Our AI Saved My Life

Brent: If I do want to fix it, I have to get my breastbone sawed in half and my chest pried open.

Jamie: In the setting of an open heart surgery, the risk is still going to be about 1% that you could die of the surgery that day or 30 days thereafter. And we know that your 30 day risk of dying of this event is lower than the risk of that surgery.

Brent: Welcome to Death Clock. I am your host, Brent Franson. Today we speak with Doctor Todd Dorfman and Doctor Jamie Doucette. This is a very personal episode. Doctor Dorfman is my concierge doc, my private doc, and Doctor Doucette is my cardiologist. As you'll hear, I learned through a routine scan looking at plaque in my heart that I have an anomalous coronary artery.

Brent: And the long story short is that the odds of my dying suddenly during or after exercising are much higher than the average person. I've run marathons, ultramarathons. I've been active my whole life, so I'm really grateful to be alive. It's been a bit of a jarring finding, and my choices aren't great. It's either to exercise less, which is going to take time off my life, or to do an open heart surgery.

Brent: And with a procedure that just hasn't been done that many times, we don't really know if that will actually fix the issue. So it was a good opportunity to talk. We talk a little bit about that, but we try to focus the conversation on things that are going to be relevant to everybody. In particular, what should we be thinking about in terms of heart health?

Brent: How should we be thinking about our biomarkers? These scans, like CT scans for a calcium score, CT scans—which is the scan that I got—and then how to think about incidental findings. We were just doing a scan to look at the plaque in my heart, and we identified this anomalous right coronary artery. So they're wonderful docs. It's a really deep and, I hope, helpful conversation about preventative health in the context of understanding your heart and understanding heart disease.

Brent: And then it's got a little dose of my own personal situation, which is trying to figure out, do I cut myself open in an open heart surgery to fix this thing or not? Hope you enjoy.

Brent: Doctor Todd Dorfman and Doctor Jamie Doucette, welcome to the show.

Todd: Thanks for having us.

Jamie: Thank you for having me.

Brent: I'm going to ask you guys to share both of your backgrounds in one moment. But this is an episode that requires a little bit of a tee up. On last week's episode, we had on Doctor Todd Dorfman, who's a concierge doc, a private doc here in Boulder, to give us the perspective of the private doc and how the private doc thinks about preventative health.

Brent: In that episode, we talk about the CT scan. It was actually recorded a couple of months ago. We've been waiting on it, and that episode was recorded prior to my receiving the results of my own CT scan. A CT scan is a coronary angiography, but basically what it's doing is it's looking for plaque in the heart and it looks at four different types of plaque: two types of hard plaque and two types of soft plaque.

Brent: And because I have high cholesterol, I think this is why Death Clock recommended it to me. So Doctor Dorfman recommended it to me and said, "Go get a CT scan." That's how I connected with Doctor Dorfman. I go in and get the scan. The scan is a dye-based scan, so they put an IV in your arm and put iodine into your blood.

Brent: That allows the CT scanner to provide a picture of what's happening in the heart and to give you a pretty good sense of whether you have plaque in your heart, what kind of plaque it is, and how much is there. The findings for me were interesting, to say the least.

Brent: The first finding was I don't have any plaque in my heart. I have high cholesterol, and I've got some elevated biomarkers based on measurements from the blood—your typical biomarkers like ApoB, Lp(a), and cholesterol. But I don't actually have any disease in the heart. There's no soft plaque or hard plaque.

Brent: Okay, that's good; I was worried about that. But I did have an incidental finding. We've talked about this on the show, particularly in the context of full body scans, where sometimes when you scan the body, you find something you're not expecting to find or something you're not looking for.

Brent: These can be pretty problematic in the context of full body scans. You can get false positive, ambiguous results, and then you have to figure out whether you're going to biopsy a nodule in the lung, with all the associated risks.

Brent: That's the primary criticism of full body scans. In this case, what was identified was that I have an anomalous right coronary artery. There are two coronary arteries—one on the left, one on the right. My right coronary artery originates on the left side, and because it starts where it shouldn't, it has to take a different path to go where it needs to go.

Brent: It has an inter-arterial course, passing between my pulmonary artery and my aorta—the two largest arteries in the heart. Basically, what it means is I'm at higher risk of sudden death during or after exercise than the average person. I'm 43 and I've been exercising my entire life. So I'm going through a set of tests with Doctor Doucette, who's a cardiologist, to figure out the next step.

Brent: It seems like the options are: one, change my exercise routine; two, continue exercising as I have been; or three, get open heart surgery to resolve the issue. It's a tricky set of decisions that underpins an interesting conversation around incidental findings, heart scans, and heart health more generally.

Brent: With that tee up, let's first do quick intros. Doctor Dorfman, do you want to give a brief bio, and then Doctor Doucette, follow with yours?

Todd: I'm a concierge doc in Boulder, Colorado. Brent came across me because I do a lot of advanced testing, including cardiovascular testing, with the goal of trying to mitigate risk moving forward for each of my patients. That's how I met Brent, and that's how we got to this podcast.

Jamie: I'm a cardiologist. I've been practicing here for a little over 25 years, and I've worked with Todd for that entire duration. Todd didn't mention that he's one of the finest emergency department physicians I think has ever lived, but that's just my opinion. We usually have a mutual admiration society of two. I did all my training at Texas Heart at Baylor in Houston.

Jamie: I've been practicing general and interventional cardiology for 25 years here in Boulder, with a strong interest in preventive medicine. If I meet someone having a heart attack, I'll fix the immediate problem, and then I'm very interested in ensuring that patient never has another cardiovascular event in the future.

Jamie: And so that's been my area of expertise and interests.

Brent: Doctor Doucette, let's touch quickly on this anomalous coronary artery. What is your sense of it? It seems this is most commonly found in autopsies of teenagers—someone starts exercising, the heart doesn't like it, and they die suddenly.

Brent: I'm 43, and I've run marathons and ultramarathons. This was discovered incidentally; we weren't looking for it. How common is this, and how concerned would you be if you were me?

Jamie: For one thing, you mentioned that they used iodine. Almost all contrast these days is non-ionic contrast with very minimal amounts, primarily because it's less likely to cause a true allergic reaction. So CCTA is thought to be a very safe test regarding contrast medium. Regarding anomalous coronaries, they are frequently diagnosed, sadly, at autopsy.

Jamie: Generally, the risk of an anomalous coronary depends on which coronary is anomalous and the course of the anomalous artery in relation to the great vessels, like the aorta and pulmonary artery. Sometimes when the right comes off the left or the left comes off the right coronary cusp, just above the heart muscle itself, they can take a retro-aortic course.

Jamie: The pulmonary artery is an anterior structure, and the aorta is behind that. What is thought to be a more dangerous course is when the artery goes between the great vessels. There's a lot of speculation about why that might be more dangerous. Primarily, as you exercise, you increase pressure in the aorta.

Jamie: Your blood pressure can go up by 40, 50, or even 60 mmHg from baseline when exercising, which drives up the mean arterial pressure. Pulmonary artery pressure also goes up by 15 to 20 mmHg. In that circumstance, the extrinsic pressure from those great vessels could compress the walls of the coronary artery and result in ischemia, or inadequate blood flow to the heart muscle.

Jamie: The primary risk is related to cardiac rhythm disturbance due to ischemia. Think of taking a garden hose and kinking it, as opposed to having dirt or debris in the lumen. In the case of the coronary, it affects where the blood flows.

Jamie: So you don't have debris or blockage in your pipes, as you pointed out. But there is potential for extrinsic compression of the vessel that could result in lower flow to that side of your heart—in this case, the right ventricle and the bottom of the heart—because coronary circulation there comes from the right coronary artery. It is a leading cause of death in young athletes under age 35.

Jamie: The longer you've lived without an event—35 years of age seems to be the cutoff—the more you've selected yourself out as a lower-risk lesion than someone who is 18 or 19. Regarding the incidence of the disorder, we're finding more of these because CCTA and coronary calcium scores are becoming more common, so they're being picked up incidentally on scans.

Jamie: So I think what's historically been thought to be less frequent or less common is probably more common than we once thought.

Brent: To summarize: when you're exercising, the heart expands. For most people that's fine because the right and left coronary arteries run along the outside of the heart, so they aren't pressed between the pulmonary artery and the aorta.

Brent: There's no risk of the hose getting stepped on. But because my right coronary artery starts where it shouldn't, it passes between those two larger arteries. They can expand during exercise and cut off blood flow—stepping on the hose—because it's in a place where the body doesn't expect it to be.

Brent: And that can cause sudden cardiac arrest and death.

Jamie: In a nutshell, I think that sums it up.

Todd: I would add that a piece of the right coronary is intramural, meaning it's in the wall of the aorta. There are two reasons it could get pinched off: one is the part passing between the pulmonary artery and the aorta, and the other is the part in the wall of the aorta.

Todd: Doctor Doucette and I discussed this at length because it impacts the decision of whether to fix this surgically. I think that's an important piece.

Brent: Doctor Dorfman, how do you think about recommending a CT scan versus other scans given the risk of incidental findings? We've had oncologists on the show who uniformly advise against full body scans, feeling the risk of chasing incidental findings like lung nodules isn't worth it.

Brent: This is an organ-specific scan, not a whole-body scan, but how do you approach that in your practice? Is this an incidental finding that's beneficial, making the risk profile around false positives different?

Todd: It's a great question because this is a true positive finding: we found something real on the scan, and we have to decide how to handle it. Anytime you do screening tests, there's always a chance of an incidental finding, a false positive, or a false negative.

Todd: It depends on how you look at things as a patient and how I look at them as a clinician. If this is a life-altering diagnosis, how do we best deal with it? On one hand, major open heart surgery carries risk and may not even fix the problem.

Todd: It's unclear if surgery truly lowers your chance of sudden cardiac death moving forward. On the other hand, we could completely restrict your active lifestyle, leaving you sitting unhappy on the couch. Our job now is to find something in between and advise you to the best of our ability.

Todd: To me, this is a good finding. I like data, and this gives us the opportunity to make a more informed decision moving forward. So I think it's a valuable piece of information.

Brent: Doctor Doucette, would you agree? If I ask oncologists whether everyone should get an annual full body scan if cost weren't an issue, they firmly say no.

Brent: What's your response if I ask the same about CCTAs? If everyone got a CCTA scan every five years starting at age 40, would you recommend that?

Jamie: The data on CT scanning is less robust than for coronary artery calcium scoring. Calcium score data is well established, though not as widely accepted by cardiologists as I'd like. A calcium score is a similar test done without contrast to light up the artery lumen.

Jamie: It looks at the blood vessel wall to measure and quantify calcium, indexing it for age and gender. In appropriately aged patients, that test has better prognostic value for predicting heart attack risk than a stress test.

Jamie: It's a better test in an asymptomatic person than a stress test for predicting risk over 5 to 10 years. I really like coronary artery calcium scoring. If you have calcium in your coronary arteries, you effectively have coronary artery disease.

Jamie: If the score is above 100, you have coronary artery disease, even if asymptomatic. If you're above the 50th percentile rank for your age and gender, your risk of a cardiovascular event is higher than if you were below it.

Jamie: So that test is great for an asymptomatic patient who knows they are at risk. For example, if you're a 43-year-old man like you, Brent, and your father had a heart attack at 45, getting a coronary calcium score is a great idea.

Jamie: Getting a CCTA to look at an angiogram in an asymptomatic person has less robust data on predicting risk.

Brent: To summarize: a CT scan for a calcium score is low-risk and inexpensive (a couple hundred dollars). You don't typically get it through standard primary care insurance, but it takes 15 minutes without needles.

Brent: It estimates 10-year heart attack risk. A CCTA is more expensive and also off-menu unless requested through private doctors. It looks at four types of plaque: two calcified/hard and two soft.

Brent: The calcium score only shows calcified hard plaque. CCTA gives that plus three additional scores. You could have zero calcified plaque but significant soft plaque, which carries an even higher heart attack risk.

Brent: Doesn't CCTA include what you get from a calcium score plus a more in-depth picture?

Brent: Or am I looking at it incorrectly?

Jamie: You're thinking about it correctly. That's why age is a key factor: younger patients are less likely to have measurable calcium, so a zero score can give a false sense of security.

Jamie: I've seen six patients suffer heart attacks or unstable angina with a zero calcium score, likely due to unidentified soft plaque.

Jamie: The difference is radiation exposure from CCTA. For a calcium score, radiation is quite low. A recent trial calculated the lifelong risk of developing cancer from a chest CT scan.

Jamie: The calculated risk was roughly 1 in 250 additional risk, so radiation exposure is a valid consideration with CT-based technology.

Todd: New dual-source CT scanners have reduced radiation delivery from 10–15 millisieverts down significantly.

Todd: Doses are now down to 2–4 millisieverts with even better imaging. The hospital in Boulder is installing one now. It's making the test much safer while yielding better information.

Todd: A Dutch study showed that 20–25% of people with zero calcium still have soft plaque. Improving test safety makes this data much more accessible.

Todd: Better imaging means we will uncover more incidental anomalous findings.

Brent: Doctor Doucette, you mentioned a "one-hit" concept that shifted my view on radiation. I used to think radiation risk was purely cumulative over time.

Brent: So getting a scan every five years would mean a limited cumulative effect. But you noted that if radiation hits a cell at a vulnerable moment during transition, it could cause cellular damage in a single instance.

Brent: Is that the right way to think about it—that risk isn't strictly cumulative, but can stem from a single exposure event?

Brent: Is that accurate?

Jamie: That's true. Cumulative dose is one issue, but there's also the "one-hit" theory where a single scan damages cell DNA, potentially leading to cancer.

Jamie: Recent studies calculating chest CT risk factored both theories in, estimating overall cumulative risk at roughly 1 in 250.

Jamie: In your case, an anomalous coronary won't change over time, so repeat scanning isn't necessary. However, tracking plaque progress via annual calcium scores is popular because it's inexpensive.

Jamie: In Colorado, patients can self-order heart scans and mammograms without a doctor's order thanks to state legislation.

Jamie: Data shows that if your coronary calcium score grows less than 15% annually, your risk remains lower regardless of baseline score.

Jamie: Under 10% is even better, and a decreasing score is a great prognostic sign for the next 3 to 5 years.

Brent: So to clarify: you wouldn't recommend CCTA (dye-based) universally, but you would recommend standard coronary calcium scoring?

Brent: Is that because calcium scoring provides sufficient prognostic value with less radiation risk than CCTA?

Brent: I would wave...

Jamie: The data is better established, especially relative to age. I wouldn't scan women under 50 with calcium scoring because calcification is rare then. My paternal grandfather had a heart attack at 39, so I started getting calcium scores every 5 years starting at age 35.

Jamie: If a patient presents with elevated cholesterol or blood pressure, we can start with lifestyle interventions. However, if their calcium score exceeds the 50th percentile for their age and gender, it indicates more calcified (and likely soft) plaque, prompting more aggressive treatment.

Jamie: I use it as a decision tool for patients with high cholesterol to determine if interventions beyond diet and exercise are required.

Jamie: It offers better prognostic data than a stress test when answering a patient's core question: "What is my risk of sudden cardiac death?"

Jamie: I had a patient pass a stress test with flying colors who died six months later playing basketball. Calcium scoring wasn't available then, but I wish it had been.

Jamie: And six months later he dropped dead playing basketball. That was in the days before calcium scoring was available, but I sure wish I'd have had that test available to me at that time.

Brent: Stress test is different than a Cat score than a CT.

Jamie: A stress test uses no radiation; you walk on a treadmill while connected to an EKG and blood pressure monitor to watch for blood flow issues in real time.

Jamie: The issue is that a stress test usually requires over 70% artery narrowing to trigger an abnormal result. Yet more heart attacks occur from 30–50% blockages simply because more people fall into that category.

Brent: So it's a cruder measurement that catches things late. I view cholesterol as a surrogate marker—high cholesterol doesn't automatically mean you have heart disease, though there's high correlation.

Brent: My CCTA showed zero plaque despite high cholesterol. You advised against statins for now, favoring lifestyle adjustments first given the absence of disease.

Brent: How do you approach a patient with high cholesterol but zero plaque, versus someone with normal cholesterol who shows significant plaque burden?

Brent: So how do you think about a patient you see that has high cholesterol and no plaque following one of these scans or has one, you know, has normal cholesterol level or other blood based biomarker. But when you look at the scan, you see a bunch of plaque in the heart.

Todd: Surrogate markers only tell part of the story. About 20–25% of people with normal lipid panels still have significant plaque. I have a patient with ideal lipids who has plaque in her carotid, stomach, peripheral, and coronary arteries.

Todd: You could never predict that from standard lab work. We're looking at the disease phenotype—how genetics, surrogate markers, and lifestyle manifest in the arteries.

Todd: Vascular disease and stroke kill the majority of people, so early identification is low-hanging fruit.

Todd: Instead of waiting for a major blockage to trigger an abnormal stress test, I want to identify people early so they never build a dangerous plaque burden that risks rupture and heart attack.

Todd: It's a proactive shift. Standard insurance often requires symptoms before approving advanced testing, but we focus on early screening to prevent events altogether.

Todd: You want to stay off medication if possible. With high cholesterol but zero disease phenotype, why prescribe a statin with potential side effects? We try diet and exercise first.

Brent: You want to stay off of meds? If you can. In the case of statins, you would say, hey, we don't the you know, your phenotype is no disease. And so why are we going to put you on a med that has side effects? We don't love that your cholesterol is high like we would prefer it was normal. But let's try to use diet and exercise to bring it down because there's there's no disease here.

Todd: At 43 with zero plaque in your coronaries or carotids, it's very unlikely you'll rapidly accumulate dangerous plaque over the next decade maintaining your current lifestyle.

Todd: I would re-test in five years to check for plaque accumulation, but starting statins for a zero soft and hard plaque score isn't indicated.

Todd: Score soft and hard. Zero. And you're a healthy guy in all other respects, doctor.

Brent: Doctor Doucette, how do you view blood biomarkers? Beyond standard cholesterol and triglycerides, we now have access to ApoB, Lp(a), and particle size fractionation. What is most important on standard labs for evaluating risk?

Brent: Preventatively from a just standard go to lab core quest blood tests to look at cardiovascular risk and cardiovascular health.

Jamie: For LDL cholesterol, particle composition matters as much as the overall concentration. If two patients have an LDL of 130, their risk depends heavily on particle size.

Jamie: A patient with thousands of small, dense particles is far more likely to develop disease than someone with large, buoyant particles that don't embed easily in vessel walls.

Jamie: In a patient with low cholesterol but widespread plaque, NMR spectroscopy to measure particle size and count provides critical context.

Jamie: Guidelines for "normal" LDL keep dropping: from 160 to 130, then 100, 70, and now under 55 for high-risk patients. What is typical in the general population isn't necessarily optimal.

Jamie: And now some of the expert guidelines are saying if patients are considered to be high risk or highest risk, that the LDL cholesterol target in milligrams per deciliter should be less than 55, so it keeps crashing down what's considered normal. And just because it's the usual measurement in the population does not mean that that's the normal measurement if you follow it.

Jamie: I mean.

Brent: So if LDL particle size skews small, risk increases because small particles cross the endothelial lining into vessel walls more easily, forming plaque over time.

Brent: And if a higher percentage is small particle, I'm more concerned about that because it has the smaller particles. I don't know if they get caught on the walls of the artery. They going to stick to the walls, the artery or something a little bit more easily than the large particles do. And so if it's a lot of large particles, I'm less concerned than if it's a lot of small particles, even if that LDL number is exactly the same in both of these patients that we're comparing.

Jamie: LDL moves into vessel walls via diffusion. Higher counts of small particles increase the likelihood of lipid accumulation in the vessel media, generating plaque over time.

Jamie: Actually. And veins, and it can move into the vessel wall with higher particle numbers, smaller size, you're just going to be more likely to coalesce LDL cholesterol in the wall, the blood vessel or the media of the blood vessel, and result in a plaque over time.

Brent: This level of detail isn't on a standard lipid panel. A patient has to explicitly ask for advanced testing like lipoprotein fractionation to see particle sizes.

Brent: You're doing like some cardio IQ panel. That's an additional panel to your typical like HDL, LDL, total cholesterol, triglycerides. You're going to have to ask about this specifically and push your primary care doc on it.

Todd: Looking directly at the disease phenotype via imaging bypasses some of those surrogate panel questions. Even with poor particle profiles on paper, you currently show zero disease.

Todd: So the question is would it be worth treating just because you have small particles. And a 43 year old was not a speck of disease?

Brent: For an average patient getting an annual checkup, the standard lipid panel only shows total cholesterol, LDL, HDL, and triglycerides. Getting particle counts requires ordering a separate specialized panel.

Brent: It's not going to give me the particle sizes. I've got to push that doc. And I've got to say, hey, I want to make sure I think I think the word is lipoprotein fractionation. I want to know what are the particle sizes. And that's actually on your end, doc, something that you've got to order. In addition to standard lipid panel for us to get that level of detail.

Brent: Is that right?

Todd: That's correct. We can approximate particle number using Apolipoprotein B (ApoB). Elevated ApoB relative to LDL concentration suggests a higher count of small, dense particles, which portends higher cardiovascular risk.

Todd: Because, again, you probably have lots of small particles.

Brent: Is ApoB a replacement for a standard lipid panel, or would you want both?

Jamie: Standard screening panels calculate LDL rather than measuring it directly. As long as triglycerides are under 150, that calculation is accurate within 3–5 mg/dL.

And what's left over is presumptively LDL cholesterol. And that's because measuring LDL cholesterol directly was quite difficult. It was only done in a few labs around the world, and it was very expensive. Now, direct LDL measurements can be made quite readily. The truth is, is that on a standard panel, as long as your triglycerides are less than 150, the LDL calculation works out within 3 to 5mg per deciliter for the most part.

Jamie: Our primary goal is preventing major adverse cardiac events—heart attacks, strokes, or emergency surgeries—regardless of whether a patient's calcium score is high or low.

Jamie: I don't really care if patient's calcium score is 1000, let's say, which would be a very high score. I just want to make sure that they don't have a heart attack or stroke related to. Right. Because that's what we're trying to prevent. Has major adverse cardiac events like being dead or having a stroke, having a heart attack, or having to have emergency surgery or stent implantation.

Jamie: Not everyone needs an ApoB test. But if a patient has borderline risk or early plaque and wants to avoid medication, an elevated ApoB strongly indicates that statin therapy would be beneficial.

Jamie: You have some plaque. That's been identified. Let's throw that in there. Patient doesn't really want to go on medication. Well, then in that circumstance, an apob level that's pretty tightly correlated with particle number. If the number is high making up your LDL, then we have very effective therapies for lowering LDL particle number, primarily statins. Work in that regard.

Jamie: So I like doing tasks or considerations that would change what I would recommend for the patient is most important.

Brent: Standard lipid panels provide good directional information for most people without requiring specialized ApoB testing.

Jamie: It does. However, cardiovascular risk involves inflammation alongside lipid levels. Inflammatory markers like hs-CRP help predict risk not fully explained by cholesterol numbers alone.

Jamie: It's a difficult scenario when you start making recommendations to the general population about how they should be screened.

Brent: How do you view patients having vastly more health information available directly to them? Non-physicians are now actively tracking Lp(a), particle sizes, and requesting CT scans.

Brent: Is this increased patient engagement ultimately beneficial, or does it lead to unnecessary requests for unhelpful or risky procedures?

Brent: And we're going to have people who are taking their preventative, you know, their health preventatively more seriously, or it's as a doctor, it's it's a little bit annoying. People are asking for things they don't need or that might harm them.

Todd: It's a double-edged sword. Patients are better informed and ask great questions. In my practice, people seek out proactive disease prevention rather than brief 15-minute standard visits.

Todd: While patients occasionally bring up questionable claims, engaged patients who want to take action make overall care better.

Todd: And do you want to see him or not? So I think we're beyond. Yeah. Sometimes it gives us a clue and sometimes that informs a patient. But to me, it's been better because the patients are really interested in doing something.

Brent: What do you think, doctor?

Jamie: An informed patient is great, but pushing back on expert medical recommendations isn't always in their best interest.

Jamie: Patients sometimes bring pages of research expecting to teach me about cardiovascular disease when I've studied it since 1989.

Jamie: When an engaged physician listens and provides a tailored recommendation, dismissively rejecting it without trying the therapy is unwise.

Brent: Direct-to-consumer companies often promote services doctors don't recommend, like routine full body scans.

Brent: The divide between consumer enthusiasm and physician caution around screening technologies is striking.

Brent: The key takeaway is that the human body is complex, and determining overall risk requires evaluating a confluence of factors.

Brent: Even with a true positive like my anomalous right coronary artery, trade-offs exist between proactive surgery, lifestyle changes, and monitoring.

Brent: Navigating medical decisions requires balancing expert advice, personal values, and risk tolerance.

Brent: I approach this process with humility and trust in expert guidance. Doctor Dorfman, any closing thoughts?

Brent: It's like, okay, now we know it's we think we're glad that we know, but what are we going to do? And it's not like there's an obvious answer of of what to do in this case, I think got to bring a lot of humility and to defer to the experts, defer to the defer to the docs. Anything you want to add before we go, Doctor Dorfman.

Todd: It comes down to shared decision-making: discussing all options together so you can make an informed choice.

Todd: And ultimately, you know, you're going to make an informed decision. And I think that's sometimes the best we can do.

Brent: Doctor Doucette, if I choose surgical repair, is open heart surgery dividing the sternum the only option?

Jamie: Other options exist. We reviewed cases of anomalous right coronaries with inter-arterial courses. Because randomized trial data is lacking, staying up-to-date with case series is crucial.

Jamie: Watchful waiting is a reasonable, studied strategy that avoids immediate invasive risks. An invasive angiogram can provide finer detail on intramural course features, like slit-like orifices, to guide decisions.

Jamie: So adopting a strategy of watchful waiting is reasonable has been studied in a prospective trial, which is not nearly as accurate as a double blind, placebo controlled trial. But we haven't expose you to the risk of invasive procedures. Either. You would have an option to do a CT, an invasive angiogram that would give us better detail about the intramural course of your right coronary artery, whether or not it has a slit like orifice or sharp angulation, which are known to be risk factors for poor outcomes.

Jamie: Even at top-tier surgical centers, open heart surgery carries a ~1% 30-day mortality risk.

Jamie: Your short-term risk of a fatal event from exercise remains lower than the 30-day surgical risk.

Brent: That highlights the decision complexity: weighing surgical risk against long-term active lifestyle goals.

Brent: Surgical recovery and inherent procedure risks make this a tough call.

Brent: I feel fortunate to work with both of you. We're scheduling a cardiac catheterization in six weeks to gather clearer details before making a final decision.

Brent: Thank you both so much for joining today and all of the work that you do really appreciate it.

Todd: Thanks for having us, Brent.

Jamie: Thanks for having us.

Brent: Death Clock is recorded in Boulder, Colorado. Music by Patrick Lee, produced by Patrick Gudino, and hosted by yours truly, Brent Franson, founder and CEO.