Welcome, my name's Dr. Warrick Bishop. I'm a cardiologist, I'm an author and a keynote speaker. I'm CEO of the Healthy Heart Network. I'm all about trying to help people live as well as possible for as long as possible. Heart disease is huge in Australia. Every 20 minutes someone suffers a heart attack. Most of these could probably have been avoided if only we knew what to do. This podcast is all about helping you understand blood pressure, weight, cholesterol for better health. If you enjoy this podcast, I would be honoured for a five-star review. You can share it with your family and friends. It may well save someone you love. Hi, my name is Dr. Warrick Bishop and welcome to my podcast and videocast station. I really do appreciate that you have taken the time to have a listen. And I hope you find the content informative. Well look, today I'd like to share two stories that have come across my desk. And I think both are pretty important, otherwise I wouldn't be bothering sharing them. The first is in an area where I've had a lot to do with in the last decade to two decades. And that's in looking at treating people. young people with elevated cholesterol. Now the United States Preventative Services Task Force, which goes by the acronym USPSTF, has recently suggested that there is just not enough current evidence to recommend screening for lipid disorders in children and therefore patients. age 20 years of age or less. Now I have to say this is pretty interesting because in the space of familial hypercholesterolemia which is families where there is elevated cholesterol levels we see premature coronary artery disease and it is a significant cause of mortality and morbidity well historically we think of this condition in such a way that if you get one of the dominant genes from a family member you're called heterozygous so you have one gene not two if you have two you're homozygous if you're homozygous you quite possibly have a heart attack because of very elevated cholesterol levels, before 20 odd years of age. If you're heterozygous, then as a male, you might expect to have a heart attack potentially before 50 years of age, and as early as 40 years of age. And certainly, depending on other risk factors, that could be earlier or later. Obviously, smoking would make that earlier. Obviously, hypertension would make that earlier. When we're dealing with people who may have events at 40 odd years of age, our thinking has been, if we can change the trajectory of that plaque build-up within the arteries by treating early, then we may have a really good chance of extending the lifespan of these people to an age-matched equivalent. So, our teaching... And the way I've applied the science that I've understood till now has been that we are open to commencing lipid lowering therapy in patients with clear-cut familial hypercholesterolemia from as young as seven or eight years of age. Now, to be even more precise around that in Australia, These days we now have genetic testing which allows us two things. If we can identify an adult who's got familial hypocholesterolemia and that adult is our index case or the first person within a family that we find, we can run genetic testing on that individual looking for one of the major... genetic defects that is associated with familial hypercholesterolemia. The advantage of that, and we can do that through a Medicare supported test, the advantage of that is once we've identified the genetic abnormality we can then do a much simpler test if you like throughout the rest of the family screening for that particular abnormality to see if Brothers, sisters or children have the same condition. That's called cascade testing where we know what the defect is that we're looking for because we found it in our index case or our first presentation case and then we're looking for it through the rest of the family. We are cascading that testing through the family. Well, that particular testing gives us extremely good accuracy in being sure about whether cholesterol disorders for a young person are related to the genetic disorder that's been passed on genetically. And in that situation, we've been really quite emboldened here in Australia by implementing and embracing early therapy at a low dose, but early as possible to reduce the exposure of the artery wall to elevated levels of cholesterol. Well, interesting that the US Preventative Services Task Force are not supportive of that. It goes a little bit against the grain of what we would do here in Australia, and I think it's going to be an interesting space to watch in the future. If you were to come and see me at the moment, I would certainly have the conversation about therapy for people under 20 years of age in the right setting so let's leave cholesterol behind and let's talk about something else that pops up with some regularity and that is the safety of giving testosterone to men as they move into their later years well there's always been some concerns about testosterone replacement therapy and concerns around all sorts of risks that could be inherent, whether it increases risk of cancer, particularly, say, prostate, whether it increases risk of heart attack. What other risks might it carry? Well, fairly recently, a large trial called the TRAVERSE study, which looked at about 5,000 men aged between 45 and 80, has released its results. And that particular trial randomized that 5,000 odd men in that age group to daily transdermal testosterone gel, so rubbing on a tiny bit of the hormone, versus placebo, and they did that for almost two years. Importantly, the outcome of this study told the researchers, and therefore us, that there was no increased risk of first occurrence, of composite death from cardiovascular causes which include heart attack or what we call myocardial infarction or stroke. So this is really, really important and it's brought a bit of clarity to a space where there's been over the years quite a bit of uncertainty. The other really big finding was there was no increased risk of prostate cancer. And this was over a 33-month follow-up period. So they extended the period of time where they followed for risk of cancer. And that makes sense. That's also really, really important because if you think about the prostate, it would be an organ that could well be sensitive to testosterone levels. So no increased risk of heart attack or stroke, no increased risk of prostate cancer. Were there any downsides? Well, interestingly, there seemed to be a small uptick in the incidence of atrial fibrillation. How do we explain that? Well, I don't think I can. And in fact, interestingly, when they spoke to the researchers, they didn't necessarily have a good explanation either. Interestingly there was a very small increase in acute kidney injury and again difficult to know how to explain that. Doesn't seem to make sense. The interesting thing was that the numbers are pretty small but still statistically significant. So a little bit of a surprise in terms of acute kidney injury and there also appeared to be a slight increase. in the risk of pulmonary embolism. Now the risk of atrial fibrillation was something in the order of 5.2% in the treatment arm versus 3.3% in the non-treatment arm. So we're talking maybe two men out of 100. And the incidence of acute kidney issues was approximately 3.5% 2.4%. So not huge differences but notable. One of the most striking differences though that surprised it appears everyone was that there was an increase in the number of fractures in the men who had treatment with testosterone and of course this goes against the grain of expectation which was that it should reduce risk of fracture and again looking through the research notes there's no clear reason or explanation as to why an increase in testosterone may increase risk of fracture in these individuals well having a think about it myself it may well be that one of the things that testosterone did was improve quality of life and therefore improve activity. They certainly documented an improvement in the treatment group of sexual function and sexual activity, but it's quite possible, and I don't see any documentation of them measuring it, that there was also increased muscle development and increased energy levels. And both those things may have emboldened the men in the treatment group to have undertaken more rigorous activity. And the consequence of that increased rigorous activity, which could be anything from climbing ladders to playing rugby, rugby with their grandchildren, might be that they ended up... undertaking activities that put them at greater risk. I'm not sure we will know the answer to that, but I will keep an eye out in that space because it's fascinating. So testosterone, certainly good for sexual function, certainly good for sense of well-being, doesn't increase risk of heart attack, doesn't increase risk of prostate cancer, appears to have a very small increased risk of atrial fibrillation, kidney injury and pulmonary embolism. and a very questionable association with an increased fracture risk, which might be explained away by just feeling better and being more active. Well, I hope you found that interesting. I thought it was an interesting one. I'm going to wish you the very best again. I really appreciate you for taking the time to listen in. For now, I hope you live as well as possible for as long as possible. Take care and bye for now. Join the Healthy Heart Network and become part of our growing community. If you're interested in your heart health and risk of heart attack, then join the Healthy Heart Network for only $5 as a lifetime member. This represents $55 worth of value. We offer and help people understand their present state of heart health. what their current level of risk is, and the positive steps they can take to improve their risk of heart attack in the future. Go to www.healthyheartnetwork.com.au and click the Join the Family button.
