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. My name is Dr. Warrick Bishop and I'd like to welcome you to my podcast station and of course to the Healthy Heart Network. Today I'd like to tell you a story about Conrad and I've titled this podcast What Could Have Happened If. This was an amazing story that happened just recently to me. Conrad is a 54 year old gentleman who is a big guy. He carries a bit too much weight, but even if he were trimmed to his ideal weight, he'd still be over 100 kilos, so a big man. His lipids, it would be fair to say, are a bit on the untidy side. He admits to having sort of elevated blood pressure actually for a good number of years. And on speaking with him and looking at his past history, I got the sense that that blood pressure was fairly poorly managed. He had a wife, Donna, who is a fantastic support and a driver to looking after Conrad, and she had been proactive. And this is interesting because my observation more often than not is that when it comes to health-related issues, it's the lady in the partnership. It's the woman who drives the preventative issues. Now, if you were talking about blokes and outboard motors, I can absolutely assure you that most blokes would get their outboard motor serviced and flushed and greased and oiled and the right fuel and all those sort of things. But when it comes to health, the very best thing you can have is a woman who cares for you if you're a bloke, because blokes don't do preventative health well. Anyway, Donna was just fantastic. She actually had a bit of medical now because she was a medical receptionist and was familiar with some terms and was also aware of the suffering that can come from illness, particularly preventative illness or illness where we may be able to modify risk, things like coronary artery disease. And Donna wanted to make sure that her husband was in good shape. She'd seen the GP with her husband and Conrad had been sent to a cardiologist, not me, but he'd been sent to a cardiologist in the town that I work in and had been put through a stress echo. Now, at time of presentation for that test, Conrad's presenting characteristic, Conrad's presenting uh requirement was a risk assessment he had no symptoms whatsoever so well in my practice i think putting people through a treadmill test when they have absolutely no symptoms is going to be a low yield result um and if you've read my book which i hope you have uh because i sort of write about this for that very reason um i don't think stress testing is a great test for the majority of times to help us evaluate risk in people who are asymptomatic, like Conrad was. Anyway, the stress echo was all good. There was no problems and Conrad was reassured. Donna, however, was not reassured. Donna had been privy to conversations about... a different way to evaluate risk. She'd been aware of technology which allows us to literally image the health of the arteries. You guessed it, cardiac CT imaging. And Donna realised that until Conrad had had his arteries looked at, we really didn't know what the health of his arteries was. Because you might... have a stress test which doesn't show a problem but that just means that there isn't a blockage there right now. It doesn't tell us the health of the arteries into the future. Well a little bit of extra research and Donna I think found my book and found through her general practitioner that my area of interest in the town that I work is prevention and is in fact cardiac CT imaging. So I got the chance to provide a second opinion on Conrad's risk assessment. Well, I explained that for risk, cardiac CT imaging is currently not a guideline recommendation in Australia, though the Europeans and the Americans both have it in their lipid and preventative guideline documents. That in Australia, it's not covered by a Medicare rebate, so it's an out-of-pocket expense. That there is a small dose of radiation associated. Each time we scan the heart, It's about the same dose as a mammogram. So well within the realm of what we would think is a reasonable dose of radiation for a preventative strategy in a very common condition. I also explained that my preference is to use injection of radiation contrast, so x-ray contrast, x-ray dye, if there's calcium present on the non-contrast images. So I do... My study is in two stages. The first stage is without any injection of contrast. If the heart is completely clear of calcium, I stop at that stage. If there is evidence of calcium, I like to inject contrast. I explain to Conrad and Donna that there's a very, very small risk of contrast-related reaction with that injection. But I only do it if there's any evidence of abnormality within the arteries. I cover a lot of that in my book if you are interested in more detail. Well, to cut a long story short, before I make it long again, Conrad went off and had his cardiac CT scan. On the day of the test, I was called up and notified that the injection of Comtrust not only outlined his arteries, but outlined his coronary arteries, but outlined his pulmonary arteries. And lo and behold, Conrad... had significant bilateral pulmonary embolism. Well, what does that mean? What that means is he had clots in both sides of his lungs. Extensive. We don't even know why. He'd done a little bit of travel. He'd had no clear-cut symptoms. Remember, he'd had a stress test, a stress echo, in fact, only weeks earlier and had apparently got through that without any problems at all. It turned out that his brother had probably had some problems with forming clots before, and so had his mother. There was a suggestion that there may be a family history, and we did all sorts of screens looking for the sort of proteins or genes that could be linked with an increased risk of forming clots and thrombus in the lungs. Well, needless to say, Conrad was immediately commenced on blood thinning agents to immediately start to reduce his risk of dying from multiple pulmonary emboli. This is a serious condition. Well, with that fire put out, or at least being started to put out, question then swings around to what's going on with his coronaries. And lo and behold, His coronaries demonstrated no focal narrowing, no tight stenosis, no blockages, which was completely consistent with the stress echo. But he had very significant plaque, which wasn't narrowed, but carried very high risk over the next five to 10 years to such an extent that the intensity to therapy I wanted to bring to his case was high to very high. non-calcific plaque he had remodeling he had a lot of it and he was much higher risk than would be assessed by either a risk calculator and certainly much higher risk than assessed by the falsely reassuring stress echocardiogram well needless to say Conrad is now having his lipids well titrated. And in fact, I'm looking to get his LDL cholesterol levels down to better than current European Society of Cardiology guidelines recommendations. And these guidelines are only just released a few weeks ago in Paris. That's a few weeks ago being about September 2019. We're going to aim for an LDL cholesterol of less than 1.4 millimoles per liter. We're going to... improve his blood pressure which is elevated his average blood pressures are running at about 140 over 90 and we're going to drive those down to 120 over 80 we're going to get some weight loss happening we're going to make sure his sugars are well controlled and we're going to make sure he is on lifelong anticoagulation so the title of this podcast was what could have happened if and the end of that sentence is Donna hadn't insisted he come to see me or someone who would follow up with a proper risk assessment doing a cardiac CT scan to image the arteries but lo and behold also image the pulmonary arteries and make for this man two life-saving diagnoses. If that doesn't put the hair up on the back of your neck, nothing will. So I told Conrad not to buy a lotto ticket because I reckon he's used his luck up. And I've told him to order a ham for Christmas because he'll be around to enjoy it. I hope you've enjoyed this podcast. It's an extraordinary story. It's just, I think when I caught up with Donna and Conrad just recently about this, there was, there was quite possibly a tier or two shed understanding the significance of what had just happened. Okay, going to wrap up there for four. Before I become an emotional wreck myself, I hope you've enjoyed this podcast. As always, if you have any questions, please drop me a note. That'd be members at drWarrickbishop.online. If you have any suggestions for any future podcasts, please let me know. As always, thank you so much for taking the time to listen. I do wish you the very best health. Please. Oh, until next time, please don't die from a heart attack and please don't get pulmonary embolism. Take care and 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.
