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How to Keep Your Ticker Ticking
Heart disease is the culmination of risk factors that have accumulated over time. Dr. John Osborne, Head of Cardiology, discusses heart health, cholesterol and cardiovascular fitness.
Featuring:
John Osborne, MD
Dr. Osborne obtained his Bachelor of Science with Honors from Penn State University, his M.D., magna cum laude, from Jefferson Medical College and his Ph.D. in cardiovascular physiology from Thomas Jefferson University. After graduation, he continued his post-doctoral work at Harvard Medical School and Brigham and Women's Hospital in Boston, Massachusetts, where he completed his internship, residency, and research residency in Internal Medicine and a Fellowship in Cardiovascular Disease. While at Harvard, Dr. Osborne published many articles on atheriosclerosis, vascular biology, and molecular genetics. His clinical training focused on non-invasive techniques, and he is the only physician board certified in Cardiology and Internal Medicine, Lipidology, Clinical Hypertension, Cardiac CT Angiography, Echocardiography and Nuclear Cardiology. His clinical interests include preventive cardiology, metabolic syndrome, hypertension, congestive heart failure, cholesterol disorders, and cardiovascular genetics. He was recently named as one of only ten Fellow's of the National Lipid Association in 2019 and is currently pursuing his MSc in Cardiovascular Management, Outcomes, and Economics at the London School of Economics and Policy. Transcription:
Scott Webb (Host): You know, the older I get, the more I worry about the health of my heart. Like many of you, I have risk factors. Joining me today to help us understand risk factors and what we can do to keep our hearts healthy is Dr. John Osborne, Head of Cardiology for the Low T Center. This is Age is Just a Number by the Low T Center. I’m Scott Webb. Dr. Osborne, great to talk to you again. We’re talking tickers today which is your specialty. So, heart disease seems to come out of the blue for many and many who die of a heart attack never had any symptoms. Why is that?
John Osborne, MD (Guest): So, heart disease is really the culmination of a disease that’s been there 20 years, 30 years, 40 years. So, it’s been there a long, long time. In fact, this plaque that really is the start of the whole process starts in many people even in their teenage years. But it is a very slow palatial process, I like to call it. It moves very slowly. And we don’t usually have trouble, problems, symptoms, flunk a stress test, have any awareness that this disease is there until we have generally at least a 70% blockage.
So, when we have symptoms of heart disease, we don’t have a little bit of heart disease. We have lots of heart disease. And that’s why we still encounter many people feeling okay, and then they find out they need multivessel bypass surgery to fix multiple blockages. And that occurs every day. Just because the fact that our symptoms are really at the very, very end of a very, very long process.
Host: Okay so, I think I’ve heard this. I don’t think I’m imagining this. That sometimes stress tests can lead to some misleading results that it’s not maybe the go to for heart specialists like yourself as perhaps maybe it was in the past. So, what are some other ways that we’re detecting heart related issues that people might have something called a cardiac colonoscopy, I think I’ve heard that. How are we determining where we are with patients?
Dr. Osborne: One of the things that I see a lot of in the patients that I see is that there’s still a very large in general, dependence upon things like stress tests. When you think of a stress test, it’s generally where we have people run on a treadmill, we have it wired for sound I like to say, we have some EKG leads on them, we might do some other as we call it imaging, maybe with nuclear isotopes to better image the heart or with and echocardiogram which is a cardiac ultrasound to also image the heart during this time. The problem with these techniques is that A: None of these techniques will pick up any blockages that are less than 70%. So, if someone say you have a normal stress test; what they’re saying is that you probably don’t need a stent, a balloon or bypass surgery.
It doesn’t say and I can’t say that your blood vessels are normal. I think that’s one problem when we don’t communicate well to patients. Number two is that most heart attacks don’t occur with a 70% blockage. You might have symptoms but that generally wont cause a heart attack that sort of comes out of the blue, sudden, catastrophic event that in about half of men and two third women, the first symptom of heart disease is you die. And that’s not acceptable anymore. So, because of that, we have been, and this really started back in the 1980s, we really decided that we need to have tools that are far better, for more sensitive that pick up heart disease long before you have a severe blockage.
And the other thing about stress tests by the way, as I’ll mention is that about 25% of the time, the stress test will look fine, you’ll pass it, and there is a sever blockage. So 25% of the time, you have got a severe blockage and the stress test will look okay. That’s a real problem. And then the flip side of that is, and that’s a called a false negative. The flip side is a false positive, that is the stress test looks funny and in fact, you don’t have a blockage and then what happens then is that you then are lead to other procedures and invasive procedures things like heart catheterizations and angiograms, all of those things that are about $20,000 the involve invasive testing, putting catheters or tubes into your heart, there’s risk of strokes, heart attacks, bleeding, lots of other complications. Only to find our you’re actually fine.
So, because of that, the standard approach of doing stress tests and heart catheterizations is really no longer satisfying or acceptable. A much better tool that we sort of call the cardiac colonoscopy but is in fact called a coronary artery calcium score, is a far, far better tool to pick up heart disease long before, years before we ever get in trouble from it.
Host: I want to talk about cholesterol versus inflammation. I think that everybody knows that high cholesterol numbers can be bad and that’s what clogs our arteries. I’m obviously oversimplifying it. But is it true that really, it’s inflammation more than just your cholesterol numbers that ultimately impact the development of plaque?
Dr. Osborne: One thing about cholesterol that I always like to tell people and I partly do this to make them smile and maybe make them laugh a little bit when I say this. is I love telling people that cholesterol is not a risk factor for heart disease. Now there are some people, well outside of the mainstream arguing from really nonscientific approaches that say cholesterol has nothing to do with heart disease. Well that’s completely 100% absolutely wrong. And the reason I like to state or say or kid people that cholesterol is not a risk factor for heart disease is that cholesterol, I like to tell people is heart disease. So, in other words, there is no plaque that you will ever find in anybody’s heart or any other blood vessel in your body that doesn’t have cholesterol in it.
Okay. It is 100% there at the scene of the crime. Now the problem is that cholesterol levels in an individual are really not terribly helpful. In general, there is a correlation that shows high cholesterol is bad and lower cholesterol is good, but I can show you people all across the spectrum. Some people have high cholesterol, particularly LDL cholesterol who have completely normal blood vessels and no plaque. I can show you people with well below average levels of cholesterol on no blood cholesterol medications who have tons of plaque. In fact, we call them plaqueaderms or vasculopaths. These people have plaque in all kinds of blood vessels beyond the heart, in the carotid arteries in the neck, in the legs et cetera.
So, cholesterol levels in an individual are a pretty poor indicator of whether that cholesterol is actually sticking. So, because of that, that gets us back to that discussion about other tools to actually see is the cholesterol sticking and that becomes that discussion about the coronary artery calcium score or as we called it before the cardiac colonoscopy. Cheap, effective, simple, highly sensitive to pick up early heart disease, very simple to do, has been standardized literally how we both take the pictures and score the pictures since the early 1990s.
So, on the cholesterol side of things, cholesterol is mandatory. It is central. It is necessary. It, however, may not be sufficient. So, here’s where we get into the inflammation argument. So, people can have average cholesterol, below average cholesterol but in people who have inflamed blood vessels, which of the things that we can fix, we generally talk about tobacco, we talk about diabetes, we talk about high blood pressure. And there are other factors too. Stress, overweight, obesity, also family history plays a role. So, lots of different things can contribute to inflammation or as I like to explain it, think of this as sticky vessels and so ultimately whether we form plaque or not really depends upon two interacting things; one is cholesterol which is mandatory, necessary, has to be there but may be high, may be average, may be low but the other part is inflammation.
So, obviously, if someone has things that give them inflammation, that we can fix such as using tobacco of any form, if you have diabetes or prediabetes and attending to that, if you have weight issues, we need to attend to that. If you have blood pressure problems, we need to attend to that. So, it’s really a holistic approach to all of these different factors that I mentioned that can dramatically reduce the risk of cardiovascular events, heart attacks and strokes and other vascular problems.
Host: That’s a great answer doctor, I just love the way you put things. You have such a interesting way of putting spin on things and I imagine you do bring smiles to people’s faces. So, in light of all the things we’ve talked about, risk factors, cholesterol, calcium score, what makes the Low T Center’s approach different or dare I say, better than others?
Dr. Osborne: What we do at the Low T Center is we understand. So our average guy is a 48 year old guy who obviously sees us because he doesn’t feel good. Right? There’s a reason why people come to Low T Center and obviously if you have low T or other symptoms that cause fatigue and not feeling good, loss of strength, erectile dysfunction, all of those things that plague many, many middle aged guys, what we appreciate as well is that we will attend to those things and there’s a lot of things that can cause that, low T, thyroid issues, sleep apnea. So, we have a very sophisticated highly effective system to kind of identify those issues and work with you and correct those but the other big picture here from 30,000 foot view is that our average 48 year old guy over the next ten to twenty years, his main medical issue that will likely happen, unless we change the trajectory now is a cardiovascular event, a stroke, a heart attack. Balloons, stents, bypass surgery, that I would argue and in fact the science is very good that at least 80% of those events and I think that’s a conservative number are entirely preventable.
So, our approach is to be very proactive, to use the latest evidence based scientific guideline based approaches that are already out there but are very, very poorly implemented. So our goal is to be very proactive, use these evidence based technologies and tools like coronary calcium scoring, checking and following blood pressure that again is an asymptomatic condition in many people. And we see lots of guys that have uncontrolled high blood pressure all the time. Feel fine. But as an example for blood pressure, starting from a blood pressure of 115/75 every time we go up 20 points higher on the top, so from 115 to 135 or from 75 to 85;either one of those numbers; just 20 points higher on the top or ten points higher on the bottom; by itself, independent of age, sex, cholesterol, diabetes; doubles your risk of a fatal stroke or a heart attack. If you go up another 20 or 10; you double that again, if you go up another 20 or 10, you double that again. So, someone with a blood pressure of 175/105 is at 800% greater chance solely from the blood pressure along than someone with a blood pressure of 115/75. So, we’re going to make sure that blood pressure is checked and monitored and taken care of and controlled if appropriate.
We also do the same thing with blood sugar and diabetes. And it’s not just diabetes, it’s also prediabetes which is farm team for diabetes as I like to say. And then also cholesterol. Which is completely asymptomatic until you have a problem. So, we’re going to check that. Many of our patients it’s not on the radar, it hasn’t been checked. I feel fine. Why would you want to check it. So, we’re going to check all that in addition to other factors and really guide people and change the trajectory and even changing it a little bit now multiplied over years to decades, dramatically changes the likelihood of cardiovascular events and also too by the way. It’s not just cardiovascular events, we know that atherosclerosis, plaque buildup, diabetes, prediabetes is also highly correlated and associated with dementia, memory loss, so, it’s not just cardiovascular disease, but the better we understand and take care of these factors; many of them are asymptomatic now but turn out to be major disasters down the road; the better that we can help our guys.
Host: Thanks Dr. Osborne. Great to talk to you again. Call 866-806-8235 or go to www.lowtcenter.com for more information or to book an appointment. And thanks for listening to Age is Just a Number by the Low T Center. If you found this podcast helpful, please share it on your social channels and be sure to check out our entire podcast library for topics of interest to you. I’m Scott Webb and we’ll talk again soon.
Scott Webb (Host): You know, the older I get, the more I worry about the health of my heart. Like many of you, I have risk factors. Joining me today to help us understand risk factors and what we can do to keep our hearts healthy is Dr. John Osborne, Head of Cardiology for the Low T Center. This is Age is Just a Number by the Low T Center. I’m Scott Webb. Dr. Osborne, great to talk to you again. We’re talking tickers today which is your specialty. So, heart disease seems to come out of the blue for many and many who die of a heart attack never had any symptoms. Why is that?
John Osborne, MD (Guest): So, heart disease is really the culmination of a disease that’s been there 20 years, 30 years, 40 years. So, it’s been there a long, long time. In fact, this plaque that really is the start of the whole process starts in many people even in their teenage years. But it is a very slow palatial process, I like to call it. It moves very slowly. And we don’t usually have trouble, problems, symptoms, flunk a stress test, have any awareness that this disease is there until we have generally at least a 70% blockage.
So, when we have symptoms of heart disease, we don’t have a little bit of heart disease. We have lots of heart disease. And that’s why we still encounter many people feeling okay, and then they find out they need multivessel bypass surgery to fix multiple blockages. And that occurs every day. Just because the fact that our symptoms are really at the very, very end of a very, very long process.
Host: Okay so, I think I’ve heard this. I don’t think I’m imagining this. That sometimes stress tests can lead to some misleading results that it’s not maybe the go to for heart specialists like yourself as perhaps maybe it was in the past. So, what are some other ways that we’re detecting heart related issues that people might have something called a cardiac colonoscopy, I think I’ve heard that. How are we determining where we are with patients?
Dr. Osborne: One of the things that I see a lot of in the patients that I see is that there’s still a very large in general, dependence upon things like stress tests. When you think of a stress test, it’s generally where we have people run on a treadmill, we have it wired for sound I like to say, we have some EKG leads on them, we might do some other as we call it imaging, maybe with nuclear isotopes to better image the heart or with and echocardiogram which is a cardiac ultrasound to also image the heart during this time. The problem with these techniques is that A: None of these techniques will pick up any blockages that are less than 70%. So, if someone say you have a normal stress test; what they’re saying is that you probably don’t need a stent, a balloon or bypass surgery.
It doesn’t say and I can’t say that your blood vessels are normal. I think that’s one problem when we don’t communicate well to patients. Number two is that most heart attacks don’t occur with a 70% blockage. You might have symptoms but that generally wont cause a heart attack that sort of comes out of the blue, sudden, catastrophic event that in about half of men and two third women, the first symptom of heart disease is you die. And that’s not acceptable anymore. So, because of that, we have been, and this really started back in the 1980s, we really decided that we need to have tools that are far better, for more sensitive that pick up heart disease long before you have a severe blockage.
And the other thing about stress tests by the way, as I’ll mention is that about 25% of the time, the stress test will look fine, you’ll pass it, and there is a sever blockage. So 25% of the time, you have got a severe blockage and the stress test will look okay. That’s a real problem. And then the flip side of that is, and that’s a called a false negative. The flip side is a false positive, that is the stress test looks funny and in fact, you don’t have a blockage and then what happens then is that you then are lead to other procedures and invasive procedures things like heart catheterizations and angiograms, all of those things that are about $20,000 the involve invasive testing, putting catheters or tubes into your heart, there’s risk of strokes, heart attacks, bleeding, lots of other complications. Only to find our you’re actually fine.
So, because of that, the standard approach of doing stress tests and heart catheterizations is really no longer satisfying or acceptable. A much better tool that we sort of call the cardiac colonoscopy but is in fact called a coronary artery calcium score, is a far, far better tool to pick up heart disease long before, years before we ever get in trouble from it.
Host: I want to talk about cholesterol versus inflammation. I think that everybody knows that high cholesterol numbers can be bad and that’s what clogs our arteries. I’m obviously oversimplifying it. But is it true that really, it’s inflammation more than just your cholesterol numbers that ultimately impact the development of plaque?
Dr. Osborne: One thing about cholesterol that I always like to tell people and I partly do this to make them smile and maybe make them laugh a little bit when I say this. is I love telling people that cholesterol is not a risk factor for heart disease. Now there are some people, well outside of the mainstream arguing from really nonscientific approaches that say cholesterol has nothing to do with heart disease. Well that’s completely 100% absolutely wrong. And the reason I like to state or say or kid people that cholesterol is not a risk factor for heart disease is that cholesterol, I like to tell people is heart disease. So, in other words, there is no plaque that you will ever find in anybody’s heart or any other blood vessel in your body that doesn’t have cholesterol in it.
Okay. It is 100% there at the scene of the crime. Now the problem is that cholesterol levels in an individual are really not terribly helpful. In general, there is a correlation that shows high cholesterol is bad and lower cholesterol is good, but I can show you people all across the spectrum. Some people have high cholesterol, particularly LDL cholesterol who have completely normal blood vessels and no plaque. I can show you people with well below average levels of cholesterol on no blood cholesterol medications who have tons of plaque. In fact, we call them plaqueaderms or vasculopaths. These people have plaque in all kinds of blood vessels beyond the heart, in the carotid arteries in the neck, in the legs et cetera.
So, cholesterol levels in an individual are a pretty poor indicator of whether that cholesterol is actually sticking. So, because of that, that gets us back to that discussion about other tools to actually see is the cholesterol sticking and that becomes that discussion about the coronary artery calcium score or as we called it before the cardiac colonoscopy. Cheap, effective, simple, highly sensitive to pick up early heart disease, very simple to do, has been standardized literally how we both take the pictures and score the pictures since the early 1990s.
So, on the cholesterol side of things, cholesterol is mandatory. It is central. It is necessary. It, however, may not be sufficient. So, here’s where we get into the inflammation argument. So, people can have average cholesterol, below average cholesterol but in people who have inflamed blood vessels, which of the things that we can fix, we generally talk about tobacco, we talk about diabetes, we talk about high blood pressure. And there are other factors too. Stress, overweight, obesity, also family history plays a role. So, lots of different things can contribute to inflammation or as I like to explain it, think of this as sticky vessels and so ultimately whether we form plaque or not really depends upon two interacting things; one is cholesterol which is mandatory, necessary, has to be there but may be high, may be average, may be low but the other part is inflammation.
So, obviously, if someone has things that give them inflammation, that we can fix such as using tobacco of any form, if you have diabetes or prediabetes and attending to that, if you have weight issues, we need to attend to that. If you have blood pressure problems, we need to attend to that. So, it’s really a holistic approach to all of these different factors that I mentioned that can dramatically reduce the risk of cardiovascular events, heart attacks and strokes and other vascular problems.
Host: That’s a great answer doctor, I just love the way you put things. You have such a interesting way of putting spin on things and I imagine you do bring smiles to people’s faces. So, in light of all the things we’ve talked about, risk factors, cholesterol, calcium score, what makes the Low T Center’s approach different or dare I say, better than others?
Dr. Osborne: What we do at the Low T Center is we understand. So our average guy is a 48 year old guy who obviously sees us because he doesn’t feel good. Right? There’s a reason why people come to Low T Center and obviously if you have low T or other symptoms that cause fatigue and not feeling good, loss of strength, erectile dysfunction, all of those things that plague many, many middle aged guys, what we appreciate as well is that we will attend to those things and there’s a lot of things that can cause that, low T, thyroid issues, sleep apnea. So, we have a very sophisticated highly effective system to kind of identify those issues and work with you and correct those but the other big picture here from 30,000 foot view is that our average 48 year old guy over the next ten to twenty years, his main medical issue that will likely happen, unless we change the trajectory now is a cardiovascular event, a stroke, a heart attack. Balloons, stents, bypass surgery, that I would argue and in fact the science is very good that at least 80% of those events and I think that’s a conservative number are entirely preventable.
So, our approach is to be very proactive, to use the latest evidence based scientific guideline based approaches that are already out there but are very, very poorly implemented. So our goal is to be very proactive, use these evidence based technologies and tools like coronary calcium scoring, checking and following blood pressure that again is an asymptomatic condition in many people. And we see lots of guys that have uncontrolled high blood pressure all the time. Feel fine. But as an example for blood pressure, starting from a blood pressure of 115/75 every time we go up 20 points higher on the top, so from 115 to 135 or from 75 to 85;either one of those numbers; just 20 points higher on the top or ten points higher on the bottom; by itself, independent of age, sex, cholesterol, diabetes; doubles your risk of a fatal stroke or a heart attack. If you go up another 20 or 10; you double that again, if you go up another 20 or 10, you double that again. So, someone with a blood pressure of 175/105 is at 800% greater chance solely from the blood pressure along than someone with a blood pressure of 115/75. So, we’re going to make sure that blood pressure is checked and monitored and taken care of and controlled if appropriate.
We also do the same thing with blood sugar and diabetes. And it’s not just diabetes, it’s also prediabetes which is farm team for diabetes as I like to say. And then also cholesterol. Which is completely asymptomatic until you have a problem. So, we’re going to check that. Many of our patients it’s not on the radar, it hasn’t been checked. I feel fine. Why would you want to check it. So, we’re going to check all that in addition to other factors and really guide people and change the trajectory and even changing it a little bit now multiplied over years to decades, dramatically changes the likelihood of cardiovascular events and also too by the way. It’s not just cardiovascular events, we know that atherosclerosis, plaque buildup, diabetes, prediabetes is also highly correlated and associated with dementia, memory loss, so, it’s not just cardiovascular disease, but the better we understand and take care of these factors; many of them are asymptomatic now but turn out to be major disasters down the road; the better that we can help our guys.
Host: Thanks Dr. Osborne. Great to talk to you again. Call 866-806-8235 or go to www.lowtcenter.com for more information or to book an appointment. And thanks for listening to Age is Just a Number by the Low T Center. If you found this podcast helpful, please share it on your social channels and be sure to check out our entire podcast library for topics of interest to you. I’m Scott Webb and we’ll talk again soon.