**EP252: Take Your Medication & Future Therapy** **Dr. Warwick Bishop:** I believe we can prevent heart attacks. We can put in place strategies to reduce risk. We can literally plan to change your future. Welcome, my name is Dr. Warwick Bishop, and I'm a cardiologist, an author, a keynote speaker, and CEO of the Healthy Heart Network. I'm all about trying to help people live as well as possible for as long as possible, and that includes heart attacks, which impact Australia enormously. We're talking about a heart attack almost every 10 minutes and over 20 people per day dying from a heart attack in Australia. That's on a backdrop of over 9 million people globally being impacted. The sad truth is many of these could have been averted if only we knew what to do. Well, this podcast is all about that: weight, blood pressure, cholesterol, general health, and driving health literacy. I'm on a mission to help not just prevent heart attacks but improve general health on a global scale. If you enjoy this podcast, I would be honored if you could give it a five-star review and share it with your family and friends. It may even lead to saving someone you love. I really do appreciate you taking the time to join me. Today, I'd like to talk about two things. One is taking your medication, and that's called adherence. The other thing I'd like to talk about is a potential therapy that's on the horizon for future consideration, and that's called electroporation. That's using electricity to break up cell membranes and make a difference in the way the cells leak or allow things through or even damage cells. But more about that later. First, let's talk about medication, which is a little bit of a soapbox for me. I regularly ask my patients to make sure they carry a list of their medications. I don't expect people to be able to remember all those complicated names, particularly in this world of generics where there are different names, often for the same medication. I don't expect people to remember the doses either. So please write your medications down on a list somewhere. Imagine you were in an accident or taken to the accident emergency for some problem in an emergency situation. It's not hard to imagine how valuable being able to tell your doctors exactly the medication you're on could facilitate and improve and ensure your best health care. So carry that list in your wallet or on your phone. Have it up to date. People who have a Webster pack, slide the little leaflet out of the top of your Webster pack and carry that in your purse or wallet. It really is one of the most significant things you can do to help for your own best healthcare. Now, when you do take your tablets, and they've been prescribed for you by your doctor, then I would like to think, and I would like you to consider, that your doctor has put into context the pros and the cons of that medication for your particular situation. And on balance, believes that that medication will be good for you. Now, it's really important you understand that these tablets only work if you take them. I deal with people who sometimes will take the script, take the tablet briefly, and then drop off it for various reasons. Well, taking medication is called adherence. Adhering, sticking, sticking to the regime you've been given. Adherence. So, adherence is a really big issue. Obviously, in my own practice, if someone is unsure about the medication I've given them, my door is always open to discuss what I believe the pros and cons are for that individual so we can talk about it as adults and put into place the best strategy for that individual. That may include dose adjustment because of side effects, or it may include dose adjustment because of fears or concerns about potential side effects, but either way, it really is a situation where best communication is absolutely vital. Well, having said all that, which is my soapbox, I want to jump on to adherence in a different aspect. This popped up in a paper I saw just recently. There's been some research looking into adherence in clinical trials. Well, this is really important because if you think about it, the clinical trials and the results of those clinical trials are what guide our therapy and what we believe is best for our patients. Well, what if the adherence is flawed in those trials, and therefore our interpretation is misdirected and potentially thrown out of kilter? Well, that appears to some degree to be the case in two trials that have been looked at, one called MASTER. Dual antiplatelet therapy. MASTER is the name of the trial. D-A-P-T stands for dual antiplatelet therapy. Anyone who's had a stent in an artery knows that you take your aspirin plus another agent, which is just like aspirin. Both those agents work against the platelets so that you don't get clogging up of the artery. That's two agents to block the action of platelets, therefore called dual antiplatelet therapy. Well, in a review of MASTER DAPT, dual antiplatelet therapy, the trial, they were comparing short duration of dual antiplatelet therapy with longer duration of dual antiplatelet therapy. In scrutinizing exactly what went on, it turns out that the patients randomized to the one-month dual antiplatelet therapy continued their therapy out to six months in up to 25 percent of those patients. So almost a quarter continued with dual antiplatelet therapy in spite of the protocol of the study. Well, this only creates confusion; it waters down our belief that stopping dual antiplatelet therapy at one month is as safe as the trial initially suggested. It certainly confirms that out to six months is clearly indicated, but you can see that by a failure of adherence to the protocol, and in this case, patients taking more than they were actually prescribed, we've muddied the waters. The ischemia trial, which I've mentioned before on previous podcasts, was all about figuring out if maximal optimized medical therapy could provide as good outcomes as a PTCA or a stent in stable angina patients. The thoughts around this particular trial were that by using an early intervention, we could help or support the patients who had poor adherence. And so they looked closely at whether this concept of early intervention, doing something to someone who may not take their tablets, would be beneficial in the longer term. Well, it turns out it wasn't. It seems that you need to take your tablets regardless of an early intervention or not. The early intervention didn't improve adherence. It didn't improve outcomes. And so our belief that taking a, if you like, a physical approach, an interventional approach to patients who may be poor at their adherence, well, although it sounds good in theory, didn't seem to bear out in the data. So, taking your tablets, adherence, please. You've got to own it. You need to talk to your doctor if you have any uncertainties. Please be educated and carry a list. That makes a big difference. Remember, as we look at adherence, even in clinical trials, it's complicated. Well, I hope you found that interesting. The other thing I want to share with you is a technology that came out at the Cardiac Society just recently and was considered one of the hot topics. The technology is called electroporation, and it's currently being used in a number of different settings, particularly at the moment for disrupting cellular integrity to allow chemotherapeutic or cancer drugs into particular areas. The concept of electroporation is that you use electricity to disrupt the cell membrane and therefore change its functionality. In the setting that it's currently being used for cancer drugs, the amount of disruption is fairly minimal, meaning that the cells lose their integrity but don't die. And then the cancer drug can pass to where it needs to go, and then the cells regenerate and heal. Well, if you turn up the dose of electroporation, if you increase the damage from the electricity, you can actually lead to destruction of those cells. It turns out that this can be a very well-controlled, very safe way of interfering or disrupting, damaging permanently cells, and this looks like a technology that may well be used in the process of atrial fibrillation ablation, which currently uses thermal techniques—freezing or heat. The problem with freezing or heat is that they go more broadly than the immediate area, and so electroporation may well provide an even safer option for that in the future. Well, that's about it for me for now on those topics. Take your tablets and keep an eye to the future. I hope you found that interesting. If you have any queries or questions, drop us a note. If you've got any ideas for future podcasts, please give us a heads up at info@drwarwickbishop.online. For now, I'm going to thank you again for tuning in. I really do appreciate it. If you've found this helpful, interesting, and informative, share it with a friend and even give it a like somewhere. Till next time, I wish you to live as well as possible for as long as possible. Take care, and bye for now. Visit us at www.virtualheartcheck.com.au.