Latest / Hardiness with Dr Paul Taylor / AI, Imaging, and the Future of Preventing Heart Attacks Early with Dr James Thompson

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AI, Imaging, and the Future of Preventing Heart Attacks Early with Dr James Thompson · Hardiness with Dr Paul Taylor

• 0:09
  Speaker 1: Dr.
• 0:09
  Speaker 2: James Thompson, welcome to the podcast.
• 0:12
  Speaker 3: Thank you, Paul. Really glad to be here and thank
• 0:15
  Speaker 3: you for this platform.
• 0:17
  Speaker 4: Mate, you've got an important message, which is all about
• 0:20
  Speaker 4: heart health. We know that cardiovascular disease is the world's
• 0:25
  Speaker 4: biggest killer. um still actually in australia interestingly i don't
• 0:29
  Speaker 4: know if the same in the states for females dementia
• 0:32
  Speaker 4: has just taken over heart disease as the biggest killer
• 0:36
  Speaker 4: of females um why the difference in males and females
• 0:41
  Speaker 4: well it's.
• 0:41
  Speaker 3: A good question uh and still i want females to
• 0:46
  Speaker 3: be wrapped up into this because it's a big component
• 0:49
  Speaker 3: of it but uh females are uh different in cardiovascular
• 0:55
  Speaker 3: disease where estrogen, um, protect, uh, for the earlier timeframe now, uh,
• 1:04
  Speaker 3: once menopause. So typically there is a 10 year lag
• 1:08
  Speaker 3: for women. However, like you said, it's still approaches that
• 1:12
  Speaker 3: the number one killer globally of us humans, uh, is
• 1:17
  Speaker 3: heart disease and in particular cardiovascular or coronary disease. Yeah.
• 1:23
  Speaker 4: And as you just alluded to, there are women tend
• 1:26
  Speaker 4: to be protected because of estrogen. But once they go
• 1:28
  Speaker 4: through menopause, that protection pretty much disappears, doesn't it? And
• 1:33
  Speaker 4: they start to slowly catch up on males, which is
• 1:36
  Speaker 4: not something you want to catch up on, let's be honest.
• 1:39
  Speaker 3: Yeah. Welcome to the human population. It comes to us all.
• 1:44
  Speaker 4: So James, we should go through your background actually before
• 1:47
  Speaker 4: we dive into this. So you're a medical radiologist and
• 1:51
  Speaker 4: you really sort of specialize in the heart, preventative stuff.
• 1:58
  Speaker 4: But just give our listeners a bit of a background
• 2:02
  Speaker 4: on you, medical school, training.
• 2:05
  Speaker 2: How long does all of this stuff take?
• 2:08
  Speaker 3: Yeah, thank you. I do like to do this part because...
• 2:13
  Speaker 3: what we're doing here, right? The younger generation calls it
• 2:17
  Speaker 3: the buy-in, right? So, so why you're listening to me
• 2:20
  Speaker 3: is I have a medical degree and I have almost
• 2:25
  Speaker 3: 20 years of experience in this particular specialty, cardiovascular disease,
• 2:32
  Speaker 3: coronary artery disease, what we're going to be talking about
• 2:35
  Speaker 3: and AI applications or the advancement of AI into this space. So,
• 2:41
  Speaker 3: I got into medicine because I love learning and I
• 2:43
  Speaker 3: don't mind it, uh, doing it all my life. I
• 2:47
  Speaker 3: plan to, I'm not a person that is looking to retire.
• 2:52
  Speaker 3: The longer I go, God bless, uh, the more, uh,
• 2:57
  Speaker 3: knowledge I gain and the more helpful I can be
• 3:01
  Speaker 3: to humans and the younger generation of trainees. So, yep. Uh, uh,
• 3:08
  Speaker 3: high school, medical school is four years. And then you
• 3:11
  Speaker 3: get into, in the States, picking a specialty. I picked radiology, right?
• 3:18
  Speaker 3: That's another four years. I picked radiology because it is
• 3:23
  Speaker 3: all imaging within medicine. And it's also the area that's
• 3:28
  Speaker 3: often the cutting edge space, right? So radiologists, I like
• 3:33
  Speaker 3: to say, we own the computers and we own the
• 3:36
  Speaker 3: machines that include CT ultrasound and AI. So all of
• 3:41
  Speaker 3: the computer power advancements since the early days have been
• 3:48
  Speaker 3: through and powered through radiology. Typically the patient doesn't see
• 3:53
  Speaker 3: me though. So after residency of four years, I can
• 3:56
  Speaker 3: continue on in a specialty type fellowship. I picked cardiovascular imaging.
• 4:02
  Speaker 3: So another year of advanced cardiac imaging. And to just
• 4:08
  Speaker 3: unfold that a little bit, typically what I'm talking about
• 4:11
  Speaker 3: there is utilizing CT and MRI machines in the imaging
• 4:17
  Speaker 3: of the heart, not an easy task. It's a action sport, right?
• 4:22
  Speaker 3: The heart basically is the only moving structure within the body.
• 4:27
  Speaker 3: And it is a challenge to image with those machines. Um,
• 4:33
  Speaker 3: And then into practice. And then 17 plus 20 years
• 4:40
  Speaker 3: of being in advanced cardiovascular imaging and looking at parts
• 4:46
  Speaker 3: and inside the body. However, as a radiologist, I look
• 4:49
  Speaker 3: at everything, right? So I don't read cardiovascular. I read brain, MSK, gastrointestinal, GU, everything, orthopedics, everything. Wow.
• 5:02
  Speaker 3: We're typically seen as a doctor's doctor, right? Yeah. Because
• 5:07
  Speaker 3: the patient doesn't usually see us. We're the ones that read.
• 5:11
  Speaker 3: We oversee, optimize the examinations. And then we read those
• 5:15
  Speaker 3: examinations and provide a diagnosis or a reading of the
• 5:21
  Speaker 3: images to the clinician who typically ordered the scan. So
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  Speaker 3: I like to say I use x-ray vision and I've
• 5:29
  Speaker 3: been looking in people for 20 years and However, you
• 5:32
  Speaker 3: might not have seen me, but I've seen you. And
• 5:35
  Speaker 3: you've seen it a lot, right? So I can read 100,
• 5:40
  Speaker 3: 200 patients a day of imaging. So I get a
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  Speaker 3: wide breadth or a statistical balance of different pathologies that
• 5:51
  Speaker 3: occur in the body.
• 5:53
  Speaker 4: Interesting question that's just popped up just because it's top
• 5:55
  Speaker 4: of mind. So my little guy, Oscar, plays soccer. and
• 6:00
  Speaker 4: got quite a bad injury a couple of weeks ago.
• 6:02
  Speaker 4: I thought he had torn his hip flexor. We took
• 6:06
  Speaker 4: him to the GP, and the GP said, let's do
• 6:09
  Speaker 4: an ultrasound and an X-ray, both of which came back negative.
• 6:15
  Speaker 4: And we went and got an MRI, and it turns
• 6:18
  Speaker 4: out that he hadn't injured his muscle, but the tendon
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  Speaker 4: had pulled a piece of the bone away from the attachments.
• 6:26
  Speaker 4: so which probably should have been picked up by an
• 6:29
  Speaker 4: x-ray i'm sure you're thinking but the the radiologist meant
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  Speaker 4: made no mention of it but but tell us the
• 6:36
  Speaker 4: the kind of before we dive into the cardiac stuff
• 6:39
  Speaker 4: the kind of use cases of x-ray ultrasound and then
• 6:45
  Speaker 4: mri and we'll get into ct scan and stuff later
• 6:47
  Speaker 4: on so so why is mri a better picture.
• 6:51
  Speaker 3: I love it this is a great question um So
• 6:54
  Speaker 3: this comes into the, there is no perfect test. We
• 6:59
  Speaker 3: utilize tools in medicine to get an answer. And our
• 7:05
  Speaker 3: best way to get that answer is the tool that
• 7:08
  Speaker 3: we use. The idea that you're sharing is that different
• 7:16
  Speaker 3: tests have different advantages and disadvantages. I'm gonna throw out
• 7:21
  Speaker 3: some terms I'll unfold them a little bit so they
• 7:23
  Speaker 3: don't sound so esoteric, but there's typically three contrasts that
• 7:30
  Speaker 3: are important in all imaging, whether it's spatial resolution, contrast resolution,
• 7:37
  Speaker 3: or temple resolution. And all of those really, you can
• 7:40
  Speaker 3: kind of understand just because we are taking pictures. It's
• 7:43
  Speaker 3: a lot like a camera or a television, right? Temple
• 7:47
  Speaker 3: resolution is the quickness with which you can acquire images.
• 7:50
  Speaker 3: If you're acquiring multiple images, your refresh rate, right? If
• 7:55
  Speaker 3: you want to watch a sports game on television, you
• 7:58
  Speaker 3: want the one with the best space or tempo resolution,
• 8:03
  Speaker 3: that's going to give you 120 or 240 Hertz, right?
• 8:07
  Speaker 3: You don't want the slow 60 Hertz one. And then
• 8:10
  Speaker 3: it's going to drive you crazy when the, when the
• 8:13
  Speaker 3: action's going on. The other is, spatial resolution. So the
• 8:17
  Speaker 3: difference between two adjacent or subjacent points, your ability to
• 8:22
  Speaker 3: differentiate those comes into play. So some imaging shows those
• 8:27
  Speaker 3: differences a lot better than another. You'd always don't want
• 8:32
  Speaker 3: to know that though, right? Because sometimes if you're looking
• 8:35
  Speaker 3: at two dark plots or spots next to each other,
• 8:39
  Speaker 3: you don't often have to resolve those two. In pathology,
• 8:43
  Speaker 3: a lot of times it's the difference in the contrast,
• 8:48
  Speaker 3: the true contrast of the examination, whether it's black or white.
• 8:53
  Speaker 3: If a pathology that you're looking for is white and
• 8:56
  Speaker 3: it's on a black background, it's easy to identify. So
• 9:00
  Speaker 3: some of the things you're finding with X-ray, fantastic spatial resolution,
• 9:05
  Speaker 3: differentiating two dots next to each other. However, it's a
• 9:09
  Speaker 3: summation exam where it's getting its contrast resolution from going
• 9:17
  Speaker 3: through the entire body and it can't resolve it in
• 9:20
  Speaker 3: a 360 degree orientation. That's where some of the other,
• 9:25
  Speaker 3: we call them volume scan imaging, i.e. the advanced imaging
• 9:29
  Speaker 3: that costs more, CT, MRI, right? You went for MRI,
• 9:34
  Speaker 3: which was the straightaway great choice there because it has
• 9:37
  Speaker 3: fantastic contrast resolution. That's why it's so powerful. We can
• 9:42
  Speaker 3: see so many different structures tendons, muscles, fluid, all of
• 9:47
  Speaker 3: these things are very readily visible. Unlike x-rays, right? X-rays,
• 9:54
  Speaker 3: a single examination, taking photons straight through and acquiring them
• 9:58
  Speaker 3: on a, on detector on the other side. You can't
• 10:02
  Speaker 3: really look around. So you saw an avulsion fracture, right?
• 10:05
  Speaker 3: That's a lot more visible with an MRI, but you
• 10:09
  Speaker 3: can't quite go, right? And I know you're in the military, right?
• 10:13
  Speaker 3: So you can't quite go to the go to the
• 10:16
  Speaker 3: bazooka right away. Let's, let's, let's tear up, you know,
• 10:20
  Speaker 3: let's move along the decision pathway. Um, but it's a
• 10:24
  Speaker 3: great example because in advanced imaging, what I do, that's
• 10:28
  Speaker 3: why it's important to be able to get a clear
• 10:33
  Speaker 3: image of a moving heart with a CT machine. That's
• 10:36
  Speaker 3: a mechanical machine rotate around the human body with an extra,
• 10:41
  Speaker 3: it takes the x-ray machine, just, loops it around the patient.
• 10:47
  Speaker 3: It's quite impressive to see, a mechanical wonder, but it
• 10:53
  Speaker 3: is still challenged somewhat in temporal resolution, that ability to
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  Speaker 3: resolve sequential images when you're looking at a beating heart,
• 11:02
  Speaker 3: same with MRI.
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  Speaker 2: Yeah, cool.
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  Speaker 4: And I think you touched on a point there, and
• 11:09
  Speaker 4: And using that case, particularly in Australia where we have Medicare, right,
• 11:15
  Speaker 4: so it's government funded, the doctor will go for the
• 11:19
  Speaker 4: lowest cost thing that can do the job. And I
• 11:22
  Speaker 4: think they're supposed to do that. That's why it wasn't straight.
• 11:25
  Speaker 2: To the MRI.
• 11:27
  Speaker 4: Whereas, you know, if Oscar was a professional soccer player,
• 11:31
  Speaker 4: they wouldn't have bothered with an X-ray and an ultrasound.
• 11:33
  Speaker 2: They would have gone straight to an MRI, right? So
• 11:35
  Speaker 2: a lot of it.
• 11:37
  Speaker 4: Yeah, a lot of it is a time and a
• 11:41
  Speaker 4: cost thing, I think, more than everything else. But let's
• 11:44
  Speaker 4: now come back to the heart. So when we talk
• 11:49
  Speaker 4: about that screening of the heart, population level, nice and cheap,
• 11:56
  Speaker 4: cholesterol screening, right?
• 11:58
  Speaker 2: So a lot of debate there.
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  Speaker 4: I think even in scientific circles about the predictive value
• 12:07
  Speaker 4: of cholesterol in terms of heart disease. I've read data
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  Speaker 4: that half of people who have their first heart attack
• 12:14
  Speaker 4: have normal cholesterol. So what are the pros and cons
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  Speaker 4: of cholesterol as a first line?
• 12:22
  Speaker 2: And then we'll get into the deeper stuff.
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  Speaker 3: I love it. So that's why I'm here. This is fantastic.
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  Speaker 3: So my message I'm bringing, right, is that cardiovascular disease
• 12:32
  Speaker 3: or coronary artery disease is still the number one killer worldwide.
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  Speaker 3: And that's a significant statistic. One that may be able to,
• 12:44
  Speaker 3: or what I'm bringing may be able to change. Right.
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  Speaker 3: And what you're talking about cholesterol is how we've always
• 12:51
  Speaker 3: done it. However, we're starting to move the science a
• 12:55
  Speaker 3: little bit on that. And we're referring to it more
• 12:58
  Speaker 3: as population-based medicine. Right. And a surrogate marker. What do
• 13:04
  Speaker 3: those mean? Well, when I'm talking about population based medicine,
• 13:09
  Speaker 3: medicine is moving towards and the power of some of
• 13:13
  Speaker 3: this imaging can get to personalized, individualized diagnoses and treatments.
• 13:21
  Speaker 3: Very important. Right. And it's a surrogate marker, meaning it's
• 13:27
  Speaker 3: not the actual disease itself. So look at cholesterol. Is
• 13:31
  Speaker 3: that coronary artery disease? No. So it's a surrogate marker.
• 13:36
  Speaker 3: So like you're saying, and like the education that I
• 13:41
  Speaker 3: provide or train trainees in, the science shows that you
• 13:46
  Speaker 3: can have high cholesterol and low events. Those people exist
• 13:53
  Speaker 3: and vice versa. Right. So that's the one that becomes
• 13:56
  Speaker 3: more troublesome is if you have, low cholesterol and you're
• 13:59
  Speaker 3: doing everything you think you personally think is, is optimizing it,
• 14:04
  Speaker 3: but you still have heart attacks. And that's where we're
• 14:07
  Speaker 3: finding ourselves in this position where in 2026 for over
• 14:12
  Speaker 3: a century, I mean, 160 years, cardiac coronary artery disease
• 14:17
  Speaker 3: still remains number one killer that does not have to
• 14:20
  Speaker 3: be at this time. And we're starting to see the
• 14:24
  Speaker 3: science and the guidelines move in this direction. And that's
• 14:28
  Speaker 3: why I'm and I appreciate the platform. I want to
• 14:32
  Speaker 3: make some of these difficult concepts very clear to the population,
• 14:40
  Speaker 3: the humans, right? And what I'm looking to do is
• 14:43
  Speaker 3: take heart disease or the number one killer of the
• 14:48
  Speaker 3: number one public health epidemic and move that needle the
• 14:53
  Speaker 3: other way. And that is possible at this point with
• 14:58
  Speaker 3: the advanced imaging, that's why I'm a radiologist, not typically
• 15:02
  Speaker 3: the person you see on podcasts and things like that.
• 15:06
  Speaker 3: We're typically behind the scenes, right? I like to say
• 15:10
  Speaker 3: I've seen behind the curtain for so long. However, if
• 15:15
  Speaker 3: the actors aren't delivering their lines on stage, we'd sometimes
• 15:19
  Speaker 3: have to come out and clarify what's happening on the inside.
• 15:22
  Speaker 3: And that's more easily accessible nowadays with The power of communication,
• 15:30
  Speaker 3: the internet, things like that, which didn't exist before. Remember,
• 15:34
  Speaker 3: I've been doing this for 20 years, so I've seen
• 15:36
  Speaker 3: the changes that have occurred. And a lot of these,
• 15:41
  Speaker 3: this information is more accessible to people than ever before.
• 15:45
  Speaker 3: So some of the differences, right, that we'll talk about,
• 15:48
  Speaker 3: even just as simple as calcium score versus ETA imaging.
• 15:53
  Speaker 3: What's the difference? Why is it important? Is it important?
• 15:57
  Speaker 3: And if we're going to move the needle on this disease,
• 16:01
  Speaker 3: then yes, it is important. And I do want people
• 16:04
  Speaker 3: to know what the differences are and how AI is
• 16:08
  Speaker 3: fitting into this. Because AI is setting things up quite
• 16:12
  Speaker 3: a bit. Yeah.
• 16:14
  Speaker 4: And we will get into all of that in a second.
• 16:16
  Speaker 4: I just want to really lay the groundwork for people.
• 16:21
  Speaker 4: Total cholesterol, LDL cholesterol, we know have its limitations. I
• 16:27
  Speaker 4: think the science is saying probably ApoB and LP little
• 16:32
  Speaker 4: a are a bit more useful. Can you tell just
• 16:36
  Speaker 4: our listeners what that difference is and why ApoB and
• 16:42
  Speaker 4: LP little a might be more useful cholesterol than just
• 16:46
  Speaker 4: total cholesterol or LDL cholesterol and then We'll get into
• 16:50
  Speaker 4: some of the more advanced stuff. Let's just build the
• 16:52
  Speaker 4: picture up for the listener.
• 16:54
  Speaker 3: I love building it. So LP little a, right, is
• 17:00
  Speaker 3: a very good marker for patients. If you get an
• 17:04
  Speaker 3: LP little a for early personalized disease with hereditary markers, right?
• 17:11
  Speaker 3: So if you get a little A, you can associate
• 17:16
  Speaker 3: that with increased disease prevalence at a more personalized level again,
• 17:24
  Speaker 3: but in the idea of patients with their family history, right?
• 17:33
  Speaker 3: Whereas ApoB, right, is a better marker than cholesterol when
• 17:39
  Speaker 3: we're looking at non-hereditary and cardiovascular disease with blood work.
• 17:49
  Speaker 4: Yeah so the lp little a that's a once only
• 17:53
  Speaker 4: test isn't it that's that's the key thing you do
• 17:55
  Speaker 4: that once and it never changes and and there's a
• 17:59
  Speaker 4: bit that they can infer about your as you said
• 18:01
  Speaker 4: your hereditary risk And then we have ApoB. Then if
• 18:06
  Speaker 4: we're leveling up then, so let's talk about a calcium score.
• 18:12
  Speaker 4: So what is a calcium score? What is it looking for?
• 18:15
  Speaker 4: And can you be lulled into a false sense of
• 18:21
  Speaker 4: security if you have a low calcium score? Yes.
• 18:26
  Speaker 3: So I like to call this, lately I've been calling
• 18:29
  Speaker 3: it the calcium score paradox. Whereas I think you're kind
• 18:35
  Speaker 3: of bringing it to light, but calcium score you often
• 18:38
  Speaker 3: think of when you're thinking of preventative measures, right? Screening almost, right? However,
• 18:46
  Speaker 3: calcium score, and I want to slow down a little
• 18:49
  Speaker 3: bit and get very clear with my words and the message, right?
• 18:54
  Speaker 3: Is that calcium scoring identifies calcium on your coronary arteries,
• 19:01
  Speaker 3: In a calcium score, right? You can see calcium elsewhere.
• 19:04
  Speaker 3: It's a non-contrast CT examination. No contrast. You get a CT.
• 19:10
  Speaker 3: Very easy. And it identifies calcium on the coronary arteries.
• 19:16
  Speaker 3: Great marker. Great science. Great data. However, we know that
• 19:24
  Speaker 3: coronary artery disease comes in two forms. Non-calcified? And that's
• 19:32
  Speaker 3: why I put non-calcified in front on purpose, because I
• 19:36
  Speaker 3: want people to know it's how disease starts. So if
• 19:41
  Speaker 3: you have non-calcified plaque, you can still have a calcium
• 19:46
  Speaker 3: score of zero and have disease. And you could have
• 19:51
  Speaker 3: significant disease. So the analogy I use for this is
• 19:56
  Speaker 3: if you get cut on your skin, right? At first
• 19:59
  Speaker 3: it's a cut, it's bleeding, and then your body heals
• 20:01
  Speaker 3: it with a scab. So a scab is calcium. It
• 20:06
  Speaker 3: shows that you've been through battle, right?
• 20:09
  Speaker 4: Yeah, nice.
• 20:10
  Speaker 2: I like that analogy.
• 20:12
  Speaker 4: You know what? That's probably the best explanation that I've
• 20:16
  Speaker 4: had of the calcium score because.
• 20:18
  Speaker 2: I think what some people don't realize is that.
• 20:21
  Speaker 4: Laying down the calcium actually can make the plaque or
• 20:27
  Speaker 4: does make the plaque less risky because it's the soft
• 20:32
  Speaker 4: plaque that's easier to break off, isn't it, and cause
• 20:36
  Speaker 4: an aneurysm or something else. Can you just expand on
• 20:38
  Speaker 4: that a little for our listeners?
• 20:39
  Speaker 3: Sure. Absolutely. And the lexicon we use in medicine for these,
• 20:44
  Speaker 3: they're always great, right? When you have calcium, you call
• 20:48
  Speaker 3: it established disease, right? You have established disease. So that
• 20:52
  Speaker 3: just means it's your body healing itself, right? It's laying
• 20:55
  Speaker 3: down little scabs on your coronary arteries. And the more
• 20:58
  Speaker 3: calcium you have, right, the more disease you've had. However, very,
• 21:04
  Speaker 3: very importantly, it starts off as coronary artery disease starts
• 21:10
  Speaker 3: off as non-calcified plaque. And the lexicon we use for
• 21:13
  Speaker 3: that has changed over the years, the most recent years, right?
• 21:17
  Speaker 3: At first we called it soft plaque. Then we called
• 21:21
  Speaker 3: it non-calcified plaque. Then we called it vulnerable plaque. And
• 21:24
  Speaker 3: then we call it high risk plaque. So you can
• 21:28
  Speaker 3: kind of see just even from the terms, what we're
• 21:30
  Speaker 3: talking about, it's significant, right? So not only do we
• 21:34
  Speaker 3: have a calcium score of zeros, but you can have
• 21:37
  Speaker 3: significant high risk disease and how plaque works or coronary
• 21:46
  Speaker 3: artery disease works is it's just what people have always said.
• 21:51
  Speaker 3: And I say that cliches are cliches for a reason there. Uh,
• 21:56
  Speaker 3: I was an English major at one point in my life,
• 21:58
  Speaker 3: so I was never allowed to use them in my reports.
• 22:03
  Speaker 3: but it's because it's an overused statement, right? But the
• 22:06
  Speaker 3: reason it's overused is it's such a succinct way to
• 22:09
  Speaker 3: say something in human nature and human nature knows that
• 22:13
  Speaker 3: this is a silent killer. And that's why it's happening
• 22:18
  Speaker 3: when you're young, you just don't know it. And that's
• 22:21
  Speaker 3: a message I'm bringing. Don't think of a 70 year
• 22:24
  Speaker 3: old male as coronary artery disease. Let's get this way
• 22:28
  Speaker 3: front forward. We're realizing that, That coronary artery disease starts
• 22:34
  Speaker 3: just like we kind of always know, silently. You just
• 22:36
  Speaker 3: don't know it's there. And it's non-calcified to start. And
• 22:41
  Speaker 3: then as your body heals it in an inflammatory response
• 22:45
  Speaker 3: is it begins to calcify it. And sometimes you can
• 22:49
  Speaker 3: even have a little fluck of calcium and not show
• 22:51
  Speaker 3: up on the calcium score, right? You can actually even
• 22:54
  Speaker 3: have calcium like that. The algorithm we use for it
• 22:57
  Speaker 3: uses certain thresholds of density. Ah, ah, ah. for the
• 23:01
  Speaker 3: calcium score. So anyway, my point just with that is
• 23:04
  Speaker 3: there's a very large window in the front of this,
• 23:08
  Speaker 3: and we're not using CTA for screening yet, or I
• 23:15
  Speaker 3: want to make that clear that the test that we'll
• 23:17
  Speaker 3: move to next is not screening. But when we're looking
• 23:21
  Speaker 3: at And I'll do the stats, right? 70% of people
• 23:25
  Speaker 3: are considered, depends on the studies you're looking at and
• 23:29
  Speaker 3: the science that we're doing, but 70% of people are
• 23:31
  Speaker 3: often considered low risk at the time of their first
• 23:34
  Speaker 3: heart attack.
• 23:35
  Speaker 2: That's right.
• 23:36
  Speaker 4: And the first heart attack kills a lot of people,
• 23:40
  Speaker 4: doesn't it?
• 23:41
  Speaker 2: I remember seeing a stat, it was like 40 or 50%.
• 23:43
  Speaker 4: First heart attack. So people can be walking around.
• 23:49
  Speaker 2: So let's build this picture, Jim.
• 23:50
  Speaker 4: Somebody can be walking around they can have done cholesterol
• 23:54
  Speaker 4: and their cholesterol is fine.
• 23:55
  Speaker 3: Right.
• 23:56
  Speaker 4: And they can go, well, I just want to make
• 23:58
  Speaker 4: sure that I'm all good. So they then go and
• 24:01
  Speaker 4: get a calcium score and that calcium score is zero.
• 24:04
  Speaker 2: Right.
• 24:04
  Speaker 4: And they're maybe in their forties or their fifties. So
• 24:07
  Speaker 4: they're walking out of there now going, I'm at very
• 24:10
  Speaker 4: low risk of heart disease. But as you say, they
• 24:13
  Speaker 4: can have these soft plaques, these, I can't remember what
• 24:17
  Speaker 4: you call them.
• 24:17
  Speaker 3: Yeah.
• 24:19
  Speaker 4: High risk, high risk as they now are, these high
• 24:21
  Speaker 4: risk plaques. And then all of a sudden, bang, that
• 24:25
  Speaker 4: can break off, block your artery, and then bang, there's
• 24:29
  Speaker 4: a heart attack or there can be an aneurysm or
• 24:31
  Speaker 4: something like that. So this is, I think what we're
• 24:36
  Speaker 4: laying bare here is the limitations of the screening and
• 24:41
  Speaker 4: the population screening that at a population level, it's pretty good.
• 24:46
  Speaker 4: But when we get down to the N equals one level,
• 24:49
  Speaker 4: it can be either very good or completely useless. What
• 24:52
  Speaker 4: we've talked about so far in terms of your risk, right?
• 24:56
  Speaker 3: Yeah. So, uh, and cholesterol, trust me, it is very good.
• 24:59
  Speaker 3: It's a very good test. So once you have disease too,
• 25:02
  Speaker 3: it's great to follow how you're doing. Cause if your arteries.
• 25:05
  Speaker 5: Are in a state of inflammation, uh, that slick central
• 25:11
  Speaker 5: tube layer, uh, is very smooth and delicate, but once
• 25:15
  Speaker 5: it starts getting, micro fractures and things like that.
• 25:19
  Speaker 3: These sticky molecules stick to them. Um, the, the, the
• 25:23
  Speaker 3: message I'm bringing is, and I usually use, uh, I
• 25:28
  Speaker 3: like to put names, uh, faces to these things.
• 25:31
  Speaker 5: Right.
• 25:32
  Speaker 3: And Bob Harper, right. You know, Bob Harper, uh, no
• 25:36
  Speaker 3: celebrity trainer. He's a celebrity trainer on the biggest loser.
• 25:40
  Speaker 2: Oh, yes, yes, yes. And the biggest, biggest USA ball popper.
• 25:43
  Speaker 5: Yeah.
• 25:43
  Speaker 3: I know the guy.
• 25:44
  Speaker 2: Yeah.
• 25:44
  Speaker 3: Think about it. I mean, it, This is the epitome
• 25:47
  Speaker 3: of health. He's a celebrity trainer. And he's going to
• 25:53
  Speaker 3: fit into the category of 70% of people are considered
• 25:55
  Speaker 3: low risk at the time of their first event, right?
• 25:58
  Speaker 3: Where he died and was resuscitated while working out at
• 26:02
  Speaker 3: the gym. And the average age, right? The average age
• 26:07
  Speaker 3: of sudden coronary death is 50 years old.
• 26:13
  Speaker 4: Wow.
• 26:14
  Speaker 3: Yeah, that's really young. And the first symptom in more
• 26:17
  Speaker 3: than 50% of people, I think this is what you
• 26:20
  Speaker 3: were getting at, the first symptom in more than 50%
• 26:24
  Speaker 3: of people is heart attack or death. So these are
• 26:31
  Speaker 3: really what I call kind of tongue in cheek, statistically heavy.
• 26:36
  Speaker 3: I mean, that number one killer, number one public health epidemic,
• 26:42
  Speaker 3: most of us are considered low risk. It's young. And
• 26:47
  Speaker 3: the first symptom often is just death and heart attack.
• 26:51
  Speaker 3: That doesn't have to be the case in this day
• 26:53
  Speaker 3: and age. So another analogy, right, that I'm going to
• 26:56
  Speaker 3: or another phrase or cliche that I'm going to bring
• 27:02
  Speaker 3: up is seeing is believing. And that's kind of what
• 27:04
  Speaker 3: we're getting at here. I'm a radiologist, right? I look
• 27:08
  Speaker 3: at pictures, images inside the body. We can take images
• 27:14
  Speaker 3: of this actual body. plaque, we can look straight at
• 27:18
  Speaker 3: and understand now the phenotypes and the progression of coronary
• 27:26
  Speaker 3: artery disease. However, it's younger than we very much consider.
• 27:32
  Speaker 3: So that's kind of the message I'm bringing. And you
• 27:35
  Speaker 3: brought it up at the beginning, even women, right? They
• 27:37
  Speaker 3: get a little bit of a delay. However, they're usually
• 27:43
  Speaker 3: in control of the healthcare with the family unit and
• 27:46
  Speaker 3: things like that. I want the whole community and the
• 27:51
  Speaker 3: whole family unit to understand the power of this test
• 27:55
  Speaker 3: that I'm going to get into in this space of
• 28:00
  Speaker 3: coronary artery disease and its ability in early preventative optimization.
• 28:09
  Speaker 4: Yeah. So I'm a kind of a bit of a
• 28:12
  Speaker 4: poster boy for more advanced imaging, right? Because I had
• 28:17
  Speaker 4: gone to my doc, you know, I had all the tests,
• 28:19
  Speaker 4: my cholesterol is high, but I have gone and done
• 28:25
  Speaker 4: sub-particle testing and it's all the big fluffy LDL that's high,
• 28:29
  Speaker 4: which is not pathogenic, right? And so... And I know
• 28:34
  Speaker 4: my triglyceride, HDL ratio and all of these sorts of things.
• 28:37
  Speaker 4: So I was thinking I'm reasonably low risk, but then
• 28:39
  Speaker 4: I had a calcium.
• 28:41
  Speaker 2: Score and I think it was 18 or 20, right?
• 28:43
  Speaker 2: And my doctor's like, don't worry about it.
• 28:46
  Speaker 4: He says, we don't worry about it until it's in
• 28:48
  Speaker 4: the hundreds.
• 28:49
  Speaker 2: And I remember walking out of there thinking, I don't
• 28:52
  Speaker 2: like that. I just don't like that. I'm in my
• 28:54
  Speaker 2: fifties now.
• 28:54
  Speaker 4: Now I'm very fortunate that I play soccer, football with
• 28:58
  Speaker 4: a cardiologist. And I actually said to him, hey, mate,
• 29:02
  Speaker 4: I actually want to get more advanced stuff done. So
• 29:05
  Speaker 4: he said, look, get a referral from your GP. And
• 29:08
  Speaker 4: he did all the different tests on me, which the thing,
• 29:13
  Speaker 4: case in point here, it's not about the disease, but
• 29:17
  Speaker 4: turned out that I had a bicuspid aortic valve, a
• 29:20
  Speaker 4: congenital heart defect that never would have been picked up, right?
• 29:25
  Speaker 4: And could have, if it wasn't picked up, well, certainly
• 29:29
  Speaker 4: would have at some stage caused heart disease, probably heart failure,
• 29:34
  Speaker 4: possibly sudden cardiac death, burst aorta, all of that sort
• 29:38
  Speaker 4: of stuff. So it need to convince me of the
• 29:41
  Speaker 4: benefits of that advanced screening. But if we come back
• 29:45
  Speaker 4: to the conversation around heart disease, so now let's talk
• 29:51
  Speaker 4: about the more advanced imaging that you do. So what
• 29:54
  Speaker 4: does it give us that everything that we've talked about
• 29:58
  Speaker 4: so far doesn't give.
• 29:59
  Speaker 3: Us yeah it's a great question so calcium scoring to
• 30:04
  Speaker 3: move on from that we kind of understand right that
• 30:07
  Speaker 3: it doesn't pick up the early non-calcified plaque it picks
• 30:10
  Speaker 3: up the calcified plaque like it did in your case right.
• 30:13
  Speaker 4: And so james does everybody who has plaque the non-calcified
• 30:19
  Speaker 4: does it eventually calcify or is that a slower process
• 30:24
  Speaker 4: in some than others or is it just It's that
• 30:27
  Speaker 4: early disease, and it can be vulnerable, and then bang,
• 30:29
  Speaker 4: you just get unlucky.
• 30:31
  Speaker 3: Yeah, we're following the science on this. So where this
• 30:35
  Speaker 3: is coming from, right, and it's actually helpful to kind
• 30:37
  Speaker 3: of understand why we're here at this point with advanced imaging,
• 30:43
  Speaker 3: is the first time that CT was placed into guidelines,
• 30:47
  Speaker 3: population level, was in the NICE guidelines, right? I don't
• 30:52
  Speaker 3: know if you're familiar with those, but that's the UK, and...
• 30:56
  Speaker 3: That was when we placed in and the frontline for
• 31:00
  Speaker 3: that was calcium scoring, right? So you kind of started
• 31:04
  Speaker 3: off and this is population-based. So you're looking at almost
• 31:07
  Speaker 3: the entire rate of 2 million people. So the cohort's huge.
• 31:12
  Speaker 3: And what we saw was that first test, if you
• 31:17
  Speaker 3: were considered low risk, you would get a calcium score.
• 31:19
  Speaker 3: And if you were zero, you were considered, okay, you're fine.
• 31:23
  Speaker 3: You can move along. You're not coronary artery disease. But
• 31:26
  Speaker 3: what we started to find was that of those patients
• 31:32
  Speaker 3: that left, right, almost 10, maybe even some studies you
• 31:37
  Speaker 3: look at, maybe upwards of 15, but it's in between that,
• 31:40
  Speaker 3: had significant disease. And not only significant disease, but 2%
• 31:44
  Speaker 3: of them had MACE, major adverse cardiovascular events. So quickly,
• 31:50
  Speaker 3: we restructured that. those guidelines moved to calcium scoring out.
• 31:55
  Speaker 3: So it should tell you something, right? It's not good enough, right?
• 32:00
  Speaker 3: And we started doing CTA, which I'm going to talk
• 32:04
  Speaker 3: about as a frontline test. And we started to get
• 32:07
  Speaker 3: really large scale, robust data and, and just generalize scientific
• 32:15
  Speaker 3: information from it.
• 32:16
  Speaker 1: So what that is, Sorry, James, just before you do that,
• 32:21
  Speaker 1: that's a great example of why these population-based studies need
• 32:27
  Speaker 1: to be done and the information that we can get
• 32:30
  Speaker 1: for them.
• 32:30
  Speaker 4: Because the thinking at the time was this calcium score
• 32:33
  Speaker 4: is excellent.
• 32:34
  Speaker 2: Let's do it on everybody. And, you know, it'll be really,
• 32:38
  Speaker 2: really effective.
• 32:38
  Speaker 4: And it was only because of that study and following
• 32:41
  Speaker 4: those people in the different cohorts they actually find, ah,
• 32:46
  Speaker 4: maybe it's not so good after all, right?
• 32:48
  Speaker 2: And that's what science does. Science evolves, right?
• 32:51
  Speaker 3: Absolutely. You have to follow the science. And what you're
• 32:54
  Speaker 3: mentioning is very important. The statistical data only comes in
• 32:58
  Speaker 3: with large-scale cohorts. And if you're going to do prognostic data,
• 33:06
  Speaker 3: diagnoses on patients, you really want strong data. those double
• 33:13
  Speaker 3: blind multi-center trials to come in showing you that the
• 33:17
  Speaker 3: statistics support mathematically what you're thinking. So in this case,
• 33:24
  Speaker 3: they moved to contrast enhanced CT as the frontline test.
• 33:32
  Speaker 3: And that's when we started understanding the direct visualization of
• 33:39
  Speaker 3: coronary artery disease plaque. we started understanding how powerful looking
• 33:45
  Speaker 3: at that mixed plaque compositions, whether it's how much of
• 33:53
  Speaker 3: it is non-calcified, how much of it is high risk,
• 33:56
  Speaker 3: how much of it is calcified, what's the total plaque burden.
• 34:01
  Speaker 3: So all of this data started to come in and
• 34:04
  Speaker 3: so much more powerful, right. Then our, population-based medicine? Because
• 34:11
  Speaker 3: now we're looking at individualized, that person specifically has coronary
• 34:19
  Speaker 3: artery disease, and then to get at the treatments earlier.
• 34:22
  Speaker 3: Because even though prevention just seems smarter, we also have
• 34:26
  Speaker 3: to follow that science. So is this helpful in the
• 34:29
  Speaker 3: downstream effects of treatment and outcomes?
• 34:35
  Speaker 4: And does it prevent more deaths than what we currently have, right?
• 34:39
  Speaker 4: And so tell people what is happening with that contrast.
• 34:44
  Speaker 2: Is that where they inject the contrast?
• 34:46
  Speaker 4: So you go into the CT scanner, then you come
• 34:49
  Speaker 4: out and then they inject the contrast and you go
• 34:51
  Speaker 4: back in and they look again, which I had done
• 34:54
  Speaker 4: a couple of weeks ago, actually, as a bit of
• 34:56
  Speaker 4: a follow-up.
• 34:56
  Speaker 2: Post-surgery, right?
• 34:58
  Speaker 3: Oh, good. So you know. Yeah.
• 35:01
  Speaker 2: So talk our listeners through.
• 35:02
  Speaker 4: what's happening there and why the contrast is particularly good
• 35:07
  Speaker 4: for you sitting on the other side, interpreting the results.
• 35:11
  Speaker 3: Yeah, it's a great question. So that's a point I
• 35:13
  Speaker 3: want to make, right? Is calcium scoring is so easy.
• 35:17
  Speaker 3: I call it the touchless car wash. You just go in,
• 35:21
  Speaker 3: you lay down on the table and the scanner does
• 35:26
  Speaker 3: its thing and you're all done. CT is a little
• 35:28
  Speaker 3: more involved, right? If you're going to get calcium, really
• 35:32
  Speaker 3: good images of those coronary arteries. You do have to
• 35:36
  Speaker 3: optimize the heart rate, slow it down, make it as
• 35:39
  Speaker 3: rhythmic as you can, because you're going to be taking
• 35:42
  Speaker 3: images of this thing, just like an action sport, right?
• 35:47
  Speaker 4: Uh, is that why, sorry, James, is that why they
• 35:49
  Speaker 4: get you to breathe and hold your breath and stuff
• 35:51
  Speaker 4: like that as they're going through this?
• 35:53
  Speaker 2: Okay.
• 35:54
  Speaker 3: Uh, there's a lot of, I could get into that
• 35:56
  Speaker 3: cause I'm radiology. There's a lot of optimization to it
• 35:59
  Speaker 3: and I love talking about it. Um, But yes, make
• 36:04
  Speaker 3: no mistake, these heart rates are moving at 70 beats
• 36:11
  Speaker 3: per minute, if not more. Some people are 80 and
• 36:14
  Speaker 3: even above, and irregular sometimes. The contraction of the heart
• 36:17
  Speaker 3: isn't always smooth. That's a contracting muscle. And you put
• 36:22
  Speaker 3: on an EKG lead to let the computer communicate with
• 36:31
  Speaker 3: the patient contractions, right? And then you'll give IV contrast
• 36:37
  Speaker 3: and time it where you get optimization of the coronary
• 36:40
  Speaker 3: arteries and as still of a beating part, right? Usually
• 36:46
  Speaker 3: end diastole right before it contracts again. And you image
• 36:50
  Speaker 3: during that cycle and you get these images. And once
• 36:55
  Speaker 3: you get really good images, and this is a point
• 36:57
  Speaker 3: I should bring up, CT can become so powerful. And
• 37:01
  Speaker 3: that's a test I'm kind of talking about. We're not
• 37:03
  Speaker 3: talking MR yet, if we will. But CT is so
• 37:08
  Speaker 3: powerful because it can look at those tiny coronary arteries,
• 37:12
  Speaker 3: millimeters in diameter. And that's where the spatial resolution of
• 37:16
  Speaker 3: CT becomes so powerful. It's a little challenged with the
• 37:20
  Speaker 3: temporal resolution, depending on the scanner you're on. And getting
• 37:23
  Speaker 3: an action image of the heart is not simple. So
• 37:28
  Speaker 3: you want to kind of slow the heart rate down,
• 37:31
  Speaker 3: calm yourself, breathing, slow breaths, hold your breath, settle some
• 37:35
  Speaker 3: heart even more. And then you get these really nice images.
• 37:38
  Speaker 3: But once you get those, the accuracy is unparalleled in
• 37:44
  Speaker 3: many of the imaging that I do in radiology. So accurate, right?
• 37:48
  Speaker 3: That means reproducible between different readers and different centers. And
• 37:54
  Speaker 3: I will bring into that not just readers, but A.I.
• 37:57
  Speaker 2: AI, yeah. Obviously, that's what came in there.
• 38:01
  Speaker 3: That's why it's becoming so powerful with AI is it's
• 38:05
  Speaker 3: so reproducible. Once you get that pure scan, 360 degrees
• 38:11
  Speaker 3: of volume scan of the heart, that data is yours forever, right?
• 38:17
  Speaker 3: It's images, but then AI and these algorithms and these.
• 38:25
  Speaker 3: Extra medicine, I call them sometimes, can then start to
• 38:29
  Speaker 3: take a look at those images and curate all of
• 38:34
  Speaker 3: that data. Because at the fundamental level, we're talking pure physics.
• 38:38
  Speaker 3: This is photons. Electromagnetic radiation, like photons that you're collecting
• 38:46
  Speaker 3: at the basic, basic level. And once you have that
• 38:51
  Speaker 3: blended into computerized data, You can take that and curate
• 38:54
  Speaker 3: in so many ways. And that's how it's becoming so
• 38:57
  Speaker 3: powerful in this space is we're able to really take
• 39:00
  Speaker 3: a look at all the different levels of data off
• 39:07
  Speaker 3: of that CT scanner for the AI algorithms.
• 39:11
  Speaker 4: And if lots of people weren't studying physics at school,
• 39:13
  Speaker 4: we wouldn't have all this shit, right?
• 39:15
  Speaker 2: This is physics in the real world, isn't it?
• 39:19
  Speaker 3: Yeah. Yeah. Yeah, so I like to say to people,
• 39:21
  Speaker 3: you know, we talk about AI and medicine, but in radiology,
• 39:24
  Speaker 3: we've always had algorithms and AI from almost the get-go.
• 39:31
  Speaker 3: That's what those images coming off the detectors are. You're
• 39:36
  Speaker 3: collecting photons, and then you're changing those sinusoidal data sets
• 39:43
  Speaker 3: into visual representations.
• 39:47
  Speaker 4: Now, a cardiologist once told me he described the artery
• 39:52
  Speaker 4: as a bit like a donut, right? And so the
• 39:56
  Speaker 4: center of the donut, that's where the blood runs through.
• 39:59
  Speaker 4: And that's typically where we see on some of these tests,
• 40:03
  Speaker 4: we see the plaque on the inside of the donut
• 40:05
  Speaker 4: and the calcium lays over the top. But he said
• 40:09
  Speaker 4: often the plaque and the really risky plaque.
• 40:11
  Speaker 2: Is in the actual donut, right?
• 40:16
  Speaker 4: Can you explain to our listeners what he was meaning
• 40:20
  Speaker 4: by that? And does a CT let you see inside
• 40:25
  Speaker 4: the donut itself rather than in the whole of the donut,
• 40:29
  Speaker 4: just in the whole of the donut, if you get
• 40:31
  Speaker 4: what I'm saying?
• 40:32
  Speaker 3: Great question. And the answer is yes and yes. CT
• 40:36
  Speaker 3: not only sees inside with the contrast, like you were
• 40:38
  Speaker 3: having me explain a little bit, that's what the contrast
• 40:40
  Speaker 3: is needed for, and outside. It sees the whole thing.
• 40:45
  Speaker 3: it's so powerful that way. And I'd like to blend
• 40:47
  Speaker 3: this in because one of the things I'm trying to
• 40:49
  Speaker 3: do is blend different worlds here where I'm blending what
• 40:54
  Speaker 3: we're talking about, academic cardiology and medicine, scientific medicine into
• 41:00
  Speaker 3: an earlier preventative space and then diagram it with health
• 41:06
  Speaker 3: and fitness and diet and exercise opens up that space.
• 41:12
  Speaker 3: Because what I want to unfold a little bit is yes,
• 41:17
  Speaker 3: those little tubes are basically little tubes, tiny six millimeters
• 41:21
  Speaker 3: or so in diameter and tapering quickly to feed your
• 41:24
  Speaker 3: heart muscle. And I want people or your, your listeners
• 41:27
  Speaker 3: to understand at the basic level, your heart, and I
• 41:32
  Speaker 3: can unfold it as a little more scientific than this,
• 41:34
  Speaker 3: but it's a pump, right? And it's pumping oxygen and
• 41:38
  Speaker 3: nutrients all over your body from your tippy head to
• 41:43
  Speaker 3: your tippy toe. You need oxygen and nutrients, and your
• 41:49
  Speaker 3: only way to get it all over your body is
• 41:52
  Speaker 3: by your heart pumping it around. It has to be
• 41:55
  Speaker 3: a healthy heart. It's a muscle, right? So that muscle
• 42:00
  Speaker 3: only gets its oxygen and nutrients from three tiny little
• 42:04
  Speaker 3: coronary arteries that come off your aortic root and feed
• 42:09
  Speaker 3: that muscle. And I'd like to explain it's even a
• 42:12
  Speaker 3: little more tight than that because even though I said three,
• 42:16
  Speaker 3: the right-sided one only feeds that main muscle pump in
• 42:21
  Speaker 3: its most distal aspect or the terminus of it. And
• 42:27
  Speaker 3: the left one comes off as one and then splits
• 42:30
  Speaker 3: into two.
• 42:31
  Speaker 2: Right, okay.
• 42:33
  Speaker 3: Important vessels and they're very small and delicate, right? So
• 42:37
  Speaker 3: they're your only way to get oxygen to your muscle.
• 42:41
  Speaker 3: So once they start to get clogged up, just like
• 42:44
  Speaker 3: a tube, right? They start to distribute less oxygen. One,
• 42:52
  Speaker 3: the coronary arteries to your heart muscle, and then secondarily
• 42:55
  Speaker 3: your heart muscle to the rest of your body.
• 42:57
  Speaker 4: Yeah.
• 42:59
  Speaker 3: Oxygen all the way out, right? You're, you're in health
• 43:01
  Speaker 3: and fitness. So how do you get them out to
• 43:04
  Speaker 3: those tendons? And, you know, so distally, that has to
• 43:09
  Speaker 3: be a good, strong, healthy pump.
• 43:14
  Speaker 4: And case in point, James, is that when people have
• 43:17
  Speaker 4: advanced diabetes, they can get gangrene in their feet and
• 43:22
  Speaker 4: their feet, basically the flesh will start to rot. And
• 43:26
  Speaker 4: that's why they have to have their feet amputated. And
• 43:29
  Speaker 4: that's because the tiny little capillaries that deliver that blood
• 43:34
  Speaker 4: nutrient and oxygen, they get blocked up first before the
• 43:38
  Speaker 4: major ones do, right? And that's what you see manifested
• 43:42
  Speaker 4: in diabetes and amputated feet. And probably, is that to
• 43:46
  Speaker 4: do with the eye as well, or is that a
• 43:48
  Speaker 4: different thing?
• 43:49
  Speaker 3: It's all of them. Diabetes is a tough disease and
• 43:52
  Speaker 3: diagnosis because you're right, it's going after your small arteries
• 43:57
  Speaker 3: and the delicate distal arteries. just like in the coronary arteries, right?
• 44:03
  Speaker 3: And that's why I want people, you only get one
• 44:06
  Speaker 3: show at your three, or like I said, really like
• 44:10
  Speaker 3: one or two coronary arteries. And if they get clogged up,
• 44:15
  Speaker 3: you know, the other treatments aren't perfect. They're not solutions, stenting, bypassing.
• 44:22
  Speaker 3: And people don't realize that, and that's why this preventative
• 44:27
  Speaker 3: space is becoming so important Right. That if you see it,
• 44:32
  Speaker 3: personalize it and do something about it early when you're younger. Right. Remember,
• 44:38
  Speaker 3: first symptom is usually 50 years old. This is the
• 44:41
  Speaker 3: busier time of your life. Right. You're you're raising a family.
• 44:45
  Speaker 3: You're starting a profession. You're usually putting yourself to the
• 44:49
  Speaker 3: side a little bit at those times. And this is
• 44:51
  Speaker 3: the time I want people to be the most cognizant.
• 44:56
  Speaker 3: of cardiac or coronary artery disease, have a heads up, right?
• 45:01
  Speaker 3: That this is significantly important. Number one, public health epidemic.
• 45:06
  Speaker 3: And you can keep your coronary arteries as clean as
• 45:10
  Speaker 3: you can through one, what I call pre-medicine medicine, right?
• 45:17
  Speaker 3: And then are also powerful and increasingly quiver of drugs, right? right?
• 45:25
  Speaker 3: We're getting so many drugs, but often you don't want to, right?
• 45:29
  Speaker 3: And most people, including me, you want to optimize the
• 45:32
  Speaker 3: pre-medical stuff first. So this is the space where we
• 45:35
  Speaker 3: are really getting into preventative medicine.
• 45:40
  Speaker 4: Yeah.
• 45:40
  Speaker 3: Yeah.
• 45:41
  Speaker 4: And, and, and a big chunk of that pre-medicine is lifestyle, right? That's,
• 45:46
  Speaker 4: that's how you prevent it in the first place.
• 45:49
  Speaker 3: So most cardiologists or most family physician, most, physicians are
• 45:56
  Speaker 3: still getting this information. So it's still almost a secondary
• 46:02
  Speaker 3: recommendation for diet and lifestyle, right? Uh, it's a secondary one,
• 46:08
  Speaker 3: but it's, I do believe it'll become more of a forefront, uh,
• 46:12
  Speaker 3: because these earlier tests, um, are giving us power in
• 46:19
  Speaker 3: that earlier preventative space.
• 46:23
  Speaker 4: Yeah. Um, It's interesting you talk about the pre-medicine or
• 46:28
  Speaker 4: preventative stuff, particularly the lifestyle stuff. You know, when we
• 46:32
  Speaker 4: think about exercise, just a slight tangent here, you know,
• 46:36
  Speaker 4: exercise and mental health, we see that when you look
• 46:39
  Speaker 4: at all the interventions for mental health, exercise beats medication
• 46:43
  Speaker 4: hands down every time, right? And I say to people,
• 46:47
  Speaker 4: and particularly when I show them the data, I say,
• 46:50
  Speaker 4: what is very clear here is that exercise is is
• 46:54
  Speaker 4: an antidepressant. But what I also say to people, there's
• 46:57
  Speaker 4: not a lot of people talk about this.
• 46:59
  Speaker 2: Is being inactive is an active depressant.
• 47:04
  Speaker 4: And I think the same thing here would apply in
• 47:08
  Speaker 4: terms of heart disease, that we know that yes, exercise
• 47:12
  Speaker 4: can be preventative, but if you're sedentary, it is an
• 47:16
  Speaker 4: active agent in the development of coronary artery disease. It's
• 47:21
  Speaker 4: not like hey, if I exercise, it's good for me.
• 47:25
  Speaker 2: And if I don't exercise, I'm neutral. It's like, if
• 47:28
  Speaker 2: you're not exercising, you're not eating well, you're not sleeping well, you.
• 47:32
  Speaker 4: Are introducing active agents into the development of the cardiovascular disease.
• 47:38
  Speaker 3: I love that you're saying it. You and I are
• 47:40
  Speaker 3: so aligned this way. It's why I was excited to
• 47:42
  Speaker 3: talk to you today. I believe we are now bringing
• 47:46
  Speaker 3: these two seemingly different or previously different farther apart worlds together.
• 47:54
  Speaker 3: I think, I think if you look right, I say too,
• 47:58
  Speaker 3: I have these, we all have our clever catchphrase, but you,
• 48:01
  Speaker 3: you have about 360 joints in your body. You're an
• 48:05
  Speaker 3: action figure. You were meant to move and exercise. I'd
• 48:11
  Speaker 3: even like it to almost be called something different because
• 48:14
  Speaker 3: I don't want it to be seen as a workout
• 48:17
  Speaker 3: or an exercise. I want this to be a human thing.
• 48:20
  Speaker 3: You were meant to move. It's not always easy. However,
• 48:25
  Speaker 3: your heart's a pump. And like I said, even at
• 48:28
  Speaker 3: the most basic level, I want to bring those worlds
• 48:30
  Speaker 3: together where, yes, you and I are extremely aligned. I've
• 48:33
  Speaker 3: heard you talk many times on these topics. They're extremely
• 48:39
  Speaker 3: important pre-medicine medicine. But in the context of the heart,
• 48:43
  Speaker 3: it's a muscle. It's literally a muscle. And it's pumping
• 48:47
  Speaker 3: everything you need, oxygen, around your body. And you need
• 48:51
  Speaker 3: that going on. And the only way to keep that
• 48:55
  Speaker 3: happening is cardiovascular health.
• 48:58
  Speaker 4: Yeah.
• 48:59
  Speaker 5: Yeah.
• 49:00
  Speaker 4: And there's, it's really interesting that the, that I like
• 49:07
  Speaker 4: that whole idea of the action figure that we have
• 49:11
  Speaker 4: 360 joints and we have 600 odd muscles, right? Yeah.
• 49:16
  Speaker 4: We are, and I have to say this, our biology is,
• 49:20
  Speaker 4: is built on physical activity. And I think, James, the
• 49:25
  Speaker 4: biggest wow factor that I get in.
• 49:28
  Speaker 2: Terms of exercise and particularly.
• 49:31
  Speaker 4: The heart is telling people about the Dallas Bedrest and
• 49:35
  Speaker 4: Retraining Study. that was done, I think it was in
• 49:39
  Speaker 4: the 1960s originally, when they took four young men and
• 49:43
  Speaker 4: they put them in three weeks of complete bed rest,
• 49:47
  Speaker 4: where they just.
• 49:48
  Speaker 2: Had minimal movement.
• 49:50
  Speaker 4: They looked at their hearts before and afterwards, and they
• 49:54
  Speaker 4: found that, this is the work of Benjamin Levine, they
• 49:57
  Speaker 4: found that three weeks of bed rest aged the.
• 50:00
  Speaker 2: Heart by 30 years.
• 50:02
  Speaker 3: Wow.
• 50:04
  Speaker 2: And people's jaws hit the floor. And then they retrained
• 50:08
  Speaker 2: these guys.
• 50:09
  Speaker 4: And they actually got their hearts to better than it
• 50:13
  Speaker 4: was beforehand with six or nine months of training. But
• 50:16
  Speaker 4: the beauty of this study is they followed them up.
• 50:19
  Speaker 4: And 40 years later, found these men who were now
• 50:23
  Speaker 4: in their 50s, 35, 40 years later, they were in
• 50:26
  Speaker 4: their 50s. And they went and they brought them in and.
• 50:28
  Speaker 2: They imaged their hearts. And their hearts were healthier.
• 50:32
  Speaker 4: In their 50s than they were in their 20s after
• 50:35
  Speaker 4: three weeks of bed rest.
• 50:37
  Speaker 2: And that to me is just bonkers. But there's a
• 50:40
  Speaker 2: really nice line of research that's come out.
• 50:43
  Speaker 4: I can't remember where the university is that Benjamin Levine works,
• 50:46
  Speaker 4: but they then retrained these guys again in their 50s
• 50:51
  Speaker 4: and made their hearts younger by about 20 years. And
• 50:54
  Speaker 4: then they found a different cohort in their 60s and
• 50:57
  Speaker 4: did the same training program. And they got nowhere near
• 51:00
  Speaker 4: the benefit that they did when they were in their 60s.
• 51:04
  Speaker 4: So they were saying, do not wait.
• 51:07
  Speaker 2: Until your 60s.
• 51:08
  Speaker 4: And I work with people all the time, and I'm
• 51:10
  Speaker 4: sure you see them, James, who are very career driven.
• 51:14
  Speaker 4: They're very successful and they know they're a bit out
• 51:17
  Speaker 4: of shape, but they go.
• 51:18
  Speaker 2: When I retire, that's when I'll get fit. And often
• 51:23
  Speaker 2: they don't see retirement. Right.
• 51:25
  Speaker 3: It's so hard. You know, just for statistics, we see
• 51:29
  Speaker 3: that in space medicine, right, where you take away gravity and,
• 51:33
  Speaker 3: and a lot of these cardiovascular and musculature, uh, are challenged.
• 51:37
  Speaker 3: So it seems common sense again. Uh, but. But it's
• 51:42
  Speaker 3: not that common.
• 51:43
  Speaker 2: No, that's the thing. Yeah.
• 51:45
  Speaker 3: Most people. So that's the thing. And I, that's why
• 51:48
  Speaker 3: I'm excited to talk with you. Like some of these
• 51:51
  Speaker 3: things that I often don't get into this space. Uh,
• 51:55
  Speaker 3: where it's difficult, right? If you're a, and I know
• 51:59
  Speaker 3: some of your demographics with listeners, if you're working eight
• 52:02
  Speaker 3: hour weeks, I mean, listen, I'm type A, you know,
• 52:04
  Speaker 3: and I work all the time, but you have to
• 52:07
  Speaker 3: find space for yourself. And it's what the younger generation
• 52:11
  Speaker 3: calls non-negotiable, right? I'm Gen X, so I have a
• 52:14
  Speaker 3: little different ways of phrasing things, but non-negotiable. And it's
• 52:19
  Speaker 3: very difficult. Listen, there's always something challenging it. You're your
• 52:25
  Speaker 3: job or your other challenges. Wouldn't mind if you know,
• 52:31
  Speaker 3: you know, worked all the time, but finding space for yourself.
• 52:35
  Speaker 3: And I'm not going to unwind that a little bit here,
• 52:37
  Speaker 3: but you really have to get into a space. And
• 52:40
  Speaker 3: I've heard you talk about it where you're eating, right?
• 52:43
  Speaker 3: You're watching what you eat, you're exercising and you're feeling good.
• 52:47
  Speaker 3: And that, and that's a loop and the other loop
• 52:50
  Speaker 3: of not eating right. feeling not right and not exercising
• 52:54
  Speaker 3: is a loop and they do not cross easily. So
• 52:57
  Speaker 3: find something in your life that works for you. And
• 53:01
  Speaker 3: I blend all of them. I think you heard me
• 53:05
  Speaker 3: kind of talk about a human movement, whether it's weight training, stretching, yoga, Pilates,
• 53:11
  Speaker 3: you're going to, I like to blend them all together
• 53:14
  Speaker 3: because you're going to find a place where it works
• 53:16
  Speaker 3: for you and you can stick to it because consistency is,
• 53:20
  Speaker 3: is the only thing that works in this space in
• 53:23
  Speaker 3: the pre-medicine medicine. Yeah.
• 53:26
  Speaker 4: And I think that's a really good point about people,
• 53:31
  Speaker 4: you know, the most important thing around exercise is to
• 53:33
  Speaker 4: find something you enjoy. But I would also say there
• 53:37
  Speaker 4: was a very recent research paper that was released where
• 53:42
  Speaker 4: they had been following this cohort of people in the
• 53:45
  Speaker 4: UK biobank for 20 years, and they had been worrying
• 53:48
  Speaker 4: physical activity measurement data. And they then were able to
• 53:54
  Speaker 4: actually quantify for the first time based on data, the benefits,
• 54:01
  Speaker 4: relative benefits of moderate, vigorous and light physical activity. And
• 54:05
  Speaker 4: what they found in this cohort, because obviously a bunch
• 54:09
  Speaker 4: of them died, a bunch of them didn't, and they
• 54:10
  Speaker 4: actually had real data of how much they moved and
• 54:13
  Speaker 4: what intensity. They found that the prevailing thinking for 30
• 54:17
  Speaker 4: years is that one minute of vigorous is worth two
• 54:19
  Speaker 4: minutes of moderate.
• 54:21
  Speaker 2: They found in this cohort, one minute of vigorous was.
• 54:24
  Speaker 4: Worth between five and nine and a half minutes of
• 54:27
  Speaker 4: moderate in terms of disease protection. And they looked at
• 54:31
  Speaker 4: cardiovascular disease and MACE.
• 54:34
  Speaker 2: And they looked at all cause mortality. They looked at cancer.
• 54:37
  Speaker 2: They looked at diabetes.
• 54:38
  Speaker 4: And they found that one minute of vigorous was worth
• 54:41
  Speaker 4: between 52 and 170 minutes.
• 54:44
  Speaker 2: Of light physical activity.
• 54:46
  Speaker 4: So for me, it is you've just got to get
• 54:51
  Speaker 4: into those higher cardiovascular zones where you're out of breath
• 54:55
  Speaker 4: deliberately because that is what drives the adaptations and what
• 55:00
  Speaker 4: makes your heart bloody stronger. Not walking is not going
• 55:04
  Speaker 4: to cut it anywhere near as much as the vigorous.
• 55:07
  Speaker 3: Stuff, right? You know, you and I are aligned there too.
• 55:10
  Speaker 3: I'm in medicine, medicine. So I, and I've heard you
• 55:13
  Speaker 3: say this before, any movement I'm happy with and I'm
• 55:16
  Speaker 3: moving the needle. So I know on a bell curve
• 55:18
  Speaker 3: distribution of humans, I talk to some will just never
• 55:22
  Speaker 3: get what I'm talking about. Some don't need me at all,
• 55:25
  Speaker 3: but it's that bulk in the middle that I'd like
• 55:27
  Speaker 3: to move the needle on. And you are absolutely right.
• 55:31
  Speaker 3: Once I have the moving, I have other catchphrases. I
• 55:34
  Speaker 3: like to say people call it VO2 max. I call
• 55:37
  Speaker 3: it lung burn. If you're getting exercise where your lungs
• 55:40
  Speaker 3: burn a little bit, you're definitely getting oxygen to the
• 55:44
  Speaker 3: deep acinar structures. And if you're really looking for health cardiovascular,
• 55:51
  Speaker 3: it takes those extensions to then pull your own cardiovascular
• 55:57
  Speaker 3: health up to those areas. And I go with the guidelines,
• 56:02
  Speaker 3: so I'm happy with 30 minutes, but really for myself
• 56:05
  Speaker 3: and most people, something of 60 minutes that you're doing
• 56:09
  Speaker 3: or that time to yourself is probably where you need
• 56:12
  Speaker 3: to get to. Uh, because I only find right that
• 56:17
  Speaker 3: during any workout, my time that I'm usually hitting and
• 56:21
  Speaker 3: you can, like you said, you can, they call it
• 56:23
  Speaker 3: biohacking now, but you know, you can quantify this stuff
• 56:26
  Speaker 3: and it's really helpful, but you start to get those
• 56:29
  Speaker 3: burns or the, the, the real healthy zone, two and
• 56:34
  Speaker 3: three stuff within the 40 minute, you know, timeframe.
• 56:37
  Speaker 2: Yeah. Yeah. I love the long burn thing. Um, I'm
• 56:41
  Speaker 2: going to add that to my, we need to lift
• 56:43
  Speaker 2: heavy shit. We need to lift every shit and do
• 56:46
  Speaker 2: lung burn.
• 56:48
  Speaker 3: If you don't know what lung burn is, we have
• 56:51
  Speaker 3: to talk.
• 56:52
  Speaker 2: Yeah, that's right.
• 56:52
  Speaker 4: Exactly. Now let's talk about MRI. I am aware of time,
• 56:58
  Speaker 4: but I do want to talk about MRI because we
• 56:59
  Speaker 4: haven't talked about that. So what does an MRI of
• 57:03
  Speaker 4: the heart give you that you don't see on the
• 57:07
  Speaker 4: CT scan? We've talked about like the CT is kind
• 57:09
  Speaker 4: of like, a 3D model where.
• 57:12
  Speaker 2: You can look inside. It's pretty cool shit, right?
• 57:14
  Speaker 4: But what does MRI give you, a cardiac MRI that
• 57:18
  Speaker 4: a CT doesn't?
• 57:20
  Speaker 3: That's another really good question. And I'll unfold it this way,
• 57:24
  Speaker 3: as I usually tell the residents and even my passions
• 57:27
  Speaker 3: in general, even though I'm bringing CT to the world
• 57:31
  Speaker 3: as a preventative early test for coronary artery disease and
• 57:36
  Speaker 3: number one public health epidemic, MRI is just the most
• 57:39
  Speaker 3: elegant Powerful test out there, especially for cardiac imaging. So
• 57:45
  Speaker 3: once you move beyond the structural and AI applications of
• 57:50
  Speaker 3: coronary artery disease, because that spatial resolution is still so
• 57:54
  Speaker 3: much better with CT, everything else is better with MRI.
• 58:00
  Speaker 3: Temporal resolution. So I can acquire those images in cardiac
• 58:04
  Speaker 3: MRI real time. I don't even need sometimes to slow
• 58:08
  Speaker 3: the heart rate down. The heart rate beating faster lets
• 58:12
  Speaker 3: me acquire the images quicker. So the temporal resolution is
• 58:15
  Speaker 3: just so powerful. And then the imaging itself, it's dealing
• 58:20
  Speaker 3: with electromagnetic radiation differently or electromagnetic ways where we're dealing
• 58:28
  Speaker 3: then with it's a big magnet and we're pulling the
• 58:32
  Speaker 3: protons in the patient's body and changing those to send
• 58:37
  Speaker 3: back electromagnetic waves that we detect. But the contrast.
• 58:43
  Speaker 4: That's such clever shit, isn't it? Sorry to interrupt, but
• 58:47
  Speaker 4: isn't that such clever shit?
• 58:49
  Speaker 2: It really is.
• 58:50
  Speaker 3: Yeah. So all of the... And then talk about tissue...
• 58:55
  Speaker 3: So the contrast then you can do so many different
• 58:59
  Speaker 3: things with and easily. So I can change the tissue
• 59:03
  Speaker 3: characterization on my images so easily. I can look at
• 59:08
  Speaker 3: fluid versus fat versus muscle versus all different structures. And
• 59:15
  Speaker 3: AI is helping in those areas as well, where I
• 59:18
  Speaker 3: can then quantify the tissue characterization. So some of that
• 59:23
  Speaker 3: below the level of coronary arteries or microvasculature we call
• 59:29
  Speaker 3: it the actual issue of the heart. You can look
• 59:33
  Speaker 3: at all of that powerfully. So I can look at
• 59:36
  Speaker 3: structure and function, the function of the heart, you know,
• 59:39
  Speaker 3: and I sometimes refer to MRI or I've been told
• 59:43
  Speaker 3: in training, it's a super echo, right? Echoes ultrasound waves.
• 59:46
  Speaker 3: And it's a nice image, but MRI is just, again,
• 59:49
  Speaker 3: you're getting a volume scan of this, uh, of this
• 59:53
  Speaker 3: heart and for structure function and the, and the contraction,
• 59:58
  Speaker 3: Then you can take a look at the flow through
• 1:00:01
  Speaker 3: the heart separately. 4D flow, all of these vector changes
• 1:00:07
  Speaker 3: in the protons themselves. And then on top of that,
• 1:00:11
  Speaker 3: you can then look at tissue characterization and quantify the
• 1:00:15
  Speaker 3: fibrosis or tissue signal, T1 or T2 in the heart.
• 1:00:21
  Speaker 3: I don't know if that got a little bit out there,
• 1:00:23
  Speaker 3: but the point is you can do so much with MRIs.
• 1:00:27
  Speaker 3: but CT is still more powerful for the spatial resolution.
• 1:00:33
  Speaker 3: MRI is not as good. It's close, but it's not
• 1:00:36
  Speaker 3: as good with the spatial resolution.
• 1:00:38
  Speaker 2: So I'll give you a little anecdote that you'll enjoy.
• 1:00:42
  Speaker 4: After my surgery, I had the Ross procedure for my
• 1:00:46
  Speaker 4: aortic valve.
• 1:00:48
  Speaker 2: Which was traveling along well. And then I felt my
• 1:00:51
  Speaker 2: cardio went backwards, right?
• 1:00:53
  Speaker 4: So got some investigation, ended up seeing a guy called
• 1:00:57
  Speaker 4: Professor Andre Laguerche.
• 1:00:59
  Speaker 2: Who has an MRI machine.
• 1:01:01
  Speaker 4: He's adapted it to have exercise bike pedals at the
• 1:01:05
  Speaker 4: end of the MRI machine. So I did the MRI,
• 1:01:09
  Speaker 4: then did an exercise MRI. So you're pedaling like mad
• 1:01:13
  Speaker 4: and looking at the blood through to the chambers of
• 1:01:16
  Speaker 4: the heart and stuff like that, to your point. But
• 1:01:20
  Speaker 4: he brought me out and said, I found something I
• 1:01:23
  Speaker 4: wasn't expecting.
• 1:01:25
  Speaker 2: Come and see this.
• 1:01:26
  Speaker 4: Showed me the MRI image and a big chunk of
• 1:01:30
  Speaker 4: my left ventricle was not moving. And he said, that
• 1:01:33
  Speaker 4: looks like scar tissue. That is scar tissue. It's fibrotic
• 1:01:37
  Speaker 4: to the point where you talked about the fibrosis. And
• 1:01:40
  Speaker 4: then he said, I think you have cardiac sarcoidosis.
• 1:01:45
  Speaker 2: But anyway, that has now been investigated. I had a
• 1:01:47
  Speaker 2: heart biopsy, came back negative.
• 1:01:49
  Speaker 4: They now think that I've probably had some sort of
• 1:01:53
  Speaker 4: an infarct that may be a one-off.
• 1:01:56
  Speaker 2: But to your point, I was like, well, how do
• 1:01:59
  Speaker 2: I know it's a one-off?
• 1:02:00
  Speaker 4: Because the area that's damaged is fed, I knew was
• 1:02:05
  Speaker 4: fed by the.
• 1:02:05
  Speaker 2: Right coronary artery. So I said, I want to know
• 1:02:08
  Speaker 2: this shit.
• 1:02:09
  Speaker 4: So I spoke to my surgeon, got another CT scan
• 1:02:12
  Speaker 4: to then check the integrity of the.
• 1:02:16
  Speaker 2: Little buttons and things like that.
• 1:02:17
  Speaker 4: So I am the poster boy of all things imaging, right? Yeah,
• 1:02:25
  Speaker 4: if it wasn't for cardiovascular imaging, I'd be dead pretty soon.
• 1:02:28
  Speaker 2: There's no doubt about it.
• 1:02:30
  Speaker 3: You're healthy as an ox now, I could tell.
• 1:02:33
  Speaker 4: But that's the point is that there are those different
• 1:02:37
  Speaker 4: technologies do different things that we just would not have
• 1:02:41
  Speaker 4: had a clue. Like 20 years ago, Nobody would have
• 1:02:45
  Speaker 4: known that, that, um, without this imaging that a, I
• 1:02:49
  Speaker 4: had an issue and then the followup and things like that.
• 1:02:52
  Speaker 3: Right.
• 1:02:53
  Speaker 4: So that's the point is the advances in this stuff.
• 1:02:57
  Speaker 3: Yeah. And, and like I always do in my lectures
• 1:02:59
  Speaker 3: with the students, uh, cause they sometimes fade on me.
• 1:03:02
  Speaker 3: I like to summarize the, you know, the important or
• 1:03:06
  Speaker 3: salient points that we're talking about here. And I want
• 1:03:10
  Speaker 3: people to know how important cardiovascular disease is, right. public health,
• 1:03:16
  Speaker 3: how young it is, right? It's, it's in your starting
• 1:03:19
  Speaker 3: in your thirties and twenties, uh, twenties and thirties, sometimes twenties, thirties, forties,
• 1:03:26
  Speaker 3: and how it can be non calcified can be the
• 1:03:29
  Speaker 3: high risk plaque early. Yeah. Now, again, symptoms matter, right?
• 1:03:33
  Speaker 3: We have to follow the science and the data that
• 1:03:35
  Speaker 3: we have, but there is an opportunity in that, in
• 1:03:39
  Speaker 3: this strength of CTA, like you're talking about looking at
• 1:03:42
  Speaker 3: the coronary arteries for early preventative measures and for getting
• 1:03:50
  Speaker 3: ahead of, right, even medicine in your health optimization.
• 1:03:57
  Speaker 4: And James, is that now happening in the United States
• 1:04:00
  Speaker 4: where people are able to come and have a CT
• 1:04:03
  Speaker 4: scan from a preventative perspective?
• 1:04:07
  Speaker 3: I'm bringing this so early to you. I think it'll
• 1:04:09
  Speaker 3: still be another five years. The message I'm bringing is
• 1:04:14
  Speaker 3: really fresh most physicians don't even know this is going on.
• 1:04:19
  Speaker 3: If you go to most physicians, they'll say, like you
• 1:04:24
  Speaker 3: had your physician, calcium score of zero and you're fine,
• 1:04:28
  Speaker 3: which may be the case, right? You have to understand.
• 1:04:32
  Speaker 3: But the message that this is bringing with the power
• 1:04:37
  Speaker 3: of contrast enhanced cta to look at those coronaries the
• 1:04:42
  Speaker 3: number one killer basically the thing you have to know
• 1:04:46
  Speaker 3: right because if you if you get beyond coronary artery
• 1:04:50
  Speaker 3: disease and the heart attack you know most things i
• 1:04:53
  Speaker 3: mean that's the thing that's going to get most people
• 1:04:57
  Speaker 3: um so then if you have symptoms right it becomes
• 1:05:01
  Speaker 3: so powerful that way too say you have chest pain
• 1:05:04
  Speaker 3: and you go in If you didn't have a CTA,
• 1:05:07
  Speaker 3: you would not know almost the data is almost 100%.
• 1:05:11
  Speaker 3: It approaches 100% negative predictive value, meaning if you have
• 1:05:16
  Speaker 3: a normal coronary CTA, you do not have coronary artery disease.
• 1:05:22
  Speaker 4: That's the moment right there, right? That is the thing.
• 1:05:25
  Speaker 4: Like all of these things, as you talked about, are
• 1:05:28
  Speaker 4: proxies or limited valuations. And clearly, I think, James, some
• 1:05:34
  Speaker 4: people will be going, well, the reason we don't do
• 1:05:36
  Speaker 4: this at a population level is because of the cost.
• 1:05:39
  Speaker 4: But I think the cost of someone with undiagnosed cardiovascular
• 1:05:43
  Speaker 4: disease and then the knock-on effects to other comorbidities that
• 1:05:49
  Speaker 4: then have to be treated in the healthcare system at
• 1:05:53
  Speaker 4: an increasing cost as they age and add in more
• 1:05:56
  Speaker 4: and more comorbidities, like if The preventative stuff, if we
• 1:06:01
  Speaker 4: did that, would pay for itself numerous times over, wouldn't it?
• 1:06:05
  Speaker 3: Yeah, so this is where it's pure science, and I'm
• 1:06:08
  Speaker 3: a scientist. So, you know, we have to have the
• 1:06:12
  Speaker 3: large cohorts, the randomized, controlled studies, if we're going to
• 1:06:16
  Speaker 3: do prognoses and outcomes. You know, we have to follow
• 1:06:20
  Speaker 3: that science. This just makes sense, right? But we have
• 1:06:23
  Speaker 3: to figure out whether that plaque and treating it or
• 1:06:27
  Speaker 3: knowing it really can move the needle on coronary artery disease?
• 1:06:32
  Speaker 3: You suspect yes, but these tests are out there and
• 1:06:37
  Speaker 3: to be asked for, right? This is a conversation with
• 1:06:40
  Speaker 3: your physician at this point, right? It's now in ACC
• 1:06:44
  Speaker 3: AHA guidelines as the class one A test, only class
• 1:06:48
  Speaker 3: one A test, meaning the science behind it and the
• 1:06:53
  Speaker 3: recommendations are the highest level. The only class one A
• 1:06:57
  Speaker 3: test in ACC, AHA, American guidelines, and Europe as well,
• 1:07:02
  Speaker 3: for no known disease and low risk. So if you're
• 1:07:07
  Speaker 3: low risk and you have no known disease, this is
• 1:07:11
  Speaker 3: the test of choice by far. But most people in
• 1:07:15
  Speaker 3: medicine don't even know that yet, right? Wow. Information is
• 1:07:19
  Speaker 3: coming so fast. And the challenges of a physician or
• 1:07:27
  Speaker 3: physician or extender, nurse practitioners, all of these to be
• 1:07:31
  Speaker 3: up to date on the latest pure science and what's
• 1:07:36
  Speaker 3: coming is a challenge, right? So it takes these kinds
• 1:07:40
  Speaker 3: of messages. And I have a symposium I put on
• 1:07:43
  Speaker 3: here in Tampa Bay, Florida of advanced cardiovascular imaging, just
• 1:07:48
  Speaker 3: bringing this message and getting the message out of where
• 1:07:51
  Speaker 3: the science is moving, right? So we're at the leading
• 1:07:54
  Speaker 3: edge of this stuff. but that's why it's so important
• 1:07:58
  Speaker 3: because it impacts so many humans. Number one, public health epidemic.
• 1:08:03
  Speaker 3: This is an opportunity for significant changes, good changes in
• 1:08:12
  Speaker 3: medicine with just death, right? And downstream heart failure. Some
• 1:08:19
  Speaker 3: people don't understand is it's not just the heart attack
• 1:08:21
  Speaker 3: and death, right? But all of that downstream. So when
• 1:08:24
  Speaker 3: you're 60 or 70, and your heart muscle has been
• 1:08:28
  Speaker 3: not getting oxygen and nutrients and is fibrosing or dying,
• 1:08:33
  Speaker 3: you are not having that pump providing oxygen and nutrients
• 1:08:36
  Speaker 3: all over your body.
• 1:08:38
  Speaker 4: And to the point is that's how it affects other organs,
• 1:08:42
  Speaker 4: brain included, because we're now seeing that heart disease significantly,
• 1:08:48
  Speaker 4: if not dramatically, is increasing your risk of Alzheimer's and
• 1:08:50
  Speaker 4: other forms of dementia because the brain's an organ that
• 1:08:53
  Speaker 4: needs bloody oxygen and nutrients like everything else, right? Because
• 1:08:56
  Speaker 4: the heart is the center of all of this stuff, right?
• 1:09:01
  Speaker 4: I mean, I can tell that you're excited about this
• 1:09:06
  Speaker 4: potential for prevention. And I think it's established that people
• 1:09:11
  Speaker 4: can in the States go and get this as a
• 1:09:12
  Speaker 4: preventative test.
• 1:09:13
  Speaker 2: I would imagine I need to look this up to.
• 1:09:16
  Speaker 4: See if they're available in the UK and in Australia,
• 1:09:20
  Speaker 4: because now we're seeing whole body MRIs that people can
• 1:09:23
  Speaker 4: go and pay private companies for. I will actually do
• 1:09:28
  Speaker 4: a look up and see if you can go and
• 1:09:30
  Speaker 4: get a private CT scan without having to jump through
• 1:09:33
  Speaker 4: 17,000 different hoops through the medical system. What are you
• 1:09:38
  Speaker 4: excited about in terms of the future and particularly about
• 1:09:43
  Speaker 4: how AI can help all of this?
• 1:09:46
  Speaker 2: I mean, you've alluded to it a little bit, but
• 1:09:47
  Speaker 2: what do you see on the horizon?
• 1:09:50
  Speaker 3: Yeah, another great question. And one of the reasons I'm
• 1:09:53
  Speaker 3: so excited or passionate is I love it when, or
• 1:09:57
  Speaker 3: I got into medicine to make an impact. And this
• 1:10:00
  Speaker 3: will be the biggest one. This is the number one
• 1:10:04
  Speaker 3: public health epidemic. So if a test, that I do
• 1:10:07
  Speaker 3: and I know a lot about will impact the most humans.
• 1:10:11
  Speaker 3: I want to help lead that conversation to show not
• 1:10:15
  Speaker 3: only what it can do, but to bring in those
• 1:10:19
  Speaker 3: other aspects we talked about of a lifestyle, to place
• 1:10:23
  Speaker 3: it into a full human context. The most exciting stuff
• 1:10:28
  Speaker 3: that's coming, right, and people always love these things, is
• 1:10:33
  Speaker 3: the AI is characterizing all of that CT imaging. So
• 1:10:38
  Speaker 3: I also say this, about a thousand AI algorithms have
• 1:10:42
  Speaker 3: been approved by the FDA since 2025. About 900 are
• 1:10:49
  Speaker 3: in radiology.
• 1:10:50
  Speaker 4: Wow.
• 1:10:52
  Speaker 3: Another 50 are in cardiac. So you can see it's
• 1:10:57
  Speaker 3: basically a bullseye on what I do. But if you
• 1:11:01
  Speaker 3: take all 1,000 of those, only two are reimbursed. And
• 1:11:07
  Speaker 3: that's what I'll get at is basically the two that
• 1:11:09
  Speaker 3: are reimbursed are the AI algorithms for flow quantification, FFRCT,
• 1:11:17
  Speaker 3: on CT imaging. That now blends anatomy with physiology, flow.
• 1:11:23
  Speaker 2: Yeah, yeah.
• 1:11:25
  Speaker 3: CT has always been an anatomy volume scan test, but
• 1:11:29
  Speaker 3: now we're able to curate data off of that to
• 1:11:33
  Speaker 3: quantify flow. So not only can we look at where
• 1:11:37
  Speaker 3: your lesion is in your coronary arteries, but is it
• 1:11:41
  Speaker 3: challenged by flow limitations? What's the flow say through that
• 1:11:47
  Speaker 3: lesion specific disease? And we can quantify the plaque characterization.
• 1:11:53
  Speaker 3: So how much high-risk plaque do you have? How much
• 1:11:56
  Speaker 3: calcified plaque do you have? And from our science, we're
• 1:12:00
  Speaker 3: now getting to the point, what are the outcomes and
• 1:12:04
  Speaker 3: prognoses of these things? Data coming, right? And this is
• 1:12:11
  Speaker 3: very early, although it's in Europe now. Europe has already
• 1:12:15
  Speaker 3: green-lighted the looking at outside of the coronary artery in
• 1:12:21
  Speaker 3: the fat adjacent to the coronary artery. This is called
• 1:12:25
  Speaker 3: fat attenuation index. This is inflammation around the coronary artery.
• 1:12:34
  Speaker 3: So we suspect, right. And it would make sense that
• 1:12:38
  Speaker 3: the coronary artery plaque or disease is coming from, like
• 1:12:43
  Speaker 3: you were alluding to earlier inflammation. So we quantify, the
• 1:12:49
  Speaker 3: inflammation adjacent to the vessel. And does that have downstream
• 1:12:56
  Speaker 3: effects on prognosis and outcomes? That fat outside the vessel
• 1:13:01
  Speaker 3: is a very special kind of fat. It's cardiometabolic. I'm
• 1:13:05
  Speaker 3: sure you've heard this term. This term ties the heart
• 1:13:10
  Speaker 3: and the renals together because they share certain things like
• 1:13:15
  Speaker 3: mRNA together and inflammation and a cardiometabolic picture where that
• 1:13:22
  Speaker 3: coronary artery is also very special because its outer layer
• 1:13:27
  Speaker 3: does not have a layer that all of the other
• 1:13:32
  Speaker 3: arteries in your body have. It's purely communicating with that fat.
• 1:13:39
  Speaker 3: So that outside is able to directly communicate with inflammatory cells.
• 1:13:47
  Speaker 3: And we're looking at, or it's science is showing that
• 1:13:51
  Speaker 3: that is a precursor, right? For this coronary artery disease.
• 1:13:56
  Speaker 3: So really the question is how early can we get?
• 1:13:59
  Speaker 4: Yeah.
• 1:14:00
  Speaker 3: Yeah.
• 1:14:00
  Speaker 2: Yeah. Cool. I like that. That's, that's exciting.
• 1:14:03
  Speaker 4: It, it, I tell you, it must be a pretty
• 1:14:06
  Speaker 4: exciting time to be in the field that you are in.
• 1:14:10
  Speaker 2: I had no.
• 1:14:11
  Speaker 4: Idea just how AI was so leaning towards radiology in
• 1:14:19
  Speaker 4: general and particularly the cardiac stuff. So I think definitely
• 1:14:23
  Speaker 4: the future is pretty bright in terms of cardiovascular disease prevention,
• 1:14:29
  Speaker 4: which I think is much better.
• 1:14:30
  Speaker 2: I think we'd all agree.
• 1:14:31
  Speaker 4: Prevention is it's cheaper it's more effective and it's a
• 1:14:35
  Speaker 4: shitload less painful than tertiary treatment right so james this
• 1:14:39
  Speaker 4: has been absolutely awesome and you have certainly had an
• 1:14:43
  Speaker 4: impact i'm sure on the people listening to here i
• 1:14:46
  Speaker 4: know that i'll have certainly lots of 30 40 and
• 1:14:48
  Speaker 4: 50 or something listeners who hopefully might just go actually
• 1:14:53
  Speaker 4: i need to go and see my doctor and get
• 1:14:54
  Speaker 4: some stuff checked out and and if a handful of
• 1:14:58
  Speaker 4: that of people have done that because of this podcast
• 1:15:01
  Speaker 4: then I tip my hat to you because you're having
• 1:15:03
  Speaker 4: a real impact.
• 1:15:05
  Speaker 2: And I'm sure you're having an impact on lots of
• 1:15:07
  Speaker 2: other areas. Is there any other thing that you would like.
• 1:15:10
  Speaker 4: To leave our listeners with or any question I haven't
• 1:15:13
  Speaker 4: asked you that I should have asked you?
• 1:15:16
  Speaker 3: No, that's a wonderful conversation. I really appreciate you, Paul.
• 1:15:20
  Speaker 3: Thank you.
• 1:15:21
  Speaker 2: Cool. That was bloody awesome. Thanks, Jim.
• 1:15:23
  Speaker 4: Oh, now, where can people go to find out a
• 1:15:26
  Speaker 4: little bit more about you?
• 1:15:28
  Speaker 2: Where should we send them to?
• 1:15:30
  Speaker 3: Yeah, so I have a lot of social media, but
• 1:15:35
  Speaker 3: my LinkedIn is very active. Usually I have a lot
• 1:15:38
  Speaker 3: of stuff there, and I have a company that I'm
• 1:15:42
  Speaker 3: bringing this preventative CT imaging to because I know it's
• 1:15:47
  Speaker 3: going to be, like you're talking about, an access issue, right?
• 1:15:50
  Speaker 3: So that's preventi.ai, and it's just what you said. It's
• 1:15:55
  Speaker 3: access to the early advancements. in cardiovascular, basically it's CT
• 1:16:02
  Speaker 3: imaging of the coronary arteries for the number one public
• 1:16:06
  Speaker 3: health epidemic. But those are mainly my spots. And I
• 1:16:09
  Speaker 3: also put on a symposium in Tampa Bay, Florida for everyone,
• 1:16:14
  Speaker 3: but it's a symposium. So it's geared towards the advanced imaging,
• 1:16:17
  Speaker 3: but I really want primary care and nurse practitioners and
• 1:16:21
  Speaker 3: the early frontline people of heart disease to be there
• 1:16:26
  Speaker 3: to understand where the medicine is going and the lexicon
• 1:16:30
  Speaker 3: of how it's used. And that's a South S W
• 1:16:35
  Speaker 3: F L C I S.com Southwest Florida, cardiovascular imaging symposium.com.
• 1:16:46
  Speaker 2: I see why I see why you've abbreviated that. That
• 1:16:51
  Speaker 2: is awesome.
• 1:16:51
  Speaker 4: We will put all of the links into the podcast
• 1:16:54
  Speaker 4: for people. Um, Thank you for your time because I
• 1:16:56
  Speaker 4: know you're a busy man and I'm not sure what
• 1:17:00
  Speaker 4: time it is over in Florida, but I'm sure it's probably, yeah.
• 1:17:04
  Speaker 4: But so thank you for your time and your knowledge.
• 1:17:08
  Speaker 4: I think you've probably opened up a lot of people's
• 1:17:11
  Speaker 4: eyes and not only individuals, but any healthcare practitioners who
• 1:17:16
  Speaker 4: are listening to this, I think will certainly have had
• 1:17:18
  Speaker 4: their eyes open as well.
• 1:17:19
  Speaker 2: So thank you, mate. You're certainly having an impact.
• 1:17:22
  Speaker 3: You're the best. Thank you.