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 I'd like to welcome you to my podcast channel. Today I'd like to share with you some of the insights and some of the learnings from the recent meeting I went to in Adelaide as part of the South Australian Heart and Medical Research Institute weekend on the 10th and the 11th of May. The weekend... was absolutely excellent in terms of its content. There was a large slant towards cholesterol lowering and prevention, but there was also talk about peripheral vascular disease, cardiac failure and heart attacks. So it covered a broad range of information and really was a terrific and well-organised weekend. I'd like to share with you some of the highlights or bits that I'm taking away. Because I think they're interesting. One of the first comments was we had an international speaker called Gabriel Stieg, who is one of the primary researchers, or lead researchers, in the Odyssey trial, which recently released data suggesting that using these new PCSK9 inhibitors in the post... heart attack syndromes, so people who've had heart attacks who are very high risk with high cholesterols, that events in the future could be reduced by getting LDL cholesterol down to very low levels. And they basically tried to titrate those very low levels down to somewhere around 0.6 millimoles per litre, which is very low compared to where we currently sit in Australia. with current Australian guidelines. Our current Australian guidelines suggest that we need to keep LDL cholesterol down to less than 1.8 millimoles per litre in patients who have had an event. So this is nearly three times lower. One of the really interesting things about this is that people ask questions. Could lowering your LDL cholesterol that much cause a problem? Well, one of the things that Dr. Stig related was that when they looked at the genetic absence of particular receptors in certain populations, so actually found individuals and families with very, very low cholesterols, and these are cholesterols as low as 0.25 millimoles per litre, so even less than half of the 0.6 millimoles per litre in the Odyssey trial, in this group of patients with a genetic mutation. which led to them having very low cholesterols, there was absolutely no apparent consequence when those patients, those individuals and their families were examined for the effect of a low LDL cholesterol. Well, this is, I think, really important information because constantly patients are asking me, how low should you go? And I guess to a large degree, this sort of indicates that the lower is probably better based on the Odyssey trial. And at least from genetic observation, it appears that there is no negative signal from getting LDL cholesterol down to these very low limits and even lower. So this is a space that I think will be discussed and interpreted in time to come, but certainly an interesting starting point and good information. One of the subsequent presentations was by a doctor called Boo Yeap. who's an endocrinologist from Queensland. And his presentation was clear and articulate and really useful. One of the things that I took away from it was that there's a new class of drugs called sodium and glucose transport blockers. And these tablets, these medications, actually allow diabetics to release more sugar from the kidneys. And in a number of trials now, this is shown to be beneficial. not only for their diabetes, but really interesting, also beneficial for their cardiac failure. So these drugs are going to be seen more and more in cardiology clinics. The practical part of this presentation from Dr. Yeap was that these agents can lead to a condition called ketoacidosis with normal blood sugar, and this is something we need to be aware of, and certainly... is a situation that can arise if we don't hold these agents around time of surgery or don't hold these agents when these patients may be otherwise sick. So ketoacidosis is a consequence of the sodium glucose transport blocking agents. We also had Gabriel Stieg come back and speak with us about a trial called the REDUCE-IT trial. which looked at using EPA, a component of fish oil, to treat people with high triglycerides. Now there's been all sorts of to-ing and fro-ing about triglyceride management and fish oil and EPA in the past, but this particular study took people with high triglycerides, gave them a high dose of EPA, and followed them for 10 years. So it really was a great way to ascertain if there was a benefit. clearly showed that giving large doses of EPO, one of the components of fish ore, to these individuals with high triglyceride made a real difference. One of the fascinating things though is that the selection of the patients with high triglyceride determined who would benefit but at the other end of the trial when they looked at the people who benefited it wasn't necessarily related to the triglyceride level. I don't think we quite understand that. But it is certainly interesting and certainly keeps fish oil alive and more research will come in that space. One of the really nice things about the SAMRI meeting was that there were case studies. And one of the cases that we rolled onto was a really complicated case of a patient with high cholesterol levels. And this led on to a very interesting discussion about the formation. of cholesterol crystals within plaque and how crystals of their own in tissue can give rise to inflammation. Well, we know from a fairly recent trial called the Cantos trial that if you lower inflammation with a particular anti-inflammatory monoclonal antibody, you can reduce risk of heart attack. There's also been some really nice work done in Australia using an agent called colchicine, which historically we use for crystal gout. Colchicine, we think, may well have a role in altering the inflammation response caused by crystals within plaque. And there's a lot of work being done in that area in Australia. So an interesting one to watch in the future. We had another presentation on the reduction of cholesterol levels. And discussion was centered around concerns regarding memory and cognitive function. Well, we know, because I've already mentioned, that the individuals who genetically have very low LDL cholesterols don't appear to show any adverse signal or adverse problem with that. Makers of evolocumab, which is a monoclonal PCSK9 inhibitor, to lower cholesterol actually undertook a trial called the Ebbinghaus study, where over two years they lowered LDL cholesterols to very low levels and watched patients very closely. Pleasingly, this study showed no neurological symptom whatsoever. doesn't appear to be affected by this. It doesn't give us longer term information, but it certainly gives us a good reassurance, at least in the first instance, and certainly goes against some patients being concerned about their memory fading as soon as they start taking an LDL lowering agent. So certainly very interesting. One of the next cases that we looked at included patients with atrial fibrillation who needed stents. And these are people who need anticoagulation for the risk of atrial fibrillation, giving rise to stroke, but also need antiplatelets to stop the stent from clogging up. The discussion was really interesting, and we talked about Ticagalor and Prezegrel. because they're very potent antiplatelet agents in general not being used with anticoagulants. But the discussion also came to the point where we talked about clopidobrol, which is sent not to work in 30% of patients. So the more we spoke about it, the more it seemed apparent that there was nothing but controversy in this space and some uncertainty. I think at this stage... The feeling is that aspirin and clopidogrel are probably preferred in the early setting. However, if someone is putting in your stent in the situation where you need an anticoagulant as well, you'd be well advised to take their advice because I'm sure that based on the stent they put in and their experience at the time, they will be across those issues. The other thing was that we talked about a trial called the Global Leaders Trial, and interestingly, they looked at using Ticagalor for a 24-month period. Well, the really interesting thing was that Ticagalor, as a single agent, worked better than our current regimes at 12 months, but at 24 months, its efficacy dropped off and, in fact, was less effective than our current regimes. So go figure that. A situation where if you're on something for too long and there are side effects, people may drop off it and therefore the benefit may be lost. A really interesting space again. The last case study that we had that I went to was on cardiac failure and this was a terrific reminder of how complex and how many options for treatment we have. This includes things like ACE inhibitors. AT2 blockers, spironolactone, beta blockers, Coralan, the sodium glucose transport blockers, Secubitrol and Valsatin, which is in Tresto, iron infusions, and on and on. And this was an absolutely fascinating talk, which I can't possibly cover in detail here, but a tremendous reminder of how many options we have available to us in this space of cardiac failure. I'm going to wrap up my summary summary here. I'm going to wish you the very best for your health, and if you have any queries or questions, shoot them in, and we'll try and deal with them. Thanks so much for listening, and as always, I wish you the very best. 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.
