none of the risk, Yeah, and see stuff that I couldn't see. And that was 20 years ago.

So you could still use— be on insurance?

So 20 years ago, no. I mean, no, it was all— they wouldn't cover it. They called it experimental.

Okay, and they still do?

Well, if you have symptoms, right? I got chest pain, breathing, you know, what we call angina, which could be chest pain, right? Or it could be shortness of breath, right? Because there are different flavors of it. Then insurance will pay For cardiac CT.

Okay.

Right?

But not this.

But not in the absence of symptoms.

Yeah, right.

Well, by our age, you all have symptoms. I mean, the shortness of breath and the—

Well, right. And again, you can have chest pain from lots of stuff. Yeah, your esophagus, your gallbladder, I mean, back, musculoskeletal. So symptoms are not helpful because about half of people, the first symptom of heart disease Is it kills them. Yeah, that's the first symptom. And then you have lots of people— in fact, if you look at data, people go to the ER with chest pain, right? Big concern, I'm having a heart attack, right? 90% of the time it's not cardiac. Yeah, okay, only 10%.

So do you— so getting back to this, you said if you have symptoms too. So if we had had symptoms, would Medicare or— Yeah.

Yeah, if you have symptoms. So remember, you don't have symptoms until— if you want to use an oncology metaphor, right— until you have stage 4 disease.

Right.

Then they'll pay for this, which is okay. Well, how about let's try to catch it at stage 1, right, when it's curable?

Right.

Yeah. So it's the financing mechanism behind medicine Is pretty broken, right?

Are you familiar with the, I guess you call them concierge doctors, MD VIP?

Oh yeah, of course, yeah.

Okay, yeah, well, my, my doctor retired, and so I went to see my new doctor, and he's an internal medicine, you know, guy. And so we were getting to know each other, and so I said, I got a procedure coming up in 2 weeks. So I was telling him, you know, about this and gave him the And he went like, I can't believe this. I've been telling my patients for years it's about the soft plaque in the blood.

Exactly.

Yeah, he's excited.

So he's so excited for me. He emailed me the other day and says, let me know now when you come back from the thing. Because then what I'm hoping is that this will be a conduit if it— he goes and then they send out wellness letters and recommend.

So he said, I'll be sending all my patients When you think of the 30,000-foot view, roughly 45% of all of the deaths year in, year out, even during COVID are cardiovascular, right? Strokes and heart attacks, right? 45% of the deaths. What do we do to detect that form of potential mortality? What do we do to find it early? Nothing.

Yeah.

We just wait till it happens.

Yeah.

So the mode right now is, We wait till you have symptoms. Remember, in half of men and women, the first symptom is you die from the disease. Yeah, right. So that's kind of crazy. And if you don't die from the disease as your first symptom, then you've got such bad disease because you're already having symptoms, then you probably need a mechanical fix— stents, bypass surgery, all that stuff, right?

Well, and I just went through my, my neighborhood Friends of Florida. I mean, by time you get the 60s, and I went, oh my gosh, you— let's see, the next 2 doors down, then the street around.

Oh, absolutely.

All these men that have had stents.

All of them got stents and everything.

Or bypass surgery.

So let me tell you something.

It was amazing.

And I'm glad you're sitting down.

I'm like, they would probably all be dead if—

Right. Well, and I will tell you, here's another interesting Fact. Okay, all the mechanical things we do, the stents, the bypass surgery, I'll throw in balloons. We don't really use balloons anymore, they don't work too well. But your stents, your bypass surgeries improve symptoms.

Yeah.

Okay, so they're going to snowplow that plaque to the side, right? Right, that's a stent. Okay, uh, or if you have lots of blockages like your mom, then we lay down new conduit, new pipe.

Yeah.

Right? Because you got so much plaque and blockages, right? Then you get bypass surgery. For the vast majority of people, there are some exceptions, and it's only with bypass surgery and, and particularly with stents, there is no mortality benefit of getting a stent.

Yeah.

Doesn't save your life.

Right.

Right?

I will tell you what does save your life. is the medical therapy.

Right.

Treating blood pressure, cholesterol, diabetes, all those different things, right? That is what actually treats the disease. That treats the plaque. The mechanical things either push it off to the side like a snowplow or lay down new pipe conduit to improve blood flow. So the mechanical things treat symptoms. They do not treat the disease. They do not treat plaque. What treats plaque Diet, exercise, control the blood pressure, get your cholesterol down, diabetes.

Taking the medication to dissolve or—

The medication.

Yeah, your medication to get rid of it.

So all those guys that got the stents, right, the stent didn't save their life. In fact, we do these studies every 10 years.

Well, they, in their mind—

Of course. Well, intuitively it makes sense, right? You just, you go, right? They'll show you the picture, you see the blockage, there's after the stent, it's open, you go, whew, close call.

Yeah.

The blockages that are 70+% or more are generally calcified plaques that don't rupture.

Yeah, it's not going anywhere.

It's the 20s, 30s, 40s, 50s that don't cause symptoms. Those are the ones that are more lipid-rich. Those are the ones that rupture and cause sudden cardiac death.

Right.

Right?

Right.

So when we used to do stress tests, we actually found The wrong aspect of the disease.

Right.

The blockages.

Right.

And the intuitive part was— and we in cardiologists— cardiology thought this way for a long time— that if you fix the blockage, you fix the problem.

Right.

No, it just treats symptoms.

Right.

Because if you have a 70% blockage, what do you think is peppered around the rest of your blood vessels?

Right.

20s, 30s, 40s, 50s, all ready to keep growing. Or to rupture.

Yeah, right.

Right? So every 10 years starting in the '90s, we would do these studies. These are sponsored by the NIH, so I say that, so no pharmaceutical company shenanigans, right? So we would do a very simple study, and we did this, we've done this roughly every 10 years. In the '90s, we did what we call optimal medical therapy. So take care of blood pressure, diabetes, cholesterol with the tools we had back then, which are not nearly as good as now. And that was compared to optimal medical therapy, diet, exercise, not smoking, all those things. Optimal medical therapy and optimal medical therapy with balloons. So we did that study in the '90s, and guess what? The people got balloons had less symptoms, less angina, no impact on mortality, no impact on cardiovascular mortality, no impact on heart attacks.

Right.

Right? Right.

Less angina. 'Cause they had blockages. We fixed the blockages. So my interventional colleagues, the ones that do the stents, go, well, that can't be true, 'cause we know if we put a stent in there, it's gonna save your life and prevent a heart attack. Although I told you why that's not gonna work.

Right.

Right, 'cause they're finding and treating the wrong part of the disease. So 10 years later, we did another trial. This is 2008, called the COURAGE trial. Everybody had angina. had to have a positive stress test, and then they were randomized to optimal medical therapy— diet, exercise, not smoking, blood pressure, whatever— optimal medical therapy, and, and now either a balloon or a stent, because now we had stents, right? We did the trial, came out, no difference in mortality, no difference in heart attack risk.

Yeah.

But my colleagues on the interventional side still could not believe, right? We know this saves lives. and keeps people alive and prevents heart attacks. So 2019, optimal medical therapy versus, now this time, 100% stents and—

Yeah.

Contemporary modern-day stents, and about 15% of people had bypass surgery. Here's the population they looked at. Everybody had angina, right? You had to have real deal classical angina, and you had to have it confirmed with a positive stress test.

Right.

Right? So not just subjective symptoms, but we had to confirm it with a stress test that was at least moderate to severe. That's the people we enrolled. Then they got randomized to optimal medical therapy or optimal medical therapy and what we call revascularization, so stents or bypass surgery. We followed them out over 3.3 years. Interestingly, so the people who got stents and bypass surgery had less symptoms, they had less angina.

Mm-hmm.

Okay, not terribly shocking. But interestingly, a lot of the people on optimal medical therapy got better with symptoms as well.

Right.

Because your heart will create collaterals and work around those narrowings, right? The people that got bypass surgery or stents, most people, 85% got stents, had more periprocedural heart attacks. 'Cause we're going in there, we're blowing up stents in the arteries, gruel and debris flows downstream, so they had more heart attacks because of the procedure, right, that were due to the procedure, than the people just getting off medical therapy. But if you then fast forward 3.3 years later, no difference in heart attack rates, no difference in mortality, right? And this is using state-of-the-art stents and what we call drug-eluting stents.

Yeah.

And also the medical therapy got better, right? We got better drugs for cholesterol, blood pressure, diabetes, etc. So, you know, both of those technologies improved, but every time we do this test and compare optimal medical therapy to optimal medical therapy and revascularization, the people with angina have less angina, not shocking, but the people who had angina with time and medical therapy got better too, but no difference in mortality, no difference in heart attacks.

Wow. Wow.

So that's why I'm a preventative cardiologist, because I want to find the polyp Take care of the polyp and here's— Right, before you get cancer. What we've done is basically saying, imagine an oncologist that only treats stage 4 cancer. You come to him with a stage 1 lung cancer, which is completely curable. You just take it out. You don't need chemotherapy or radiation. You just surgically remove it. You're done. You're cured, right? Imagine you show up at the oncologist that only treats metastatic cancer. He says, yeah, I got stage 1 cancer. It's completely curable. However, I only treat metastatic disease, stage 4 metastatic disease. So let's have you come back maybe 5 years. We'll see if it's still here. We'll just kind of watch it go. Now, when you come back 5 years from now, it'll be spread. It'll be locally invasive. It'll be widely metastatic. And then I'm going to show you the real exciting science of how we treat cancer. You're going to get proton beam therapy. You're going to get $100,000 a month chemotherapy. You're going to get surgery. We'll throw in robotic surgery. You're gonna have this incredible technology thrown at that cancer. You're still gonna die like a smell, but you'll see the incredible technology that we have to treat metastatic cancer. Hopefully at this point you're running out the door, right? Well, that's insane. And yet we do that for the disease that kills 45% of us.

Right, right. I understand.

It makes no sense.

And the next thing that I have, you know, when I talk to people about this is that, of course, we all want to be positive and we think we're fixed, you know. So I was talking to a guy the other day and he said, well, Floyd, I just had my surgery 9 months ago. I'm fixed.

Surgery?

What kind of surgery?

I said, Chris, bypass.

So I said, Chris, think of yourself as a car tire. You just went flat. You took it down to the thing and they Patched a hole in there. You're driving down the highway and all of a sudden you're feeling good, then you realize, you know what, I might have some more nails in the tire of this thing, but I don't know whether they're there or not. Wouldn't you want to know that you might be going to have your tire— and he went, well, okay, well, call me when you get back.

Well, it's interesting, in the old days, right?

Most people are defensive, like, oh, I'm fine.

Right. So in the old days, right, people would get bypass surgery and they would be told it'll last 7 or 10 years, right?

Yeah.

Because remember, bypass surgery doesn't treat the disease, it treats the blockage, which is a complication of the disease. So all those other plaques that weren't 70-plus percent that they didn't bypass, that are full of lipid and cholesterol-rich plaques, the 20s, 30s, all the stuff in the wall, well, it keeps growing.

Yeah.

So yeah, you're going to grow out of that bypass surgery because all those other plaques, if you don't treat the plaques, are going to come back, right? So what's interesting in people now that have bypass surgery, right, if we find the disease so late that you need bypass surgery, sorry about that. If we'd only done this a few years beforehand, you never would have needed it, but whatever. You didn't die, we found it, you need bypass surgery. That's $150,000. If we found it early, you never would have needed it because we treat the plaque. And by the way, when we treat plaque, it's not just the heart. Not only do we lower the risk of balloon stents, bypass surgery, heart attacks, killing over dead, but equally we lower the risk of strokes.

Right. Well, I was going to say that.

Because that plaque, it's exactly the same. Well, we can use this technology to look at the carotid arteries.

Or the clots that come from legs.

Yeah, we can use this technology to look at anything from the top of your head to the bottom of your toes. So depending upon the question we want to ask, what issues there might be, we can even do hands. We've done feet. So people have, you know, you get actually plaque and blockages in the hands and stuff. So yeah, so we can do all that. I will tell you, if we did that, you know, you look great. You have a little tiny bit of plaque.

I have leg veins.

Well, right, but the veins, that's a whole different issue. Yeah, we're talking about the high pressure clean water supply. The veins are the sewers. Veins never get plaque.

It's other issues with the veins.

Veins can get dilated. They have valves that are critical for keeping the blood, but they don't get plaque. You can get clots in the veins too. But yeah, the varicose veins, whole different scenario there. But yeah, it's pretty amazing. I mean, most people who got the stents go, He saved my life. Well, there's no evidence for that.

Right.

Of course. Well, and I think some of my colleagues who were in that industry, they won't correct you if you say that.

No. Okay.

Comes in their quarterly bonus. Right.

Well, and it's, you know, I hate to get too conspiracy-minded, but Me too. Most of my colleagues work for a hospital, right? The vast majority. 20 years ago, we're all independent, right? Or in groups, right? Well, where do you get your bypass surgeries and your stents done?

Right, I understand. It's not hard to figure out.

St. Vincent's, UAB, right? What gives them the money to build the next heart hospital? The stents, the balloons, the bypass surgeries. Not Preventing the disease, right?

Right.

So as a preventive guy, I got to take a vow of poverty because that's not where the money is, right? It's all in waiting till you have metastatic disease, then we stem it, balloon it, bypass it. You know, heart cath, $20,000, which are irrelevant nowadays. We still do a couple million every year in the US, which is terrible. Uh, I haven't done one for 20 years as a cardiologist because we got this, and the technology's only gotten better, right? We haven't even gotten into the AI yet, which we'll have. But a heart cath is $20,000 MSRP, right? Doesn't fix anything, doesn't diagnose anything. It's a $20,000 diagnostic test.

Some people make money.

Right. Which I was able to stop with just CT, even without the AI, 20 years ago, right? CT is better, faster, cheaper, easier, no complications, 5% of the cost. If you need a stent, now we're talking 50 to 70, and if you need bypass surgery, about 150.

Yeah.

So what builds your next wing?

Yeah, I understand.

Right.

And, and also say, I gotta rib my GI colleagues again, that concept of the cardiac colonoscopy. Let's find the polyp, take care of the polyp, and you don't get the cancer, right? Everybody gets that, so that's why everybody should get their colonoscopies. I like to rib my GI colleagues a little bit because when you think of it, if they find a polyp, they just scrape it out.

Right.

Right? They don't have drugs to treat or prevent polyps. In my world, we have a multitude of highly effective drugs and tools and approaches from diet, exercise, quitting smoking, treating cholesterol, blood pressure, diabetes that have been proven to lower the risk of cardiovascular events, of strokes and heart attacks, right? The problem is we use all those tools Usually after the fact. So the most important life-saving aspect of the stent your friends got was not the stent. It was now they said, oh, we need to really treat your cholesterol. We need to take care of your blood pressure, right? That actually is the most important medical thing that happened that will change their trajectory from more stents or heart attacks or cardiovascular death. It wasn't the stent. It was the fact that they said, oh, you have heart disease.

Right. Right.

So, oh, but I was going to say, but in my world, right, my— the GI docs, everybody get their colonoscopy, find the polyp, take care of the polyp. They keep scraping it out, which is great for them because, yeah, business, right? It's an annuity. In my world, we have pharmacologic Drano, right? So not only can we detect disease that kills by far more people than any other single disease, but we also have proven tools That prevent the strokes, the heart attacks, the sudden cardiac death, the need for defibrillators. Sorry, because most of the people getting defibrillators are people who had heart attacks. Not everybody, but most of them are people who had heart attacks that, you know, they're, they're, they're, they came, you know, that's a near miss, right?

That's right.

Yeah, no one gets a defibrillator.

They're fortunate.

Because, you know, you just look like you need one. Yeah, right.

Yeah.

Yeah.

So you got to get lucky twice. One, you got to have a bystander to see you, right? And you got to have somebody to bring a defibrillator.

Exactly, right.

And within about 6 minutes. So you got to be lucky.

10% mortality per minute, right?

Yeah.

Yeah. Thanks everybody for joining us on this very special program. Uh, of course, I think all our programs are special, uh, but this has been a really remarkable day, uh, for all of us here. Myself on the cardiology side, and I know for Clare and Floyd, it's been incredibly enlightening as you learned. But this is the Clear Cardio path. This is the Clear Cardio way. And I think unfortunately, this is how everyone should proceed to help eliminate the largest cause of death by far in the US, which is cardiovascular disease. We're out there to make a difference, and thank you again for joining us today. But also be sure sign up, click below, Clear Cardio, find out what we're doing. We have lots lots of great videos and educational aspects about how we can work to prevent heart disease and stroke for that matter as well. Please click below. Please subscribe if you like this. Program, you want to see more, please subscribe as well. Please do that below. And until then, we're just going to keep working to eliminate heart disease at Clear Cardio.