Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name's Dr. Warrick Bishop and I'd like to welcome you to my podcast and videocast station and of course to the Healthy Heart Network. Today I'd like to share with you a case from earlier this week. I'm going to talk about Trevor who's a 69 year old gentleman who came to me earlier this year with some shortness of breath. I'm going to talk about his case because he represents a situation where So misunderstanding and misinterpretation were going to lead to mismanagement and misfortune. So when Trevor came to see me earlier in the year, his general practitioner had sent him because of some shortness of breath, I put Trevor through a treadmill test. And although we didn't find any major lack of blood flow to his heart, he was certainly short of breath. and short of breath to enough of an extent that I thought it would be reasonable to have a look at his arteries in more detail to see exactly what was going on. Remember, the treadmill test is a functional test and tells us how well someone is working, how much blood is getting to their heart, but it's not an anatomical test. It doesn't tell us what the health of the arteries really looks like and whether there is build-up of plaque or rust in the pipes, for want of a better term. Anyway, for Trevor we got on and we did get a CT scan. It turned out that in the past Trevor had been found to have a lipid profile or a cholesterol profile that just looked like it might be increased risk. And his GP in the past had tried. a torvastatin, Lipitor, a cholesterol-lowering agent to try and reduce that risk in a primary prevention setting, primary prevention meaning to try and stop Trevor having an event, a first event. Well, when we got the CT results back for Trevor, they were interesting, and they were of a particular... configuration. They were of a particular sort which represent two ends of a spectrum. When we look at coronary arteries and we look at calcium and we look at plaque build-up, more often than not, the amount of calcium that we see on the non-contrast images normally gives us a fair appreciation of what might be going on with the non-calcific plaque in the arteries. We do have two ends of a spectrum, though. We have situations where people put lots and lots of calcium in their arteries but yet don't seem to have the non-calcific plaque or cholesterol-dominant plaque in association with it that you might imagine. Sometimes we see that with long-distance runners or long-distance athletes. The other end of that same spectrum is that sometimes we see people with not very much calcium in their arteries, but quite a lot of soft plaque or non-calcific plaque or the cholesterol dominant plaque. So the amount of plaque that we're really concerned about is far greater than represented by the calcium score alone. Well, it turned out for Trevor that he was in that second group. He was in a situation where his risk... As suggested by the plaque burden, and if anyone's listened to any of my other podcasts or if anyone's read my book and you've heard me talk about the C-plus algorithm for reporting risk, where I use calcium, calcium score percentile, low attenuation plaque or soft plaque, unfavourable remodelling, stenosis and sight. to help come to a conclusion about risk, then you'd understand that this gentleman would have a low calcium, a low calcium score percentile as it happens. But he had very considerable low attenuation plaque and he had stenosis and remodeling. So he actually had very high risk features. In spite of the fact that his calcium score was less than 30 for a man who was nearly 70 years of age and that his calcium score percentile was somewhere around the 20th centile, i.e. supposedly within the best fifth of men his age. Anyway, really important you hold on to that information because when I saw Trevor with this information, I explained to him. The risk I believe inherent from a CT scan was very high and my intensity to therapy, my intent to treatment was going to be a high intensity therapy. This was quite a number of months ago and I gave him a different cholesterol agent. I gave him rosuvastatin. I understood that he'd had problems with atorvastatin previously. I said, I recognize this. I don't want you miserable, but we do need to mitigate that risk as best we can. I'd like you to start the medication low, maybe half a tablet every other day, and gradually increase it. If you have symptoms, come back. Reduce the dose again, because what I'd like you to do is find your maximal tolerable dose. Anyway, this patient came back to me just this last week. And said, oh, Doc, you'll be cross with me. I said, I won't be cross with you. Why would I be cross with you? He says, oh, I haven't been taking my tablets. I said, well, why wouldn't you do that? We talked about this last time. You've got really high-risk features. He said, oh, no, I remember you telling me that I was only 20 and 20 wasn't bad. And I went, oh, mate, you didn't get the whole picture. Your score was low and your calcium score percentile was low, so the amount of calcium was low. But the other features within your study were high, high risk and carried a greater than 50% chance of a heart attack in the next decade. That's incredibly high risk. I said, why would you make this decision by yourself? Why would you try and interpret your scan when in fact I've done thousands of these? I've written papers on this. I've even written a book on it and I even get asked to be involved. in writing guidelines around this technology. Why would you do this by yourself? He said, I spoke to my GP about it. And he said, I had low risk features. I said, oh man, now I am. I'm not sure, but maybe I am getting angry. And what am I angry about? I'm angry that a lack of common sense around an interpretation of a result. put this gentleman at significant, unacceptable, increased risk. With reassurance from his general practitioner, it turns out his general practitioner is a fantastic doc who's used CT imaging as much as any of the other general practitioners in Hobart. I know that this GP has a really good handle on CT compared to other GPs, but missed the opportunity. to understand the complexity of both the calcium score and the CT coronary angiogram coming together. And that's partly because, as you might imagine, the GP doesn't normally get the chance to review the images in their entirety and therefore come to a final conclusion. That's what I try and do as part of my own assessment for a patient. Needless to say, I was distressed. I was upset that this gentleman, who had coped without problem. And he told me this. He was fine on half a tablet every other day. So he doubled it. A full tablet every other day. He was fine. Then he went to a full tablet every day. And he was fine. And then he doubled it. Two tablets every day. Then he got some aches and pains and threw the tablets away. I'm not sure if you see that as I see it. But it was just a very frustrating situation where a lack of understanding, a lack of recognising exactly what we're dealing with left this patient undertreated and with unacceptably high risk. It is so important that you really get clarity around what's going on. It's a reminder for me. I'm distressed that I didn't convey that message to him the first time, even though I got him to take a picture of my rough working diagram, which down the bottom had very high risk written on it. So if he was going to interpret the working diagram I gave him, if he'd at least read the bottom bit, he would see it was very high risk. Anyway, we talked about this perhaps with more intensity than I would have liked. I believe I made it completely clear to Trevor what I believed the risk was inherent from the scan that we did on his arteries, what I believed the benefit would be with being on appropriate risk modification medication, and the importance... of if he wants to make a change to his medication based on an assessment I've given him, could he please come back and talk with me? Even though his GP is a fantastic doctor who is really very experienced, one can't expect the GP to be up to speed with everything in all areas of medicine. I don't expect that. But I do expect the patient to come back and talk to me. if I've given them clear instruction and they want to change it. Because we need to work out a solution. That's the whole point of trying to be a specialist and work with individual patients to meet their needs based on the literature that's available with the medications we have to get that person's best possible outcome. Really. If it were that easy that we could just make decisions by ourselves or go through a decision tree on the computer, then my job would be redundant. Well, I think it's going to be a while before that's the case. I really wanted to share this case with you because it just represents misunderstanding, misinterpretation, almost a missed opportunity, almost misfortune. Can I please, please empower you, encourage you that if a specialist puts you on a treatment regime, whatever it might be, if you're having troubles with that treatment regime, please talk to your GP. I have no issue with that. That's exactly who you should talk to. But if you're going to change that medication with the GP, please bring the specialist into that conversation. Think about it. It just makes sense. And at the end of the day, it's for your best outcome. If Trevor hadn't come back and seen me, if he decided for some reason he didn't like me or his GP was doing a great job, then there was a 50% chance over the next 5 to 10 years that he would have a major coronary event and drop dead. And we can't do anything after that. I'm all about saving lives, buying quality of life. I don't want to make people miserable on tablets. That's not my objective. My objective is for people to live as well as possible. for as long as possible. And if that requires to and fro and adjustments of medications and working together with the patient and finding a regime or routine that is specific for them but does the best job for them possible, then that's what I want to achieve and I'm the person to do it. Well, that was a bit of a rant today. I hope it gave you some insight. I hope it's reminded you that if someone is making decisions for you, you recognise that those people are specialists in their field and you should bring them into the equation when you're deciding the importance of that therapy. I'm going to leave it there. I hope I've given you some important stuff to think about. I feel a lot better for sharing it with you. As always, I wish you the very best and until next time, please don't die from a heart attack. Goodbye. You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
