Heart Attacks are Preventable!

EP78: PCSK-9 Inhibitors

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. Episode Summary Dr. Warrick Bishop, a practicing cardiologist and author, discusses PCSK9 inhibitors—a new class of cholesterol-lowering drugs. The episode explores how these monoclonal antibodies work at the molecular level, their clinical benefits compared to traditional statins, and their current availability in Australia, with particular focus on how high-risk patients can access them. Key Takeaways: Statins remain the foundation of cholesterol management as they are effective, affordable, well-tolerated, and extensively studied over two decades. PCSK9 inhibitors are monoclonal antibodies that prevent the breakdown of LDL receptors, allowing them to be recycled and remove more bad cholesterol from the bloodstream. PCSK9 inhibitors can lower LDL cholesterol by 50-60% more than statins combined with ezetimibe in high-risk patients. The discovery of PCSK9's role in cholesterol management came through genetic research showing that people with low PCSK9 levels had better cardiovascular outcomes and longevity. Clinical trials (Fourier and Odyssey) have demonstrated mortality benefits with PCSK9 inhibitors, particularly in high-risk patient populations. In Australia, PCSK9 inhibitors are currently government-funded only for patients with familial hypercholesterolemia who meet specific criteria. Private patients unable to meet PBS criteria can self-fund PCSK9 inhibitors for approximately $1,500-$3,000 annually, with potential health fund contributions reducing out-of-pocket costs to around $100-150 per month. PCSK9 inhibitors are particularly valuable for patients who are intolerant or unresponsive to statins, ezetimibe, nicotinic acid, and other traditional cholesterol-lowering agents. These drugs also lower lipoprotein(a) levels, providing additional cardiovascular benefit for patients with elevated levels of this risk factor. Read more

EP77: Blood Pressure - How Low To Go?

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 addresses a common clinical concern: blood pressure management, specifically discussing a recent patient case where a GP reduced the patient's blood pressure medication based on low readings despite the patient experiencing no symptoms. Key Takeaways: Blood pressure directly reflects the workload and effort of the heart; lower blood pressure means less strain on the heart as a pump. Chronically elevated blood pressure causes wear and tear on the heart, leading to thickening of the left ventricle and dilation of the left atrium. High blood pressure significantly increases the risk of developing atrial fibrillation and can eventually lead to heart failure over a lifetime. For patients with existing heart failure, lowering blood pressure as much as possible is critical to reduce the workload on an already compromised heart. Beta-blocker medications like bisoprolol are often pushed to the highest tolerable dose because maximizing these medications provides optimal cardiac protection. The purpose of measuring blood pressure is to determine if it is too high and needs to be lowered—not to check if it is too low. Low blood pressure without symptoms is beneficial and requires no adjustment to medication; symptoms, not numbers alone, should guide treatment decisions. Over-medication causing symptoms such as lightheadedness, dizziness upon standing, or wobbliness should prompt a reduction in blood pressure medication. The ideal approach is achieving the lowest possible blood pressure without causing any symptoms, maximizing heart protection while maintaining quality of life. Read more

EP76: What Is Heart Failure?

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 introduces cardiac failure (heart failure) as a critically important condition affecting over 38 million people worldwide, including 10% of those over 75 years old. Dr. Bishop emphasizes the need to demystify the terminology and explain the condition in accessible terms, while exploring how evolutionary biology helps us understand why cardiac failure produces its characteristic symptoms. Key Takeaways: The term "cardiac failure" can be unnecessarily frightening to patients; using alternative terminology like "dicky ticker" may be less confronting while still accurately describing the condition. Cardiac failure is a widespread condition with significant global impact, affecting over 38 million people worldwide and having consequences for individuals, families, communities, and economies. The heart is a pump responsible for supplying blood to all organs in the body, so dysfunction can compromise circulation to multiple organ systems beyond just the heart. Common symptoms of cardiac failure include shortness of breath (especially during exercise), fluid retention and swelling, fatigue, lethargy, depression, and impaired function of organs like the kidneys and liver. Evolutionary mechanisms designed to preserve circulation during acute blood loss (such as fluid retention triggered by ancient survival receptors) become counterproductive in chronic cardiac failure. Receptors in the heart, major blood vessels, and kidneys evolved to detect circulatory inadequacy and trigger fluid retention—a response that saved our ancestors but now worsens cardiac failure symptoms. The shortness of breath and fluid accumulation characteristic of cardiac failure result from ancient physiological preservation responses that are misplaced in the modern cardiac context. Understanding the evolutionary basis of cardiac failure symptoms provides valuable insight into how the condition should be managed long-term. Read more

EP75: Bad Joints, Good Heart, Glucosamine

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 cardiovascular health expert, hosts the Healthy Heart Network podcast. In this episode, he explores recent research on glucosamine—a popular supplement commonly used for joint and cartilage health—and its potential cardiovascular benefits. The discussion centers on a recent UK meta-analysis of glucosamine trials that suggested a possible reduction in cardiovascular events among users. Key Takeaways: Recent pooled data from approximately 15 glucosamine trials suggests a potential reduction in cardiovascular events among glucosamine users Glucosamine likely exerts anti-inflammatory effects, which may be beneficial since inflammation plays a role in plaque formation and coronary disease The landmark Cantos trial demonstrated that targeted anti-inflammatory agents (canakinumab) significantly reduced cardiovascular events, providing strong evidence that inflammation is a key factor in heart disease Current research is exploring other anti-inflammatory agents like colchicine (traditionally used for gout) as potential cardiovascular treatments While the glucosamine data is promising and theoretically sound, it remains speculative and should not yet be considered standard therapy for heart disease prevention Glucosamine appears to be safe for cardiovascular health with no adverse effects observed in current data People taking glucosamine for joint pain can do so with confidence, knowing it may offer modest cardiovascular benefits as an added bonus Further trials are ongoing to better understand the relationship between anti-inflammatory interventions and cardiovascular disease prevention Read more

EP74: Antiplatelet With Antibiotic Action - Serendipity In Action

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 hosts the Healthy Heart Network podcast/videocast, where he discusses recent cardiology news and research. In this episode, he shares a fascinating discovery about Ticagrelor, an antiplatelet medication commonly used after acute coronary syndromes, which researchers have observed may have unexpected antibiotic properties against multidrug-resistant bacteria. Key Takeaways: Ticagrelor, an antiplatelet drug given to patients receiving stents after heart attacks or unstable angina, was observed to correlate with lower infection rates in those patients compared to those who didn't receive it. Researchers followed up on this observation by conducting structured studies to investigate whether Ticagrelor actually has antibiotic properties beyond its known effect on blood platelets. Ticagrelor appears to have an antimicrobial mechanism of action that is completely separate from its P2Y12 receptor activity used to prevent blood clotting in stents. The drug demonstrates particular promise against multidrug-resistant bacteria, which have developed resistance to many modern antibiotic therapies—a major clinical problem. The therapeutic doses required to kill bacteria in petri dish studies are far too high for safe human use, as they would cause dangerous bleeding. The goal of future research is to identify and isolate the specific antibiotic component of Ticagrelor so it can be purified separately from its antiplatelet effects. Scientists aim to develop a new class of antibiotic therapy based on the active ingredient from Ticagrelor, potentially targeting difficult multidrug-resistant gram-positive bacteria. This discovery represents an example of serendipitous scientific discovery, where an incidental observation led to a potentially groundbreaking therapeutic avenue. Read more

EP73: SAMHRI Meeting - May 10 & 11, 2019

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 who believes that informed patients receive the best healthcare. In this episode, he shares key insights and learnings from the South Australian Heart and Medical Research Institute weekend conference (May 10-11), which covered cholesterol management, prevention strategies, peripheral vascular disease, cardiac failure, and heart attack treatment across a broad range of cardiovascular topics. Key Takeaways: PCSK9 inhibitors can safely lower LDL cholesterol to very low levels (around 0.6 mmol/L) in high-risk post-heart attack patients, reducing future cardiac events, with genetic evidence showing no harm even at levels as low as 0.25 mmol/L. Current Australian guidelines recommend LDL cholesterol below 1.8 mmol/L for post-event patients, but emerging research suggests lower targets may be more beneficial. Sodium-glucose transport blockers (SGLT2 inhibitors) are a new drug class that helps diabetics while also providing cardiac failure benefits, but requires careful monitoring to prevent ketoacidosis with normal blood sugar. The REDUCE-IT trial demonstrated that high-dose EPA (fish oil component) significantly benefits patients with high triglycerides over a 10-year period, though the mechanism and patient selection criteria remain not fully understood. Cholesterol crystals within arterial plaque trigger inflammation, and agents like colchicine (historically used for gout) may help reduce this inflammatory response. Lowering LDL cholesterol to very low levels does not cause memory or cognitive problems, as confirmed by the Ebbinghaus study and genetic evidence. Managing patients with atrial fibrillation who require stents is complex and controversial, requiring balance between anticoagulation (for stroke prevention) and antiplatelet therapy (to prevent stent clotting). The Global Leaders Trial showed that Ticagalor as a single agent worked better than standard regimens at 12 months but lost efficacy by 24 months, suggesting potential long-term compliance issues. Cardiac failure treatment involves numerous options including ACE inhibitors, AT2 blockers, spironolactone, beta blockers, SGLT2 inhibitors, and iron infusions, requiring careful individualized management. Read more

EP72: We Can Do Better

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 filmed from the Maldives, Dr. Bishop shares two case studies that illustrate gaps between optimal cardiac care and current clinical practice, highlighting the importance of patient advocacy in healthcare decisions. Key Takeaways: Stress tests alone are insufficient for assessing arterial health; they only detect significant blockages that are already late in the disease process and may miss early plaque buildup. Patients with family history of heart disease should advocate for direct imaging of their arteries rather than relying solely on functional tests like treadmill assessments. Performing stress tests on asymptomatic patients who are clearly fit may reflect business interests rather than genuine clinical necessity. CT coronary angiography (with contrast) provides valuable information about plaque presence and quantity, enabling better risk stratification and treatment intensity decisions. A 30% arterial narrowing on CT imaging is non-flow-limiting and will not cause symptoms, as approximately 70% narrowing is needed to produce hemodynamic obstruction. Proceeding to invasive coronary angiography after a non-flow-limiting finding on CT without symptoms constitutes over-servicing and carries unnecessary risks to patients. Invasive coronary angiography cannot show greater detail than CT for a 30% lesion and is therefore an inappropriate follow-up test in asymptomatic patients. Over-servicing wastes community resources and increases individual patient costs while exposing patients to unnecessary procedural risks. Patients must actively ask questions and seek appropriate imaging to ensure they receive evidence-based care aligned with their actual risk profile. Healthcare technology must be used with integrity and clinical judgment to serve patient outcomes rather than financial incentives. Read more

EP71: The Italian Hour - Interview With Renato Delfatti

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 joins host Renato to discuss heart health education and disease prevention. The episode centers on Dr. Bishop's book "Have You Planned Your Heart Attack?" and explores why early detection and understanding of arterial health is crucial, even for apparently fit individuals. Dr. Bishop emphasizes that educated patients receive better healthcare outcomes and advocates for preventive scanning and lifestyle modifications before heart problems develop. Key Takeaways: Fitness and healthy appearance do not guarantee protection against heart attacks; arterial health is not always reflected by external health indicators. Plaque buildup in arteries is a complex process involving cholesterol deposits that can block blood flow, but can be modified through medication and cholesterol-lowering strategies. Early detection of plaque through advanced imaging allows for intervention before a heart attack occurs, making preventive scanning and monitoring worthwhile. Plaque can be reduced or even reversed in some patients when cholesterol is lowered sufficiently, as demonstrated through serial scanning and clinical experience. There is a significant gap between cutting-edge medical technology and widespread adoption by general practitioners due to lack of established guidelines and slow implementation timelines. Patient education and informed understanding of heart health conditions empowers individuals to have meaningful conversations with their doctors and actively participate in prevention strategies. A heart attack (medically termed myocardial infarction) occurs when lack of blood flow damages heart muscle; the underlying issue involves arterial blockage rather than sudden failure. Dr. Bishop's book uses accessible language, humor, cartoons, and real stories to make complex cardiac concepts understandable to non-medical audiences. Free resources including a 12-13 episode TV series and book previews are available on Dr. Bishop's website (www.drWarrick.com) to help people learn about heart health before committing to the full book. Long-term medication compliance and lifestyle changes are essential for managing cholesterol and preventing heart disease, rather than short-term interventions. Read more

EP70: Cholesterol: Confusion And Controversy

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 and improving heart health outcomes through informed decision-making. In this episode, Dr. Bishop addresses the confusion and controversy surrounding cholesterol management and statin therapy by exploring why polarized opinions exist among patients despite established medical guidelines. The episode was prompted by heated discussions in his Facebook group "Know Your Real Risk of Heart Attack," particularly from a member named Jeff who held strong anti-statin views based on personal research. Key Takeaways: Cholesterol is an association with heart disease, not a direct causation—meaning high cholesterol increases risk at the population level but doesn't guarantee individual heart attacks. For patients with established heart disease (prior heart attack, stent, or bypass), lowering cholesterol with statins is clearly supported by 30-40 years of research and significantly improves outcomes. Treatment decisions should distinguish between high-risk and low-risk patients—those with existing arterial plaque benefit most from cholesterol-lowering therapy, while asymptomatic patients with only elevated cholesterol require more careful consideration. Before treating high cholesterol in otherwise healthy individuals, discussion with a GP or specialist (lipidologist/preventative cardiologist) is valuable to assess actual risk. Arterial imaging tests can help determine if cholesterol plaque buildup is actually present, informing whether aggressive treatment is necessary for asymptomatic patients. Treatment decisions must account for multiple risk factors including blood pressure, smoking, diabetes, exercise level, medication side effects, and individual health objectives. Statins are both effective and safe in treating patients with established heart disease, with strong evidence supporting their use. Patient education and informed discussion reduce polarization—patients should seek reliable information sources rather than relying on anecdotal internet research. Read more

EP69: CTCA Risk Consultation

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 educated patients receive the best care. In this episode, he conducts a consultation interview with his patient Wayne and Wayne's wife Maureen, sharing Wayne's preventative cardiology journey after discovering significant coronary artery disease during routine screening at age 65. The episode highlights the importance of proactive heart health assessment and the life-changing impact of preventative imaging. Key Takeaways: Preventative cardiac imaging can detect serious conditions in asymptomatic patients who might otherwise walk out of a GP appointment and collapse without warning. Wayne's intuition about needing a "proper heart check" led him to seek advanced imaging rather than relying solely on traditional GP assessments like blood pressure checks and stethoscope examination. CT coronary angiography revealed substantial plaque buildup in Wayne's left main coronary artery—a critical finding that without treatment could have resulted in sudden cardiac death as his first cardiac event. Not all cardiologists emphasize preventative imaging; some colleagues offer only treadmill tests, meaning patients could receive different management strategies depending on which specialist they consult. Aggressive cholesterol-lowering therapy is particularly beneficial for patients with documented arterial plaque, as it can stabilize and potentially reduce plaque burden over time. The controversy surrounding statin side effects is often overstated; Wayne experienced no side effects, and the decision to use statins should balance individual risk-benefit rather than relying on generalized concerns. Preventative cardiac screening costs ($600-700) represent excellent value when considered as an investment in decades of life expectancy and safety, comparable to spending on vehicle maintenance. Delay in seeking preventative care is common; Wayne contemplated getting screened for five years before finally acting, highlighting the need for patients to prioritize health assessment earlier. Regular surveillance through repeat stress testing and imaging every couple of years allows doctors to monitor plaque progression and adjust treatment strategies accordingly. Patients should prioritize seeking preventative cardiac assessment if they have risk factors, as early detection transforms cardiovascular risk from "unacceptably high with no awareness" to substantially reduced risk with active management and education. Read more