68 – How Advanced Screening Saved My Life | A Candid Talk with My Cardiologist

Marcus: [00:00:00] If you enjoy this content, please take a moment to rate and review it. Your feedback will greatly impact our ability to reach more people. Thank you.

Vic: Okay, Dr. John Riddick, thanks for taking time on your Saturday to do this. Appreciate it. Happy to be here. So this is episode two of our heart health kind of focus series with experts in the heart care field. Uh, for the listeners, if you haven’t heard episode one with Dr. Reddy, I’d recommend you start there, because we really lay the foundation that then John and I are going to build on.

Vic: Um, let’s jump into it here. So, thanks for doing this, John. You and I are personal friends, and then you became my, uh, cardiologist. Recent, maybe not recently, a year, year and a half ago, you have the exact dates. I do.

Marcus: And

Vic: I wanted to do in this [00:01:00] episode something that I haven’t seen enough of, or really any of, which is use my own experience as a patient and we’ll be, we’ll be able to go, cause it’s me and you’re my doctor, we can go into a lot of detail that you wouldn’t be able to share otherwise.

Vic: And I think

Dr. John Riddick: we’re okay.

Vic: I think we’re okay from HIPAA. Spoke to our attorney last night at dinner. Yeah, good. And I think that, uh, what’s interesting is that it’ll allow us to dive into some more detail that would be hard to talk in generalities. But I also want to caution the audience that each situation is unique to that patient.

Vic: So even if they have labs that look on the outside similar, they have a different family history, they have a different overall heart situation, different medical situation, and they should talk to their own cardiologist. This is meant to be educational, not

Dr. John Riddick: Or primary care doctor. Or primary care doctor.

Dr. John Riddick: Which is where your story starts.

Vic: Yes, that’s right. And so [00:02:00] before we jump into my story, I want to just get your, uh, personal background. How did you get into medicine at all? When did, I think you knew you wanted to be a doctor pretty early on, but talk about your journey and when you wanted to be in medicine, I think your, your dad, you have family members that are in medicine.

Dr. John Riddick: That’s right. So, um, grew up in New Orleans, um, with our mutual friend Lamar. And, uh, my dad was a first generation doctor. He. Went to Vanderbilt Med School, did residency at Wash U, fellowship in endocrinology. Always thought he would be in Nashville. And in the 50s, basically, couldn’t find a job in Nashville, moved to New Orleans, started a medicine program at an auctioner clinic.

Dr. John Riddick: where he practiced medicine for over 50 years. He was, uh, at some point became the medical director of the Ochsner Clinic.

Vic: So, hold on, back up. He started [00:03:00] the medicine practice at

Dr. John Riddick: Ochsner? He was kind of, you know, Ochsner Clinic, to go into the, was started in the 40s by a group of surgeons from Tulane who defected.

Dr. John Riddick: It was primarily a, you know, At that point, vascular surgery. They didn’t really even have heart surgery back then, but it was primarily a surgically driven clinic kind of modeled after the Mayo Clinic. Yeah. But, and hi, they were starting to ramp up their medical subspecialties. Endocrinology was a pretty nascent field in the, uh, late fifties at that point.

Dr. John Riddick: And just to, sorry to interrupt, just for

Vic: the listener, sorry. The medic send practice is labs, um, pharmaceuticals, right. Treatments that do not involve. intervening and cutting open the body or going into the body. Is that close to right?

Dr. John Riddick: Yeah, internal medicine, more of the thinkers, diagnosticians, ordering labs, physical exam,

Vic: where, where, where surgeons

Dr. John Riddick: are more, you know.

Vic: So, so Osher started off as a surgery [00:04:00] practice mostly, and then your dad helped them build out the medicine side.

Dr. John Riddick: He was their first endocrinologist in 1959. And so, Insulin had recent, relatively recently become clinically available and he was a thyroid expert. So that was his medical practice, but he moved into a more administrative role, became the medical director of the clinic.

Dr. John Riddick: He was the first non surgeon to do that in the 70s. The clinic was separate from the foundation and the hospital. They merged in the 90s. He became the CEO of that enterprise for 15 years or so. And, so I grew up,

Vic: uh, You grew up as a son of a, of a doctor at a lo at the local Oshner. Correct. You went to Duke with the idea that you wanted to be a doctor.

Vic: True. Did you know you wanted to be in, in cardiology or in heart, heart care broadly? Or did, or what was the thought process?

Dr. John Riddick: So, as we discussed, when you, I had had, Orthopedic surgery [00:05:00] when I was a junior in high school tore my meniscus lock auctioner actually one of the auctioners did my surgery so like you a you know undersized running back like we were at speed.

Dr. John Riddick: You had a lot of speed. No, not at all, actually. And, um, that was part of the problem. And so as we discussed, if you are a guy going into medicine and have any athletic history, you immediately think I’m going to be an orthopedic surgeon. So I would say I went to Duke thinking, I want to go into medicine.

Dr. John Riddick: If I had to pick a field, it’d be orthopedic surgery. I had surgery. That was my exposure. But you really don’t understand what’s involved with different specialties till you’re in med school doing clinical rotations. I would say cardiovascular, Medicine or cardiovascular surgery were on the table for me because in addition to being a doctor exposed that way, my dad had a heart attack [00:06:00] when he was 47, 48.

Dr. John Riddick: Oh, wow.

Vic: Okay.

Dr. John Riddick: This is in the 70s. He was, uh

Vic: And how old were you? I was three. Oh, okay. Yeah.

Dr. John Riddick: Their treatment was basically lay in the bed for You know, a week, and take it easy. So here

Vic: he is, he’s 40. So there was no bypass surgery or, uh, intervention that was that effective?

Dr. John Riddick: Now, uh, so angioplasty was just beginning.

Dr. John Riddick: First, Andrea grew into the first balloon angioplasty. You know, late seventies, that was not clinically available. Bypass surgery was available, but it was still more or less in its infancy. They weren’t using, not to get in the weeds. And this is Dr. Reddy’s domain, the internal mammary artery, that part of bypass surgery wasn’t mainstream quite yet.

Dr. John Riddick: And when

Vic: your dad’s second. Heart attack occurred you were 10. Is that right? So you remember that? I

Dr. John Riddick: remember that.

Vic: But that still didn’t change your idea of I’m an athlete. I might want to do orthopedics or whatever So you go you go to Duke and then [00:07:00] you went to med school What year of med school do you start to get interested in the medicine side of things?

Vic: of clinical work.

Dr. John Riddick: But traditionally, the first two years, at least, things have evolved somewhat, but back then at Vanderbilt, 1997, the first two years are more classroom based.

Marcus: Okay.

Dr. John Riddick: Anatomy, pathology, biochemistry, and then, you know, you get some exposure, but it’s not until you’re traditionally your third, fourth year, third year, primarily, where you’re doing clerkships.

Dr. John Riddick: So going around doing different rotations in the hospital, there’s some basic ones you have to do, internal medicine, general surgery, pediatrics, psychiatry. You know, um, and then you start to kind of hone in as we were discussing earlier Typically I find that people sort of sort themselves out typically based on personality People who are like minded typically pick fields and if you look [00:08:00] to your predecessors See, well this person Seems a lot like me and their interests and the way they carry themselves and what they do and they’ve chosen this field you’re just like well, maybe I should look at this field and you kind of it’s kind of a Sort of a shortcut to deciding which is the field if you just look at the personalities because certain every field has a certain Personality, I would say and

Vic: so what is the intervention?

Vic: So you’re an interventional cardiologist. So I what is that personality?

Dr. John Riddick: So, we’re kind of like the orthopedic surgeons of internal medicine, kind of, um, uh, if there’s a narrowed artery and it’s narrow, it needs to be opened. Orthopedic surgery, this bone is broken, it needs to be fixed. In interventional cardiology, this artery is narrowed, it needs to be opened.

Dr. John Riddick: Yeah, you

Vic: can take an active role in, Intervening and correcting what’s wrong with the patient, or at [00:09:00] least that’s the, that’s the plan. You can’t always do that.

Dr. John Riddick: So my, I’m simplifying it obviously, but I picked, I decided I wanted a field where I could do some office based clinical work. I wanted to have some imaging, uh, exposure where I could read imaging.

Dr. John Riddick: And I wanted to have a procedural skill where I could actually do something procedurally. And there, there are not a ton of fields where you can do all three. ENT, um, orthopedic surgery, there’s some surgical subspecialties. But within internal medicine, there’s gastroenterology and cardiology. Cardiology primarily, where you can do a lot of clinical medicine.

Dr. John Riddick: There’s a lot of imaging, echocardiograms, stress test, now CT, which we’ll talk about, and obviously, as a cardiology, so we did intramuscular medicine, pick cardiology, within cardiology, there are multiple pathways within cardiology, but there’s the interventional [00:10:00] cardiology, so traditionally, heart attacks, like you said, someone comes in with a blockage, Yeah, they’re having a heart attack.

Dr. John Riddick: You open it up. Um, there’s electrophysiology, the electricians, we’re the plumbers. Yeah. Then you have the electricians, electrophysiologists who do ablations and pacemakers, then you have

Vic: Yeah, so for someone who’s not, um, a clinician, our audience is sort of a mix of industry folks and entrepreneurs and people that are interested in, in healthcare innovation broadly.

Vic: So the, for the cardiovascular system There is the vascular system, all, all of the veins and arteries that are providing the plumbing, as you said, to move the blood around. Yes. Then there’s the heart that has a physical Um, movement, it’s, it’s physically pumping through the chambers, and there’s valves and aspects of that.

Vic: Oxygenated

Dr. John Riddick: blood through the arteries, and it all comes back. And then there

Vic: [00:11:00] is the electrical signal, I guess that coordinates how the muscles all work together to pump. Is that close to right? Within the heart, yeah. Within the heart muscle, or within, around the heart muscle?

Dr. John Riddick: Within the heart. These intrinsic pacemakers, which fire off and then there’s the wiring that takes the electrical signal from the top of the heart, the atria down through a governor called the AV node, then into the main pumping chambers, the ventricles.

Vic: Yeah, and so there’s so then the physical heart in your chest. Yes, Dr. Ready would open up and. And, uh, do surgery to correct something, maybe, uh, replace a valve or do something like that, or, or bypass, I mean, like, create a new piece of the plumbing artificially to, to route blood differently. So, like, my dad had,

Dr. John Riddick: yeah, like, it sounds like they, you find other, called conduits, other, uh, Typically, that’s the vein, the veins in your leg, or [00:12:00] the mammary arteries, internal mammary arteries, where they basically reroute blood from the aorta around the blockage and plug it into the arteries beyond the blockage.

Vic: They like create, I think about it in a, in a river system. They create a new path for the blood to flow through that didn’t exist previously.

Dr. John Riddick: And so that is, uh, typically done for, depending on where blockages are and the extent of the blockages. then depending on the surgical risk, because there’s obviously a risk to having open heart surgery, that is a great option for someone like my dad, who is 55 with a hundred percent blockage in one artery and critical blockages in the other main arteries.

Dr. John Riddick: Classic, classic candidate for open heart bypass surgery. So there’s

Vic: this electrophysiology. They’re

Dr. John Riddick: surgeons. There’s a surgeon,

Vic: cardiac surgeon. Yes. And they are opening You up and working on something and then, uh, interventional [00:13:00] cardiologists would be going into the, into the overall veins and artery system from inside the veins and putting a stint in or doing something, not necessarily inside the heart, but adjacent to the heart or in other parts of the body.

Dr. John Riddick: So, for a heart attack, uh, we go in, typically these days, in the radial artery. Okay,

Vic: in your wrist. In your

Dr. John Riddick: wrist. Eighty five percent of the time. I thought it was through the thigh,

Vic: but you

Dr. John Riddick: Femoral artery is the traditional way that we used to do that, but because of bleeding risk, there’s been a shift over the past decade where majority, um, in most centers would go through the radial artery.

Dr. John Riddick: Much more easily compressible, less bleeding risk, where we go to the, the first branches off the aorta, which feed blood to the heart or the coronary arteries. Those are the ones when they block up with plaque, cause angina, if there’s not enough blood getting there, or a heart attack if they [00:14:00] become 100 percent blocked.

Dr. John Riddick: So we

Vic: Yeah, it’s almost, it’s kind of meta, but that is the heart providing blood to itself.

Dr. John Riddick: It’s the arteries carrying blood to the heart muscle. To the heart itself, yeah. When those coronary arteries Get blocked off and you can’t feed blood oxygenated red blood cells to the heart muscle. The heart muscle dies.

Dr. John Riddick: That’s a heart attack. So we go in there through the wrist, snake a wire. This is why we say it’s like plumbing. Have a long plastic tube called a catheter. Take pictures with x ray contrast. There’s a x ray camera on top of the patient. And then we feed wires down there if there’s a blockage. Then when over those wires, we have balloons and stents, stents are metal scaffolds.

Dr. John Riddick: Crimped on top of the balloon that we inflate the balloon, stent opens up the artery from the inside, you deflate the balloon, take the balloon and wire out, so that’s fixing a blockage from the

Vic: inside. The stent itself remains, you take out the tools that you use to get it there.

Dr. John Riddick: Exactly.

Vic: And the [00:15:00] patient walks home that night?

Vic: Um, depending on the setting. Or one night, but it’s a pretty minimally invasive. If

Dr. John Riddick: it’s a elective procedure and you’re doing it for angina, so symptom relief for chest tightness from the heart not getting enough of blood flow. You can go home. There are parameters, obviously, to do it safely, but same day discharge is a very real thing.

Dr. John Riddick: If you’ve come in with a heart attack, you’re Then there are other issues at play where you’re monitoring heart rhythm, heart pumping.

Vic: But just distinguish from cardiac surgery, the recovery time is significantly lower. That’s right.

Dr. John Riddick: And so, Dr. Reddy and I, um, I was after, so I did, you know, my cardiology, at Emory, then interventional cardiology at Emory.

Dr. John Riddick: And I don’t know for, I was hired at Centennial, Centennial Heart, to start a Yeah, [00:16:00] here in

Vic: Nashville. Here

Dr. John Riddick: in Nashville, a structural heart program. So structural heart is a subset of interventional cardiology. Which when I joined the practice in 2008, did not consist of much. But now structural heart primarily involves I don’t know if Dr.

Dr. John Riddick: Reddy talked about this, but Dr. Reddy and I started this program together in 2011. I think the

Vic: first in Tennessee, or the first in, maybe not the first. in

Dr. John Riddick: Tennessee, but, uh, pretty early on.

Vic: Yeah, and this is, um, you’re going in through one of the veins, but you’re working on the heart itself, as opposed to normal interventional cardiology, where you might be servicing the plumbing that feeds the heart Oxygenated blood, but it’s not actually fixing a structure of the heart like a valve.

Dr. John Riddick: Correct. The traditional procedure [00:17:00] of coronary intervention called PCI, percutaneous coronary intervention, for opening these coronary artery blockages, for TAVR, that’s transcatheter aortic valve replacement. So we’re replacing the valve with the same technology as a stent. It’s actually, that’s where the concept came from.

Dr. John Riddick: It’s a metal. frame, but instead of the stint just being the scaffold, they’re now leaflets sewn inside this, this scaffold and the original, um, Edwards valve was bovine pericardial tissue. So this concept is the same as a stint, except the equipment’s a little bigger. So we, we can’t go in the wrist. We go in the femoral artery.

Dr. John Riddick: We snake a wire, except instead of going down the artery, it’s actually going into the heart chamber itself. We inflate the valve inside the aortic valve and basically open up this narrowed aortic valve with a stent that now has [00:18:00] leaflets inside of this stent that take over.

Vic: Yeah. So it replaces the valve, but you do not have to We call that do open is not, you’re not putting ’em on a, on a heart lung monitor.

Vic: You’re not stopped at their heart yet that they’re awake. In fact, the

Dr. John Riddick: first one ever done in Ruan, France in 2004, the patient was awake. And we’ve kind of had a whole, whole sort of journey with this, but most patients are, are lightly sedated, maybe less even than a colonoscopy. Yeah. For a majority of these cases.

Vic: So I just want to, can go home to recap for a minute. Like in, uh, in the late seventies. The first, uh, stints were invented. Is that right? Your dad didn’t have access to that when he first had a heart attack. It started

Dr. John Riddick: with just a balloon, balloon angioplasty. Which

Vic: would just like push the, push the blockage to another area.

Vic: Whether that is good or bad, let’s leave for the moment. But, but it was. It was a step.

Dr. John Riddick: It was a, [00:19:00] it was great. It was actually a lot of progress, but it was incomplete.

Vic: Yeah. And so that is 40 to 50 years ago.

Dr. John Riddick: Yeah. I think it was 77, you know, training at Emory, Andreas Grunzig, the, the developer of balloon angioplasty was recruited to Emory in the early eighties.

Dr. John Riddick: He developed this in Austria. So did you train under him? No. So he, the historians will know he passed away in a plane wreck in the mid eighties. Doctors are notoriously terrible pilots and, um, Oh, he was flying? He was flying. Um, but he developed balloon angioplasty, came to Emory, recruited by Spencer King and John Douglas, and they, Emory was sort of the forerunner back then, along with, um, You know, Cleveland Clinic and others, but Grunzig wanted, as the story goes, wanted to be part of a university, academic university.

Dr. John Riddick: So he felt like Emory felt fit the bill better than Cleveland Clinic or Mayo [00:20:00] Clinic, either way, there was a lot of collaboration in the 80s, but there was a famous course, the epic course at Emory, where John Grunzig trained a lot, particularly in the southeast. A lot of the initial interventional cardiologists.

Dr. John Riddick: Particularly in Nashville, there’s a huge Emory connection. Um, so the balloon angioplasty was the first step.

Vic: The first, so that’s in 77.

Dr. John Riddick: 77, but kind of catch it. All these epic training courses are sort of early eighties, you know, 82, 83, say 84. I think forensic passes away around that time. Then someone comes up with a stint.

Dr. John Riddick: The idea of putting a metal scaffold on the balloon, so one of the main issues was called vessel closure. The vessel’s open when the balloon’s there, but you take the balloon away, the vessel closes down. Yeah,

Marcus: yeah.

Dr. John Riddick: Or you’ve torn the vessel, dissected it, and then it’s not structurally intact, and so it’s at risk for closing down.

Dr. John Riddick: So then someone, Paul Mauchat, they [00:21:00] created a stint out in California, and it’s one of the original commercialized stints that wasn’t until 87, 88, 89. Commercially, stints really became available.

Vic: And what I think is really interesting, Is that these things build on each other like you can’t, at least I think it would be hard to imagine a stint before the balloon intervention is in place, and then you and see new both are collaborating.

Vic: There’s a there’s a surgeon and a cardiologist. Now we’re placing a valve. That’s right, which would have been. impossible to imagine in 1975, but now it’s done and it’s much better for the patient.

Dr. John Riddick: So, by and large, I’d say there are a lot of things that go into the decision to have, we still do open heart surgery for some valve disease and some aortic valve disease, and

Vic: there are a lot Yeah, and Sinu talked through that decision tree a little bit, yeah.

Vic: Okay, so

Dr. John Riddick: But there’s a collaboration, in fact, a collaboration that has been, there was a period of [00:22:00] time where heart surgeons and interventional cardiologists, when stents really, the next iteration on the interventional front were drug coated stents, drug eluting stents, which the metal frame held the artery open, but there was a scarring.

Dr. John Riddick: Reaction where the arteries would narrow back down. So then the next bright idea is let’s put these anti neoplastic, so chemotherapeutic agents on the metal so that scarring reaction doesn’t occur in the arteries. So the first drug eluting stint, J& J came out with Cypher in 2003, Boston had Taxis in 04, there became a little bit of a slightly acrimonious relationship between heart surgery and interventional cardiology.

Dr. John Riddick: You’re funneling

Vic: volume away.

Dr. John Riddick: Yeah, and um, not always, picking the right procedure for the right patient. There are a lot of, you know, a lot of sort of perverse incentives sometimes in medicine. The beauty of TAVR has been, it is a requirement that a heart surgeon and interventional cardiologist as a [00:23:00] team have to evaluate the patient, not only evaluate them, have to be, in the procedure involved in the procedure together.

Dr. John Riddick: So we now have this kind of mandatory valve conference where we use it for all sorts of reasons where the surgeons and the cardiologists. Yeah, what is the best course

Vic: of treatment for the, for each patient? You go through, it’s not, there’s a lot of subtle aspects to it, but the surgeon and the interventional cardiologists are discussing the pros and cons.

Dr. John Riddick: It’s a much more, uh, it’s much better for patient care to have different vantages, people thinking about different options, because you have, I have, uh, internal medicine, then cardiology, then interventional cardiology background. Dr. Reddy has a general surgery, cardiovascular surgical perspective. And, you know, you get to hear both or the patient usually gets to hear both now, which is good.

Vic: I think your dad was probably correct that you have continued to learn every. Every patient is somewhat different and then the procedures themselves have gotten more and [00:24:00] more advanced and you’re learning new ways to do it.

Dr. John Riddick: So the procedure I do the most of, uh, TAVR. I did three of them in training as part of the initial trial at Emory where when Three obviously does not make you’re not an expert.

Dr. John Riddick: Yeah, and particularly these are you know, the first three in the southeast Yeah, maybe Three of the first 20 in the united states to say that I was minimally involved as the fellow in these procedures So I had no concept really of what it was like to do a taver, but to industry’s credit they have laid out pretty um this is now over a decade ago, pretty well delineated pathways for educating medical systems, hospitals, how to do this safely.

Dr. John Riddick: And it’s been rolled out pretty, pretty safely, I’d say. So

Vic: how many taverns do you do per year, roughly?

Dr. John Riddick: 250. 250.

Vic: That’s incredible. So almost one a day. [00:25:00] But first of all, like work days,

Dr. John Riddick: we have the benefit here in Nashville where we have three centers doing them. Uh, so it’s a consolidated effort in Nashville and there’s definitely some benefit to having that level of volume.

Dr. John Riddick: Whereas other cities, Tennessee is a CON state, there are not many open heart surgical centers and that’s a requirement to do TAVR, you can only do them in Nashville. Hospitals that do open heart surgery, obviously, heart surgeons are part of the procedure. There are other non CON states, not to get political, where, you know, in some cities, say Dallas, Texas, where they have, you know, maybe 15, 16 places that would offer that.

Dr. John Riddick: Dallas is a bigger city, but, you know, per capita, it’s, you know, it’s a little more diluted. And so there’s a happy medium. There’s a lot

Vic: of studies, I think I can maybe try to find them, but I think it’s pretty well established that if a surgeon does. A higher volume of procedures that the quality is better.

Dr. John Riddick: Well, it’s [00:26:00] laid out in Taver. There are plenty of articles. There’s a threshold. The number is probably somewhere between 120 to 150 a year. Beyond that, it seems like it plateaus, but there’s a minimum. There’s an incremental benefit to doing more up to a certain number. And so, if you can get to that number.

Dr. John Riddick: It’s like anything, I

Vic: think, if you do something fairly often, you, you get better at it.

Dr. John Riddick: It makes sense, you know, which is a good reason to go. If you’re out there thinking about surgery, I think one of the best predictors is the number of that procedure done in that particular facility by that particular operator, you know.

Dr. John Riddick: Yeah.

Vic: Okay, and then the last, uh, category of, um, heart clinician is the cardiologist without the interventional cardiologist on the, on the front end. So talk to how that is different.

Dr. John Riddick: Well, so there, there’s, uh. Maybe there’s more than few. There are, so there are now [00:27:00] imaging. Okay. Specialized general cardiologist.

Dr. John Riddick: So, so I’m at Centennial Heart. We’re kind of a, a bigger, you know, a downtown at Centennial. So a bigger group. Yeah. You have every flavor. 23 of us now. And so we have five electrophysiologist, seven interventional cardiologist. Then we have three imaging. specialized general cardiologists who have done extra training in reading cardiac MRI, cardiac CT, on top of the other more basic tenets, imaging of cardiology, which are echocardiograms.

Dr. John Riddick: Stress testing, but basically the distinction is they do, um, they do CT reading, MRI reading, and now what’s called invasive transesophageal echo, which helps guide us during our structural procedures. So we have the imaging based general cardiologist, then we also have heart failure transplants. General cardiologists who focus on people whose heart pump, [00:28:00] the actual pump is weak, who have congestive heart failure, and the kind of sort of end stage of that would be people who need LVADs or heart transplant.

Dr. John Riddick: So that’s its own niche. We have one, two, three, four, four, um, heart failure transplant general cardiologists. We do LVADs at Centennial. We partner with Vanderbilt for our transplants, but we have a transplant surgeon Who is part of the team at Centennial. So, and then there are just pure general cardiologists who do sort of, you know, one of them runs our lipid clinic, the cholesterol clinic, one runs our hypertrophic cardiomyopathy clinic, um.

Dr. John Riddick: Right, so they would be focused on the medicine side,

Vic: which means, um, lab testing, pharmaceuticals. Mm hmm. Uh, maybe lifestyle changes. Exactly. Yeah. Okay. And,

Dr. John Riddick: Every, at Centennial at least, uh, it feels like we all have, [00:29:00] everyone has trained at these great places and has all this advanced training, so. There are very few, in fact, the only true general cardiologists we have are retired interventional cardiologists.

Dr. John Riddick: Yeah, yeah. Who have gotten to that stage of their career. So, in some ways, we have no general cardiologist, which means Everyone is kind

Vic: of

Dr. John Riddick: somewhat there. Means everyone is a general cardiologist to some degree. Which is where Which is what I need, so that works for me. I came in, although I am not a I’m a structural interventional cardiologist.

Dr. John Riddick: Three days of the week, but two days of the week. I’m a general cardiologist.

Marcus: Yeah,

Dr. John Riddick: one day of the week every other week I’m in Camden, Tennessee where it’s very, you know, basic primary care to high blood pressure to high cholesterol and so I have Which is what I wanted. A, a kind of spectrum of practice.

Vic: Yeah. Yeah. So, um, thanks for going through that. It’s a lot about your biography, but I think, yeah, sorry, [00:30:00] there’s a, there’s enough complexity and the reason I wanted to do this series is it takes some time. I mean, I talked to Nu for an hour. We’ll talk for an hour, but the concepts are understandable. I think, I mean, I think it’s, the plumbing analogy makes sense to me.

Vic: The details of it, I don’t know if I need to know, but like how you put a stint in with a balloon and then you leave the scaffolding behind, I can understand the basics of that. And so what, what I wanted to shift to now is heart disease is the number one killer in America, maybe globally. I think there’s something like two to two thousand to three thousand people a day.

Vic: die of some kind of heart disease, heart, heart attacks and heart disease. And yet on the hopeful side, as we just talked through that there’s been a lot of [00:31:00] innovation building on work that was done in the seventies and eighties. And, but it’s continued and getting better and better. We have a lot of diagnostic tools and we will have a lot of medicines, a lot of pharmaceutical tools, even before you start to get to interventions, whether it is.

Vic: Through the vein or cutting open and operating and so well, it is a really deadly disease I think it also is true that I have some hope that we can make progress and Continue to fight against it and make people live longer with heart disease?

Dr. John Riddick: For sure. I think there’s been a real increase in the pharmacologic side of treatment recently with newer cholesterol medicines coming out.

Dr. John Riddick: Um, we’ve made a lot of advances on the procedural side over the past 25 years and not that we don’t continue to advance there. We do. [00:32:00] Um, I think a lot of the coming Benefits and technology will be on the imaging side, the non invasive side CT scan, which we’ll talk about, but also with early detection comes the ability to get ahead of it with medicines.

Dr. John Riddick: Not to mention we haven’t even discussed lifestyle. Obviously there are some basic tenants. Yeah.

Vic: So let’s, so let’s jump into my case and then I want to try to use it as a, as an illustration because the audience doesn’t care about me personally, except for the fact that it hopefully can. Uh, unearth some aspects of how other people should think about heart disease.

Vic: So, um, where I want to focus first is that, um, I believe Cardiovascular disease is a, uh, accumulation of, um, problems over many years. Would you say that’s accurate?

Dr. John Riddick: Yes, by and large, it’s a [00:33:00] progressive problem of multiple risk factors coalescing to the buildup of, when we’re talking about coronary artery disease in particular, of buildup of plaque in these arteries that starts narrowing the blood flow.

Dr. John Riddick: And that’s a combination of lifestyle, genetics, um, blood pressure, blood sugar, cholesterol, whether or not you’re a smoker, how much exercise do you get, how’s your diet, you know, all these risk factors. Now, there does become a tipping point sometimes, um, where these, Plaques build up to a certain threshold Sometimes you’re not so lucky, you know, like my dad at the bank where you probably have a 50 60 Plaque not causing any problems it Quote unquote ruptures or unroofs or erodes and the blood doesn’t like that plaque being exposed to the bloodstream and the blood decides I’m gonna wall that off put a clot on it to get all [00:34:00] that fat Cholesterol plaque out of the wall that shouldn’t be in the bloodstream.

Dr. John Riddick: That’s that’s bad. There’s a thrombus right now You have a hundred percent blockage. That is in

Vic: general So there’s a correct cute event that you would want to and that I have patched that up But if you patch it too much then you block the whole stream of blood. So that’s

Dr. John Riddick: your body’s, uh, the analogy is, you know, as cavemen bleeding, the body’s like, uh, these, the blood vessels are exposed to things and the, you don’t want to bleed to death.

Dr. John Riddick: So the body walls off this bleeding vessel. So you don’t, but we are no longer cavemen. We live in, a society where we’re not bleeding to death, by and large, we’re building a plaque. And so this cholesterol thankfully gets walled away, typically in the walls, kind of covered over. But occasionally, if the plaque is exposed to the bloodstream, the body will put a clot.

Dr. John Riddick: In an attempt to, [00:35:00] you know, keep that out of the bloodstream, and now you’re, have 100 percent blockage in the artery, you’re having a heart attack, this is really what you’re trying to avoid, because now, part of the heart can die. It builds up

Vic: over many years, but it can present acutely. It can present

Dr. John Riddick: acutely, but it doesn’t have, exactly, back to your point, and with the imaging that we, Are doing these days we should be able to get ahead of this and there are a lot of risk factors that traditionally that we follow but I think your case highlights the fact that sometimes these traditional risk factors there they’re incomplete you know we there’s stuff we don’t understand there’s certain things we don’t know what to know how to measure what to measure

Vic: yeah and so maybe the patient doesn’t always tell their primary care doc well I mean let me just start on my situation so I was, um, you know, a husband, a [00:36:00] dad working a lot in my twenties and thirties.

Vic: I got an annual checkup most years, but I wasn’t very focused on it. And when I was Showing up at that primary care visit, it was an overall assessment of my health in 10 minutes, 15 minutes. I mean, and there’s nothing wrong with those two. I was at Heritage Group first, and then I moved over to the Frist Clinic.

Vic: And I think they both were great doctors. I didn’t bring up to them that both my grandparents, both my grandfathers died of heart attacks. On one side, pretty young, at like, I think, 64, 65.

Dr. John Riddick: Is he a smoker?

Vic: I don’t even know. I don’t think he was at the end, but it’s hard to know if he smoked early on. I could ask my dad [00:37:00] that.

Vic: Um, and then, I never brought that up. And so, in your 20s and 30s, there isn’t a lot of screening for heart disease. And, my, I guess my first question is, what do you have on my records in, back in the history, and should I have brought that up, and that I’d been more active in cholesterol screening or other screening early on, because heart disease, um, it is building up, every year it’s building up.

Vic: And if there is a family history, would it make sense to be more focused on cholesterol or being attentive to it in your earlier years, or is that not helpful?

Dr. John Riddick: I think 100% You should be attentive to your cholesterol. I mean,

Vic: Always, no matter what. Yeah.

Dr. John Riddick: I mean, they check it in the pediatrician’s office now.

Dr. John Riddick: Yeah. Okay. So, a hundred [00:38:00] percent, particularly if there’s a family history, Um, your blood pressure, your blood sugar, your cholesterol, Your smoking status, your BMI, your diet, I mean, that should always be addressed starting at a very, I mean, obviously. Yeah, so Day one. I mean, from the time you’re probably 12 years old, in fact, I mean, in a pediatrician’s office, these things should be addressed.

Dr. John Riddick: And so your cholesterol should be followed closely. Now, family history of early onset heart disease is a big risk factor. It’s usually first generation relatives, so when you talk about second generation grandparents and the lifestyle that people lived probably in the 50s, we’re talking, like my dad, it’s hard to know because diets were terrible, smoking was ubiquitous, um, It it’s hard to know genetically is that as much of a predictor when you’re [00:39:00] talking about I mean there If you say I have my mom at age 41 Not a smoker has a heart attack.

Dr. John Riddick: That’s a huge red flag

Marcus: Yeah,

Dr. John Riddick: grandparents in their 60s and the 50s who had uh may or may not have smoked It doesn’t move the needle a lot for me. Yeah That doesn’t mean we don’t focus on your cholesterol and all your the traditional risk factors.

Vic: Okay, so Um Let’s pick a

Dr. John Riddick: time when I was healthy,

Vic: what do you have as far as my stats?

Vic: Well,

Dr. John Riddick: starting with your Frist Clinic days. Yeah, okay. June of 2018. You want me, I’ll just read out.

Vic: Yeah, whatever you think is important to talk through. From

Dr. John Riddick: a cardiovascular perspective, your total cholesterol was 215, pretty good, the upper range of normal is 200, triglycerides 86, that’s normal, HDL, that’s normal.

Dr. John Riddick: Good cholesterol, 74. That’s excellent. LDL, bad cholesterol, 124. If you look at the lab values, less than 130 [00:40:00] is the goal. So, your, there’s a score. Have I showed you this? Well, there’s an app. No, no, no. Okay. A, your ASCVD score. And so that’s atherosclerotic cardiovascular disease. And it

Vic: takes all of those numbers you just read off and somehow, uh, weights them in an appropriate way?

Vic: It gives

Dr. John Riddick: you, I was trying to, I should have showed you this earlier. So, based on your age, sex, race, blood pressure, and your blood pressure, you were 47, your blood pressure was 110 over 72. Okay, so my age was

Vic: 47, blood pressure was 110 over 72. Fixed blood

Dr. John Riddick: pressure, actually. I would say good cholesterol, maybe not great, but good cholesterol, your BMI.

Dr. John Riddick: It was 26, which is a little, just a touch high, but not bad. So these are the inputs here though. Okay. So there you are. I’ll

Vic: put this. In history of diabetes?

Dr. John Riddick: No. Is

Vic: this asked available to the public? Yeah. So I’ll, I’ll put that in [00:41:00] the show notes so people can check it out. ASCVD score. So this is part of the guidelines.

Vic: And so the Frist Clinic uses something similar to this.

Dr. John Riddick: But yeah, this is, these inputs obviously are, those are the important, your cholesterol, your blood pressure. Dr. Barfield,

Vic: who we’re both friends with, um, was my doc then, and I, I think he’s great. I, I, I like him. He has left practicing full time. He has.

Vic: Um, but other than that, he’s wonderful. Um, when I was 47 years old, I had those, those set of labs. And is it right to say that every primary care doc would have looked at it and said that’s reasonably healthy?

Dr. John Riddick: Yeah, your ASCVD score, try to, I want to say this correctly, but it was 1. 4 percent. So that’s the percent risk of [00:42:00] having a cardiovascular event.

Dr. John Riddick: Over the next 10 years.

Vic: Okay, so I was 47, I’m 53 right now. So that was 6 years ago. And

Dr. John Riddick: so, anything less than 5 percent is considered low.

Vic: Okay. Now, with all those scores, the Frist Clinic sent me home with a clean bill of health.

Dr. John Riddick: Correct.

Vic: Yeah. And so now, let’s move forward to the next one, because the scores don’t stay really positive.

Vic: Forever. I know. I don’t know how it evolves. The question is like, how does it evolve, and what should the listener be looking for that is the first thing that happens? If, is that, is there a first thing that shows up?

Dr. John Riddick: So at that point, I mean, I think you get the, the clean bill of health. The question would be, do you do any additional tests?

Dr. John Riddick: To ferret out your risk. Yeah, so those [00:43:00] things would be a calcium score or there’s some blood tests Lipoprotein little a, apoprotein B, those are cholesterol measurements, CRP, which is an inflammatory marker. So, but we could have ordered that. You could have, but by, I mean, typically by the guidelines, if you’re in a low risk category with your ASCVD score.

Dr. John Riddick: then you would not.

Vic: Now, if the listener is wanting to kind of lean into this and really gather more information, is there any downside to getting the calcium score or uh, protein little, lipoprotein little A or ipoprotein B? Is there, is that a blood test? What’s the, calcium is not a blood test, I don’t think.

Vic: So the

Dr. John Riddick: calcium score is a CAT scan. Yeah. Lay on the table. No IV. You’re kind of in and out. It’s typically 69, 70, [00:44:00] 50. You can often just go on your own. The only downside is there’s a minimal amount of radiation. Um, so for a 47 year old guy And then the other, the two

Vic: proteins, little A and B Okay, so lipoprotein little A Those are blood tests, right?

Dr. John Riddick: Apoprotein B, eh, or, yes, they’re blood tests. So they’re cholesterol.

Vic: They’re markers

Dr. John Riddick: for cholesterol. Markers. There’s, there’s Less, less data traditionally. The

Vic: B seems like the bad actor, I think. It’s bad.

Dr. John Riddick: Yeah. It’s a precursor, it is in many ways The LDL captures it, but not, the LDL is a calculated number, the bad cholesterol, LDL cholesterol is calculated based on formula.

Dr. John Riddick: And so it’s not directly measured typically. And so there are times where the, yes, the APO, lipoprotein B is a better test, but it’s not universally adopted yet, you know, it’s kind of right now, again, [00:45:00] recommended for people. So. In sort of the borderline

Vic: range, which I wasn’t really, but there’s not a lot of downside.

Vic: Maybe it’s 70, 50, 70, a little, little radiation to do a CAT scan. So

Dr. John Riddick: the CAT scan for the calcium score there, I’m pretty aggressive. I think calcium scores are pretty easy to do. They’re easy to do. We’re looking, cholesterol, don’t get me wrong, it is important, it’s probably the main driver of coronary artery disease, along with smoking and diabetes, but, um, a lot of these other, there, you know, CRP, which is also a consideration, that’s a blood test, that’s an inflammatory marker, having inflammation is bad, but it’s very nonspecific.

Dr. John Riddick: You know, you can have inflammation, and what does that mean? I mean, certainly, there’s a lot of data for it. I’m not discounting it. And there’s a whole school of thought using CRP more aggressively. I like the idea, particularly as an interventional cardiologist, a calcium score is actually looking at [00:46:00] your anatomy.

Dr. John Riddick: I mean, it’s a simple approach, but hey, here are your arteries. Here is calcium. That should not be there. The calcium score should be zero. Should have zero calcium.

Vic: When you’re 47, with that Very low risk factors, you, one would expect the calcium score to be quite low, zero. Should be zero. And calcium score is a lagging indicator, I think.

Dr. John Riddick: It’s a lagging indicator because the plaque gets developed as fatty plaque that then gets converted. It’s like, it’s like

Vic: capped or covered over with calcium somehow. Converted

Dr. John Riddick: to calcium, but yes. Yeah, it’s a stabilizing thing. In fact, turning it into calcium, you know, atherosclerosis is hardening of the arteries.

Dr. John Riddick: It’s a stabilizing mechanism to keep this plaque, you know, like we talked about eroding into the bloodstream and being exposed to the bloodstream. Calcifying it typically walls it off [00:47:00] even further, stabilizes it. Makes it less likely in the early stages when it’s non obstructive, not narrowing the actual path of the blood flow.

Dr. John Riddick: It’s a good thing, but it is definitely a marker that plaque is being developed, which is not normal.

Vic: And so with hindsight, I might have done other tests at that point, but I didn’t. So let, let’s move forward to the next, uh, data point.

Dr. John Riddick: So the next data point was March of 2020. So Two years later? Two years later, you’re 49.

Dr. John Riddick: Like I said, I didn’t

Vic: always hit the annual one that well.

Dr. John Riddick: I gotta say, this is pretty good, though. Um, It’s less, I mean, it’s 18, well, it’s almost two years. Either way, your total cholesterol is pretty similar. 222, triglycerides 49, HDL 77. Excellent. So your good cholesterol is really good. LDL, bad cholesterol, 135, a little worse, [00:48:00] 130 is the threshold for, I mean, these days we use the ASCVD score, but yes, blood pressure 112 over 70, BMI 27.

Dr. John Riddick: Put on a few pounds, yeah. ASCVD score, 1. 8%. Very low, low. In fact, when you input all these metrics, it’ll give you an optimal, optimal risk based on intervention. So, if you gave a statin, or you gave a blood pressure medicine, or you quit smoking, or you took an aspirin, What can you improve your ASCVD score to?

Marcus: Yeah.

Dr. John Riddick: In both those instances on this calculator here, ASCVD score is actually lower than your optimal score. Not sure how that happens. I’m not the expert on these calculators, but either way. But it suggests that a statin is not required.

Vic: Correct. You’re not

Dr. John Riddick: even, but again, um, I’m not sure. [00:49:00] This is where I think obviously there are things that we don’t know, we’re not measuring, we don’t know what we don’t know, we’re trying to figure out.

Dr. John Riddick: Yeah, I didn’t get a calcium test.

Vic: Yeah,

Dr. John Riddick: yeah. You know, would a CRP been helpful? Would a calcium score have been helpful? I think, well, we can keep going, but maybe, maybe. Maybe, but yeah. I mean, I’m quick to do calcium scores. Again, it’s an easy test. And, uh, In a 49 year old woman who doesn’t have any risk factor, you might argue the radiation risk may, uh, because of breast cancer, it may be a consideration.

Dr. John Riddick: Yeah. For a 49 year old guy, you know, I think the risk

Vic: is high. I mean, I get radiation flying in planes. I mean, the radiation is not something that I personally am scared of. I mean, in moderation, once in a while.

Dr. John Riddick: And I think it’s more on a population level. You know, if you start looking at populations, if we start calcium score screening every 45 year old woman, are we going to save more lives than we harm [00:50:00] by inducing a breast cancer here or there?

Dr. John Riddick: And that’s where it’s an individual discussion with the patient and their physician. And so, but I’m definitely more aggressive, even with someone who’s, I mean, these are pretty good numbers, blood pressure 112

Vic: over 70. But the LDL, I still would have probably

Dr. John Riddick: done a calcium score. Right, because the

Vic: LDL went up in a, in a way that was, uh, went from like 110 to 134.

Vic: So here’s the

Dr. John Riddick: problem, you’re LDL 135, we have a mutual friend who, uh, had a heart attack. And that, we’re not gonna, not promoting anecdotal medicine but we are always influenced by cases and certainly when you have, we’re at an age where we’re 50 year old guys and 50 year old men have heart attacks with LDLs of 135, even more frightening, we, there’s a physician I know who had a heart attack with a zero calcium score and an LDL of 135, which kind of gets us to where we’re going and Yeah.[00:51:00]

Dr. John Riddick: But, yeah, I mean, there are things

Vic: that we

Dr. John Riddick: are still not measuring.

Vic: You could ask your, if you’re listening, you could ask your physician, Hey, what about a calcium score? Just to get information. And if you do that once every five years or ten years, the amount of radiation is pretty small.

Dr. John Riddick: Usually, we would say the warranty is good.

Dr. John Riddick: If it’s a zero score, probably good for ten years. Yeah. You could be extra aggressive and think about repeating it sooner, but um, I think the firma, again, depending on your risk profile and your age and your family history, the calcium score, uh, I’m a big proponent. Yeah, right. Okay. So, but by guidelines, you were not a candidate.

Dr. John Riddick: Yeah. You know?

Vic: Okay. So that

Dr. John Riddick: was four years ago. That was, yeah, March of 2020. Okay. ASCVD score 1. 8, again, less than five is low, five to 7. 4 borderline. The borderline’s kind of when you start to really think about it. Yeah. Five [00:52:00] percent. And I was at 1. 8. Your 1. 8 risk of an event. Yeah.

Vic: But something changes because.

Vic: So

Dr. John Riddick: then. Yeah. Something changes. Yeah.

Vic: COVID. COVID happened. I don’t know how that affected my. I don’t know either. My heart score, but it did.

Dr. John Riddick: Um, so April of 2023, I was not involved yet, but to your, I don’t know if this was a discussion that you brought up or maybe Dr. Barfield decided we’re going to check some of these things.

Dr. John Riddick: So you got a lipoprotein little a, and it was 11, which is normal.

Vic: Dr. Barfield recommended that. I think, I think he had just started adding, like, he’s drawing blood anyway and he just started screening for these additional markers. That’s my recollection of it. It wasn’t looking for anything in particular.

Vic: It wasn’t Vic Gatto going in demanding it.

Dr. John Riddick: Apolipoprotein B 119. Yes, that was

Vic: concerning. Less than

Dr. John Riddick: [00:53:00] 90 is normal. You’re elevated there.

Vic: Yeah.

Dr. John Riddick: Um,

Vic: that was the yellow flag that made him, um,

Dr. John Riddick: Greater than 130 is when we really worry. So you’re still not like in a crazy high range on your Apo, Lipo, Protein B.

Dr. John Riddick: But it, that’s a, that actually tracks though your LDL on this visit through your legislator has gone from 135 to 156. So 156, that starts to really get your attention for LDL bad cholesterol. Total cholesterol, 256. Triglycerides, 58. HDL, 88. So, I mean, you’re good cholesterol. Really impressive. So now your ASCVD score has gone up, but only to 2.

Dr. John Riddick: 9%. So still in the low range, your optimal risk is You’re now at a range where it says, well, we could bring you down to 2. 6 percent with an intervention, which would be a stat.

Vic: [00:54:00] Yeah. Now to give, uh, the Frist Clinic and Dr. Barfield credit, even though it wasn’t a bunch of red flags, he was, I recall him calling me and saying this, uh, whatever it is, I can’t say a protein B.

Dr. John Riddick: Apolipoprotein B. Right, right. Yeah,

Vic: ApoB. Is not a good thing to have up above the range.

Dr. John Riddick: That’s. Exactly right.

Vic: Yeah, that was my translation. I’m sure he said something different and he said I’d like you to get a calcium.

Dr. John Riddick: That’s right He recommended that you get a calcium score

Vic: and because I am um healthcare investor and really interested in this stuff, I I had listened to a book called Outlived by Peter Atiyah, who’s a longevity, he’s a doctor, but he’s been focused on longevity.

Vic: And he was suggesting in the book that if you’re going to get a calcium score, you might as well get a CT angiogram, is that close to right? Is that right? Yeah. CT angiogram?

Dr. John Riddick: [00:55:00] Coronary CCTA. Coronary CTA, coronary. And

Vic: I asked Dr. Barfield about that, and his response was, I don’t know, but that’s not. Our recommended course of treatment.

Dr. John Riddick: That’s true.

Vic: And, that’s right. I mean, I think he was, he was accurately portrayed. Coronary

Dr. John Riddick: CTAs are primarily for symptomatic people. Yeah. By guidelines. Because

Vic: I am, uh, a privileged asshole, and I have your cell phone, I, I called you directly, even though I wasn’t a patient, and asked you. This

Dr. John Riddick: happens all the time.

Dr. John Riddick: It’s okay. Right. I mean, this is. It And, uh, but I was, I was

Vic: seeing, you know, I was at the first clinic two floors down from you. I would have been referred, I mean, Dr. Barfield would have referred me up to your practice, whether it was you or someone else.

Dr. John Riddick: At one point there, I don’t know exactly in the sequence, but he refers you to Dr.

Dr. John Riddick: Honeycutt, my partner.

Marcus: Yeah,

Dr. John Riddick: yeah. He is our expert [00:56:00] general, well he’s an imaging expert, general cardiologist, but kind of our chief primary preventive cardiologist. Yeah, which is what I needed. Lifestyle, dietary. I don’t need a structural heart

Vic: cardiologist, structural cardiologist really yet, hopefully.

Dr. John Riddick: Correct. Which is No, you don’t. Yeah, but you and I know each other. Yeah. So I called you out of

Vic: band.

Dr. John Riddick: Yeah.

Vic: And I just asked the question. I think I want this CT angiogram, and yet it’s not recommended, which makes me feel like maybe. I need to think through it twice, and my recollection is you said there’s not a lot of risk to it, you have to take this die, it’s kind of a hassle, but the real barrier is cost.

Vic: It costs, uh, 400 something dollars. Is that, well correct me, where is that wrong?

Dr. John Riddick: So, just backing up one step. Dr. Barfield did recommend you start Crestor, Resuvastatin, 5mg, and [00:57:00] change your diet to as much of a plant based Mediterranean diet.

Vic: Right, which I’m already, uh, pescatarian.

Dr. John Riddick: And so, I will say

Vic: also, at that point,

Dr. John Riddick: your blood pressure was normal again, and your BMI had come down to 25.

Dr. John Riddick: So, a normal, BMI, upper normal, but normal BMI, you’re exercising a ton, you’re almost pescetarian, so there’s not a lot of room on your diet and, uh, because one of the key concepts of starting a statin for primary prevention, because, you know, at this point we’re, we’re debating calcium score versus coronary CTA.

Dr. John Riddick: So before you even get to that point, you know, it’s plant based diet, you’re pretty much doing it. Do we risk benefit of a statin here? A shared decision making model, does it make sense? The risks of myopathy or myalgias or muscle aches are low? What is the, yeah, so, so that’s part of the discussion. Five milligram

Vic: statin

Dr. John Riddick: of Rosuvastatin.

Dr. John Riddick: That’s a not a

Vic: [00:58:00] lot of muscle. I haven’t experienced muscle aches. I, well that’s a,

Dr. John Riddick: that was a pretty, uh, pretty lightweight, that’s a lightweight about as low initiation and Right. Rosuvastatin is a great statin. It’s sort of our newest, it’s um. The side effect profile is pretty good, although I’m on a tour of a statin and have been for, for a long time.

Dr. John Riddick: Generic Lipitor never had a problem. But one of the key concepts is a shared decision making for primary prevention. Does it make sense to take a statin? The pros and the cons between you and your doctor, the risk and benefit, drug interactions, side effects, by and large, most issues with statins. In my mind, they’re overblown.

Vic: There’s something with Lipitor in the liver and drinking alcohol. You have to

Dr. John Riddick: monitor all statins, you have to monitor, um, your liver function test. And, but by and large, these things are reversible. Even if you do have muscle aches, [00:59:00] um, Usually, the times you get in the biggest amount of trouble are when you’re taking statins with other medicines that interact and that can cause some dangerous situations.

Dr. John Riddick: So in my situation,

Vic: I was on no medications.

Dr. John Riddick: So back, just backtracking, your ASCVD score has gone up to 2. 9 percent with your LDL 156, your APO B is elevated. He recommends this low dose of a statin after some shared decision making with you. And you’re already doing great with your diet and exercise, so it probably made sense to give a statin a shot.

Dr. John Riddick: Then the, the question is, calcium score or coronary CTA, even now, you could argue, You don’t even need to do any of that. Um, because you have a one risk enhancer, it’s called the APOB is up, but it’s not way up, you know, just start treating you with a statin. But I, again, I would have done exactly what Dr.

Dr. John Riddick: Barfield did, which would [01:00:00] have been recommended a calcium score or a coronary CTA. And I probably would have started with a calcium score as well. But for your knowledge and my reading, my requesting for reading a book, get more

Vic: information from the CT. So here’s to

Dr. John Riddick: that discussion. Yes. So the radiation is significantly higher on a coronary CTA.

Dr. John Riddick: This becomes a, this particularly for women is a consideration. at 50, you’re 52 at this point, a 52 year old woman. That’s not a, I think a coronary CTA is a legitimate, you know, discussion over lifetime risk. Yeah. But, but for me, I think, and so again, not to be anecdotal about it, but having seen a friend with a heart attack at LDL of 135 and a friend with a heart attack with a zero calcium score.

Dr. John Riddick: You know, I am, and being an interventional [01:01:00] cardiologist, I do a lot of heart caths. So that’s why I go in and take pictures invasively of the arteries based on my partner’s ordering CT angiograms the coronary CTA. I am Becoming more and more aggressive with coronary CT angiograms, but again the risks of radiation There is contrast which some people can react to Um, to your point, it’s uh, the biggest impediment or barrier many times.

Dr. John Riddick: The guidelines recommend it for chest pain evaluation. We’re talking here, you’re having zero symptoms. Right. For the record. Yeah. And exerting yourself quite actively.

Vic: Yeah. So I’m not I’m working out hard and I don’t have any symptoms and yet I’m in someone that I will I don’t worry about radiation once in a while.

Vic: I’m not, I’m not like working in a diagnostic center. So as

Dr. John Riddick: I’m talking to you, I’m with you. I’m like, I’m not worried about a one time dose of radiation. Uh, I’m [01:02:00] not worried about the contrast. You’re working out hard. So you could say, well, You know, uh, when we do treadmill tests, um, that is a stress test, right, that rules out blockages more than 70%.

Dr. John Riddick: So the arteries have to narrow more than 70 percent to give you an abnormal treadmill test. I’m pretty sure you’ll have a normal treadmill test because you’re doing it every, you’re working out every day. And then you could say, well, could you do an exercise? You could do in plain treadmill tests are about 60 percent accurate.

Dr. John Riddick: They’re not the best test. You know, it’s kind of a. There are times when they’re great, but for you, I didn’t see the need. Then there’s the talk, you know, should we do, like, an exercise imaging based study? So there’s exercise echocardiograms, exercise nuclear stress testing. But again, these are more tests for people who have symptoms.

Dr. John Riddick: You’re not having any symptoms. So the question is, I think a calcium score is a great start. And then I was asking, I was asking,

Vic: could I [01:03:00] go up one level and then

Dr. John Riddick: I didn’t take much convincing for me. I said, you know what? One, you get the calcium score with a coronary CT. So you get that. Uh, and then two, you get to see exactly what the arteries look like.

Dr. John Riddick: You get to see the heart pumping. The valves moving, the heart chamber squeezing. You get this, all this incidental, which, and sometimes is a good thing, sometimes a bad thing. Yeah. All this ancillary information of your lungs, pulmonary arteries, pericardium, the sac your heart sits in, your pleura, the sac your lungs sit in, you name it.

Dr. John Riddick: Your chest wall, it catches the upper abdomen, your lower Yeah. So if there’s a liver You get a lot of information. You get a lot of information. And the

Vic: downsides are, you have to tolerate the contrast, which is not fun, but I’ve tolerated it fine.

Dr. John Riddick: Usually we give nitroglycerin to vasodilate your arteries, and potentially a beta blocker, metoprolol, to slow your heart rate, to get in pictures.

Dr. John Riddick: [01:04:00] See, I,

Vic: I, because I have a low blood pressure, I didn’t have to do those. You probably didn’t need the beta blocker. I didn’t need those things, yeah. And then

Dr. John Riddick: nitroglycerin gives you a headache, but sometimes they, they, we forego the nitroglycerin. Yeah. Yeah. In fact, One of our friends said, I’ve done that once.

Dr. John Riddick: I’m never doing it again. So I don’t think they asked me if I wanted it. We have a great imaging team, but not only that, we’re lucky. I went to

Vic: Premier Radiology. You went to Premier. Which was great. It was a good experience.

Dr. John Riddick: We have the latest, greatest thing at Centennial, the fastest, best CT angiogram on the market.

Dr. John Riddick: CT machine, I should say. Um, But you went to Premier, which, you know, it’s your mistake, but I’m just kidding. Just closer. Just closer to my house. I’m sure it’s more convenient. By a mile. Yes. Yeah. And then, so they had pricing. So this gets to the, the ultimate question became, well, the barrier inconvenience of getting it.

Dr. John Riddick: And so it’s, it was, I looked at the [01:05:00] order sheet they had, I think it was 4. 50 for your CTA. Because insurance isn’t gonna

Vic: Compared to like 50 to 70 for calcium. Correct. Insurance doesn’t pay for it.

Dr. John Riddick: Insurance does not pay for it. Now whether they

Vic: should or shouldn’t is a different question, but they don’t right now.

Dr. John Riddick: They will, not for this indication. They will pay for it. It’s the, the best test for people with, Atypical chest pain, not to go down this rabbit hole, it’s the number one, it’s the primary recommended test for people with chest pain where you’re not clear about exactly, you’re kind of low suspicion that it’s actually a blockage, but could it be, you know, because back to the.

Dr. John Riddick: the benefit. It can look at your esophagus, your lungs, your pulmonary arteries.

Vic: Yeah.

Dr. John Riddick: All these things. So,

Vic: and so I went through it as a precautionary matter to gather data.

Dr. John Riddick: CTA is usually out of pocket. Yeah. And so it’s probably cheaper. This is a discussion we had last night. Best way to save money for the healthcare system.

Dr. John Riddick: You’d be shocked to hear this. There was a move by [01:06:00] one of our friends that said all pricing should be the same outpatient versus inpatient. He happens to, you know, run outpatient infusion centers. And that also

Vic: would be good for

Dr. John Riddick: me. Yeah. But, uh, there is probably, I’m guessing it’s probably slightly cheaper at Premier than maybe at Centennial.

Dr. John Riddick: Yeah. Maybe 5. 50 versus 4. 50.

Vic: Order of magnitude, but yeah. So we’re talking about 500 or less. Don’t quote me on any of

Dr. John Riddick: these numbers, uh,

Vic: they’re a variable. I don’t work for Centennial, so I can say whatever I want on health further. So the, uh. The order of magnitude is 500, or less. Correct. 400 to 500, and the calcium score is under 100, 50 to 100.

Vic: Correct, correct. And so, it was not a difficult decision for me to make. I, I am lucky I spent 500 on all kinds of stuff that is not as important as this. And so I went ahead and went forward with it. And so what did we find out in it? One more, one more [01:07:00] downside.

Dr. John Riddick: The reason why we don’t do this, aside from the risks we’ve already talked about, are incidental findings.

Dr. John Riddick: And so sometimes you find, and this is where it comes, To the healthcare at large, the downstream testing that can come from incidental, incidentalomas, they’re called, incidental findings on CAT scan. There’s a lump

Vic: on your lung. And then we’re going to have to go down this rabbit

Dr. John Riddick: horn of, you know, working up a thyroid nodule, uh, renal cyst, uh, you name it.

Dr. John Riddick: CAT scan picks up a lot. And, um, So

Vic: we could be good, but it could also be a false alarm and not could

Dr. John Riddick: be bad Yeah, and so that’s why it’s never probably going to be recommended. Yeah as a population based screening tool, but but for for a self individual a person who’s discussing it with their physician and so just as a Anecdote, when we got this new CT machine, um, [01:08:00] CT scanner at Centennial, top, top of the line, you know, all the bells and whistles, they needed to calibrate it and adjust it.

Dr. John Riddick: All, they offered free CT scans to all of our partners, is to come in as healthy volunteers, just to kind of, you know, and people, by and large, everyone, yeah, yeah, yeah, yeah, you get a formal read and everything, free of charge, and, um, by and large, every cardiologist signs up for it. And I agree. Everyone, their intellectually interested, well, you spend all your life dealing with with it, right?

Dr. John Riddick: You want now I’d like to see it. Yeah. I’ll, between you and I, I have a zero calcium score, but I’ve been on a max dose of Lipitor for, because of my family history, and I didn’t know additively how it would help me just yet. So I, in full disclosure, did not do it. I’d say the vast majority of. the folks from our age got men.

Dr. John Riddick: I don’t know if our two female partners did it, but the men by and large did it. [01:09:00] One had an over call on one of their blockages, had to get a heart cath. So this is the negative downstream effect. Had a heart cath. Turns out his, uh, Narrowing was fine. It’s okay. That was a false alarm. False positive. Yeah.

Dr. John Riddick: That is, so when you talk about the risks, it’s false positives, downstream testing, start chasing things. Yeah. And then he had, what if he has a heart, heart cath? The invasive procedure. Now we’re doing this on our partner and we tear the artery and it has to have a stent or even worse, go to surgery. Or even worse, you could imagine.

Dr. John Riddick: So then you can see where, yeah, it is a discussion. But again, I was with you. I’m like, GL and I already, yeah. And I already did it, so I already made that choice. Okay. So we made the choice we get, so we pivoted. This is what I wrote. In May of 2023, we pivot to coronary CT angiogram. Mm-Hmm. . So the results, your calcium score comes back 203.

Vic: Yeah, which is

Dr. John Riddick: way higher. It should be zero. [01:10:00] Yeah, right. And zero to 100 is mild. 100 to 400, moderate. Greater than 400 is severe. So if I had seen that, if we had just done the calcium score and I had seen 200, then I probably would have recommended a coronary CTF. Right, right. Anyway, so you made the right call.

Dr. John Riddick: So we did it all at once, but that was luck. You made the right decision. Without, yeah, right. Right. And so this. So, where is this calcium? So, the benefit to the coronary CTA, when you do a calcium score, you basically are looking for calcified plaque. It’s a pretty, I say low quality, it’s low radiation, but what they do, what, I don’t read these by the way, but they find the calcium plaque, they basically trace it and based on the density.

Dr. John Riddick: It’s called the Hounsfield units of the CAT scan and the area you get a score. So based on area and density. It doesn’t tell you though how significantly narrowed an artery is. It just tells you where it is. This is the calcium score. This is the calcium score. The coronary CTA, [01:11:00] unless you have some artifacts, blooming artifact it’s called, it’ll tell you exactly what you need to know.

Dr. John Riddick: Now, in my mind, this was going to be a zero calcium score. Your arteries were going to be beautiful, and I would call you and say, I’m glad we did this. You have a 10 year warranty. Right. The ApoB’s up. That was your

Vic: expectation.

Dr. John Riddick: We’ll do a low dose of statin, and we’ll move on. But you have a, so looking, you know, Actually, at the precise narrowings in your, there are three main arteries, there’s, well, on the left side, you have the left main artery, which branches into the left anterior descending, which goes down the front of the heart.

Dr. John Riddick: Some people refer to that as the widow maker. We try not to use that term. Circumflex artery on the left, which wraps around the side. And then you have your right coronary artery on the right. And so, so when my dad had his heart attack, his right artery blocked off in the late 70s, and then he went in.

Dr. John Riddick: And his LAD, the Widowmaker, had a 90 percent blockage. So you have a 50 percent blockage in [01:12:00] your left anterior descending.

Vic: Right. Which, that was shocking to

Dr. John Riddick: me. Primarily calcified plaque.

Vic: Which is good. It’s good that it’s calcified. It’s not

Dr. John Riddick: a mixed plaque. It’s not a soft plaque. It’s not a thin cap to the extent that CT can define that.

Vic: So it’s, it’s relatively good, it’s 50 percent blocked, which sounded very negative to me, still sounds negative to me today. But it’s not normal. Yeah, it’s not, it’s not good. Some people say, well,

Dr. John Riddick: isn’t that expected? And I mean, just because we expect to see it and we see it a lot in middle Tennessee doesn’t mean it’s normal.

Dr. John Riddick: Or good should be and so ignored my calcium

Vic: score should be zero and it’s two hundred and three. Yes. And my the arteries that provide my heart with oxygenated blood run of them. Yes. Nicknamed the Widowmaker for bad reasons is 50 percent blocked. And true. I was very nervous about that. And your response was it’s not [01:13:00] there’s no way it’s good, but we don’t need to put a stint in to it’s.

Vic: Much more blocked.

Dr. John Riddick: So the indication for stents are primarily the best data is for people having heart attacks. There is At a minimum, having chest pain or angina, but with, with feature, with high risk features, uh, without any symptoms, um, then there’s no indication. Now,

Vic: the first step is At some percentage blockage, you have symptoms.

Vic: Yes. I mean, by definition. Yes. If it’s 100%, you definitely have symptoms. Somewhere between 78 and 100, most people begin to have symptoms. Is that fair?

Dr. John Riddick: Yes. Yeah. And so If you come in with a heart attack, obviously and we’re checking blood work, we’re checking a protein that’s released from the heart muscle when it’s damaged, called a troponin.

Dr. John Riddick: When the heart muscle is damaged because of lack of blood flow and it releases, the cells die, releases [01:14:00] this protein in the bloodstream. This is when, yeah, obviously things have taken a different turn and you’re gonna have a heart cath. We’re going to be ready to put a stent in if there are severe blockages everywhere.

Vic: Yeah.

Dr. John Riddick: You need to see Dr. Reddy and have bypass surgery.

Vic: Yeah. Based on your surgical risk. And so with my results from the CTA, I spent my 450. Yeah. In my mind, it, it changed the course of treatment because we learned a lot of data that we weren’t aware of before that, that reading.

Dr. John Riddick: Yes.

Vic: My statin increased.

Vic: So you went Increased.

Dr. John Riddick: I thought, as it turns out, you went from Based on that, you went on a baby aspirin. So there’s a lot of conflicting data about baby aspirin for primary prevention. So preventing a first event. I, as a rule, if your calcium score is over a hundred, I think there’s a benefit to a baby aspirin in someone who’s low bleeding risk.

Dr. John Riddick: Yeah. And then your statin, I thought, [01:15:00] turns out, went to 10 milligrams, which is still a moderate intensity.

Marcus: Mm hmm.

Dr. John Riddick: And 20 and 40 are considered the high intensity doses of rosuvastatin. So you went from, before you ever started, you were prescribed five, then we got that data, and then we started at 10. Yeah.

Dr. John Riddick: I don’t know. I’m at 40 right now. So, yeah, so,

Vic: so. So I think what happened is I came in six months later or something like that.

Dr. John Riddick: And so we. That was on, so you went on 10 and then that was from A-L-L-D-L of, we’ll keep it simple. LDL was 1 56, so we repeated it in September and on 10 milligrams of Rosuvastatin, your LDL went down from 1 56, I said to 100.

Dr. John Riddick: So that’s pretty good. But um, in your HDL again. As always, 78 was excellent, triglycerides 50, total cholesterol [01:16:00] 188. So, we didn’t like that, I didn’t think that, you know, I think our target It was

Vic: improved, but not, I think you wanted it 70 ish. 70 or less. Yeah.

Dr. John Riddick: Yes, we wanted it 70 or less. So we bumped you from 10 to 20.

Dr. John Riddick: So then, in February of this year, your LDL was 80. On 20 of your Superstat. LDL 80, HGL 68, Triglycerides 54, Total Cholesterol 159. Which was improved, but again, We’re kind of walking you there. Then we bumped you from 20 to 40.

Vic: Right, which is where I am now. And I have no negative side effects on the 40. As far as I can tell.

Vic: That’s

Dr. John Riddick: the max dose of a stat. That’s, I think, whatever we get with that. It’s what we’re gonna get from a statin. Now based on your next reading, their consideration would be something called Zetia, which is a non statin cholesterol medicine. It’s a pill. But I’m pretty confident looking at the [01:17:00] trajectory, your next reading will be LDL less than 70.

Dr. John Riddick: Which is why we were discussing doing it.

Vic: Right. And so the hope is, let me make sure I have this right. I think it is, if I get below 70 of the, um, LDL, which is the worst one, the worse one. Yeah, LDL cholesterol is the

Dr. John Riddick: bad one.

Vic: Uh, that below 70 suggests that you need some level of it to, just to live your life.

Vic: Your body needs some cholesterol, is that fair? You couldn’t get it to zero.

Dr. John Riddick: So, because, it used, there was some thought you could be too low and, uh, run the risk of, and the thought was cholesterol’s important for cell wall integrity. There was a theoretical risk for intracranial bleeding if your LDL got too low.

Dr. John Riddick: I think that’s more or less debunked, and that the guidelines would say there’s no level, there’s too low. There’s no, there’s no lower threshold. It’s not a J point thing where you get to a certain point and you’re actually [01:18:00] worse off. What does 70

Vic: indicate? Does that mean that I’m not building up new plaque in the

Dr. John Riddick: best education that we know?

Dr. John Riddick: So this is the key now. So you have this 50 percent blockage. And right now you’re scheduled to see me in a few months with a treadmill test. Because just to confirm that this I trust that you’re not having any symptoms.

Vic: Yeah, I will call you if I have symptoms. We’re gonna prove it on a

Dr. John Riddick: treadmill.

Vic: Yeah.

Dr. John Riddick: Um, and see, to make sure that that area is And we’ll get

Vic: another cholesterol score. And we’ll check your

Dr. John Riddick: cholesterol. And so, and we’ll decide, you know, there is no level that’s too low. So, you, you can There was Because of artifactual readings, it’s a calculated number, we now have injectables, Repatha and Praluent, which are every two weeks self injected.

Dr. John Riddick: [01:19:00] PCSK9 inhibitors, different mechanism. Typically, for someone like you, I don’t think we’re gonna get to that point. with where we are, because it’s between you and I, it’s a pain in the butt. Yeah. Give yourself an injection every two weeks for, for a number. Uh, but you can actually get down to negative cholesterol, negative LDL numbers because of the way it’s calculated.

Dr. John Riddick: But you can get direct LDL measurements of, in the, you know, single digits, like teens, like. Yeah. Unbelievably. The lower the better. Lower the better.

Vic: My. The body would not be, um, getting worse. The blockages and the The goal

Dr. John Riddick: is, yeah, we don’t want any more buildup of any more plaque.

Vic: Right.

Dr. John Riddick: Now this plaque is calcified.

Dr. John Riddick: So you can say, well, can I make it go away? Well Probably not. A calcified plaque is probably there to stay. There’s some evidence for mild regression with fatty plaque. But the bottom line is, for someone like you, it’s a stabilization thing. We want to prevent any [01:20:00] progression. We want to prevent any events.

Dr. John Riddick: Yeah. I want to die of something else. You don’t want to die. Not

Vic: the Widowmaker being 100 percent blocked. And

Dr. John Riddick: so to your point, usually, in theory, you’d like to think it will progress in a stepwise fashion if it were to progress. Hopefully it won’t. And you would have symptoms. But what we really want to prevent is an erosive acute event where you’re having a heart attack.

Dr. John Riddick: And that’s where the aspirin comes in. That’s what aspirin does. It’s an anti platelet agent. Prevents platelet derived thrombus from forming, and the statin also stabilizes everything. So that’s the goal, is to keep this from progressing at all. And if it stays 50 percent for the rest of your life, well then, no harm, no foul.

Dr. John Riddick: I mean, I can, I seem to

Vic: be functioning okay with 50 percent blockage now. But I, uh, it got my attention, definitely. And the statin does not have any side effects today for me. And so in a month or so, we’ll do the stress test and do another cholesterol. Check your cholesterol, check your LFTs. Hopefully we’ll be down [01:21:00] at 60 or 50 or something.

Dr. John Riddick: I imagine it’ll probably be in the 60s. Yeah. And at that point, I don’t think I’d recommend Zettia, which would be the next step, the pill. But then the, the harder part, so stress, again, stress testing to rule out greater than 70 percent blockage, the question becomes, well, when can I repeat the CTA and see exactly what it looks like?

Dr. John Riddick: At least that’s what usually people ask me. And that’s where you really have to decide what’s the additive value in that. That’s another radiation exposure, all the things we discussed. And so, I have been, I won’t say strong armed, but mildly strong armed into repeating a coronary CTA on a two to three year interval on someone.

Dr. John Riddick: And it’s not the end of the world. I don’t know. If it’s going to change your treatment plan, which for this person, this individual, it would have. They were ambivalent about [01:22:00] increasing anything they wanted to see. For you, I think we’re committed to a max treatment plan.

Vic: My current philosophy is I want to get the cholesterol down as low as possible.

Vic: I’m open to, so maybe we need to talk about

Dr. John Riddick: Zettia,

Vic: I’m open to Zettia injections, or Zettia is

Dr. John Riddick: just the pill, but then,

Vic: or yeah, so we can talk about it. I think, um, I like the trajectory, I don’t have it in front of me, but I went from like 150 to 100 to 80. And 70 is the marker that is, um, that’s better if I’m below that.

Vic: So, like, I’m trending pretty well, but once I, once I level out, if I’m leveling out at 68, I might want to talk about Zettia. If I’m leveling out at 38, then we should discuss it. It’s, it, that, I, I am a, you know, I want to be not close to the edge. Cause it’s my heart [01:23:00] and it, it’s scary and if I can, if I don’t have side effects from the medicine, I feel like I, I should do what I can do to prevent it.

Dr. John Riddick: Yes, I, um, wholeheartedly agree. I’m a huge proponent of statins. I’m an interventional cardiologist again and I have my biases and, but I live. Several days a week, taking care of people having heart attacks and, and often the risk factors, they don’t necessarily line up all the time. Which is indicator that we have more work and research to do, but, I’m, you, we, especially this day and age, there’s a lot more.

Dr. John Riddick: Not to get political, but, uh, metis skepticism, medical skepticism, you know, questioning of, you know, the healthcare industry and far big pharma. And so I, we deal a lot of the time with, uh, statin skeptics that, and as we discussed, some people think they’re intolerant often. [01:24:00] It’s not true intolerance, but yeah, my mother in

Vic: law, um, heard about this story and she Said to me statins are evil.

Vic: You shouldn’t be taking statins and my response was well I i’ve already taken them and I have a 50 percent blockage. So I’m going to do what my doctor said, but there is that out there, whether it is real or not real, it doesn’t matter, there’s some people that think that.

Dr. John Riddick: I mean, some, you know, most cardiologists would say sprinkle statins in the water, but, um, That might be a step too far.

Dr. John Riddick: There are, I mean, you know, there are theoretical risks of slightly increased risk, uh, risk of diabetes, there’s a question of long term risk of dementia on statins, My response is typically, I mean, if you’re having your blood sugar monitored, that doesn’t matter. I don’t think that’s ever going to be an issue for you.

Dr. John Riddick: The most common cause of dementia is vascular dementia, which is from [01:25:00] atherosclerotic vascular disease. I mean, I think it’s a risk benefit thing.

Marcus: Yeah.

Dr. John Riddick: So I don’t think statin should be in the water. And I think you should always have a healthy skepticism before you ever start a medicine, which is why the whole basic tenet, again, for primary prevention is to discuss the risks and benefits.

Dr. John Riddick: The harder time are, you know, someone’s come in near death with a heart attack, and then you’re seeing them back, and you still can’t convince them to take a stand. But, you know, sometimes you can’t convince people to quit smoking either. And so, that’s, you know, people are going to make decisions. I mean, for me, it’s a generic

Vic: medicine.

Vic: Not very expensive, and it’s very tolerable. I mean, I take it once a day, it doesn’t seem like it, I haven’t noticed anything. So, the last question I have is that, um, I have two sons who are in their teenage years, right? So, they’re young. Should they get a calcium test any time? Should they just monitor their cholesterol?

Vic: Should they do the, the [01:26:00] epilipoprotein B, which seemed like the trigger for Dr. Barfield? That was easy. I mean, that was just already in the blood work, but easy from my point of view. I don’t know if it’s easy for Centennial.

Dr. John Riddick: Um, now it’s easy. It’s easy. I, again, by guidelines, would not be recommended. I mean, I think having Blood pressure, cholesterol, blood sugar, not smoking, healthy lifestyle for someone who’s, your sons are what, 17 and 19?

Vic: But I do think that when they turn 30 or something, they maybe should check

Dr. John Riddick: it. Correct. There’s not a lot of

Vic: downside to get a calcium test when you’re 30 or, or something. I think the question is,

Dr. John Riddick: what, you know, it’s a risk benefit again with radiation with a calcium score. It’s low risk. It’s a matter of what are you going to do differently?

Dr. John Riddick: with the information. For instance, have we checked your calcium score in 2018? Well, no, all this started. Yeah. If it had been LDL was 124, your risk score was 1. [01:27:00] 4%. So I don’t, I don’t think it would have been, I’ll be honest.

Vic: Well, it should have been zero. It should have been zero. So if it was not zero, That would have been

Dr. John Riddick: another risk factor.

Dr. John Riddick: I bet it probably would have been less than 50 though. Probably would have been 20 or 30.

Vic: Yeah. No, I think it would have been positive, not zero.

Dr. John Riddick: I agree.

Vic: And I would have started a statin then.

Dr. John Riddick: I agree. But that would have been at age, you would have been, you were 47.

Vic: Right.

Dr. John Riddick: So that’s a different question than, Twenty.

Vic: Yeah. Right. Yeah. I don’t think below 30, it really makes sense, but somewhere 30 to 47, I think it maybe does. If you have, now they have, they have reason about family history because I’m, I’m their dad. And then my dad had, has AFib. Which I didn’t know at the time, it’s happened in these last five years, he’s gotten it.[01:28:00]

Vic: So,

Dr. John Riddick: AFib

Vic: Not related?

Dr. John Riddick: No, not generally. I mean, you can, their way, it’s your heart, so to say it’s completely unrelated, but for your dad, he’s never had a heart attack, right? No. Never had structural damage because of coronary artery disease. That means AFib is often a reflection of high blood pressure, sleep apnea, other risk factors for AFib that cause things that make your left atrium enlarge.

Dr. John Riddick: So that’s, it’s a little different. I mean, they’re related spectrum than coronary artery disease, but AFib and coronary artery disease are not directly linked unless you’ve had a heart attack from coronary artery disease, which then causes your left atrium to dilate. But um, AFib in your dad. If there’s no good explanation, it’s probably a risk factor for AFib in you.

Dr. John Riddick: So, that’s something to monitor. My blood pressure has

Vic: been good for a long time. Oh, your blood pressures are perfect.

Dr. John Riddick: You [01:29:00] actually have a negative sleep study in there, too. We didn’t talk about that. My

Vic: wife, uh

Dr. John Riddick: Which is important to always think about. Well, she

Vic: was positive. That I had sleep apnea because I snore, but I went and got a sleep study.

Vic: Which is a great thing to do. Which was, which was not fun to do, but great to have the result. Because I didn’t have sleep apnea.

Dr. John Riddick: You probably have more septal, nasal septal issues. Yes, right. So snoring, but there’s definitely, for people we see with high blood pressure, certainly AFib, sleep apnea screening is, Always on the list of considerations for sure.

Dr. John Riddick: It’s a great question. At what point do we start checking these risk enhancing risk factors, the APOB, the lipoprotein little a. The lipoprotein little a is usually like, it’s a one time test. It’s either you have it or you don’t type of thing. And that is not unreasonable [01:30:00] given that yours is normal. I doubt that’s probably not going to be a risk enhancer for your kids either.

Vic: The way I think about it is that They, I need to communicate with them. To me, like people that are listening, you should talk to your kids, talk to your parents so that you understand your own family situation. And then if they have a LDL score or an Aproprotein B or A, or A, that is, I On the edge of it’s starting to get slightly high or it’s trending in a way that is not good, then you could then use that and talk to your doctor and discuss like, does it make sense to run another test?

Vic: Calcium score is not without risk, but it’s not dramatic risk.

Dr. John Riddick: I’d agree again. I have a low threshold for calcium scoring. Um, And most of the incidental findings that you run in there with lung nodules are, they’re pretty minor, [01:31:00] and depending on who you’re using it to screen, you know, I found several people with aortic aneurysms and other not so great things.

Vic: Yeah, which is good to catch. That

Dr. John Riddick: is very good to catch. And the coronary CTAs, again, uh, because of all the stuff we’ve talked about, I’m not sure if it’ll ever be, kind of, everyone’s just gonna get one, like, you know, futuristic, everyone’s just gonna get zipped through the CAT scanner to see, kind of like everyone gets a colonoscopy, uh.

Marcus: Yeah.

Dr. John Riddick: I don’t know, I don’t know if we’ll ever get there. I think the technology, it’s certainly improved and it makes it, for me, pretty easily, easy to be convinced. Like after our discussion, I’m, particularly for 50 year old men.

Vic: Yeah. For me, it was, um, worth the risk of additional radiation and the contrast and finding something that would send us on a whole nother journey.

Vic: Track, um, and the cost [01:32:00] and it ended up, which it wouldn’t necessarily with everyone, but it ended up unearthing a lot more information that let you as my cardiologist. Better advise me on to increase my statin and now monitor more carefully.

Dr. John Riddick: Right. So I think, I think in the right, in my case, it worked out for in the right patient.

Dr. John Riddick: It is, it’s great. And for people with chest pain, it’s, it’s fantastic these days. Yeah. So, and yeah, the technology, it will, we haven’t even talked about ai, but the AI components that go into CT reading, um, there, we didn’t talk about. FFR, which is a way to analyze whether or not that 50 percent blockage is obstructing flow.

Dr. John Riddick: I think it’s not, there’s a way to measure whether hemodynamically, is it actually the sort of add on sort of analyses they do on CAT scans now. It’s pretty impressive.

Vic: Did

Dr. John Riddick: I

Vic: have that on mine?

Dr. John Riddick: You did not. I did not. [01:33:00] Well, that was done in Premiere, so. Ha ha ha. Yeah. Yeah. No, it’s newer. It’s. Yeah. Pretty new kind of technology, and we’re doing a lot of correlation between CT, FFR, and then going to the cath lab.

Dr. John Riddick: And. Directly measuring the flows in the arteries with invasive techniques and

Vic: yeah, so

Dr. John Riddick: yeah Hopefully

Vic: I’m gonna manage my diet and take a statin keep my LDL low below 70 Hopefully half of that and not be in these very complex Interventional things but it’s good to know they’re there if I need them.

Dr. John Riddick: Yeah Wow Again, technology keeps moving forward. Yeah, keep learning new techniques. So,

Vic: okay. Dr. Riddick, thank you for doing this. Very helpful. My pleasure. A lot of data in this episode, but I think it is helpful. People can listen to it and then make some notes. They can talk to their primary care doc. Ask, I mean, I think the [01:34:00] real key is empowering the patients to have a meaningful discussion with their doctor about what, what does this mean?

Vic: How does it affect me? Cause each patient’s different. Arming the patients, I think is, ends up in a better place.

Dr. John Riddick: For sure. And you got to ask sometimes.

Vic: Okay. Thanks for your time. Appreciate you taking a Saturday to do this. My

Dr. John Riddick: pleasure. Thanks Greg.