I was trained at a time when the therapy for infarction was morphine, oxygen nitroglycerin, aspirin, and prayer. As one of two fellows in a 1000 bed military USAF hospital, I put in countless SG catheters to optimize the wedge pressure! Seemed like a good idea at the time.
We've come a long way certainly.
Fast-forward 40 some years and I rode in the ambulance with my neighbor to our heart hospital. He called me at 10 o'clock having chest pain. We arrived at the heart hospital 10:49 PM and he was stented at 11 pm. (I called ahead) . He had a normal ejection fraction fracture post MI.
That sounds like a lot of progress except when I went to target yesterday to look for some battery operated Christmas lights and I realized just looking around I'm not sure you need CRP testing to see who is at risk.
I guess on a personal level if you're interested in your health and your neighbor happens to be a cardiologist you can find and stabilize, vulnerable plaque and prevent infarction.
On the flipside what has changed is that if I blindfolded you and dropped you into a strip mall ; unless you could look at a local trees you would have no idea where you were in the United States. You would see McDonald's, a cheesecake, factory, dine in movie theater with buttered popcorn and 80 ounce sugar filled sodas being served to sedentary people.
I worked with a group of cardiologists and we opened up a partial meal replacement Diet program The patients bought plant protein meals to replace two meals a day. They actually saved money since they weren't eating out. We took off close to 18,000 pounds but dieting is not easy. These were very vocal and aggressive cardiologists but the best we could do is get 7% of the patients even to consider the diet!
When we talked to the insurance companies about supporting the program, even with a nominal $25 a week contribution- they said they were not in the long-term health business.
They said they were in the money management business. The average patient changed insurance companies every 18 months so why should prevention be on their dime. This was a true conversation.
Medicare is not a great payer for prevention as well.
The GLP's if they can be provided, may turn out to be the penicillin of our generation.
Removing processed sugar from the food chain, and certainly from the consumer, I think will save more lives than any other intervention.
But what do I know I put those stupid swans in and still gave Lasix and fluids!
A great deal of this sailed over my head, but nonetheless, there is always knowledge to be gained from your essays. In this one:
First, you state: “Unlike stable plaque, the vulnerable plaque does not contain dense calcification. (This one of the reasons I have never ordered a CT calcium score for any patient since they are often highly misleading).” Do you mean by this that vulnerable plaque does not show up on a CT calcium score?
Second, and even more important, was your observation “We have far better ways to identify vulnerable patients and we’re not doing it” and you noted the PRS score. It came to my attention recently that, for older patients, using the LDL as a proxy for propensity to heart disease is problematic, at least for those who have no prior history of CVS. It sounds like the PRS score could be important for overcoming that deficiency in assessment.
Last, and related, I would welcome your view on the relative merits of the MESA, PREVENT, and PCE calculators as predictive of propensity to CVS.
I have reached the tender age of 77 with no obvious CAD. I have hyperlipidemia and a very high lipoprotein (a). I take Lipitor, timed-release niacin, and high-dose omega-3. So far, so good!
As a 40 year interventional cardiologist I have taken a statin since their inception around the late 1970s Just got a calcium scan for the hell of it with some mild LAD disease around 100 At 78 probably ok but would like to see what CT’s with ffr would reveal Also wonder about colchicine benefit
Read this and still don’t quite get it. Are you saying that the narrowing we have focused so much in may not be the key to an MI.. trying to wrap my mind around the pathophysiology
Fascinated by this. Me, 78 y/o F with hyperlipidemia, lifetime high TC 355 LDL 249 in 2016. Statin intolerant. Coronary calcium zero in 2010 followed by cath which was totally clear. CCTA in 2020 zero calcium. CP only with exercise 2022. Two cardiologists said couldn’t be blockage because calcium 2 years ago was zero (!!!) so take ntg when you go for a walk. Finally went to 3rd doc in 2023 who ordered a cath that showed 83% occluded LAD, successfully stented and now on repatha. Presumed dx CMD. All inflammatory markers normal, cholesterol pattern A. Reading your Substack to try to understand/ assess future risk. And maybe find which med centers might be helpful.
I live in Bend OR where orthopedic care is phenomenal, CVD not so much. I am 78 years old, female and have always been very active. Since first being tested for cholesterol at around age 32, I have had high LdL and HDL total 245. Calcium score in 2012: 60. 2019 my internist ordered a calcium test, it was 400. He put me on 40mg of Lipitor and within 10 days I felt like a truck had hit me and my urine was dark brown. I immediately looked for alternatives and followed Dr. Michael Gregor’s 12 A Day whole food plant based diet. My cholesterol has remained in normal range, but my internist wanted 2 more calcium tests over the next 3 years. Second one was 538. I found Cleerly in my research and, since no doctor in Oregon used this, I registered with Dr. Wexler and Heartbeat. He ordered the test with contrast (about 3 years after the first scan) score was 638, but the Cleerly report didn’t find “sticky plaque” and deemed my results were mild to moderate. My doctors didn’t give any credence to my Cleerly results.
Are there any cardiologists in Oregon who use these newer tests and medications?
I missed this sent copy to a friend from Bhutan where I spent four trips to help with orthopedic iverseas. She wanted to get her medical degree here, cost overwhelming and difficult to get accepted. A queen had offered a full ride to Germany. Meant another language. Now she has practiced in Germany as general internal medicine and is in cardiology fellowship of course German researchers are up to date, nut for me conversing is fun. And inflammation may help my issue 16 years ago. Hard to keep up when retired, but when busy every day the rate of change iverwhelming
Have a look at what Artrya is doing in this space also EchoIQ using ultrasound to detect heart failure and aortic stenosis both incredibly accurately, it’s quite incredible how quickly this is happening 💖
You say Caristo has not received FDA clearance but this press release says rhey did in March. https://www.caristo.com/caristo-secures-fda-clearance-ushering-in-a-new-era-of-ai-powered-heart-attack-prevention/. “STAMFORD, Conn, March 11, 2025 — Caristo Diagnostics, on a mission to transform the diagnosis and treatment of cardiovascular disease, today announced it has received U.S. Food and Drug Administration (FDA) 510(k) clearance of its CaRi-PlaqueTM technology, an AI-assisted image analysis application to aid the diagnosis of coronary artery disease (CAD).”
Excellent as always.
I was trained at a time when the therapy for infarction was morphine, oxygen nitroglycerin, aspirin, and prayer. As one of two fellows in a 1000 bed military USAF hospital, I put in countless SG catheters to optimize the wedge pressure! Seemed like a good idea at the time.
We've come a long way certainly.
Fast-forward 40 some years and I rode in the ambulance with my neighbor to our heart hospital. He called me at 10 o'clock having chest pain. We arrived at the heart hospital 10:49 PM and he was stented at 11 pm. (I called ahead) . He had a normal ejection fraction fracture post MI.
That sounds like a lot of progress except when I went to target yesterday to look for some battery operated Christmas lights and I realized just looking around I'm not sure you need CRP testing to see who is at risk.
I guess on a personal level if you're interested in your health and your neighbor happens to be a cardiologist you can find and stabilize, vulnerable plaque and prevent infarction.
On the flipside what has changed is that if I blindfolded you and dropped you into a strip mall ; unless you could look at a local trees you would have no idea where you were in the United States. You would see McDonald's, a cheesecake, factory, dine in movie theater with buttered popcorn and 80 ounce sugar filled sodas being served to sedentary people.
I worked with a group of cardiologists and we opened up a partial meal replacement Diet program The patients bought plant protein meals to replace two meals a day. They actually saved money since they weren't eating out. We took off close to 18,000 pounds but dieting is not easy. These were very vocal and aggressive cardiologists but the best we could do is get 7% of the patients even to consider the diet!
When we talked to the insurance companies about supporting the program, even with a nominal $25 a week contribution- they said they were not in the long-term health business.
They said they were in the money management business. The average patient changed insurance companies every 18 months so why should prevention be on their dime. This was a true conversation.
Medicare is not a great payer for prevention as well.
The GLP's if they can be provided, may turn out to be the penicillin of our generation.
Removing processed sugar from the food chain, and certainly from the consumer, I think will save more lives than any other intervention.
But what do I know I put those stupid swans in and still gave Lasix and fluids!
Thank you again. I really enjoy the writing.
Thanks for your perspective, Matt. Very helpful
A great deal of this sailed over my head, but nonetheless, there is always knowledge to be gained from your essays. In this one:
First, you state: “Unlike stable plaque, the vulnerable plaque does not contain dense calcification. (This one of the reasons I have never ordered a CT calcium score for any patient since they are often highly misleading).” Do you mean by this that vulnerable plaque does not show up on a CT calcium score?
Second, and even more important, was your observation “We have far better ways to identify vulnerable patients and we’re not doing it” and you noted the PRS score. It came to my attention recently that, for older patients, using the LDL as a proxy for propensity to heart disease is problematic, at least for those who have no prior history of CVS. It sounds like the PRS score could be important for overcoming that deficiency in assessment.
Last, and related, I would welcome your view on the relative merits of the MESA, PREVENT, and PCE calculators as predictive of propensity to CVS.
Thank you, as always, for bringing us the news.
First question: yes
Second question: Yes, definitely
Last: I don't think these calculators are good enough since they don't take into account the new layers of data we can easily and inexpensively obtain
You’ve just given a gold mine of helpful information that is easily understandable to anyone. Many thanks.
I have reached the tender age of 77 with no obvious CAD. I have hyperlipidemia and a very high lipoprotein (a). I take Lipitor, timed-release niacin, and high-dose omega-3. So far, so good!
As a 40 year interventional cardiologist I have taken a statin since their inception around the late 1970s Just got a calcium scan for the hell of it with some mild LAD disease around 100 At 78 probably ok but would like to see what CT’s with ffr would reveal Also wonder about colchicine benefit
Read this and still don’t quite get it. Are you saying that the narrowing we have focused so much in may not be the key to an MI.. trying to wrap my mind around the pathophysiology
Both, not either or
Fascinated by this. Me, 78 y/o F with hyperlipidemia, lifetime high TC 355 LDL 249 in 2016. Statin intolerant. Coronary calcium zero in 2010 followed by cath which was totally clear. CCTA in 2020 zero calcium. CP only with exercise 2022. Two cardiologists said couldn’t be blockage because calcium 2 years ago was zero (!!!) so take ntg when you go for a walk. Finally went to 3rd doc in 2023 who ordered a cath that showed 83% occluded LAD, successfully stented and now on repatha. Presumed dx CMD. All inflammatory markers normal, cholesterol pattern A. Reading your Substack to try to understand/ assess future risk. And maybe find which med centers might be helpful.
CCTA would have picked up a/the LAD lesion. You had just a CT calcium score without angiography. Glad it got resolved!
Fwiw, this is the test I had done 2 years prior to the LAD blockage.
I don’t think it was “just” a calcium test. These are the terms that I cut and paste directly from MyChart:
CT CORONARY ANGIOGRAPHY:
CTA CORONARY ARTERIES 3D WITHOUT AND WITH CONTRAST
I post this to question the diagnostic limits of this test.
I live in Bend OR where orthopedic care is phenomenal, CVD not so much. I am 78 years old, female and have always been very active. Since first being tested for cholesterol at around age 32, I have had high LdL and HDL total 245. Calcium score in 2012: 60. 2019 my internist ordered a calcium test, it was 400. He put me on 40mg of Lipitor and within 10 days I felt like a truck had hit me and my urine was dark brown. I immediately looked for alternatives and followed Dr. Michael Gregor’s 12 A Day whole food plant based diet. My cholesterol has remained in normal range, but my internist wanted 2 more calcium tests over the next 3 years. Second one was 538. I found Cleerly in my research and, since no doctor in Oregon used this, I registered with Dr. Wexler and Heartbeat. He ordered the test with contrast (about 3 years after the first scan) score was 638, but the Cleerly report didn’t find “sticky plaque” and deemed my results were mild to moderate. My doctors didn’t give any credence to my Cleerly results.
Are there any cardiologists in Oregon who use these newer tests and medications?
I missed this sent copy to a friend from Bhutan where I spent four trips to help with orthopedic iverseas. She wanted to get her medical degree here, cost overwhelming and difficult to get accepted. A queen had offered a full ride to Germany. Meant another language. Now she has practiced in Germany as general internal medicine and is in cardiology fellowship of course German researchers are up to date, nut for me conversing is fun. And inflammation may help my issue 16 years ago. Hard to keep up when retired, but when busy every day the rate of change iverwhelming
Have a look at what Artrya is doing in this space also EchoIQ using ultrasound to detect heart failure and aortic stenosis both incredibly accurately, it’s quite incredible how quickly this is happening 💖
Ok will rethink this.
Excellent as allways
A review about hormones replacement therapy for
Women and men
See below
You say Caristo has not received FDA clearance but this press release says rhey did in March. https://www.caristo.com/caristo-secures-fda-clearance-ushering-in-a-new-era-of-ai-powered-heart-attack-prevention/. “STAMFORD, Conn, March 11, 2025 — Caristo Diagnostics, on a mission to transform the diagnosis and treatment of cardiovascular disease, today announced it has received U.S. Food and Drug Administration (FDA) 510(k) clearance of its CaRi-PlaqueTM technology, an AI-assisted image analysis application to aid the diagnosis of coronary artery disease (CAD).”
Yes, that's only a partial approval for their technology, more is spending