The interview meeting with Todd Eldredge on CIMT got rave technical
reviews but it really didn't get that many views and it was obvious why. It was
just - it was too dang long. It was over an hour and, unless you're really into
details on something like that, it's hard to gather and dedicate a full hour on
something like CIMT. So what I did was take excerpts on key topics and this
topic is: Looking at Plaques Versus Overall Arterial Age. There's - those are
two totally different ways of interpreting CIMT. The plaques,
themselves, are like peaks and valleys and the overall arterial age is the
amount of overall LDL that's been deposited there. So again, which way is
the right way to do it? The short answer is both. But we're going to talk about
that and Todd's going to explain a little bit more detail. Thank you.
(Todd:) So what I'm going to do is talk Mean Max first, if that's okay, because (Dr. Brewer:) Okay, While
you're picking it up, I'll give my version and then you can correct my
errors the - one of the other things about Todd's reports - and I could show them if
you - and you can show it, if you've got my most recent report from April.
Todd routinely reports both mean Max and common IMT. Now, he'll explain what those
mean but the issue with this is a lot of
companies, even CIMT companies just report arterial age and tell you whether
or not you've got - look whether they see what's called a discrete plaque.
Well, if you look at the the literature, the science - the science would indicate
that there are two different things and both independently have a significant
on predicting your risk for heart
attack and stroke. so Todd, you want to take it from there and clean up the mess
I just created? (Todd:) No, I don't think it's a mess at all. Let me - I've actually got
some images that I think I can bring up that will add clarity to that. Let me
just - yeah, here we go. So - so let me just take a second to bring those images up
for you if that's all right and if you - if you'll kind of talk - I'm showing is
a piece of our report and this has been - we have taken the patient name and a
lot of the you know - so that we were hip compliant but so you'll see that
there's several - there's actually five areas on our report that are coded green
light, yellow light, or red light. Green meaning good, obviously. Yellow meaning
let's be cautious, and red meaning you probably need some treatment and this is
gross oversimplification, Dr. Brewer, I would never - I would always
defer to a physician to treat but as grossly oversimplified, conceptually, we
we would take people that are in the yellow and probably try to manage that
with lifestyle changes and people that are red may - may be candidates for
pharmaceuticals and that's - for anybody listening, please, that is a gross, gross
gross oversimplification. So please don't take that and act on it. The (Dr. Brewer:) I would say as a
Doc, it's not as much of an oversimplification as you're saying but
(Todd:) So there - there's average mean and average max region and
the way to think about the difference between these two: the average mean is
what we're doing is taking about 600 measurements and averaging them together.
Now, that may not mean too much to you but think about a mountain range where
there's peaks and valleys, right? and - and an average measures both the peaks and
the valleys and averages them together. That's what the average mean is. So we're
- we're looking at everything up and down, the apex of the peak, and the
the lowest part of the valley. We're measuring all of that together and we
come up with an average mean so that's the way to think about that. It's
inclusive of peaks and valleys. The average CCA max region, by contrast
what it does in the same views, so three angles on the right, three angles on the
left. What we're doing is taking the six thickest IMTs so we're just measuring in
a mountain range where there's lots of peaks, we take the the tallest peak and
measure it and we say - and then we take all - so the tallest peak in this
image, then the tallest peak from this image, and then the tallest peak from
this image, and we average all of those together. So it's the average of the
peaks if you will. (Dr. Brewer:) Right. (Todd:) Now, Amy and Brad published data
with - in conjunction with Johns Hopkins using our data and what they found is
that there's actually information - the Delta between these two data points when
you - atherosclerosis is a very rough disease that undulates and so the more
that the further the delta or the spread between the max region and the average
mean, the more atherosclerotic - the more likely they were to have atherosclerosis
and by contrast, when we're healing a patient the - the smaller that delta the
- the less difference there is between those two, the more likely they are to
have a healed patient so it was evidence of efficacy of treatment if you will so
those two data points are not unimportant and just while I'm
talking about the report, it's important to understand that only three of the values
on the report are alert values and the reason for that is the alert values are
those values that have - that are tied in the literature to a hazard risk ratio or
an inflated risk, right? if the value that is shown - if there's a
particular number that would indicate that a patient has increased lifetime
risk, then we show that an alert value. If we put a value and it does not have an
alert value it doesn't mean it's unimportant but you know like the
arterial age, people love that number. That's great, we would never want a
physician to treat to the arterial age because that's - that's
just a coefficient. There's no - there's no alert value there and quite frankly
what a coefficient means for those that may not be familiar with that, it's just
another way to say a number so what we've done is taken the average
mean IMT and we've plotted it on a map that measures, epidemiologically,
where you should be for your age and gender and we say "Oh well, this
thickness looks more like somebody who's 70 than somebody who's 60, or this looks
like somebody that's more closer to a 30 year old instead of a 50 year old" and so
it's a - but it's a coefficient. We must be careful when using coefficients. For
treatments, I always recommend keeping our eyes focused on those two metrics
right there. (Dr. Brewer:) So, could I interrupt and just maybe try to put it in my third
grade or sixth grade perception that common IMT is more like just the average
where an average of all of them, whereas Mean Max is the average of the
peaks. It's that you take the biggest plaques and say - you average those out.
(Todd:) Yep (Dr. Brewer:) And both of those numbers, when you look at the science - both of those are
very important but again when you go to a lot of - you go to a lot of INT providers,
they don't really give you that. So again, that's one of the reasons that I came to
you. Anything to add to that topic? (Todd:) No. Well, if we talk about literature and
literature searches this is important as well because some of the protocols only
take a single caliper measurement and so their entire study is based on one
caliper - one measurement as opposed to measuring 600 measurements and you
can appreciate that one caliper measurement is not going to be as
accurate or reproducible as taking 600 and so we have to always focus on
and the - I would say the vast majority of the early studies took three
measurements on each side so that was more akin to the - what we post as our max
region, so it's important that we understand how the measurements were
taking - taken, in order to understand better
what the true risk is.