How NOT to Measure Heart Attack Risk – Stress Tests & Stents
Plumbing comes from the main in the
street. It comes under your yard. He comes into the house. You keep
noticing that you’re getting problems with your plumbing, and you find
out after the plumber coming in a couple of times and fixing things that you’ve
got dirt coming in. You’ve got a break between your main and your house.
Of course, when the plumber comes in and puts new pipes, it’s going to make things
better but for how long? That’s as close of an analogy as I can
get. Yes, stents do help for symptoms. Yes, bypass grafts do help for symptoms. Do
they change the probability of dying? No But we know what changes that
changes the probability of dying myself. Any comments? I know that even among my
patient population and my subscribers that tends to create some anger and
frustration. Anybody want to air it? Comment? Concern? Okay, thanks. So there’s got to be a better way, and
yes, there is and we’ll talk about it in just a minute. We’ll skip over that.
You’ve heard me make the comment about we’re
missing the vast majority of people that are at risk for heart attack by
doing a stress test. This was not me. This was I think… this was Vanderbilt or
Princeton. Sorry, they’re all the same to me. So do you recognize what this is? This
is a heart… I mean this is an artery. It’s a cross-section. That’s a nice clean
artery. This has got a little bit more. 45% occlusion. 60%.
70%. 90% occlusion. You’re only getting a little bit of
blood through there and this is the line. If you are over here, you have symptoms,
and you’ll have a positive stress test. If here, you’re not going to have
symptoms. 68% of heart attacks occur in this group. Why is that? These guys
clearly are not at greater risk than these guys. Why is it so much? Why is
it over two thirds here? Well, think about it. Think about what I said earlier
about diabetes and insulin resistance. Insulin resistance actually causes more
damage on a population basis because there are dozens, maybe hundreds of us
that have insulin resistance and don’t know it. For everyone that has full-blown
diabetes, same thing here. There are dozens and dozens of us over
in this category for every one person over here. So yeah, I mean there’s just so
many more people in this area. That’s where the heart attacks are occurring. So
PC angiography. That’s when you do have that positive stress test and they say,
well, you know, you say, is that real, is that a real
problem? Well, I saw a couple of things on your EKG when you know well I didn’t
have any pain. What do you not want to do? Look who’s gonna not want to look. So you
go into the cath lab, and the first thing they do is stick this big
needle in your groin. And yes, if it sounds like I’m trying to scare you to
think twice about getting a cath lab and then or getting a stress test, I am at
least full disclosure. I’m trying to get you to think about that there’s too many
of those being done. Now, the first cardiac cath was done by mistake.
It was done by Mason Sones. I think his from Cleveland Clinic. May have been Mayo. No, maybe Mayo. 1958. He was doing pediatric aortogram. They were
looking at aorta of kids to see if they had problems there. He got a little
too far. The entry to the coronary arteries is very close to the aortic
valve. It went in there. He got this great picture. The heart stopped beating. They
were able to get it started again. So for most people, that’ll be at least a bad day.
He was very excited because look at the anatomy and for sure the anatomy is
compelling. You see all of these. Anybody not see these areas of plaque. So if
you’ve got people having heart attacks and you see these kind of areas of
plaque and you know how to stent them. That’s exciting,
very definitive anatomy there. But it’s definitive of what? It’s definitive of
having a plaque there and unfortunately we’ve learned a lot more about the
science of plaques. There is no such thing as a vulnerable plaque.
I hope looking at these images help you understand. Though you look at that and
you think that’s nothing, that’s scary-looking in there.
Your docs not making this up, but that doesn’t mean that it’s not bad advice.
So we’ll get a coronary angiogram. Cover that real quick. Like I said earlier,
consider angiogram and that’s an option. It’s a good option. It’s being found in the
COURAGE trial and these SCOTT-HEART trial. Both showed that it’s better. If you’re
going to go the standard route and just say, hey Doc, my uncle had a heart attack,
can we get a stress test? If you’re going to go that route at least get a CT
angiogram as well. What will it show you? It’ll show you
more stuff than you find on the angiogram. What will that do? Let me get
you to thinking about I’ve got problems you know the next time you reach for the
refrigerator door. You’re going to get a picture of that plaque, and it’s going to
help motivate you to do something different from what you’ve done in the
past. So the study showed it was “not inferior.” Basically, it meant… it ended
up meaning it’s better. So don’t just do the stress tests alone. At least
do stress tests plus the CT angiogram. Do you plan to make any changes as a direct
result of being here? Yes. Can you describe one of them? I’m
probably not going to take something. I was thinking of taking… medication-wise,
yeah I take no medications now. I’m off 11 of them in the last two years. Wow. And
so, it’s really benefited me. What I’ve learned.
So you’ve adapted a healthy lifestyle.
Yeah fat adaptive. And I know you take your own personalized data. Have you
influenced anyone else around you towards the same work you’re doing for
yourself? I have tried in one particular case. I have a friend that just said, I’m
not doing that. And he just has triple bypass two weeks
ago. He’s just talking about diet now.