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Dr. Soram: Well, welcome everybody, this is Dr. Soram and I have a very special guest to interview today. Dr. Ron Karlsberg is a clinical professor of medicine at the David Geffen School of Medicine at UCLA, is an expert clinical interventional cardiologist. He has extensive experience in consultative cardiology, clinical research and is the recipient of 300 research grants in cardiology research. In addition, he has published over 200 peer review papers, book chapters, local, national and international presentations and is a frequent lecturer and a very much invited guest today. I am very grateful to have him. He has a special interest in digital medical imaging and is a consultant both to industry and has developed an acclaimed electronic medical record system. Today I’d like to welcome Dr. Karlsberg to my podcast to talk about some new developments in cardiology specifically something called a cardiac CT angiogram. So Dr. Karlsberg, please what is a cardiac CT angiogram.
Dr. Karlsberg: Well, good afternoon and thank you very much for inviting me to this program. A cardiac CT angiogram is a noninvasive office based study in which one can actually identify and diagnose the coronary arteries. Previous to this study, the only kind of study that was available to do this involved being hospitalized and a catheter placed in the artery, one day hospitalization with additional risk of morbidity and mortality. In some ways this study is quite revolutionary and is a game changer.
Dr. Soram: Well that’s very, very interesting. Now what is the difference, we’ve all heard of these calcium scores or EBCTs, what’s the difference between a calcium score and a cardiac CT angiogram?
Dr. Karlsberg: Well, there are two kinds of plaque, there is plaque which has been there for many years over the process of atherosclerosis and this results in calcification of the coronary arteries. This is an early stage of coronary artery narrowing and coronary artery disease. This calcification can be identified with a simple X-ray technique without injection, without an IV. It turns out that the volume of calcium that is in the coronary arteries is directly related to events. In fact if an individual does not have calcium in the coronary arteries, they have at least a 95% chance of not having any coronary event over the next five years. So even this test alone is one of the most sensitive and specific tests that we have for cardiac events.
Dr. Soram: Fantastic, now how does one go about…? What is the physical procedure, if one of our listeners goes and gets cardiac CT angiogram, what exactly is going to happen to him? You mentioned getting an IV, how does all that work?
Dr. Karlsberg: Well, the study we just spoke about is a calcium score that is often done in combination with the next study, which you mentioned which is the cardiac CT angiogram. The cardiac CT angiogram, now an IV is started, a very small amount of contrast is injected in the veins and the X-ray images are obtained with sophisticated CT equipment and the injection is timed so that the dye fills the coronary arteries. Then using enhanced computer software, we are able to create a three dimensional image of the heart and actually see the coronary arteries. This involves one test that is just beyond the calcium score. The advantage of the cardiac CT angiogram is get to see the entire structure of the heart, we get to see the muscle, often the valves and the coronary arteries, but in the coronary arteries, now we are able to identify the early plaque or noncalcified plaque which is the precursor of the calcified plaque. We are able to see even plaques which may be at risk or inclusion in obstruction that can cause heart attacks.
Dr. Soram: Yes and I’ve had patients that I’ve referred to that have had this and some of them have had no calcium but they have a significant amount of that soft plaque.
Dr. Karlsberg: Yes, so the soft plaque actually is perhaps the most important kind of plaque that we can identify. First of all this is an opportunity for treatment and second of all it’s probably the plaque that causes most of the damages. Most individuals with heart attacks do not start off with 90% obstruction, but they start off with a great abundance of plaque which ruptures and closes the arteries over a very short period.
Dr. Soram: That’s the important thing I want my listeners to understand that this soft plaque can rupture or break off and then it’s like closing off a water pipe if the artery gets closed off or included. Ron, what do you see is the advantage of the CT Angiogram over a simple cardiac treadmill test that is so common in our society?
Dr. Karlsberg: Well, exercise stress tests are very helpful because they are a general screening study and there is about four or five different kinds of exercise stress; a regular stress test, an exercise test where you image the heart with ultrasound, exercise test on a bicycle and an exercise test with pharmacological agents or the most sophisticated exercise test where we use nuclear imaging. In general exercise test are the measure of the consequences of reduced blood flow, so once an exercise test is abnormal the arteries are likely to be 80, 90 percent or more severally blocked. The other problem with exercise test, and I’m sure your listeners recognize individuals like President Clinton, who had regular exercise tests, is that it can miss narrowings and it can miss even serious disease, so serious disease can be missed by exercise test. The best use of an exercise test is to measure the effects of narrowing, once you know that narrowing is present and then to use an exercise test to determine whether or not medical therapy, surgical therapy, dentine therapy or no therapy is indicated.
Dr. Soram: Very good explanation and I think… Then you mentioned the nuclear treadmill test often called Thallium or sestamibi, does that kind of account for advantage of the CT angiogram over these nuclear studies as well?
Dr. Karlsberg: I don’t know if I want to characterize one test as superior to the other but I think what is important is the ordering of test and that’s the subject of a great deal of research, which test should be ordered first, which test should be ordered when. Keep in mind that cardiac CT angiography is a new technology. There is an enormous database on the nuclear test that you mentioned over the last 20 years. So we know these tests do serve an excellent purpose in prognosticating and helping us make treatment decisions. So we have to be cautious about integrating the new test and still not lose the knowledge base and advantages of the exercise test. I wouldn’t describe them as necessarily competitive, but the proper use of them and combination where one test without doing mutuality of testing, those are the important issues that we have to understand.
Dr. Soram: A question my patients often ask me because I order, as you know, the CT angiogram as a screening test at my office for people over 50, do you think that Tim Russert, who died at age 58, he was the host of Meet the Press, do you think that if he had a CT angiogram he might be still alive today? As a routine screenings CT angiogram I mean.
Dr. Karlsberg: Alright well, I rather not discuss the Tim Russert case because I don’t know all the details of that, but let’s just take the fact that exercise stress testing can miss serious disease. That you can have a subtotal narrowings, you can have narrowings of the main artery, you can have narrowings of all three arteries. The one advantage or one of the advantages of cardiac CT is that it never misses serious disease. You can on occasion be on a situation where you can’t see the disease or it’s not an adequate study and additional testing is necessary but given, if it’s a good study, if it’s well performed at a high quality center and interpreted by a certified individual who is familiar with this technology, you will not miss serious disease and exercise testing underestimates the amount of atherosclerosis. Keep in mind, the exercise test is only helpful if there is 80 to 90% narrowing, if there is a 65% narrowing with noncalcified plaque the exercise test would not see that, that plaque could rupture and cause an acute infarction.
Dr. Soram: Yes, very well explained, thank you. Now something that my patients often ask me is two things, are there any risks to getting a CT angiogram and the second thing is how much radiation are they getting with a CT angiogram?
Dr. Karlsberg: Well, the risk is to a CT angiogram is very modest, it is the risk of course, is not zero. The main risk to a CT angiogram might if an individual is allergic to the contrast that we use, but we have medications that can be used to prevent any kind of contrast reaction and even individuals who’ve had contrast reactions, generally do not have any problems if they are properly identified and treated before the test.
Dr. Soram: The contrast medium is iodine?
Dr. Karlsberg: It is always an iodine related substance, although it may have a very small amount of iodine. The second risk is the fact that an IV is started, so individuals might feel a little discomfort. On very rare occasions, individuals can have complication from little needle insertions in veins and that extremely unusual.
Dr. Soram: Yes, so that wouldn’t be any higher than being in the hospital itself.
Dr. Karlsberg: No or giving blood at your office.
Dr. Soram: Yes exactly.
Dr. Karlsberg: We also use medications to prepare the heart; in theory these medications can cause complications in over 5,000 cases that we have performed here, as one of the earliest centers in the world to do this has had zero complications from medication use. Then there is always the risk of radiation that you discussed. Our center and other centers have invented ways to reduce the radiation by 90%. Today, a cardiac CT can be obtained at the same radiation level as a calcium score, which is a certified reasonable screening study and essentially can be translated into the kind of radiation that you receive on multiple airplane trips. So the radiation argument is essentially over, although there, you have to be careful what center you got to and have to understand that it takes a while for the information to reach the internet. I know a lot of patients look this stuff up and there is a lot of articles and concern about radiation use. Notwithstanding, that there seems to be a great increase in the amount of CT scans and we have to be certain that when we use CT technology which does use radiation and is an appropriate indicated screening test or appropriately indicated diagnostic test, in that these tests not be performed indiscriminately without considering the fact that individuals are exposed to a very small amount of radiation. We do not believe this radiation actually has any adverse effect the adverse effect is really one in theory that is extrapolated from different kind of radiation from survivors of World War II radiation.
Dr. Soram: Yes, I know that about a year or two ago, there was a big article in one of our big national newspapers that a lot of my patients read that really had scared them that I think did not clearly represent the low amounts that you’re describing with this test. I’m not sure if the author was fully informed at that time but as you said that with the internet and everything information moves fast as well as misinformation moving fast. Who typically gets such a test as a CT angiogram?
Dr. Karlsberg: Well I think the clearest indication is of course an individual who is having symptoms often described as chest pain or chest pressure. This is particularly true if they never had a diagnosis of coronary artery disease and the coronary arteries are unknown. Cardiac CT for that kind of individual might be the most specific and sensitive test and the good news about cardiac CT for that individual, if he has no plaque either calcified or noncalcified, which we described as soft plaque, then that individual is very unlikely to have a cardiac event in the next five years. In fact with a totally normal cardiac CT, the negative predictability, which is the terminology used in predicting when someone will not have an event, is 99%. It is actually higher than a coronary angiogram which is done in the hospital.
Dr. Soram: Really?
Dr. Karlsberg: Yes, because with the cardiac CT where you see the wall of the artery, the calcium and the noncalcified plaque and so many individuals have all sorts of chest pressure are very relieved to learn that they can’t have a heart attack. That simple study which is essentially done with seven seconds of acquisition reduces all the downstream testing that these patients have. That particular patient, not infrequently goes through a series of tests, maybe EKG, maybe blood work which is also necessary exercise testing consultation and the simple seven second test can tell you if he has disease and needs additional testing or does not. The second kind of patient who might require or might benefit from a cardiac CT is what we would call the A symptomatic individual. Now that is an area which we would call cardiac screening and the final word, the final answer on cardiac screening, whether it should be done with a calcium scan or not or with a cardiac CT, which is even more controversial, is still out there. From my point of view and the point of view from us in practice, we are able to see very dramatic changes when patients have screening cardiac CT and our research, we’ve shown several things. Number one, we’ve identified patients with plaque who would have normal cholesterol and who otherwise not be treated.
For some individual’s normal cholesterol is not good enough, they need almost a kind of cardiac chemo therapy that you might first start with holistic approaches and if that doesn’t reach therapeutic goals, you might need very small doses of medications. With screening we’re able to identify individuals and in our research and others, we’ve shown this can reduce the progression of disease. Thought at this point in time, although there is some doctors who do not advocate screening, I think the doctors who are involved in preventive cardiology and preventing disease, can use cardiac screening as a reasonable opportunity to identify who might have an heart attack in the future.
Dr. Soram: Yes, I have a patient about a year ago that actually referred to, you might remember, he is the president of one of the major studios in LA, he flies very often like at least once or twice a month long flights and he came into town with literally chest pain, right in the center of his chest, radiating down his left arm. Now he was only 45-years-old, so this… I referred him over to you and luckily that day there was an opening and you were able to do one of these CT angiograms and his arteries were completely and totally wide open. Subsequently, we realized that his chest pain was due to acid reflux but at the time it was a very ominous thing for the president of a studio to be having chest pain radiating down his left arm. From my point of view, we just cut to the chase with this scan which I know the imaging takes seven seconds but the in and out time that I’ve observed when I had the scan myself was total for the patient about 30 minutes between the time they arrive, they change their clothes. So in 30 minutes we were able to reassure him and he was literally able to go back to work as opposed to another situation, where years ago he might have been put in the hospital for observation.
Dr. Karlsberg: Yes and we also see individuals who have very strong family histories of premature arthrosclerosis and arthrosclerosis does have a genetic component to it. He may come in here with advanced genetic tests that you can purchase from Berkeley lab or whole other combination risks test indicating risk. All these surrogate measures, some of these individuals simply do not have the expression of the gene even at the age of 50 and 60. So this test can really be a life changer for someone who their whole life assumed they had Arthrosclerosis and will have coronary disease. That’s another circumstance where sometimes a negative test is helpful, of course we have the individuals who are the opposite who are really going to have widow makers in which exercise testing maybe equivocal and that’s another very strong indication for cardiac CT if an exercise test was done first and the exercise test suggests that there may be a blockage.
In the past these patients have been referred to coronary angiography, now they have the option of having a cardiac CT and in many cases Cardiac CT can replace a coronary angiogram. We have published data starting from 2005 and has shown this instance that cardiac CT has been integrated into the work up of the patient. We have reduced the number of diagnostic counts by over 50%. One cardiac cath costs approximately 20 cardiac noninvasive coronary angiograms. For every cardio cath you don’t do, you’re able to under the system you are able to afford cardiac CT. I mentioned the risk which is substantially is modest, I don’t want to scare anyone away from an angiogram, but there is modest risk in an angiogram where there is modest risk in an angiogram where there almost no risk in a cardiac CT.
Dr. Soram: You mentioned the word widow maker, just so our listeners know, what is that?
Dr. Karlsberg: Well if the coronary arteries look very similar to a tree and the main branches or the big branch or the tree limb itself down below, if that receives an obstruction all the branches down beyond the obstruction cannot get blood and if that involves a substantial amount of the heart muscle, should that artery close then the patient would be unlikely to survive. Cardiac, even exercise stress test can miss these sorts of very critical narrowings. Then these narrowings need not have any symptoms whatsoever. Most people who have their first heart attack, do not have significant symptoms weeks and weeks ahead, most of these individuals have only symptoms for a short period of time or no symptoms and then suddenly have a cardiac even when that artery closes.
Dr. Soram: Now, does insurance cover a cardiac CT and how does insurance look at this new technology?
Dr. Karlsberg: Well, the good news is that some insurances do pay for cardiac CT. We worked to present our original research in 2005, 2006, 2007 and in 2006 already Medicare provided a list of appropriate indications of which does not include screening, but does include reasonable use of the technology when it’s likely that it might obviate the need for a coronary angiogram. So Medicare generally does pay for cardiac CT both in patients who have known disease and in patients who have no disease. Now in recent years, some of these insurance carriers have agreed to pay but there are others and particular the majors which includes BlueCross which is the worst offender who refused to pay for cardiac CT, even if it would obviate the need for a coronary angiogram. We’re hoping…
Dr. Soram: Which is much more expensive?
Dr. Karlsberg: We’re hoping that this year that BlueCross will take up this test and find it reasonable. They tend to hire very conservative consultants and such. But none of insurance companies are at this point and time, are really willing to pay for screening and that’s true for the calcium score except when the three risk factors in Medicare patients or screening of cardiac CT or calcium score with minimum symptoms and few risk factors. Frankly, for those who can’t afford that study, that is probably the best study to determine if you are at risk of a heart attack but the insurance companies at this point and time are not paying for screening.
Dr. Soram: Yes and I’ve done some of the math and realized that if a typical 50-year-old man with mild risk factors for heart disease and did a CT angiogram, whatever that costs and you came out with a big zero and everything, as you mentioned earlier, he wouldn’t need another test for another five years. If you do the math of doing a simple treadmill test or maybe stress echo every year to two years, I would think the dollars would still be saved by doing the CT angiogram.
Dr. Karlsberg: Then there is those patients who have modestly elevated cholesterols, now I’m not speaking of pathological levels of cholesterol. You know we do want to treat patients with elevated cholesterol but if they are modestly elevated and they have no calcified or noncalcified plaque, these are individuals in which pharmaceutical medications for cholesterol treatment and or aspirin cannot improve their prognosis. We’re not advocating that all patients come off of their cholesterol medications, but we might be using different goals. There are individuals, that if they have calcified and noncalcified plaque, who actually need a form of what I would describe as cardio chemotherapy. We want to reduce the cholesterol to such low levels that there is actually a reverse movement of the cholesterol from the wall of the artery into the blood stream and not quite dissolving. We know in animal studies and some human studies using wires in the coronary that we are able to regress coronary disease by three, four percent a year as opposed to the normal progression of disease which is three or four percent per year.
So if you consider that it is almost a five or ten percent change in the progression of disease by getting that bad LDL, that bad cholesterol, down to 15 or 16. That we have new drugs available actually in our research foundation this month where the HDL can be increased by 130% and the LDL decreases an additional 100%. So we are testing this drug in patients with optimal treatment who had events, who’ve already have optimal treatment, to see if the envelope for reducing events can be pushed even further than we currently do with optimal therapy.
Dr. Soram: Beautiful, wonderful. I think I like that word cardiac chemotherapy because to get the LDL that low, like you are saying, around 50 requires very aggressive use of the statin family of drugs.
Dr. Karlsberg: It’s an aggressive use, but in individuals who have modest elevated cholesterol, it can be done without aggressive medications. In young healthy patients, very, very small and safe doses of these medications have very dramatic effects and sometimes we even use less than the prescribed dose. We may use a pill cutter, use half of the lowest dose and that patient is really exposing themselves to remarkably low risk and the risk benefit ratio in those patients is very high, who benefit from using these low dose medications which are very effective, really favors the treatment and use of these drugs.
Dr. Soram: Fantastic, this is just wonderful information Ron. Now, question that my listeners probably have and the question my patients ask me, they’re interested in this test the information that we get from it is so valuable, how much does this test cost if a person wants to pay out of pocket?
Dr. Karlsberg: Well, the test involves, is a little bit different than a radiology test. The test in our center includes an interpretation of the test with a patient viewing the images on the work station in three dimensions.
Dr. Soram: Wow, they can see their own heart while you are talking about it.
Dr. Karlsberg: They’ll see it in three dimensions, they can slide through the arteries, it’s colorized, we have had movie producers in here wanting to use this technology for a new fantastic voyage through the heart. So it comes with an assessment of risk, an interpretation of the study and in that scenario it is a $1,500 study. Now you can go out and purchase this study for less, but you have to be cautious that it is done with the proper timing, the preparation even, though the test takes seven seconds to run, 30 seconds to set up, the patient should be evaluated a head of time. Most patients receive should receive medications to make their heart very regular. You might consider this technology as the old cameras we had, we want them to hold still before we see the image. We need the heart rate regular at 60 and sometimes that we need medications to get that there, very safe and easy medications. We need patients, in addition, to be very relaxed when they come in, well hydrated and not on any diabetic drugs that may affect their kidneys. I’ve expanded the question a bit form the $1,500 dollar test, but I wanted to explain why it cost that much.
Dr. Soram: Sure, now if I’m coming in to do the test, are there any other preparations that I would you would recommend I do.
Dr. Karlsberg: Well the first thing that we ask is that you don’t schedule it on a busy day. This is not a test where you want to put on a very tight schedule, it takes some time. First of all, if it’s an insurance test, our office has to go and authorize the insurance carrier, often that’s done before you arrive. If the heart rate is just not perfect, we might want to adjust it a little bit with some oral medications or even intravenous medications. We want to be sure that you’ve had enough fluids that your kidneys are normal, we don’t want to use the contrast if your kidneys are abnormal. We want to make sure that you don’t have extra heart beats.
We want to be sure that risk benefit ratio favors doing this test. We have patients who come into the center which it’s not appropriate for them to have a test. They may have had a test three or four months before and they forgot and did not realize they had a test, we want to screen them so they don’t get the test unnecessarily a second time. So that’s pretty much what’s involved and then we want time to go over the test with them and time to be sure they are feeling well before they leave the center. That’s always the case that we’ve had really no complications and since 2005 when this technology was introduced to [inaudible 00:31:18].
Dr. Soram: Fantastic, what a great track record. If a person has this test, do they need additional testing of any sort?
Dr. Karlsberg: Well, if the test shows that the only blockages or no blockages and the blockages are less than 50%…
Dr. Soram: Less than 55.0%.
Dr. Karlsberg: Yes, then we would ask that this patient get medical management, get the form of chemotherapy that we talked about, chemocardiotherapy, It doesn’t have the same adverse implications as chemotherapy with cancer.
Dr. Soram: Of course.
Dr. Karlsberg: Pills for the heart and those patients might need no additional testing. We get a pretty good view of the muscles of the heart and the valves, occasionally some of these patients may need echocardiograms that measure blood flow across valves, but often they do not need to have an echo. They may or may not need a carotid testing. If the artery is completely clear and they have no plaque or symptoms they probably don’t need carotid testing. Although if they do have plaque, you might want to check the carotid because stroke is another reversible and preventable disease and so in this circumstance, they might need no additional testing other than blood testing.
However, if they have too much calcium, where we cannot see through the arteries and/or they have very severe symptoms, they may go on taking required exercise testing and in some circumstances patients will require the standard invasive angiogram that is performed in a hospital. In those circumstances, you can always be assured that the patients have serious disease or they have enough disease so the test is inaccurate and we can’t see how much disease they have. That happens infrequently but there are occasions where the invasive angiogram in the hospital is necessary and that’s still a very safe and appropriate test.
Dr. Soram: Yes, so would that be the main time that the CT angiogram might not be accurate if the plaque is very dense?
Dr. Karlsberg: If the plaque is very dense it might not be accurate but at least you identified the patient has disease. If the heart rate is very irregular you might see artifacts and if the patient moves during that seven seconds and doesn’t follow breathing instructions, it can lead to test that are not diagnostic.
Dr. Soram: This test by and large can replace most hospital based testing that is required.
Dr. Karlsberg: I wouldn’t say most hospital based testing I would say that in patients who have had mild symptoms or symptoms which were not clearly anginal in nature or from the heart, this test could replace angiogram in those patients or in patients who have equivocal exercise test. In the patient that has true cardiac pain that is very clear with no risk factors and no previous disease or if the artery is threatened to go on to closure with warning signs, those patients do need to be in the hospital, this test would not prevent that. Those patients most likely need go to the cardiac catheterization laboratory to precisely determine the status of the arteries to be certain that in an emergency opening would stance or sometimes even with bypass surgery, be sure that it’s not necessary. Patients who have true, very clear heart symptoms and risk factors and then biochemical or electrocardiographic evidence that the artery is changing, that it is getting there or is closing, those patients need expedient hospitalization. We wouldn’t stop to get a cardiac CT for those.
Dr. Soram: Right, I totally understand and my question originally and your answer was excellent was, asymptomatic patient who was just coming in and had a good score would not need to go into the hospital for any testing?
Dr. Karlsberg: No and this, in the research that we’ve done and others have validated, this test is most likely to reduce downstream testing.
Dr. Soram: Yes, now question patients ask me all the time, “Okay doc when do I get my next test?” and I think I would divide that question in two; when the patient has zero plaque and zero calcified or soft plaque or when a patient has mild to moderate plaque.
Dr. Karlsberg: When a patient has mild to moderate plaque and they’re had a cardiac CT, it might be that they require additional CT’s for some time. We don’t actually know the answer to that quest, but we would suggest is that periodically, we know that they have some narrowing and now we know we are looking for 80% narrowing while they’re on maximum medical therapy and those patients might be better served by exercise testing downstream and not repeat CT’s. If individuals have had no plaque, you could consider repeating a calcium score in three to five years and then if they have converted from zero to positive, that might have a slightly higher risk and those patients might require a little bit greater vigilance. The exception might be individuals who have stents or bypasses, in those cases we can use CT to see if the stents are open where exercise testing might not be as accurate. Patients can learn if their bypass arteries are open. We just published the longest and oldest series of cardiac imaging with bypass patients.
We followed some 300 patients over 30 years and in those patients who didn’t go to the cath labs, so they had fewer symptoms, 80% of the bypasses were open after that 30 years, which was a higher number than we knew about. So bypass surgery still can be a very effective therapy for individuals who have severe multi-vesseled disease which the stents or the angioplasties that were used are not going to be comprehensive enough. So CT in those circumstances maybe repeated at certain intervals depending on what the cardiologist and the internist feel is appropriate.
Dr. Soram: The person, just to reiterate, that came out with no plaque, you would recommend?
Dr. Karlsberg: Well, we would recommend modest cholesterol control. We certainly would use a number, for the audience to hear, LDLs. I think that the threshold where an LDL begins to be serious abnormal is above 120. If someone has no plaque, no calcified or noncalcified plaque and has an LDL of 160 or 170, I would like to see that LDL brought down to 100 at least or 130 would be nice to use in homeopathic approaches and dietary discretion get the LDL to the low hundreds. If they have disease, it’s a whole different situation in that circumstance, we want to see that LDL 60 and it may be that the LDL needs to be 40 and 30. The new study that we are doing will be able to achieve LDLs that are 30 and 40 and HDLs which were increased by 100%.
So we may actually see, may be the last heart attack for those of your viewers who didn’t have a chance to view the CNN production that described it, it was called the Last Heart Attack. You can see that if we start cholesterol therapy very early, prevent the disease and identify the disease with imaging, maybe we can beat this heart attack, maybe we have seen the last heart attack. I will tell you as an interventionist where I spent nearly a lifetime opening arteries that were diseased, in my own practice we are not seeing patients go to the cath lab. We’re not seeing patients with heart attacks after they become regular patients, we don’t see the kind of disease we used to see. I’m almost beginning to feel like a dentist during the cavity era, where a dentist used to have cavities and used to fill the teeth and now with fluoride and proper dental care, they are not seeing as many cavities, it’s beginning to feel that way.
Dr. Soram: That’s really wonderful, it’s really quite remarkable. I wish that the developments in some of the other fields of medicine, especially cancer, whereas progressive as these things that we are talking about right now, it’s wonderful. Common question, before we bring things to a conclusion, I’m trying to think of every question that my listeners might have is and patients ask me this, they have claustrophobia, can they get this test are they going to be cooped up in a tiny little chamber?
Dr. Karlsberg: Well, that’s the best part of this here; the ring the patients go through is not an MRI ring. There is a lot of confusion with patients that they are going to be… They may have had an MRI which is a very closed chamber and some patients have difficulty with this. They are never inside of the chamber, except as they are passing through for seven seconds which is basically one breathe hold. So they hold their breath and by the time they need to breathe again they are outside the chamber. The chamber is about four body sizes, so it doesn’t even come close to you. So it’s not a claustrophobic experience, we have never had a patient who was claustrophobic with this technology.
Dr. Soram: In my recollection, when I had the test, as opposed to an MRI where the chamber is about three or four inches from your face, the top of this scanner is about three or four feet above, away from your body as I recall is that about right?
Dr. Karlsberg: Yes, that is correct.
Dr. Soram: Yes, so it’s a big open giant donut it’s not at all a narrow tube. Good Ron, I think… One other question, are there any times when, I think we kind of discussed this, but anytime when the test should not be performed? You mentioned earlier people with kidney problems and perhaps diabetics on medication are there any other times…?
Dr. Karlsberg: Well we can deal with diabetics who are on medications by pretreating them. I would think that the most dangerous use would be in patients who have kidney abnormalities, in which this amount of dye could result in them even ending up with dialysis. So we’re asking, of course, that the kidneys be tested and the test be recent, before they get the contrast agent and that’s probably the greatest risk. The next greatest risk might be individuals who are allergic and we would describe really to the contrast which is also very rare. Again, with medications, it almost never occurs. Finally, all the other risks are really theoretical risks that really don’t apply to individuals; it really applies to large numbers of people and even the cancer risk. When we are talking about increasing the cancer rate by a certain percentage, say one percent or five percent, you’re changing the cancer rate and that’s even high but let’s use the one percent number. From a risk of cancer that anybody might achieve it might be 25%, if they had excessive medical imaging way beyond what we would have, maybe that would increase to 26%. So we’re looking at an incremental extremely small numbers and certainly there is no evidence that radiation is a real medical risk with this particular test. But kidney failure is the major risk only in those individuals who have abnormal kidney function to begin with.
Dr. Soram: Great information Ron. Well this has been most illuminating, I know from my listeners but also for me I learned a few very interesting things. Can you give us your website and I know that you’re the director of the cardiovascular research institute and you’ve developed and directed the CVMG advanced imaging center which we’ve been talking about today. If people want to learn more about you or learn more about your center, how can they find you?
Dr. Karlsberg: Well the best way is on the web at www.CardioVascularMedicalGroup.com and our research foundation is CVRF.net cardiovascular research foundation.net. Those are the two entities that support some of the research and activities and the clinical care and of course any of your patients can contact you and you know how to get ahold of us.
Dr. Soram: Yes and I will have those websites in the show notes with this show and then also if they want to contact you to make an appointment to see you as a doctor the information will be on your site as well, is that right?
Dr. Karlsberg: Yes, that’s correct.
Dr. Soram: Okay, great. Ron, this has been fantastic I’m so grateful to you for this and I look forward to talking with you, I’m sure about a patient during the week and I just want to thank you so much for coming on this show and helping everybody understand the power of this test.
Dr. Karlsberg: My pleasure and thank you very much.
Dr. Soram: Thank you.
About Dr. Soram Khalsa
As an MD, Dr Soram specializes in Integrative Medicine combining diet, nutrition, acupuncture, herbs and nutrition. Visit Dr Soram’s Healthy Living Store where you’ll find high-quality nutritional supplements:
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