so plaques are dangerous for two reasons one they narrow the artery and can give you angina but the second one which is more important actually is cracking when the plaque cracks and you all know that I give my talks on why the plaques crack they crack because of inflammation in the plaque the plaque is almost like a pple and it bursts on the inside of the artery so you need an anti-inflammatory lifestyle you need an anti-inflammatory diet so that your plaques don't crack and cause a heart attack so when the plaques form in the arteries you definitely want to stabilize them you want to go on the anti-inflammatory diet anti-inflamatory lifestyle which we'll talk about that's a whole separate talk but if this artery Narrows down and now let's say that this plaque healed itself the guy didn't even know about it but now he's got a blockage here at what point does it reduce the blood flow cuz today's talk is about ffr when this blockage on average is greater than 75% narrowed that's when the blood here will be diminished now when the Blood starts getting diminished the p patients will one they may get chest pain pressure tightness heaviness when you walk you climb stairs you exercise you get a pressure tightness or you may get short of breath when you walk or you may feel palpitations all the or worse you may feel nothing the worst part is 80% of people who have a blockage more than 75 they don't even have chest paint so not having chest pain or pressure doesn't mean anything it just means that you don't have a proper angina warning system it's the guy who's getting chest pain when he's exercising he's lucky because he'll go to his doctor complaining of chest pain and this will come to attention the tragedy we have in America today is that many people have this blockage but they're not getting chest pain so they go undetected they go undetected and then one day when it completely shuts down they're getting a heart attack plaque should not rupture plaque should not be growing you can have plaque we can stop them from going anymore we can stabilize them and if the plaque is more than 75% it restricts flow why would I care if he not having chest pain right why would you care if he's not having a chest pain so what well the problem is this piece of muscle here when it's not getting enough blood supply you can run into an arhythmia and the muscle will also not work very well so if it's an arhythmia let's say that this patient runs up the stairs he can get an A rhythmia because the muscle is not getting enough blood supply so suddenly his heart goes into ventricular fation it passes out that's sudden death doesn't wake up until the parag Medics come and even then he may not come out of ventricular fibrillation so we consider about a rhythmia number two muscle damage that when this ejection fraction the pump gets weak the patients May complain of short of breath they may be going into congestive heart failure because that muscle is not getting enough blood supply so we see a lot of patients who come here we have shortest of breath and the ejection fractions are not so good the heart is weak not damaged it's not dead all it is is blockage and we improve the blockage and the muscle starts working again and then they're fine right so we are concerned about blockages because we don't want them to get in arhythmia and we don't want the heart muscle to get weak over time so it's important to know whether you have what is known as a flow limiting lesion this is a lesion right you want to know whether it is flow limiting is is it limiting my flow you have to know that so I do calcium scores on patients and if I see that the calcification build up then I want to know whether it's doing this which narr it or is it just sitting in the wall how do I do that I do a stress test right that's been traditionally what we do so when you do a stress test then you can tell by EKG with so all of a sudden he gets s ression on his EKG say say ah you're not getting blood supply to your heart muscle you plun your stress test you need further testing that's one way to do it the other way is a nuclear test so when you do a nuclear test what you do is injecting the radioactive material and you can show on the stress test that this artery is not getting enough blood supply but this artery that's on the side here that's getting plenty blood supply and the one at the back is getting plenty blood supply so you can see that on the nucleus stresses so that's how you tell if someone has a blockage or not so they have they have calcium it may be sitting in the wall or it may be narrowing the artery you don't know you want to know whether the arter is narrowing inside or not the dangerous stuff you need to do a stress test you look at the EKG portion and you do a nuclear stress test right now this is how we were doing until some years back now we do angiography and and CT geography so now I'm going to come to that so on cardiac C you're injecting the artery but that's an invasive test and if we see a blockage and it's a tight blockage you usually know that this thing causing a problem right these days we also do CT scans so let me now introduce you to angiography okay angiography angiography means you're taking a picture of the artery how you can go inside from your arm or from the leg and shoot the dye into the arteries and see the blockages so now now runs a problem so here's an artery just like before and I'm putting dye on the inside so I bring my catheter here and I'm shooting the dye into the artery am I going to be able to see what's on the outside here no I'm only seeing the inside so it comes here and it might be narrowed like this it might be narrowed like this that's on the angiogram and I look at that and I say aha this is about 60% narrow and I might want to put a stent in you to open that blockage up but is that an accurate measurement is it an accurate measurement on angiogram and my answer is no unless it's really really tight very difficult to know whether this is flow limiting or not on the angiogram on the angiogram you just see there's a blockage but you can't tell whether it's actually limiting flow or not you need a functional test to tell you whether it's actually limiting the blood flow or not that is why before we do angiography we always do functional testing that's a good Golden Roll you must know whether the blockages are just sitting there and maybe they're not obstructing flow maybe it's only 60% maybe it's 70% you got to do a stress test or you got to do some other form of testing to know that it's a flow limiting leion angiograms don't tell you whether it's flow limiting or not that just tells you you have a blockage and that's the tragedy because what's happening today is we do neography without functional testing three arteries he's got a blockage in all three oh yeah three vessel disease bypass surgery but out of those three arteries two of them may not be having a flow limiting lesion how would you know that how do you know because look there are so many of my patients have three vessel disease blockages in all three Aries you got to know which one is causing a problem and which one is not otherwise you're going to take a photograph and find three blockages one in each artery and say okay you need three stance or you need bypass surgery and that's happening all the time so a patient comes in let's say a diabetic patient he's experiencing a little bit of discomfort comes to the doctor the doctor says you know what you've got all these risk factors let's just go straight to C you cap the patient you'll find blockages next thing you know he's getting anoplasty or he's getting Bast surgery without having known whether those arteries are reducing blood flow or not so then might say well now there blockages are being bypassed so he's going to live long no not necessarily because if it was not reducing the blood flow in the first place putting a bypass to it is that going to make you better if you already get imp planty blood flow down that artery and now you put a bypass to it or you put a stent in here what benefit did you get out of that you're still getting plenty of blood flow getting through it what did you do now that's the question that's the problem that we are having you see coryan disease is very pervasive it's out there people have it that's a whole different topic that we're going to talk about in my future lectures too and those that have already done on why people are getting blockage es but the problem is that those who have the blockages are not being adequately diagnosed as who really needs revascularization who does not whose arteries are really clouded and whose are not clouded and all they need is a prevention program a prevention program to prevent it from cracking and getting worse if it's not limiting your blow leave it alone putting a stent in a is that's not restricting blood makes no sense so do I have studies to show you I do and I'll show them to you in a minute that if you do put a stent in a blockage that's not really FL you know needed because there's plenty blood going down there but oh let's just get rid of it it's sitting over there let's just stun it is that patient going to live longer in fact he's going to live less cuz now he's going to get the complications of stent thrombosis which can occur in one or 2% of patients tent restenosis which is scarring inside the stand which can occur in up to 5 to 6% of patients even with drug eluting STS so you've taken somebody who this thing was not causing any flow limitation and you put a St in them and you made them worse off than they were before no benefit see so just because there a blockage doesn't mean you need to go in and revascularize it either surgically or percutaneously using angop plastic you got to know whether it's actually causing a flow limitation or not and that's why we need better testing so in the cath lab when we do angiography when I do angiography let's say that you came to the cath lab in the hospital came to me because you're having some chest pain and they said you need a hard cat POS stand placement I'll do the angram and I've got no stress test to go by all I have is the angram then this is what I would do okay here's your anagram here's your right coronary artery this is your circumflex artery going to the back this is the artery in the front and I bring my catheter from the arm usually now bring it right up here like this and inject the D and then bring it over here and inject the die so I'm going to see where the blockages are okay now I told you he might have a blockage so let's let's give him a blockage it's right here got blockage oh my gosh he's got a blockage maybe this is a problem blockage right so this is where I do an invasive ffr fractional flow Reserve in the cath lab ffr how am I going to do this it's very easy those who are all Engineers here should know I take a wire a very fine wire it's a pressure wire it measures pressure and I bring it in my catheter slide it here and I slide it through the blockage and I position the wire there got it and I'm measuring the pressure difference here versus here makes sense right if there's a difference in the pressure here versus here that means this Legion is capable of decreasing blood flow so we don't have this technology but now we have this and we've really perfected this is called fractional flow Reserve so it is looking add the ratio the ratio of the pressure here versus here I maximally Vaso dilate this muscle which is I don't think you should get involved with those terms but basically I'm giving adenosine to maximally vasod dilate the arteries here and then I'm looking to see if I can create a gradient across that Legion so if I'm creating a gradient the pressure here is higher than here and if my ffr is less than 0 8 1.0 being normal now I know I'm restricting my blood flow now I know yes this leion needs to be stented because it is capable of decreasing blood flow if the ffr is greater than 0.8 that blockage is not flow limiting I mean it's got a blockage I can see it but it's not flow limiting I'm getting a physiological d L see then cuz the other alternative would be stop send him out for a stress test bring him back again if he fails his stress test so this way we can do the ffr in the cath lab itself like the on the spot so this is how ffr started in the cat lab so in the cast lab I can determine if he's got a blockage what's its ffr and let's say he's got another blockage over here and maybe he's got one over here I can do the F power for each one so I take that wire I slide it down each one now why is this so important cuz let's say this this gentleman had one two three blockages if I didn't do the ffr I'm going to say he's got three vessel disease call the surgeon let's operate do you get it and a lot of that is going on you have to have precise data without data you can't just do things this are this this I told you if I put a St here here and here and they were not needed the stent can thrombose you may get a complication of bleeding from medications that you're supposed to get or you may get restenosis restenosis is scarring inside the Sten so whereas you could have contined and actually what happened is that you just had something bad to eat and having indigestion that's what brought you to the hospital and you end up getting a St do you see the danger here that is why ffr is so fantastic you take the while you put it down across each Legion and you fine so have studies been done to show that if you go with the direction from the ffr and then to the stent so ffr directed stenting does that lead to better outcomes than if you just angiographically look at it and stend it the studies have been done so in those studies they took the patients who had angiographic data like this three blockages and compared them and their outcomes to those who had blockages but they only got stance according to the ffr so stenting versus ating ffr directed versus Geographic Direction which had better outcomes better outcomes of those who had ffr because you're only doing the lesion that really were blocking and restricting the flow so that that data is very solid data now so we know this data so having this knowledge now am I going to take you to the cast lab every time to put that wire inside your artery it's invasive so is there another way that we can do this is there another way I told you about the stress test the stress test doesn't tell you about that particular Legion it just tells you that this portion of the heart is not getting in blood supply so patients often tell me well what's my percentage blockage I pass I failed my stress test all I can say to you is that the front of the heart is not getting enough blood supply it could be from a blockage here here here or here I don't know and how tight it is I don't know all I know it is probably more than 75% it could be 80 it could be 90 it could be 95 it could even be 100% with collaterals all I know is that the front is not getting in our Blom so you still need an angiogram you got a positive stress test you still need an angram you need anatomical data to see where the blockage is and what to do with it okay so there you go so this is helpful in the cast lab when I'm inside the cast lab that's very helpful cuz I'm already there I'm going to do ffr so is there another way so let's look at CT scans so you all know that we are doing CT scans now right so let's talk a little bit about CT scans and how that has changed what's going on in a ctel you're injecting dye in a vein and it's going into the arteries and once again it's going into each artery the dye is going there you're doing a CT scan and you can actually see the blockages but we have a problem we have a problem here's the artery and I'm going to draw some plaque in here we've got some calcium blow up a nice big chunk of calcium here okay look it's on the outside little bit is going on the inside too let's give it a little bit more let's give it like about a 30% blockage okay so the CT scan shows you this but the problem is when x-rays go through calcium it tasts a shadow so you overestimate the blockage so when you're looking at the CT engine GRS you say ah this guy's got a 50 60% blockage well what is it so we have notice that with CT angiograms it tells you that there's a blockage tells you there's calcium doesn't tell you accurately what the percentage is and if you read your CT and reports it'll all be between 40 and 60 60 to 70% but they're never really that accurate because it's a visual estimation okay it's a visual estimation and it can give you an overread on the stenosis it's called blooming artifacts it doesn't really tell you functionally what's going on in that artery doesn't you need more valuable information to know that so City scans are extremely harmful first of all if your city scan shows you have no calcium you don't have corn disase that's why I like City scans that's why like corny calcium scores so the thing I do is I look at Cory calcium so let's say you came to me and you having some issues and you're concerned that I got Harding of the arteries my father had a heart attack my brother just had bypass surgery do I have a problem I'll get a calcium scoria that's the first thing I'm going to get on cuz it's so easy to do it's a lowlevel city scan looking for calcium in the walls of the Aries if if your score is zero do you have cor disease you know you done go home you done stop eating that garbage cuz that's what giving you heart but follow my videos so that's why I like calcium scoes now if your calciums come back positive yeah you got calcium 0 to 100 is mild 100 to 400 is moderate more than 400 is severe then I'm going to say okay you know this is a problem we can either go to a stress test to see if these blockages are actually causing you a problem or we can do a CT angiogram so we do the CT angram and the report comes back saying aha 50 to 60% blockage right there well 60 could be 70 for this could be 40 so it's too wish Washi I need to know whether that's actually capable of reducing your blood flow or not so now once again comes ffr so we didn't have this technology the technology is now there where you can actually then take the CT anagram and send it out to California and have ai look at it AI has some uses after all and that report may come back and say this is a flow limiting Legion the ffr on this Legion is 0.6 that's abnormal right totally no6 so that means yes this leion needs to be fixed you need to stem to this one but this other R3 that was here Branch big br Big Branch also here and it also had a blockage in it and the ffr it looked like it was about 50% but the power on this one was 0.9 and then the right cor also had a problem there was a 50% blockage there also because remember cor arri disease is systemic disease it's not just a focal disease you got blockage in one artery you have blockage in another one as well all your arteries are going to have some degree of PL there's no such thing as single vessle disease if you look hard enough it's an all three arteries so this report would come back saying 50% here 50% here 50 to 60% here but the ffr is only abnormal here so what does that mean that means you go in and you fix this blockage if you can fix it with a stent and you get rid of that blockage so now the flow is going to be restored you've done something good otherwise you're going to say well these other blockes you know you're just better off doing backpass surgery so focus focus in on the blockage the one that's functionally important F Bar functional fractional flow Reserve has to be the main state of future we have to look at functional testing either you're going to do a nucleus tesis or you're going to do a CT scan that's going to tell you what's going go on so the way we're working our patients right now is we are we're still doing a lot of stress testing too so I'm just going to give you a little background on the physiology of what happens here's the muscle when you're exercising your Vaso dilate all these little little blood vessels they open up and when you're running jogging when you're doing any kind of exercise so at rest there may be plenty blood going in but when this vasil dilates that's how you get more blood coming down cuz your vas are dilating when you exercise your Vaso dilate so you're getting more blood that's needed cuz you Vaso dilate here so you're drawing more blood into the heart muscle and that's how we measure ffr in the catha we give a baso dilator into the artery baso dilates all of this and then you create a gradient a difference in pressure between this and this so by doing ffr on these patients we are going to be able to identify lesions that really need to be fixed and lesions that need to be left alone so my particular interest is to leave leave V leave the blood vessels alone that's highlighted it if you have a flow limiting Legion on ffr I'll intervene in but I only want to put in what's necessary only the bare minimum needs to be done because the biggest problem is all these other plaques why am I telling you that they are the problem because it in all my experience I've seen the rule of 70s I'm going to explain the rule of 7s 70% of heart attacks occur in blockages that are less than 70% I mean suddenly this thing cracks and it became 100 so it was less than 70 the day before yesterday he could climb Mount Dora he had no problems how come he's having a heart attack today because the plaque cracked so I'm more interested in taking blockages and stabilizing them try to make sure that they're not going to get worse in the future keep them stable as well you can shrink these a little bit you can't get rid of them if your calcium scores 1,800 it's not going to go down to 500 but what you can do through an anti-inflammatory diet and anti-inflammatory lifestyle is to make sure that that doesn't get any worse and number two it doesn't crack CU if it cracks a blood clot will form on it so that's the whole point the point about doing that ffr is to tell you that fix only this one leave the rest alone the rest are to be managed systemically physically diet sleep stress toxins nutrition fixing your hormones fixing your gut microbiome that that's what's going to take care of these blockages not a stent cuz these days what's happening is that most people think that you have a blockage then you're going to get a stent and then you're going to be on aspirin and maybe some Plavix and then you're going to get a stattin and you're done and I'm saying to you that that's the that you may need the St but what you really need is a big work off as to why you got the plaque and what are you going to do to stabilize the plaque what did you do what did you do but you got to know what made that plaques happen in the first place and most plaques occur because of inflammation inflammation and this inflammation comes from what inflammation is when you're attacking something foreign what are you attacking that's foreign it's all you how can you be developing a pumple on the inside of the artery that's full of inflammatory materials in here there's t- cells in here there's B cells in there and there's macrofiles that are dying in there and releasing the calcium and that's all that calcium inside there what it is is inflammatory and nobody has really come up with a solution or answers to where that information actually comes from they'll say it's inflammation but they don't know where it's coming from and I'm going to tell you tonight what I think I think most of that inflammation comes from your gut because your gut is the difference between what's outside you and what's really you you see you could to understand why your body is mounting an immune response against what so it's a separate topic but these days I look for gut sources of inflammation where you have either what is known as gut permeability issues because you have food sensitivities or you have a dysfunctional microbiome you got microbiome the bacteria in your gut are not right and I'm seeing this over and over again that these patients if you sit and talk to them long enough you'll find out that they all have a gut problem and this is what's causing the translocation of lipopolysaccharides from the gut into the bloodstream which then get taken up by the LDL molecules the bad cholesterol molecule as you all know them as and create what is known as small dense particles these small dense ldls tell you there the information going on in the body and these molecules get taken up by the macras and then the macrophases engulf them all and of course these particles also activate the endothelium so it activates the endothelium so the endothelium gets duded the the glyco Kix gets destroyed and then these molecules come along here and the white cells come here the macrophases and they get stuck to that area over here and then they get they go inside and they die in the wall and now you're getting a plaque right there it's all to do with inflammation so the looking for sources of inflammation is very important it starts with the gut also starts with your lifestyle it starts with how much you're sleeping how you're stressing whether you have parasympathetic or sympathetic nervous system activation whether you whether you have heavy metals in your body all these things cause these formations so once they fall then you need to know whether it's actually flow limiting or not and if it's flow limiting then you do an intervention so you can do stenting or by B surgery but if you reverse engineer every patient you got to reverse engineer every patient with coronary disease otherwise you're just taken care of the stent or the bypass and you've just stopped go back you got to reverse engineer reverse engineering is very important okay so he's got the blockage why does he have it let's go back let's take a look at this guy he's got hyperinsulinemia what does that do that causes nitric oxide depletion promotes aerosis promotes obesity promotes fatty liver so he's got pre diabetes he's got a very high insulin level wow that causes the formation of eosc disease right there causes high blood pressure as well all that denudes the endothelium that causes problems in the arteries so it's said High insulin sugars of course high sugar also destroys the lining of the arteries because it glyat them and destroys the glyx which is the tactive lining on your arteries they get destroyed as well so aha so he's got a hormonal problem he's got hypoinsulinemia then you look at his fatty liver and say something wrong with this guy's liver so see of metabolism what's going on why did he get a fatty liver oh he's getting stuff that's coming up from his gut and causing a fatty liver you chase those issues and Chase the uh the the the the gut bacteria and try to fix that because that could that will stop this onslaught of what I call metabolic endotoxemia so you reverse engineer get back to prevention look for all those risk factors but the exciting thing today I wanted to introduce to as ffr because you know people who have blockages you know people who have positive calcium scores and they need to know what their ffr is so if they're not going to do a stress test they should at least get a CT angiogram and on the CT angiogram you can tell that yes he's got blockages here here here here here which lesions are actually causing there's so many patients that I see where the CT scan show glor calcium they pass the stress test and the ffrs are all okay so what are you going to do with those patients they have a calcium score of 1,800 and they're walking around feeling great stresses is fine no problem CT Angel no problem there just have lot of calcium well they live with that calcium just don't die from the calcium so stabilize it don't Don't Let It crack now when it cracks a blood clot forms so a heart attack is just as much inflammation causing the plaqu to crack and key point is also hematological that means if your blood is very thick and sticky and it's hyper quable you're going to get a small crack and a big plot got it you see some people can crack to the same extent but if his blood is clotty and you have a high viscosity because your hemoglobin is really high let's say or you have lipoprotein lay which will predispose you to larger blood clots then you are going to get a large blood clot she may rupture and just get a small little blood clot and her heal over and she's don't and the rate of progression of disease in you is going to be far more than her because every time you both crack she's just getting a small clot and it's healing over and just the percentage went up by 5% or 6% only in him every time it cracks the stenosis is getting progressively more and more and more because larger clots form in it because when the clot forms it then gets covered over so my point is when you're looking at the work up of these patients you need to look at inflammation which I told you about already you also look need to look at your blood is your blood clotty I look at that so we got to determine whether your blood is predisposing you to large blood clots or not that's why we do the advanced lipid panel we do blood counts and that gives us a lot of information to predict what will happen to you how how rapidly is your calcium going up so let's say you got a calcium score this year of 1800 and next year is 2,500 you have a problem you got the bur as all you're cooking inside so you need to find out what's going on in you so there's so many things we look at besides it okay I told you about the in inflammation I told you about the blood clots there are other things also nutritional deficiencies cause this to progress also bad food all the processed food all the Mad reaction which is all these aging products when know when when you take for example your food and you excessively Brown it and excessively cook it all those molecules get absorbed into your body and they cause hardening of the arteries as well so it's not just what you eat it's also how you're cooking your food kill your food and then it kills you you you got to be careful how you cook your food also so it's not only what you eat and of course those are all topics of discussion for another day but it's what you eat how often you eat and what you eat how did you cook it now what kind of oils did you use in it so how easily oxidized was it it gets really complicated oxidation is really important so if you're eating a lot of vegetable oils for example you're going to get a lot of oxidative stress in your body and that oxidative stress is going to hurt your arteries big time and it's going to cause acceleration of plaque formation there a lot of things to look at so we do a deep dive into all these things um so all that doesn't sound very glorious but putting a stent in somebody or sending them for bypass right you're now a real doctor but I'm saying to a real doctor is not that some of my technician friends who help me when I'm doing angop plasy they can probably do it on their own and probably do a better job than L of others that I know so what I'm saying to you is that a great cardiologist is not one that can only do a great stint yeah you hope he does a good stint too or a great surgeon that does great surgery but the better one is the one that's going to make sure you don't get progressive disease and that you don't rupture your plaques and that you will die with your plaques not from them and by the way the same processes that I talk about you about inflammation and lifestyle also reduce your risks of having uh a stroke blindness kidney failure some cancers diger have joint disease neurogenerative diseases of the head so there's so many benefits because ultimately it all comes down to inflammation our lifestyle will cause chary disease and all the other diseases that I just mentioned all come down to our lifestyle so we need a lifestyle change that's what we all need today it's a lifestyle change so we talk about the parasympathetic nervous system nervous system and I teach patients how to hack the parasympathetic because parasympathetic is the healing aspect of your system if you're only sympathetic all the time you're going to get blood clots if I take some adrenaline and shoot it into you you're going to make blood clots right now your platelets become really sticky and jittery see what I'm saying because you're ready for war fight flight flight so everything impacts my arteries and whether is I'm going to rupture and whether I'm going to get a big blood clot on it or not depends also on my demeanor how I am whether I'm happy or joyful or do I feel stressed or do I feel angry because how is my body interpreting what I'm living right now is going to determine What's Happening Here my entire physiology changes see so it's fascinating I think corat disease is linked to everything else and that is why we are very very aggressive in the in this uh field and all of you are here because you're interested to prevent heart disease yeah today's lesson is that most of you don't need a stent most of you are not going to need a bypass that's only for patients who have tght blockage either they're having symptoms or they have objective evidence of lack of circulation if you don't have objective evidence with the nucleus Fest test or or EKG changes then you must get some form of testing if it's an angiogram you do an ffr before you stand or you do a CT angiogram and you look for an ffr and if the ffr is high then I'm much more likely to say you know what you need to come to the cat lab with me because now I need to go in and when I do my angiograms on those patients with positive ffrs I'm doing my own ffr in the lab as well so I measure the ffr put the wire down make sure this Legion does really need to be fixed and then fix it and the outcomes are so much much much better than if you just blindly go in and put STS in remember if I put a big stent over here and now there's only a short bit of artery over here and let's say God forbid you renar this whole segment here where the stande how you going to bypass this patient in the future see stenting is not that a great solution to everything because you need a nice piece of Ary here to put a bypass into but if there's only a tiny piece of water left and you bypass into that the bypass will shut down because there's no flow so stenting changes your future and your future options as well that is why we must make sure the ffrs are done and only open up the blockages that are causing a problem see you do an anagram the beginning of the AR may have a narrowing there's a moderate area here but let's say that there's a really tight one here then just put a stent here and then you can measure the F far across this one what often happens is that they see that there's a 50% here there's a 90% here right but if you put put the wire down and you do a pullback ffr a pull back ffr that tells you there's a drop across this one oh no there isn't this one oh yeah there it is I saw the blood I saw this I saw the pressure change then you put a stent in this one and not this one on the CT Ango when you get the ffrs back I've already seen that on many patients what happens is the far here may be abnormal it may not accurately tell you exactly which blockage but on the angiogram when I'm doing it I can accurately pull back and see exactly which lesion is causing the drop in the pressure on the ffr and stent only that particular BL and leave the rest alone CU St flow limiting and then comes the hard work here's your diet here's your lifestyle this is good this is your nutrition this is going to be your metabolic workup these are the prebiotics or whatever I'm going to give you this is your insulin how we're going to manage your insulin resistance this is going to be your sleep pattern from onward this is what you're going to do to hack your parasympathetic nervous system this is what you're going to do and you talk about these things get the patient through everything and they'll be doing great so I'm going to stop right there because I know we started real late but if you've got any questions on ffr or anything to do with corat disease I'm happy to take a few few questions yes sir very good point so I'm going to show you how we do that so remember we're not stressing the patient at that time they are lying down even on the CT scan it's only a matter of literally seconds that you're doing it so there's no fluctuations in your blood pressure but with each heartbeat it's fluctuating right so okay so bear with me here this is an entry and I came in with my catheter I'm going draw a catheter inside it's a hollow tube and inside that catheter I have my wife the one that's going to measure the pressure and here is the blockage and I want to see what it's doing here right right so what it's going to do is I'm going to measure two pressures one pressure is going to come from this catheter which is measuring the pressure here you see this opening here has an opening here right my Hollow catheter because this wire doesn't take up all the space inside my Hollow my cathet so there's a pressure reading here that I'm going to be getting so with each heart bit I'm getting a pressure now this wire is measuring its own pressure and that pressure is going to also at the same time simultaneously it's going to go okay so I'm getting two simultaneous pressures and then the computer calculates for me what the epip is because if there is no change in here the pink one should be the same as the blue one identical they is mostly in the heart area in the wall of the artery the calcium score is in the wall of the artery that's see when these macras that cause the inflammation when they go inside the wall of the artery they die there and they liberate all that calcium and that's what the calcium is the graveyard of inflammation sex scaring if you have lot of calcium that means at some point you had so much inflammation in that artery they left behind all the scars now scars are scars let it stay a scar how if you have a scar you don't keep opening it up right you stabilize it as long as that scar doesn't get any worse in the future you're fine don't let It crack don't build up more scar on it leave it alone so the calcium is in the wall of the artery it's in it it's in the wall and it can negatively remodel the artery that means it's now encroaching into the Lumin or positive reming it's encroaching onto the outside of the lumen of the artery yeah but calcium is no good you shouldn't have any you should have a zero calcium score and the lower the better so now with the calcium scores it's the most predictive of how long you're going to live very predicted if your calcium score were high you would have comfort to either with the CT scan or the cap lamp or a nuclear stress test some score so low cast score so low you don't need all that it's not encroaching onto any of your artery Lumen it's not narrowing down your artery so you're very fortunate now those who have a high calm score we don't just do one study we do one now we do another one in within 2 years so let's say that your calcium score today is very high let's say it's 1,800 and then 2 years from now two years from now your score comes back at 1850 it's gone up a little bit it's gone up by less than 10 less than 10% in two years that's good but if it comes back now at 2,100 you're cooking so this person there he's going to come in and we just going to open him up completely I want to know everything about you where are you living what you're doing what's your lifestyle what you eating what time you go to bed what time do you wake up in the morning what are your stools like cardiologist I want to know what your stools look like describe them to me how often do you have a bow movement what causes gaseous distension let's look at your metabolites let's take a look at your your heavy metals do you have you know how many people have heavy metals Mercury lead I never thought this was important as a cardiologist I'm finding that these patients are toxic heavy metals cause atherosclerosis so look at that also then I'm going to look at your liver and look at your insulin levels look at your sugar levels you're very fortunate your calcium score is so low now you still have to be careful so that you don't develop more Calum in the future and also make sure that you don't do up the other illnesses that people get because just because you you spared your cies are you going to spare your brain what's worse than a heart attack heart attack I'll come fix you who's going to fix your brain if you get Dementia or a stroke and dementia dementia I don't believe that dementia is just dementia dementia is vasular it's vast muscular and a lot of dementia today is inflammatory so all to do with blood vessels every organ is as good as it blood supply that's a golden statement every organ is as good as a blood supply you want to have excellent organs in your body you make sure your blood vessels are good that's a golden state but nobody believe you see what's happen that we are all so insul we think about each organ individually and every doctor looks as his own organ I say that the biggest organ in the body is your blood vessels your endothelium you want to keep your liver healthy give it good blood supply your intestines your brain your eyes your heart everything give it good blood supply and basically comes down to this making sure that all your blood vessels are good the Vaso dilate properly Ed it's all blood supply it's all the blood vessels dilating or not dilating ating appropriately it's all to do with blood vessels so it's very important so yeah you may Dodge the Cory bullet make sure you don't die from the one of the other bullets you see yeah and I'll take it even further that even a lot of the C of the cancers are driven by metabolic disease they driven by metabolic disease so if your calcium score is zero you're good for 5 years at least but if your kosm score is less than 100 I'll do it in about 3 years if it's more than 100 at least every 2 years if is very high probably for the first couple of years do it every year because I want to know how stiff your curve is and get aggressive get aggressive you're not going to get rid of it but it's an indication something's going on I need to find out what is it what is it in my physiology that I'm cooking why am I cooking inside yeah find it and RSE it so and in a nutshell the bottom line is p attention to what you put in your mouth and how often you put it this yeah very good question so what makes it crack you're saying what made that plaque crack I'm going to draw you a plaque and then I'll show you how it cracks so this plaque has a thin capsule over the front thin layer this is called the endothelium it's a thin single layer and it is protected by the glyco which is like little hairs and this layer is a thin layer mono cellular layer like that behind this plaque there's this build up here and there's some build up here right so you're saying what makes it crack I'm going to show you at the edges here are t- cells and B cells are inflammatory cells they are in inflammatory cells because they they're going after something and inhale fat globules where did the fat come from the fat came from white cells macras and they saw that LDL particle the small dense particle and it's full of fat because it's got cholesterol in it but it's also got that LPS on it so that's a deranged particle so this white cell comes and gobbles it up I drew it out of scale this is supposed to be much bigger it gobbles it up so now I have all of them in here and when these cells come here and they attached here and go inside here and they die in here and all the calcium is here and the fat is laid out so it's all here and these are the foreigners the cholesterol is not the cholesterol you ate the fat that's in here is not the fat that you ate it's the LDL cholesterol but it's not because your cholesterol level is high it's because your LDL was deranged it became abnormal why because of information in the body BEC small dense that's why we do Advanced lipid panels I don't do total LDL CU a total LDL does not predict who's going to get a heart attack or who's going to get a a stroke it doesn't 50% of patients who come to the hospital with a heart attack of normal ldls but what you should be looking as your small dense Elia and you can only get that on the advanced lipid panel so most doctors don't even order Advanced lipid panel you have to order an advanced lipid panel to know whether you have small dense LDL or not today that's inside the plaque now this all in here is there's a wall going on in here so these t- cells and B cells are producing substances that dissolve the tissues in here they are called Matrix metalin proteinases so they dissolving just like how when you get an infection you get a hole when you get a pus comes out and there the whole left band everything is liquefying right it liquefies the tissues in so the Matrix metan or proteinases they degrade the materials inside in an active inflammation so this thing will burst because if there's a thin cap this is called a cap if it's very thin and weak it will burst and when it bursts the blood that's floating inside the blood string sees it and opens up so what makes this inflammation that's active inflammation that if you have a stable plaque with no inflammation going on in it it'll just be full of calcium only there will not be inflammatory cells here nor will there be much fat there cuz it's old history now you just got calcium hopefully people have mostly just calcium left behind I don't want to see information the question is how can you tell if there's information in there good question right how do I know that you are this with inflammation versus another guy who's got this and all it is is just calcium how do I know the difference there is a test that you can do it's called The Plaque differentiation you can actually on the C scan see where you have only calcium and way you have calcium and fat but we haven't perfected it yet it gives an indication of the ratio of how much fat and calcium you have and how much just calcium you have when I was doing my research in my old days I would take a wire a temperature wire and I'll pass it along the artery and when the temperature rises there's inflammation in that plat and also there are certain Imaging techniques that you can use where you can actually shine light up into the walls and get a optical coherence test and you can actually see if this L if this p is inflammatory or not you get some ideas on that but we haven't perfected that science to the point where I can say to you that oh yeah you going to plaque over here and yeah it's perfectly okay you're going to be all right no instead of looking at that in this way what I look at is your markers your HS CRP level is it high or low if it's high your plaques are probably inflamed if you have small dense LDL your pla are inflamed if you have a high insulin level high sugar level these are all indications that your plaques are probably very inflamed CU you have inflammation going on so individually I can't go to your plaque and tell you whether your plaque is inflamed or not but I can do blood test on you to see what's going on and number two is I can repeat your calcium's SC in a year if it's going up then they all inflamed CU they're growing they're growing stable packs don't grow anymore so if your calcium's going up you have a problem if your C is up that's C reactive protein if you have small dense ldls if you have high insulin levels high sugar levels all these are blood tests that we can do to give us an idea that you are inflamed Therefore your plaques are inflamed yeah one day I hope we have a test where we can inject something into you and it'll light up this artery and show me this one's hot this one's cold so this one is very active this one is not but then let me ask you a question since you asked this let's see if you can answer this here's a artery and you've got a blockage here of 30% and it's it's just calcium this one is 30% but it's very active what are you going to do with that it's not limiting FL oh so you see by point that if you have inflammation in the plaque what's the treatment it's still systemic you need to treat the whole patient so even if I find a plaque that's hot if it's not obstructing I'm not going to stent it if the ffr on that plaque is good I'm just going to leave it Al what I'm going to do is Chase you systemically all of you I'm going to treat the whole of you from the morning you wake up to the time you go to bed and what Ty of sleep you have at night everything will need to be evaluated and changed because you are inflammatory so inflammatory plaques require a systemic treatment not a localized treatment a localized focal lesion requires a localized treatment okay so that's a very good statement I'll repeat it again a localized focal lesion that is hemodynamically significant requires a localized treatment put a stent in it or bypass it all other plaques require systemic therapy coronary arter disease is a systemic disease take that to the bank coronary Ary disease is a systemic disease it can have local manifestations too but it's really a systemic disease that's a whole new paradig of thinking that it's a systemic disease not just a localized disease it's also occurring in your brain it's occurring in your corit it's occurring in your ilcs it's occurring in your kidneys so it's a systemic disease and that's how we got to look at it it's this is a systemic disease yeah yeah but it's a great point but one day we might be able to actually identify these more clearly in research it was fun because I'll put that slide by wire past here and the temperature would suddenly go up here for a it would be normal at 98.4 this would go up to 98.9 and then back to 98.4 they were hot they were hot you just open up a can of worms because I'm going to tell you it's not genetic less than 10% of all all the diseases are genetic but of course Everyone likes to think it's just genetic genetic genetic no it's not it's EP gentic ah what does that mean you see you just open up a can of wors it's not genetic it's epigenetic ultimately all your physiology in your body is happening because of your genes right so it's not just the genes that you were given by your parents it's what you've done two those genes because of your lifestyle diet mental and physical being mental and physical being that changes the expression of your genes so your genes turn on and turn off and which ones have you turned on which ones have you turned off that's epigenetics you see from the time you were born to now your genetic expression is totally different this is a whole new paradigm of thinking this is brand new thinking people are getting to you about epigenetics most people don't even know what epigenetics is so they someone to blame their own genes jeans jeans it's not that now it may look like it's running in the families because if the families have the same Lifestyle the same diet they live the same way they metabolize the stresses in the same way they eat the same thing they their lifesty then it looks like they all getting the disease because guess what the epigenetics are the same too and this we know from tun studies as well and they have perfectly same genes but you your genetic expen that changes so I'm empowering you today to disempower genetic genetics is not what controls diseases its expression of disease is genetic ultimately because what happens is the genes are just there to to to translate proteins they make proteins but which proteins they going to make that instructions comes from you the environment that goes in turns and offs off and turns on certain genes and then your nucleus is just doing what it's supposed to do oh you want that protein all right I'll make it for you and makes that protein so answer to your question in long and short is no genetics play very little role very little role in all diseases all diseases it's the science is telling us that this is mostly epigenetic and that's in your control you see it empowers you you're not a victim of your gen but you created your epigenetic expression you guys should love worms where is the because that's a question I asked all my professors and nobody ever had an answer but today I'm telling you that most of this inflammation is coming because of three things going draw them for you as a general r one is called metabolic endotoxemia and that is coming from your gut so I think bacterial wall products you got leaky gut or you have wrong bacteria in your gut so this is one causes inflammation number two your hormones are off and that can cause inflammation in your body information is you're fighting against something right fighting against something what is that something what is that Foreigner in you that it's fighting against that's causing this inflammation right that's what you're asking and then the third thing is toxins because your immune system is fighting against toxins in your body for example if I give you a lot of lead or Mercury right now your body is going to mount a reaction or it's going to change its its its its uh Redux potential and that's going to change a lot of your physiology in your body so it's complicated CU see we only think of inflammation as infectious things that cause inflammation like pneumonia or getting a big boil on your skin but inflammation also because when your own physiology is changing either because you have toxins or your hormones so inflammation is a catch bag for a lot of things it's not just bacterial or or bacterial products it's also your hormones toxins and you can also develop an inflammatory mure if you don't have enough nutrition or the wrong nutrition so for example if you have a lot of deficiencies in your body you your homeostasis is is not going to be normal so it's a complicated question I will give you a separate talk on that one day yeah but it's a complicated subject but most of it that is actionable is check your gut check your hormones particularly insulin and sugar make sure you're not toxic make sure that you don't have and B ways toxin not just lead and all these things by toxin are made Plastics I'm talking about your makeup and your creams and all these estrogen receptor Agonist your soap your shampoo I don't need it cuz I got no hair left no shampoo but all these are plasticizers that get into your body antibiotics they're a toxin they're killing the bacteria in your gut artificial sweeteners colorings emulsifiers preservatives they're all toxins they're not supposed to be in you and they act through the microbi microbiome they going to know all these things going to check all these toxins in your system and get rid of them and then your nutrition or 40 sudden nutrient depleted we don't have enough nutrition in our body because of the type of foods so we got will replenish our nutrition get rid of toxins fix our hormones and fix our gut that of things going on a little complicated yeah that's a great question so far it's I would say I can't give you an exact number but from from the experience that I've had and from everything I'm reading it is at least 80 to 90% accurate because like I told you only my wire is so precise that I can move it 4 mm and 5 mm and I'll get a different FF all so it's very accurate and telling me exactly the location of the blockage um it's not that precise with ffr with CTS it gives you more about that segment see and it is an evolving technology also we're still learning about it but the bottom line is if you have an abnormal ffr on your CT angio you going go in and look at the whole artery anyway so you'll be able to see all those parts andt only the ones that you see Ang geographically tight but also corroborate with a invasive ffr the technology is changing cu the AI that we have today for this is going to be different another four years from now it is changing very very rapidly so I think it's going to become better and better with time and it's a learning C for Physicians also for all of us as to how we interpret these results so but it's another you see look the bottom line is the studies have been done that if if you look at patients and you do the ctfr and it's not bad but they have disease they got cast and you just follow them for 15 years how many 15 years the outcomes are good because they didn't have a very significant ctfr so a negative ctfr is very helpful to me because it tells me that the studies tell me that I can leave that patient I don't have to St him he's got a lot of calcium he's got a lot of blockages everywhere but none of them are tighten up and if I just do my prevention program they'll do better and by the way in those studies you know what was the prevention program not much they were giving them stattin basically and get a little bit of beta block and a little bit of ace inhibitor or something like that whereas today's prevention program that I do is much more more than that so I can expect even better results than that so sometimes it's not a positive ffr that's going to help you it's a negative ffr you don't have problem so leave it alone now let's just put you on very aggressive therapy you should test for it anyway now that the tech technology I'm going to explain to you why I'm going to explain to you why a patient who has blockages in all three arteries the right cor artery the circumflex and the LED here's the heart how can this patient who's got let's say you do have 80% here 80% here 80% here now these are all significant am I right or wrong but you're not having any chest pain because I told you 80% of patients never get chest pain so let's say you do have this now I inject radioactivity in to you stress test you're going to get decreased flow here here and here so when I look at the image it's uniform but let's say you you did not have this one here and here there was only 10% you would see decreased blow here good circulation here decreased blow here on the image you say ah you failed your stress test because you have decreased flow here but when all three arteries are down you're going to get uniform decrease in flow so you're going to see what I what I call homogenous decreased uptake of radioactivity there's no heterogenity because the way you interpret a nuclear stress test is you're looking for heterogenity heterogenity means one part of the heart getting lots of radioactivity one part not but how come this person not it's got a blockage there but if all three are a blockage there's no disparity you got it so this is very important for patients to realize that if your calcium score is very high and if you have blockages in all three arteries you can get a false negative nuclear stress test that patient if it's young calcium score is very high just do the CTA with it fall cuz you don't want to be caught with somebody that has very high grade blockages in all three arteries that gave you a false negative nuce so a lot of judgment is needed there too but with such a high score negative look is it probably okay because your functionality is still important able to get around clan m Dora and come back no problem but to just make it feel better you should do CTA with e now when we send up these studies for ffr evaluation some segments if the vessels are too small or too thin they cannot really adequately analyze those so it's not always the case that you're going to get every segment of your artery analyzed sometimes they can't analyze some POS so there are some technical issues as well but generally speaking most of the time you get a pretty good reading you can't see everything yeah it's another it's another tool in our armentarium to H down on who's the troubled kid on the Block I don't need to worry about these guys but that guy there I need to worry about him get him in there I might even cast him become more aggressive more information more I can hone in on that guy like I said if the is ffr is fine on that other patient he even though he's got a high castom score and it's been stable now for three years or 4 years I can sit back my data shows me he's going to do fine he's going to do all right see so those Studies have all been done we do know that a negative ffr is a good thing yeah okay well thank you for coming out tonight thank you and if you liked this video here's one that I would recommend and if you want to see my 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