038 - Revolutionizing Heart Health: Dr. John Osborne & Dr. Paul Taylor

Welcome to the podcast.

Thank you so much, Paul. It is a pleasure and an honor to be here.

It's an absolute pleasure to have you on. As I said just before we started, I've got a bit of a vested interest in this area, which most of my listeners know about. So, you call yourself a preventative cardiologist, which I am a big fan of for obvious reasons. For those who don't know, I got diagnosed with a bicuspid aortic valve. John will go through what that is, but only because I play soccer with a cardiologist and said, hey, I want to get a bit of a screen. I'm not a big believer in cholesterol as a predictor of whether you've got heart disease. I think there's so much more to it, which John will go into. But John, talk us through maybe a little bit the kind of— Anatomy of the heart, or you talk to yourself, you'd say that you're a general contractor.

So, yeah. So, when people ask me what I do, I love to say, because I'm a little snarky, I'll say, what do you do? And I say, well, I'm just a general contractor. I do some electrical, I do some plumbing. Right? So, that's kind of what cardiology is. It's electrical and plumbing basically. Right?

And my cardiologist had actually said to me, hey, when I was getting tested, we'll look at the rooms of your heart. And the electrics and the plumbing. So, talk us through those things to people and what typically tends to go wrong with the rooms, the electrics, the plumbing.

Yeah, no, that's a great example. The most common issue that people encounter over the course of their lives, and again, it can be a whole spectrum of things, right? You can have valve issues like you had, you can have plumbing issues, but basically, the the water supply to the heart that supplies the blood, oxygen, nutrients, and all that. You can have fluid around the heart. You can have cardiomyopathies, weakness heart. So, any of the parts of this complex machine and also electrical issues can go wrong. Right. But, probably statistically the most likely thing to go wrong that most people encounter will be the formation of and the deposition of plaque in the blood vessels, which if it extends enough, will cause anything from heart attacks. And by the way, that same plaque that forms in the blood vessels of the heart can also form anywhere else in your body, right? It can be in the neck causing strokes. It can be in the legs causing what we call peripheral arterial disease, that is buildup of plaque And blockages in the legs where people can't walk. And, in the worst scenarios, actually leads to amputation and things like that. So, plaque can be very systemic. It can be in any blood vessel of your body. But, more times than not, it sort of manifests or comes out in the heart causing blockages, which can cause symptoms like shortness of breath, heaviness, tightness, chest pain.

Hmm.

We call it angina, particularly with exertion or when you exercise or work out or go upstairs or whatever, and typically improved with rest. So, if your symptoms get worse with exercise, improve with rest, if you have a heaviness, a tightness, a burning, an ache, usually not a sharp pain or knife-like or lancinating pain or ice pick type pain, but usually more of a heaviness, a pressure, ache, burning, somebody sitting on my chest. worse with activity, worse with exercise, gets better with rest, you need to give me a call because that can certainly be a symptom of what we call angina. But, here's the problem. Plaque behaves in ways that you probably don't think of and we don't really well explain it to the lay public. You can have zero symptoms. I feel fine, just got off the soccer field like you did and have a massive heart attack. So, what happens most of the time is plaque builds up in the heart, it mostly forms out in the wall of the vessel. So, think of the vessel, the blood vessel as a donut. We get really worried about the donut hole, but actually where all of this is occurring is actually in the donut itself.

Yeah.

And, when plaque builds up, it literally will expand outwards into the donut, not inwards into the donut hole. And, all of this is occurring and you have absolutely no symptoms. I feel fine. I like to say I had a normal stress test last week and it was normal. And, you could have extensive deposition of plaque and buildup in those blood vessels and have absolutely no symptoms and pass stress tests all day long.

Oh, you can even pass an exercise stress test, isn't it?

Oh, absolutely. Yeah. So, let me tell you a little secret of cardiology, okay? I don't do stress tests anymore and I'll I'll tell you why.

Wow.

So, if you go to a cardiologist, no matter where you're at, what country, if you go to a cardiologist, you'll get predictably an EKG, pretty worthless. You'll get a stress test, pretty worthless. And even if those things look worrisome or concerning or whatever, you might graduate to an invasive heart catheterization or angiogram as we call it. That's the invasive test. We put Catheters, I call them silly straws, right? They're big long tubes. When I trained, we did them through the groin, right? Now, the only change in that procedure is now we go through the wrist. And, I suspect you probably had that done. It was through the wrist.

Yes.

It's less risk of bleeding and such. But, any of those tests can absolutely 100% every day miss plaque.

All right. Interesting.

And particularly with stress tests, here's the thing you need to know. It takes a 70% blockage of the donut hole of the channel, we call it the lumen, before you have symptoms or flunk the stress test. So, if you're completely normal or 10%, 20%, 30%, 40%, 50%, 60%, 69%, Your stress test will be normal. So, the good news, bad news is our vessels are bigger than they need to be, right? We have huge reserve, right? The downside is we have huge reserve. So, they need to be really plugged up before we ever manifest symptoms or show up or flunk a stress test, right? So, they're very insensitive and insensitive to early disease. And in fact, I always think of this, if you think of heart disease versus cancer, right? With a stress test, waiting for symptoms or waiting till you flunk a stress test, it really is only detecting cancer at the stage 4, widely metastatic, widely advanced level. Impossible to detect it at stage 3, 2, or 1.

Absolutely.

And then it gets worse. Because when we do a stress test, it's all predicated upon blood flow and interrupting blood flow. But again, our vessels are really big. We can put up with a lot of plaque and blockage in the vessels and still have adequate blood flow, even with exercise, right? The other problem is we're not actually visualizing the blood vessels, right? We're just looking at blood flow. So, even with what's called nuclear cardiology, where we do, we do about 10 million of those in the US, With nuclear cardiology, there's a 25 to 40% false negative rate. That means there is a severe blockage. It should have picked it up and it missed it. So that's rather dangerous.

Did you say 40%? Oh, John, you've just gone.

I'm just gone.

You're not— sorry, you just, you just cut out there for a little second. Okay. Back. And so you said a, did you say, just recap on that. Did you say a 25 to 40% false negative?

False negative rate. Right. So we pat you on the back, say you have the heart of an 18-year-old, and then you have heart attack next week, next month, next year. So high rates of false negatives, which is really concerning. Secondarily concerning is a high rate of false positives, right? So there is no blockage, You do the stress test, looks funny, equivocal, right? Then you graduate to an invasive heart cath, $20,000 in the US, invasive test, you know, die, risk of heart attacks, strokes, damage to the kidneys, infection, bleeding, right? Only to find out, yeah, you look fine. And in fact, here's an interesting statistic. Shit's too bad. Currently, of all the people undergoing diagnostic invasive heart cath like you had, before your heart valve procedure. 70% of the time, even despite stress test looks funny or they have symptoms or whatever, 70% of the time we'll find no significant blockage. So, if you have to go to the cath lab, you already stand only a 30% chance of them finding some bad blockage. 70% of the time, it's a false alarm. Still $20,000.

Wow.

And hopefully no complications ensued. But, and we do it in the US, we do 2.5 million diagnostic heart casts a year.

My God.

10 million nuclear stress tests a year.

Wow.

And these are thousands and thousands and thousands of dollars. Now, with the technology I've used, and I've been using it for 25 years, it became so good literally 20 years ago this year, back in 2005, that I stopped cathing people and stopped doing heart, doing stress tests because there really was no value to it. So stress tests, heart caths are all 20th century technology.

Really? Even the, so the, is it, is, sorry, just recap, John, is the heart cath, is that the, like a CT angiogram?

Is that— No. So a heart cath is when we, they're usually done in a hospital. It's in like an OR kind of scenario, Everybody's gowned up and stuff, and then they take these catheters, just long tubes, straws basically. And, in the old days where I trained, we'd put them in the groin. Nowadays, and really the only thing that's changed the last 30 years is we go through the wrist, but then we take that catheter, that tube, advance it all the way up into the heart, and then inject dye directly into the blood vessels of the heart. While we're taking x-ray movie pictures and watching that dye fill the vessels. Right. And if we see it tapering or an hourglass, we can go, oh, okay, there's a blockage. Right.

Right. Gotcha. So that's, so that's what they did on, that's what they did on me. And I remember I was lying there looking at the screen and seeing my, seeing, seeing my arteries on the, on the screen, which, right.

Yeah.

It was pretty cool.

Yeah. Yeah. Yeah. I, I stopped doing those 20 years ago.

20 years ago? Yeah.

That's how good cardiac CT is.

Right. Okay. So, you are not— so, talk us through then.

That's preventative. I mean, that's kind of one of the aspects of preventative cardiology, right?

So, tell us what exactly what a cardiac CT is. Sure. Take us through that.

What I evolved to 20 years ago, and I'll tell you why, is what's called cardiac CT. CT stands for computed tomography, right? So that is the big donut, right? We have 2 main imaging tools, right? We use MR. So that's the big, I call that the coffin, right? That's the big tube. They stuff you in the big tube. It's kind of tight, right? That's an MR. That's not what we use at all, right? We use a big open donut, Right? So you're not stuffed in anything, it's just you're in the middle of a big donut. And so we use that machine. These are fancy versions of CT. We've been doing CT since the '70s, but we have what I call the iPhone 17 version of cardiac CT machines. Very high resolution, extremely fast, and amazing AI built into that, as you can imagine. And then also very low radiation because these CT machines do emit radiation. So we want to make sure that we minimize that for lots of good reasons. So we use a very, in fact, our machine, I have to gloat a minute. Our machine was the first machine of its type, a 640-slice machine installed in North America. That was 3 years ago. Now, right now there are 8 of these in the US, but ours was the very first. Wow.

Because my understanding was that CT scans used to be quite high radiation. You're saying yours is the newer version that's lower radiation?

Yeah. So, in the old days, right, 20, 25 years ago, the dose of radiation could be pretty high, right? So, we measure that in something called millisieverts, right? To make sense of that, every year on the face of the Earth exposed to gamma rays from the sun and isotopes that are around us that everybody is exposed to, we'll get about 3 millisieverts of radiation exposure a year, right? Even if you lived in a lead box, you're going to get 3 millisieverts of radiation. In the old days, the radiation doses could be about 20 millisieverts. Okay? So equivalent to several years of background exposure. By the way, nuclear stress tests, of which we do, again, very insensitive, high rates of false positives, negatives. We reviewed that before. We do 10 million of those in the years, 10 million of those a year in the U.S., unfortunately still. They're going to give you about 30 to 40 millisieverts of radiation. It's a lot. And, I've run into patients who go, oh, yeah, every year I come in for my nuclear stress test, year in, year out. Right? So, you're getting roughly 10 to 15 years worth of background radiation.

Wow.

With the current state-of-the-art CT machines, we can take these incredible high-resolution images of the heart. They're 3-dimensional images, which I'll talk about here in a second. And, we can do that at a radiation dose of 0.2 millisieverts. Wow.

Jesus. And, as you alluded to, John, you're getting a much better image. You're getting as close to an image as if you took the heart out and had a look at it and turned it around.

I call it, and my staff always cautions me about doing this, but I'm going to do it. I call it the virtual autopsy. Okay. Emphasis on the virtual, not the autopsy. And literally what we can see, and here's the problem with plaque, right? So, plaque doesn't really grow inward, at least not early on. Plaque literally will be warehoused in the wall of the vessel, right? So, cholesterol starts building up in the blood vessel wall. And the, and the vessel goes, well, wait a minute, I don't want to get a blockage. So it, it actually expands outwards, right? So it literally uses the wall of the vessel, the donut I call it, to warehouse that cholesterol as it's getting deposited in the, in the vessel, right?

Yeah. So you're getting a bulge, you're not getting a growth inside.

Late.

Okay.

Years to decades later, the vessel basically will almost double in size. Then it begins to grow inward. But remember, we don't have symptoms, chest pain, angina, till we have a 70% blockage of the donut hole. But all of the disease and the early stuff is all occurring in the donut. Okay.

So gotcha.

When we do stress tests, the threshold of detection starts at a 70% blockage of the donut hole.

It's unbelievable that a stress test—

I used to cath people. This is why I stopped cathing people 20 years ago. When we do cardiac CT, it really is the virtual autopsy. We can see everything in the heart. We can see your bicuspid valve. We can see the heart function, the squeeze of the heart. If you had old heart attacks, congenital heart disease, holes in the heart, fluid around the heart, right? Anything that you can see on an echocardiogram like you've had, that's the ultrasound we do of the heart, we can see on cardiac CT except much higher resolution. So, we get all that free data like a free echo, right?

So, John, a quick question here. So, why would you do an echocardiogram rather than a CT? Is it just a cost thing and equipment availability?

Partly is cost, but it really depends upon the question you're answering. So, if I want to know, is the heart squeezing normally? Is the pump pumping normally? Do I have old heart attacks? Do I have what we call cardiomyopathy? In other words, weakness of the heart muscle. Do I have congenital heart disease or what we call structural heart disease? In other words, the chambers aren't hooked up to the right pipes. So stuff you're born with. If I have a valve I'm worried about, is it leaky? Is it narrowed? Is it bicuspid? Echo is great to be able to look at all those things. Okay. It's simple. It's non-invasive, no radiation. There's no harm. It's great. What the one thing it doesn't tell you though is the blood vessels of the heart, the coronary arteries. We see none of that on echo.

Okay.

So, when the question is, do I have plaque? Forget about even blockages, right? Because you can easily have lots of plaque and no blockages, right? Because people worry about blockages, but that's really a late manifestation of a 20 to 30-year-long disease, right? What echo does not tell you, cannot tell you, is anything about the blood vessels that supply the heart muscle, the coronary arteries. That's where we use CT. Now we get the free echo, I like to say, right? So when we do cardiac CT, we can look at the valves, bicuspid valves, leaky valves, narrowed valves, prolapsing valves, the heart function, the squeeze of the heart, the thickness of the heart muscle, blah, blah, all those things, right? So we get all that data for free, but most importantly, and the main reason is to determine if we have any plaque buildup in the blood vessels.

Okay. And John, does an echo or any of those other tests, whether it's an MRI or any of those things, do they pick up anything that the cardiac CT does not pick up?

So, the other tool we do use as an imaging tool, we talk about echo, cheap, easy, accessible, no radiation, great for heart function, valves, structural stuff, leaky valves, narrow valves, right? That's its domain. If you have a cardiomyopathy, that is a weakening of the heart muscle, and that could be due to a variety of things, genes, viruses, some obscure causes, old heart attacks, right? So, if you need to look at the heart muscle or Rarely, it doesn't happen often, but you can get tumors of the heart, things like that. So, if you need to look at the heart muscle, is there a problem with the heart muscle? Is it squeezing okay? Are there tumors of the heart? MR is really good for that. What MR is not good at because it has actually quite low resolution, right? Because with cardiac CT, we have very high resolution. We have resolution now with the current CT machines that we use, Coupled with amazing AI, we can see down to about a quarter of a millimeter or 250 microns, okay? Which is very high resolution. MR, we're stuck at about 2 to 3 millimeters. So, it just doesn't have resolution to be able to see the coronary arteries and see plaque and those issues. So, if and when you need to understand if is there plaque, How much plaque, where it's located, quantify plaque, which we can now do with AI, which I'll touch on in a minute, that really is the domain of cardiac CT. And, I don't see anything in the near term in the next several years that's going to replace cardiac CT as far as other imaging technologies at this moment.

Interesting. Okay. Now, my understanding as well, just to go into these things and their effectiveness, is that an echo Is the results of the echo are largely dependent on the person doing the echo? There's a lot of subjectivity around it, right? Because—

Well, yeah, 2 parts, Paul. Yes, the echo tech, which is critical. These are really, really highly trained people to become really good. It's probably about 5 to 10 years till you become really good, right?

Okay.

So that's just acquiring the images. Then you need what I call the nut behind the wheel, the person reading the echo. So it's really dependent upon, and then of course the echo equipment, right? So you really have to make sure that every one of those boxes is ticked off, the right equipment, the right experience tech, and the right reader to really extract appropriately. Because again, you can miss stuff, you can overcall stuff with Again, wrong equipment, tech, or reader. So yeah, so there's a lot, a lot of experience that it requires and the right equipment and the right tech to be able to really extract all of the data. And there's an amazing amount of data that we can derive from echocardiography. But again, you have to have all 3 legs of that stool be there.

Yep. Yeah, interesting. And then I obviously had, so I had an echo and then I had a transesophageal echo where they stick this tube down your throat. All right. And it goes down there. And yeah, John, you'll laugh at this because I went in to get it done and they were going to give me an anesthetic. And I said, oh, look, let's not worry about the anesthetic. And the guy's like, are you crazy in the head? And I'm like, well, because I would've had to stay in the hospital for 2 hours and I had something to do later on. So I did one of those without an anesthetic, which was a touch uncomfortable. It's got to be said.

Yes. Yes.

And they prepped me just in case. They said, look, I'm happy to try this. We're going to prep you just in case. And if it doesn't, if you're gagging too much, then we'll do that. But anyway, because that gives you a bit more insight, doesn't it? When you've got that tube down, it's much closer to the heart and you can see stuff that you don't normally see on a normal echo. Right.

Yeah, exactly. It sort of takes it from not quite black and white, we'll say color TV to HDTV as far as the resolution because you really get that probe where the ultrasound probe is located basically right on top of the heart by swallowing it because your esophagus, your food pipe literally sits directly behind the heart. So, you can get it right on top of the heart and get much better higher resolution images of the heart by doing the—

Cool. Now, we will dive into the whole plaque thing and go really deep on this. There's just one thing I wanted to cover off though. Can you let people know about leaky valves, right? And so why, if you're born with a bicuspid valve like me, with 2 leaves on your aortic valve, why is that more prone to leaking? And then, If you have a normal tricuspid aortic valve, what sort of factors, is it all just lifestyle or is it just aging that causes that valve to leak? If you're exercising more, is it more likely to leak or less likely to leak? Let's just talk about the leaky valve stuff first and then we'll go on. And, there's one other thing I wanted to talk about, the chambers and the thickening of the wall, the pathological versus physiological in athletes.

Mm-hmm.

Maybe just give our listeners an overview of that and then we'll go back and dive deeper into the backstory.

Yeah. So, great question. So, just to kind of remove some of the medical-ese from this. So, the aortic valve, which is one of the 4 heart valves, it's the last valve where the blood passes out of the heart and to the rest of the body, is a critical valve. And basically, I mean, lots of things can happen to it. You can have congenital abnormalities, malformations, trauma, all kinds of stuff. But, the valve normally has 3 leaflets.

Okay.

We call them cusps, but they're just leaflets and they're very, very tightly— it's very, very tight fit and finish, right?

Yeah.

So, they perfectly open and close. They do that 100,000 times a day, by the way, and they fit perfectly together so that when the heart is filling with blood and that valve is closed, The blood does not leak back through that valve, right? They perfectly— perfectly closes. And then when it opens, they're very thin but incredibly strong. They're very thin so that they basically fold back. And then when the heart squeezes and pumps the blood out, they provide no— basically no resistance to the flow of blood through that valve. So the normal tricuspid valve, if you were to look at it from the surgeon's view, looks like a Mercedes-Benz sign.

Yes. Yeah, yeah.

If you're older, maybe a peace sign, but it looks like a Mercedes-Benz sign looking at it from the surgeon's view, right? With a bicuspid valve, what happens is that those 3 leaflets, 2 of the leaflets get stuck together.

Okay?

Imagine like a perforation, but it doesn't perforate, right? So 2 of those leaflets are stuck together, and the thought is that Again, that valve is opening, closing 100,000 times a day. After about 50-ish, maybe 60 years, that valve, because the fit and finish isn't perfect, will begin to calcify, will begin to fibrose, right? And you'll see calcification building up the valve. And that can either cause one of two things. More typically, the valve gets narrowed, right? So it becomes very stiff. It's not thin. It doesn't open and close easily. And, the valve itself becomes very thick and restricts the blood flow coming out of the heart. We call that aortic valve stenosis or narrowing.

Yeah. Okay.

And, as that valve narrows, the blood still has to get out of the heart. And so, the heart has to work even harder to push even harder through that thin— that small hole rather. And so, it bulks up just like muscle. The heart muscle will bulk up too. The work the heart muscle does is blood pressure work, so it will literally thicken up. Okay? Now, a similar kind of thing can happen in highly conditioned people. One is called eccentric, the other is called eccentric hypertrophy. Eccentric hypertrophy, which is what athletes get and very conditioned aerobic people and all that get, There is some thickening, but the whole heart gets a little bigger, the walls of the heart get a little thicker, and that's completely normal and that's conditioning. In concentric hypertrophy, which is pathological, which is abnormal because of the restriction, in this case, of that valve becoming narrowed, the heart really doesn't enlarge, but it begins to get very, very thick. And, that is abnormal.

Hmm.

The good news is you get the valve fixed, And, and that gets better too.

Yeah. But isn't there a point, there's a certain point because that chamber will start to stretch? Well, I'm talking about regurgitation here, which was the issue.

The other issue, right? So most of the bicuspid valves, it, it's aortic valve stenosis. The valve gets narrowed. Okay. And then creates those issues. Um, and, and the symptoms of that would be you get short of breath when normally you wouldn't, right? Normal activity, you just can't Can't do it. I could mow the lawn. Now I can't. Chest pain, because all that thick muscle requires a lot more blood flow. So, you can start getting angina or chest pain even though there are no blockages in the blood vessel of the heart. And then, the worst sign is you begin to faint and pass out because literally you're not pushing enough blood through that valve. And, when that starts happening, you're just about ready to go, right?

Right.

The other issue, which is not as common as stenosis, is leakage, or we call it regurgitation or leakage. In which case, again, the valves get less flexible. They're open adequately, but they need to be able to also close and they don't close adequately, which case the valve then stays open when it should be closed. And all that blood that it just pumped out of the heart, a lot of that then regurgitates or leaks back into the chamber. So, the problem is now the heart has to pump, and I'll make up numbers. You've got the blood coming into the left ventricle via the normal pathway from the lungs, but then you have all the blood that leaked back when it shouldn't have leaked back. So now, you're pumping, and again, I'll make up numbers, 2 quarts when it should pump 1 quart. And the issue there is that that's a more potentially even more dangerous issue because the heart can begin to enlarge. Because of all that extra volume it has to pump. And there is a point, there almost is no point where the valve gets too narrowed as long as you have a pulse and breathing where fixing that valve won't correct the problem, right? Even if the heart gets very bulked up and you've had it a long time and all that stuff, if you fix the valve, the heart will recover. But if the valve is leaky, there is a limit to how much it can, how much you can stretch out that sweater.

Yeah.

And you can stretch it out if it's been long enough and severe enough. And even if you fix the valve, the heart stops working properly. So even fixing the valve in the setting of aortic valve regurgitation or leakage, if you wait too long, can be really dangerous 'cause you fix the valve and the heart's shot.

And this, this is why I'm a very lucky boy because when they find me, so my, mine, For the listeners, I don't know if I said at the start, mine was proactive. I asked because I played soccer with a cardiologist. I said, hey mate, I want to know, I really want to know what my heart looks like. I really don't care about the cholesterol. How's my heart working? And, they found that my regurgitation level was at about 50%. So, half of all the blood going out was coming back in.

That's a lot. If I had to choose between stenosis or narrowing versus leakage regurgitation, stenosis every day.

Right.

Because again, if you make it to the OR, we fix the valve, the heart will be fine.

Yeah.

Yeah. If you wait too long with a leaky valve, with aortic valve regurgitation, you may fix the valve and the heart's shot.

Your heart's shot. You get heart— and we call that heart failure, John? Is that what's known as heart failure?

Yeah, that's heart failure, right? That's not reversible. Yeah.

And I was not a kick in the arse off that. I think my surgeon said, and look, this is from memory, you might be able to correct it, but he said once it gets to 60, 65%, you pretty much guaranteed that you're going to have heart failure.

Yeah. Yeah. And, you know, we have lots of sophisticated ways with echo, by the way, to measure how much blood is coming back, how big that leaky hole is. We can do all that with echo. It's phenomenal. But yeah, I mean, it can get very leaky. And as I said, if you happen to pick it up late, it's bad. It's really bad. So, kudos to you, Paul.

Yeah. Well, I tell you what, it's the message to everybody out there is be proactive about your health because if I hadn't been proactive about my health, I would not be around in 10 years. I would Probably guess, if not before that, because your aorta can also stretch, which mine had started to do, and that could just burst one day and then you die instantly, right?

Yeah. And, and very commonly with a bicuspid valve— I talked to you there earlier before— but with a bicuspid valve, the other thing that goes along with that is you get an aneurysm of the aorta, right?

Yeah.

Uh, I call it the A word. We don't like the A word, right? Because people think appropriately bad stuff, which, which it is. And, and as that Aorta stretches and enlarges, there are no symptoms whatsoever. The first symptom of that, if it, you get an aortic dissection, it literally gets so big that it rips open. And the mortality rate once that aorta rips open is 10% per hour. Oh, wow. Yeah.

Yeah. 'Cause your blood's just leaking out of your body, right? Yeah.

It's really bad.

Yeah.

And a lot of the problems is that it can mimic, even with an aortic section, it can cause chest pain. You know, unless you're thinking of it, you could easily miss the diagnosis. And then that patient is sitting in the ER for a few hours as you're scratching your head, what's going on with them, right? EKG looks good, right? But they can have a ruptured aorta. And again, our, the mortality rate is 10%. Per hour once it ruptured.

Bloody hell. Yeah.

So you, you, you got your valve fixed, your heart's great. Yeah. And you didn't have an, an aneurysm of the aorta, which is awesome, right?

Yes.

But again, the aneurysms are particularly dang— I mean, all this stuff is dangerous, right? Because the symptoms are very delayed. The process starts decades before, but the symptoms are delayed until the, until it's catastrophic. But if once that aorta ruptures, it, it is Really bad. And up until it ruptures, zero symptoms.

And, and this is interesting, right? Because for me, I was still playing soccer, over 35 soccer at 53 years old. Had, had no symptoms. Now, on reflection, John, you know, my, I, I noticed my fitness going down, my cardiovascular fitness on reflection, but like, you're getting older, you know, you're getting older, right?

You're competing against all these 35, 36-year-old guys, right? And you go, eh, I'm just getting older. And that's the really duplicitous part of this process because you can easily go, eh, I'm just getting older. Right. It's not that hard. I'm fine. Right. So it really can really be very deluding.

And what my cardiologist said, he said, people who, like me, who are into their fitness, you'll notice, hey, geez, my fitness is dropping off. And you just work harder. You work harder and you can accelerate the issue, right? So, it's a bloody tricky thing. Now, let's come back to the plaque. So, when you do have a little bit of plaque, it can be either calcified or non-calcified. Now, my understanding of that has changed a little bit, that the calcification can actually be a good thing because it's stable.

Yeah.

Right. So, talk us through stable versus unstable plaque.

Sure. So, we'll go all the way back to the beginning. So, when plaque is beginning to develop, and I'm going to point out one thing, Paul, you mentioned it earlier and you're absolutely correct. Whether you form plaque or not is very, very poorly correlated with your cholesterol levels.

Yeah.

Right. I saw a guy last month, 65, felt fine, no symptoms, had a normal stress test a year or 2 ago. We put him in the CT machine. Of his 3 major blood vessels of the heart, one was completely blocked off. Holy shit. And 2 of the other branches had severe blockages in them. Okay? No symptoms, feel fine, normal stress test, right? On top of that, I said, any cholesterol issues? Now, I had all his labs, right? I looked at his cholesterol numbers. His cholesterol numbers were perfect. He looked like somebody already on drugs to treat cholesterol. That's how great they were, right? So I completely agree with you. Cholesterol is the paradox, right? The stuff that forms the plaque is cholesterol, right? That is the fertilizer. However, your cholesterol levels really tell you nothing about is that cholesterol sticking?

Yeah. Yeah.

And then conversely, I saw a young woman, she's 72, had a high, you know, years of high cholesterol. And I said, I don't care what your cholesterol is. I only care if it's sticking. We put her in the machine. She had no plaque. So cholesterol, remember when we measure cholesterol, only measures cholesterol floating by in the bloodstream. Tells me nothing about is it sticking.

Does the particle size, John, give you so small dense LDL?

Is that a bit more risky? Yeah. We've looked at that and that was kind of a fad a number of years ago. In reality, it really doesn't give you much useful information. And I'll tell you and your audience, the 3 cholesterol tests you need, right? One, you only need once, and I'll tell you what that is.

Lp.

Exactly, Lp. So, if you want to have a really good handle on your cholesterol levels, remember that doesn't tell me if it's sticking. The only way to know if it's sticking is you get in the machine. We look under the hood. That's where cardiac CT comes into play. But, on the cholesterol front, you'll get a standard lipid profile. That's your total triglycerides, HDL, LDL. Okay. But again, really doesn't tell me if it's sticking or not. You'll get an Lp once. That's a form of cholesterol that's pretty common. It is a really, really nasty form of cholesterol. It's super sticky, it's super clotty, and it's super inflammatory. So, it really promotes the formation of plaque. It is 100% genetic and 20% will have it, 80% won't. So, we check that once. If it's high, Then we know and we can take care of it. If you're normal, it will never become abnormal. Does not vary with diet, exercise, weight loss, anything that, that, you know, that, that you can change lifestyle-wise. So Lp, we check once. If it's normal, you're done. You don't have it. Yahoo. Great for you. Great for your family. Great for your kids. If it is high, then we actually have people say, hey, I need to talk to my brother, my sister, my kids, sometimes even depending on their age, mom and dad. So Lp, lipid profile. And then the last one that's really replaced the particle number, particle size, all that kind of stuff. It's cheaper, it's quicker, it's more accurate, is called ApoB or apolipoprotein B. So that really is all you need to have your cholesterol checked.

But again, and do you put any stock in ApoB to ApoA ratio?

All ratios Are non-useful. Wow. Right.

Okay.

Whether it's HDL ratios, blah, blah, blah, triglyceride HDL, LDL, total cholesterol HDL, even ApoA. ApoA is a little bit better, more scientific way of measuring HDL, which is what ApoA is. But any of those ratios are terribly useless. Remember, all those ratios were derived because we're trying to guess, right? We don't know. We're trying to guess by numbers if you have the deposition of plaque in your blood vessels, right?

Yes.

And we're talking risk, right? If your ratio's high or low, or God knows, your risk is higher or lower, but that's risk. I don't deal in risk anymore. I put you in the machine and we see it. It's there. It's not, it's binary. It's zeros and ones.

Yeah.

Right. So, 'cause it's all those tests and, and many heart tests that many people are still doing. They'll get the multi-thousand-dollar panel and you got greens and reds and yellows and all that stuff. All of that was predicated upon, I have no idea how to see plaque. I didn't have a way to see plaque or measure it or detect it or use AI that we now do. So, I'm going to get these numbers to try to guess if you have plaque.

Yes.

Well, that's a waste of time, money, and blood. Yeah. Get the machine.

And not without risks, as you said earlier on, John, having some of these procedures that are not as predictive as CT, you know, any procedure that you have is going to have risks. Of course, any medication, which we'll get onto medication, any medications have risks with it. Right.

So, so absolutely. So we don't really treat risk anymore. We either treat people who have plaque or they don't have plaque.

Yeah.

And that's it. I mean, people that have high cholesterol and have no plaque, have perfect cholesterol, lots of plaque. So I completely agree with you. Cholesterol is a really, really poor indicator of whether that cholesterol is sticking. Remember, we're just measuring how much cholesterol is floating by in your bloodstream, tells you nothing about is it sticking.

And my understanding, John, is that about 50% of people who have a heart attack have got normal cholesterol.

Oh, absolutely. Yeah. Right. So using cholesterol to guess whether you have plaque or not, you will lose every time. Right. That's a casino game. Wow. Wow. The house always wins. Right.

So, so what is very clear, and I think just to recap for the listeners, cholesterol, almost useless. You want to know your Lp, and you want to know your ApoB and you want to know about the stickiness, cardiac CT is absolutely the way to go. But, probably different, John, in here in Australia than in the States because of our medical system, right?

Yeah.

It's a little bit different. And, going straight to a cardiac CT, probably not going to happen, right? Because they want to do the cheaper tests first.

Well, what's, what's interesting is in reality, cardiac CT is a fifth or is rather 10 to 5% of the cost of a heart cath.

Really?

Yeah. Oh, it's dramatically cheaper. Wow. I had it just in the state of Wisconsin. Right. Depending on what kind of stress test, there's different kinds of stress tests and all that. Again, generally, Will be even cheaper than a stress test. And if you do cardiac MR, which we kind of talked about, which is a great tool to look at the heart muscle and such, is like really expensive, right? I mean, that's a few thousand bucks. So cardiac CT is actually quite inexpensive. Medicare reimbursement in the US for cardiac CT is $378.

How much is the cost of the actual thing?

Yeah. So Medicare reimbursement, right, for our Medicare heart— Out-of-pocket cost is $378.

Wow.

Wow. Yeah. Cheaper than stress tests, dramatically cheaper than a heart cath, dramatically cheaper than an MR.

So way more—

in reality, it's not cost. The biggest thing is habit, right? So I trained 30 years ago. Cardiac CT didn't exist. Couldn't even imagine it, right? So I always trained in stress tests and heart cath, and I did all those things. And then roughly about the turn of the century, 21st century, We began to develop some really crude early machines. These weren't even the iPhone 1. I'll call it the iPhone 0.5, but they're using basically crude versions of cardiac CT. And I could see, oh, I get where this is going. Hardware, software, technology will all kick in. And guess what? This is where the path is going. So that's when I switched over. 25 years ago to cardiac CT. And then, in 2005, the first of what we call 64-slice machines came out that really were where the rubber met the road, right? That's what I— we really— and that's 20 years ago when I gave up doing heart caths because on a heart cath, even a heart cath, which many of my colleagues would call a gold standard, here's the problem. All I can see is the donut hole. We talked about the donuts and donut hole. All I can see is the donut hole. I have no idea what's happening in the donut. Is there hard plaque? Is there lipid-rich plaque? Is there soft plaque? Is it growing outside? Right? So, you can have a perfectly normal heart cath and still have substantial plaque or atherosclerosis because it's hiding in the wall. Yeah. You can only see that on, well, 2 tests, cardiac CT. Now, we have AI to even, which is the microscope, Applied to cardiac CT. It's cardiac CT now with AI, which is new over the last 4 years. But the only other way that I could see the plaque that we can now see, detect, measure, track, and quantify is with cardiac CT and AI. The only other way that we could detect that plaque, measure that plaque, quantify that plaque is with an autopsy.

Jesus.

And most people decline that opportunity. So cardiac CT is pretty easy thing. So in reality, preventative cardiology is really predicated upon fantastic imaging using cardiac CT and now AI. There's no role for stress tests. There's no role for heart tests. And by the way, even the TEE that you had, yeah, we get such beautiful pictures that in my patients with aortic valve disease like you do, we take the pictures. It takes literally 1 second to take the images. Right? Several thousand slices, all in less than a second. We get all that echo data. We can measure the valve, look at the valve, do all that stuff. I can also make sure your coronaries are okay, which is the real reason you had the heart cath.

Yeah.

In one test, that's a fraction of the cost of all the stuff you went through and completely non-invasive. We put an IV in your arm, stick you in the donut. This, the actual scan with this particular machine we have, which is pretty fancy, but But, it might take 5 or 10 seconds. Ours is less than a second to get these incredible high-resolution 3-dimensional images. And then literally we can take your heart apart, fly up and down the vessels, turn 'em, spin 'em, rotate 'em, and then use AI to detect the soft plaque. That's the active plaque, the lava, the lipid-rich plaque, right? That is the stuff that ruptures, breaks off, flakes off, cause heart attacks, or if that's up in the neck, a stroke. That is always the plaque that starts the whole process. But over time, the plaque will naturally, or with help, medications, diet, exercise, lifestyle, will actually convert from the lava, the soft lipid-rich, waxy, buttery stuff into the hard stable plaque, which is the calcified stuff. That's the cement. Once it's the cement, that's the cinder cone, the extinct volcano. It's not going to break off, flake off, rupture, cause problems. It's just an old scar, right?

Yeah.

So, our goal is to identify the lipid-rich soft plaque. At the same time, see if there's blockages. But again, you could have a perfectly normal heart cath, no blockages, and have extensive plaque in the blood vessels. Identify the soft plaque, quantify that soft plaque now with AI, And then treat that. And the goal is, as you said before, really to get it into that hard calcified plaque. And we're really doing 2 things. We're converting cholesterol that's already in the blood vessel into the hard plaque, and we're preventing any further cholesterol get in the vessel to cause more plaque buildup in the first place. And that's how we're going to cure heart disease. That is strokes and heart attacks, the plaque stuff, right? Which is different than valve stuff. That is, Jesus, that is, wow.

That's super interesting.

So, I would argue, right, analogy, I would argue with the tools we currently, and the knowledge and the tools, the literature, even the tools to treat plaque, stop plaque, we literally have the cure for heart disease. Here's our problem. We don't look for the cancer. We have the cure for cancer.

Yeah. We know that.

But we don't look for it early. We wait till it shows up. We wait to have symptoms, chest pain, angina, need stents or balloons. All of that is the equivalent in the world of cancer of stage 4 advanced metastatic cancer, right? None of the tools we have available that we historically have used in the 20th century, heart cath, echoes, stress tests, EKGs, none of them are early detection tools.

So you, we're really talking the difference here between healthcare and sick care. Absolutely. Because most healthcare is actually sick care.

It is. It's not healthcare at all. So, you know, we do colonoscopies, we do pap smears, we now do chest CTs in smokers for lung cancer. You know, we do all these things to detect early cancers, but the disease that kills more of us, whether it's US or Australia, than any of those other cancers, dramatically is heart disease that we can now pick up decades before we get in trouble and take care of it and treat it. So it becomes a big nothing burger, but historically we haven't.

And how expensive are these machines, John, particularly the new 64 slices?

Yeah, so the machine we have, I'd pocket about $2.3 million.

Right. And how expensive would be an MRI machine? Any idea?

Oh, it depends. I mean, there's a span of them, but those are, those are certainly in that same price range up to several million dollars. Wow.

Okay.

So, so it's like in the big scheme of things, and they have to be super cooled with helium. So the upkeep, oh man, it's, ah, yeah, that thing burns through money.

So the cost over the life cycle is significantly more.

Oh, absolutely. And then the techs are not inexpensive too, right?

Right. But then when you think about then the return on investment, and I'm talking about the global return on investment in terms of preventing and saving lives, you compare it against the old technology.

I hate to do this, but I've got to—

I'm sorry.

We're all trying to get to—