Heart Attacks are Preventable!

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

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