<p><a href="https://peterattiamd.com/ethanweiss2/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=230320-pod-ethanweiss2&utm_content=230320-pod-ethanweiss2-podfeed"> View the Show Notes Page for This Episode</a></p> <p><a href="https://peterattiamd.com/subscribe/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=230320-pod-ethanweiss2&utm_content=230320-pod-ethanweiss2-podfeed"> Become a Member to Receive Exclusive Content</a></p> <p><a href="https://peterattiamd.com/newsletter/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=230320-pod-ethanweiss2&utm_content=230320-pod-ethanweiss2-podfeed"> Sign Up to Receive Peter's Weekly Newsletter</a></p> <p>Ethan Weiss is a preventative cardiologist at UCSF, an entrepreneur-in-residence at Third Rock Ventures, where he is working on a project related to cardiometabolic disease, and a previous guest on The Drive. In this episode, Ethan compares and contrasts the diagnostic imaging tools, CAC (coronary artery calcium score) and CTA (CT angiography), used to image plaque—including the latest in CTA software—and how these tools inform our understanding of ASCVD risk and guide clinical decision-making. Ethan discusses the types of plaque that cause events and the data that make a case for optimal medical therapy over stenting outside of particular cases. He explains why high blood pressure is problematic and walks through the data from clinical trials testing aggressive treatment. He talks about the best way to actually measure blood pressure, why we shouldn't simply accept that blood pressure rises with age, and how he uses different pharmaceutical agents to treat hypertension. Additionally, Ethan explains our current, but limited, understanding of the role of metabolic health in ASCVD. He discusses the impact of fat storage capacity and the location of fat storage and explains how and why there is still a residual risk, even in people who have seemingly normal lipids, don't smoke, and have normal blood pressure.</p> <p><strong>We discuss:</strong></p> <ul type="disc"> <li>Ethan's entrepreneurial work in the cardiometabolic disease space [4:30];</li> <li>Calcium scans (CAC scores) and CT angiography (CTA), and how it informs us about ASCVD risk [6:00];</li> <li>Peter's historical CAC scores, CTA results, and how one can be misled [10:45];</li> <li>How Peter's CTA results prompted him to lower his apoB [14:45];</li> <li>Calcium scans vs. CT angiogram (CTA) [21:15];</li> <li>How Ethan makes clinical decisions based on CTA results and plaque burden, and the importance of starting treatment early to prevent ASCVD [28:15];</li> <li>Improved methods of CTA to grade plaque lesions and how it's shaped medical decisions such as stenting [33:45];</li> <li>Why Ethan favors optimal medical therapy over stenting outside of particular situations [41:45];</li> <li>The need for FFR CTA, and the potential for medical therapy to eliminate ASCVD [54:00];</li> <li>The fat attenuation index (FAI) and other ways to measure inflammation in a plaque [57:30];</li> <li>Statins and exercise may increase the risk of calcification, but what does this mean for risk? [59:45];</li> <li>The root cause of statin hesitation despite evidence that statins are a profoundly important intervention [1:05:30];</li> <li>Importance of keeping blood pressure in check, defining what's normal, and whether we should just accept higher blood pressure with age [1:10:45];</li> <li>Blood pressure variability, how to best measure it, and data suggesting the enormous impact of keeping blood pressure down [1:21:00];</li> <li>Drugs for treating high blood pressure recommended by the ALLHAT trial [1:35:15];</li> <li>What the SPRINT trial says about the aggressive treatment of hypertension, and the risks of such treatment [1:38:15];</li> <li>Confirmatory results in the STEP trial for blood pressure, and how Ethan uses the various pharmacological agents to lower blood pressure in patients [1:43:15];</li> <li>The role metabolic health in ASCVD: what we do and don't know [1:51:00];</li> <li>The impact of fat storage capacity and the location of fat storage on metabolic health and coronary artery disease [1:56:15]; and</li> <li>More.</li> </ul> <p>Connect With Peter on <a href="https://twitter.com/PeterAttiaMD">Twitter</a>, <a href="https://www.instagram.com/peterattiamd/">Instagram</a>, <a href="https://www.facebook.com/peterattiamd/">Facebook</a> and <a href="https://www.youtube.com/channel/UC8kGsMa0LygSX9nkBcBH1Sg">YouTube</a></p>
Actionable Insights
1. ApoB Target for Atherosclerosis Prevention
Aim for an ApoB target between 30-40 mg/dL, using pharmacological intervention if necessary, to aggressively manage and prevent atherosclerosis. Do not wait for significant stenosis or high calcium scores to initiate treatment, as ApoB is a causal agent.
2. Achieve Optimal Blood Pressure (120/80 mmHg)
Strive to maintain blood pressure as close to 120/80 mmHg as possible, regardless of age, as clinical trials show significant mortality benefits. This is crucial for long-term kidney, heart, and brain health, provided treatment does not cause harm like dizziness or kidney dysfunction.
3. Accurate Blood Pressure Measurement Protocol
To accurately measure blood pressure, use an automated cuff in a quiet room, seated and relaxed, taking three measurements five minutes apart and averaging them. This method, used in clinical trials, provides a reliable baseline, and a 24-hour ambulatory monitor can offer a comprehensive assessment.
4. Prioritize Optimal Medical Therapy for Plaque
Focus on optimal medical therapy for plaque management, regardless of plaque characteristics or volume, especially in asymptomatic individuals. Stenting without symptoms has not shown benefit over medical therapy, which should be maximized to control the disease.
Understand that the location of fat storage (visceral vs. gluteo-femoral, indicated by fat mass ratio) is a critical indicator of metabolic health and cardiovascular risk, potentially more impactful than overall fat mass or smoking status. Aim to prevent fat accumulation in visceral and organ areas, as this is associated with worse outcomes.
6. Statins: Benefits Outweigh Calcification Risk
Understand that statins are a profoundly important intervention for cardiovascular health and may increase coronary calcification, but this calcification is not indicative of increased risk. The overall benefit in reducing cardiovascular events is clear, so do not let fear or misinformation prevent their use.
7. Avoid Smoking for Health
Eliminate smoking entirely, as it is an unambiguous and significant risk factor for cardiovascular disease and numerous other health problems. Not smoking dramatically improves overall health and reduces risk.
8. CT Angiogram for Detailed Plaque
Consider a CT angiogram (CTA) for a more comprehensive assessment of plaque burden, including soft plaque, which is not visible on calcium scans. Be aware it is more expensive and involves contrast and slightly more radiation than a calcium scan; inquire about the radiation dose as it can vary.
9. Calcium Scan for Initial Risk Assessment
Consider getting a calcium scan as a low-risk, inexpensive tool to assess existing plaque damage and overall heart attack risk. However, be aware that a zero score does not guarantee the absence of plaque, especially in younger individuals, and other risk factors should still be aggressively treated.
10. Tailor Blood Pressure Medication Choice
Prioritize achieving blood pressure control with first-line agents like thiazide diuretics, calcium channel blockers (e.g., amlodipine for ease of use), or ACE inhibitors/ARBs. For patients with existing atherosclerotic coronary disease or diabetes, ACE inhibitors/ARBs are often preferred due to their renal protective benefits beyond just lowering blood pressure.
11. Recognize Lipodystrophy Through Physical Exam
Be aware that visual inspection, particularly observing very skinny, muscular legs with a disproportionate pot belly, can be a crucial step in identifying lipodystrophy. Clinicians should undress patients to properly assess body fat distribution, as this condition is associated with severe metabolic and cardiovascular risk.