Heart Attacks are Preventable!

EP135: Discussing High Cholesterols in Families - Familial Hypercholesterolaemia

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 with Dr. Karam Kostner, a lipidologist and cardiologist specializing in familial hypercholesterolemia (FH). The episode explores familial hypercholesterolemia—an inherited condition causing dangerously high cholesterol levels from birth—and discusses why early diagnosis and treatment are critical for preventing premature heart disease. Key Takeaways: Familial hypercholesterolemia is an autosomal dominant inherited condition affecting approximately 1 in 200-300 Australians, with higher prevalence in certain populations including Lebanese, Middle European, Mormon, and Ashkenazi Jewish communities. FH is not a matter of "if" but "when" patients develop coronary disease; however, it is entirely treatable through early intervention starting in childhood, potentially preventing heart attacks and delaying disease progression. Diagnosis relies on clinical calculators (such as the Dutch Lipid Score or Simon-Broom criteria) that assess LDL cholesterol levels, family history, clinical signs, and cardiovascular disease history, with genetic testing confirming defects in LDL receptors, ApoB, or PCSK9 genes. Treatment typically begins with statins at age 10, progressing to combination therapy with ezetimibe in young adults, and PCSK9 inhibitors for those with inadequate response; severe cases may require apheresis (a dialysis-like procedure) or liver transplant. Cardiac CT imaging is valuable for visualizing arterial plaque buildup and improving patient engagement with treatment, using radiation doses comparable to mammograms and helping clinicians determine appropriate therapy intensity. Family screening is essential because detecting one FH patient enables identification of siblings, children, and other relatives; Australia and New Zealand have established an FH registry to facilitate family follow-up. Distinguishing FH from general high cholesterol requires careful assessment of LDL levels, family history of early cardiovascular disease, and clinical features like Achilles tendon thickening or corneal rings. Additional risk factors such as smoking, high blood pressure, diabetes, and obesity significantly accelerate coronary disease development in FH patients, making aggressive management of these conditions crucial. Recent Medicare rebate approval for genetic testing by specialists will improve accessibility and support family screening initiatives across Australia. Read more

EP134: Discussing Statin Intolerance 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, hosts this episode with guest Dr. Karam Kostner, a lipid expert and cardiologist from Queensland. The discussion focuses on statin intolerance—a common concern among patients—exploring its definition, prevalence, and practical management strategies in clinical practice. Key Takeaways: Statin intolerance is defined as the inability to tolerate at least two different statins due to clinical side effects, though true intolerance is less common than patients perceive. Muscle pain occurs in approximately 5% of statin users taking higher doses (atorvastatin 80mg, rosuvastatin 40mg), but most musculoskeletal pain is coincidental rather than statin-caused. Rhabdomyolysis, the most serious muscle-related side effect, is extremely rare (approximately 1 in 10,000 to 1 in 80,000 patients) and involves significant muscle pain with CK elevation of 5-10 fold above normal limits. Statins actually prevent vascular dementia and cognitive decline in most patients; short-term memory loss attributed to statins is extremely rare despite popular concerns. Studies show that in a placebo-controlled challenge, approximately 75% of patients reporting statin intolerance could tolerate statins when blinded, while only 25% experienced genuine side effects. Different statins carry different risk profiles; older statins like fluvastatin and pravastatin show lower muscle-related side effects compared to high-dose atorvastatin and rosuvastatin. While statins may slightly increase glucose levels in pre-diabetic patients, this small risk is offset by cardiovascular benefits in diabetic patients. Clinical management strategies include trying multiple statins at varying doses, using low-dose statins three times weekly, and adding ezetrol to achieve cholesterol targets. Magnesium orotate (800-1200mg daily) is an evidence-based, safe, and cost-effective supplement that reduces statin-related muscle symptoms in many patients. Coenzyme Q10 supplementation may help some patients resistant to magnesium, though conclusive evidence from large trials is limited. Read more

EP133: Funny Beats In The Heart - Ventricular Ectopic Beats (VEB)

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 passionate health educator who believes informed patients receive better healthcare. In this episode, he provides a comprehensive explanation of ventricular ectopic beats—irregular heartbeats that cause palpitations—including how they occur, why they feel alarming, and how to manage them in patients with structurally normal hearts. Key Takeaways: Ventricular ectopic beats are characterized by a "funny thump or flop" sensation in the chest, often feeling like the heart will jump out of the body, and typically occur when patients are relaxing. Diagnosis involves using a Holter monitor to record heart activity while the patient notes when palpitations occur, allowing doctors to match symptoms with the abnormal electrical pattern on an ECG. An ultrasound of the heart is essential to confirm the heart is structurally and functionally normal; ectopic beats in structurally abnormal hearts represent a different and more serious concern. Ventricular ectopic beats occur when cells in the ventricles become "agitated" and fire abnormally between regular heartbeats, causing electrical signals to spread inefficiently across the heart rather than through normal conduction pathways. The sensation people feel results from the irregular beat coming early, a pause that follows, and then a stronger-than-normal beat that occurs because more blood has accumulated during the longer pause. Ectopic beats are more likely to occur during relaxation or lower heart rates; when the heart beats quickly during exercise, it's difficult for extra beats to "squeeze in," similar to inserting a stick between the spokes of a spinning bicycle wheel. Stress is a major trigger for ventricular ectopic beats, along with gastric and esophageal reflux issues due to the neurological proximity between the heart and digestive system. These beats are generally benign and do not require medication; they typically resolve on their own as stress decreases and life circumstances change. Recommended management strategies include omega-3 supplements (effective in 60-70% of patients as a membrane stabilizer), magnesium supplementation, relaxation techniques, and increasing physical activity. Read more

EP132: A Patient With Hard-to-Treat Heart Palpitations

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 speaks to the Healthy Heart Network membership group and shares a compelling clinical story about palpitations, a symptom that has been appearing frequently in his practice. Through a patient case study spanning several months, Dr. Bishop illustrates an important lesson about the relationship between emotional wellbeing and cardiac symptoms. Key Takeaways: Palpitations are a common cardiac symptom that can present with rapid heartbeats (supraventricular tachycardia) or irregular beats (ventricular ectopic beats), and diagnosis typically requires monitoring devices like Holter monitors. Medical interventions for palpitations include beta blockers and calcium channel blockers as first-line treatments, with electrophysiological ablation procedures available as an advanced option for certain arrhythmias. Not all palpitations have a purely physiological cardiac cause; anxiety, stress, and emotional distress can significantly contribute to or even be the primary driver of palpitation symptoms. A patient's emotional and psychological state—including relationship stress and anxiety—can manifest as physical cardiac symptoms that fail to respond to standard medical treatments. Sometimes the most important diagnostic tool is asking open-ended questions and listening carefully to patients; Dr. Bishop's direct inquiry about what else might be going on revealed the true underlying issue. Lifestyle interventions such as magnesium and fish oil supplementation may help manage certain types of palpitations alongside or instead of pharmaceutical approaches. Resolution of emotional stressors can lead to complete resolution of cardiac symptoms, demonstrating the mind-body connection in heart health. As a physician, recognizing the limits of medical expertise and acknowledging when issues fall outside one's specialty is crucial for truly helping patients. Read more

EP131: Controlling Blood Pressure With A Procedure, Renal Artery Denervation

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 is a practicing cardiologist and author dedicated to patient education in heart health, believing that informed patients receive better care. In this episode, he explores renal denervation, a cutting-edge procedure that targets the sympathetic nerves controlling blood pressure around the kidneys. The discussion centers on the recent Spiral HTN trial, which demonstrates promising results for this non-medication approach to treating high blood pressure. Key Takeaways: Renal denervation involves destroying the sympathetic nerves (fight-or-flight nerves) that run along the renal arteries to the kidneys, which contribute to elevated blood pressure regulation. The concept originated in Melbourne in the 1990s when researchers hypothesized that sympathetic nerves controlling the kidneys could be contributing to high blood pressure, leading to the first procedure in 2007. The Simplicity 3 trial, which used a sham control procedure, showed disappointing results with minimal blood pressure reduction differences, effectively halting the technology's advancement for years. The failure of Simplicity 3 was partly attributed to non-standardized catheters and operators with insufficient experience in the technique, rather than the concept being fundamentally flawed. The new Spiral HTN trial used an improved catheter design with a corkscrew curl that allows easier application and nerve destruction without requiring extensive operator expertise. The Spiral HTN trial showed statistically significant results: 24-hour blood pressure reduction of 4 mm Hg systolic and office blood pressure reduction of 6.5 mm Hg systolic compared to sham procedure. The procedure was found to be incredibly safe with zero procedural complications reported in the trial. Blood pressure reductions achieved through this procedure offer approximately a 20% relative risk reduction in cardiovascular events for patients. This technology could reduce medication burden for patients with difficult-to-control hypertension and may improve the natural day-night blood pressure variation pattern. The procedure may primarily benefit patients with recalcitrant (difficult-to-treat) hypertension, and future considerations include cost and potential Medicare reimbursement eligibility. Read more

EP130: COVID-19 From A Cardiologist's Perspective

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 is a practicing cardiologist and author dedicated to improving patient care through heart health education. In this episode, he addresses COVID-19 from a cardiological perspective, focusing on practical guidance for patients during the pandemic and clarifying misconceptions about blood pressure medications and COVID-19 risk. Key Takeaways: Phone consultations have become a vital tool for delivering healthcare during COVID-19, with the Australian government quickly implementing this option to maintain patient care while people isolate at home. For phone consultations to work effectively, patients should be punctual, find a quiet location free from interruptions, and consider using speakerphone so family members or carers can participate. First consultations are best conducted face-to-face when possible, as they require building rapport and reading non-verbal cues; however, phone consultations work well for follow-ups, especially for elderly, frail, or mobility-impaired patients. Patients should prepare for phone consultations by writing a list of issues they want to discuss and presenting them early in the call, along with an up-to-date medication list, to maximize the limited time available. A study in The Lancet suggesting ACE inhibitors increase COVID-19 risk was purely theoretical and lacked supporting evidence; the paper did not even verify whether hypertensive patients were taking these medications. Blood pressure medications, including ACE inhibitors and angiotensin-2 receptor blockers, should not be discontinued, as hypertension and diabetes rates in COVID-19 patients match general population rates with no clear evidence of increased risk. Patients should organize a sensible 4-6 week supply of medications by liaising with their pharmacist and potentially arranging delivery, allowing delivered medications to sit for four days to eliminate any viral contamination. Hoarding medications selfishly and unnecessarily—such as clearing pharmacy shelves of Ventolin inhalers or other essential medications—deprives vulnerable patients of life-saving treatments and represents thoughtless behavior during the crisis. Patients should follow standard COVID-19 precautions including hand washing, social distancing, and avoiding contact with people recently on cruise ships, while maintaining sensible preparation without overreacting. Read more

EP129: General Talk On Valves

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, believing that informed patients receive the best care. In this episode, Dr. Bishop provides a comprehensive overview of the heart's four valves—the tricuspid, pulmonary, mitral, and aortic valves—and explores the various problems that can affect them. He explains how valves function as one-way gates in the circulatory system and discusses the conditions that lead to valve disease. Key Takeaways: The heart contains four valves (tricuspid, pulmonary, mitral, and aortic) that work as one-way systems to ensure blood flows in only one direction through the heart chambers. Left-sided heart valves (mitral and aortic) experience the most wear and tear because they operate under higher pressures—around 100 millimeters of mercury compared to 20-30 in the lungs. Heart valves can malfunction in only two ways: they can become stenosed (too narrow, restricting blood flow) or regurgitant (leaky, allowing backward blood flow). Bicuspid aortic valves (having two leaflets instead of the normal three) are a congenital condition that increases premature wear and tear, potentially leading to valve replacement. Rheumatic fever from childhood infections is a major cause of both aortic and mitral valve disease, causing scarring and narrowing over time. Bacterial endocarditis (infection on valve leaflets) and other infections can permanently damage valve tissue, causing leakage or narrowing even after the infection clears. Floppy mitral valve syndrome is a congenital condition where leaflets are abnormally redundant, causing increased wear and tear that can lead to rupture and leakage. Tricuspid valve leakage commonly occurs when lung pressures are elevated or when right heart failure causes the fibrous ring holding the valve to dilate. The pulmonary valve rarely causes problems due to its low-pressure environment, though congenital narrowing can occasionally occur. Valve disease typically presents with shortness of breath and reduced exercise capacity rather than chest pain, and can often be detected through heart murmurs that doctors identify during physical examination. Read more

EP128: Astronauts & Blood Flow in Space

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 through his podcast and videocast station. In this episode, he explores the fascinating intersection of space medicine and cardiology by examining how astronauts' bodies respond to microgravity, particularly focusing on unexpected changes in blood flow and vision. The episode bridges historical space exploration achievements with cutting-edge medical research discoveries made possible through astronauts' participation in space station experiments. Key Takeaways: Early space programs were concerned with basic bodily functions in zero gravity, but astronauts proved remarkably capable of adapting to the space environment despite discomfort. Approximately 10 years ago, NASA researchers discovered that astronauts in space were experiencing swollen optic nerves, flatter eyeballs, and vision changes—symptoms initially addressed simply by providing corrective glasses. A research team studied 11 astronauts' blood flow patterns in the jugular vein (the main neck vessel returning blood to the heart) across different body positions on Earth and compared findings to their physiology in space. Five of the 11 astronauts showed stagnant or reversed blood flow in their jugular veins while in space, meaning blood entering the brain through carotid arteries was not flowing back out normally, causing fluid accumulation. Stagnant blood flow in veins creates a significant risk of deep vein thrombosis (blood clots), a concern astronauts typically face after immobilization, such as following surgery. Female astronauts taking oral contraceptive pills face compounded clot risk, as hormonal contraceptives already increase clotting tendency when combined with blood flow stagnation. Commercial space tourism presents a critical medical concern, as paying passengers may lack the rigorous health screening and superior physiology of professional astronauts, making them vulnerable to dangerous clotting complications. Understanding how gravity loss affects bodily adaptation is essential for developing safety protocols and medical interventions for both professional astronauts and future space travelers. Read more

EP127: Seeing The Forest For The Trees - Paperwork Over Patients

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 who hosts this educational podcast focused on heart health and cardiac care. In this episode titled "Wood for the Trees," Dr. Bishop addresses what he perceives as an excessive emphasis on bureaucratic protocols and documentation in modern hospital practice, arguing that rigid adherence to guidelines is sometimes prioritized over patient care and common sense clinical judgment. Key Takeaways Modern hospitals have introduced increasing levels of bureaucracy, red tape, and rigid protocols that burden nursing and medical staff, often driven by the pursuit of standardized "best practices." While checklists and structured guidelines are essential in medicine to prevent errors and save lives, the system has shifted to make tick-box compliance the primary objective rather than patient welfare. Clinical parameters and limits (such as heart rate thresholds) have become arbitrary cutoffs that don't account for individual patient variation, medication effects, or clinical context. Dr. Bishop experienced a situation where a patient on heart-rate-lowering medication with a pulse of 48 bpm was flagged for being 2 bpm below the 50 bpm limit, despite being clinically well—illustrating how rigid limits override clinical judgment. Excessive focus on documentation bureaucracy creates significant opportunity costs and stress, diverting time and attention away from actual patient care activities. During the same week as the heart rate incident, two patients actually missed critical medications—including a patient who didn't receive anticoagulation for a mechanical heart valve and another who missed anti-chest pain medication—due to the misdirected focus on documentation over patient wellbeing. Protocolization and tick-box systems prevent clinical staff from thinking critically and prioritizing what truly matters in patient care. The rigid bureaucratic approach is causing burnout and demoralization among experienced healthcare professionals who recognize the disconnect between compliance and quality care. Read more

EP126: Major Trial Changes in Cardiology Thinking

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 passionate educator dedicated to helping patients understand their heart health through evidence-based information. In this episode, Dr. Bishop discusses the recently released ISCHEMIA Trial, a landmark cardiology study that challenges conventional approaches to treating stable coronary artery disease. The trial's findings have significant implications for how cardiologists decide between invasive stenting procedures and conservative medical management strategies. Key Takeaways The ISCHEMIA Trial is a landmark, double-blind randomized controlled trial involving over 5,000 patients that compared early interventional stenting strategy versus optimal medical therapy in stable patients with moderate to high-risk coronary artery narrowings. The trial's primary finding shows that major adverse cardiac events (MACE) outcomes were essentially equivalent between the early intervention group and the optimal medical therapy group after 3.5 years of follow-up. Optimal medical therapy includes aggressive cholesterol management, aspirin therapy, blood pressure control, and lifestyle modifications including diet and exercise—often without the need for stent placement in stable patients. The ISCHEMIA Trial was designed to validate earlier findings from the BARRY 2 and COURAGE trials, which suggested stable patients could be effectively managed conservatively rather than immediately undergoing stenting procedures. The trial excluded patients with left main coronary artery disease, as these individuals represent genuinely high-risk cases that require intervention and would have skewed the results. While early intervention resulted in fewer symptoms at one year, the placebo-controlled ORBITER Trial demonstrated that sham procedures produced nearly equivalent symptom reduction, highlighting the power of placebo effect in symptom improvement. The trial should reduce unnecessary stenting procedures performed by interventional cardiologists and encourage more thoughtful, individualized conversations between doctors and patients about the actual need for intervention. Factors influencing whether a patient should pursue early intervention include patient age (younger patients may benefit more), symptom severity, medication compliance, amount of at-risk heart muscle, and plaque location. Dr. Bishop's clinical practice already incorporates conservative management strategies, using CT coronary angiography and periodic stress testing to monitor stable patients on optimal medical therapy rather than immediately recommending stents. Read more