032 - Ask Me How I AVOIDED DEATH | #clearcardio

But I'm overweight, and so I knew there was a little bit of risk, but I'm thinking, I'm gonna die like everybody else, but I'm not gonna die—

I gotta correct you.

Okay.

None of my patients are overweight. Some are under height.

Okay, I could be—

None of my patients are overweight. I just wanna point that out.

Well, I've told people the only thing that kept me from playing in the NBA was lack of height and talent.

Exactly.

You know.

So hello and welcome everybody to yet another Power Is Prevention here at Clear Cardio. Delighted to have you again. So we're gonna be talking today To a longtime friend and colleague, Dr. Tim Ritter. Tim Ritter is an incredible gastroenterologist, especially a specialist in GI, and he's gonna tell his— a little bit about his professional life and what he does. He's incredibly accomplished. But also, we have an intersection between what I do in preventive cardiology and Tim, and he's gonna talk about that, and we'll talk about his cardiac journey as well. If anything, today he's gonna be talking about below the diaphragm, and then we'll both be jointly talking about above the diaphragm as well, as I like to say. So with that, Tim Ritter, the amazing Tim Ritter, gastroenterologist extraordinaire, as I like to say. Again, long-term colleague, longtime colleague, longtime friend. I've known Tim for over 25 years.

Oh, at least.

At least 25 years. And so we actually used to work shoulder to shoulder in the hospital, Me taking care of cardiology and Tim in the GI world. And he's gonna kinda tell you what he's doing nowadays.

Sure.

Some very, very exciting things professionally. And then we'll kinda move on to kind of how we continue to work together to keep him healthy, happy, and above ground for the next several decades.

Sure.

So Tim, so tell me, so we go way, way back. If you wanna think about it as stem cells, I was the undifferentiated stem cell 25 years ago, or 28 years ago when I moved here. I moved to Texas in 1997, so it was 28 years ago, and that's when we first met. I was, if you wanna think about stem cells, an undifferentiated cardiologist just doing general cardiology, and I know you were, by that point, you were already, when did you start practicing?

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So I started in '93.

Okay, okay, so you beat me a little bit.

Yeah, by just a few years. And I was the same way. I was doing general GI for the first, you know, 10 to 15 years of my practice. But, you know, as we all do, you find things about your job that you love. And I developed a real passion for inflammatory bowel disease, Crohn's disease and ulcerative colitis. So my practice morphed to where I am now, where all I see now is ulcerative colitis and Crohn's, which is the thing many of my partners would rather not be seeing because they're time-consuming and complicated. They're also sick patients, and there's a lot of joy in getting them back to health, as I'm sure you see with cardiac disease as well. So over the last 15 or 20 years or so, I've just done inflammatory bowel disease. And there's been huge advances in that space. And so because of that, we opened up a clinical trials program where we've been working with a lot of pharmaceutical companies in developing new therapies for inflammatory bowel disease. And I've been really, really invested in that part of our practice for the last several years. And our practice has then grown to be a very large, multi-state practice. So we have clinical research sites around the country, and I help oversee all those sites. And then I do a lot of consulting with pharma on how to best design trials that are patient-friendly and yet give all the information that's needed to really bring these drugs to market, or not, if they're not supposed to be there.

Well, I'm so excited to know that I knew you before you got famous.

I don't know if I'm famous or not.

And you still pick up my phone, which is pretty great.

I always answer the phone.

Now that's phenomenal, and I know, you know, this is all run out of Grapevine, Texas, right? Which is sort of the headquarters for that, and you're really involved really nationwide with these products.

Yeah, we've got research sites in Seattle, Washington, Phoenix, Arizona, Connecticut, Florida— well, actually not Florida yet, but multiple sites in Texas, Chicago, all throughout the Midwest. And then we partner with another network called Iterative Health. They've got another like 40 sites. And so together we can really deliver a huge network of high-quality trial sites to these studies. Wow.

So when did you get kind of into the research world?

Probably about 15 years ago.

Really?

Yeah. And it started slow. And I had no idea what I was doing, and I did it poorly. But then, like everybody else—

That's my line.

But, you know, you learn, and you get better, and then as you move along, you realize how to really do it well, and how to really— I think what you learn is to not take every research trial, to look at the ones that are really good for patients. 'Cause we wanna make sure these things are safe, we wanna make sure they're effective.

Kinda like an actor in the script, right? You learn, this is not a good script.

This is not the way to do this, yeah.

And this one's good. Very cool. So just out of curiosity, how many trials are you running in your organization right now?

So across the network, we probably have about 100 different trials. About half of those are in inflammatory bowel disease, what I do, Crohn's and ulcerative colitis. And about half are in metabolic liver disease. We see a lot of fatty liver, which is very integral to the cardiac stuff.

Absolutely.

So there's a lot of great—

East meets west. Liver meets heart.

Yeah, and it all revolves around the microbiome from the gut, right?

Yeah, yeah.

So yeah, so we do a lot of liver trials. I'm just now dipping my toe to personally doing the liver trials because they're now looking at the GLP-1s for fatty liver disease, which is something I've always had an interest in for a variety of reasons. And so, but yeah, that's— and then we'll do the occasional trial for eosinophilic esophagitis or IBS or reflux or the other GI disorders.

Right, right. Well, that's so exciting. So how many patients do you think you have involved in these trials right now?

I can tell you we had 6,000 research visits last year.

Wow.

So, across all the sites. Yeah, yeah, yeah.

That's so cool. I mean, it's really key. I mean, it's great. I love clinical medicine. I love taking care of patients. But it's also super exciting to be involved with really the cutting edge of what we're gonna be doing 5 and 10 years down the road.

Well, I tell people there's 2 things about my practice I like. I still love sitting in a room with a patient, taking care of the patient. And then I love the the time we spend with our coordinators going over how the research trials are going. I mean, those two, those part of the week, that's not work. That's fun.

Yeah, absolutely. Well, as I like to say, and I think you could probably say this too, I've never worked a day in my life. I just get paid to do my hobby.

There you go. I like that. That's a good line.

Yeah, you may steal it.

I will. It's like the last little line from a friend of mine. I told a patient in the trials, I can get you tomorrow's medicine today.

Yeah, there you go. Or, you know, I love it. A quote that I always love saying, right, which is really the same concept, is— and this was from— I have to attribute this— it's from William Gibson. So William Gibson, sci-fi writer that gave us the term cyber, right? So he said, the future is already here, it's just not evenly distributed. Oh, I like that, right?

Yeah, that's good.

So in reality, you're in 2035 and you're trying to educate everybody back in 2025 on What we should be doing and what's coming.

There's a lot to that.

Yeah, I kind of feel that way in my world of preventative cardiology too, but I won't dwell on that. So I do have to ask, so in that world, because I'm very interested, in fact, I believe I've had some very peripheral involvement in that space, looking at some of the drugs that cause some potential cardiac issues with some of those drugs. And we've talked about that before. But it is really a fascinating area.

Fortunately, I don't have it.

in my family has it, but it really seems like there have been some major, major advances in the last few years.

Yeah, beginning in 1998 when infliximab came out and we had the first really effective anti-inflammatory therapy, the field's just exploded so that we've learned, you know, when I was in medical school, immunology was the class that you showed up for and then tried to forget.

And I was successful.

Yeah, and now it's everything. It's the entire, this whole immune cascade of driving these disease processes, we have all of these different medications that very selectively address one small piece of the immune system where we can modify inflammation in the colon, in the small bowel. And then, you know, in all the other fields I'm not involved with, whether it's rheumatoid arthritis or multiple sclerosis or things like that. And so the— just the drugs are getting continually safer and continually more effective.

Mm-hmm, mm-hmm.

And it's been absolutely fascinating.

Well, I do have to ask. So from your seat in that ulcerative colitis, Crohn's world, what are you most excited about? What really goes like, this is really cool stuff?

I'm always excited about the next drug.

Okay.

So I love what we have. There are drugs right now in trial called TL1As that are going to be, we hope, another step forward in treating inflammation. There are a number of other mechanisms out there. that are being looked at. And so, you know, every time we take a step forward, we have one more tool to help a patient.

Yeah, yeah. Well, that's really exciting, and I'm very, very happy for you, and frankly very proud as your friend to know that you're really deeply involved in really helping to transform care for our patients with some really, really problematic GI issues.

Yeah, they are. These patients are miserable.

I remember 30 years ago as an intern, right, we'd get the Crohn's patient, Oh, what a disaster.

It was steroid surgery and—

Fistulas.

Yeah, fistulas. It was just— there was nothing you could do.

I mean, you actually kind of felt better for the ulcerative colitis people that just fixed the large bowel because you could always take it out, right? And we still do that sometimes. Not great, but at least you could take it out. But with the Crohn's or regional ileitis patients, oh.

Yeah, they had some miserable—

Really bad.

And now most of the time we get them happy, healthy, and You know, living normal lives.

Yeah, well, it's a tribute to you and what you've done.

Thank you.

Thank you, Tim. So speaking of more good news, I'd love to hear— so, you know, we knew each other and colleagues and all that stuff, but I'd love to hear kind of what evolved that brought us back together on that, to go above the diaphragm.

Sure. So, you know, I've always struggled with my weight, but I've never really had many cardiac risk factors. And so at the hospital that you used to work at, that I'm still at, about 20 years ago, they put in their first cardiac CT program. And in order to get certified to do it for Medicare, they offered these free scans. And so I said, well, you know, I'll do that. So I went in.

In Texas, it's like free beer.

It's free beer. Yeah, it's free beer. I think they gave me a beer, actually. But anyway, so I went in and I had this coronary CT and it was pristine. Crystal clear, right? I had a neurologic thing a couple of years later. I had an MR angiogram, crystal clear. So I'm thinking I don't have diabetes, my cholesterol is fantastic, I don't have hypertension, I don't smoke.

Any family history?

Well, I'm adopted, so I don't know.

Yeah, big black box.

Yeah, but I'm overweight, and so I knew there was a little bit of risk, but I'm thinking I'm gonna die like everybody else, but I'm not gonna die—

I gotta correct you.

Okay.

None of my patients are overweight. Some are under height.

Okay.

None of my patients overweight. I just want to point that out.

Well, I've told people the only thing that kept me from playing in the NBA was lack of height and talent. Exactly.

Again, my line too.

So anyway, so I'm thinking, you know, I'm not gonna live forever.

So you get a perfect scan 20 years ago.

Perfect scan.

Both, you know, head, neck, heart.

Head, neck, everything.

No risk factors.

LDL 70, baseline native LDL is 70, you know, and so I'm thinking You know, I need to be watching out for cancers and all the other stuff, and I don't need to worry about my vascular system.

Sure.

And then about 3 or 4 years ago, I'm really working hard to lose weight and going to do well.

So I have to tell you, so we would call you— you're gonna love this— we actually have a term for it: SMRF.

Okay.

So a SMRF in our world is someone who doesn't have standard modifiable risk factors.

Yeah.

We call them SMRFs.

Okay.

As it turns out, about 15— for everybody out there, 15% of people with heart disease are Smurfs. They eat right, exercise, great cholesterol, no diabetes, no smoking, and they still get heart issues. So Smurfs are pretty common. So you're a Smurf. Yeah, I am a Smurf. And thank you for wearing the right color shirt as well.

Oh, okay. There's a story with that actually, I can tell you.

Well, we got time.

So anyway, I'd always— I'd been put on a GLP-1 to try to lose some weight, and I've always followed my blood pressure. I've always checked it. once a month or whatever. And I started getting a little hypertensive about 3 years ago. And it wasn't bad, 145 over 90 kind of thing. And so like every really bad doctor, I treated myself. And it didn't really work. I don't even remember what I put myself on, but it didn't work. And so at some point I said, you're an idiot, go see your internist and let someone who knows what they're doing actually take care of you. And so I went and saw my internist who, like you, I've been friends with forever. And he got my blood pressure under control. And then he gave me a whole list of things I needed to do. One of which was a calcium score. And I'm like, well, that's a waste of time, but if you want me to go do this, I'll do it. And you can remind me, I don't know what a normal is, like less than 150 or something?

Well, I'm gonna say, so for you and everybody else, with a calcium score, the only normal score is 0.

0, okay.

Right, that's the only normal score. Anything that's not 0 means you have plaque.

Well, mine was not 0. In fact, mine was a few thousand.

Yeah, I forget the number, but it was well above. It was like 2,500, 2,800. I was thinking 1,000 plus.

Scared the crap out of me. Right.

No pun intended.

Yeah, I mean, so, you know, so I'm at home talking to my wife about, you know, when do I schedule the bypass, right? You know, I mean, but it really got my attention. And so I saw another buddy of mine, a cardiologist, and he wanted to do a stress test, which with my orthopedic problems, we did a nuclear stress test.

Right.

Correct me if I get the terms wrong, there were no significant ischemic changes, but I had transient ischemic dilation, which can suggest multivessel disease or left main disease.

So what that means, after the stress test, the heart dilates. Normally it shouldn't. So that's a concern. It could be other things, but a red flag perhaps.

And I've never had a symptom— chest pain, short of breath, anything like that. And so he said, you ought to go see you. I said, well, sure, I know John, I'll be happy to, and get one of these CLEARLY studies, 'cause he didn't wanna cath me 'cause I have no symptoms.

Sure.

And they weren't gonna do anything. And I'm in full panic mode at this time. And so that's when we reconnected and I got the first CLEARLY study and it showed significant, primarily right-sided disease, but I've also got a right-dominant system.

Right.

So, and I don't remember the numbers, but 30, 35% occlusion.

Yeah, I mean, you know, we break it up into Occlusive, non-occlusive, obstructive, non-obstructive, right? Stents, balloon surgery versus medical therapy. So yeah, so the good news is we didn't see any blockages, right? So we had the opportunity to just kind of work on this medically. So anyway.

And so, you know, I consulted with you and we talked about multiple different things and we came up with a regimen of a variety of things to really drive my LDL down. As low as I can get it. And over the next 3 years then I've had 2 subsequent studies and have had some regression of the plaque. So it makes me, it excites me that I'm actually doing something that is positively impacting what I never expected to have in the first place.

Right. Well, and I have to tell you, to drill into the details, which I think are very interesting and I think One of the reasons I wanted to have you share your story is that we did 3 scans, right?

Right.

First scan, okay, no blockages, no problem. Okay, we got a good baseline, we know what we're dealing with. And the nice thing with cardiac CT now coupled with AI we use, Cleerly, is that we can very precisely see how much plaque there is, see if there's blockages, detect plaque, and then also quantify plaque very, very precisely, right? None of that was possible till we had CT coupled with AI. It's amazing. So we did that, okay, says, Good news, we don't need stents or surgery or block— we don't have blockages, and we could just work on treating this thing medically, which is great. We did the second scan, and the second scan had me a little confused and just a little worried. Because what happened with the second scan— because we, we pretty much largely threw the kitchen sink at you, right? So I think you were already on, or I started—

I forget.

I think we had you on Repatha already.

No, you started me on Repatha.

Okay.

I was on a low dose of a statin.

Got it. Ezetimibe, I think?

Rosuvastatin.

Okay.

And I was on a baby aspirin at the time.

Got it. Okay.

And I was on tirzepatide, a GLP-1.

Got it.

Okay.

Yeah, and so I remember the first time we ever met, I mean, looking at your numbers, the cholesterol numbers, they look great, right? On a statin, aspirin, you know, we talked about the tirzepatide or Zepbound Manjaro, which is great for the heart and great for lots of stuff. But— and your numbers look great, so we put you back in the machine the second time and the plaque actually got worse despite your numbers. A little bit. A little bit, right? But it didn't— I like to see it go down, the trend down, not up. And so the interesting part behind that was in the past all I could look at was surrogates. I look at cholesterol, going cholesterol's lower, then we must be better.

Right.

Without actually knowing, is the plaque better?

Right.

And that's the big, big advance in being able to do cardiac CT over time, detect plaque, quantify plaque, and for the first time ever, track plaque. Is the plaque actually behaving? Is it doing what we want it to do with the medication on board. And as it turns out, you had great numbers, but the plaque actually went up a little bit, which I didn't like. So in light of that, we said, okay, you're getting the whole kitchen sink. I held a little bit back from the kitchen sink. I said, you're getting the whole kitchen sink. So at that point, I think we put you on Repatha.

Added Repatha, added colchicine.

Exactly.

And earlier on, we had actually switched from aspirin to clopidogrel.

To clopidogrel, right. So basically, for those at home, so we changed the antiplatelet drug that prevents the blood clots, from aspirin to kind of a super aspirin drug called Plavix or clopidogrel. We put you on a drug called Repatha, which is a really, really very potent, very effective drug to lower cholesterol.

It's a very, very cool mechanism.

Yeah, it's a very, very cool mechanism. I won't bore you with the mechanism, but bottom line is it will hammer your cholesterol, right?

My cholesterol, if I remember correctly, went from 70 with rosuvastatin, went to about 54. And with Repatha, it's essentially undetectable.

Yeah.

It's 4.

Yeah.

Sometimes it's 3, sometimes it's 6.

That cholesterol, you know, none of it's good. None of it's good. Just drive it down. So we threw the whole kitchen sink at you. We had the atorvastatin, the Repatha, and I will say, this is very cool. So this is hot off the press. I don't think you'd seen this yet. So I just came back from New Orleans from the American Heart Association meeting. It's like GI Week for you guys. So it's the American Heart Association meetings in New Orleans. And on this last Saturday, they presented data on a trial called VASELIUS. So VASELIUS was basically you. So these are people who didn't have a heart attack, didn't have a stroke, but we diagnosed them with asymptomatic or high risk for heart disease or asymptomatic plaque from calcium scoring or CTA or whatever, but did not have an event.

Right.

And that's the goal. We don't want you to have an event. So we took 12,000 people, Everybody was on statin therapy, and we randomized half of them to placebo. You're doing fine. The other half got Repatha. And again, they were on statins. You could even be on Zetia or zetamibe, which is a great drug that modestly lowers LDL on top of statins. And what we found is 4.5 years later, 25% further reduction in balloon stents, bypass surgery, heart attack, strokes. 36% reduction specifically in heart attacks, 19% reduction in cardiovascular death, and by the way, a 20% reduction in all-cause, any-cause mortality.

That's pretty cool.

Simply by taking Repatha.

Yeah.

Right, driven by the reduction in cardiovascular events. And the other thing, so really amazing, great data on efficacy, on the benefit of that drug, on top of all the usual things we do. And the other thing is, if you look at tolerability, side effects, Equal numbers of people on Repatha stopped Repatha in this placebo-controlled trial, right? So half the people got placebo, half got Repatha. No one knew. Investigators didn't know, patients didn't know. But equal numbers of patients on Repatha stopped Repatha as in the placebo arm. So no difference in side effects, basically, which was very cool as well.

I've had none.

So it was really a really big deal. So as it turns out, as of Saturday, I love Repatha. I've been a big fan of it. But as of Saturday, I found out I have a lot more Repatha-deficient patients in my practice than I thought. So it really is going to be a practice-changing trial. So hot off the press there for you, Tim. Of course, we were all over that beforehand.

When we're done, if you wouldn't mind emailing me that study, I would love to read it myself.

I will. So Vesalius, V-E-S-A-L-I-U-S, Vesalius trial, but I'll send that to you. It's a big, big deal, so I'll send that to you. And so anyway, we did all that. The other thing we did is we added on another novel drug. So a drug called colchicine that has been used for decades for lots of medical conditions, probably most notably gout.

Right.

It's miraculous for gout. We also use it for pericarditis.

Oh really?

Oh yeah, it's phenomenally effective. And also pleurisy too.

Oh really?

So it just blocks inflammation. So we had data from trials done over the last several years That if you had someone with chronic coronary syndrome, as we call it, CCS, basically chronic CAD, right, that if you gave them colchicine, again, on top of aspirin, blood pressure drugs, cholesterol drugs, all those things, that it further lowered cardiovascular events by another 31% in a cholesterol-independent way. So in light of that score going up a little bit, not going down, but going up, we really got— That's a big number. We got even more aggressive about your numbers. We threw on some colchicine. So we not only, as I like to say, the cholesterol is the fertilizer. We turned off the faucet, we got rid of the fertilizer on the cholesterol side with Repatha and those drugs, and we threw on this anti-inflammatory drug, colchicine. And then, drum roll please, we put you back in the scanner, and the good news was, I love happy endings, we actually saw the plaque starting to come down.

Yeah, by a significant amount.

It did, it did. And what's really great, and I think the take-home message is that, you know, numbers are great. We're gonna look at blood pressure and cholesterol and those factors. We can even measure inflammatory markers like hs-CRP that you guys measure too, I believe. All the time. In your world. We measure it for vascular inflammation. You measure it for GI inflammation. And we can use drugs like colchicine in our world. We have proof of that. But it's really wonderful when we can actually track Plaque. Are the drugs that should be working, working in you? Not in general, not on average, but are they working in you? And that's really one of the cool, cool advantages of the ability to do cardiac CT, follow plaque over time, and literally track to see, are the tools we're using working in you? Not just someone who looks like you, but you yourself.

Same thing we do with Crohn's. We get them on therapy and all the numbers can look good, But at some point you're gonna wanna either relook with a scope, or we're doing a lot of intestinal ultrasound and looking at bowel wall thickness.

Oh really? Oh wow.

And say, hey, this inflammation's going away. So that's what you wanna know.

Right, so you wanna look back at the disease. Is the disease better, right? So it's funny, again, our paths cross again as far as all that interesting tools, biology, and advances. So in the future, we won't have GI problems, we won't have heart problems, You know, you and I will be on some island somewhere. Works for me. Drinking drinks with umbrellas in them.

It'll be beautiful.

I would like that.

So, well, listen, I know I, again, very grateful for you sharing some of your very, very valuable time with us and giving us a beautiful update on ulcerative colitis and Crohn's and also sharing your story as well.

Happy to do it. Thank you very much for taking care of me. I really appreciate it.

You know, as I say all the time, I do not have patience, I just have a really, really extended family.

Hey, I like that too.

And I'm gonna tell you, so A, I have an extended family, so nothing can happen to you, but B, it's not really altruism. Nothing could happen to you. I'm not gonna let you ruin my record, so it's really not about you.

Okay.

Okay, but if you benefit from that, I'm all about it. It's all cool.

Very good.

Again, thanks so much for your time today. Really appreciate it. And I know we'll be working together for a long, long time, whether you like it or not. And again, thanks again for coming out. And be sure to subscribe. Click below, Clear Cardio. Subscribe to our YouTube channel. Do you have a website or YouTube or anything?

No, I've got a partner of mine that has a podcast called The Gut Doctor.

Okay, awesome.

It's very good. A guy named Neal Parikh.

Oh yeah, yeah, yeah, I know Neal. Yeah, awesome guy.

Fantastic.

Okay. Well, yeah, so, so check out the—

Gut Doctor.

The Gut Doctor, that'll be awesome. Subscribe to Clear Cardio and Power Is Prevention, and we will be back very soon.