033 - The Test That Could Save Your Life: Coronary CTA With AI Explained | #ClearCardio

Our biggest problem as cardiology is we're not looking for the early disease. We're not doing, as I call it, the cardiac colonoscopy or the mammogram.

And I recommend for all my patients to get coronary CT angiogram.

So if you have a positive calcium score, I always like to tell everybody that whatever that number is, whether it's 1 or 10 or 100 or 1,000, If it's not zero, so here's one point, if it's not zero, you have the disease.

Hello and welcome everybody.

Just a quick little tidbit that my very, very longtime and very good friend Raju Kasuri are going to talk about. Raju Kasuri is an esteemed interventional cardiologist. So I detect things and he fixes things is how I like to put it. So we're going to talk just a few minutes about the role of early detection of heart disease with something that is growing in popularity. More people are doing it, more doctors and healthcare providers and clinicians are recommending it, but it actually has a very interesting history. This particular test we're going to talk about, and I'll— I'm going to have you hanging on for a few minutes here. This particular test really started— we started doing this heart test back in the 1980s. We developed a scoring system for this particular heart test back in 1990, so a long, long time ago. And there were a lot of adherence, a lot of people interested in this, but it really, really never took off until the last several years. And early detection of heart disease, particularly people who have no symptoms, I feel fine, I always like to say normal stress test last week is so incredibly important. So I think of this test as the desert island test. So if I had one cardiac test to do on my desert island, I had nothing else, I think it'd be this test. And so we're going to be talking about calcium scoring. So again, I have my good longtime friend. I've known Raju for Over 25 years, if you'll allow me to say that. We have been working and doing and saving lives and stamping out disease for a quarter century, and we just want to take a few minutes and talk about the role of calcium scoring. If you don't know what calcium scoring is, please, this is your time to listen. Or conversely, if you do know what it is or if you've had one, listen to us because we're going to give you some really important aspects. Some things to know about calcium scoring, some dos and don'ts, etc. The big news is do it. Calcium scoring is great, but we're going to talk about some of the nuances and some of the in-the-weeds aspects of calcium scoring as well. So, Dr. Khosravi, again, my longtime friend and colleague. The weird thing is he's never gotten older since I've known him. I have, but— But he's never gotten older. So, tell me what you think of and how you use calcium scoring as an early diagnosis— early diagnostic test for asymptomatic patients who— where they're worried or we're worried or maybe they got some lab tests are off or family history or lifestyle or something that says, hey, we need to look deeper at this and see if we have some early plaque forming.

Well, first of all, thank you so much for this opportunity, John. And thank you for keeping me healthy. And by the way, Dr. Osborne is my my personal cardiologist.

So nothing can happen to you, Raju. So far, nothing can happen to you. Nothing will ever happen.

He has been in spite of my so many risk factors. I have type two diabetes for a long time, as you know. Hypertension, cholesterol, strong family history. Thank you for keeping me going.

And and you know, we will keep you going for a long long. I will warn you, Raju, I hope you have a big, big retirement program because you're gonna need it. Okay, well, so nothing can happen to you, and I'm just being selfish because I like you a lot.

Oh, thank you. Thank you.

Thank you.

Thank you.

It's not about you, it's about me.

Yeah, I know you're on the mission of eliminating heart attacks from human life. Yeah, I truly admire you, adore you for that. Okay, and yeah, this one—

We are co-conspirators.

Yes, yeah, I appreciate that.

So, so how do you use calcium scoring?

Hello everybody and welcome.

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Yeah, actually, I do not want people, and also not only just patients, members, but also the medical community, not to get too confident just by having zero calcium score. I do not want people to get too confident. Just calcium score zero does not mean everything is okay.

Right.

We are at this time in this current era, we need to identify the plaque when it is at the beginning stages, not to wait. In order for the plaque to turn into calcium, it generally takes actually several months to a few years. Okay. So our goal is to identify the plaque at the beginning stages. I have seen more than a few number of times people having Zero calcium scores, having some vague symptoms, exertional dyspnea, and the primary care doctors and the other physicians may say, well, your calcium score is zero, your stress test is normal, nothing would happen. People should not go home with that false confidence.

Yeah, I think you bring out a great aspect of it. So, a calcium score will show old plaque, not new plaque, not early plaque, not active plaque, I call it the lava, right? The stuff that's going to break off, flake off, cause heart attacks. It's only going to show me the old established plaque. I call it the cinder cone or the extinct volcano.

Okay.

So, if you have a positive calcium score, I always like to tell everybody that whatever that number is, whether it's 1 or 10 or 100 or 1,000, if it's not 0, So, here's one point. If it's not zero, you have the disease, right? You have plaque. Now, we don't know if you have blockages, we don't know how much lipid-rich plaque, but a calcium score is kind of the tip of the iceberg. We really have no idea how much—

Absolutely.

Iceberg there is below the water. But if you get a non-zero calcium score, you got plaque, and I think that's very important. Conversely, as you were saying too, be somewhat careful if they say your calcium score is zero, because what that means is we don't have any calcified plaque, but we can have tons of the— on a calcium score, invisible lipid-rich, soft cholesterol-rich plaque that is not yet calcified, particularly in younger people.

Okay.

And I can tell you, as I love to say, good judgment comes from experience, and experience comes from bad judgment. A number of years ago, in fact, we were practicing together, saw Kind of middle-aged woman and did a calcium score, zero. And I said, oh, that's great, and love that. And then it must have been a year— I'm sorry, a month or two later, she had a heart attack. In fact, you stented her.

Yeah.

And I was like, oh, yeah, reminder.

And she's a physician, by the way.

And she was a physician, exactly. I remember her well. And so, I have to admit, I kind of got burned on that. And, in fact, studies show anywhere, depending upon the population of the study and such, anywhere between 10% up to 50% of people with a zero calcium score, if you do a more exacting test, a more accurate test like cardiac CT, and now we have cardiac CT with AI, you'll find 10% to 50% of people with a zero calcium score will actually have detectable plaque.

Yeah.

I think it's a great tool. It's accessible, it's relatively inexpensive, no prep, no IV, no contrast, don't have to fast. You just get them in the machine. And I think, you know, versus some of the old tools we used, which we didn't, to detect heart disease, I think it certainly is an advance. And I'm glad that more and more physicians and clinicians and people are getting them. But I think there's a little bit of a cautionary story, right? Zero is great. Zero is much better than not zero, but be careful, right? If you had a lot of risk factors, bad family history, lifestyle issues, you have what I call North Texas underheightness, which some people call underweight, overweight, but I call it underheightness. But if you have those risk factors, particularly diabetes, particularly smoking, or again, a family history of heart disease or early heart disease, So, look askance a little bit if you get a zero calcium score. And then the converse is I've seen people with huge calcium scores and they can have no blockages. Now, they clearly have plaque, they have atherosclerosis, etc., but even a very high calcium score doesn't necessarily mean you have a blockage.

Right.

But I think it— I always— the way I explain calcium scoring is like a mammogram, right? So we do not diagnose— when you think of it, we don't diagnose breast cancer off a mammogram. We say it looks okay, but again, you can have false negatives. That is a zero calcium score or a normal mammogram and still have breast cancer. But if it looks funny, funky, I like to say, then we don't stop there and say, oh, we have breast cancer. We say no. need a biopsy. So, we do a biopsy, we get tissue and say, yeah, it is or it's not. So, I always like to think of the mammogram and the calcium score, again, not perfect tools, but that's what we use to screen the population. But, if there's a question, if you're 0 and you go, that doesn't make sense, I got risk factors, family history, I'm not sure, or— and certainly, if it's not 0, there is some calcium, we've already established you have plaque, Then, we need to go to the equivalent of what I call a biopsy. And, that would be your cardiac CT. And then, now, we have this amazing AI that we can layer on top of that that I call the microscope. We can now apply a microscope to your heart and determine absolutely 100%, are there blockages we need to worry about, which many times they're not. If there are, then you take care of that.

Right.

And then, but more importantly, where the plaque is, what kind of plaque is it? Hard plaque, soft plaque, how much plaque you have. We can now do that, measure that with AI down to a 10th of a cubic millimeter.

Hmm.

Which is about a 10th of the volume of a period at the end of the sentence to give an idea how small a volume that is. And then that's really gonna be the future of cardiovascular prevention and early detection. In fact, I love to think, if you kind of think about this versus cancer, right? So, that's the number 2 killer. Heart disease, strokes, and heart attacks, number 1 by far. That imagine we had a cure for cancer, but we never looked for it. We just waited until it showed up and it was already terrible and advanced and widespread.

Right.

Well, that'd be ridiculous if we had a cure for cancer. I would argue with all of the tools we have to treat plaque, to treat atherosclerosis, to stop it, and by the way, yes, we can reverse it. So, I wouldn't say we exactly have a cure for heart disease, but it's quite impressive.

Yeah.

Our biggest problem as cardiology is we're not looking for the early disease. We're not doing, as I call it, the cardiac colonoscopy or the mammogram.

Yeah.

So, again, any calcium scoring is good. It's far better than not having calcium scoring, frankly, because I think many people, no symptoms, I feel fine, normal stress test.

Right.

We get a calcium score, it's positive. Okay, let's investigate further. But again, be a little careful if it's zero, particularly if you have risk factors, diabetes, smoking, family history, etc. And a positive calcium score doesn't mean you're going to die or need stents or surgery. It just means we need to investigate further.

Absolutely. I literally, I have stopped doing calcium scores for my patients for the screening of coronary artery disease. The only time I use to detect how much calcium on the aortic valve, if there is any question about severity of the aortic valve. And I recommend for all my patients to get coronary CT angiogram, get to the bottom of it. 100% with AI-powered technology. Yeah.

I mean, it's a whole new era, right? I think when that becomes more typical, right now people are discovering the calcium scoring and then we're the first to say, well, yeah, there's something better. That's okay. Technology, science, tools, literature moves on. And I think that that's a great thing, right? Nothing should be static. Particularly when heart disease still kills more people than in the US and worldwide than any other disease. We need all the early diagnostic tools we can get.

Absolutely. No, the great thing about this, what you are doing, John, while you try to make all these changes in the lifestyle and their pharmacological approach to control atherosclerosis in eliminating heart attacks, you're also fixing their fatty liver.

Yeah.

Their metabolic health.

Right.

And we are in return also reducing at least some of the cancers because at least half the cancers are related to the metabolic disease.

Yeah, absolutely. No, a great point, right? So it starts at heart disease.

Right.

It doesn't finish there, right? Metabolic-associated steatohepatitis, as we call it, or MASH, right? Which is liver disease, which could be both genetic as well as lifestyle. Even interestingly, I find this absolutely fascinating because, again, this is an important marker for cardiovascular disease and causes cardiovascular disease, which is sleep apnea, right? Some of the tools we now have, like the GLP-1s, remarkably effective, really the first medicine ever indicated to treat sleep apnea. When you think of sleep apnea, people snoring and gasping and CPAP and the masks and—

Yeah.

Boring machines. Well, now we have medical tools that are highly effective at stopping and eradicating obstructive sleep apnea. And obstructive sleep apnea then contributes to heart disease and cardiovascular stress and arrhythmias and all that stuff. So, it's an amazing time that we live in.

It is.

The number of tools we have to treat plaque, to stop plaque, our toolbox is overflowing. If you look at the pipeline and what's happening, it's gonna get even, even better. I think the single biggest thing we need to do is we need to look earlier. We need to find it before you have symptoms, before you have a heart attack, before a stroke, or frankly, before you keel over dead. So—

Well, I'm glad you're also eliminating, seems like dementia and Alzheimer's disease too.

Yeah, absolutely.

While doing all these things.

In fact, we're waiting for, at this moment in time, waiting for 2 trials double-blinded randomized placebo-controlled trials with semaglutide, AKA Wegovy or Ozempic, where these patients have pre-Alzheimer's. We call it MCI, mild cognitive insufficiency. And half get placebo, half get semaglutide, not for diabetes, not for heart disease, not for weight loss, but because of its— there's a lot of data that suggests it would help to slow or prevent the progression onto Alzheimer's. via anti-inflammatory pathways and neural anti-inflammatory pathways. So those trials just wrapped up in the last month or two.

Wow.

We're anticipating those results from those trials, EVOKE and EVOKE Plus. They're basically identical trials, 2 large double-blinded randomized placebo-controlled trials will be out very, very soon. So we're just really, really anxious to hear that. We may continue to expand. Just, we start as these tools for cardiovascular disease.

Right.

And then we end up Taking care of a lot of the other things you mentioned, cancer and Alzheimer's. I think of the big things that we really need to have on our radar is what I call CNN: cardiovascular, neoplasia, and neurodegenerative, right? You got it. So, watch CNN because that's really— those are big, big factors that I think we all worry about. Is it going to be a heart attack, a stroke, cancer? Or Alzheimer's, right? Everything else that happens to us kind of, you know, yeah, we get in motor vehicle accidents and fall off ladders and all kinds of crazy stuff. But I think a lot of us, as we have birthdays, as you and I have had— well, I've had them, you haven't. Yeah, it's CNN. Watch out for CNN. Absolutely.

John, it's truly great and I'm very honored. I really thank you, and yeah, let's keep doing the best to eliminate heart attacks and strokes and cancers and dementia as well.

Let's go for it all, right? Well, we've been a great team for a quarter century, and I look forward to the next quarter century.

Super, John.

All right.

Thank you, Raju.

Thanks for joining us. Hopefully, this is helpful, a little brief bit on calcium scoring, kind of where that stands. And then as we evolve in our better tools to better detect and detect more accurately and more precisely early heart disease long before we ever have symptoms. And ultimately that will mean that yes, we will get to the point as I've crowed about for years that my ultimate goal, your ultimate goal, let's just eliminate heart disease. And as we do that, we'll probably eliminate a lot of other stuff. I totally agree. CNN, right? Cardiovascular neoplasia, neurodegeneration, Alzheimer's, cancer, et cetera. So I think the next 25 years are gonna be very exciting.

I urge, request everyone to get coronary CTA with AI-powered technology starting at the age of 40 years. And if any additional risk factors like some Asian community, Hispanic community, We have not a bad idea to start even at age 35 years.

I completely agree. I think that's the only way we're really going to make a dent in the increasing risk of cardiovascular death that has actually been increasing for the last 15 years. It had been going down, down, down every year, year after year. Total cardiovascular deaths fell every year till 10 years ago or 15 years ago. So we've got to turn that around. And I think imaging and cardiac CT with AI is really gonna be a godsend for us for early detection.

If anyone is worried about radiation these days with the current technology we have, with 640 slices, we can minimize the exposure to 1 millisievert. Our annual exposure from the atmosphere is about 6 millisieverts in the US. Right.

So a very, very, very small fraction. So, if that's ever been a concern or worry, it's simply not with the latest technology and software upgrades that we have. So, if you're worried, or maybe even if you're not worried, we got to look under the hood.

Yeah.

Raju, it was a pleasure. Thanks so much. Thanks for coming on. And, you know, every day I love doing what I do. I love cardiology. I know you love it too.

Absolutely.

Because there's so much benefit that we can help, that we can use to benefit our patients. And it's been a great ride for 25 years and it'll be another great ride for another 25 years.

I have no doubt.

Absolutely. Absolutely. I love to see patients outside. Never want to see anyone coming in with the heart attacks.

Agreed.

I, every time I see a heart attack or a stroke, I go, there was a failure of prevention.

Yeah.

Right.

Because that didn't start last week, last month, last year. It goes back years and years, the genesis of that. So let's first of all just agree to stop heart attacks and strokes. Very simple.

Let us start doing the job for all the medical community.

Absolutely. Yeah.

All right, Rajesh, a pleasure.

Thank you, John. Thank you so much.