Heart Attacks are Preventable!

EP198: Blackouts and Syncope

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, believing that informed patients receive the best care. In this episode, Dr. Bishop provides a comprehensive overview of syncope (blackouts), explaining the various medical causes and sharing a successful clinical case study of a patient with vasovagal fainting. The episode emphasizes the importance of proper diagnosis and treatment for this common but potentially serious condition. Key Takeaways: Syncope is a medical term derived from a word meaning "pauses" and refers to blackouts or loss of consciousness that require proper medical evaluation. Blackouts can originate from three main sources: the brain (such as seizures), the heart (too fast or too slow), or blood pressure regulation issues. Seizure-related blackouts are typically characterized by warning signs (aura), violent shakes or tremors, and specific seizure patterns that distinguish them from cardiac causes. Cardiac causes of syncope include arrhythmias (heart racing) or conduction failures that cause sudden pauses, often resulting in sudden collapse. Orthostatic hypotension (blood pressure drops upon standing) is a common cause of blackouts, particularly when moving from resting to upright positions. Vasovagal syncope results from overactivity of the parasympathetic nervous system (rest and digest response) and presents as a "simple faint" triggered by emotional stress, blood, needles, or other specific stimuli. Dr. Bishop successfully treated a 70-year-old patient's decade-long fainting episodes using a two-pronged approach: beta blockers to dampen heart rate acceleration and anticholinergic agents (like BuskPam) to attenuate the parasympathetic response. Treatment strategies for vasovagal syncope should address both the initial rapid heart rate increase and subsequent dangerous slowdown using low-dose medications that carry minimal risk. Patients experiencing syncope should consult both their general practitioner and a cardiologist, as driving restrictions or exemptions may be necessary depending on the underlying cause. Syncope is a treatable and common condition, making proper diagnosis and intervention essential for patient safety and quality of life. Read more

EP197: Thinking About Cholesterol Getting Into 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 Introduction Dr. Eric Bishop is a practicing cardiologist and author dedicated to educating patients about heart health and the latest advances in cardiac care. In this episode, Dr. Bishop discusses cholesterol and coronary artery disease, focusing on the research of Vladimir Subotin from the Russian Academy of Sciences, who proposes an alternative mechanism for how cholesterol accumulates in artery walls. The episode challenges conventional understanding while emphasizing that lowering cholesterol in high-risk patients demonstrably reduces heart attack risk. Key Takeaways The traditional view holds that cholesterol particles (LDL) circulate in the bloodstream and deposit in artery walls at points of wear and tear, but this mechanism is difficult to directly observe in living organisms. Subotin's research suggests cholesterol may not primarily enter arteries from the bloodstream but rather accumulates through an alternative pathway. Artery walls consist of three layers (tunica intima, tunica media, and tunica adventitia); when examined under microscopes, cholesterol deposits appear in locations inconsistent with the traditional inside-to-outside migration theory. Arterial wear and tear triggers local inflammation and irritation, causing cells to release tissue factors that signal the body to send repair materials, including cholesterol, to the damaged area. Subotin proposes cholesterol travels into the middle artery layer via the vasa vasorum—tiny blood vessels that supply nutrients to the artery wall itself—rather than crossing from the arterial lumen. Regardless of the specific mechanism by which cholesterol enters artery walls, clinical evidence confirms that lowering LDL cholesterol in high-risk patients reduces their future heart attack risk. Coronary artery disease is multifactorial; cholesterol alone does not explain the disease, and factors like inflammation, blood pressure, and arterial wear and tear all play important roles. Read more

EP196: Funny Valve and Big Aorta

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 provides a comprehensive overview of bicuspid aortic valve disease, explaining what it is, how it develops, and how it's managed. He emphasizes that educated patients receive the best healthcare outcomes and discusses both the valve condition and the associated aortopathy (aortic dilation) that can occur. Key Takeaways: A bicuspid aortic valve is a congenital condition where the aortic valve has two leaflets instead of the normal three, making it the most common congenital cardiac abnormality. Bicuspid aortic valves function in an unbalanced manner similar to an engine running on three cylinders instead of four, causing premature wear and tear compared to normal tricuspid valves. The condition is typically not apparent until mid to late adulthood (40s-60s) when the valve begins to deteriorate, though it can be detected earlier through family history screening, heart murmurs, or incidental imaging. An aortopathy (weakened aorta with dilated connective tissue) frequently accompanies bicuspid aortic valve disease, which is a critical concern because severe dilation can lead to life-threatening rupture or dissection. Blood pressure management using ACE inhibitors (like perindopril and ramipril) and angiotensin receptor blockers (like candesartan and valsartan) effectively slow aortic dilation beyond their blood pressure-lowering effects. Surveillance using ultrasound and CT imaging is essential, with CT scans providing accurate aortic measurements; aortic replacement is typically considered when diameter reaches 45 millimeters (normal is 35-38 millimeters). Treatment options depend on severity: valve-only replacement, aorta-only repair, or combined valve and aorta surgery; valve replacement can be performed via open heart surgery or transcutaneous aortic valve implantation (TAVI). Family screening is strongly recommended because bicuspid aortic valve is genetic, and early detection with proper management allows patients to maintain near-normal life expectancy without significantly compromised health outcomes. Read more

EP195: Liquorice of All Sorts

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 patient education about heart health. In this episode, Dr. Bishop explores licorice—a common confectionery and herbal remedy—and explains the serious cardiovascular risks associated with excessive consumption, including how it can trigger pseudo-hyperaldosteronism and dangerous changes in blood pressure and electrolyte balance. Key Takeaways: Licorice is derived from the root of the Glyzira glabra plant and is consumed as candy, tea, or herbal supplement, often for digestive and bowel health benefits. Excessive licorice consumption can cause pseudo-hyperaldosteronism, a false elevation of aldosterone-like effects that mimics the body's stress response to low blood pressure. Aldosterone is a crucial hormone that regulates fluid balance, salt retention, and blood pressure through the renin-angiotensin system activated in response to physical stress or low blood pressure. Glycyrrhizin, the active ingredient in licorice, blocks enzymes that break down cortisol and aldosterone, leading to increased levels of these hormones in the body. Just 100 milligrams of glycyrrhizin can trigger problematic effects; a standard 300-gram bag of licorice contains six servings, each with 100 milligrams of glycyrrhizin. A single licorice tea bag can contain up to 100 milligrams of glycyrrhizin, meaning consuming more than one per day risks causing pseudo-hyperaldosteronism. Excess licorice leads to sodium retention, potassium loss, fluid retention, and elevated blood pressure, posing particular risks for those already suffering from hypertension. Other herbal supplements present cardiovascular risks: garlic, ginkgo, and echinacea can thin blood and increase bleeding risk when combined with anticoagulants; St. John's Wort reduces absorption of beta blockers and statins. Green tea, alfalfa, ginseng, and ginger can interfere with blood thinners like warfarin, while grapefruit can elevate statin levels to dangerous concentrations. Patients should consult their pharmacist before combining herbal supplements with prescription medications to avoid potentially serious drug interactions and adverse health effects. Read more

EP194: Monitoring Medications With Dr Begg

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, hosts this episode with his colleague Dr. Alistair Begg, also a cardiologist from Adelaide. The episode focuses on the comprehensive monitoring protocols cardiologists implement when starting patients on cardiac medications, including cholesterol-lowering drugs, blood pressure medications, and rhythm management therapies. Key Takeaways: Blood tests are essential for monitoring both the effectiveness of cardiac medications and their potential side effects, particularly for drugs like statins that can affect muscle and liver function. Creatinine kinase (CK) and liver function tests (LFTs) should be monitored in patients on statins, but baseline measurements are important since normal CK levels vary by individual and can be elevated by exercise, dehydration, or physical activity. A CK elevation requires clinical judgment—mild elevations may be monitored without stopping medication if the drug's benefits outweigh the risks, while significant elevations (such as over 2,500-3,000) warrant immediate investigation and potential medication discontinuation. ACE inhibitors and angiotensin-2 blockers used for blood pressure management require periodic kidney function monitoring, as they can potentially deteriorate kidney function, particularly in older patients. Diuretics can affect potassium levels and cause dehydration, necessitating regular blood test monitoring alongside blood pressure measurement. 24-hour ambulatory blood pressure monitoring is valuable for detecting white coat hypertension and determining whether patients actually require medication before starting treatment. Rhythm management medications require ECG monitoring to detect drug-induced changes in heart rhythm patterns, particularly monitoring the QT interval for drugs like sotalol and characteristic changes for flecainide. Amiodarone requires regular thyroid and liver function testing, as approximately 25% of patients in some regions experience thyroid abnormalities while taking this medication. Cardiologists should involve patients in medication decisions by discussing both benefits and risks, which increases patient engagement and medication adherence. Effective medication monitoring involves dual tracking: assessing therapeutic effectiveness (cholesterol levels, blood pressure control, rhythm stability) and surveilling for potential adverse effects through blood tests and ECG findings. Read more

EP193: To-Do Lists With Dr Begg

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, hosts this episode with Dr. Alistair Begg, a senior cardiologist specializing in rehabilitation based in Adelaide. The discussion focuses on practical "to-do lists" patients should follow when consulting with cardiologists, managing medications, and preparing for medical appointments to ensure optimal care and understanding. Key Takeaways: Patients should bring an up-to-date list of their current medications to consultations, as medications may have changed across different healthcare providers, hospitals, or specialists without central coordination. Creating a written list of questions before visiting a cardiologist helps patients maximize their consultation time and remember important topics they want to discuss. Patients must understand the purpose of each medication, potential side effects to watch for, whether repeats are available, and distinguish between generic and brand names to avoid confusion. Avoid planting nocebo effects by not over-emphasizing side effects; frame medications as "generally well-tolerated" to prevent patients from experiencing imagined adverse effects before even leaving the consultation room. Taking medications at the same time daily establishes routine and improves compliance; some medications require specific timing (e.g., azetamide at night, some with food, others on an empty stomach). If a dose is missed, wait for the next scheduled dose rather than doubling up, as doubling is more likely to cause harm; missing doses of blood pressure medications or blood thinners is more critical than missing statins. Regulation 24 prescriptions in Australia allow patients traveling for extended periods to obtain up to six months of medication supply rather than being limited to one-month supplies. Split medication storage between hand luggage and checked luggage when traveling to ensure backup medications are available if one set is lost. Generic medications contain the same active ingredient as branded drugs but are cheaper and produced by multiple companies; however, differences in fillers and colorings can affect tolerability in some patients. Generic drugs have a wider approval margin (80-120% effectiveness) compared to branded medications, which may impact both effectiveness and tolerability for individual patients. Read more

EP192: Ketogenic Diets and the Heart

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 potential role of ketogenic diets in cardiac failure management, examining the science behind ketone metabolism and how it might benefit heart function while considering its place within current cardiovascular health guidelines. Key Takeaways: Ketogenic diets originated in the 1920s as a treatment for pediatric epilepsy and have since shown potential benefits for neurodegenerative diseases, diabetes, non-alcoholic fatty liver disease, certain cancers, and weight loss. A ketogenic diet typically consists of 70-80% fat, 10-20% protein, and 5-10% carbohydrates, which reduces insulin levels and allows the body to convert fatty acids into ketones for energy. Ketosis is a normal metabolic state that endurance athletes naturally enter after 35-45 minutes of exercise, demonstrating that using ketones as fuel is a natural bodily process. The heart can utilize ketones as an unregulated energy source, raising the theoretical question of whether ketogenic diets could improve cardiac function in heart failure patients. Current research on ketogenic diets specifically for cardiac failure is limited, despite evidence from the EMPA-REG trial showing that reducing glucose levels benefits cardiac failure outcomes. Ketogenic diets contrast sharply with current cardiovascular guidelines that recommend fruits, vegetables, and whole grains—foods that are restricted in keto due to carbohydrate content. Dr. Bishop favors moderate carbohydrate reduction (rather than full ketogenic restriction) as it can reduce insulin levels, aid weight loss, improve HDL cholesterol, and lower triglycerides. While some patients may report subjective benefits from ketogenic diets in cardiac failure, any such approach should only be undertaken under close medical supervision by a cardiologist. Dr. Bishop does not currently advocate ketogenic diets specifically for cardiac failure treatment due to insufficient evidence, though he remains optimistic about future research in this area. More research is needed to definitively establish the safety and efficacy of ketogenic diets in cardiac failure before broader clinical recommendations can be made. Read more

EP191: Fish Oil and Vitamin D For Atrial Fibrillation

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, Dr. Bishop discusses findings from the VITAL Rhythm study, a large-scale clinical trial examining whether omega-3 fish oil and vitamin D supplements can reduce the incidence of atrial fibrillation. He explores what these results mean for patients and the broader picture of cardiovascular health. Key Takeaways: The VITAL Rhythm study followed approximately 25,000 people over five years and found 900 cases of atrial fibrillation, providing robust statistical data for analysis. Omega-3 oil supplementation (1 gram daily) showed a slightly higher atrial fibrillation rate (3.74%) compared to placebo (3.43%), though this difference did not achieve statistical significance. Vitamin D supplementation (2,000 IU daily) showed no difference in atrial fibrillation rates compared to placebo over the five-year study period. While the VITAL Rhythm study questions fish oil's role in preventing atrial fibrillation, it does not negate omega-3 oils' established benefits including triglyceride reduction, blood pressure lowering, and reduction in sudden cardiac death from dangerous heart rhythms. Omega-3 oils provide broader health benefits beyond heart health, including support for brain development in children, brain function maintenance in elderly, and joint health and inflammation reduction. Vitamin D plays multiple critical roles in health including bone and calcium metabolism, immune system function, cholesterol profile management, and mood regulation, particularly in regions with limited winter sunlight. The study's findings should be interpreted within context—it addresses atrial fibrillation prevention specifically, not the overall cardiovascular and health benefits of these supplements. Dr. Bishop recommends consuming fatty fish regularly and supplementing with fish oil if dietary intake is insufficient, alongside vitamin D supplementation during seasons with limited sun exposure. Adequate sun exposure (approximately 10 minutes, three times weekly, to significant body areas like the back, abdomen, or legs) can help maintain natural vitamin D levels. Rather than dismissing these supplements entirely, patients should consider them as part of a holistic approach to health rather than as single-purpose preventive measures against atrial fibrillation. Read more

EP190: Interview with Dr Zalstein Talking Anesthesia (Part 3)

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 patient education advocate, hosts this episode featuring Dr. Sandy Zelstein, an anaesthetist and colleague, for their third interview together. This episode focuses on how patients can prepare for surgery and the importance of heart-related considerations in the preoperative period. Key Takeaways: Patients typically don't need to select their own anaesthetist; surgeons work with trusted anaesthetists they've built strong professional relationships with over time, forming coordinated teams that deliver better outcomes. Strong working relationships between surgeons and anaesthetists are critical for effective communication, problem-solving, and patient safety, whether those relationships are purely professional or extend to personal friendships. Patients must bring an accurate, detailed list of all medications to their preoperative appointment and carry this list with them at all times, as medications can be critical for managing blood pressure, blood thinning, and cardiac conditions. Red flags that require immediate disclosure to your anaesthetist include previous anaesthetic complications, allergic reactions to anaesthetic agents, difficult airways, and history of severe nausea and vomiting after surgery. Patients with diabetes need special planning because blood sugar levels can drop dangerously during anaesthesia, and many diabetes medications must be modified or stopped during fasting periods before surgery. Patients with implanted electrical devices like pacemakers or defibrillators must disclose these, as surgical diathermy (electrical cutting and coagulating tools) can interfere with device function. Blood-thinning medications must be reported to both your surgeon and anaesthetist before surgery to prevent excessive bleeding during the procedure. Patients should develop a preoperative medication management plan in advance, especially those on newer diabetes medicines that can cause complications during fasting periods. Read more

EP189: Interview with Dr Zalstein Talking Anesthesia (Part 2)

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 patient education advocate, hosts this episode with Dr. Sandy Zalstein, an anaesthetist colleague, in their second interview together. The discussion focuses on practical challenges anaesthetists face when preparing patients for surgery, particularly those with complex medical conditions, and emphasizes the importance of patient optimization and risk assessment before elective procedures. Key Takeaways: Anaesthetists assess patients using a four-part framework: evaluating risk, optimizing health status, planning appropriate care, and anticipating potential complications or pitfalls. Patient optimization varies significantly based on urgency: elective procedures allow time for comprehensive optimization to achieve the lowest perioperative risk, while emergency cases require rapid "resuscitation" optimization on-site. Elective surgery patients should be "beautifully optimized" with identified health issues assessed and addressed by appropriate specialists before proceeding to surgery. Anaesthetists may delay or cancel elective surgery if patients aren't adequately optimized—for example, a patient with severe heart valve disease and reduced cardiac function was appropriately declined surgery until proper cardiac optimization occurred. Clear communication about surgical risks and benefits is essential for patient preparation and family understanding, as modern medicine no longer operates in a "zero-risk" world. Surgeons and anaesthetists should work collaboratively to educate patients, with surgeons explaining procedural risks and benefits, and anaesthetists then discussing anaesthesia-specific considerations and outcomes. Intermediate-urgency cases require anaesthetists to work with other clinicians to address acute issues quickly while still optimizing the patient within available timeframes. Patient education and engagement in the consent process directly impacts emotional preparedness and outcomes if complications occur. Read more