Welcome, my name's Dr. Warrick Bishop. I'm a cardiologist, 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. Eric Bishop and welcome to my podcast and videocast station. Thanks so much for tuning in. Today, I've got the opportunity to speak with... professor alan rosansky this is the second time i've had the chance to speak with alan thank you so much for coming back alan how are you thank you for having me it's a pleasure to be here look for those who missed part one uh go back and have a listen um alan well Without going into his bio, he's highly, highly credentialed. He's been in the space for many, many years as a clinician and as a researcher, producing multiple papers about heart health, researching from way back in the mid 80s, looking at all sorts of aspects to do with what drives healthy outcomes for hearts, talking about physical well-being, mindset, emotional. social connection, purpose, and even how we handle stress. So go back and have a listen. You'll also get the chance to listen to Alan's bio, which is huge. But I'm going to put that aside because there's some really interesting aspects that I'd like to invite Alan to tease out for us. And that's really talking about what we've seen in terms of changes in the way heart disease has presented over the last couple of decades. Would you like to just give an overview of that and then maybe we'll drill down a bit, Alan? Sure. Well, there's been dynamic changes in terms of how we treat patients and the factors that drive illness and heart disease. The good news is that we've got all of these risk factors identified, powerful medications for diabetes, high blood pressure and cholesterol. And we saw over time that Many of the aspects of heart disease were decreasing in terms of their severity. And I began to look at our data. At this time, I was looking at data from Cedars-Sinai Medical Center, where uniquely they have captured all data on all patients coming in for stress testing since 1991. So I'm looking at this data in about year 2010, and I'm seeing a signal that I had not seen before, which was that we were seeing a marked decrease in the number of patients. when they came in for stress testing, were manifesting what we term myocardial ischemia, a lack of blood supply during exercise. And if you go back to the early 1990s, we're seeing this in about one third of our patients who were diagnostic patients, people we didn't know for sure that they had heart disease. And by 2010, that had fallen to only 5% of our patients. So that was a marked decline. And that was really good news. I continue to look at these temporal trends. And one thing that I was seeing over that time, and of course, this was a time, let's frame it in terms of the public, where we were having an obesity epidemic since the 1980s, and that followed with a diabetes epidemic. And so those we knew, but what I began to also notice, wow, look at the number of patients who cannot do treadmill exercise. They're required to do pharmacological stress testing because they can't achieve an adequate heart rate when we put them on a treadmill. And we were looking at this data and we said, wait, When you just can't go on a treadmill, your risk for dying prematurely over the next 10 to 12 years increases by threefold, which is a marked increase. That was the most powerful single risk factor we were identifying. So then I looked at this temporal data in terms of what's driving mortality. And I looked at this in about 2015, 2016. We began to look at this data. And you would have said, wait. We have less ischemia, less people coming in with what we call typical angina, which is the pain you get when you stress yourself. And so by these criteria, our mortality rate should have dropped in our stress test population. But as we looked at the mortality rate, it was totally flat. The mortality rates hadn't changed in the stress test patients. What was driving the mortality now? The inability to get on a treadmill. People were becoming short. People coming in with complaints of shortness of breath, which was a symptom which was increasing in society, and there's reasons for that, and diabetes, which was also increasing. So in other words, we've had a historic change, if you will, in what are the drivers of mortality risk in our current patients. We're doing such a great job in treating heart disease when we identify it, but over the long term. your ability to be active, stay physically active, and your ability to take care of your risk factors, like being overweight, being way overweight, and metabolic health become increasingly more important in terms of your long-term risk. Yeah, so this is really talking about slim individuals with coronary artery disease being... morphing into the risk category of obese individuals who are short of breath and dying at the same rate. So bad arteries and being way overweight probably are offering the same risk to individuals. Is that what your work sort of was suggesting? Yeah, we are very, I think we become very reductionistic for those of us who are in the stress labs because we're used to just measuring ischemia and reporting risk. But if you take two 65-year-old men who come in with the same symptoms, one who could exercise to a high workload on a treadmill, and the other couldn't do that at all in quite pharmacological stress testing for us to do our test, and they had the same symptoms, and both of them had a normal scan, we're going to report out that they have a low risk based on looking just at their ischemic risk. But when we look at their global risk, they're quite different. And we're not doing the job that we have to, to report out that global risk for patients. And I think we need to do that more. Yeah, that's interesting. I'm starting to try and think of the metric that you'd use to try and relay that. While I think of it, for those listening, if you're wondering what pharmacological stress means, what Professor Rozanski is talking about is... When a person can't do the exercise of an exercise test, they can lay on a bed or sit in a chair or lay in the scanner and we can infuse or run in through the vein drugs that really drive the heart and mimic exercise. So it's really, we call that a pharmacological stress test. It just gives us exactly the same physiological results. So for those wondering what that means, it's a little... way that we can get around for people who can't exercise properly. Well, it was a good news in terms of our emerging understanding of this, because as we start to expand to a more global, look at the global drivers of risk, and we look at the lifestyle factors, we started asking patients years back a simple question on a scale of one to 10, actually with zero to 10, how much exercise do you get? A single item question. So we have now published four papers. First one was the patients who went into a chronic calcium scanning. And we looked at how they did long term in terms of outcomes, in terms of mortality risk, according to this question. And we found that the exercise data was highly predictive from the single item question. So it was very synergistic with the calcium data. So if you had a high calcium score, but you exercised well, you decreased your risk. And if you had a low calcium score, but you didn't exercise, you increased the risk, so there was like a medium where they were almost equal in terms of the risk. Then we applied the same question, and people went to coronary angiography through the non-invasive technique, and then people undergoing PET scanning, which is a form of nuclear cardiology, where we're looking at the perfusion to the heart during stress, applied the same question, and it was predictive of outcome. Now, why that's good news is that by asking this simple question, you can provide the doctors with important risk data, mortality data from the simple question. So you can identify to the doctor, hey, you know, there's no ischemia on the test, but your patient is reporting they're getting no physical activity. Now the doctor has a handle on that and can begin coaching the patient so that you just don't give them a clean bill of health, so to speak, because they didn't have ischemia on the stress test. We have to be more holistic today because these are factors now driving risk much more than they used to. Well, this is really touching on the tip of the iceberg of preventative cardiology. What you're really speaking to is recognizing people who may be at risk over and above the objective data that we have at any given moment in time. And that really is the way that we start to structure a preventative strategy. What I'm hearing is that you may be dealing with individuals who don't necessarily have clear markers of disease at the moment, but that doesn't mean that they're off the hook down the line or in the future. I think one of the tricks or one of the confounders around that is how we would quantify it so that it became something that had a meaningful, I guess, a meaningful comparator across different situations. Have you thought about that quality of quantification of exercise to bring to that conversation, Alan? Yes, yes. We can quantify that quite well. If the patient can exercise, it turns out the more you can exercise, the lower your risk. So people who can exercise for nine or 12 minutes using a standard protocol have lower risk than people can only exercise six minutes. If they require pharmacological stress testing, we still ask them to do an easy walk protocol. And it turns out that if they can't do that, they're at substantially greater risk than the people who can do even a very small amount of physical activity. The biggest drivers of... why people can't do exercises, physical deconditioning, and usually orthopedic problems, musculoskeletal problems, which we're not addressing enough as well with our patients. A lot of patients have limitations that they're not thinking about, they're not aware of enough. And these can be readily treated, right? But we're not driving the patients to the doctors as soon as we can. The 2018 In the U.S., I don't know what they do in Australia, but in the U.S., every 10 years now, we have new guidelines in terms of exercise for the public. And for the longest period of time, it was about get 30 minutes of exercise, five times a week, 150 minutes exercise. If it's vigorous activity, you can cut that in half. But in the patients that I deal with, and I'm sure you deal with, we're talking about getting sedentary people to get on the playing field. So the 2018 guidelines, the Physical Activity Guidelines for Americans in 2018 published, I think, earth-shattering new suggestions, new guidelines, which based on new data, based on accelerometer data, said any amount of physical activity, no matter how much, no matter how short, adds to your physical well-being. So all of a sudden, wait a second, I don't have to coach my patients to do this vigorous exercise. Let me get them on the playing field. Get my patient to do five minutes of stair climbing, walking around, park your car further from the store, maybe walk to the post office instead of that, make a game out of it. And these are things that promote health, and these are now guideline-driven. So this is very exciting, and that's why this single-item exercise question is synergistic and important. Ah! One, I can identify people who aren't exercising. And now I have better ways to coach my patients credibly. I just got to get them moving more. And we can be excited about giving that data to our patients. And it can be very effective. Yeah. Look, one of the things that's just popped up as a question as I'm listening to you is this concept of the number of years ago, a couple of decades ago, we were seeing. people who weren't necessarily overweight but with coronary artery disease demonstrated at a rate of 30 odd percent on treadmill testing these days the rates are positive treadmill tests are much much less and the people with poor exercise capacity or inability to exercise carry much greater risk what what's the final uh what's the outcome that you're measuring for those individuals uh who are not exercising is it a cardiovascular outcome is it or cause mortality and the reason I'm asking that for those listening is to try and understand if there's if it's a cardiovascular related risk that this lack of exercise reflects or is it a cause is it a risk associated with developing cancer for example or dementia or another condition that may lead to death. What's the outcome data you're measuring on those, Alan? That's a great question. So in our own data, we are just looking at all-cause mortality because we haven't had the data about cause-specific outcomes. But we look at specifically cardiovascular outcomes. The data tracks exactly the same. It's the same risk factors. It's being sedentary. It's having poor control of your blood pressure, poor control of your diabetes, high cholesterol. These are the same factors. And it's also true with cancer risk. So when you look at people, let's say, who have low calcium scores, cancer is a big driver of outcomes in those people. And these same risk factors are important. For that, we know that lack of physical activity is associated with a whole number of cancers. So it's a great question, but really you do the right things and you're going to bring down the chronic risk of all these factors. Yeah, I think you're exactly right. And we're starting to see more and more a recognition of what would be called cardiometabolic. And cardiometabolic pertains to heart-related issues and troubles with the metabolism driven by obesity and prediabetes, diabetes. And we're starting to recognise that much more as a, I guess, a syndrome or a cluster of conditions. And really importantly, that syndrome doesn't... just drive coronary disease as you said it does drive cancer it does drive renal disease it drives liver disease because we're seeing fatty livers and that and fatty liver disease progressing right through to severe hepatic steatosis which is a lot of fat in the liver is really becoming the major cause of cirrhosis in our community, surpassing alcohol. And the other thing that's tied into this is dementia. So this cardiometabolic process, it's disastrous. And anything you can do to unwind it will be to the good. And as you think about it, it doesn't really matter what... is killing you. Death by any cause is premature death by any process is problematic. So we want to be trying to avoid it, whether it's kind of vascular or not. So it was a somewhat academic point asking what the split is, but it really underlines the importance of trying to be sensible about weight and exercise. I just had a thought. I wonder if I could share it. Please. I'm listening to ourselves talk. It's occurred to me that we as doctors tend to talk to our patients in the future tense. You know, do this, exercise more, you know, watch your weight, and you're going to have less heart disease, less fatty liver, less dementia. But in the present tense, if you exercise, if you watch your weight, if you sleep right, you know, you're going to feel better. You're going to have more energy. You're going to be happier. I know any other... podcast, we talked briefly about well-being with exercise. My dear friend Jim Blumenthal of Duke did these prospective randomized studies with people with depression. He randomized them to an antidepressant or to an exercise training program, and he did just as well on both. So it was really quite remarkable. And the data that exercises like an antidepressant now is so solid. And I think talking about the present tense with patients in terms of why to do this becomes as important as a future tense. It's just a thought I had as we were talking about this. Look, I think you're exactly right and that the conversation for engagement is always difficult because our obligation is to do our job as well as possible if we see someone who could benefit from losing weight and exercising. we will speak into their lives because we have an obligation to ourselves to try and impact that person in the most positive way we possibly can. It's often interpreted as us sticking our nose into people's business, but I often try and say to people, that's not the case. I just, it really is my job. My pride and my profession is to try and make a difference for us. No, I'm not judgmental. No. I'm not having a chip at you. I really do want to help. But how we get that connection and get people to move, I've got a very quick story. I had a patient a number of years ago who was a big guy carrying much too much weight, blood pressure up through the roof, had that ruddy complexion, looked like he drank too much. He probably did, but stretching his T-shirt. And he had a little bit of a demeanor about him, which made me feel like if I... encouraged him too much, he might just smack me in the face. So I gave him some guidelines. In fact, I gave him a recommendation to reduce carbohydrate. For a number of people who put on that central adiposity, putting an eye to the carbohydrate is often beneficial. Anyway, I didn't think too much about him. I gave him a little piece of paper with how much carbs to do. And this guy, he looked sick when I saw him, right? Ruddy complexion, glazed eyes, just an angry aura, an angry, yeah, an angry presence about him. About three months later, I got a phone call saying this guy had collapsed in the supermarket. Now, I know that you know what this is like because when you get a call about a patient and something's going wrong, your heart sinks. Oh, no, what's happened? um for those listening we take i mean doctors really i can speak for i'm sure for the vast vast vast majority of doctors we take that very seriously if someone under our watch has something go wrong it's like it's through the heart Anyway, it turns out that this gentleman collapsed in the supermarket because he'd lost so much weight since I'd seen him that his blood pressure was low. And it was a simple fix. He didn't hurt himself. Thankfully, we reduced his blood pressure. I still didn't see him. And I saw him about six months later. So it was nine months interval. When this gentleman came back, Alan, he he was a different man walking through the door. He was he'd lost somewhere around. 15 to 20 kilos. His face looked healthy. He actually had a sparkle in his eyes. As he was talking, he said, oh, Doc, so glad you told me to go do that exercise and follow that diet. He says, I go out for a walk every morning. I feel great. I go out for a walk in the afternoon. And if I can, the missus will come with me. He says, I've got much more energy. He said, and even the sex is back, Doc. This guy, this gentleman's life had completely and utterly changed. It was beautiful, actually. You sort of wish you could bottle it and give it to everyone. Yeah, that's what we want. That's what we want. We taste it and we want it for others. Absolutely. Yes. I'm going to wrap up. I've just had a story. If you've got a story, would you like to share one? Well, I thought generically, as you said this, I used to run a cardiac rehab program. cedars-sinai years back and we would get these old um these older patients who were really very sedentary and frail and frail in those days was younger than today so like this one woman she was 71 years old and she hadn't seen a sight of any exercise equipment and she was terrified of being on a treadmill so we slowly started getting her you know, going. And it was, we had a phase three program. So this extended best, passed in three months, about five or six months, she says to me, Doc, you know, I wouldn't want to have a heart attack, but it really was the best thing that ever happened to me. So I remember that. It was very simple. It's a beautiful silver lining. Alan, I think there we might draw a line under it. Thank you so much for sharing. I really feel like... Well, I feel like we've been doing the same job for a number of years. We've been sharing a similar perspective. So thank you so much for sharing. Thank you for having me. It's been a pleasure to be on. For those listening, as always, I am super grateful that you've given your time to listen to this, and I really hope you found it valuable. I'm sure you have, actually. We've covered some really good stuff. It's been an absolute delight sharing with Professor Alan Rozanski. For those listening, I'd love you to tune in next time. If you'd like to subscribe, that'd be great. And if you can think of someone who'd enjoy my podcast, please share it with them as well. For now, I hope you live as well as possible for as long as possible. And until next time, take care and bye for now. Hi, ever wondered what your risk of heart attack is? You should. It's the single biggest killer in the Western world. We're talking one death. less than every 30 minutes in Australia, one death less than every 60 seconds in the United States, 9 million deaths globally per annum. Well how do you check your risk? Well you can go to www.virtualheartcheck.com.au you'll find out about your risk and what can be done beyond that to be even more precise.
