Heart Attacks are Preventable!

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

EP188: Interview with Dr Zalstein Talking Anesthesia (Part 1)

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, interviews Dr. Sandy Zalstein, an anaesthetist colleague, to explore the critical role of anaesthesia in modern surgery. The episode demystifies anaesthesia for patients, covering its definition, historical development, and the decision-making process between local and general anaesthetic approaches. Key Takeaways: Modern surgery is impossible without modern anaesthesia; anaesthetists do far more than just put patients to sleep—they manage pain, protect vital functions, and address chronic health conditions before, during, and after surgery. Anaesthesia has evolved dramatically since the mid-1800s, progressing from crude methods like nitrous oxide (laughing gas) and ether to sophisticated halogenated compounds, with Tasmania having an early connection to ether adoption in the 1800s. The choice between local and general anaesthesia depends on three critical factors: patient characteristics, surgical requirements, and anaesthetic considerations, requiring a thorough assessment by a qualified anaesthetist. Local anaesthetics numb specific areas via injection and work well for small peripheral procedures, while regional techniques (like spinal anaesthesia) can numb larger body areas; general anaesthesia is necessary for surgeries requiring airway control or procedures on major body cavities. Contrary to common belief, local anaesthesia is not universally safer than general anaesthesia for all patients; however, for certain vulnerable populations (elderly or chronically ill patients), local anaesthesia with sedation may pose fewer risks. Increasingly, anaesthetists use combined techniques—mixing local/regional anaesthesia with general anaesthesia—to optimize pain relief and improve outcomes before, during, and after surgery. General anaesthesia in healthy patients is remarkably safe in the modern era, but anaesthetists today face growing complexity managing older patients with multiple chronic conditions requiring various medications. Anaesthetists must optimize patients' existing health conditions before surgery, making collaboration with cardiologists particularly important for managing cardiac and systemic risks. Read more

EP187: Atrial Fibrillation and Food

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 Episode Summary Introduction Dr. Warrick Bishop is a practicing cardiologist and author dedicated to educating patients about heart health. In this episode, he explores the relationship between diet and atrial fibrillation, examining which foods and beverages can trigger or help manage this common heart rhythm condition. The discussion covers specific dietary components and practical recommendations for reducing atrial fibrillation risk through nutritional choices. Key Takeaways: Alcohol is a direct trigger for atrial fibrillation, particularly through binge drinking, and can also raise blood pressure and disrupt sleep; moderation is essential with no more than 1-3 glasses daily recommended. Recent research suggests moderate caffeine consumption (up to 3 cups of coffee daily, approximately 300mg) may not increase atrial fibrillation risk, though energy drinks with high caffeine and sugar should be avoided. Trans fats should be eliminated completely, while monounsaturated fats from olive oil, nuts, and avocados may help lower atrial fibrillation risk. Excessive salt intake drives blood pressure elevation and increases atrial workload; daily intake should remain under 2.5 grams, and processed foods should be limited. High sugar and refined carbohydrate consumption increase atrial fibrillation risk, particularly in diabetic patients who have a 40% higher likelihood of developing the condition. Vitamin K intake consistency matters only for patients on warfarin; newer anticoagulants (NOACs) eliminate dietary interactions with vitamin K-rich foods like broccoli and spinach. Undiagnosed celiac disease increases atrial fibrillation risk through inflammatory processes triggered by gluten intolerance. Grapefruit can reduce the effectiveness of amiodarone and increase statin levels, creating potential drug interactions for atrial fibrillation patients. The three most powerful lifestyle modifications to reduce atrial fibrillation risk are maintaining a healthy weight, controlling blood pressure, and practicing alcohol moderation. A Mediterranean-based diet with abundant vegetables, beans, whole grains, and healthy fats represents the optimal dietary approach for atrial fibrillation prevention. Read more

EP186: Interview 3 With Cardiologist Dr. Michael Zema

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 Episode Summary Introduction Dr. Warrick Bishop, a practicing cardiologist and author, hosts this third interview with Dr. Michael Zemmer from Chattanooga, Tennessee, author of "Modern Healthcare Delivery: Deliverance or Debacle." The episode focuses on the erosion of patient-centered care in modern healthcare systems, exploring how financial incentives and time pressures have fundamentally undermined the critical one-on-one doctor-patient relationship and shifted focus away from preventive medicine. Key Takeaways: The one-on-one consultation between doctor and patient is invaluable and irreplaceable, conveying trust and care that cannot be replicated through telehealth or other remote modalities. Modern healthcare systems have created a fundamental tension between patients expecting adequate consultation time and doctors operating under severe time constraints (often 12 minutes per visit), preventing optimal care delivery. Historical reimbursement structures dating back to the 1930s with Blue Cross Blue Shield prioritize procedural and surgical interventions over cognitive and preventive services, creating a financially-driven hierarchy in medicine. Procedural specialists earn significantly more than primary care and preventive care providers—sometimes three times as much—despite preventive medicine's proven value in keeping patients healthy. The healthcare system inadvertently rewards providers for allowing patients to become sick and then treating them, rather than rewarding prevention and wellness maintenance. Prevention receives "lip service" but lacks genuine prioritization because it is less exciting, shows results over longer timeframes, and generates less revenue than acute interventions. Time spent on thorough patient history, physical examination, and communication can prevent unnecessary or harmful procedures, as demonstrated by Dr. Bishop's example of a patient with chest pain who avoided unnecessary cardiac catheterization through proper physical examination. Over-reliance on a single diagnostic tool or skill set leads to inappropriate intervention, exemplified by the phrase "if the only tool you have is a hammer, everything looks like a nail." Current reimbursement disparities between specialties have contributed to the decline of primary care and internal medicine, with physicians pursuing higher-paying procedural specialties despite greater training requirements. Young physicians must balance technological advances with meaningful personal communication and relationships with patients and peers, ensuring technology serves rather than replaces human connection in healthcare. Read more

EP185: Interview 2 With Cardiologist Dr. Michael Zema

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 focused on patient education about heart health, welcomes back Dr. Michael Zima for part two of their discussion about Zima's book, "Modern Healthcare Deliverance or Debacle?" With 40 years of experience as a cardiovascular physician, Dr. Zima explores the fundamental issues in modern healthcare delivery that prompted him to write this comprehensive guide for both providers and patients. Key Takeaways: The deteriorating doctor-patient relationship is driven by severely limited consultation times (averaging 12 minutes), which is inadequate for proper patient assessment and connection. The rise of physician extenders (nurse practitioners and physician assistants) fills a necessary gap caused by medical school enrollment not keeping pace with population growth, but patients often lack understanding of their qualifications and roles. Healthcare operates in isolated silos where cardiologists, administrators, nurses, and technologists function separately without adequate interconnection, reducing overall care quality. The fee-for-service payment model incentivizes volume over quality, creating misaligned financial incentives that can waste resources rather than improve patient outcomes. Administrative costs consume 28 cents of every healthcare dollar in the U.S., never reaching direct patient care—an unsustainable drain on the system. Providers are the ultimate gatekeepers controlling costs and outcomes, making behavior change among clinicians critical to balancing cost containment with quality care. Retail clinics and urgent care centers serve a practical role in healthcare delivery by providing accessible alternatives to emergency departments and reducing wait times for minor complaints. Telehealth shows promise but has limitations: it lacks physical examination capabilities, which are essential for proper diagnosis, though emerging technology may enable remote technicians to perform and record exams in real-time. First-time consultations should occur face-to-face because they require rapport-building, body language interpretation, and the ability to detect subtle cues that video or phone consultations cannot adequately convey. Patients should be treated as individuals, not just medical records—a shift away from documentation-heavy practices designed to survive third-party payer audits. Read more