Can You Prevent a Heart Attack Before it Happens? | Dr. John Osborne, MD

Show Notes

Put 100 people with no symptoms into a modern cardiac CT and only about 1% of them come back completely clean. Roughly a third are already in the most severe stage of plaque buildup, and most of them have normal cholesterol and a normal stress test.

Cardiology, for most of its history, has been a rescue service. You get chest pain, you go to the ER, someone puts in a stent. Dr. John Osborne has spent 30 years trying to flip that upside down. He is Harvard trained, holds a PhD in cardiovascular physiology, and has been doing cardiac CT for about 25 years, which puts him among the earliest adopters of the technology anywhere. He now runs Clear Cardio, a telecardiology practice built around cardiac CT and AI plaque analysis and licensed in more than 35 states.

The test most people have heard of is the calcium score, and Osborne is careful to say it is not a bad test, just an incomplete one. Calcium is the hard, inert rubble left behind after an event, what he calls the extinct volcano. It is a marker that something happened, but it is not the thing that kills you. The plaque that kills you is the soft, lipid rich kind, the lava, and a calcium scan cannot see it at all. Depending on the population studied, 10 to 50% of people with a calcium score of zero are still walking around with significant soft plaque in their arteries.

Cardiac CT paired with quantitative AI changes that picture completely. The scan itself takes about a second. The AI then measures plaque in cubic millimeters, separates it by type, and, most usefully, lets you track the same plaque over time to see whether it is growing or shrinking. Osborne stages total plaque volume from one to three, with stage three starting at 750 cubic millimeters and carrying roughly a 40% 10 year risk of a heart attack or stroke if nothing is done.

What surprised Ravi most in this conversation is how badly cholesterol numbers predict any of it. Across hundreds of thousands of AI exams, Osborne says there is no correlation between plaque burden and LDL, non-HDL, ApoB, or Lp(a). He describes two patients with an identical LDL of 108 who had lived in the same house for 42 years, one with zero plaque and the other with a volume of 1640. Lipids are a risk factor. Plaque is the disease. His argument is that you should find out whether you have the disease before you spend years arguing about the risk factor.

The encouraging part is that plaque is not a one way street. Against a background progression rate of about 10% a year if you do nothing, Osborne routinely sees 10 to 20% reversal within a couple of years with a personalized plan built around lipids, blood pressure, and tobacco, and he has seen as much as 50%. He also makes the case for reaching goal with a low dose combination of two or more agents rather than pushing a single statin higher and higher, and discusses the first oral PCSK9 inhibitor, which was approved the day before this recording.

Episode Resources

• Clear Cardio website
• Clear Cardio on YouTube
• Dr. Ravi Kumar’s Website
• Dr. Ravi Kumar on LinkedIn
• The Dr Kumar Discovery on YouTube
• The Dr Kumar Discovery on Apple Podcasts
• The Dr Kumar Discovery on Spotify

In this episode, you will discover:

• A zero calcium score is not a clean bill of health: Depending on the population studied, 10 to 50% of people with a zero score still carry significant lipid rich plaque that the scan simply cannot see
• The extinct volcano and the lava: Calcified plaque is the inert rubble left behind after an eruption, while the dangerous plaque is the soft, lipid rich kind that grows quietly for years and then ruptures
• What AI adds to the scan: Quantitative analysis reveals plaque that was previously invisible, measures it in cubic millimeters, and tracks the same plaque over time to show growth or regression
• Plaque is reversible: With a customized plan, 10 to 20% reversal in a couple of years is common and Osborne has seen up to 50%, against a background progression rate of about 10% a year if nothing is done
• Lipids are the risk factor, plaque is the disease: The first question should always be whether disease is actually present in your vessels, not what your numbers look like
• Cholesterol does not predict plaque burden: Across hundreds of thousands of AI exams there is no correlation with LDL, non-HDL, ApoB, or Lp(a), illustrated by two patients with an identical LDL of 108 and wildly different plaque volumes
• The radiation question, in context: On high end equipment the cardiac CT dose is about 20% of a mammogram, for a disease that kills roughly 10 times more women than the cancer mammograms screen for
• The single most powerful intervention is free: Quitting tobacco in any form cuts cardiovascular event risk by about 50% within a year, before any cholesterol treatment, diet, exercise, or weight loss
• How plaque volume is staged: Total volume is graded one to three, and stage three, which starts at 750 cubic millimeters, carries a 40% 10 year risk of stroke or heart attack if untreated
• Start with combination therapy, not statin escalation: A low dose combination of two or more agents lowers cholesterol better and with fewer side effects than pushing a single statin to its ceiling
• The first oral PCSK9 inhibitor: Approved the day before this recording, delivering the same LDL and Lp(a) lowering as the injectables with side effects Osborne calls close to placebo
• Stress tests miss early disease entirely: About a third of Osborne’s stage three patients feel completely fine and have a normal stress test
• Nicotine turns Teflon into Velcro: Receptors on the vessel lining respond to any form of tobacco, including vapes and pouches, and change how the artery wall behaves
• The third plaque type: Low density noncalcified plaque is rarer, and when it shows up it is a major risk factor for rupture

Key Takeaways

Find out whether you have the disease before you argue about the risk factors. Almost every cholesterol debate people have online is an argument about a proxy. Plaque in your arteries is the actual disease, it is now directly measurable, and knowing your plaque volume answers a question that no lipid panel can.

The calcium score answers a narrower question than most people think it does. It sees calcified plaque only, which is the residue of past injury rather than the active threat. A zero score is reassuring for calcium and silent about the soft plaque that causes most events, which is why it should not be the end of the workup for someone with a real reason to look.

Plaque burden and cholesterol numbers do not track each other. Two people can have the same LDL and completely different disease. That is not an argument for ignoring lipids, since lowering them is still the main lever for treatment, but it is a strong argument for imaging rather than estimating.

Plaque volume is a number you can move. Progression runs about 10% a year untreated, and a plan that addresses lipids, blood pressure, and tobacco typically produces 10 to 20% regression over a couple of years. The scan gives you a before and after, which turns prevention into something you can actually verify.

A normal stress test does not mean your arteries are clear. Stress tests are built to find flow limiting blockages, which is late stage disease. About a third of the patients Osborne finds in stage three feel completely well and would have passed one.

Tobacco is the highest yield thing on the list, and nicotine counts. Cutting event risk by about half within a year of quitting beats what any single drug does, and the effect runs through nicotine receptors on the vessel lining, so vapes and pouches are not a loophole.

Combination therapy at low doses beats maxing out one drug. Stacking two or more agents at modest doses tends to reach goal with fewer side effects than driving a single statin to its highest tolerated dose, and the toolbox is now large enough that statin intolerance is rarely the end of the road.

Transcript

[00:00:00 –> 00:00:13] Dr. Ravi Kumar: Welcome back to The Dr Kumar Discovery. I’m Dr. Ravi Kumar. Today, I’m sitting down with Dr. John Osborne. He’s a preventative cardiologist who spent the last 30 years changing the paradigm of cardiology.

[00:00:14 –> 00:00:49] Dr. Ravi Kumar: Now, when you picture a cardiologist, you probably picture someone who shows up after the crisis happens. Chest pain in the ER, a stent, maybe a bypass. Dr. Osborne built his entire career trying to flip that version of cardiology upside down. Using a CT scanner and artificial intelligence, he can look inside your arteries right now, long before you ever feel a symptom, and tell you exactly how much plaque you have, what kind it is, and whether it’s the stable kind or the kind that’s about to rupture and cause a heart attack or a stroke.

[00:00:49 –> 00:01:17] Dr. Ravi Kumar: So by the end of this conversation, you’ll understand the difference between a calcium score and a real cardiac CT, why a normal stress test tells you almost nothing, what kinds of plaque actually kill people, and what an evidence based plan to reverse plaque looks like. This is gonna be a great episode. So before we get into all that, Dr. Osborne and I are doctors, but neither of us are your doctors. Nothing here is medical advice.

[00:01:17 –> 00:01:44] Dr. Ravi Kumar: Take this knowledge that we’re giving you, ask better questions, and work with your own physician to build a healthier life. And just to be clear, this show is separate from my role as assistant professor at UNC. And one more thing, about 100,000 people tune into The Dr Kumar Discovery every month, but only a fraction of you are subscribed. So if you like this podcast and what I’m doing, please hit subscribe on YouTube or follow on Apple Podcasts or Spotify.

[00:01:44 –> 00:01:59] Dr. Ravi Kumar: It takes about three seconds, and it helps grow the reach of this show more than anything else you can do. And if you’re able to leave a rating on Apple Podcasts, I would be super grateful. Alright, let’s get into it. My name is Dr. Ravi Kumar.

[00:02:00 –> 00:02:29] Dr. Ravi Kumar: I’m a neurosurgeon in search of the causes of human illness and the solutions that help us heal and thrive. I want you to join me on a journey of discovery as I turn over every stone in search of the roots of disease and the mysteries of our resilience. The human body is a mysterious and miraculous machine with an amazing ability to self heal. Let us question everything and discover our true potentials. Welcome to the Dr Kumar Discovery.

[00:02:32 –> 00:02:44] Dr. Ravi Kumar: Dr. Osborne, thanks so much for joining us on the show today. I’m really excited to talk to you because you do something that I think most people have never heard of, and that’s preventative cardiology. Can you tell us what that is?

[00:02:45 –> 00:03:07] Dr. John Osborne: Sure. So, hey, everybody, and again, thanks, Ravi, for having me on, and it’s both a pleasure and an honor. So preventative cardiology is really a different concept. It’s extremely simple. Just like everybody understands and knows why we do colonoscopies and pap smears and mammograms for cancer, each one of those diseases killing maybe a couple percent of us, right?

[00:03:07 –> 00:04:04] Dr. John Osborne: How about we think of and apply early detection long before we have symptoms, chest pain, angina, lung distress test, need stents, balloons, why do we apply imaging to answer that question if we have early, we call it preclinical asymptomatic plaque, which ultimately is sort of just like colon cancer, the polyp that can turn into cancer. And then coupling that with literally decades worth of data that shows we have incredibly effective and a very large toolbox, as I like to say, of tools that can stop and reverse plaque, which is what is going to kill roughly about 40% of us because of strokes and heart attacks. So that in essence is preventive cardiology. I’ve been doing it for 30 years, in fact, first several years, probably decade, didn’t even know what I was, except I was into preventing heart disease. And the term preventive cardiology really didn’t come out till about 20 years ago.

[00:04:04 –> 00:04:08] Dr. John Osborne: So, I kind of occupied that space, but didn’t even know what to call myself.

[00:04:09 –> 00:04:26] Dr. Ravi Kumar: Yeah. Well, think it’s fascinating because, like you said, we practice preventative medicine in a very niche group of problems in medicine. Most of medicine is actually wait for the disease to happen, and then treat the symptoms. I mean, that that is the most of medicine. That’s what I do as a neurosurgeon.

[00:04:26 –> 00:05:06] Dr. Ravi Kumar: I wait for people to have spine problems or a brain tumor, and then I treat it surgically. But with heart disease, I mean, that takes an extraordinary amount of lives from people in this world. It is just it is a huge killer. And the fact that we’ve generally just been waiting for it to happen and then seeing how we can pick up the pieces, it’s like a moment that, yeah, maybe we should look beforehand, figure out if the disease process is actually happening, and then try to intervene and prevent it from becoming a full blown disease. And so when you told me about this, I was like, yeah, of course, this is what we we should be doing.

[00:05:07 –> 00:05:18] Dr. John Osborne: Well, I, you know, I think Ravi, you you said it beautifully, but I think the best ideas are the ones you go, well, of course. Why did I think of that? That’s just so obvious. Right? Yeah.

[00:05:18 –> 00:05:55] Dr. John Osborne: And some things that are obvious are not being implemented. And again, I’ve been working in this area for 30 years. I was a leader in doing cardiac CT, which is really, by the way, which I’m sure we’ll get into, the critical tool for understanding heart disease of any kind, whether early or late or whatever. And then another massive breakthrough just several years ago is taking that high resolution three-dimensional imaging that we obtained from a CT machine, and then applying AI on top of that. We were doing this six years ago before most people even kind of heard of AI, and of course everybody awash in it now, and it really is just an incredible tool.

[00:05:55 –> 00:06:18] Dr. John Osborne: In cardiology, there was a lot of guessing, a lot of maybes, could bes, probabilities, right? With imaging, cardiac imaging, I like to say it’s binary. It’s zeros and ones. You have it, you don’t have it. If you have it, here’s exactly how much, where it’s located, what kind, all of that detail, from a test that literally we obtain the data in a scan that takes less than a second.

[00:06:19 –> 00:06:36] Dr. Ravi Kumar: Wow. Okay, so that was my next question, is like, if you’re so if you’re going to prevent, find out if someone needs to have intervention and prevent cardiovascular disease from happening, how do you do you get the data? How do you know that that’s happening? And it’s with this CT coronary angiogram. Is that what you’re Sure.

[00:06:36 –> 00:06:40] Dr. Ravi Kumar: Talking Okay. So explain to us explain to us what that is.

[00:06:40 –> 00:06:51] Dr. John Osborne: Sure. So for everybody out there, I’ll start real basic. So a CAT scanner is computed tomography. That’s the donut, we call it, the donut of destiny. So it’s the big donut you see, right?

[00:06:51 –> 00:07:06] Dr. John Osborne: And I’m going to be careful to differentiate that from an MRI. MRI, very different technology. I call that the coffin or the tube, usually pretty constrained, they got to slip your whole body in, etcetera. That’s not what we use. We use a CAT scanner.

[00:07:06 –> 00:07:29] Dr. John Osborne: It’s just a big open donut, much bigger hole, we call that the bore. In fact, our particular machine has the biggest bore in the industry, b o r e, by the way. And so we use that machine, and it’s really the hardware inside, and then of course all of the software. There’s probably over a 100,000 CAT scanners in The US of different kinds. We have Fiats and we have Ferraris.

[00:07:30 –> 00:07:49] Dr. John Osborne: We’re fortunate enough, our machine is a Ferrari. In fact, our machine was the very first installation of this machine called an Atlas, which is a 640 slice CT machine. I started out 20 years ago with a 64 slice machine. That was state of the art 20 years ago. Now it’s six forty.

[00:07:49 –> 00:08:30] Dr. John Osborne: Again, we were the first install of this machine in North America, and our office up in Manhattan actually has the second install of this machine. So we put an IV in, give you some contrast, some IV contrast. As we do the scan, the scan itself literally takes one second to obtain that high resolution data. And then from that, lots of processing goes on using multiple levels of AI, and then ultimately that will output very, very precise and accurate and reproducible numbers about blockages, narrowings, but frankly, that’s just the beginning of it. It tells us how much plaque there is measured in cubic millimeters.

[00:08:30 –> 00:09:27] Dr. John Osborne: So I can tell you exactly how much plaque you have in your whole heart, or per vessel, or per segment, further break that down or categorize it into the different kinds of plaque, because there are different kinds of plaque. There’s hard plaque, which is the inert, I call it the extinct volcano, right? Evidence there was an eruption, there was a volcano, it was was active, but is now old and has now become inert, and doesn’t rupture, not growing, not active. More importantly, we can see, and it’s really the only practical tool you can see it with, we can see the lava, the lipid rich soft plaque, the stuff that is growing active that can break off, flake off, we use the term rupture, and cause heart attacks, if that happens to be in the heart, or, in the neck, we call that a stroke. So the AI really does unbelievable things, And the big advent of AI does three amazing things that we could not do before, even with CT, as much as I love CT, what we call CT angiography.

[00:09:27 –> 00:09:45] Dr. John Osborne: In other words, using the CT machine to take an angiogram of the heart non invasively. AI allows us to see literally plaque we could not see before. We call it radiomics. It literally can extract data and make it visible to us what otherwise was invisible. So it can literally see plaque we can’t see.

[00:09:45 –> 00:10:14] Dr. John Osborne: And by the way, the plaque that was really difficult to see before is actually the lava, active growing lipid soft plaque. So incredible for that. Number two, precisely quantify it so we can know exactly how many cubic millimeters of plaque you have in your whole heart, And that becomes important because we now have a staging system, like cancer stage one, two, and three. And then thirdly, something we could never ever do before. And I know it sounds pretty like, well, of course, but we could never do this before.

[00:10:14 –> 00:10:38] Dr. John Osborne: We could now track plaque quantitatively over time. That was impossible to do until we had quantitative AI. So we can literally do a baseline now, or we’ve had people who had CAT scans in the past without AI, run both of those through the same AI, and go over time, either retrospectively or prospectively, is that plaque growing? Is it getting worse? Is it getting better?

[00:10:38 –> 00:10:55] Dr. John Osborne: Are we seeing regression? That was an impossible question to answer until we had the advent, just a few years ago, of quantitative AI to not just detect, but also very much quantify how much plaque there is.

[00:10:55 –> 00:11:20] Dr. Ravi Kumar: Yeah. That’s fascinating because, I mean, medicine runs on data, And that’s why we draw labs and we follow numbers. And, you know, plaque burden, coronary artery disease risk, has always been kind of an empiric evaluation. You know, you use these scoring systems or Right. You and you look at numbers and epidemiology, and you say this is your likely chance of having a cardiovascular event.

[00:11:21 –> 00:11:54] Dr. Ravi Kumar: But now you can actually physically look inside the artery, measure plaque burden, and basically assess someone’s risk at how the disease is progressing and and what their risk of cardiovascular events is. Now one thing I just wanna clarify for the audience real quick is what a plaque is. And I think most of my listeners will know what this is because I have a pretty smart audience. But so when you get an injury to the endothelial wall of a vessel, that’s the very inside of the the artery or the or the vessel. It’s actually under another layer called the glycocalyx.

[00:11:54 –> 00:12:53] Dr. Ravi Kumar: But when that’s injured, cholesterol and white blood cells go in there to repair it. And if that cholesterol becomes oxidized or if the the injury to that vessel wall is continuous and you have this continuous repair process, you form these plaques of it’s an accumulation of macrophages and lipids, oxidized lipids, that that can’t get out essentially. So over time, that can grow and grow and actually narrow the vessel and reduce blood flow, but that’s not the really the biggest risk. The risk is that if that plaque actually ruptures and opens up to the bloodstream, which is what’s flowing through the vessel, a whole bunch of these little molecules called platelets, these little cell pieces called platelets, will start sticking and binding to fibrin and form a clot. And that can block the blood through through the artery and cause a heart attack or a stroke, or it can actually embolize and go to a distance place.

[00:12:53 –> 00:13:22] Dr. Ravi Kumar: So if you get a a rupture in your neck, in the artery in your neck, it actually can go up to your brain and cause an ischemic stroke. So that’s the danger with plaque. And what doctor Osborne was saying is that, hey, these calcified plaques, they’ve run their course burnt out, and now the body’s done something called dystrophic calcification, where it’s like basically walling off and saying, hey, we’re sealing this off. This was a problem, but we got it fixed. And those are the ones you see on coronary artery calcium scans.

[00:13:22 –> 00:13:22] Dr. John Osborne: Correct.

[00:13:22 –> 00:13:44] Dr. Ravi Kumar: But they’re not the dangerous ones. It’s the soft ones that you can only see with CT angiography in conjunction with AI that cause the problems because the soft plaques are the ones that rupture and create these embolic or these thrombotic events. So do you do any coronary artery calcium scans, or is it are you pretty much all CT angiography?

[00:13:44 –> 00:13:48] Dr. John Osborne: Yeah. No. No. Great question. And and by the way, Ravi, you’re hired.

[00:13:49 –> 00:14:08] Dr. John Osborne: Brilliant. Love it. You did a better description of all that, of plaque than I do. So a couple things about calcium scoring. We don’t do calcium scoring because if you come in to see us, we are going to answer the key question, do you have plaque of any kind, which we can see and document and categorize and quantify?

[00:14:08 –> 00:14:34] Dr. John Osborne: And here’s the practical part, if we did a calcium score, that’s a different scan than the cardiac CT scan. So we’d have to give you more radiation. And whether your calcium score was zero or not zero or some number, it really doesn’t matter, because we’re going to do the more definitive tool to come up with all those numbers. So we basically save the radiation, let’s just apply that radiation that we’re going to use. We’re always very, very cautious with using radiation.

[00:14:34 –> 00:14:49] Dr. John Osborne: And I will say the dose of radiation that we use for this in these Ferrari type machines is about 20% of a mammogram. Wow. So many women have mammograms every year, two years or so. Yeah. Over decades, right?

[00:14:49 –> 00:15:13] Dr. John Osborne: 40s to 70s or so, as I recall. We don’t have to do our scans that often, and we can obtain this beautiful high resolution three-dimensional imaging, which then we can do AI processing on, for a dose of radiation that is a small fraction of a mammogram with the equipment that we have. So fortunately, radiation dose kind of really falls out. Calcium scoring is a great technology. We’ve been doing it since the eighties, by the way.

[00:15:13 –> 00:15:48] Dr. John Osborne: Its limitations are two major things. One, it sees plaque, but only the hard inert plaque. In other words, after the event has occurred, after the eruption has occurred, right? It can’t see the lava, the active plaque, as you pointed out beautifully, the plaque that is most likely to suddenly rupture and ruin your day or ruin your life, and whether that’s in the heart or the arteries in the neck. Depending upon the population age studies, anywhere between ten up to 50% of people with a zero calcium score will have significant lipid rich plaque that a calcium score will miss.

[00:15:48 –> 00:16:09] Dr. John Osborne: So you can have lots of false negatives. The other main thing calcium score doesn’t do, whether that score is zero or not zero, And when I think of calcium scores, it’s either zero or not zero. The only normal score is zero. Drives me crazy when I hear well, I apologize to anybody out there, but when when I hear colleagues say, oh, it’s a low calcium score. Okay?

[00:16:10 –> 00:16:18] Dr. John Osborne: That’s kind of like you saying, Ravi, it’s just a little glioblastoma. It’s not much at all. It’s barely there. Right? Well, it’s the disease.

[00:16:19 –> 00:16:42] Dr. John Osborne: So I’m going to say zero or not zero for a calcium score. Obviously, 10, a 100, a thousand is different, but zero, not zero. But again, tells me nothing about the lipid rich plaque, the active plaque, the plaque that can rupture. And also, by the way, tells us nothing about blockages. You could have an enormously high calcium score, and we see guys, more typically guys, women too, that walk in with calcium scores at 2,000 or 3,000.

[00:16:42 –> 00:17:11] Dr. John Osborne: They think they need bypass surgery. They’re writing out their final wills, getting all their affairs in order. And of course, we’ll do cardiac on them, and we’ll find there’s a lot of plaque, but it’s mostly hard, and it’s all out in the wall of the vessel in the donut, not encroaching upon the donut hole. And again, you have no idea with your calcium score, whether it’s zero or very, very high, is there a block or not? And we get all of course, we get all that data free, if you will, or included when we do the our AI exams.

[00:17:12 –> 00:17:28] Dr. Ravi Kumar: Yeah. So that yeah. So coronary artery calcium scan, that’s what everyone hears about pretty much. And if you want to score a zero because it basically predicts a very low risk of cardiovascular event. But what you’re saying that there’s 10 to 15% of people who have a

[00:17:28 –> 00:17:29] Dr. John Osborne: 10 score of to 50.

[00:17:29 –> 00:17:31] Dr. Ravi Kumar: 10 to fifty, five zero.

[00:17:31 –> 00:17:56] Dr. John Osborne: It’s five zero, not fifteen, ten to 50. It’s my mumbling, I apologize. But yeah, it’s 10 to 50, and you leave with a zero calcium score going, I’m great. I will tell you, this is my own personal experience, a while back, probably at least 10 years ago, there was a woman in her 50s that had a calcium score of zero, and I said, That’s great. No, this is long before we had AI and all that.

[00:17:56 –> 00:18:13] Dr. John Osborne: I said, Okay, zero calcium score. That’s great. It must have been two months later she had an MI. So no, had we done cardiac CT, if AI existed back then, we would have said, Yeah, it’s zero, because it’s all the nasty lipid rich soft rupture plaque. Right.

[00:18:13 –> 00:18:17] Dr. John Osborne: And it would have changed, you know, my recommendations for her. So Sure.

[00:18:17 –> 00:18:43] Dr. Ravi Kumar: Yeah. So basically, CT angiography with AI is the is the next step up in predicting and and analyzing and quantifying cardiac or atherosclerotic disease. I wanna jump back to this, the radiation question again, because that that kind of really blew my mind that, you know, most people are don’t want CT scans because of the radiation dose.

[00:18:43 –> 00:18:43] Dr. John Osborne: Sure.

[00:18:43 –> 00:18:50] Dr. Ravi Kumar: It’s the the highest dose radiation machine we have hospital. Can do some fluoroscopy for a long period of time.

[00:18:50 –> 00:18:53] Dr. John Osborne: External beam radiation. Yeah. External well, if you’re treating tumors, yeah,

[00:18:53 –> 00:19:09] Dr. Ravi Kumar: that’s different for sure. But but CT scans and it’s not it’s not negligible with CT scanners. If you you can look at children and count the number of CT scans they get before the year of one and then see a correlation with lymphoma rates and things like that.

[00:19:09 –> 00:19:10] Dr. John Osborne: Yeah, absolutely.

[00:19:10 –> 00:19:33] Dr. Ravi Kumar: Adults, there’s less risk with adults because we’re developed and our cells are more mature. But when you said that a CT angiogram is less than 30% of a mammogram, that makes it almost like a no brainer. Hey, here’s this low radiation, very accurate way to know if you have something that kills a majority of Americans. I mean, kind of blows my mind.

[00:19:34 –> 00:19:56] Dr. John Osborne: No, agree, right? I think, again, everything we do in medicine is always risk versus benefit, right? And I will say roughly about one in three women will die of cardiovascular disease. They’re getting their mammograms every year, or two years or so, for decades, which absolutely is perfect. Hopefully that’ll continue to evolve as technology evolves into non radiation techniques.

[00:19:56 –> 00:20:25] Dr. John Osborne: But we’re going after the disease that kills 10 times more women, year in, year out, strokes and heart attacks, with technology that, to put this into layman’s perspective or anyone’s perspective, we can get these incredibly detailed high resolution images for the radiation cost of 20% of a mammogram. So I think that’s a good upside versus downside, risk versus benefit Absolutely. Analysis, as you pointed

[00:20:26 –> 00:20:39] Dr. Ravi Kumar: Yeah. Hey, guys. I created this podcast because there’s too much confusion out there. There’s too much noise, too many conflicting messages about our health. My goal was simple when I made this podcast.

[00:20:39 –> 00:20:57] Dr. Ravi Kumar: I want to cut through all of that and give you information that you can actually use. If that resonates with you, here’s how you can help. Leave a rating and a review on Apple Podcasts. Share an episode that resonated with you with someone else that you care about, and that’s how this show grows. That’s how we reach more people who are searching for answers.

[00:20:57 –> 00:21:18] Dr. Ravi Kumar: Thanks for being a part of this, and I appreciate your help. Okay, so let’s say you have a patient, they come in for a CT angiogram, they have no symptoms. You know, maybe their mother or their father had an MI, and they’re worried about it. They’ve had normal cholesterol their whole life, and they just want to know, hey, what is my risk? You do a CT angiogram.

[00:21:18 –> 00:21:33] Dr. Ravi Kumar: I’m I’m setting up a hypothetical here. So you do a CT angiogram, and you see significant plaque burden. First question I have is what qualifies as significant plaque burden, and then what do you do about it?

[00:21:34 –> 00:21:52] Dr. John Osborne: Yeah. So when we get the AI report, it will tell us two different ways of giving us an idea of the total plaque burden. We have two different measurements. One is just total cubic millimeters of plaque summed out throughout the whole heart, and that includes both hard and soft. It will then break it down into how much is hard, how much is soft.

[00:21:52 –> 00:22:30] Dr. John Osborne: There’s a third kind of plaque called low density noncalcified plaque. Tends to be pretty scarce, but when you do see it I talked about the lava, the soft lipid rich plaque. This other plaque, called low density non calcified plaque, which again tends to be more scarce, if you see that, that is a major, major risk factor for plaque rupture. So again, tells us a lot of very useful information, but we will get an output of cubic millimeters or something called percent athermobuline, just another way of getting a handle on the total plaque volume. And the risk is continuous, right?

[00:22:30 –> 00:23:10] Dr. John Osborne: If you, 1% of us, and this is I think a couple of striking statistics I’ll share with everybody, using what I call the microscope of AI, using cardiac CT, incredible resolution, coupled now with AI, 1% of us will be zero. So 99% of us, as I like to say, mere mortals, if you get in the machine, we will find plaque. So it is a continuum. We have three stages, which describe how much plaque there is, stage one, two, and three, stage zero is zero, stage one, two, and three. And the higher the stage, and these are measured in cubic millimeters, the higher the stage, the greater your risk over the next 10 years of a cardiovascular event.

[00:23:10 –> 00:23:38] Dr. John Osborne: So we validated all of this against events. If you’re in the highest stage or stage three, your cardiovascular event rate over the next 10 years is 40%. So four out of ten in the next 10 years, if we do nothing, we’ll go on to have a stroke or heart attack. And then stage two and stage one are lower risk. So we can understand that risk and then put them on the right pathway, because we’re not a scan and flee organization.

[00:23:38 –> 00:24:19] Dr. John Osborne: Obviously, we use incredible technology to get us important, incredibly important and relevant clinical questions. But then we work with patients once we know where they stand to work to reverse plaque, which we’re actually quite successful doing. And I will say now with quantitative AI, so we can actually document that. Usually after a couple years or so, kind of doing, you know, working with us, coming up with very customized, bespoke, precise strategies for the particular individual, generally we’ll see plaque reversal, not stopping, but plaque reversal, usually at least ten, 20% is pretty common. And we’ve seen up to 50% in a couple years.

[00:24:19 –> 00:24:44] Dr. John Osborne: Wow. A couple years. Yeah. And remember too, background rate of plaque progression, if we do nothing, if we don’t know about it, is about 10% per year. So in a couple years we can go instead of we can watch instead of having a 20% increase, as we’d expect if we didn’t do anything about it, to about a 20% reduction in the span of a couple years, which is incredibly exciting.

[00:24:44 –> 00:25:01] Dr. Ravi Kumar: Well, yeah. So I I do wanna ask what kind of strategies you’re using, but I have another quick question about something you said. That 1% of people with zero plaque burden, what do they look like? Are they mostly women? You know, it’s really interesting, and this is where I have

[00:25:01 –> 00:25:21] Dr. John Osborne: to be very, very humble, Robbie. Doing cardiac CT for 25 years, now with AI over the last six years, we were the first to begin to use AI, cardiac AI, the country, of course. And all of that, of course, is evolving rapidly. Here’s the layout, right? Again, 1% of us will be zero, yahoo, right?

[00:25:21 –> 00:25:30] Dr. John Osborne: We say, Hey, I’m so happy for you. You’re a zero, right? You’re great. Eat right, exercise, don’t start smoking. We’ll see you in several years, because you may not always be zero, but you’re zero now.

[00:25:30 –> 00:26:09] Dr. John Osborne: The opposite extreme, the stage three people we call severe, based on that plaque burden, which is a lot, a third of our patients getting in the machine for the first time, I feel fine, no symptoms, no chest pain, no angina. I like to say normal stress test last week, a third will be stage three the first time we image them. So I will be the first to say, I don’t know. This week, two interesting cases just from this week, a couple, both 62, married for 42 years, height, weight proportionate, good health, no bad habits, no diabetes, smoking, etcetera. He had a little bit of blood pressure, wasn’t being tended to, but it is now.

[00:26:09 –> 00:26:22] Dr. John Osborne: But she didn’t. They both came and got scanned, because they just wanted to know. They had family history of heart disease in both of their families. And she was zero after 62 years. Remarkable.

[00:26:22 –> 00:26:35] Dr. John Osborne: Yahoo, that’s great. He got in, again, no symptoms, no chest pain. He’d never had a stress test. By the way, their cholesterol levels were identical. They were both, their LDL for the record was 108, both identical LDLs, okay?

[00:26:35 –> 00:26:56] Dr. John Osborne: He got in the scanner, his total plaque volume was 1640. Stage three, heart disease, as we call it using quantitative plaque analysis, starts at 750. Wow. So two people, same cholesterol, same environment for 42 years, right? Exercise, diet, etcetera.

[00:26:56 –> 00:27:17] Dr. John Osborne: Zero or 1640. So I’m going to say, I don’t know. I think, yes, there is women more likely than guys can be zero. Younger people more likely than older people, but we had a woman this last year who was 86 years young, wanted to know zero. I would not have predicted that.

[00:27:17 –> 00:27:39] Dr. John Osborne: So I will say I am very humbled, and I do not know until you get the machine. I will tell you one interesting thing is now with hundreds of thousands of AI exams later, we and other partners have looked at the relationship of plaque to LDL, whether we look at LDL, non HDL, ApoB, Lp, and guess what? There’s no correlation. Yeah. I woulda guessed

[00:27:39 –> 00:27:55] Dr. Ravi Kumar: that because I think it’s multifactorial. It is. Yeah. So let me ask you this then. I know this is very, like, empirical and might not be based on studies, but have you ever seen low or no plaque in people with very high LDL cholesterol?

[00:27:55 –> 00:28:13] Dr. John Osborne: Yeah. So I I was just saying, two people on Monday I mentioned, the husband and wife, a woman I just talked to either today or yesterday, forget. Anyway, 48, had clear high cholesterol. So her LDL ran basically over 200. Her APOB, which is really what we look at, was 180, but still very, very high.

[00:28:13 –> 00:28:28] Dr. John Osborne: Right? I mean, into the familial hypercholesterolemia, had seen three cardiologists, had seen a lipidologist at Johns Hopkins, great place, and every one of them said, You need to be on drugs. Okay? She had done drugs before, done statins, had bad side effects, just couldn’t take them. Okay.

[00:28:28 –> 00:28:52] Dr. John Osborne: Hair loss and muscle aches and all kinds of crap. So she came to us, she found us, and they said and you know, she knew, We’re going to answer the most important question. Know what your cholesterol numbers are, that was known, but do you have the disease? And I always underscore this to people. Remember, lipids, cholesterol, and many other things, but lipids, really critical and central, are a risk factor.

[00:28:52 –> 00:29:03] Dr. John Osborne: They are not the disease, they’re a risk factor. What we start with is, do you have the disease? How much, where it’s located, what kind? Right? So we put her in the machine, she’s 48.

[00:29:03 –> 00:29:24] Dr. John Osborne: Now again, does a great job on diet, exercise, lifestyle, height, weight, proportion, doesn’t smoke, all those things. Right? ApoB of 180, LDL of 230, age 48, so 48 times around the sun to develop plaque, zero. That’s So I told her, two options. Watchful waiting, you do not have the disease.

[00:29:25 –> 00:29:33] Dr. John Osborne: Cholesterol is a risk factor. It has not gotten into your vessels. Yahoo. Diet, exercise, don’t start smoking. See you in a few years, make sure you’re still zero.

[00:29:33 –> 00:29:53] Dr. John Osborne: Get the can down the road. Nothing’s going to happen to you in the next few years. You don’t have the disease today, despite having risk factors. Or the other options we have now have lots and lots of drugs and tools, and one just got a new novel one, which is really mind blowing, just got approved yesterday by the FDA. Anyway, we have a very large toolbox of cholesterol lowering drugs beyond statins.

[00:29:54 –> 00:30:21] Dr. John Osborne: And I will say you can never be too thin, too rich, or have too low an LDL cholesterol. And if you think about twenty or 30 years of the same lady, same woman, yeah, I mean, probably at some point that cholesterol will catch up with her and she’ll start depositing black. But we could say definitively 100%, in her case, you’re a zero, my friend. And, it’s wonderful to be able to give people choices. A proactive approach, which is okay if you like, or just watch for waiting.

[00:30:21 –> 00:30:38] Dr. John Osborne: Either way, it’s fine. Nothing’s going That’s very cool. Again, our machines, we have the luxury and the honor of having Ferrari’s really amazing resolution, very quick scans, literally less than a second or less, and also very low radiation. Yeah. Okay.

[00:30:38 –> 00:30:47] Dr. Ravi Kumar: So I need a cardiac CT. I want to know. I think all my listeners need one, honestly. I mean, we haven’t even talked about you can do to reverse plasmidity.

[00:30:47 –> 00:30:51] Dr. John Osborne: Robbie, I just want to point out, we’d never talked before, never met before, no money passed hands. Okay? I just

[00:30:51 –> 00:30:55] Dr. Ravi Kumar: want to point out. Yes. No. No. I mean, we’re not dealing in the currency of money right now.

[00:30:55 –> 00:31:09] Dr. Ravi Kumar: We’re dealing in the currency of vitality and longevity. And this is something that honestly, I mean, the more I’m hearing about it, the more I’ve read about it, the more I think it should be on that schedule of preventative exam.

[00:31:09 –> 00:31:31] Dr. John Osborne: It will. As you know, you know this too, Ravi, medicine moves just like plaque at a glacial pace, right? The big problem in medicine is implementation. Amazing tools, data, literature, almost every week, if not every day. And then it takes 17 years to make sure that everybody gets those scientific breakthroughs.

[00:31:31 –> 00:31:46] Dr. John Osborne: So we’re horrible, horrible, horrible implementation. I will tell you, you know, I’m pretty good at reading the tea leaves, where things are going. I call it the Wayne Gretzky approach to cardiology. Don’t go where the puck is, go where it’s going to be. I’ve really been blessed to kind of have a good sense of where things are going.

[00:31:46 –> 00:32:06] Dr. John Osborne: So I agree, I think this will be standard of care. It’s not today. And we at Clear Cardio are just not going to let tens of thousands, hundreds of thousands of people have events, keel over, die. Lindsey Graham, and as an unfortunate, very famous person this last week, it just has to stop. And the key there are two key things.

[00:32:07 –> 00:32:29] Dr. John Osborne: Early detection, which we’ve never done. We do it for cancer. We don’t do it for heart disease, which kills about a million people a year in The US, even during the COVID eras. And then coupling that, so again, we’re not just come in, get a scan, here’s your data, good luck. We really closed the loop, 30 years in preventive cardiology, two doctorates, Harvard trained, seven boards.

[00:32:30 –> 00:32:39] Dr. John Osborne: So in our patients that have the disease, we’ll celebrate the zeros. They aren’t common, but we’ll celebrate that. We even give you a refund, by the way, if you’re a zero.

[00:32:40 –> 00:32:40] Dr. Ravi Kumar: It Oh,

[00:32:40 –> 00:32:42] Dr. John Osborne: keeps getting better. Yeah.

[00:32:42 –> 00:32:43] Dr. Ravi Kumar: I like that policy.

[00:32:43 –> 00:32:47] Dr. John Osborne: That’s Yeah. Kind That’s cool. I mean, hey, you know, yeah. It’s a reward. Even better data.

[00:32:47 –> 00:33:16] Dr. John Osborne: And then for those that do have plaque, then we will set up a personalized, bespoke, customized precision plan, given that person’s, whatever those person’s factors are, that is causing the plaque with the goal of plaque reversal. And then we put them back in the machine and see, not only are the numbers better, I like to say, which is really all we had before quantitative plaque CT, we go, Your cholesterol’s better. Was my plaque better? I have no idea. But your cholesterol’s better.

[00:33:16 –> 00:33:25] Dr. John Osborne: But we can now no longer stop at maybes, could bes, possiblys, but just facts. Here it is in 2026, there it is in ‘28.

[00:33:25 –> 00:33:43] Dr. Ravi Kumar: Okay. Yeah, no, that’s fantastic. So let’s talk about one of these bespoke plans. And obviously bespoke means it’s different for every person, but if you can kind of generalize what a plan to reverse plaque would look like in someone who’s got a positive cardiac CT.

[00:33:43 –> 00:34:14] Dr. John Osborne: Sure. Yeah, so one central thing, we kind of round up what I call the usual suspects, right? The big four modifiables, okay? But there’s a lot of others, but the big four, tobacco, and I will say tobacco generically, not just smoking, but I don’t care whether you smoke it, chew it, snort it, inject it, rub it on your skin, use a ziclonic. There literally are nicotine receptors on the endothelium that you were talking about earlier, that when activated, turn your vessels from Teflon into Velcro, and you do not want Velcro vessels.

[00:34:14 –> 00:34:30] Dr. John Osborne: Okay? So no form of tobacco is, and in fact out there, there’s a trend right now, which really is pretty frightening to me, where they’re talking about using nicotine patches as noetics to better, faster brain and memory and stuff.

[00:34:30 –> 00:34:31] Dr. Ravi Kumar: Oh, yeah, you and me are

[00:34:31 –> 00:34:32] Dr. John Osborne: Again, no both data on that.

[00:34:33 –> 00:34:35] Dr. Ravi Kumar: Know data, but podcast on that. Mean, Yeah.

[00:34:35 –> 00:34:44] Dr. John Osborne: Well, thank you. And, you know, there is no form of safe nicotine. Right? Mhmm. Some people say, well, I smoke a cigar.

[00:34:44 –> 00:34:53] Dr. John Osborne: You know? And I’m going to say, there’s just no form of safe nicotine. What you’re asking me to do is say, Dr. Osborne, I want to do a little bit of cyanide. How much is the safe amount of cyanide?

[00:34:53 –> 00:35:38] Dr. John Osborne: Yeah. Anyway, so tobacco, high blood pressure, which of course is, you know, connected to lots of other, maladies and cardiometabolic disease, insulin resistance, prediabetes, diabetes, all very, very important to understand, check out, understand, and modify. But I will say critical and central to everybody with plaque are lipids, because that is ultimately there, always there at the scene of the crime. So 100% of people, and I’ve seen, I’ve read articles in the cardiology literature, 33%, 50%, 60% of people with heart disease have high cholesterol. Well, anyone who has plaque, whatever your cholesterol is, whether it’s high or average or even below average, if you have plaque, if it’s getting deposited in your blood vessels, is too high for you.

[00:35:38 –> 00:35:58] Dr. John Osborne: Someone else may get away with it, but not you. So cholesterol management is absolutely critical, and then from there we sort of build it out. And then there are lots of other factors. Kidney disease plays a role here. A whole variety of inflammatory conditions, such as lupus, rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis.

[00:35:58 –> 00:36:47] Dr. John Osborne: So there’s a really large number of what we call risk enhancers that many of them we can treat, and also help use that understanding to further go after to attack the plaque. The other thing too is, and I don’t want to forget this, I don’t want to accuse me, it’s not just meds and all that, but it’s also absolutely 100% diet, exercise, lifestyle. So one of our other things that we have at Clear Cardio that I’m very proud of is an amazing, we call it the functional side. It is the lifestyle, diet, exercise, coaching, accountability. We have a whole separate program that’s open to all of our patients on the lifestyle functional side as well, because I think that’s the pillar of the preventative pyramid no matter what you do, but certainly critical to cardiovascular disease as well.

[00:36:47 –> 00:36:47] Dr. John Osborne: Right.

[00:36:48 –> 00:37:01] Dr. Ravi Kumar: Okay. So there’s a lot to unpack there. I’m going to ask you about each one individually, of if that’s okay, because I really want my audience to kinda understand all these things. First, let’s talk about the lipid lowering strategies. And I’m with you there.

[00:37:01 –> 00:37:10] Dr. Ravi Kumar: If someone’s developing vessel disease, atherosclerosis, they are depositing cholesterol in their arterial walls. That’s just

[00:37:11 –> 00:37:13] Dr. John Osborne: it’s is that’s what always it there at the scene of the crime, and not by accident.

[00:37:13 –> 00:37:45] Dr. Ravi Kumar: And that doesn’t mean it’s the causative factor, and you already mentioned that. But whatever you’ve got going on, it’s usually inflammation, metabolic health issues, you know, like smoking, high blood pressure, you’re damaging those vessel walls, and you have too much of the repair molecule getting embedded in the wall, and it’s causing a problem. So that when you’ve documented cardiovascular disease, that’s when you start wanting to lower lipids. Right. It’s fertilizer.

[00:37:45 –> 00:37:49] Dr. John Osborne: Right? It’s the essential fertilizer. You you can’t have plaque in the absence of cholesterol.

[00:37:49 –> 00:38:08] Dr. Ravi Kumar: You can’t have plaque with it in the absence of cholesterol. And you can’t have life in the absence of cholesterol too. Should just put that out there because cholesterol is in every cell membrane. All your hormones, your vitamin D, everything is those are all built on cholesterol. But it has to be in healthy homeostatic range for your biology.

[00:38:08 –> 00:38:19] Dr. Ravi Kumar: So let’s say someone has a problem with statins. They’ve tried several, they can’t tolerate them, they’re What developing artery do you do with those patients?

[00:38:20 –> 00:38:26] Dr. John Osborne: Yeah. Great question. So, you know, statins, as I like to say, we’ve got a very big toolbox. We got wrenches. We got flatheads.

[00:38:26 –> 00:38:35] Dr. John Osborne: We got Phillips heads. So this is again where it becomes very personalized to the patient. Statins, the advantages. We’ve had them for 40 years. They have certainly developed.

[00:38:35 –> 00:38:53] Dr. John Osborne: We have very good statins. The earlier ones had more side effects and issues, not nearly as potent, but we’ve had them for 40 years. They are tried and true. We have done more studies with statins than any other drug in the history of humanity. So I think we have a great, great understanding of the benefits, the harms, the side effects, etcetera.

[00:38:53 –> 00:39:04] Dr. John Osborne: And they’re cheap. So that’s the advantage. They’re easy, they’re cheap, they’re proven. Not everybody can take them or tolerate them. The great thing is up to about 20 years ago, that’s pretty much largely the only game in town.

[00:39:04 –> 00:39:32] Dr. John Osborne: Now we have a whole variety of other non statin drugs that not only lower cholesterol, some more, some less, not only lower cholesterol, but also have been proven to lower the risk of what people really care about, which is strokes, balloons, bypass surgery, heart attacks, and killing over dead. So we have a very large toolbox. Think interesting, a lot of our patients have been I’m not the first responder. They’ve been through lots of other people beforehand and hear different opinions. They’ll always say, I’m not going to take a statin.

[00:39:32 –> 00:39:43] Dr. John Osborne: I said, let’s first of all understand, do you have the disease? How much? Where it’s located? Get all that detail. Then let’s talk about what are possible solutions to this.

[00:39:44 –> 00:40:25] Dr. John Osborne: Right? And again, cholesterol is critical and central. It is the stuff that gets in the blood vessels, but there’s so many we’ll always address that, but there are also so many other ways of also further mitigating risk and layering on all of these other benefits on top of one another, which allows us, which is my goal, to try to ratchet that risk of cardiovascular events as close to zero as we can possibly get. Okay. And I will say, big news in the cholesterol lowering arena, we’ve got other non statin agents that are not statins, that don’t have the same cetaphric profile, ezetimibe, we have bempedoic acid, we’ve had PCSK9s for 11, we have a number of those.

[00:40:25 –> 00:40:46] Dr. John Osborne: And big, big news yesterday. And oral, all the parenteral drugs, these PCSK9 drugs, drugs like Praluent, Repatha, and a couple others, are all delivered via needles. You got to inject yourself, or sometimes you have to go into an infusion clinic every six months. The first oral PCSK9 was approved yesterday in The US, well, worldwide. Huge advance.

[00:40:46 –> 00:41:07] Dr. John Osborne: Now it’s a pill, delivers the same horsepower of LDL lowering, and also Lp lowering, by the way, and has placebo like side effects. Yeah. So we don’t even have enough time, but if I can tell you what’s in development in the preventative cardiology space, or even more specifically the lipid space, absolutely mind blowing.

[00:41:07 –> 00:41:28] Dr. Ravi Kumar: Yeah. So it’s- There’s some really exciting stuff coming. Mean, there’s antisense RNAs for LP, and Exactly. I mean, the the the fact that a PCSK9 inhibitor can come orally now is gonna open it up to a huge population of people that either couldn’t afford it or couldn’t just couldn’t do it logistically or don’t want an injection.

[00:41:28 –> 00:41:36] Dr. John Osborne: Well, and even these are injectable drugs, but they have a cold chain to throw on top of that. Right? Yeah. Got to keep them, right, they can’t get hot.

[00:41:36 –> 00:41:50] Dr. Ravi Kumar: So the oral PCSK9 is a big, big deal. So is it fair to say that there’s not a single person that you can’t push their lipids down? Absolutely. You can push everyone’s LDL Absolutely.

[00:41:51 –> 00:42:09] Dr. John Osborne: Okay. And a lot of times what we do is we start with a cocktail, right? And strategically, here’s why. Always better to use a couple drugs, or it could be three or four even, but a couple drugs at low doses, you’ll get much better cholesterol lowering and a much lower risk of getting side effects, right? Yeah.

[00:42:09 –> 00:42:16] Dr. John Osborne: So statin monotherapy, you know, here’s your statin, that’s it, is just not appropriate anymore.

[00:42:16 –> 00:42:17] Dr. Ravi Kumar: Yeah. Is it done? Sure.

[00:42:18 –> 00:42:36] Dr. John Osborne: Yeah. Not anything I would do. Yeah. And again, it’s understanding their ApoB, their LDL, their LP, all of those things help us determine where they’re starting from, how much plaque they have, where we need to go. All of those things kind of get cooked into this calculator, and then we say, ah, do X, Y, and Z.

[00:42:36 –> 00:42:50] Dr. John Osborne: And my goal rather than and it’s an annoying thing to me. A lot of times even people start drugs for cholesterol. They start a low dose and then they increase, and that doesn’t work. And, you know, a year later, your cholesterol is still not under control. We’ve drawn blood four times.

[00:42:50 –> 00:43:08] Dr. John Osborne: You paid for blood, blah, blah, blah. Still not under control. So one of the things that we do that’s a little different is, I know where your cholesterol is coming from, or how much what it what those values are. I know where I want to be. Let’s pull off the right combo off the shelf first time that gets us a bullseye, Right?

[00:43:08 –> 00:43:14] Dr. John Osborne: Yeah. No more missing the target anymore. So just, again, a lot of little stuff that we bring to the table.

[00:43:14 –> 00:43:30] Dr. Ravi Kumar: Yeah. No. I mean, that’s really neat. I mean, and folks, you’re hearing this from Dr. Osborne, Single statin monotherapy for cardio cardiovascular risk mitigation is not a thing anymore in a creative, open minded doctor’s hands.

[00:43:30 –> 00:43:43] Dr. Ravi Kumar: But that’s what most of us will get. It’s because, like we had talked about, I call medicine a freight train. Takes a long time to get going, and then Yeah. And then it’s hard to churn. And, you know, right now, medicine has to churn.

[00:43:43 –> 00:44:07] Dr. Ravi Kumar: And Yeah. That freight train has got all its momentum running down this, you know, monotherapy statin mitigation of cardiovascular disease and without preventive care. And so we need to get there, and it’s gonna happen. But, you know, if you’re listening to this, you you you can see that there are people out there practicing a more open minded, creative solution. And I think that’s perfectly how I describe it, Dr.

[00:44:07 –> 00:44:16] Dr. Ravi Kumar: Osborne, is very creative. You’re using all this data. You’re looking at things without an insular thought process, and I think it’s really cool.

[00:44:17 –> 00:44:33] Dr. John Osborne: Well, thank you, Ravi. And I will say, you know, two doctors, a PhD in cardiovascular physiology. I was fortunate enough to train at Harvard, wonderful place. I’m happier living in Texas, but Harvard’s a great place to do all my training. And so I am very scientifically based, right?

[00:44:33 –> 00:44:46] Dr. John Osborne: You know, there’s lots of stories, there’s lots of anecdotes. All of my decisions will be based on hardcore, double blinded, randomized, placebo controlled trials. So, you know, I’m very science based. You know? Yeah.

[00:44:46 –> 00:45:05] Dr. John Osborne: If it works and I see a study come out and I go, Oh, wow, this is really important. My practice will change the next day. So that new oral PCSK9, not even pharmacies yet, it won’t be in pharmacies for about a month, by the way. But I’ve already got a list of people ready to go. So we do not have inertia in practice.

[00:45:06 –> 00:45:21] Dr. John Osborne: If there’s important new science that happens, we implement that. And we, of course, weigh the upsides, downsides, how good the science that is. But when it’s a big breakthrough, like the oral PCSK9s, guess what? My patients are gonna get them tomorrow, or at least when they become available in pharmacies.

[00:45:21 –> 00:45:50] Dr. Ravi Kumar: Yeah. And randomized controlled trials are the way we prove causation and the way we prove, you know, prove basically treatment effect, but they don’t change medicine very quickly. Mean, it’s it’s our gold standard, and they come out and, you know, 10 years later, that’s when medicine starts to change. So I think it’s really cool that you don’t let inertia, you know, rule your practice. But, also, you know, doing things evidence based, I think, is very important.

[00:45:50 –> 00:46:15] Dr. Ravi Kumar: You can’t do things by empirical evidence. You have to do things on evidence. But there’s two other things that I think are very important that we combine in our practice, and I can see that you do that. One is common sense, using common sense to make decisions in conjunction with clinical data, and creativity. Open minded is maybe the better word to describe it is open mindedness or non dogmatic thinking.

[00:46:15 –> 00:46:49] Dr. Ravi Kumar: Because, you know, a lot of medicine, you know, what you learn in medical school and then what your, you know, mentors maybe taught you, that’s what you do for the rest of your practice. Yeah. That career might last 40 years, and you’re still, you know, doing what, you know, what your mentor did or what you learned in medical school. So I think it’s really important to find a physician that’s open minded, follows the evidence up to date, is open to making changes and saying, hey, I was wrong about this, or this the evidence told me to do this, but now the evidence is saying something different, so I’m gonna change my practice.

[00:46:49 –> 00:46:50] Dr. John Osborne: And

[00:46:50 –> 00:46:54] Dr. Ravi Kumar: those are the kind of doctors I look for for myself, and and I I can see And, that you’re doing

[00:46:55 –> 00:47:04] Dr. John Osborne: honestly, that’s the joy of medicine. Right? Whether you’re a neurosurgeon or me in cardiology or whomever in medicine is the joy. Right? The fact that it always changes.

[00:47:04 –> 00:47:31] Dr. John Osborne: It will constantly change, and for the most part, in the better. And what a wonderful thing to be able to understand this, talk the language, read papers, and then translate that into the healthcare of my patients, and not 10 years down the road, but when that data comes out. And, that’s the joy of medicine. I love to say, I suspect you too, Ravi, but I love to say, I’ve never worked a day in my life. I just get paid to do my hobby.

[00:47:31 –> 00:47:52] Dr. John Osborne: And, along the way, save some lives and strokes and heart attacks and stents and blooms and all those But, you know, I I will tell people my ultimate goal is to eliminate heart disease. Right? That’s the ultimate goal. No long way. If I help you out and nothing happens to you, and you become, or you have a, as I like to say, a medically boring life, yahoo.

[00:47:52 –> 00:48:13] Dr. John Osborne: Right? But I’m out to cure everybody and eliminate the heart disease. We really are coming to that. The key things, early detection, which we’re just not doing, and never have done in cardiology, with exception of maybe the calcium score, which is an okay tool, but it’s the mammogram. We’re doing the biopsy I like to express, right, as far as kind of the difference between those two.

[00:48:13 –> 00:48:28] Dr. John Osborne: There’s the known knowns. And then applying 40 years worth of data that we have about how do we affect and reduce and reverse, and can we? Yes, of course, plaque that kills roughly about 40% of us. For me, it’s every day is just joy. You know?

[00:48:28 –> 00:48:41] Dr. John Osborne: I love my patients. I love taking care of them. But where that joy comes from is really feeling like we’re really at the cutting edge of all of these technologies. And I wouldn’t want to be anywhere else, whether on the diagnostic or the therapeutic side.

[00:48:42 –> 00:48:55] Dr. Ravi Kumar: Yeah. Very cool. Well, let’s quickly go through some of these other things that you do, these modifiable risk factors. So hypertension, you talked about tobacco, or actually nicotine of all forms, including vapes and pouches Including all

[00:48:55 –> 00:48:57] Dr. John Osborne: vapes. Yes. Thank you. Yeah. Yeah.

[00:48:57 –> 00:49:04] Dr. Ravi Kumar: Right. And one thing I’ll mention there with nicotine, I have nicotine affects the spine, so I see a lot of degenerative spine problems from

[00:49:04 –> 00:49:06] Dr. John Osborne: nicotine, all forms of it. Mhmm.

[00:49:06 –> 00:49:25] Dr. Ravi Kumar: But there’s something around the big arteries called vasovasorum. It’s it’s it is the arteries that feed the arteries. So the arteries, they need blood flow into their muscular layers that surround them. And and those vasovirsorum are they’re they’re small diameter, and nicotine is a potent vasoconstrictor. Yeah.

[00:49:25 –> 00:49:43] Dr. Ravi Kumar: It that means it causes makes the vessels pinch down. And so small vessels have more downstream effects than large vessels when exposed to nicotine. So I think that the arteries are becoming becoming a little ischemic from Oh, 100%. Yeah. Vasorum coming I

[00:49:43 –> 00:50:20] Dr. John Osborne: I mentioned how we turn the lining of the vessel, you know, from Teflon to Velcro, but they have so many other adverse events. And when we talk about cancer, I’m just going to keep this in the cardiovascular space. And I will say, again, just one thing about smoking. I think a frightening statistic for abdominal aortic aneurysms, right? The three main drivers, being a male, sorry, it is what it is, having high blood pressure, which obviously can be treated, diagnosed and treated, and having smoked more than 100 cigarettes in your lifetime.

[00:50:20 –> 00:50:32] Dr. John Osborne: That’s five- More, yeah. Not five cartons, that’s five packages of cigarettes, just to illustrate a potent factor tobacco is for that particular vascular disease. Yeah.

[00:50:32 –> 00:50:36] Dr. Ravi Kumar: If you smoke, still quit. It doesn’t matter how much you smoke in the past, still And I

[00:50:36 –> 00:50:50] Dr. John Osborne: will say for cardiovascular events, if you quit smoking or using tobacco, it’ll be broadly, in one year, you lower your risk of a cardiovascular event by 50%, just from that. Forget treating cholesterol, diet, exercise, weight loss, right?

[00:50:50 –> 00:50:53] Dr. Ravi Kumar: Could you imagine if we had a pill or a drug that did that? Yeah. Would be

[00:50:53 –> 00:51:01] Dr. John Osborne: a blockbuster. Exactly. 50% in one year. Right? Massive discount available every time you don’t do that.

[00:51:02 –> 00:51:17] Dr. Ravi Kumar: So tobacco’s very hard to quit. Nicotine is the third most addictive drug in the world, and I know we have some listeners in there that maybe use nicotine. Maybe it’s a pouch, something that you think is not not very harmful, but it is. There’s a drug called varenicline. It’s usually called Chantix.

[00:51:17 –> 00:51:34] Dr. Ravi Kumar: It is very effective, and the side effects are usually pretty tolerable. Some people can’t tolerate the side effects, but most of my patients who want spine surgery, I won’t operate on them if they’re using nicotine. I prescribe them Chantix, varenicline, I would say 90% of them can quit smoking.

[00:51:34 –> 00:51:38] Dr. John Osborne: Yeah. No. I agree. It’s it’s a phenomenal drug. We have an older drug called Zyban or Wellbutrin.

[00:51:39 –> 00:52:00] Dr. John Osborne: Not nearly as effective, but Chantix is the old brand name, or varenicicline. Just amazing. It’s a wonderful Yeah. Yeah. And I will tell you, this is funny, in just today’s journal, American College Cardiology, is a really fascinating trial using that same drug, the smoking drug, but for people who have these frequent PVCs that can drive people crazy, they can be really, really frequent.

[00:52:01 –> 00:52:16] Dr. John Osborne: That drug, via blocking the acetyl nicotine receptor, lowers PVCs by 60. Wow. Yeah. Nothing to do with smoking. But an interesting article I just literally saw a few minutes ago before I joined you, so wow.

[00:52:16 –> 00:52:31] Dr. Ravi Kumar: That’s another thing that AI is going do, Dr. Osborne. It’s going to repurpose drugs Mhmm. For other conditions. Because, you know, the human mind can only recognize so many patterns and basically together so much data.

[00:52:31 –> 00:52:44] Dr. Ravi Kumar: But AI can look at these broad swaths of data and say, hey, the shape of this molecule fits the receptor involved downstream in this disease process. Try these two. See what happens.

[00:52:44 –> 00:52:44] Dr. John Osborne: Mhmm.

[00:52:44 –> 00:52:49] Dr. Ravi Kumar: And, you know, the next thing you know, we’ve got, you know, varenicicline treating PVCs and

[00:52:49 –> 00:52:52] Dr. John Osborne: that we never would have anticipated.

[00:52:52 –> 00:52:52] Dr. Ravi Kumar: Yeah, yeah.

[00:52:52 –> 00:52:54] Dr. John Osborne: So, yeah, it’s a great era So to be

[00:52:55 –> 00:53:03] Dr. Ravi Kumar: let’s talk about diet and lifestyle. What are you recommending as far as exercise? What are you telling your patients to do, and how are you telling them to eat?

[00:53:03 –> 00:53:26] Dr. John Osborne: Yep. So exercise, you know, I take a very broad, simple approach to that. I think many people kind of get into, if I don’t exercise just this and that, and do this perfectly in the right form, and X number of minutes, and this incline, and all that, I can’t do it perfectly, so therefore I won’t do it. My approach is to say, I want you to be active. I try to avoid the word exercise.

[00:53:26 –> 00:53:51] Dr. John Osborne: That sounds like a sentence. Okay? I say, be active, do something that can fit into your lifestyle easily, do it at least 30 minutes a day, most days of the week, that’s just straight from the American Heart Association of moderate exercise. And I tell people, find something that gets you active, that you like to do, or at least dislike to do, that gets your heart rate up gets hot and sweaty. Even walking, great.

[00:53:51 –> 00:54:11] Dr. John Osborne: Or, you know, again, the faster you walk, even the better. But we really work with people. We had a woman, we were just talking about it today in our functional group, that six months ago was having atrial fibrillation. She was a young woman in her early sixties, having atrial fibrillation, and she had some plaque, she was worried she’s going to die. If she moves, she’s going to die.

[00:54:11 –> 00:54:26] Dr. John Osborne: Anyway, so we started doing chair exercises with her six months ago. Fast forward now, she’s walking three miles a day. Wow. And her weight’s down, I mean, she’s a whole different person. We work with you.

[00:54:26 –> 00:55:07] Dr. John Osborne: Know, wherever you’re starting from, if you’re an incredible extreme athlete, Yahoo, we’ll work with you on that, of course. But more likely than not, we have a lot of people that just aren’t, and we’re going to meet you and work to find a exercise regimen, activity regimen that’ll work with you, and then of course work in accountability to increase that over time. On the diet side of things, it’s a fascinating area. I’m always going to go with the best data, the best science we have right now is really going to favor the Mediterranean type diet style, right? It lowers mortality, lowers cancer, lowers weight, reduces diabetes, treats diabetes, lowers cardiovascular events, of course.

[00:55:07 –> 00:55:35] Dr. John Osborne: So that probably is the single best diet. Or if you have hypertension, we usually recommend the DASH diet, which is really the Mediterranean diet, but low sodium and incorporating low fat dairy, which by the way, dairy actually lowers blood pressure. So those are kind of, in general, are sort of But it’s really working with a patient, accountability, meeting them where they’re at, you know, if you’re already exercising or maybe you’re really afraid to, and then just working with you to accomplish those goals.

[00:55:35 –> 00:55:44] Dr. Ravi Kumar: Yeah. Okay. Very cool. And I would add one thing about the Mediterranean diet, which is by far the most studied diet. It’s not low fat diet.

[00:55:44 –> 00:55:54] Dr. Ravi Kumar: It’s Oh, absolutely. Yeah. Generally a high fat diet. And, you know, both, you know, you and I came through the low fat craze. And that is that has changed, folks.

[00:55:54 –> 00:56:08] Dr. Ravi Kumar: The freight train of, you know, medicine and dietary recommendations might still be going down this partially in that low fat track, but no, fat is good for you, it’s the right type of fat that’s good for you, and that makes a big difference.

[00:56:09 –> 00:56:22] Dr. John Osborne: Yeah. A 100%. I love telling people, it shocks, still shocks some people, I’d say, eggs are health food. Enjoy your eggs. Or to paraphrase someone famous, if you like your eggs, you can have your eggs, as an example.

[00:56:22 –> 00:56:22] Dr. Ravi Kumar: Right?

[00:56:23 –> 00:56:23] Dr. John Osborne: A lot

[00:56:23 –> 00:56:23] Dr. Ravi Kumar: of

[00:56:23 –> 00:56:28] Dr. John Osborne: nutritional thought out there is just not correct.

[00:56:30 –> 00:56:38] Dr. Ravi Kumar: Yeah. Diet and religion, those two things. Right. Hard to talk about once you got your mind made up about Yeah, exactly. Okay, so great.

[00:56:38 –> 00:56:50] Dr. Ravi Kumar: So Dr. Osborne, let’s say some of my audience wants to get a cardiac CT. How can they get ahold of you, and can they come see you, or do they have to Yeah, great question.

[00:56:50 –> 00:56:54] Dr. John Osborne: Will say 99 of everything we do is all telecom.

[00:56:54 –> 00:56:55] Dr. Ravi Kumar: Okay.

[00:56:55 –> 00:57:24] Dr. John Osborne: And we’re licensed in over 35 states. So we can meet you, greet you, we’ll coordinate labs, all of that stuff. So, yeah, we’re as far away iPhone or your computer. And our scanners though right now are Dallas, Manhattan, Park Avenue, 60th, and then Miami Beach will be opening up in August in Scottsdale, and we anticipate towards the end of the year, San Diego and San Francisco. But we’re taking what we call the cancer approach to expansion.

[00:57:24 –> 00:57:37] Dr. John Osborne: Want to be locally invasive and widely metastatic. Sorry about that. That’s a tasteless joke, but I can’t help myself. So we’re really going to take the power of prevention. We really do want to help to eliminate heart disease.

[00:57:37 –> 00:57:45] Dr. John Osborne: What we’re doing right now is just not getting us there. In fact, cardiovascular deaths have increased year after year ever since 2011.

[00:57:45 –> 00:57:46] Dr. Ravi Kumar: So

[00:57:46 –> 00:57:48] Dr. John Osborne: we’re losing the battle.

[00:57:48 –> 00:57:53] Dr. Ravi Kumar: Yeah, I know. And that’s despite all these people on statin monotherapies.

[00:57:54 –> 00:58:03] Dr. John Osborne: Exactly. And not just addressing insulin resistance and weight and hypertension and many, many other, inflammation, right?

[00:58:03 –> 00:58:41] Dr. Ravi Kumar: Yeah, I mean, that’s another thing we didn’t really talk much in-depth, is that metabolic disease, which is insulin resistance, it has dramatic effects on the arterial walls, and any inflammatory condition you have in your body will cause that as well. You mentioned it with psoriatic arthritis and ankylosing spondylitis. These are inflammatory conditions, And really, vessel wall damage is is a form of inflammation. So if you have systemic inflammation because you’re not taking care of yourself, the arteries are gonna be knee in need of repair, and cholesterol is gonna go try to do it. And that’s where arterial disease happens.

[00:58:41 –> 00:58:44] Dr. Ravi Kumar: But Yep. Absolutely. Okay. So how can people get ahold of you then?

[00:58:44 –> 00:59:17] Dr. John Osborne: Yeah. So a couple things I’ll say. Clear Cardio, c l e a r, clear cardio, c a r d I o, clearcardio.com. And on the educational side, we have, I think, well over a 100 videos now out on YouTube. So just go to YouTube, Clear Cardio, lots of stuff, lots of cool educational stuff, lots of cool patient interviews, lots of lots of great stuff there for for people that want to know more about everything from heart disease and hypertension and diabetes and plaque and cardiac CT, lots of great educational things, and then prevention, topics as well.

[00:59:17 –> 00:59:29] Dr. John Osborne: So clearcardio,uh,.com or clearcardio on YouTube. And I think we’re on I don’t handle our social media, but I think we’re on pretty much all the the other social medias. But just search under clearcardio, and we’ll pop up.

[00:59:29 –> 00:59:38] Dr. Ravi Kumar: Okay. And I’ll put the links in the show notes so people will Appreciate have that. But, yeah, thanks so much for coming on the show, Dr. Osborne. It’s been very enlightening, honestly.

[00:59:38 –> 00:59:49] Dr. Ravi Kumar: And I think I mean, I’m enlightened, and I know my audience is gonna be enlightened. This is a new paradigm for treating or for preventing cardiovascular disease. So I’m I’m super excited.

[00:59:49 –> 01:00:12] Dr. John Osborne: Yeah. I’m I’m looking forward to the time, hopefully not too far in the future, where when you’re talking to medical students, you’ll tell them, yeah, we we used to put catheters and tubes in their heart and put stents and push that plaque to the side. And and worse yet, we used to cut them right down the middle and open their chest up and do bypasses, and they go, that’s unbelievable. That’s that’s crazy talk. You guys used to do that?

[01:00:14 –> 01:00:36] Dr. John Osborne: And I’ll say, yeah. And then we determined, let’s find it decades before we get in trouble, take care of it. Just like a polyp, you find the polyp, you take care of the polyp, you don’t get cancer. So all the parts are in place, and they’re only getting better month after month, really, for cardiovascular eradication. And, we just want to lead the pack.

[01:00:37 –> 01:00:39] Dr. Ravi Kumar: Yeah. Well, that’s fantastic. Thanks so much.

[01:00:40 –> 01:00:46] Dr. John Osborne: Ravi, thanks so much. Dr. Thanks so much for having me on. Really, really appreciate it. Thanks for having me on.

[01:00:46 –> 01:01:08] Dr. John Osborne: And as I love to close out every talk or every thing I do, I want to eliminate heart disease. And really what I’m asking you and all your audience to do, hopefully, you know, things have hit home today. We love doing what we do. We think ClearCart is the best. But I I would encourage you, if you have risk factors, family history, or any of those things, please, please, please get checked out.

[01:01:08 –> 01:01:30] Dr. John Osborne: Yeah. By the way, we didn’t discuss it. Stress tests, I shouldn’t I shouldn’t throw this in at the very end. Stress tests, I will tell you, coming from a preventive cardiologist, are absolutely useless. The value of a stress test is to the doc or whoever does it because they lack a Ferrari, a Lamborghini, a Cessna, a lake house, or a boathouse, or a So

[01:01:30 –> 01:01:32] Dr. Ravi Kumar: It’s certainly a crude tool when compared to

[01:01:32 –> 01:01:50] Dr. John Osborne: the It’s horribly crude tool. I stopped doing those and invasive heart cast angiograms over 20 years ago. It’s all done with Yeah. Cardiac So anyway, my goal, eliminating heart disease, and really what I’m asking you and all of your listeners to do is humbly please put me out of business. Okay?

[01:01:50 –> 01:01:53] Dr. John Osborne: Put me out of business. That’ll make me very happy. Okay?

[01:01:53 –> 01:02:09] Dr. Ravi Kumar: I actually think they’ll put you in business because you’ll be doing the preventative side of it. Be putting your colleagues out of business. That’s who they’ll be putting out of business. So okay. So, yeah, I always tell everyone, including and this is the a motto that I live by, lowest risk, highest reward, do it.

[01:02:09 –> 01:02:32] Dr. Ravi Kumar: Yeah. If it’s if it’s low risk and the rewards are tremendous, I e saving your life, why not? Know, do 100%. I do high risk, high reward things all the time with neurosurgery, but I’m all for doing the lowest risk, highest reward thing to prevent health problems or treat health problems. And this is one of them, for sure.

[01:02:32 –> 01:02:40] Dr. John Osborne: Yeah, we appreciate it. Ravi, thanks so much. Was a real honor. And I’ll tell everybody. So Ravi’s going to be on my podcast.

[01:02:40 –> 01:02:52] Dr. John Osborne: So if you want to hear more about Ravi, who is a fascinating guy, we’re going to learn all about his story and his philosophy as well. So we’re going to do podcast swapping here as well. So tune into that too.

[01:02:52 –> 01:02:54] Dr. Ravi Kumar: All right, cheers, Dr. Osborne. Right,

[01:02:54 –> 01:02:55] Dr. John Osborne: take care. Bye bye.

[01:02:55 –> 01:03:12] Dr. Ravi Kumar: All right, bye. Okay, so that conversation with Dr. Osborne really changed how I think about my own heart, and I have a feeling it did the same for you. Okay, so here’s what I want you to walk away with. You can find heart disease before you have any symptoms.

[01:03:12 –> 01:03:38] Dr. Ravi Kumar: It is a simple cardiac CT. I liken it to breast cancer. You get a mammogram every year to see if cancer’s present, and if it is, you cut it out before it becomes a thing. Same thing with heart disease. You find these plaques that could take your life if they progress using a simple cardiac CT, and then you treat it so that it never becomes a symptomatic problem in your life.

[01:03:38 –> 01:04:05] Dr. Ravi Kumar: There’s also several lifestyle changes that you should be making, and I’ve talked about this several times on many of my episodes. One, quitting tobacco in any form counts. Your cardiovascular disease risk halves within a year after quitting. Also, walking most days, eating real foods, and getting your blood pressure under control all move the needle before you spend a single dollar on any therapy. Now, if you want the level of detail that Dr.

[01:04:05 –> 01:04:27] Dr. Ravi Kumar: Osborne was talking about, that’s what the cardiac CT and AI plaque analysis is for, I’ll put a link to Clear Cardio and his YouTube channel in the show notes. Also, if someone in your life has a family history of heart disease or just assumes that a normal stress test means they’re in the clear, send them this episode. That’s exactly who it’s for. Okay, folks. Cheers, and I’ll see you next week.