**Episode Title: EP217: An Extraordinary Letter**
**Dr. Warwick Bishop:** Welcome to Dr. Warwick's podcast channel. Warwick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warwick 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 is Dr. Warwick Bishop, and welcome to my podcast and videocast station. Today, I'd like to share with you an extraordinary letter. Now, this letter came to me via a colleague, and I can't say the location, and I won't mention any names, but this letter really represents for me the very reason I've written the very first book that I wrote, which is *Have You Planned Your Heart Attack?* Well, of course, you're probably aware that I've got thousands of copies of that, and it didn't sell. So if you can think of a way to get rid of them, that'd be great. But the conversation was really important.
The conversation around *Have You Planned Your Heart Attack* has led me to where I am right now. When I picked up the technology of cardiac CT imaging for hearts, I realized it was incredibly valuable, and it allowed us to literally look inside someone and get the health of their arteries. It's obvious that sometimes people can look healthy on the outside but not have healthy arteries, and vice versa. Sometimes we see people who look for all the world like they should have had a heart attack, or they keep living, and it's inexplicable. These people may well have arteries that are surprisingly healthy, in complete contradiction to what we might imagine.
So about five years ago, six years ago, is when I started my journey to inform people about cardiac CT imaging. At the time, what I was finding was that my colleagues locally were really not embracing this technology and, to some degree, were almost a little bit disparaging. When I used to present to my colleagues about this technology, not only were they a little bit dismissive of it, which I don't really think the science supports, but they were also a little bit dismissive and derogatory of me as an individual.
I thought that, you know, it's a little bit like in sport, the difference between playing the ball and playing the man. I became very frustrated and realized that there is a lot of pushback from my colleagues regarding this technology, which, to my mind, I believe really answers the question that many patients want to know: What is my risk of heart attack? Is it high? Is it low? Is it somewhere in between? If it's high, what do we do about it? If it's low, that's great. Shall I come back and get it checked? So it's a very simple process.
Anyway, today I have the opportunity to share with you a letter that was passed on to me. I'm not going to talk about who; there's going to be no disclosure of confidentiality. I'm not even going to disclose the location, but you should know that I've got contacts in every major center in Australia. When this letter was given to me, I thought I'll take the opportunity to share it and talk around it a bit, but the backdrop is really important. Remember, the backdrop is the very reason I've built the Healthy Heart Network: to give individuals the opportunity to understand enough so that they can ask for the best healthcare possible for themselves.
So, what I'm going to read to you is a letter from a cardiologist, a specialist, a heart specialist, just like me, who's written back to a GP. The letter goes something like this:
"Thank you for referring Mr. X. This very fit 50-year-old builder does have a reasonably high cholesterol and will be eligible for treatment, but I do not think it will alter his life expectancy in the slightest. I would not do a cardiac CT (as I think this is misleading in this age group). I've given him a prescription for 10 milligrams of Crestor (or Rosuvastatin), a statin agent, to take and see if he has any symptoms from it. I will leave it up to him to continue as the case may be. Given there is no family history and he has no other risk factors, and he is otherwise very fit (and his ECG was completely normal), I would be quite happy with him not taking long-term prophylaxis. He is not eligible for a rebatable CT coronary angiogram, and for a non-rebatable scan, I do not think he should spend the money. We would be happy to see him again if required, but I think he should do very well."
Well, I won't read that again, but I will touch on it in parts. I think that is just an extraordinary letter, and there are a few things that I really can't help but feel I need to flag.
First of all, he does have high cholesterol and would be eligible for treatment, but I do not think it will alter his life expectancy in the slightest. Well, I think there is a reasonable case to be made that using cholesterol alone to try and predict someone's risk is inaccurate, and I'm supportive of that as a premise. I don't know how high this gentleman's cholesterol was. In very high cholesterols, there is no question that in a primary prevention setting—trying to stop people from having an event in the first place—giving cholesterol therapy definitely works. In this gentleman's case, it's very hard to be sure that just using cholesterol alone, if we were to do it in a population, would be beneficial or not. So, playing the odds, it's not an unreasonable premise.
Further, and I'll come back to the letter, I would not do a cardiac CT (as I think this is misleading in this age group). Well, what I can say is that for a man who's hitting 50 years of age with other parameters that are essentially average, and remember this gentleman's cholesterol is a little bit on the high side, then almost every risk calculator in the world would have this gentleman's risk at somewhere around 5 percent of an event in the next five years, or literally putting him in a population where the risk of event is somewhere around 10 in the next 10 years. Now, a 10 percent risk in 10 years, by current convention, is considered intermediate risk. It's not low risk, and it's not high risk.
Now, that's pretty important because the Heart Foundation of Australia's position paper on calcium scoring, which I was fortunate enough to be a co-author of earlier in the year, makes the point that for intermediate risk patients, cardiac CT imaging is a valid test. If you're high risk, then you should treat those risks. If you're low risk, you probably don't need any extra investigation unless there are risk enhancers like raised cholesterol. Think of this man.
So, for this gentleman, the current position in Australia would be that cardiac CT would not be misleading. If it was completely clear, it would be a great reassurance, and we would simply encourage the man to come back in five years' time. If it showed terrible arteries, as I have demonstrated over and over again in men who otherwise look fit and well, then it gives us an opportunity to recognize that plaque burden—that build-up of cholesterol—and treat it as if it were a secondary prevention situation. Knowing what's there, knowing that person has a propensity to put plaque in the arteries, I think we can be really precise about making a difference. For those people, I'm pretty sure that cholesterol-lowering therapy can make a difference to their future risk of event.
The letter goes on: "I've given him a script for 10 milligrams of Crestor, which is also called Rosuvastatin, to see if he has any symptoms from it. I will leave it up to him to continue as the case may be." Well, I'm not sure about the sort of guidance that that is offering as a professional to an individual. I know if I went and saw my accountant and he said, "Look, maybe you could try and tax deduct the fuel on your car or not, or see how you go," then I would be feeling a little bit perplexed and unsure of what I just paid for in terms of the advice to help me get my accounting right.
Personally, my feeling is this particular "take it, see how you go, don't care if you take it or not" is really representative of a lack of concern for the individual person, actually. I think that's the disappointing thing. Sometimes it's really a lack of attention to the individual situation that leads to bad medicine. So far, I think this is bad medicine.
Given there is no family history and no other risks, and he is otherwise fit—very fit—and his ECG is completely normal. Now, I'll make the point here, and this is incredibly important: A normal ECG in no way tells us what's going on in the coronary arteries. How you could put that in there is just incomprehensible. It's a little bit like saying the battery in my car is brand new; therefore, the engine can't burn oil. They're in the same vehicle, no question, but they're not connected. It's a very lame and misdirected remark.
It goes on: "I would be quite happy with him not taking long-term prophylaxis." Well, on what grounds? That, again, is a meaningless premise. He's not eligible for a rebatable CT. Fine, and we've got to follow those rules. Otherwise, we commit fraud. But here, I don't think he should spend the money on a CT scan. Well, the price of a CT scan, a calcium score, is as low as $300 or even less. The price of a calcium score plus injection of contrast in our center is a maximum of $660 to get a thorough evaluation of your coronary arteries.
Now, from my own experience, I've never been able to get my car serviced and a set of new tires for over $1,000. So that maintenance, for me, $660 to know what's going on with my heart represents incredibly good value, particularly when I could be reassured for only $300. The finances of this are ludicrous. If the man turned around and had a heart attack in the next three to five years, do you think he'd have even a second thought about whether he had to have paid $1,000 or $2,000 for that information if it could have avoided it?
Anyway, I'm probably preaching to the choir. You've probably figured that I'm a strong advocate of using this technology, and I just can't believe this appalling approach to dealing with risk. Well, I've got a little more to say about that. There is plenty of information on my website to inform you, as you probably are aware. I hope you've gleaned something from this correspondence that I shared today. It is, I think, a salient reminder that just because you're a healthcare professional, you'll get that same information from every individual.
Again, it really was that sort of letter that drove me to start this sort of process. Well, if you've got any queries or questions or anything you'd like to feedback, please let us know at info@drorichbishop.online. Otherwise, I'm going to wish you live as well as possible for as long as possible. Take care, and bye for now.
