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 is Dr. Warrick Bishop, and welcome to my podcast and videocastation. I have a special guest today, Associate Professor David Cahoon, who is co-president at the Prevention Arm of the Cardiac Society of Australia and New Zealand, and a board member of the Heart Foundation of Australia, and an experienced cardiologist, both with clinical and research backgrounds, David. Welcome and thank you for joining me. My pleasure, Warrick. Look, we've had the chance to talk a little bit off air about a recent debate that I was lucky enough and privileged to be involved with where we were talking the merits or not of cholesterol and whether doctors have it right. You'll recall, or for those listening, there were three people on the opposing team. who were saying that doctors didn't really have it right. I was on the team that sort of suggested we did. On the opposing team, we had Ross Walker, who really led off with a discussion about Marianne de Massey, who was central in the Catalyst program a number of years ago, which created a little bit of controversy and certainly a lot of discussion. Ross also discussed about the overuse of statins. Ross Walker is a well-known cardiologist in Australia. Anthony Shappie was the second speaker with an interest in nutrition, a background in professional sport, and as a registrar in neurosurgery in Western Australia at the moment, he really focused on fructose and inflammation as the drivers for plaque formation and really dismissed that cholesterol was problematic and suggested there wasn't much research for that. Steve Malhotra is well recognized as one of the cardiologists who has been influential in driving a change in the way we think about fat within the diet. He's active on social media platforms regularly and really acts to raise awareness about big pharma and our interpretation of data. presentation within the debate was really around are we interpreting the data appropriately for individuals and the role of big pharma. So, David, what I'd like to do is give you the opportunity to feedback from your own area of expertise on what some of your thoughts are with regard to some of those positions taken. Why don't we start with Ross Walker and his comments about Mary Ann De Massey, Dr De Massey, and his comments about overuse of statins. Well, we can just quickly dismiss that. I thought Norman Swan did the... did a great job criticising his own network, the ABC, pointing out it was factually wrong, selective asking people who aren't experts. And Marion De Massey is a PhD doctor who has no expertise whatsoever in primary heart disease treatment, et cetera. Yeah, she's a journalist. And like journalists, she got a story, she got ratings, but she did not... help the population stories like she had on the abc has been done in sweden have been done in denmark and with brilliant tracking of the population what we see is people stopping life saving medication increase heart attacks increase strokes increase mortality this is what happens from bad journalism bad science we call it fake science and a number of the other members on the panel and ross walker when they say there is no good evidence what they really say is i'm not an expert i don't know the evidence i haven't got a clue what about nobel prize winners uh you know like brown and goldstein who helped us understand metabolism full stop you know what when ross walker made this outrageous statement that only one out of 19 people on statins need to be on it no evidence to support that great grab for the uninformed but is inappropriate for a doctor who is meant to be interested in prevention you know the average LDL cholesterol this is not cholesterol it's the LDL particle is in Queensland, Sunshine Coast University, you could say it's an oxymoron. It's not a very learned place. The average level, published in the BMJ by the professor of medicine up there, 2.7 millimoles per litre one year after heartache when they come back in again. Absolute disgrace. Not at the target levels of the 1980s. You know what? So when Ross says outrageous comments like that, he's forgotten he's talking to doctors. This is not to the freedom fighters down in Canberra, the anti-science 10% of the community. Stop. Please, Ross, don't align yourself with those people who are anti-science. I think he said something else. LDL, LDL we need to make hormones. Oh, my God. I thought. Basic science 101. I would not be happy with a medical student. Cholesterol is the backbone of the steroid hormones. Of course it is worried. Every single cell in the body makes excess cholesterol. We need HDL to remove it so that it can be taken back to the liver and broken down and then recycled and packaged into VLDL. So to say you need LDL. That is basic, basic wrong. You know what? It's amazing. Brown and Goldstein, please read the stuff that's been published by Nobel Prize winners. They know a little bit. LDL, remember, the LDL is secreted by the liver to transport fat around the body or triglycerides to be more specific because blood is diluted salt water, as you remember, Warren. So fat. We'll call it fat embolism if it goes into the bloodstream. So it's lipoproteins. The apoproteins make it dissolve. As it goes around and around, triglycerides are removed and we get the waste product, end product, LDL cholesterol and LDL particle. We can measure the protein part of it. We can measure the cholesterol component. It is there to be waiting around to be taken back up in the liver. Brown and Goldstein, Nobel Prize winners, 1984, demonstrated that it's the receptors on the liver which are key to appropriate metabolism. Our statins, our azetamide, our low saturated fat, our PCSK9 inhibitors, all increase the receptors on the liver. to remove the LDL particle from the blood so it doesn't get into the vessel wall to cause atherosclerosis. Please, when you talk about blood cholesterol, remember that is just, it doesn't exist as cholesterol or blood. It's part of lipoproteins. Let's get... into the 1960s and 70s understanding of lipoprotein metabolism and get away from the baby talk of cholesterol and talk about we need LDL for hormones. Wrong, wrong, wrong. When we say silly things that are so wrong, no wonder the public's confused. No wonder doctors listening to the telecast who aren't experts get confused. I mean, please, if you don't know, don't say. Just say, I'm not sure. Let's be honest. Honesty is the best policy. And please, I'll stop there again. Sorry. Your mic is also reverbing a little bit, so don't get too close to it. It's sort of giving us the static. Look, what are your thoughts about Dr. Chaffee's comments on fructose and inflammation? And there's not a lot of evidence to support that raised cholesterol as a problem. And I think he tried to cite a paper that in healthy individuals over a certain age, cholesterol levels were actually higher. So fructose inflammation is not the old good or bad. Yeah, again, Dr. Chaffee, what's his background again? He's a bodybuilder. Yeah, he's a bodybuilder. Yeah, yeah. So he obviously knows and it's all natural. He's a neurosurgical registrar. Wow. If you want to know about your sore toe, ask a neurosurgeon, ask a cardiologist. Totally inappropriate his background. He's still in training to be a neurosurgeon. Why on earth is he parading as a cholesterol expert? Does he know more, more than, you know, Brown? Goldstein, you know, other Nobel Prize winners, Pete Evans. I mean, really? Pete Evans? Yeah, he thinks he knows more than Pete Doherty. I mean, really and truly? Oh, there's no evidence. Of course you don't know the evidence. You're a neurosurgeon. You spend your time in scrubs. And besides, you're a very late-life registrar. Your mic is really breaking up badly. Okay, I'll say it again. The person you said who was an expert... He is a late-life registrar, right? He's in his 40s. He's a neurosurgeon. Yes, that is not the background to be an expert in lipid metabolism, epidemiology, physiology to do with plaque regression. No wonder, Warrick, when you talked about regression of plaques, there was silence from the other team. I don't think they knew what regression of plaque was. So when someone says, There is no evidence. We say, well, what evidence did you look at? Of course, you don't know the evidence unless you're an expert in the area. I think he also said something ridiculous. The Framium study showed that low cholesterol increased coronary artery disease. Oh, look, you can't even read the original data. Misquoted Castelli. I've heard Castelli talk on many, many occasions. I've been involved in many talks, as you know, talking about the data from Framingham, the Interheart Study, the Seven Country Study, also misquoted as well. I cannot stand smear campaign and say... and lies, particularly complaining about people who have died who can't answer the smears. So poor science. Neurosurgeon, yes, if I had a neurosurgical problem, I might have a chat to him. But when we talk about cholesterol lowering, it seems he knows nothing about the Australian Lipid trial and the meta-analysis by Tony Keech for every one millimole reduction of LDL particle. LDL cholesterol is the way we measure it. 25% less heart attacks, 20% less strokes, 10% lower death rate. And today, as you know, Warren, unless you get at least 2 million more reduction of LDL, you're not trying. To say there is no evidence that lowering LDL cholesterol, get away from this cholesterol baby stuff, LDL cholesterol particle is just flies, it's just unbelievable. People could be saying such obviously wrong statement. And to infer, the heart foundation of australia the american heart association the european societies of cardiology all have it wrong all the research from uh these you know people have dedicated their life to do clinical research is uh you can't believe it because it wasn't given by it wasn't done by a grant from a socialist government it's just so nonsense i can't believe the anti-science promulgated a couple of nights ago. Only you and Stephen Myers actually held the flag of honesty. David, I'll ask you to make sure you don't shout too much because every time you do, there's a reverb down your mic. So I know you're excited. But let me ask you to come back to inflammation. One thing that Dr. Chaffee did raise was inflammation. We know from the Cantos study and we know from some of the culture scene work that inflammation is certainly important. Where are your thoughts on that and how would you frame that? Well, we've known since the mid-80s that cholesterol in your diet per se has a minor effect on atherosclerosis. Full stop. We know the LDL lipoprotein is far more atherogenic-caused. I mean, atherosclerosis is like a pimple inside your artery. We know it is far more aggressive. active if it is modified modified being is glycosylated oxidized hydrogenate it doesn't matter all ldl particles are atherogenic all are they're waste products if they are modified if you're a smoker and it's oxidized of course it's worse this is not new but to say it is inflammation only it just it's just i mean it just defies that people could be so silly we know there's more than 60 independent risk factors and risk markers that cause coronary arthritis. There are five key ones. We know when there is inflammation because you've had a cigarette, because you're anxious, before you're depressed. We all know these factors. They make the endothelium less impermeable, if you like, more leaky, and the LDL more atherogenic. But to say it's all... All inflammation is so simple. I would be very unhappy with a medical student first year. Let me roll past the second speaker and invite you to interpret Dr. Malhotra's comments about whether we're interpreting the data appropriately and whether there's benefit within the trials that really justify the therapy that we're applying to people. And after the interpretation of the data. Do you, you're welcome to make a comment on Big Pharma because Dr Malhotra quite reasonably said that Big Pharma have a vested interest and it is hard to sidestep that. Yeah, well, there's a big difference between the cardiologists, researchers. who do the trials with funding given to pay for the trials and to say big farm are corrupt i mean left-wing propaganda leave it at the door your political bend okay uh leave it at the door that you are so pure and holy because, one, you don't do any research, Mahapta doesn't do any research, and criticises everyone else. It is an absolute disgrace that someone like him has a forum to say the work done like in Australia, our lipid trial. Yes, $20 million was given to the Heart Foundation to run the trial, independent safety and data monitoring committees, as it was in the Torcetramid trial, which... as Philip Barter, our friend, ran, to say these independent committees, the expert people who look at the data are corrupt because... There was a grant given to the independent group. No one pocketed the money. It just simply paid for wages of staff. It's absolutely misunderstanding of how these research trials are involved. I was involved in our Australian MIPA trial. 9,014 patients followed for six years. As you know, this is the first trial in the world which showed lowering the LDL by one millimole per litre, decreased mortality, total mortality by 3% in six years. in six years. These are people with average cholesterol levels. We didn't know that. Now, if you had diabetes and you had low HDL, the numbers needed to treat to prevent a cardiovascular event or death was only 10 in a five-year period. Now, to say, oh, because our BMS gave $20 million, grossly unfunding, to the Hyatt Foundation, it ipso facto is corrupt. It's just ridiculous, illogical nonsense. Now, Is Mahutra going to say the same thing? If you get a government grant from a socialist government, you are left-wing corrupt as well. I mean, really and truly, read the Institute of Medicine's 300 pages on vested interests and how you can minimise that. You know, I don't think people who throw stones, be very careful, right? That's a very old saying. Okay, people in glass houses should not throw stones. Mahutra, as you mentioned. Let's put it into perspective. He does not believe vaccination is of any value whatsoever. He's an anti-vaxxer. Oh, you know, the anti-vaxxers who are down in Canberra, you know, saying vaccination kills more people than it saves. Okay, okay. You know he doesn't believe in treatment of diabetes, by the way, either. It doesn't work. We'll sidestep other aspects of Dr Malhotra's practice and opinions. But what we might do is just wrap up there. You've had the chance and I really appreciate you dissecting and commenting on the three speakers in the debate on the opposing team that I was on. But perhaps we just wrap up with a this process of coronary artery disease is incredibly complicated. The particles, the LDL particle, the lipoproteins, the interaction at a cellular microscopic level is insanely. complicated, convoluted and variable between individuals. I think it's just fantastic that we have the likes of people like yourself who have been involved in the research, close to the research to help guide the likes of me who are open to best practice for our patients. Would you like to wrap up with anything, David? Yeah. Don't shout because of the feedback on your mic. I won't shout. It'll be in small print. One, it is... Predominantly lifestyle disease on the background of genetics. So we know a Mediterranean type diet decreases first events by 30% within three year period. Beautiful study in Spain. Two, if you've had a heart attack, a Mediterranean style diet, this is south of Italy or in Greece, decreases total mortality by 50% within the five years. Two, separate to that. Look at your omega-3 index. High intake of fish decreases risk of developing heart disease and the high omega-3 index protects you. Three, look at those risk factors proven if you improve them, prevent outcomes. You need to get your LDL cholesterol, which is LDL particles, down to less than 1.4 consensus around the world, European society. It can be achieved. Please, you be enthusiastic. Your patients will be enthusiastic. They'll take the medication. Not only will they live longer, they will feel better. Always assess for depression using the PHQ2, patient health questionnaire. Depress patients. Life is miserable. They don't take your medication. That's 30% of our patients. So we have to be holistic with the W, not with holes like some of our friends, holes everywhere. We look at the whole patient because coronary disease, as you say, Warrick, is very complex. It's lifestyle and the background of genetics, but we can make a huge difference to the natural history. Medicine is all about changing the natural history to improve survival and have happy, healthy lives. Remember, the pursuit of happiness is in the American Declaration of Independence. They're very unhappy people. Thank you so much for taking the time to share. I know and I've known you for years now. I know how passionate you are about helping people live as well as possible for as long as possible. I know you're so across this data. I really appreciate that. For those listening, I hope you've got as much out of listening to Associate Professor David Cahoon as I have. Thank you so much for joining us. Take care. Pleasure. Bye for now. Okay, bye. you have been listening to another podcast from dr Warrick visit his website at dr Warrickbishop.com for the latest news on heart disease if you love this podcast feel free to leave us a review
