Cholesterol and the Calcium Score

Arthur: And a lot of people all have a new test to see if they just look at it. They overestimate. They say, oh, you have obstruction and you need a stent. That happens not to be true. It is is very bad. And the amount of plaques off versus hard is you really need the eye to know it's happened.

Arthur: Never give it. Never never never.

Intro: Never make any hard get some or any brand. Pick yourself up and keep moving through the pain. Keep moving forward. That's what you great. Thank you.

Arthur: What it comes down to today.

Brent: Welcome to death clock. I'm your host, Brent Franson. Today we speak with Doctor Arthur Agates and about heart health. Doctor agates in created the calcium score. It's named after him. It's called the agates and score. But it's. It's the lay term would be the calcium score, which measures the amount of plaque in your heart and gives you an indication of how at risk you are for having a heart attack.

Brent: It is probably the number one advancement in preventative health related to the heart and heart disease is the number one killer over the last 30 years. He's also the creator of the South Beach Diet. He is an incredible guest who's got a really deep understanding of heart health and metabolic health. And he takes us through CT scan for calcium score.

Brent: Of course, we talk about the CT scan. We talk about incidental findings. We talk about cholesterol and statins and how you should think about when to take statins and whether or not to take statins. He really is a wonderful guest, and I was just so honored to be able to have the discussion with him. I hope you enjoy.

Brent: Doctor agates and welcome to the show.

Arthur: Pleasure to be here.

Brent: I'm honored to have you here. You you know, the calcium score. You invented it. It's named after you. You know that calcium score is the kind of common name, but it's it's the agates and score. And so I can't wait to dig into everything. Calcium score. Scanning of the heart, understanding heart health. You also created the South Beach diet.

Brent: So we should we should chat about that. So before we get into everything, can you just quickly just give us a sense of your potted bio?

Arthur: You know, my dad, grandfather were actually doctors. They were they were ophthalmologists. And growing up, my dad, that was it was it was old time medicine where you had the offices were in the house and, they weren't bringing chickens for payment, but it was a little it started now. It was, it was pre pre Medicare. So trends kind of seen the whole evolution of medicine.

Arthur: But one thing I worried from early on was somebody in our class his father died of a heart attack. And so my fear was that my dad would have a have a heart attack and could that be prevented? And the early stuff was, you know, was fat and more exercise and then not smoking, which was helpful. But that's what led me really into cardiology and being interested in prevention.

Arthur: And in the early days, we really weren't doing anything for patients, with, the early cardiac care units, you could defibrillate them if they went into ventricular fibrillation. But we had no medications. We were giving all the wrong advice about diet and seeing what happened, that we ended up with such, in a sense, bad advice. We say the National guidelines in the food, your image should be really inverted and sort of how that happened, how we cut so much.

Arthur: So this is information it turned out about about cholesterol. Someone was reasonable about the time and a lot was just the march of technology. And so early on I was originally in echocardiography is my subspecialty in cardiology, the ultrasound and then that, volved in the imaging for the heart and the calcium score and how that evolved to answer a question at the time.

Arthur: And then once we were seeing plaque in a lot of hearts with not very high cholesterol, we realized there was more to that and that the low fat, high carb diet didn't work, which every cardiologist knew. And then, statins came along. And how do we know who needs a statin? Who does it? You could probably lower your your cholesterol.

Arthur: But besides that, if you were having a low fat, high carb diet, you were still in trouble. And that led to the, for low carb or good fats, good carbs, and running the South Beach diet. Since then. Last but was a keto friendly South Beach diet that we did. But whether it's paleo or the original Atkins, I do have problems with plant based diets.

Arthur: You can be healthy with a plant based diet, but it's not easy. And there's there's no data compared to low, low carb diets now. And now we've had just new toys to play with. The imaging has gotten better and better. We do something called the craft that's measuring your insulin level. After a big drink of sugar, and that tells us a lot more than just hemoglobin A1, C's, or the traditional ways of looking, at metabolic health.

Arthur: We've learned a lot more about exercise, the importance of resistance training compared to, just aerobic, and especially versus endurance training, new toys with blood pressure. We can now measure a continuous blood pressure without blowing up a cuff. And that's very recent, but there's been a lot of disinformation, misunderstanding about blood pressure. So I'm I'm having a lot of fun with all these new toys.

Arthur: And the other is the genetics has made a big it's gotten much less expensive. We know a lot more about it recently. So every time I feel we're settling for something, there's always something new. And what we really say now is we're we're in the golden age of medical science. But there's still the dark age of health care delivery.

Brent: And it seems you created one of the original toys. So let's just lay the groundwork of the the CT scan for the calcium score and plaque in the heart and what's happening. So you've got a computed tomography scan. So this is a noninvasive scan that looks at what's that looks at the amount of plaque in the arteries of your heart.

Brent: And that gives you an aggregate sense score your name which is more commonly known at least among, you know, individuals I'm sure clinicians. But for and against and as the calcium score and that is a zero plus score that's going to that's going to determine your risk of having a heart attack over the next ten years. And that's measuring calcified plaque, hard plaque in the arteries.

Brent: But that's not the only type of plaque in the arteries that can cause a heart attack. So we you speak a little bit to you can correct any of that if that's wrong in terms of calcium score on the CT scan and what's happening with plaque in the arteries and how is plaque causing a heart attack calcified or not?

Arthur: Well, one thing that led to the calcium score in the first place was the Framingham score, which took into account really just, blood pressure, cholesterol level and being a smoker or not, and total cholesterol, LDL cholesterol, very poor predictors of who's going to have a heart attack. Most people have heart attacks, have really average levels of cholesterol, and diabetics actually tend to have low levels of of total cholesterol.

Arthur: We didn't have any really good ways to assess risk in individuals. The algorithms were for big populations. One thing we learned, particularly in the 70s with pathology studies, was the total amount of plaque calcified, non calcified together was the best predictor of future heart attack and stroke. First, we didn't know that. What we knew was by the time somebody had a heart attack, most of their vessels had atherosclerosis already in in war casualties from Korea, War, Vietnam and just the young kids who died, a good percentage of them already had plus.

Arthur: So it starts early and it progresses over a long time. What we realized, the head of cardiology at Sinai when I started practicing, used you for asking me to look for culinary calcium, and I, I learned the coronary calcium literature, and then along came this new technology. If you used a traditional CT scanner, you know, that's really x rays coming in from many directions.

Arthur: And the the computer puts it all together and comes out with nice with nice pictures. But the early CT scanners took, a few seconds to get the image, but the heart was moving when it came to looking at the heart. You just got a blur. It was like shooting a racehorse horse with a camera with a slower shutter speed.

Arthur: So along came, this new technology, originally called the image on where you could do a subsetting acquisition. And for the first time, you could freeze the heart. When I first looked at that, I was interested in prevention. I knew total cholesterol and those numbers didn't help us. And here the question was, could we see the disease directly?

Arthur: As soon as we saw this new scanner, we threw some, some doctors on the scanner, came up with a protocol, and we were amazed you could see calcium very precisely. Now, as you mentioned, the calcium is hard plaque that actually doesn't cause heart attacks, but it reflects how much overall atherosclerosis you have. And once you have a very lumpy, bumpy vessel, you get abnormal blood flow, which increases how much, how fast you're laying down plaque.

Arthur: And also, the way individuals plaque, plaques, and natural history is they start is what I call cholesterol pimples. Just a little fatty pimple, but they grow to a certain size. They rupture. And when they rupture, they cause a clot. But the first clots almost never clog the whole vessel and cause a heart attack. They heal over with calcium.

Arthur: So the more calcification you see is an indication that you started with a cholesterol pimple. It popped, it healed over with a clot, and then it became scar tissue. And over the years, the scar tissue, calcified. So when you look at the any individual plaque over the years, it doesn't get the soft plaque, the scar tissue, it doesn't cause the vessel to narrow in itself either does calcium, but it makes the flow abnormal, lumpy, bumpy and abnormal flow causes plaque to, lay down more rapidly.

Arthur: We know that that plaque occurs where there is branching in vessels for people to do carotid studies. Where the carotid branch is, is always where you see the early plaque. And that's because there's more turbulence of flow. It's like if you look at, the Colorado River, where there's flow around the curve, there's always, you see, really the deposition of silt on the inside because the water is going slower on the outside, it goes faster.

Arthur: And that's where you really carve a canyon.

Brent: So just to clear, let me repeat some of this back to you and you can tell me what's wrong with it. So these biomarkers that we think of as being these primary indicators of heart health. And let's look at LDL and total cholesterol as the top indicators. What you realized was okay, fine at the population level, meaning up in a group of a lot of people, these are going to be directionally representative of, you know, an unhealthy heart or somebody who might have a heart attack.

Brent: But we knew where at the individual level, they're totally not representative. We see people have heart attacks who have healthy cholesterol levels. People who are not having heart attacks have unhealthy cholesterol levels. We knew we needed something better at the individual level, and we knew that these markers are surrogate, meaning they're a little bit of a canary in the coal mine at the population level.

Brent: But it's not heart disease in and of itself, high cholesterol. And so, okay, we realized as the technology changed that actually we could use these CT scans to look at the actual disease in the heart, which is the plaque buildup in the heart. And what you see there is you can see very early plaque buildup far ahead of a heart attack.

Brent: And when there's some plaque buildup, there's going to be more so in a case there's no plaque. It's like a clear pipe. It's a pipe with just no obstructions. It's clean and clear. Think about like a PVC pipe. But when you have these little pimples that pop, that creates little ridges in the pipe and it just it's it catches sediment a little bit easier.

Brent: And so the buildup can accelerate from there. Once there's a little bit of built and then particularly around the corners, for lack of better term, the carotid artery or the, the different places where the blood is kind of turning in the heart. But that in of itself doesn't cause heart disease. So I'll pause and let you react to that.

Brent: But first I want to ask the question related to that. Do you think the biomarkers LDL, total cholesterol, they're pointless. We shouldn't be measuring them and we should just be doing CT scans or they have some value directionally. But we've overestimated their value.

Arthur: We've overestimated the value. And by the way, your your explanation is outstanding. You you know, I'll call you to do my next lectures. Sorry to laypeople. They're very poor predictors. I have many people. One woman who's 97, with levels of over 200 cholesterol is 350 and squeaky clean vessels literally at 97. What we last was many years ago before we get our calcium score.

Arthur: But she's still alive at 97. And others, even with familial hypercholesterolemia, who would never develop plaque. Now, because of new genetics, we understand how they interact with differently in people, and then we can have people with cholesterol less than 200 who have early heart disease. The imaging is much, much better. Your chance of having a heart attack with a zero calcium score is close to zero.

Arthur: And the other point that you made, the arterial sclerosis starts really early. If you're heading for a heart attack in your 60s or 70s, you already have in your 30s or 40s, and now we actually can can image that. And depending on the family history, genetics, metabolic health, we we can see who and who we become more aggressive at at young ages and.

Brent: At what age. Because I think it's worth calling out. Maybe two things. One is it feels that our traditional primary care physicians are not recommending CT scans for calcium scores enough. There's been a huge acceleration in the awareness of the score that you created in the early 90s and that, you know, I think you deserve. I hope you've gotten some some number of awards for that.

Brent: I mean, it seems you've saved a lot of lives, but it's not at the place where it's part of a standard course of care. You can correct that if that's wrong. So if you could wave a magic wand and say, hey, at age X, we all get our first CT scan to know our calcium score. And then would it be for everybody?

Brent: Would it be for some specific subset of the population? Would it just be for people who have high cholesterol? Like if you could just wave a magic wand and say, hey, this is going to be the law of the land of preventative health for everybody. What is it as it relates to the calcium score.

Arthur: For the general population by age 40? We think all men should have their first CT. It costs nothing. The radiation is essentially zero.

Brent: It costs like $150. It's got very minimal costs. It's not not zero.

Arthur: But oh yeah, I mean the the radiation is near zero. The cost now, the cost is AC gone, gone down and it's much cheaper than not. We take a lot of people off that have zero scores, even though they have pretty high cholesterol. And women we when they're sort of postmenopausal. Now for a high risk, we do it at a younger age.

Arthur: And I'm allowed to break Kippur with my own family because it turned out my wife's father died at 52 of a heart attack. She was thin, healthy, always athletic. But we did her first scan when she was just perimenopausal and she lit up. She had a high score and her HDL was 107. This is one thing that not enough people know about, but HDL is important and it's it is a good cholesterol, but not for everybody.

Arthur: And overall when it kills get over 80 mortality actually goes up. And and we know there's several reasons why. So it turned out her heart HDL of 170 obviously wasn't protecting her. We knew there was an issue with it. We have medication that can increase the clearance of HDL. If it's over 100, it's usually not being cleared and it actually gets in the vessel wall.

Arthur: So we knew that we started treating her and she had this advanced, imaging recently. She has not had any plaque since then. So we've stopped progression in her. Now I have two sons. I always like to say, well, they may I'm not the father, but I saw them come out of her, so I know, I know she was the mother, so I, she ended up with two, genetic mutations called Lipsey, which I don't want to get into.

Arthur: But these are genes that indicate that you're HDL. You're pulling HDL out of your reservoir, but you can't dump it into the liver and then into the intestine and get rid of it, called reverse cholesterol transport. So with this gene and many others, we've discovered even people with high HDL, if you have a family history of heart disease or if you have plot, the high HDL is not not protecting you.

Arthur: So my sons I scanned in their 30s one both around 35. That was five years ago for my older son. It's time on medication. We did our super advanced testing. He's not had any new plaque since we started him on it and he was thin, athletic, no reason to have any plaque and his HDL was also over 100.

Arthur: My other son, his HDL was not that high, but again I knew he I knew he had the same genetics and he already has some plaque. We looked for soft plaque as well as hard plaque. So now seeing seeing something that early, the earlier you start prevention the less chance it's the it's very easy to prevent progression okay.

Brent: So so if I, if I just repeat this back it's basically look cholesterol HDL LDL knowing these markers matters. But there's a lot of complexity here. It's not necessarily that more HDL is better. That's typically the case. But that's not always the case. It's not necessarily if you got really high LDL the bad cholesterol, that you definitely have heart disease.

Brent: And so okay, let's be aware of our biomarkers. We're not saying don't do blood work, but there is not a substitute for doing the scan. These scans are a couple hundred dollars at most. They're very easy to schedule. They're very easy for your doctor to refer. They tend to be out of pocket. I think that's worth saying. You tend to have to pay for them out of pocket, but the cost is low.

Brent: There's a tiny bit of radiation, but nothing we'd be concerned about. And so there's not a great reason for people who are middle aged. And you draw the line at men 40 and above without a family history, and women post menopause to go get the CT scan for the calcium score and to know if whether or not there's any plaque in your heart.

Arthur: Absolutely well said. And we aware there is genetic disease, as in my wife's family and with my with my own sons. And we have so many more examples of that. We look we look at the kids earlier and depending on what the problem is, we might even at age 30 and in certain selected individuals, but not the general population.

Brent: Okay. And then let's talk about CT scans. So this is I'm telling you something I you know, you obviously know but but a coronary CT angiography, this is going to be a dye based scan. So there is a, you know, there's a needle that's put into the, into a vein and then there's a dye that's put in and it's going to show you it's going to give you the calcium score, but it's also going to give you a score of hard plaque that is not calcified.

Brent: And then two different types of soft plaque. This falls into the same category of easy to get easy for a doctor to refer. It's just it's more expensive. And there's a little bit more radiation. So why would you or would you not say, hey, those recommendations we have around getting this scan preventatively at age 40 and for women post menopause, why are we not recommending a CT scan?

Brent: Because it includes York. You know, the agates and score the calcium score, but it includes some other measurements of plaque. Why are we not recommending those for everybody? And we are tending to recommend this CT scan that only gives us the agates and score.

Arthur: It's because of the. When I mentioned the natural history of the plaque. You start with that cholesterol pimple, which is fat. It's very low density, and after it ruptures and you get a clot in a few weeks or a few months, it becomes scar tissue. And then over many years it calcified. And we've been able to use CT angiograms, really since, since the then late 90s.

Arthur: But now the new it's really it's, it's it's I, it tells you the density of every pixel in this scan. So in the big picture, the older the plaque, the more dense it's going to be. In the early days of the calcium strongly, we saw a big chunk of calcium. We thought it was more obstructive, higher risk, all kinds of issues.

Arthur: It turns out it only means it's been there a long time. The plaque had a lot of time to heal, so there's a lot of a lot of calcium. But that if you have a heart attack, it doesn't come from that big chunk of calcium. It comes from a new cholesterol pimple, which will be very low risk. Now we see, what the vulnerable part is when you just have this big cholesterol pimple.

Arthur: We don't see that all that often. But if you've had that ruptured and you're within a year or two of it, you still see some areas of fat of that very low density. So if we see any fat and we, we know this is this has progressed recently and the same, with, with the scar, which is a little more dense and the fat but less dense than the calcium.

Arthur: And from the, the, the amount of calcium, we can really tell the age of the plaque. So if somebody comes to me and they've been on a, a low dose statin for ten years, it's probably it's probably slowed progression, but it may not have stopped.

Brent: But can you see this on both the CT scan and the CT scanner? We can only see this on CTAs.

Arthur: You can see the size of calcium. I looked side by side for years of the calcium scans, so I can have a sense how old the plaque was, and if somebody who was treated for many years, we only see big chunks of calcium, we didn't see really small ones. But this is more, more sophisticated. And so something we've been treating for 20, 30 years and they come in for a scan, we see only really old, plaque.

Arthur: There's there'll be some scar and there'll be no sort of plaque, none of the cholesterol pimples. So the person has been treated on, say, a low dose statin for many years. If we see a little soft plaque or even more scar than calcium, we can tell that it's slow, that the treatment has slowed progression, but hasn't stopped it.

Arthur: Even in the last week, we had a patient who, was on a statin for many years. He went to somebody who said, you don't need to start this on a plant based diet. He had another actually calcium score had gone up quite a bit. And we we did the, the CTA and he had a big cholesterol pimple.

Arthur: And his other plaque was really old, so we could tell when he stopped his statin, he developed this new soft plaque. He developed rapidly. So we read the right back to him, back on, on the statins. And we actually knew what worked for him. And in the next six months to a year, his no new soft plaque, the fat was gone away.

Arthur: And the, you know, the calcium was increasing and the scar is actually decreasing because what becomes calcified is the old scar. We really I said, it's like carbon dating of old fossils. You we really can tell how old the plaque is. And we see differences. When people are really aggressive with a good diet, it stops progressing with, with, with the right treatment and the earlier you start, the more you can do it without medications, with, with just the diet lifestyle.

Brent: I want to get to maybe statins next, but just to, just to maybe finish this point. If somebody is saying, hey, I really want to do everything I can preventatively to be healthy. I had heard of this calcium score, and I haven't had one. And so okay, now I'm going to go get one. And I don't know, money is not an issue like I want to spend on my own health.

Brent: Do you recommend the C.T. scan for the calcium score alone, or would you recommend a CT scan to get the calcium score and the scores for the three other types of plaque that, as you say, I can actually be more problematic from a heart attack perspective than the calcified plaque that shows up on the CT scan for the calcium score.

Arthur: It depends on the age and in this situation, for people in their, you know, 50s, 60s, if they have a low or almost no plaque there, they're almost home free. And if they've had a good diet lifestyle, we can just continue it. Another example. But before we have the ccta the way we do it today, I had a young fellow, his father had a heart attack.

Arthur: We did a calcium score and he had a few calcified lesions. He wanted to do everything with diet and lifestyle. I said, that's fine. You're young enough. You have very little plaque. But we're going to repeat it actually yearly. Again, the radiation is not it's not important. And if you develop new plaques, which means you had a new fatty plaque that ruptured, became calcified, then we're going to renegotiate.

Arthur: And he did very, very well. We we know why he went off the wagon at one point and we saw new calcified plaques. So then he did go. He did go on a statin. And again, we we see people at all ages who have not have a zero calcium score. And we'll, we'll take them, we'll take them off statins, the really high risk like my son when you know, I know their grandfather died young and they had, what was clearly the same gene he did once.

Arthur: We did before the CC d.A. Was available, and he already had some plaque. And his brother had a little calcified plaque. He was 35. That was still ahead of the game, but he had quite a bit of soft plaque. So we we knew definitely to be more aggressive with him. So it really depends. You know, it depends on the situation.

Brent: But why why wouldn't you. It you know, what would be the reason that you would say don't get a CT scan. So more expensive a little bit more radiation. If you want to be as proactive about your health as you can, why would you say don't get a ccta and just get the CT scan for the calcium score?

Brent: What would that what would the reasons be?

Arthur: In general, I prefer to have the ccta, so it's only it only comes down to cost. The radiation is not significant and if I could do it on everybody, I would go ahead and do it on everybody. But if if people are, you know, are low risk, you know, averse to spending the extra money, we can still tell a lot from the calcium score.

Arthur: And the other thing is we've had calcium scores around for, you know, 30, 40 years now. We know for years, that as far as total plaque burden, what a particular calcium score means and how serious it is and the the volumes that come up with the CTAs, you can come up with them, but they're not second nature.

Arthur: That's why I still like to add the calcium score. But has the cost come down? And someday and the scanners get even better. Having the highest end scan, is what does give us the most information.

Brent: Okay, so when you wave your magic wand and you say, hey, everybody should get a CT scan for a calcium score, men starting at age 40, women post menopause. The reason you're waving that wand and not the wand that says the same thing. But it's a ccta instead of the CT scan. It's cost.

Arthur: It's cause it really comes down to cost. Yeah, and if people have issues, older people with renal function as far as giving them die, you can worsen kidney function and or having, you know, having an allergy to die. So there's some other reasons. But in a sense, if I could wave my magic wand, I would want it in everybody.

Brent: You'd want it. Everybody. Okay. And then the CT scan, just in terms of the logistics of going and getting it, I mean, what I did was I went to the website and they recommended a provider, and I got the provider and I got the clearly scan, which is basically an AI analysis on top of it.

Arthur: And, and that analysis, by the way, that's the one that does the density of every pixel on the scan. So and they, you know, they're three categories. They, they show a, red for the, for the cholesterol pimple. And, it's yellow for scar and blue for calcium. But you can look and see the age of I see a big chunk of calcium.

Arthur: I go to the center of that, what's called the Hounsfield units. That's the measure of our density, is it'll be in the thousands, whereas somebody with just a smaller calcification, it'll be, you know, a few hundred, but you can see the whole spectrum. And that's where we're learning more about the natural history of atherosclerosis. We could never see fatty plots before, like, like we can just in the last few years.

Arthur: And so knowing that natural history, how long it takes that fat to disappear, that tells me if I see even a small amount of fat, that little cluster pimple is not going to blow up and cause a heart attack, but it means it formed recently. So whatever you were on the treatment when that formed, it wasn't aggressive enough.

Brent: The ccta itself is done by your local imaging center of the same kind of places that would do the CT scan. It's about $500 instead of 150. And then the clearly analysis, that's a third party company that's going to take that scan and give this more in-depth analysis. And that's roughly $1,000. Like prices can vary. But it's really it's kind of $1,500 all in for clearly e ly.

Brent: And the CT scan versus about $150 all in for the CT scan for the calcium score.

Arthur: But billing looking the regular ccta CT that over evaluated over estimated your percents the gnosis. And by the way, if you don't have symptoms and you get on a stress test and you go for a long time even independent of each EKG, it means blood's getting to your heart. And a lot of people all say, I have a new test, the ccta.

Arthur: If they just look at it, they overestimate. They say, oh, you have obstruction and you need a stent. That happens not to be true. It's the trying to estimate flow just from a standard. Ccta it is is very bad. And the amount of plaques off first is hard is you really need the eye to know what's happening.

Brent: So you're recommending you're saying, hey, if you're going to get a ccta, just make sure you're doing clearly on top of it, because then you've got risk of overtreatment or yeah, overtreatment.

Arthur: Which, which we, we see all the time. And people who had stents bypass surgeries, that was totally unnecessary, because the drawback to the analysis, which we know is a very poor predictor of what flow actually is, it doesn't give you more information than the total calcium score is as far as who's going to get the heart attack. Occasionally you can see, you know, you can see a big cholesterol pimple on the ccta, but that's it misleads you more than it leads you in the right direction.

Brent: Okay. So that's a good point. So there's a risk on the C CTA if you do it without the clearly results of some doc saying, hey, we're seeing stenosis here. Let's put in a stent. That's a very invasive procedure. And it's not without its own side effects. And that you do not want to do that unnecessarily. And if you're getting these CTAs without clearly your risk of some unnecessary procedure like that is much higher.

Arthur: Absolutely. And it's something we see all the time. And the tests have been dubbed the Courage trial was done in New England Journal of Medicine, 2007 and more recently, Ischemia. A trial was done where if you even if you have obstructive POC, even if it's causing symptoms, if you're having a lot of pain when you walk the stent is very helpful.

Arthur: But it does not prevent heart attack and stroke. And that's because once there's an obstructive part, it's already calcified and scarred over, and those don't grow anymore.

Brent: And I think this is this is such an important point related to over screening generally, because I think that a lot of people don't understand the risk of over screening, which is why wouldn't I want to know? Of course I'll do a full body scan. I want to know I can catch something early. I'll do this CT scan.

Brent: How can that be bad? And the reason it's bad is because you can go down this slippery slope of getting diagnostics and procedures that all have some kind of side effect, that all have some risk in and of themselves that you don't need. And so that's why you want to be really well-educated, and you want to be really cautious as it relates to these preventative health screenings.

Brent: So it's not that you shouldn't do them. It's just you want to be really eyes wide open. And in this case, get the clearly you don't want to be getting stents that you don't need.

Arthur: Absolutely. And by the way, one of the objections of the to calcium score early was something is going to see a lot of plaque. And they're going to say oh we need an angiogram. And then they end up with bypass surgery or whatever. And we've certainly seen cases of that. And same with the the C CTA even even more so.

Arthur: And you want a doctor sophisticated enough to know the difference. That's the other thing. If they don't know that and unfortunately there's a big economic incentive, to go the invasive route. Yeah.

Brent: You somebody's getting paid when that stent goes in. So let's just talk quickly. And then I want to make sure we hit cholesterol. But about incidental findings. And so it seems in let's just take CT and CT scans versus a full body scan. So like something like a pre nouveau scan or and Esra scan that the rates of incidental findings are going to be much lower on CT and CT.

Brent: So an incidental finding would be we do a full body scan and we see a nodule on your lung. We don't know if it's cancerous or not. We don't know. And now we have these tricky questions about whether or not we go in and biopsy it. The biopsy itself has has some risk, but the C CTA, you know, there's an incidental finding is very personal to me.

Brent: RA I recommended a CT scan for me. I went and got one and I don't have any plaque anywhere in my heart. I do have high cholesterol and my biomarkers aren't great, but I don't have any plaque. But it did find that I have an anomalous right coronary artery. My right coronary artery originates on the left side, and it has to pass between the pulmonary artery and the aorta, which means I'm at some risk of dying suddenly while exercising that I wasn't aware of.

Brent: And so I think I'm grateful for that finding. I mean, I'm 43 and I'm not dead, so that's a data point of some kind.

Arthur: That's a very important one, because with anomalous anomalous vessels, most of them are really, really, benign and in, you know, sudden deaths in for cardiac reasons. The two top causes are hypertrophic cardiomyopathy un unrecognized, which is a very thick heart that's congenital. That diagnosis is actually over given because the vehicle echocardiography is too sensitive. And then, like, Marfan syndrome, you know, aneurysms that blow up, anomalous coronary arteries is way, way down there in very, very rare cause.

Brent: But that's a, I think, a positive, incidental finding meaning. I think I'd rather know about that than not. And so I, you know, I would I love your perspective on that. But I think the more important question is, and I think this statement is true, is that we have less concern about incidental findings that end up being harmful with CTAs and with CT scans than we do in something like a full body scan.

Arthur: Right now, it is easy to look at areas where there's an incidental, in the early days, you know, I mentioned what was the original CT technology called the image emission. You could for the first time, you could scan the whole body quickly because it required images so, so fast. And some people wanted to use it for cancer screening.

Arthur: We did not go along with that, you know, for years and years because of incidental ailments. And we didn't know what to do with them. Since then, the imaging has gotten faster and faster. The resolution has gotten better and better with both c.T. And MRI and those. Yeah, there are protocols. They now follow these instead. Long as in the early days of looking for contra calcium, we would see little lung nodules.

Arthur: And up to 20% of people was very common. And we've never been burned. Depending on the size. You may repeat it in the year, two years. You may do a Pet scan in a few, but we've never been burned. And and when we look when we do ultrasound, we take a quick look. We look at the liver mainly for liver fat.

Arthur: We see the kidneys there. There exists and Joe is little benign lesions all over the place. And now it's, it's easy enough to do. And there are the, the new blood tests, DNA and other way. You know, I've been imaging for a long time. I'm not. Not collagist, but, the thing that scared me the most, that was the the cancer that grows the fastest, and then women, it's ovarian, in men is pancreatic cancer.

Arthur: And we can, it grows so fast that you probably have to image the Patriots twice a day. The thing is, we we know, who the image. If there's a bad family history of cancer, some of the new markers of genetics are that you have a possibility of future pancreatic cancer. You you can image, we, we image where the risk is particularly an MRI with the three Tesla magnet of the abdomen shows you the pancreas, which that's where once you see it, it's too often too late.

Brent: So in my case I have high cholesterol, high LDL, you know, basically like my biomarkers, around my heart health don't look great, but I go in and get a CT scan and I got an ultrasound of my carotid arteries, and I don't have any plaque anywhere. And so my doc is saying, don't take a statin. Let's clean up.

Brent: Let's focus on diet and exercise and let's see what happens to your cholesterol. And so it seems to me that the best.

Arthur: Option I, one of the thing is the family history as far as heart attacks diabetes in the family.

Brent: No, no. Yeah. And no family history.

Arthur: So you got good genes. That's important. Yeah.

Brent: Good.

Arthur: Good genes I.

Brent: Think I do have some, you know, like a genetic predisposition to high cholesterol, but it's not something that's resulting.

Arthur: And that alone, does it doesn't really mean anything.

Brent: So it feels like the mistake we're making now is I go get a blood test, and I see that I have high cholesterol and I get on statins. And actually, what, what, what ought to be happening is okay, get the blood test and then separate from the blood tests kind of either way, based on the ages we've talked about, go get the CT scan or the CT scan based on, you know, your budget.

Brent: And then after that, you'll now know, do you actually have plaque in your arteries and then have the discussion around the statins? Does that feel like the best approach?

Arthur: Absolutely. Everybody has their own cholesterol level where it actually gets in the vessel wall. If it is in the vessel wall, you do want to decrease your LDL. And now we you know, it could be HDL there. With the genetics we can really tailor, treatment. But at your age, without the family history especially, I would not start you on a statin if you, all of a sudden gained 30 pounds and were pre-diabetic, we would yeah, we would repeat that a little bit more often.

Arthur: But the older you get at first, you might repeat the calcium score or the ccta. And in five years in general, and the longer you don't develop any plaque, the safer you are.

Brent: And then how do you think about it if somebody has these metabolic markers that are unhealthy? So if I don't have, any plaque in my heart, but yeah, my A1 see, is is pre-diabetic or on the high end of normal, which would or these or I've got, I've got my HS crp. So my C-reactive protein looking at inflammation is high.

Brent: Does that make you think differently about risk of heart attack or statins.

Arthur: Yes I mean they're you're we call your your metabolic health. And the problem was we started measuring blood sugars in the 1920s when they first developed, could inject with insulin. And to this day, the American Diabetes Association uses a one see or glucose tolerance test to diagnose, diabetes. And the fact is, if you're in your 20s or 30s and you're heading for diabetes, you will have a normal, A1 c in, in most cases.

Arthur: And we really want to know where you are on the spectrum. And there are two important things that occur. If then you're in your 20s, you're heading for diabetes at 65. First of all, if you are, you want to treat particularly lifestyle. More and more medications are may be worthwhile. And and again you want to you want to start early, but if you're 20, you're going to have almost always a normal A1, C and glucose tolerance tests.

Arthur: But you may have a lot of insulin resistance, meaning it takes a very high level of insulin to keep that A1 c low. In fact, everybody, every teenager, young adult you see with a belly has insulin resistance and some degree of beta cell dysfunction. So over time, because there's insulin resistance, it's taking more and more. This is genetic.

Arthur: And lifestyle, more and more insulin to keep your blood sugar your A1, c normal. But as your pancreas is stressed to keep making all that insulin, it's in a sense starts to burn out. It can't make as much insulin. And the insulin goes up later in, you know, a few hours after you eat, which makes you hungry. The reason why we snack so much, why we have what's called reactive hypoglycemia is because even though your total glucose may be normal, you you're it's taking a while for the beta cells in your pancreas to make the insulin.

Arthur: When it goes up and stays up, it prevents your liver from making blood sugar. So overnight, when you're, when you're sleeping, your brain is working, you're dreaming. Your heart's beating. Your kidneys are working, your blood sugar drops, you get up in the middle of the night with hypoglycemia, you know, shaking and whatever. Not usually because your liver does something called break on your genesis.

Arthur: It makes it keeps your blood sugar normal. But if your insulin is staying high for hours, and these are people with your A1, C's still normal, you'll get up in the middle of the night shaky and hungry. I had a patient where we put him on a low carb diet. We did this prep test which we knew his insulin was staying up for hours after he ate.

Arthur: And, when he came back, he he said, thank you for curing my anxiety and depression. I said, I didn't know you had this high. It's like you press. And during the day or at night he would get up feeling shaky, depressed, horrible. And this was from the rush of adrenaline trying to bring his blood sugar up. His liver was prevented from doing it from the high insulin levels.

Arthur: This is why we're hungry. And this is why terms like grazing, we're running around snacking and eating all day. It's because persistent, high in the level, it's not psychiatric. And a lot of the people say, yeah, you're crazy. You're not crazy. It's all physiologic. And we understand their physiology today.

Brent: And then would this be so you would recommend above an a1 C hemoglobin a1 C which is a blood test or a blood glucose. And a1 C is like basically a three month window. You know, basically a three month average of, glucose in your blood for like that, you know, to simplify and blood glucose to be more of a 24 hour, you would recommend an OG, which is an oral glucose glucose tolerance test.

Brent: Or you're just saying no, an insulin resistance panel is what you want.

Arthur: You know, you can when you're when you're taking the blood, do the glucose for the girl who goes to it doesn't have that much. You want the insulin level. And we call it the craft test because doctor Craft, the reason we don't all measure instant measure glucose is we can measure glucose pretty well from the dawn of of insulin.

Arthur: Although we're still expensive, you couldn't get it back that fast. It wasn't all that helpful. But the protein hormones, like thyroid hormone, like insulin, were only discovered with what's called the Indian assay from the 60s, 70s. We really only started doing clinically in the late 90s and 2000, and most people are not doing it. And so, it is it's in oral glucose tolerance us but you do an insulin instead of the glucose and that it takes experience.

Arthur: But you will have that will be abnormal in your early 20s in people who are even thin. They did this study, you know, thin undergraduates, but with family histories of diabetes. They already had had high insulin, levels on the, on, on the, on the graph testing. And then you can follow it and so, so many people say, I say you're pre-diabetic.

Arthur: Oh, tell me when I'm diabetic. The risk starts way before. And your overall feeling of health, lifestyle, overweight, anxiety, depression and, your joint pains, they will all go away. If you're truly pre-diabetic, as high in some levels and you go on a good diet, when you're younger, you'll feel much better.

Brent: Well, doctor Atkinson, thank you so much. I think just first and foremost for your work. I know there's a preventative medicine award named after you. You deserve it. In my mind. You you deserve a Nobel Prize. And so I think you've saved a lot of lives with your work, and it feels like it's only it's still beginning to accelerate in terms of the awareness of the importance, the importance of the calcium score, your namesake score, the agates and score, and everything you've done.

Brent: So, thank you so much for the time today, and thank you for your, your contribution to preventative health.

Arthur: And thank you very much. I, I really enjoyed the interaction. And your summaries are fantastic. You're you're really got it. And that, I know that helped a lot for me. The audience.

Brent: Thank you. I'm not I'm not as smart as the people as we have on the show, so I gotta figure out a way to make it simple for myself. And there's some benefit to that. But thank you so much.

Arthur: Thank you.

Brent: Death clock is recorded in Boulder, Colorado, sometime, San Francisco, California, produced by Patrick Gudino, music by Patrick Lee, and hosted by yours truly, Brent Franson, founder and CEO of.