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 videocast station. Look, today I'd like to talk a bit about taking the medicines prescribed for you. Sticking with your medications is called adherence. That's the word we use for people adhering to their prescribed medications. share with you this particular podcast and cover adherence and taking your pills. Well, quickly, the background to this particular story is I reviewed a patient back in 2013, almost a decade ago. The patient was under 50 years of age, but had significant premature coronary artery disease in the family, and we elected to undertake imaging to evaluate as best as possible exactly what was going on in his coronary arteries. Remember, this was a man under 50 years of age. Well, the imaging demonstrated clearly substantial non-calcific or fatty plaque in the left anterior descending artery. And that's pretty important because... The left anterior descending artery is the main artery down the front of the heart, and I'm sure you know that if you've listened to any of my podcasts, because we've covered the anatomy before. Anyway, fatty plaque is the plaque that can rupture. Calcific plaque tends to be more stable. So this particular gentleman had high-risk plaque, and I put him on appropriate therapy. followed him for a number of years and pretty well returned him to his GP around 2018. Fairly comfortable that we'd put in place appropriate risk mitigation with aspirin and a cholesterol lowering therapy, getting his LDL, the so-called bad cholesterol, down to levels that would be considered adequate to prevent someone who's had a heart attack already having another one. So really good control. I had put to him that perhaps we could repeat image at some stage, and although that's not a guideline recommendation, it would give us extra information about whether he's responded appropriately or not to the therapy and give us some sort of insight as to whether the plaque identified has become more stable or not. Well, I saw this patient, as I said just recently, and he had represented with... chest pain on exertion, we did a stress test which proved to be strongly positive, and we're going to proceed to invasive coronary angiography next week to look at his arteries and get more detail. He will need either a stent or a bypass, depending on what we find. Well, during the process of getting all this organized, he had a mere culpa. He had a confession. And he shared with me that soon after our last consultation in 2018, he dropped off his medication. He just stopped taking his statin therapy. And I have to say that in a fit of passion and concern for his well-being, I gave him a bit of a serve. In a way that he was pretty sure I wasn't necessarily angry at him, concern for him and what I want to do is flag for you what transpired this patient said to me that he had a friend apparently a doctor who had said to him that there seemed to be some research suggesting that statins can increase the risk of dementia well there's a couple of things to address here first of all To bat the simple one away first, there isn't any data that supports statins-caused dementia. There's 30-plus studies looking at the role of statins on cognition. And if anything, there's a suggestion that statins reduce the risk of Alzheimer's disease, probably by reducing the likelihood of people suffering with multi-infarct dementia. So that's a simple one to strike away, but the more important one is this. Really, who should you be listening to and taking your medical advice from? A well-meaning friend, even if they are a doctor? Well, I put to this patient that really, to a large degree, if he had concerns about his medication, if he really had some reservation about taking it, that I would be more than happy, in fact encouraging, to have those conversations about where the risk and benefit lies in his particular situation. In fact, with all my patients, I try and educate them at the time of prescribing a medication and say this is what we're doing, what we're doing, so that the patient knows why I'm providing a script and why I'm suggesting a particular line of care or management. It seems to make sense and I think the better educated a patient and the better the understanding, the more likely they will be adherent or stick to the suggestions. The problem is misinformation pops up everywhere. And you've got to be careful. I've had patients come back to me and say that the pharmacist looked at the script I provide and went, that's a high dose of cholesterol lowering therapy. And as you can imagine, that puts the fear of God in the patient and starts putting questions in their mind immediately as to what's going on. Family friends will often offer advice. Fancy this doctor telling this patient that statins could, might, may be linked with Alzheimer's disease. And we even have friends who have done their research on the internet who offer advice as well. The significance is profound because once you plant a negative idea into someone's head about a therapy, then it's very hard to separate out a potential nocebo effect. And a nocebo effect is the opposite of a placebo effect. And you will remember a placebo effect is giving somebody a sugar pill, but with the clear indication that it's going to be beneficial to them, and then, if you like, subliminally believing and putting in place a response to that inactive pill. but it actually gives them a benefit, a placebo benefit. So the nocebo effect is the opposite of a placebo effect. It's an expectation that a tablet will give you a side effect or a problem. So you can imagine, this is a quagmire of uncertainty, difficulty for the patient, potentially poor care, and in this particular man's case, he's got back to me... with progression of symptoms, but what if he'd had a heart attack? What if he didn't even get to the age where Alzheimer's could be a problem? That would just be a disaster. And through really poorly given, poorly offered, poorly thought through advice from someone who I think probably wanted to share their own importance by sharing some knowledge, but really didn't think around the best outcome for the patient. Well, what can you do? I would put to you that I hope most of my colleagues, when they recommend a therapy for you, approach it exactly the same way that I do. And that is to try and put into context for you as an individual what this particular therapy may well offer and why we're selecting it and what we want to achieve from it. So please, if you ever have a question about your tablets, if you ever have any reservation about not sticking with an agent or wanting to change it or thinking you should reduce its dose or that there might be a side effect, please don't unilaterally make these decisions. Please raise them. They're always important questions and your doctor, if they care, will always want to speak with you about it. and cover where the pros and cons truly lie. For this gentleman, I had clear evidence he had significant plaque in his arteries. And to be honest, it's now proven that it was significant enough that on off-therapy, it has progressed and led to him returning. But the alternate universe, there are two. If he'd stayed on his medications, we may well have seen plaque regression, and this presentation with chest pain would never have happened. And we would have had a chance to prove that with a second cardiac CT scan, comparing his plaque burden. Or he stopped his medications and instead of coming back with chest pain for investigation, he presented with a heart attack. With a one in six chance of dying there and then. Still a young man. Still given bad advice by someone who really didn't have a full handle on this gentleman's full. cardiovascular risk profile so talk to your doctor stick to your tablets if you've got any queries or questions please always ask and with that I'm going to let you reflect on the pills you're on please inquire please ask please stick with them and please speak to the person who put you on them if you ever want to change them I hope that's been helpful if you have any queries or questions drop us a note till next time I wish you live as well as possible for as long as possible and thank you for joining me. 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.
