Measuring your Heart Attack RISK – CIMT: Basics (from Todd E’s vid)

Measuring your Heart Attack RISK – CIMT: Basics (from Todd E’s vid)

August 31, 2019 10 By Bertrand Dibbert


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 [email protected] 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