Latest / Heart Health, Reimagined with Dr. Mona Shah, MD / You Found Heart Plaque. Now What?

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You Found Heart Plaque. Now What? · Heart Health, Reimagined with Dr. Mona Shah, MD

• 0:00
  SPEAKER_00: Here's a statistic that should bother you.
• 0:03
  SPEAKER_00: About half of people who have their first heart attack had no warning symptoms and no known heart disease beforehand.
• 0:13
  SPEAKER_00: Maybe you just got a coronary CT or a calcium score back and it showed plaque, 20%, 30%, sitting right there in black and white.
• 0:24
  SPEAKER_00: And maybe you feel completely fine.
• 0:27
  SPEAKER_00: No chest pain, no shortness of breath, you're exercising, working, going about your life.
• 0:34
  SPEAKER_00: So you're probably sitting there thinking, if I don't have symptoms and it's not severe, do I actually need to do anything?
• 0:42
  SPEAKER_00: My answer is yes.
• 0:44
  SPEAKER_00: Heart attacks don't only happen because an artery slowly narrows from 30% to 50 to 70 to 90 until it finally closes.
• 0:56
  SPEAKER_00: Plaque that isn't severely blocking blood flow can still rupture or erode, and the clot can form on top of it, turning a mild narrowing into a heart attack.
• 1:09
  SPEAKER_00: In fact, majority of heart attacks happen that way from a rupture.
• 1:15
  SPEAKER_00: That's why I don't look at a 20 or 30% plaque and say, it's fine, don't worry about it.
• 1:21
  SPEAKER_00: But I also don't want you to hear the word plaque and panic.
• 1:25
  SPEAKER_00: There's another way to think about this.
• 1:27
  SPEAKER_00: You found it before it found you.
• 1:30
  SPEAKER_00: That's not bad news.
• 1:32
  SPEAKER_00: That's an opportunity a lot of people never get.
• 1:35
  SPEAKER_00: I'm Dr.
• 1:35
  SPEAKER_00: Mona Shaw, triple board certified in preventive cardiology, holistic medicine, and cardiac CT.
• 1:42
  SPEAKER_00: If you've been following this channel, you already know what plaque is, how a coronary CTA finds it, and why you can have plaque with a complete completely normal LDL.
• 1:54
  SPEAKER_00: I'll link all those below rather than repeat them today.
• 1:58
  SPEAKER_00: This is the video everything else has been building toward.
• 2:02
  SPEAKER_00: Today I want to answer a different question.
• 2:06
  SPEAKER_00: Once we know plaque there, what do we actually do about it?
• 2:12
  SPEAKER_00: I think about three goals really.
• 2:15
  SPEAKER_00: Regress what we realistically can, meaning reverse the plaque as much as possible, two, stabilize what's left, and three, prevent more from developing.
• 2:31
  SPEAKER_00: So let's get into it.
• 2:34
  SPEAKER_00: First, let's try to understand what you actually found on that scan.
• 2:39
  SPEAKER_00: How narrowed is the artery?
• 2:41
  SPEAKER_00: That's called stenosis, just a fancy word for narrowing.
• 2:45
  SPEAKER_00: A 20 or 30% stenosis means that there's still plenty of room for blood to flow.
• 2:53
  SPEAKER_00: 70, 80, 90% stenosis, then we have a supply and demand issue.
• 2:58
  SPEAKER_00: Your heart needs more blood flow when you exercise, and a severely narrowed artery may not be able to keep up, which is when, oftentimes, symptoms like chest pressure or shortness of breath show up.
• 3:13
  SPEAKER_00: But narrowing isn't the whole picture.
• 3:16
  SPEAKER_00: I also want to know what your total plaque burden is.
• 3:21
  SPEAKER_00: How much plaque is there overall, even without one big blockage?
• 3:27
  SPEAKER_00: And I want to know what is your plaque made of.
• 3:30
  SPEAKER_00: Is it hard, densely calcified, stable plaque, or is it soft, mushy, non-calcified, or is it a mix?
• 3:41
  SPEAKER_00: Densely calcified plaque tends to be more stable.
• 3:45
  SPEAKER_00: Softer, non-calcified plaque isn't automatically dangerous, but some of it's cholesterol rich and more vulnerable to rupture.
• 3:57
  SPEAKER_00: I've got an entire video on what plaque is and the biology behind it.
• 4:02
  SPEAKER_00: I really think it would be helpful to watch that as well, and I'll link it below.
• 4:07
  SPEAKER_00: But for today, just know this: these plaque types don't behave the same way, and we're not trying to do the same thing to all of them.
• 4:18
  SPEAKER_00: So once we find plaque, there are three things we're trying to accomplish again.
• 4:23
  SPEAKER_00: Number one, can we regress it?
• 4:26
  SPEAKER_00: Can we actually reduce some of what's there?
• 4:29
  SPEAKER_00: Number two, can we stabilize it, make it safer, even if it doesn't shrink?
• 4:36
  SPEAKER_00: And number three, can we prevent more from developing?
• 4:41
  SPEAKER_00: Regress, stabilize, prevent.
• 4:45
  SPEAKER_00: Let's take them one at a time.
• 4:48
  SPEAKER_00: All right, so goal one, regress.
• 4:51
  SPEAKER_00: What can we realistically do with this?
• 4:54
  SPEAKER_00: How can we actually try to reverse or regress plaque?
• 4:58
  SPEAKER_00: So one of the questions I get every time I review a scan with somebody is can I make this go away?
• 5:05
  SPEAKER_00: Can I make my plaque go away?
• 5:07
  SPEAKER_00: Sometimes yes, but we need to be realistic.
• 5:10
  SPEAKER_00: I'm not expecting established, densely calcified hard plaque to simply disappear.
• 5:17
  SPEAKER_00: Where we may see real change is in the non-calcified soft plaque.
• 5:23
  SPEAKER_00: The strongest evidence we have for actually regressing or reducing plaque is substantially reducing the athrogenic particles.
• 5:35
  SPEAKER_00: Athrogenic particles are particles that cause plaque.
• 5:39
  SPEAKER_00: This is what APOB measures.
• 5:41
  SPEAKER_00: We've talked about APOB so many times.
• 5:44
  SPEAKER_00: I've got a whole video on APOB, so I'm not going to reteach it here, but the short version is the higher your particle exposure, the more plaque tends to progress.
• 5:56
  SPEAKER_00: As it comes down, progression slows.
• 6:00
  SPEAKER_00: And at low enough achieved levels across multiple imaging trials, regression becomes more likely.
• 6:08
  SPEAKER_00: There's no magic number that APOB needs to be.
• 6:12
  SPEAKER_00: In general, I like my patient to be below 90, and that's with someone who has no coronary artery plaque.
• 6:19
  SPEAKER_00: However, if I start seeing a lot of non-calcified plaque and plaque, I want that APOB number lower.
• 6:27
  SPEAKER_00: I set an individualized target based on someone's disease, risk, and labs.
• 6:32
  SPEAKER_00: Then we figure out how to get there.
• 6:35
  SPEAKER_00: I'm not married to a particular treatment.
• 6:37
  SPEAKER_00: I'm married to the goal.
• 6:39
  SPEAKER_00: What is our APOB goal?
• 6:41
  SPEAKER_00: What is our corner disease plaque burden goal?
• 6:44
  SPEAKER_00: If lifestyle gets us there, wonderful.
• 6:47
  SPEAKER_00: Sometimes supplements help.
• 6:49
  SPEAKER_00: And when that's not enough, medication becomes part of the conversation.
• 6:54
  SPEAKER_00: I've actually got a whole video breaking down lifestyle, supplements, statins, and non-statin medications, and how I think through these choices with patients.
• 7:04
  SPEAKER_00: I'll link that below if you want to go deeper.
• 7:07
  SPEAKER_00: If regression is the goal, lowering athrogenic particle exposure is our strongest lever.
• 7:16
  SPEAKER_00: But shrinking plaque isn't the only goal.
• 7:21
  SPEAKER_00: If this is the kind of cardiovascular care you've been looking for, where we're not just chasing one cholesterol number, but actually looking at what's happening inside your arteries, subscribe and like this video.
• 7:35
  SPEAKER_00: Every week I break down early detection, prevention, and precision cardiovascular care.
• 7:43
  SPEAKER_00: Goal two, stabilize the plaque that remains.
• 7:48
  SPEAKER_00: Think of it this way: if you've got a 20 or 30% plaque, you can live with that plaque the rest of your life.
• 7:56
  SPEAKER_00: We want to stabilize it.
• 7:58
  SPEAKER_00: This might be just as important as regression.
• 8:01
  SPEAKER_00: Everyone wants to hear my plaque got smaller, but changing the plaque's biology can matter just as much, even when it doesn't shrink.
• 8:10
  SPEAKER_00: Remember that softer, mushy, cholesterol-rich plaque?
• 8:14
  SPEAKER_00: Some of it's biologically active and inflamed and more vulnerable to rupture.
• 8:21
  SPEAKER_00: So one goal is making it more stable, a smaller cholesterol-rich core, a thicker protective cap, less inflammation inside.
• 8:31
  SPEAKER_00: Sometimes a shift towards denser calcified plaque is better than no change at all, because at least we've stabilized it.
• 8:41
  SPEAKER_00: That's also why an increase in calcium score, if you end up getting them repeated, doesn't automatically mean treatment failed.
• 8:49
  SPEAKER_00: More calcium sometimes isn't automatically good, but some lipid lowering therapies have been associated with a shift toward denser, more stable calcified plaque.
• 9:00
  SPEAKER_00: So if your score goes up, my answer isn't automatically something's wrong.
• 9:05
  SPEAKER_00: We look at what's actually happening, not just one number.
• 9:09
  SPEAKER_00: That's also why I like to get a coronary CT, because it can show me if the soft plaque has converted to hard plaque.
• 9:18
  SPEAKER_00: AI plaque analysis can help with that as well.
• 9:22
  SPEAKER_00: And stabilization isn't one lever either.
• 9:25
  SPEAKER_00: It's driven by the same factors that cause the plaque, which is exactly what we're about to get into.
• 9:33
  SPEAKER_00: Goal three, prevent progression.
• 9:37
  SPEAKER_00: Even if I could shrink your plaque today, I haven't solved anything if you keep building new plaque for the next 20 years.
• 9:45
  SPEAKER_00: So I ask, why did this particular person develop plaque in the first place?
• 9:50
  SPEAKER_00: This is where in my own practice, I don't just look at one number like LDL.
• 9:55
  SPEAKER_00: You've heard me talk about this multiple times.
• 9:58
  SPEAKER_00: I walk every patient through four buckets because plaque never just has one cause.
• 10:04
  SPEAKER_00: The first is athrogenic particles, that's APOB, which we just covered.
• 10:10
  SPEAKER_00: The second is your metabolic and vascular environment, insulin resistance, blood pressure, exercise, muscle mass, nutrition, and visceral fat.
• 10:22
  SPEAKER_00: Third is inflammation.
• 10:24
  SPEAKER_00: I look at high sensitivity CRP, but an elevated number alone doesn't tell me why it's elevated.
• 10:30
  SPEAKER_00: I look at is there metabolic dysfunction going on?
• 10:33
  SPEAKER_00: Is there smoking going on, poor sleep, periodontal disease, an autoimmune condition, or even chronic stress.
• 10:41
  SPEAKER_00: I want the driver, not just a lower number.
• 10:45
  SPEAKER_00: And fourth is genetics and lipoprotein A, largely inherited, so I can't lifestyle it away, but knowing it's elevated changes how aggressively I manage everything else.
• 10:56
  SPEAKER_00: Put those four together, and that's precision prevention.
• 11:02
  SPEAKER_00: I'm not treating a number, I'm treating the person who has the plaque.
• 11:06
  SPEAKER_00: People ask me about supplements constantly.
• 11:09
  SPEAKER_00: I am board certified in holistic medicine, so I'm open and welcome those questions.
• 11:14
  SPEAKER_00: I use selected ones in selected patients, but we don't have strong evidence that supplements alone regress established plaque.
• 11:23
  SPEAKER_00: And natural doesn't automatically mean safe or effective for you.
• 11:28
  SPEAKER_00: They can help with underlying disease, underlying inflammation.
• 11:34
  SPEAKER_00: I have a whole video on supplements and how they can help.
• 11:38
  SPEAKER_00: But the same goes for medication.
• 11:40
  SPEAKER_00: This isn't medication versus natural.
• 11:42
  SPEAKER_00: It's what actually works for this person.
• 11:45
  SPEAKER_00: That's shared decision making.
• 11:48
  SPEAKER_00: And here's what I want you to remember above everything else.
• 11:52
  SPEAKER_00: Hitting a target number is not the finish line.
• 11:55
  SPEAKER_00: The finish line is what that number represents.
• 11:59
  SPEAKER_00: A fibrous cap that's thicker, an artery that's less inflamed, and less likely to rupture.
• 12:06
  SPEAKER_00: The lab report is a means to an end.
• 12:10
  SPEAKER_00: Your arteries are the end.
• 12:13
  SPEAKER_00: So do we ever look at the arteries again?
• 12:16
  SPEAKER_00: Sometimes, not automatically.
• 12:19
  SPEAKER_00: Finding plaque doesn't mean a coronary CTA every year.
• 12:23
  SPEAKER_00: Repeat imaging makes sense when it can answer a real question, like whether the plaque has progressed or has it stabilized.
• 12:32
  SPEAKER_00: Have we regressed any of the soft plaque?
• 12:35
  SPEAKER_00: We don't repeat it just to repeat it.
• 12:37
  SPEAKER_00: I get a lot of questions about the difference between a coronary calcium score, a CIMT, which is carotid intima media thickness, which is an ultrasound of your carotids, and a coronary CTA.
• 12:50
  SPEAKER_00: There are different tests answering different questions.
• 12:53
  SPEAKER_00: I've got a dedicated video on that coming soon.
• 12:58
  SPEAKER_00: So you found plaque, now what?
• 13:02
  SPEAKER_00: First, understand what you found, how much narrowing, how much plaque overall, what type, and whether you have symptoms.
• 13:11
  SPEAKER_00: Second, remember the three main goals.
• 13:15
  SPEAKER_00: Regress what we realistically can.
• 13:18
  SPEAKER_00: Stabilize what's there, prevent more from developing.
• 13:23
  SPEAKER_00: And third, know your buckets, your particles, your metabolic and vascular health, your inflammation, and your genetics.
• 13:31
  SPEAKER_00: You don't need to fix everything at the same time.
• 13:34
  SPEAKER_00: You need to know which ones actually apply to you.
• 13:38
  SPEAKER_00: And fourth, build a plan.
• 13:40
  SPEAKER_00: Lifestyle, supplements, exercise, diet changes, stress management, or even medication when it's appropriate.
• 13:48
  SPEAKER_00: Oftentimes it takes a combination of those to make everything work.
• 13:52
  SPEAKER_00: Finding plaque can be scary, but it doesn't mean the story is already written.
• 13:57
  SPEAKER_00: You found it before it found you.
• 13:59
  SPEAKER_00: And now you have information, and information gives you opportunity to act.
• 14:04
  SPEAKER_00: Knowledge is power.
• 14:06
  SPEAKER_00: If you haven't watched my video on why you can have plaque with a normal LDL, watch that one next.
• 14:13
  SPEAKER_00: And if you're wondering how to actually reach these targets, I've got a full video on the treatment options, lifestyle, supplements, medications, linked below.
• 14:24
  SPEAKER_00: If this whole person approach to prevention is helpful, subscribe and like this video.
• 14:30
  SPEAKER_00: I put out new videos every week on early detection and what you can actually do about your risk.
• 14:37
  SPEAKER_00: And tell me in your comments, if you found out you had plaque, what would you want to understand first?
• 14:44
  SPEAKER_00: How to regress it, stabilize it, or prevent more?
• 14:49
  SPEAKER_00: I'll see you in the next one.