Coronary CT angiography

So you have to take things more serious and so I kind of, I kinda separate it by the, by the CAC scan.

And the problem with the angiograms, you know, the CCTA scans, the soft plaque measurements, they're ridiculously variable when doctors are interpreting them.

Yeah.

If you give-- They did a study where they gave, uh, several professional CCTA readers, they gave different doctors the same exact scan, and they got 30% variability between the doctors.

Yeah.

So, like, sometimes they tell you you have 50% plaque, but then you only have 20% plaque, or you have 80% plaque.

So I-

Yeah, so man, 'cause-

Right.

I mean, and that's, that's a key feature of all the regression trials that have been done since the early 2000s, right? Whether it's intravascular ultrasound, IVUS, whether it's CCTA or other technologies, we are always seeing some regression, regression even in a control group, right? Even in an untreated or a minimally treated group who's not at whatever goal, usually a lipid goal, we see regression, and that's partly measurement, partly it may be biology or control of other risk factors, right? We, we acknowledge that.

But just to put a bow in this, as you saw in the Cholesterol Code documentary, we were interviewing doctors, not just like Brett Sher, but for example, Dr. William Cromwell, who I was posing that question, "If we see regression, regression in this cohort, particularly confirmed regression, would that be a big deal?" And I think it absolutely is a big deal because it wouldn't be expected given how high the LDL and ApoB levels are.

Maybe.

I mean, originally, yes.

I mean, that's how the original validation was done.

It's important to make note that the original validation for CCTA and the AI tools was done largely in a clinical cohort, right? So people who had- More plaque volume because they had chest pain, because they had a heart attack, right? They- this was done mostly in patients who were getting IVUS, meaning an invasive angiographic procedure where they're inside the blood vessels in the heart.

You don't do that for somebody who doesn't need a cath.

And a 2025 Lancet Commission is rethinking coronary artery disease early detection should focus on non-calcified plaque, the soft stuff, meaning calcium scoring isn't the ideal early detection tool, and it performs especially poorly under the age of 40.

So this is why I think when we're really looking to screen, we have to be thinking about coronary CT angiography or CCTA, which images both calcified and non-calcified plaque.

It shows the severity of narrowing and high-risk plaque features.

Its accuracy for detecting obstructive disease is 81.1% versus 68.8% for a calcium score alone, and it isn't thrown off by a heavy calcium burden.

The strongest outcomes come from Scott Hart's 10-year follow-up.

It looked at the CCTA, which is the coronary angiography-guided care, lowered coronary death or non-fatal heart attack from 8.2% to 6.6%, non-fatal heart attack 6.0% to 4.3%, and major cardiac events from 10.3% to 8.3%.

That benefit wasn't from doing more procedures.

This is what's significant.

Oh, yeah

... cholesterol-- His total was over 700 for the past seven years, and he did a CAC scan of his arteries, a scan to see if he has plaque in his arteries, and he did a CCTA scan.

Both-- He did both types of scans, and both of them show zero plaque in his arteries-

Wow

Yeah.

And there's no interpretation from the doctors.

I do not like the CCTA scan, the one that's-- measures hard and soft plaque, and it's because there's huge variability between the different scans.

Like, here's the problem.

And what I love about perimenopause and menopause, because it's a known time that your cardiovascular health decreases because we're losing that protection.

It's a time to get a set point, just like you would get a mammogram, get your cardiac scan, get your CCTA and know your soft plaque versus hard plaque in your heart.

So then you know what intervention is specific.

What your intervention would be will be different than my intervention.

Stress tests and just the calcium scoring scan, they give you some information, but not enough.

You can still ride around on a horse to get to work every day, but you can get there faster in a car.

So as the technology improves, why not give yourself the most information? And quite frankly, something like a CCTA, which is a specific type of CAT scan that looks...

It actually...

But I want people to know that you can still have disease before it shows up as calcium.

And I think the best way to understand this is to understand where CT, the other test, the cardiac or coronary CTA, became a class A1 indication in chest pain guidelines.

How did that happen? Well, we first saw CT show up in guidelines in Europe, in England, right, in the UK.

So they have NICE guidelines.

Correct.

Yes.

So a CTA or a cardiac or coronary CTA, different from a calcium score, will identify all plaque on or inside the vessel, because this plaque even forms before it starts to even narrow the vessel.

So that plaque comes in basically two forms.