Heart Attacks are Preventable!

EP224: Knowing What To Eat But Not Eating It—Interview With Sally-Anne Pisk

Welcome to my podcast. I am Doctor Warrick Bishop, and I want to help you to live as well as possible for as long as possible. I’m a practising cardiologist, best-selling author, keynote speaker, and the creator of The Healthy Heart Network. I have over 20 years as a specialist cardiologist and a private practice of over 10,000 patients. Podcast Summary Introduction Dr. Warrick Bishop, a practicing cardiologist and author passionate about patient education in heart health, hosts this episode featuring Sally-Ann Prisk, author and founder of "Eating For You"—an organization dedicated to transforming people's mindset around healthy eating. Together, they explore how emotional conditioning and mindfulness can help people make sustainable, nourishing food choices rather than relying solely on dietary knowledge. Key Takeaways: Most people struggling with eating habits have adequate nutritional knowledge; the real barrier is addressing their beliefs and thoughts about food that prevent lasting change. Food-comfort associations are often formed in childhood through conditioning—for example, receiving sweet treats when hurt or upset creates a lifelong link between discomfort and certain foods. The "Eating For You" approach is based on mindfulness practice, focusing on creating awareness and making conscious choices rather than forming restrictive new habits. Dysfunctional eating patterns can be inherited through behavioral modeling from family members rather than genetics, as children unconsciously adopt their parents' coping mechanisms with food and stress. Mindfulness acts as a "circuit breaker" that creates a pause between emotional triggers and automatic responses, allowing people to question whether they truly need food or something else. The intention of mindfulness practice is not to stay calm all day, but to develop awareness of when the mind has drifted and to quickly recenter and refocus. Daily meditation practice serves as a training ground for mindfulness, helping people learn to focus on one thing before applying the skill to food choices and emotional awareness. Alcohol and cigarette use often cluster with dysfunctional eating patterns as parallel coping mechanisms, requiring the same mindful awareness approach for behavioral change. Sally-Ann's personal experience with grief-related comfort eating, despite her dietitian training and extensive nutritional knowledge, demonstrated that education alone cannot override deeply ingrained emotional eating patterns. Women often experience key health markers during major life transitions like childbirth, menopause, and parenthood, which is why Sally-Ann's work predominantly focuses on women's unique lifestyle and biological experiences. Read more

EP223: Cholesterol Therapy in 2022

Welcome to my podcast. I am Doctor Warrick Bishop, and I want to help you to live as well as possible for as long as possible. I’m a practising cardiologist, best-selling author, keynote speaker, and the creator of The Healthy Heart Network. I have over 20 years as a specialist cardiologist and a private practice of over 10,000 patients. Podcast Summary Dr. Warrick Bishop is a practicing cardiologist and author dedicated to educating patients about heart health. In this episode, he provides a comprehensive update on cholesterol therapy in 2022, addressing the confusion surrounding cholesterol management and discussing current and emerging treatment options. The episode emphasizes that while cholesterol lowering is clearly beneficial for high-risk patients with existing plaque buildup, there remains reasonable debate about preventative treatment in otherwise healthy individuals. Key Takeaways: For high-risk patients who have experienced a heart attack or stroke, lowering cholesterol definitively reduces future cardiovascular risk, and lower cholesterol levels show no clear threshold of being "too low." Statin side effects, particularly muscle aches and pains, occur in 5-15% of patients and are dose-related, meaning higher doses carry greater risk of side effects. Ezetimibe is an underutilized, generic, and affordable medication that works synergistically with statins by binding cholesterol in the gut, providing better cholesterol reduction than higher-dose statin monotherapy. PCSK9 inhibitor monoclonal antibodies (injected fortnightly or monthly) can reduce LDL cholesterol by up to 60% through a different mechanism than statins, offering powerful cholesterol control for high-risk patients. Inclicerene, an mRNA interference drug targeting PCSK9, is nearing completion of clinical trials and offers approximately six months of sustained LDL reduction from a single injection—similar conceptually to a vaccination against heart disease. Bempedoic acid is an emerging therapy that works upstream of statins via a liver-specific pathway, potentially offering an alternative for patients experiencing statin muscle intolerance without affecting muscle tissue. Gene-editing RNA therapy and other novel agents like Evanacumab (angiopoietin-like-3 inhibitor) are in development and represent an exciting future for cholesterol management, with primate studies showing potential for lifelong cholesterol reduction. The broader challenge is that many high-risk patients are not currently meeting cholesterol targets despite available medications, indicating a gap between current treatment options and their actual utilization in clinical practice. Read more

EP222: A Fishy Tail of Confusion

Welcome to my podcast. I am Doctor Warrick Bishop, and I want to help you to live as well as possible for as long as possible. I’m a practising cardiologist, best-selling author, keynote speaker, and the creator of The Healthy Heart Network. I have over 20 years as a specialist cardiologist and a private practice of over 10,000 patients. Podcast Summary Dr. Warrick Bishop, a practicing cardiologist and author, hosts this educational podcast dedicated to helping patients understand heart health. In this episode, Dr. Bishop explores the science behind fish oil supplementation, examining the evidence for its cardiovascular benefits and clarifying the roles of its two main components: EPA (eicosapentaeic acid) and DHA (docosahexaeonic acid). The discussion reveals surprising findings about which forms of fish oil are actually effective and introduces related treatment strategies for high-risk patients. Key Takeaways: Fish oil contains two main active components—EPA and DHA—that are commonly listed on supplement labels, but the evidence for their individual and combined benefits remains unclear. Low-dose fish oil supplements (like standard fish oil tablets) show minimal to no outcome benefit for intermediate-risk individuals, as demonstrated by recent studies. Purified EPA at pharmacological doses (approximately 4 grams daily) has demonstrated dramatic risk reduction in high-risk individuals with elevated triglycerides, as proven by the REDUCE-IT and JELIS trials. Combinations of EPA and DHA have not shown clear outcome benefits in clinical trials, suggesting that mixing the two compounds may negate EPA's beneficial effects, though the mechanism is unknown. Raised triglyceride levels may be a marker for underlying insulin resistance and inflammatory processes, making triglyceride management a key health priority. Phenofibrate (lipidil), a fibrate agent, is highly effective for reducing microvascular complications in diabetic patients, particularly preventing diabetic eye disease and peripheral amputation. Eating whole fish remains a healthy dietary choice, though the interaction between EPA and DHA in natural fish sources has not been studied. High-risk patients with cardiovascular disease, elevated triglycerides, and pre-diabetic or diabetic status should discuss purified EPA supplementation with their healthcare provider. For diabetic patients with raised triglycerides, phenofibrate is considered essential for preserving vision and peripheral circulation to prevent blindness and limb loss. Read more

EP221: Professor David Colquhoun on The Cholesterol Debate

Welcome to my podcast. I am Doctor Warrick Bishop, and I want to help you to live as well as possible for as long as possible. I’m a practising cardiologist, best-selling author, keynote speaker, and the creator of The Healthy Heart Network. I have over 20 years as a specialist cardiologist and a private practice of over 10,000 patients. Podcast Summary Introduction: Dr. Warrick Bishop, a practicing cardiologist and author dedicated to patient education about heart health, hosts this episode featuring Associate Professor David Cahoon, co-president of the Prevention Arm of the Cardiac Society of Australia and New Zealand. The episode discusses a recent debate about the scientific validity of cholesterol management and statin therapy, with Dr. Cahoon representing the evidence-based medical perspective against three prominent figures who challenged conventional cholesterol treatment. Key Takeaways: The "Catalyst" program featuring Marianne de Massey, a non-expert journalist, promoted medically harmful misinformation that led to increased heart attacks, strokes, and mortality when viewers stopped taking statins—demonstrating the dangers of poor science reporting. Ross Walker's claim that only 1 in 19 people need statins lacks scientific evidence and contradicts established research showing that for every 1 millimole reduction in LDL cholesterol, there is a 25% reduction in heart attacks and 20% reduction in strokes. Claims that cholesterol is needed for hormone production misunderstand basic biochemistry; while cholesterol is used for hormones, the body produces excess cholesterol in every cell, and HDL removes waste LDL particles back to the liver for recycling. LDL particles are waste products from the liver's transport of triglycerides and become atherosclerotic only when modified (oxidized, glycosylated) or when inflammation increases endothelial permeability, making lowering LDL levels a valid therapeutic target. Dr. Chaffee, a neurosurgical registrar and bodybuilder without lipid metabolism expertise, inappropriately positioned himself as a cholesterol expert and misquoted the Framingham study, claiming it showed low cholesterol increased coronary artery disease. Inflammation, while an important factor in atherosclerosis, is not the sole driver of plaque formation; over 60 risk factors exist, with five key ones including smoking, anxiety, and depression that increase LDL atherogenicity. Major clinical trials like the Australian Lipid Trial involved independent safety and data monitoring committees that were not corrupt despite pharmaceutical funding; the funding simply covered operational costs, not individual compensation. The Australian MIPA trial was the first in the world to demonstrate that lowering LDL by one millimole per litre decreased total mortality by 3% over six years in patients with average cholesterol levels. Critics like Dr. Malhotra who lack research involvement themselves question the integrity of researchers while offering no independent data, contradicting evidence-based standards. Contemporary statin therapy targets require at least 2 millimole per litre LDL reduction to be considered adequate treatment, and cholesterol discussion should focus on LDL particles rather than general "cholesterol" terminology. Read more

EP220: Pigs May Not Fly, But...

Welcome to my podcast. I am Doctor Warrick Bishop, and I want to help you to live as well as possible for as long as possible. I’m a practising cardiologist, best-selling author, keynote speaker, and the creator of The Healthy Heart Network. I have over 20 years as a specialist cardiologist and a private practice of over 10,000 patients. Episode Summary Dr. Warwick Bishop is a practicing cardiologist and author dedicated to improving patient outcomes through heart health education. In this episode, he discusses the groundbreaking January 2022 pig-to-human heart transplant performed at Maryland Hospital, where the patient remained healthy one month post-surgery. The episode explores the science behind xenotransplantation, the critical challenge of tissue rejection, and why this development represents a potential solution to the severe shortage of human donor organs. Key Takeaways: The first successful pig heart transplant into a human patient in January 2022 was a remarkable scientific achievement, with the patient still doing well at one month post-transplantation. Tissue matching between donor and recipient is critical because the body recognizes foreign cells through complex receptors (similar to blood type markers), and mismatched tissue triggers dangerous immune responses. Cross-species organ transplantation is far more complex than human-to-human transplants because it requires overcoming genetic differences between species. Scientists have successfully developed transgenic pig lines with reduced cell markers that prevent adverse human immune reactions, making them suitable for transplantation. Pigs are ideal donor animals because their heart size and structure are similar to human hearts, addressing a critical medical need. In the US alone, 15-20 people die daily from lack of available donor hearts, making xenotransplantation a potentially life-saving solution. The two major post-transplant risks are organ rejection (complicated by immunosuppressant medications that lower immunity) and infection. Humans have already used animal-derived materials in cardiac care, including pig valves and bovine pericardium valves, establishing precedent for animal-to-human medical applications. Pig heart xenotransplantation may serve as a bridge solution while longer-term alternatives like gene therapy and genetic engineering are developed. Read more

EP219: Obesity, Prediabetes, Diabetes, And Heart Attack Risk

Welcome to my podcast. I am Doctor Warrick Bishop, and I want to help you to live as well as possible for as long as possible. I’m a practising cardiologist, best-selling author, keynote speaker, and the creator of The Healthy Heart Network. I have over 20 years as a specialist cardiologist and a private practice of over 10,000 patients. Podcast Summary Introduction Dr. Warrick Bishop is a practicing cardiologist and author dedicated to improving patient care through heart health education. In this episode, he explores the interconnected issues of obesity, pre-diabetes, and diabetes, with a specific focus on their impact on heart attack risk and cardiovascular disease prevention. The discussion addresses how modern lifestyle factors have contributed to the obesity epidemic and examines both preventive strategies and treatment options available to patients. Key Takeaways: Widespread availability of high-caloric, processed foods combined with increased automation and reduced physical activity has driven the obesity epidemic in developed nations. BMI over 30 significantly increases the risk of atherosclerotic coronary artery disease (heart attacks and strokes), cardiac failure with preserved function, and atrial fibrillation. Prevention begins with awareness and education about the dangers of processed, sugar-enhanced foods, with emphasis on consuming natural, balanced diets including vegetables, meats, and fruits. Successful weight loss requires multiple factors: the individual's genuine desire to change, receiving information converted to actionable knowledge, accountability through regular face-to-face interactions, and coaching-style support with reassurance. Carbohydrate restriction, rather than simple caloric restriction alone, may be particularly valuable for carbohydrate-sensitive or insulin-resistant patients. Pharmacological options including GLP-1 agonists (like liraglutide), sympathomimetics (phenteramine), orlistat, and naltrexone-bupropion can support weight loss efforts when lifestyle modifications alone are insufficient. Bariatric surgery, particularly gastric sleeve surgery, should be considered only as a last resort for severely obese individuals, though it can produce significant and sustained weight loss improvements. Type 2 diabetes comprises 90-95% of all diabetes cases in the community and is closely linked to atherosclerotic cardiovascular disease, though improved primary prevention has reduced cardiovascular event rates in diabetics. Even modest weight loss of 5% or more delivers measurable benefits in blood pressure, cholesterol, and blood sugar levels, plus improved quality of life. Early intervention and prevention of weight gain is far more effective than attempting to reverse significant weight gain later, making continuous monitoring and prompt action essential. Read more

EP218: Update on Cardiac CT

Welcome to my podcast. I am Doctor Warrick Bishop, and I want to help you to live as well as possible for as long as possible. I’m a practising cardiologist, best-selling author, keynote speaker, and the creator of The Healthy Heart Network. I have over 20 years as a specialist cardiologist and a private practice of over 10,000 patients. Episode Summary Dr. Warwick Bishop, a practicing cardiologist and education advocate, discusses recent research updates on cardiac CT imaging in this episode. He examines two major studies—the Swedish SCAPIS study and a Korean exercise study—that validate his long-held observations about coronary artery disease screening and the role of calcium scoring in cardiac assessment. The episode explores how CT imaging technology can better risk-stratify patients and clarify the complex relationship between calcium deposits, plaque formation, and cardiovascular health. Key Takeaways: The SCAPIS study of over 25,000 people aged 50-64 found that approximately 40% of the population has coronary plaque, which aligns with the prevalence of coronary disease as a major cause of death. Men have nearly twice as much plaque as women, with approximately a 10-year delay in plaque accumulation between genders, suggesting optimal screening ages of 50 for men and 60 for women. A zero calcium score is an excellent gatekeeper for low risk; only 5.5% of zero-score patients had any plaque on contrast imaging, and less than 0.4% had significant stenosis. Calcium scores above 400 correlated with approximately 40% of cases showing significant arterial narrowing, warranting detailed imaging to understand plaque composition. The Korean study paradoxically found that exercise is associated with higher calcium scores and faster calcium progression, despite exercise reducing coronary event rates. Calcium serves dual purposes: it indicates both plaque formation/deposition and plaque stabilization, making interpretation complex without additional contrast imaging. Injecting contrast during CT coronary angiography is essential to differentiate between stabilized calcified plaque and dangerous fatty, unstable plaque in high-risk patients. Two patients with identical calcium scores can have vastly different risk profiles depending on the composition of their plaque, highlighting why calcium alone is insufficient for risk assessment. Risk enhancers like family history of premature coronary disease, elevated triglycerides, or prediabetes should prompt earlier screening than standard age guidelines. Read more

EP217: An Extraordinary Letter

Welcome to my podcast. I am Doctor Warrick Bishop, and I want to help you to live as well as possible for as long as possible. I’m a practising cardiologist, best-selling author, keynote speaker, and the creator of The Healthy Heart Network. I have over 20 years as a specialist cardiologist and a private practice of over 10,000 patients. Episode Summary Introduction: Dr. Warwick Bishop is a practicing cardiologist and author who advocates for patient education in heart health. In this episode, he discusses an extraordinary letter from a colleague cardiologist that exemplifies why he created the Healthy Heart Network and promotes cardiac CT imaging technology. The letter reveals concerning clinical judgment about managing a 50-year-old patient with elevated cholesterol, which Dr. Bishop uses to highlight important gaps in modern cardiac risk assessment. Key Takeaways: Cardiac CT imaging can reveal that outwardly healthy people may have unhealthy arteries, and conversely, people who appear at high risk may have surprisingly healthy coronary arteries—making it a valuable tool for accurate risk assessment. The cardiologist's dismissal of cardiac CT for a 50-year-old with intermediate risk (approximately 10% risk of event in 10 years) contradicts current Heart Foundation of Australia guidelines, which support cardiac CT imaging for intermediate-risk patients. A normal ECG does not indicate healthy coronary arteries; the two are separate systems, and assuming a normal ECG means no heart disease risk is medically inaccurate and potentially dangerous. Using cholesterol levels alone to predict cardiac risk is insufficient; comprehensive imaging allows doctors to identify actual plaque burden and tailor prevention strategies with greater precision. Prescribing medication with a "take it or leave it" approach represents poor medical practice and a lack of genuine concern for the individual patient's wellbeing and treatment outcomes. Cardiac CT imaging is cost-effective at $300-$660 compared to the potential devastation of a preventable heart attack, making the financial objection in the letter irrational. Risk-enhancers like elevated cholesterol should trigger further investigation in apparently healthy patients, not dismissal of diagnostic testing. Many healthcare professionals lack awareness of or resistance to newer technologies like cardiac CT that could significantly improve patient outcomes in cardiac risk stratification. Read more

EP216: Cholesterol and the Arteries

Welcome to my podcast. I am Doctor Warrick Bishop, and I want to help you to live as well as possible for as long as possible. I’m a practising cardiologist, best-selling author, keynote speaker, and the creator of The Healthy Heart Network. I have over 20 years as a specialist cardiologist and a private practice of over 10,000 patients. Podcast Summary Dr. Eric Bishop, a practicing cardiologist and author, hosts this educational episode exploring how cholesterol accumulates in arteries. He discusses the research of Vladimir Subotin, a member of the Russian Academy of Sciences, who challenges the conventional understanding of cholesterol deposition in coronary artery disease. The episode examines the mechanisms behind plaque formation and presents an alternative theory about cholesterol transport in artery walls. Key Takeaways: The LDL hypothesis—that "bad" cholesterol in the bloodstream causes coronary artery disease—is well-supported by decades of research showing that lowering LDL cholesterol reduces heart attack risk in high-risk individuals. The conventional understanding assumes cholesterol particles float in the bloodstream and cross the inner artery lining (tunica intima) to deposit cholesterol in the artery wall. Microscopic examination of plaque development shows cholesterol buildup begins in the middle layer of the artery (tunica media), not the inner lining, which contradicts the standard inside-to-outside migration theory. Subotin proposes that wear and tear in arteries triggers inflammation and signals local cells to release tissue factors, initiating the cholesterol accumulation process. An alternative mechanism suggests cholesterol enters the middle artery layer through vasa vasorum—tiny blood vessels that supply nutrients to the artery wall itself—rather than migrating from the bloodstream. The mechanism of how cholesterol enters the artery wall remains mechanistically complex and difficult to observe directly in living organisms. Coronary artery disease is multifactorial, involving not just cholesterol but also inflammation, wear and tear, and blood pressure as important contributing factors. Regardless of the precise mechanism of cholesterol deposition, clinical evidence confirms that lowering cholesterol in high-risk patients reduces their future cardiovascular risk. Read more

EP215: Plaque Rupture and Erosion

Welcome to my podcast. I am Doctor Warrick Bishop, and I want to help you to live as well as possible for as long as possible. I’m a practising cardiologist, best-selling author, keynote speaker, and the creator of The Healthy Heart Network. I have over 20 years as a specialist cardiologist and a private practice of over 10,000 patients. Podcast Summary Introduction Dr. Warrick Bishop is a practicing cardiologist and author dedicated to educating patients about heart health. In this episode, he explores the distinction between two mechanisms of plaque-related heart attacks: plaque rupture and plaque erosion. Understanding these different pathways is crucial because both can lead to heart attacks, yet they present differently and may require different treatment approaches. Key Takeaways: Plaque forms at points of arterial stress and wear, involving cholesterol accumulation and inflammation, typically developing in the middle muscular layer of the artery wall. Approximately 60% of heart attacks result from plaque rupture, where a thin fibrous cap breaks down, allowing blood to mix with the cholesterol-rich plaque core and form a clot. The remaining 40% of heart attacks are caused by plaque erosion, where the fibrous cap remains intact but the protective endothelial lining is lost, triggering clot formation without rupture. Plaque rupture typically causes sudden, instantaneous chest pain, while plaque erosion generally presents as progressive, niggly chest pain at rest that develops over hours (unstable angina). Ruptured plaques are characterized by a large fatty necrotic core (>30% of total plaque), thin fibrous cap (<65 micrometers), abundant inflammatory cells, and calcium deposits. Eroded plaques are more stable phenomena with intact thick fibrous caps, minimal calcification, less inflammation, and scarcity of the aggressive features seen in ruptured plaques. Multiple diagnostic tools exist to assess plaque, including cardiac CT imaging, invasive angiography, intravascular ultrasound (IVUS), and optical coherence tomography (OCT), with OCT providing the most detailed imaging including fibrous cap thickness measurement. Research demonstrates that aggressive LDL cholesterol lowering using statins and PCSK9 inhibitors can achieve plaque regression and increase fibrous cap thickness in over 50% of patients within 12-18 months. Plaque stabilization through cholesterol reduction supports the LDL hypothesis and suggests that optimal therapy may reduce the risk of plaque rupture events. Understanding plaque rupture versus erosion explains why patients can feel perfectly well until a clot suddenly forms and restricts blood flow, since normal flow continues until thrombosis occurs. Read more