Preventing Silent Heart Disease: From Test Result to Informed Decisions

So I'm going to just do a case presentation today, okay, so that everybody understands why this is so important, all right. So case presentation. This is a very simple case. We have basically a 45-year-old white male who comes to see us because his coronary calcium score is high on a CT ANGEL or rather a calcium score, right. So the calcium score is positive. So his coronary calcium score is positive. He's got 750 in it, okay. So when he comes in here, we ask him, hey, how are you doing? He says, I'm here because my calcium score is positive. He's not having any chest pain, no pressure, no tightness, no heaviness in his chest. He feels good. He just got this done because his primary care physician told him to get it done. His ZKG looks normal. You examine the patient. The examination is fine. And now the patient's in the room and you look at the patient and you say, okay, why do you have this coronary calcium? Why do you have all this? So in the history, what you'll need to take care of in the history is number one, did he smoke? Yes or no? Did he have high blood pressure? Yes or no? Did he have a previous history of any cardiovascular symptoms like he had blackouts, congestive heart failure, any type of cardiac history? Answer is no, no, no, no. He's perfectly healthy. He's an accountant. So what are your thoughts now on this patient, right? What are you going to do about this patient? Where did he get this coronary calcium? So what we do is the first thing we want to do is make sure that is this calcium inside the artery or is it on the outside of the artery only and not causing any obstruction to blood flow? So what kind of test do we do for that? We do a stress test. That's a functional test, right? Because a functional test will tell us if there's any lack of circulation here. So you may want to order a stress test on that patient. It'll be a nuclear stress test. Alternatively, you can do a coronary CT angiogram. Coronary CT angiogram, you're injecting the dye inside the vein and then you do a CT scan of the artery. So that's like doing a cardiac catheterization. The trouble is that today our insurance companies are so backward, they're at least 20 years behind the times and they don't know that coronary calcium means that you should be doing a coronary CT angiogram also. Because the coronary CT angiogram can do two things. It will tell you where the blockages are, where the calcium is, and you can do the FFR also on it. Now because the insurance companies don't pay for it, people are practicing medicine from 20 years ago. So as providers, we want to encourage the patients to actually do a coronary CT angiogram with FFR. Because if the CT angiogram, which only takes about 20 minutes to do it totally from beginning to end, shows us where the blockages are and whether they're causing a narrowing or not, whether they're causing a flow disturbance or not, that's one-stop shopping. You're done. You don't even need a nuclear stress test. Because if the FFR is normal, then this patient has blockage, he's got coronary calcium, but it's not causing any narrowing in the artery, you're done. But the question is that as a practitioner, we find it very difficult to practice medicine according to the insurance companies who are 20 years behind the times. So what we should be doing is telling those patients that look, you do have a choice. You do a nuclear stress test, you're going to be covered by your insurance. On the other hand, if we do a coronary CT angiogram without having any chest pain, they may not pay for it. So we want to do the right thing for the right patient. Now, of course, we are very concerned about the finances of patients because we don't want to put them into debt. But at the same time, we must do the right thing. The right thing is to do a coronary CT angiogram, offer it to them. They can make that choice. They can pay out of pocket for the coronary CT angiogram. The FFR is an additional charge because the FFR, as you all know, is that you send the CT angiogram off to California and they do the analysis on the blockages to see if those blockages are actually causing a flow limitation or not. That analysis costs a lot of money. So many times, as to the providers, my advice is that they should be talking to the patients about doing the best test possible rather than doing a test that your insurance company is approving you to do. Because whose approval is necessary? It's my approval, not the insurance company's approval that we should be looking for. So on this particular patient, the first thing you're going to do is, OK, so you've got calcium, so let's find out where it is. The next step in this workup is, why did you get this calcium in the first place? So part one is important because you want a live patient because you cannot do prevention on a dead patient. So you've got to make sure the patient is going to survive, right? Because a dead patient, you don't need prevention on that patient. So part two is then prevention. So when it comes to coronary calcium, why you got it, you need to know why that patient got it. And there's no timeline on when that calcium built up. So on this patient, what kind of test out order on this type of patient? Typically, I start first and foremost with a metabolic workup because you all know it's hyperinsulinemia. It's pre-diabetes. So you're going to order a Kraft test. Each and every one of these patients should get a Kraft test. Doesn't matter what the hemoglobin A1c is because that just means the sugar is good, but you don't know how much insulin it's taking to keep that sugar down. So you must order a Kraft test on every patient. All of you need to know what a Kraft test is, right? Kraft test is when you drink sugar water and you're measuring the insulin and the sugar levels. All of you need to know what it is. So if a patient stops you in the corridor, you should be able to say, this is what a Kraft test is all about. Oh, you're in the middle of your Kraft test. Oh, good. Not like I'm doing a test that is called Kraft. What is it? Well, I don't know. You can't say that. Everyone needs to know everything about everything. So the Kraft test is number one. Number two, you do the advanced lipid panel for the Cleveland Heart Labs or the Boston Labs or the Quest IQ Lab, but you've got to order an advanced lipid test because it's not the LDL. It is the kind of LDL that the patient has. If the patient has small, dense, deranged LDL, that is causing atherosclerosis. And if the patient has it, then you're going to look for the causes of small, dense LDL particles, which is hyperglycemia, high insulin levels, high omega-6 levels, advanced glycation end products, which include alcohol, by the way, and lastly, metabolic endotoxemia, which is the leaky gut. So if the patient's insulin is good, sugar's all looking good, then you say, well, why does this patient have this? Well, it could be that this patient has a leaky gut. And I just want to leave you just with a few things about the leaky gut because leaky gut is pooh-poohed by everybody else, but it's actually real. It's actually real. And what happens is due to two things. It's either due to bad bacteria in the gut or the wrong types of bacteria in the gut, or it's due to food sensitivities. But we question the patient with symptoms in the GI tract, and many of them don't have symptoms. So now let me tell you something. If a patient is eating and he's getting bloated and gassy after eating, that's obvious, right? Even my teenage son, son-in-law, nephew, will be able to make that diagnosis. There is something wrong with this guy's gut. Every time he eats, he's bloated, he's got gas, he's making noise, he's not happy. There's something wrong with his stomach, right? He can figure it out. So that patient probably has SIBO, right? You can either test for it or you can just go ahead and treat him because the treatment is pretty innocuous. We give them the Candibactin treatment. On the other hand, many of the patients are completely asymptomatic. They have no symptoms whatsoever. So if you have a patient who does not have metabolic disease and yet the patient has extensive coronary calcium, you need to do a GI workup. That means that you need to order the specific test looking for the gut. So you need to look for food sensitivities even though they remain have no symptoms. But a patient with extensive coronary calcium like this would need to be evaluated for food sensitivities with a Vibram blood test and maybe a stool sample also, but that discussion has to happen. For example, today I did a cardiac catheter on a patient. This patient had a stent when he was 48 years old and now he comes back again. He comes, well, it wasn't done by me, it was done by somebody else, but he's now here in the office. The catheter has got new blockages and he's only 58 now and he's going to need two more stents and everything's fine. His lipids have been perfect. His blood pressure has been good. His weight is down. He was vegetarian for many years. So the question is that why is he progressing his disease? And this is where we come in. You've got to find the cause for his small dense LDL particles and his diet is good, so you can't blame that. It's not his insulin, it's not his sugar, okay? He doesn't have toxins in his body. His mercury and lead levels are all fine. He's got a leaky gut. I can guarantee you that patient has a leaky gut. I guarantee you that he's going to have food sensitivities and or dysbiosis. And when I dug into it 10 years ago, he had an episode of diverticulitis, but he said they treated me with antibiotics for two weeks and I've been fine since then. No, you have a dysfunctional microbiome or you have food sensitivities, until proven otherwise. And if we don't explore this avenue, he'll be back 10 years from now. He'll have another two new blockages because he's going to have ongoing leaky gut. This is where you all come in as well. That if we say that this patient has leaky gut and he needs a workup, you need to encourage that patient to follow through. Many times they have hesitancies because it is an expensive test. And again, the insurance companies who are 20 years behind the times have no idea how important this is really. How important a leaky gut or permeability of your intestine is so important when it comes to inflammation. So the insurance companies don't want to pay for it. So the poor patients have to pay for it out of pocket. And it's really a disgrace that that happens. Now, once again, you still have to offer it to the patients. They'll make the decision whether they're going to actually pay for it or not. But this particular patient said, no, I can't afford this right now. The Vibrant test is expensive. For example, my stool testing is too expensive. So what would I do? 70 to 80% of the time it's wheat. So I told him to stay away from barley, rye, oats and wheat. I said, that's it. You're going to do this because you're not doing objective testing. I'm going to take my best bet. And what's my best bet? I'm going to start with wheat first. So I'm just going to cut out all wheat in your diet. But I also explained to them that they probably have other food sensitivities as well. But wheat is the big, big bull in the room. So let's go with the wheat first. But I think it's important to know. And number two, we're going to work on your microbiome no matter what, which means that all cardiac patients need to be on inulin plus FOS because you're going to feed the good bacteria. The ones with the most severe disease, like this guy, for example, I'll probably put him on some probiotics. My favorite ones are, of course, lactobacillus rutaria and acomancia. So I might probably put him on that. But they must eat fermented foods, kefir, kimchi, et cetera, et cetera, and fiber. So these types of discussions must happen with every patient. So this patient, it looks like nothing. He just got a chronic calcium score. So the old-fashioned way is simply to do a stress test and send him on his way. The new way is to look to see how much hard plaque, soft plaque, whether it's causing any ischemia or not, and moving on to finding the cause of it. If he's got a fatty liver, but the patient doesn't have insulin resistance, it's a leaky gut. So you get an ultrasound of the liver. It only costs very little. Insurance pays for it. So you've got to look for metabolic endotoxemia. You've got to do it. And then, of course, there are a whole bunch of lifestyle changes as well. So for example, on a patient like this, I would talk to him not only about his diet and if he'll attempt to stay away from all plastics, and you have that discussion. I'll be talking about infrared and near-infrared treatments, that he should be getting some sun every day, some grounding every day, some exercise every day, stress management. Stress management means he's going to be doing vagotonic exercises so that these vagotonic exercises will give him more healing, breathing exercises, silence, and stress management, the brain, the mind-brain connection. So I'll talk about the mind-brain another day, but I just wanted you all to see that this type of workup is very intense. So if you really like this video, here's another one that I think you'll really enjoy. And if you want to see one of my latest videos, click over here. And of course, don't forget to go to my website where you will see lots of educational resources and find out how you can arrange or book a consultation with me.