Heart Attacks are Preventable!

EP150: Interview With Stent Patient Brian

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, interviews Brian, a 59-year-old patient who recently underwent coronary stent placement. The episode follows Brian's journey from discovering a critical arterial narrowing through preventive screening to successful treatment, highlighting the life-saving value of proactive heart disease detection. Key Takeaways: Brian discovered a 95-99% narrowing in his left anterior descending artery (the "widow maker") despite having minimal symptoms—only slight breathlessness and heart arrhythmias during running. A CT calcium score, initially recommended by his GP years earlier but delayed, proved crucial in identifying arterial disease before a life-threatening heart attack could occur. Brian's family history of early cardiac death (no males past 50 on his father's side, his father's first heart attack at 49) made preventive screening particularly important. Despite being physically fit and maintaining an active lifestyle with surfing and bushwalking, fitness alone was not protective against significant coronary artery disease. The invasive coronary angiogram procedure was well-tolerated, described as painless and interesting, with sedation making the patient comfortable while remaining awake. Finding and treating the blockage during scheduled procedure time "between nine to five, Monday to Friday" avoided the risk of sudden cardiac death and emergency intervention. Brian's story emphasizes that subtle or easily-dismissed symptoms warrant medical investigation—his arrhythmias during beach runs proved significant despite his initial assumption they were harmless ectopic heartbeats. Patients with identified coronary disease should inform siblings and relatives to encourage them to pursue similar preventive screening given shared genetic risk factors. Proactive screening allows early detection when problems can be resolved electively rather than emergently, fundamentally changing patient outcomes. Brian's final advice: don't let busy life circumstances or reliance on physical fitness delay cardiac screening when risk factors like family history and cholesterol problems are present. Read more

EP149: Interview With Cardiothoracic Surgeon

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 passionate health educator, hosts this episode featuring Dr. Ashtush Hardika, a cardiothoracic surgeon and colleague from Hobart, Tasmania. The episode focuses on the critical importance of cardiac rehabilitation in preventing second cardiac events, exploring how post-intervention care and lifestyle changes are essential to long-term patient outcomes. Key Takeaways: Cardiac interventions (stents, bypass surgery) are temporary fixes—described as "glorified plumbing jobs"—and must be followed by comprehensive rehabilitation programs to create lasting lifestyle changes and prevent second cardiac events. Cardiac rehabilitation should be built on three key components: Education (providing accurate, scientifically-sound information about disease and prevention), Exercise (personalized, supervised programs tailored to individual needs), and Emotional support/Counseling (addressing the psychological trauma and mental scarring from cardiac events). The emotional and psychological impact of cardiac events often exceeds the physical impact, and patients commonly experience a grieving process that requires recognition and support from healthcare providers. Stent patients may underestimate the severity of their cardiac event and be less motivated to change lifestyle habits, whereas cardiac surgery patients, facing greater physical recovery demands and visible scars, often experience stronger motivation for lasting behavioral change. A multidisciplinary team approach—including cardiologists, nurses, educators, dieticians, physiotherapists, occupational therapists, psychologists, and exercise specialists—is essential for effective cardiac rehabilitation delivery. Current funding models in Australia do not adequately match the need for comprehensive cardiac rehabilitation programs, despite cardiovascular disease accounting for over one-third of adult deaths. Ongoing follow-up and re-engagement with cardiac patients should occur at minimum every 12 months, with more frequent support needed for isolated patients or those struggling with behavior change (such as smoking cessation). A dedicated cardiologist with specialized interest in secondary prevention should lead rehabilitation programs to ensure consistent, evidence-based guidance toward specific health targets for each patient. Read more

EP148: Why I Became a Cardiologist

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 his colleague Dr. Karam Kostner. The two cardiologists discuss their personal journeys into medicine and cardiology, exploring the formative experiences and unexpected circumstances that shaped their career paths. Key Takeaways: Dr. Warrick initially pursued engineering after high school but found civil engineering uninspiring, leading his father to redirect him toward careers with better job prospects, ultimately choosing medicine. A pivotal moment in Dr. Warrick's medical training occurred during hematology rotation when he discovered his colorblindness prevented him from distinguishing cell stains under microscopes, making hematology impossible despite his initial fascination with the field. Dr. Karam's career choice was influenced by his family's pragmatic guidance—his parents discouraged language studies due to future computer translation and veterinary science due to shifting industry trends, steering him toward medicine instead. Dr. Karam developed a specific niche in cardiology by combining his inherited interest in lipids (influenced by his biochemist father) with clinical practice, allowing him to distinguish himself professionally in a less-populated specialty. Both doctors experienced challenging periods during their medical training but ultimately found deep satisfaction in their cardiology careers and would choose the same path again. While both cardiologists value their careers and the privilege of helping patients through the trust and support they receive, neither would necessarily recommend medicine to their own children due to the lengthy training and significant personal sacrifice required. Dr. Warrick found his niche in cardiac imaging, particularly CT scanning, which accommodates his colorblindness since CT produces black and white images rather than color-dependent visuals. Both physicians emphasize the meaningful opportunity medicine provides to make daily, tangible differences in patients' lives, viewing their work as a privileged and nourishing professional experience. Read more

EP147: Talking LDL Particle Size

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. Karam Kostner, a leading lipidologist and colleague. The episode explores LDL particle size—a topic that frequently appears in social media and diet-related discussions—and examines whether different sizes of LDL cholesterol particles pose varying risks to heart health. Key Takeaways: Lipoproteins are protein carriers that transport cholesterol through the bloodstream; they can be understood as "buses" or "sedans" carrying cholesterol molecules, with density and size varying based on how packed they are. While LDL particles do come in different sizes and densities, approximately 99% of all LDL is problematic regardless of particle size, as clinical trials consistently show that all LDL ends up in arteries and contributes to plaque buildup. Small, dense LDL particles may be slightly more atherogenic (artery-damaging) than larger particles due to their ability to penetrate vessel walls more easily, but this distinction has limited clinical importance. For clinical practice, measuring LDL particle size is not recommended because reducing overall LDL cholesterol—regardless of particle composition—effectively reduces cardiovascular risk in both diabetic and non-diabetic patients. Diet, exercise, diabetes, and medical therapies (statins, fibrates, ezetrol) all influence LDL particle size, but the primary clinical focus should remain on lowering total LDL rather than targeting specific particle sizes. Particle size testing, while commercially available and scientifically interesting, is primarily a research tool with limited practical utility for patient management at this stage. The danger exists that patients with favorable particle size profiles may incorrectly assume they don't need aggressive LDL-lowering therapy, similar to false reassurance from high HDL levels. Clinical imaging (such as cardiac CT to visualize coronary calcium and plaque burden) and measurement of Lipoprotein(a) are more clinically useful tools than particle size analysis for assessing cardiovascular risk. Read more

EP146: Ezetemibe - What is it and What Does it Do? With Dr. Karam Kostner

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 in heart health, hosts this episode featuring Dr. Karim Kostner, an internationally recognized lipid management expert. The episode explores ezetimibe (marketed as Ezetrol), a cholesterol-lowering medication that has gained renewed clinical attention in recent years for its effectiveness in combination with statins. Key Takeaways: Ezetimibe is a cholesterol absorption inhibitor—the only drug in its class—that works by blocking a receptor in the intestine responsible for cholesterol reabsorption, reducing cholesterol levels by 20-25% in individuals. The medication remains primarily in the gut with minimal bloodstream absorption, making it very well tolerated with no significant muscle-related side effects, unlike statins, and causes only mild gastrointestinal discomfort in some cases. Individual response to ezetimibe varies based on genetics; people who are efficient dietary cholesterol absorbers (about 20% of the population) respond better than those whose bodies produce more cholesterol internally. Adding ezetimibe 10mg to a low-dose statin produces the same LDL cholesterol reduction as doubling the statin dose, making it a superior strategy for patients who don't tolerate higher statin doses. Combining ezetimibe with high-dose statins can achieve up to 60-70% LDL cholesterol reduction—a dramatic improvement compared to results from 5-10 years ago. The IMPROVE-IT trial demonstrated that adding ezetimibe to simvastatin reduces atherosclerotic cardiovascular events, including repeat heart attacks, unstable angina, and need for revascularization procedures. Achieving very low LDL cholesterol levels (under 1.7-1.8 mmol/L) through ezetimibe and statin combinations enables actual regression or stabilization of arterial plaque buildup, reducing heart attacks and strokes. Ezetimibe should not replace statins as first-line therapy since statins are more effective (50-60% reduction) and have more extensive clinical trial evidence, but works excellently as an add-on therapy. The medication is affordable at $13-14 monthly and is available as fixed-dose combinations with statins or co-packs, allowing patients to pay only one prescription fee. For statin-intolerant patients, ezetimibe can be used alone or combined with low-dose statins taken intermittently (1-3 tablets weekly) to achieve meaningful cholesterol reduction while maintaining tolerability. Read more

EP145: Deprescribing: Do's and Dont's

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 better care. In this episode, Dr. Bishop discusses the concept of deprescribing—simplifying medication lists to reduce side effects and drug interactions—through a detailed patient case study that illustrates both the benefits and potential dangers of this approach. The episode highlights the critical importance of balancing medication simplification with individualized clinical risk assessment. Key Takeaways Deprescribing aims to simplify medication regimens by removing unnecessary drugs and reducing the risk of medication side effects and interactions, but should not compromise clinical outcomes for high-risk patients. The patient in question was a 65-year-old asymptomatic man found to have significant plaque in his left main coronary artery through cardiac CT imaging, which was confirmed by stress testing and invasive coronary angiography. Dr. Bishop prescribed aspirin and aggressive cholesterol-lowering therapy (high-dose statins and ezetimibe) to achieve cholesterol levels below 1 millimole per liter, based on evidence of plaque regression and high-risk coronary anatomy. Three major recent trials (ASCEND, ARRIVE, and ASPREE) showed aspirin did not improve mortality in primary prevention populations due to bleeding risks, leading to guidelines against routine aspirin use in primary prevention settings. These aspirin trials did not use imaging to identify patients with actual arterial disease, so they may not apply to patients with documented severe coronary plaque who would benefit from aspirin's anti-clotting effects. The distinction between primary prevention (preventing a first event) and secondary prevention (preventing a second event) is clinically minimal—a heart attack patient is primary prevention only until the moment the event occurs. Recent data supports aggressive cholesterol lowering (LDL <1.6-1.7 millimoles per liter) in very high-risk patients, with the European Society of Cardiology recommending LDL targets below 1 millimole per liter for high-risk patients. A well-intentioned deprescribing decision by the patient's new GP—removing aspirin and reducing cholesterol medication—created significant clinical risk for a patient with complex, high-risk coronary disease. Deprescribing decisions must be individualized and made in consultation with relevant specialists who understand a patient's complete clinical picture and the specific reasons medications were prescribed. When a specialist prescribes a specific therapeutic regimen, there is often a detailed clinical rationale behind it, and medication changes should involve communication between the prescribing specialist and any other treating physicians. Read more

EP144: What About Imaging The Arteries - An Interview With Dr. Karam Kostner

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. Karam Kostner, a Brisbane-based cardiologist specializing in preventive cardiology and lipid management. In a unique reversal, Dr. Kostner interviews Dr. Bishop about cardiac imaging—specifically how and why clinicians use imaging technology to assess arterial health and guide treatment decisions in modern cardiology. Key Takeaways Arterial imaging is essential for clinicians to understand the extent of plaque buildup and tailor treatment intensity appropriately, and patients increasingly want direct knowledge about their own arterial health. CT imaging of the heart has only become reliable in the past decade due to technological advances that can "freeze" the heart's motion and capture clear, reproducible images. Calcium scoring (non-contrast CT) and CT coronary angiography (contrast-enhanced CT) serve different purposes: calcium scoring detects plaque markers, while CT angiography provides detailed information about plaque composition, narrowings, and artery size. Functional imaging (stress tests) is appropriate for symptomatic patients, while anatomical imaging (CT scans) is better suited for asymptomatic risk assessment in patients around age 50 for men and 60 for women. Imaging allows clinicians to move from population-level risk estimates to individual precision medicine, identifying which high-risk patients within a population will actually experience cardiac events. Cardiac CT carries minimal radiation exposure—approximately one millisievert per scan, equivalent to a mammogram—making it safer than many commonly accepted medical tests. Serial imaging protocols typically recommend repeat testing at five-year intervals for patients with zero calcium scores, though individual factors like age and risk profile modify this recommendation. CT coronary angiography carries a very small contrast allergy risk of approximately one in 200,000—three times safer than peanut butter's documented allergic reaction rate. In Australia, cardiac CT lacks formal guideline recommendations and Medicare rebates, making informed patient consent and shared decision-making particularly important for clinicians offering these tests. Imaging is generally not recommended for younger patients unless they have severe family history, very elevated cholesterol, or significant additional risk factors like elevated lipoprotein(a) or hypertension. Read more

EP143: If I've Had a Problem, What About My Family?

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 addresses the critical topic of managing and preventing heart disease in young people who have experienced cardiac events. Dr. Bishop emphasizes the importance of extending rehabilitation beyond the individual patient to include family screening and prevention, sharing compelling clinical experiences that underscore why familial risk assessment is a matter of life and death. Key Takeaways Early heart events should prompt patients to ask whether the condition could affect family members, as this is a crucial step in closing the gap between rehabilitation and prevention. High cholesterol often runs in families and is genetic; relatives of patients with high cholesterol should be screened, particularly siblings and children. A family history of early heart attacks or heart problems in men under 55 or women under 60 (without major confounding risk factors) is a significant red flag requiring action. Precision imaging of the heart arteries can provide valuable risk stratification for family members without prior cardiac events, allowing for early intervention. Smoking behavior is often inherited within families; patients who smoke and have had heart problems should encourage their loved ones to quit. Propensity toward diabetes and obesity tends to run in families and should be addressed early through weight management, as losing small amounts of weight preventatively is far easier than managing severe obesity later. High blood pressure is familial and directly increases the risk of heart attack, stroke, heart failure, and atrial fibrillation; early detection and treatment in family members can prevent long-term circulatory damage. Prevention through family screening and lifestyle modification is significantly more effective than treating advanced cardiac disease. Read more

EP142: Lipoprotein (a) With Dr. Karam Kostner

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, a practicing cardiologist and passionate health educator, hosts this episode featuring Dr. Karam Kostner, a lipids management expert from Queensland. The episode focuses on lipoprotein(a) — also written as Lp(a) — a genetic risk factor for heart disease and stroke that functions as "bad cholesterol with extra nasty bits on it," combining an LDL particle with additional protein that increases both clotting risk and arterial buildup. Key Takeaways: Lipoproteins are proteins that carry fats (cholesterol, triglycerides, phospholipids) through the bloodstream to various tissues, functioning similarly to how cream disperses in milk. Lipoprotein(a) is structurally similar to LDL ("bad cholesterol") but has an additional small protein (apolipoprotein(a)) attached, making it unique and more problematic. Lp(a) is probably the most significant genetic risk marker for heart disease and stroke, demonstrated through epidemiological studies, Mendelian randomization studies, and human clinical observations. Elevated Lp(a) levels are commonly found in families with early-onset coronary disease and are associated with increased aortic valve calcification in young people. Current treatment options include aggressively lowering LDL cholesterol, nicotinic acid (30-40% reduction), PCSK9 inhibitors, and apheresis (blood filtration), though newer antisense therapies show promise in clinical trials. Testing for Lp(a) is recommended for people with early family history of cardiovascular disease, those with unexplained heart attack or stroke at a young age, and individuals with genetic lipid disorders. While vitamin D and vitamin K show interesting preliminary associations with Lp(a) and calcium buildup, conclusive evidence is currently lacking. Managing other cardiovascular risk factors (smoking, diabetes, hypertension) aggressively is essential for people with elevated Lp(a), as is achieving very low LDL cholesterol levels. Read more

EP141: What if Coronary Artery Disease is Not a Disease?

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 cardiac health education. In this episode, he presents a provocative conceptual framework: that coronary artery disease may not be a disease itself, but rather a maladaptive physiological repair process. He explores how cholesterol's natural role in cell membrane repair, when occurring in damaged arterial areas over an extended human lifespan, could lead to plaque formation. Key Takeaways: Cholesterol serves essential bodily functions including cell membrane construction, fat-soluble vitamin transport, and hormone formation—making it necessary for human health. Plaque formation in coronary arteries is highly focal and heterogeneous rather than evenly distributed throughout the arterial system, suggesting localized factors are at play. Local hemodynamic stresses—such as high blood velocity at arterial branch points and shear stress on the endothelium—may trigger localized cholesterol delivery as a repair mechanism. The body's cholesterol-delivery repair process may function normally in younger individuals but becomes maladaptive when humans live far beyond their evolutionary lifespan of 20-30 years. Coronary artery disease parallels other maladaptive physiological responses, such as blood clot formation, which evolved protectively but can cause life-threatening complications like pulmonary embolism. Individual variations in factors like inflammation, blood pressure, arterial anatomy, and cholesterol carriers (such as lipoprotein A) may determine whether the repair mechanism remains beneficial or becomes pathological. The "widow maker" phenomenon—where a single small plaque in one location can be fatal if it ruptures—supports the theory of localized rather than systemic disease mechanisms. Read more