Heart Attacks are Preventable!

EP140: Talking Triglycerides - 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 featuring Dr. Karam Kostner to discuss triglycerides—a commonly misunderstood but important marker of heart health. The episode explores what triglycerides are, why they matter for cardiovascular health, and evidence-based strategies for managing elevated levels. Key Takeaways: Triglycerides are fats (lipids) found in cell membranes, transported in the bloodstream via proteins, and stored primarily in adipose tissue as the main component of body fat. Triglycerides fluctuate significantly after meals and calorie intake, unlike cholesterol, making a 12-hour fasting measurement essential for baseline assessment; non-fasting levels should also be monitored. Normal triglyceride levels are below 2.5 millimole per liter; levels above 10 mmol/L in the fasting state significantly increase the risk of acute pancreatitis. High triglycerides promote dangerous small, dense LDL particles that more easily penetrate artery walls, contributing to atherosclerosis and cardiovascular disease risk. Major drivers of elevated triglycerides include obesity, diabetes, smoking, hormonal changes (estrogen, testosterone, contraceptive use), genetic conditions, and excessive alcohol intake (4-5+ standard drinks daily). Low thyroid function (hypothyroidism) and heavy alcohol consumption are often-overlooked clinical causes of raised triglycerides that warrant assessment. Non-pharmacological interventions are highly effective: reducing saturated fat intake, weight loss, smoking cessation, regular exercise, and alcohol reduction. Fish oil supplementation with long-chain omega-3 fatty acids (EPA/DHA) is particularly effective for triglyceride reduction, requiring 4 grams daily from high-strength supplements since adequate amounts cannot be obtained from dietary fish alone. Statins have limited effectiveness for triglyceride management (20-40% reduction), making dietary modification the cornerstone of treatment for hypertriglyceridemia. Carbohydrate reduction may be a significant triglyceride driver, particularly in pre-insulin resistant individuals, suggesting personalized dietary approaches may be more effective than universal saturated fat reduction. Read more

EP139: Do I Need to Take Medications Forever?

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 addresses a common patient question: whether medications taken for cardiac conditions must be taken forever. He systematically explores various cardiac conditions and explains which medications are typically lifelong versus temporary based on current medical evidence and guidelines. Key Takeaways: After a heart attack, aspirin and cholesterol-lowering medications are almost certainly lifelong due to robust evidence of their long-term protective benefits in high-risk patients. Patients receiving a stent typically take dual antiplatelet therapy (DAPT) for approximately one year to prevent clot formation on the mesh structure, after which one medication may be discontinued. Bypass graft patients require lifelong aspirin, antiplatelet agents, and cholesterol-lowering medication, though temporary antibiotics may be needed for post-surgical complications. Atrial fibrillation management varies: heart rate-controlling medications are typically long-term, but antiarrhythmic agents can be discontinued if the condition becomes permanent, and anticoagulants are generally required for life. Mechanical heart valves require lifelong anticoagulation with warfarin, while tissue valves may only require temporary blood thinners or aspirin depending on individual circumstances. Cardiac failure patients should remain on preventative medications long-term even if heart function recovers, as studies show one-third of patients develop failure again after medication withdrawal. High blood pressure medications are essentially lifelong; there is no reliable method to discontinue them permanently, though emerging renal artery denervation techniques may offer supportive benefits. Some palpitations can be permanently resolved through electrophysiological catheter ablation techniques rather than requiring long-term medication. Diuretics for cardiac failure may be managed on an as-needed basis for symptom relief rather than required long-term for health maintenance. Read more

EP138: Exercise & Diet For Cholesterol Management - 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 author, hosts this episode with his colleague Dr. Karam Kostner to discuss the practical relationship between lifestyle choices, diet, and cholesterol management. The conversation focuses on helping patients understand what they can do beyond medication to manage their cholesterol and reduce cardiovascular disease risk. Key Takeaways Exercise is excellent for overall cardiovascular health and fitness but has minimal impact on cholesterol levels (lipid panels), though it may slightly lower triglycerides and raise HDL cholesterol. Finding an enjoyable exercise activity that can be sustained 4-6 times per week is more important than following generic exercise prescriptions, as adherence is key. The Portfolio Diet, developed by a Canadian GP, can lower cholesterol by up to 30% (similar to a weak statin) through foods rich in plant sterols, fiber, fish, antioxidants, and dark chocolate. Saturated fats from butter, cream, fatty meats, and processed foods actively raise LDL cholesterol and triglycerides and should be avoided, while healthy monounsaturated fats from nuts, avocados, and olive oil are beneficial. Dietary cholesterol from eggs, milk, and cheese has less impact than commonly thought because the body self-regulates cholesterol production; however, about 20% of the population absorbs dietary cholesterol more efficiently. Keto and very low-carb diets may cause short-term weight loss but promote unhealthy saturated fat intake and are difficult to sustain long-term. Diet alone cannot quickly reverse existing arterial plaque; medication combined with lifestyle changes is necessary for patients with established heart disease. Personalized diet recommendations are essential, as nutritional needs vary significantly based on age, health status, fitness goals, and existing conditions rather than following one universal diet. Alcohol in moderation does not significantly impact cholesterol levels and may slightly increase beneficial HDL, though excessive consumption raises triglycerides and increases cancer risk. Young patients with mildly elevated cholesterol have time to implement dietary changes alone, while older patients or those with existing heart disease typically need medication as an adjunct to lifestyle modifications. Read more

Know Your Real Risk of Heart Attack (Audiobook Now Available - Sample)

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: This episode features a cardiologist reflecting on a pivotal experience from 2005 when a patient he had previously given cardiac clearance to suffered a heart attack during a fun run. Though the patient was successfully resuscitated, the incident prompted the speaker to recognize the limitations of his prior assessment and motivated him to explore how modern technology can improve cardiac risk detection and management. The episode introduces the broader context of heart disease in Australia, where approximately 55,000 people suffer heart attacks annually—roughly one every 10 minutes. Key Takeaways: Early cardiac testing results (like exercise treadmill tests) can appear normal yet miss significant coronary artery disease that may develop or be undetected at the time. Even appropriate medical assessment and reassurance based on available information at the time can have limitations that become apparent in hindsight. The speaker's experience highlights the emotional and professional impact of reassuring patients who later experience cardiac events. Modern medical technology has evolved significantly over the past 10-15 years, offering new opportunities for better cardiac risk assessment and management. Heart attacks typically result from narrowing or blockage of coronary arteries and can require various interventions including medication, hospitalization, balloon angioplasty, stents, or bypass surgery. Patients typically do not expect to experience cardiac problems, suggesting a gap between actual risk and perceived risk in the general population. There is a need for improved methods of dealing with cardiac risk through better investigation protocols and management strategies. Read more

EP137: Supplements and Nutraceuticals For Lowering Cholesterol - 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 author, hosts this episode with his colleague and friend Dr. Karam Kostner to discuss nutraceuticals—natural plant and animal components—that can help lower cholesterol as alternatives or complements to pharmaceutical drugs. The episode addresses the growing interest in these supplements fueled by social media discussions about statin side effects and the desire for more "natural" cholesterol management options. Key Takeaways: Red yeast rice contains the same active ingredient as statins (derived from fungus) but lacks the rigorous quality control and standardized dosing of pharmaceutical-grade statins, making its effectiveness and safety less predictable. Fish oil/omega-3 fatty acids (EPA and DHA) are highly effective at lowering triglycerides at doses of 2-4 grams and provide additional benefits for brain health, inflammation, and joint health, making them particularly valuable for pre-diabetic patients. The effectiveness of fish oil in preventing sudden cardiac death and heart failure remains controversial, with conflicting results across different clinical trials and studies. When purchasing fish oil supplements, the critical factor is the amount of EPA and DHA per dose; liquid formulations (1 gram per milliliter) are most cost-effective, while standard capsules contain only 300 milligrams of active ingredients. Plant sterols lower LDL cholesterol by 10-15% by preventing dietary cholesterol absorption; they are available as tablets, powders, or in enriched foods like margarines and cereals. Polycosanol provides modest cholesterol reduction of 8-12% but carries side effects including headaches and increased bleeding, making it less safe than other nutraceutical options discussed. Coenzyme Q10 does not lower cholesterol itself but may help offset statin-related muscle side effects; magnesium is a cheaper alternative with comparable efficacy and additional heart health benefits. Niacin (vitamin B3) at high concentrations effectively lowers LDL, increases HDL, decreases triglycerides, and reduces lipoprotein A, but its significant flushing side effects limit patient tolerance and compliance. Read more

Audiobook Now Available - Atrial Fibrillation Explained (Sample)

Audiobook Now Available - Atrial Fibrillation Explained Read more

EP136: Narrowed Artery to the Kidney

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 Healthy Heart Network. In this episode, Dr. Bishop explores renal artery stenosis—a narrowing of the arteries supplying the kidneys—and explains why this condition is an interesting and important cause of elevated blood pressure that clinicians need to recognize. Key Takeaways: The kidneys receive approximately 25% of the blood pumped by the heart at rest and depend heavily on adequate blood flow to filter waste products, maintain fluid balance, and remove toxins from the body. Renal artery stenosis occurs when an artery supplying a kidney becomes narrowed, reducing blood flow to that organ and triggering a compensatory response. When a kidney senses reduced blood flow, it releases renin, which initiates a hormonal cascade converting angiotensin 1 to angiotensin 2, a potent hormone that constricts blood vessels throughout the body and raises blood pressure. Renal artery stenosis is a significant cause of difficult-to-control high blood pressure, particularly in young patients with severely elevated readings. Fibromuscular dysplasia, a condition characterized by fibrosis and narrowing of arterial muscle tissue, commonly causes renal artery stenosis in middle-aged women. Atherosclerotic plaque buildup in renal arteries is a frequent cause of renal artery stenosis in elderly patients. In the rare but serious case of bilateral renal artery stenosis (narrowing in both kidneys), ACE inhibitors and angiotensin II receptor blockers can cause a sudden, significant decline in kidney function by blocking the compensatory renin-angiotensin system. Patients with difficult-to-treat high blood pressure who experience a precipitous drop in kidney function after starting ACE inhibitors or AT2 blockers should be evaluated for bilateral renal artery stenosis. Read more

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