The interview video that I did with Todd Eldredge just got great, rave, technical
reviews but here's the problem: It was too long. It was over an hour so most
people, unless you've just got a real technical focus on this issue, saw that
hour and 5 minutes and said "Hmm... I don't have time" - so what I've done is
I've broken up the video and taken excerpts out for specific subtopics. in
the first one we looked basically at CIMT basics and quality and variability. In
this video we're gonna look at the Café's de Cave study,
it's the landmark study which helps us understand the significance of CIMT and
it also gives us some significant variation between CIMT and the normal
carotid ultrasound. The normal carotid ultrasound only shows a positive if
you're like 70% blocked or 1/3 to 2/3 blocked.
That's way too late. You're - you've got an 80% probability at that point of
having an event. We want to get you way back when you're at a 40% or less and
that's what a CIMT does. (Todd Eldridge:) You have to know what you don't know and you always
have to be cautious when you're reading these studies to make sure you really
understand what you're looking at and I would tell you, Dr. Brewer, we've talked
about this before but it doesn't matter if you're a medical doctor or a patient
I see gross errors in the interpretation of this data. It's easily misunderstood
that also contributes to why it's not routinely used across the board, having
said that I do want to show (just, if I could) one - a couple of studies that
because we're talking about reproducibility, (I hope this is not
taking us too far off track) this is a study - this is perhaps the best study
I've ever seen in any genre of medicine in terms of efficacy of a methodology
Dr. Brewer, what they did here is - they took 10,000 patients and followed them
for 10 years. Now, that's a big set. It's a hundred thousand man year study. That's a
big study. They don't come much larger than that and they took a group of
patients that had no risk factors. So, if they were at that - if they had high blood
pressure, you're out of the study, you can't be in it. If you had high
cholesterol, you're out of the study. If you had low HDL cholesterol, you're out
of the study. Right. They - so they deliberately chose a cohort or a group
of people that had no risk factors and they were asymptomatic and the reason
that they did that is because they knew that they were gonna have these people
sign waivers to say "We're not gonna - we're not going to receive treatment. I
agree." If I was in the study, I had to agree that I would not be treated for
the ten years of the study. Well, you don't want to have people who have
disease agreeing to that (for obvious reasons) but back in the 1990s, we really
didn't know the efficacy of IMT so we were just "let's watch and see". The won-
I'm not sure it was an error or might have been deliberate - the wondrous factor
that they left in is they had about 30% of these people that were
smokers and, as you know, smoking is a huge risk factor. Right? Huge red flag, so
off they went and they started measuring these people. Well, 21% went on to
have a heart attack or stroke. Oops! and as they went and looked at the data
IMT caught 98.6% of those heart attacks and
strokes before they happen. Maybe you know but I have never heard of another
technology in any genre of of medicine, Dr. Brewer, that has a better catch rate
than that. Home pregnancy test (just for reference) in the first trimester catch
97% - You'd expect those to be pretty darn predictive, right? but 98.6%. I want your
listeners to understand how significant that is. You will be hard-pressed. I don't
care if you're looking at cancer or any other medical condition and, by the way, I
would ask you - if you find one that is better than 98.6%, please email me at Todd@Cardiorisk.us
because I want to see it. This is unprecedented in medicine.
It's really, really good and this isn't to say that it's a perfect study.
All studies have their weaknesses, this is not without exception but that is
really, really good data. Let me show you one other data point. This is the
landmark atherosclerosis results in community study. This was the - the
landmark study that showed that the correlation between IMT and
cardiovascular or cerebral vascular risk and then (Dr. Brewer:) Can I make just a quick interruption
(Todd:) Yeah (Dr. Brewer:) I've covered both of these studies in other videos but when you're covering
them, I just want to remind my best viewers that the first one that we looked
at was Cafe de Caves or Cafe's Cave. It's a very - it's a landmark study in this
area. I'm really glad you covered it. This one's called Eric. It also had a lot to
do with diet and cardiovascular risk. Go ahead. (Todd:) Yeah, so - so what I just want the -
your listeners to see and whether they're physicians or patients doesn't
really matter, the standard of care in America is a cholesterol test and it's
problematic and the reason it's problematic is not always understood. At
the time that I stick a needle in your arm and draw blood,
what I'm really looking for is the concentration of a pathogen per unit of
blood. So, in this case, a deciliter of blood. So, what we - what we're measuring
when we do a cholesterol test is - we stick a needle in, we draw some blood out,
we say "Oh, what's the concentration? How many milliliters of cholesterol are
in a deciliter of blood?" and we crank it out as a score and what
we're hypothesizing is that the higher that concentration, the more likely one
of those particles is to penetrate into the wall of the artery but let's be
clear, at the time that we draw it out of your arm, not one drop of it is hurt
you but, by definition, it's floating around your circulatory and, in order to
hurt you, it has to get inside of that wall of the artery and get trapped there
and then it starts this whole process called phagocytosis which is very
similar to when you get an acne lesion on your face when you're a teenager. Well,
we can talk about that later, but so let - that's why there's so much
difference but the standard of care in America is a cholesterol test and it
catches, in another study we're not going to show here, caught - it catches about 18%
of the women, 25% of the men, it misses three times as many as it
catches. And that's why - and so let me just show you, this is a very high,
Dr. Brewer, you would probably never let your patients get to 160 milligrams per
deciliter blood, right? That's - It's really high. We shoot for below 100, if you're
diabetic below 130 (I think are the current standards). so 160, I want to
impress upon you, is way too high. Notwithstanding that the hazard risk
ratio. That's essentially how much risk - how much our increased risk do you have
by this condition and what they're saying is "If you have cholesterol level
above 160 milligrams per deciliter, you are twice as likely to have an event in
your lifetime" Now, that's not unimportant. We can't ignore that. We have to do
cholesterol testing because it's still responsible for half the disease. However,
it doubles the risk slightly less than that in men, if we look at the "good
cholesterol" (I hate that. Makes me cringe to say that) but
HDL has been referred to as the good cholesterol. If you're below 35 milligrams
per deciliter and you're a woman, you have just over a three-fold increase in
risk by having too low of cholesterol or in men it's a little bit lower. Now,
here's what I want you to see, the IMT test - women, if you exceed in one
millimeter which, by the way is not that thick, (I mean it is thick) you have a
19-fold increase in risk. You see the difference? and to me, the
difference is as simple as - we're taking a picture of it and
measuring it. There's no - there's no extrapolation. There's no "do you?" or "don't
you have it?", "will this hurt you or not?" Inflammation is the cause of this
disease. inflammation predicts risk of plaque. Plaque predicts risk of events so
loosely, you could say then that risk - that inflammation loosely correlates
with events but if we had added plaque to this, we would see off-the-chart
numbers. In the Café's Cave, we found that 40% of those with even the smallest non
hemodynamic plaques went on to have events in ten years so this is really
good data, if it's conducted by a laboratory that knows what they're doing
and that has the coefficients, the quality metrics to maintain good
coefficients of variability. So hopefully, that was a lot of verbage, Dr.
Brewer, but hopefully, we brought the science together so they can see it in
context. Why it matters and (Dr. Brewer:) Actually, I'm - yes, I think you did a great job. Let me
just ask you this, Todd: You know that image that Brad and Amy used that shows on the
Café's Cave group, where it's 80% if you have occlusion of the flow (Todd:) yes
(Dr. Brewer:) If you don't have that, I probably do. (Todd:) Yeah, feel free to - I
can stop sharing and I think I do have the slide, let me - give me just a second
and I've got it right here. (Dr. Brewer:) Well, while you're looking for it, I will
- I will help describe the point behind that. So, again, we're talking about a
deeper, more effective way of screening for heart attack and stroke risks, and
we're talking about a simple ultrasound of the carotid artery here; no radiation.
and, Todd, you and I can get into that a little bit later, if we get some time on
this video (maybe we'll have to do another one) but people say, and Docs will
say "We'll already have - I mean we have ultrasound of the carotid
artery, we do. We used to do that all the time and if it's positive, you do surgery.
If it's not, then you don't. Well that's no - that's not right. They're not
talking about CIMT which is showing a much more subtle - it's showing whether
plaque is there or not. Now, if somebody has a positive that obstructs the flow
they're gonna have an 80% probability of having an event if they're not treated
over the next ten years. That's true and I, actually, now that you said that, I'm
showing the wrong slide. Actually, this this slide is not unimportant, you
know what we're seeing here that - this is not the slide you were thinking about. I,
now realize what you're looking for but the problem with the standard - it's
called a duplex exam. It's a carotid ultrasound that I would say the vast
majority of the medical community is using - is and (I'm gonna use my hand again)
what it is looking for is the amount of blood flow through the hole we talked
about. The water and - think about a brook or a stream. If you have a great
big rock in it that water starts, it goes much faster over the rock, it escalates
it changes the velocity, because the hemodynamics of the flow of the water
are changed by the rock in the stream, same thing in the arteries. So, what the
duplex exam does - which is the one that is - you'll see lifeline screening
and other - it's really the workhorse in cardiology, they're looking for the
velocity changes, owing to a large plaque but here's the catch because I'm looking
through the hole, you have to be 50% or more blocked before the math - the
math that we use is very sophisticated. The math doesn't even work below 50%
blockage. So, what they do is they put their thumb out and say "Well, I think
you're about 20% blocked." That is a guess because the math simply doesn't support
it. Now, over 50%, it's actually quite useful and here's what I
want you to understand: You have to be 70%. Cardiologists can't just
go around crackin people's chests open for the fun of it. That would be completely
unethical. Nor can they run invasive catheterizations on people just for the
fun of it. So the the criteria to meet the
Hippocratic oath, which is First: Do No Harm, so that the the benefits of a
procedure outweigh the risk is 70%. You have to have this whole 70%
blocked b-before before they can ethically do
something invasively. These are surgeons so it's not their fault. They're there
- they are doing what they're trained to do and they're doing it ethically and
the ethics require them to not do something if you're less than 70%
Here's the problem with that - 86% of the heart attacks and strokes
are in people that had less than 70% blockage. What that means is - up
until minutes before they had their heart attack or stroke, they didn't have
blockage (Dr. Brewer: They didn't know, They had no clue) so to sit around and wait till your cardiologist
can treat you, you may as well take a revolver and spin the dial and pull the
trigger. It's a suicide pact and there - it's craziness to sit around and wait
til that tube gets filled 70%. It's just nuts and what we do with the INT,
instead of looking at the middle (we also look in the middle by the way) but we're
much more interested in the wall of the artery, right here. Right? we can see how -
Do you have inflammation? If you do, that's gonna - if left untreated,
inflammation will always grow a plaque. 100% of the time (over time)
absent an intervention and plaque left untreated - in a very high percentage of
the time, plaque is responsible for the atherosclerosis caused events.
it's the ruptured plaque and the subsequent chain of events that happen
from a ruptured - after a ruptured plaque that caused the heart attack or stroke
so we don't have to wait around to be 70% closed for heaven's sakes.
(Dr. Brewer:) Absolutely. Yeah, you took a you took a major chunk into what I was - where I was
going. I appreciate that. (Todd:) I know the slide you want, I don't think
it's in this slide deck. (Dr. Brewer:) That's okay I'll just see
if I can cover it verbally. So, people would say "Well, we did a - we did a carotid
ultrasound. We'd look to see whether there was a obstruction or not and
whether we need to do surgery." That's not what we're talking about. Again, we're
talking about a more subtle look and Todd just gave us a technical
explanation. What you find and what they showed with the Café's Cave study
was people that had significant plaque had a 40% risk - over 40% risk of having
an event within 10 years. So, again, major risk that we can pick up and warn our
patients up and guess who is a poster boy for that? I was one of those folks with
very few risk factors back when I was aged 57, I decided to get one of these and
if you just look at arterial age alone I had 72 year-old arteries. I do prevention
for a living. I was one of those Docs that you refer to in your book that
treats risk factors rather than treating disease