October 17, 2020
[00:01:29] Podcast Sponsors
[00:03:46] Ben's Examination at The Clinic: Guest Introduction
[00:06:04] Ben's Heart Ultrasound
[00:19:21] Carotid Duplex Scan
[00:30:38] Abdominal Aorta Ultrasound
[00:35:13] Podcast Sponsors
[00:38:15] Endothelial Peripheral Arterial Tone (EndoPAT) Test
[00:49:54] 12 Lead EKG
[00:54:40] EKG While On Treadmill
[01:09:06] Coronary Calcium Scan
[01:17:59] Reviewing The Results Of The Exam with Dr. Dandillaya
[01:24:57] Vascular Ultrasounds (Echocardiogram)
[01:29:40] Carotid Artery Scan
[01:32:18] Abdominal Aorta Ultrasound
[01:33:52] Treadmill EKG
[01:37:49] Advanced Lipid Panel
[01:52:22] EndoPAT Test
[01:56:04] Coronary Calcium Scan
[02:00:53] Closing the Podcast
[02:04:20] End of Podcast
Ben: On this episode of the Ben Greenfield Fitness Podcast.
I go out of my way to use things like beetroot. I even microdosed with sildenafil before, the active component in Viagra. And I should also be sure that if I am participating in events where passing out could potentially kill me such as a swim, I should make sure I'm really, really well topped off as far as mineral levels, hydration, et cetera.
Ram: We put you on the treadmill.
Ben: That's right. My favorite one.
Ram: Yes. With the mask and all.
Ben: Health, performance, nutrition, longevity, ancestral living, biohacking, and much more. My name is Ben Greenfield. Welcome to the show.
Alright, folks. I spent hours and hours and hours at a hospital and medical facility in L.A. doing the most advanced cardiac workup known to man and figuring out what could a fella or lady in middle age do to test every last aspect of cardiac function. Had a videographer and audiographer walking around following me the whole time for physician interviews, for deep dives into all the lab equipment they were using. This was a ton of fun and I think you're going to learn a lot. I've been wanting to do a podcast like this on heart health for a long time and I'm really hoping it helps you decode this whole world of just knowing and having peace of mind about what's going on with your ticker.
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Alright, folks. Well, this is it. You have asked me plenty of questions over the years about how you can actually assess your cardiovascular function, how you can actually know or have that peace of mind that your heart is working properly, or perhaps even find out some things about it that might require you to address things from a diet, or an exercise, or a lifestyle standpoint. So, what I've done is I've come to California, the Beverly Hills to a place called Atelier Health. And what we're going to be doing is a suite, a battery of cardiovascular function tests, which are going to allow us to look at what my own heart health actually appears to be.
Now, today, the person, the medical professional who's going to be walking us through all this is Dr. Dandillaya. And he works here at Atelier and–what's the actual style of physician you would describe yourself as?
Ram: I'm a cardiologist,
Ram: I like to call myself a preventative cardiologist. So, the intersection of lifestyle factors, and testing, and diet, all of that. So, I think this is going to be a great interchange. So, looking forward to it.
Ben: Fantastic. And to give people a preview, what are they going to get to see today?
Ram: Well, we're going to do a full cardiovascular assessment. We're going to do some blood work, we're going to do some ultrasound-based assessments, get you on the treadmill as well, and then also get a calcium score done. So, with these tools, we're going to get a good head to toe assessment of your cardiovascular system. And we'll also do some endothelial function testing, which is very important because that's a very dynamic look and it's a dynamic cardiovascular risk factor.
Ben: Fantastic. And we'll explain to you guys what each of these tests do as we go through, but if you want to visit the shownotes to learn more about anything that we do, you can find all the information on Dr. Dandillaya, on Atelier Health, on all the different tests that we do, and you can leave your own questions, comments, or feedback if you just go to BenGreenfieldFitness.com/heartpodcast. That's BenGreenfieldfitness.com/heartpodcast. That's where all the shownotes are going to be. And that all being said, let's do this.
Alright, perfect. Well, I think we're going to get started with getting your ultrasound done. So, we'll have you come on here and I wanted to introduce Michael as well.
Ben: Okay. Alright. So, this is going to be basically an imaging of the actual musculature or the–
Ram: Imaging of your heart muscle. We're also going to look at your carotid arteries, which is a great place to visualize the buildup of plaque, atherosclerotic plaque. And then, we'll also take a look at your abdominal aorta, which is another place. And then, your arteries, lower legs.
Michael: Great. So, how are you doing?
Ben: I'm doing well.
Michael: My name is Michael Crowley.
Ben: Good to meet you, Michael.
Michael: Nice to meet you. I'm a cardiovision. So, we're going to be doing your ultrasound today.
Michael: So, it will require you to remove your shirts for me, if you'd–
Ben: Alright. I think I should be able to do that. I'm wearing a mic, but we can get creative here. And there are plenty of places I can attach this including my beautiful mask.
Michael: And as we progress through the rest of the testing, which will include going to the treadmill where we'll hook you up and all of that stuff, so we'll go ahead and have you lie on back with your head on the pillow there.
Ben: Now, one thing that I know many healthy active people will find on an ultrasound like this is enlarged heart ventricle, also known as athlete's heart or, correct me if I'm wrong, doc, acromegaly?
Ram: Yeah. We see this not infrequently with our athletes, and I think part of this is that we take some very specific measures on the ultrasound, some physiologic parameters to assess whether this is creating an impact on cardiac performance or it's sort of part of that athletic heart pattern. So, some of this is a little technical, but we can walk through it, but it wouldn't be surprising to see some thickening of the walls, what we call hypertrophy, concentric hypertrophy. But as I mentioned, there will be some patterns that we can tell to see if this is abnormal or not.
Michael: Great. We're going to go ahead and roll it over a little bit on your left side so that you're facing toward [00:08:24] _____.
Ben: Good. Like so.
Michael: Like so. Great. We're going to get that left arm up. We're going to get you into a nice comfortable position, the best titanic position for me.
Ben: Alright, got it. Now, of course my mom always told me I had a big heart.
Ram: We'll find out.
Michael: And how tall and what you weight. We'll put that in because all of the measurements will be normalized to your body mass index and so forth, so we can get the body surface area calculated.
Ben: I'm 6'2″ and 181 pounds.
Michael: Alright. So, this is an ultrasound. So, just like when they look at a baby. We're going to be actually looking at your heart and all the mechanics within the heart, the valves, the walls, the chambers. We even have the ability to turn on something that we call Color Flow, which is a Doppler. So, just like they [00:09:12] _____ et cetera. So, we can actually watch the blood flow going through the heart. So, we can look at those leaky valves or things that would cause that heart to enlarge. And then, the best part is is we can take those visions that we see with the color and we can actually measure that. So, we can actually see the velocities that are going through the valves.
Ben: Wow. Amazing.
Michael: Yup. So, here we go. It's going to be a little cold.
Ben: Not too bad.
Michael: Well, for all those viewers out there that did wonder, he does have a heart.
Ben: I have a heart.
Michael: You have a heart.
Ram: Great images.
Ben: Reminds me of when my wife was pregnant, we went in, and she said, “You have a baby.” Although in her case, there were two. Now, is it common, doc, when you bring in healthy people, athletes, exercising individuals that you do indeed find things they may have been unaware of, or you do indeed find issues that would have surprised the average person for a “healthy” active person to have?
Ram: I think it's about 50/50. And I think what's really important is to look at family history because you can be totally healthy, have normal cholesterol, and then you actually have, when we do some of the scanning and so forth, we do a calcium score, we find out that there is atherosclerotic plaque developing. And that's something where it's early enough for those folks that are younger that they can really alter the trajectory of the disease.
Ben: Yeah. I think it's interesting. I believe it was James O'Keefe, who I listened to lecture at the Ancestral Health Symposium, I believe, and he was speaking to arterial stiffness in athletes, particularly endurance athletes. And he was finding, when it comes to cardiovascular mortality, a law of diminishing returns in terms of heart health once someone was exceeding about 60 minutes of intense, moderately high physical activity per day and about 90 minutes of aerobic activity. And he was actually finding markers of inflammation, atherosclerosis, and arterial stiffness, and people who were overdoing it.
Ram: Yeah. I think that's absolutely true, and there's increasing data that those folks can have accelerated atherosclerosis, their calcium scores can start to be elevated out of proportion if someone in their age and gender. So, we do see that. And I think it's a certain type of inflammation depending on–I think there's an exercise type for everybody that's really optimum. We're going to find that out and figure that out. It's going to be key and–
Ben: Yeah. And there are confining variables, too, like that's also a population is eating oodles of pasta and scones. And in many cases, a very active person is also someone who is inducing a certain amount of insulin insensitivity and rampant levels of blood glucose and other issues just related to the training to eat and eating to train phenomenon.
Ben: Right. Yeah. Well, I know many cyclists who pretty much live on three glasses of wine at night after they've ridden and a bunch of bread and pasta during the day and they're consuming 70% to 80% carbohydrates, which in many cases, I don't think does many favors from a lipid oxidation standpoint.
Ram: Correct, correct.
Ben: That or a very high intake of pupas, which I was recently over in India where they're seeing a lot of obesity and cardiovascular disease even though the carbohydrate intake has not appreciably risen. A lot of the natural cooking oils like ghee and coconut and extra virgin olive oil have been replaced by vegetable oils. As a matter of fact, I personally, from the data I've seen, think that polyunsaturated fats and some of these linoleic acids and other sources of vegetable oils are just as big a culprit for things like diabetes and insulin resistance as carbohydrates.
Ram: I think you raise a good point. We've always advocate in the cardiology community plant-based Mediterranean diet and olive oil, that type of thing. Now, there's certain purists [00:13:19] _____ that really suggests no cooking oil because of concern about when you cook things in oil so forth, there's damage to endothelium that can occur. And we can see that with some of the testing that we can do, but it's hard because these are not the most accessible tests to sort of a general population, but it's there and there's some really good validated data sets coming out of that.
Ben: Yeah. I certainly opt for heat stability, but that's always crossed my mind is, would less oil in general be better even if the oils are stable? I think a large part of that could be genetic, too. I think populations that have subsisted on, whatever, whale blubber like the Inuit, or high amounts of marbly fat, or milk and blood like the Messiah warriors, they might be more genetically adapted to those types of fats.
Ram: That's true.
Ben: Yeah. I think anytime you're dumping a bunch of oil into a hot skillet and cooking something, you're increasing risk.
Ben: I'm having the smoke point, although it's hard to have a good pork belly though that hasn't been cooked in a little bit of fat, get it crispy. And so, as you go through this ultrasound, you're simply identifying different areas, taking a photo, listening.
Michael: Exactly. So, what we do is we have a specific protocol that we follow, that Dr. Dandillaya is used to. So, it's a series of images. And then, we take each chamber in each valve and then do a set of diagnostics. So, use the color and watch the blood flow. And then, the sound that you've been hearing is the Doppler. So, that's taking actual measurements of the velocity through the valve. And so, remember, we're checking the valve for two things. We're checking for function. So, making sure that it's opening and closing correctly, it's not prolapsing, it's not stenotic, meaning, a heavy calcification, and that valve can't open and close. Or sometimes they just get a little piece of calcium on it and the valve leaks, kind of like a faucet in the house.
Michael: So, routinely, we do the echocardiograms to monitor chamber sizes, valve regurgitations, and then the progressing of those abnormalities.
Ben: And then, you're also pairing some of these parameters with actual blood work as well.
Ram: Yes. Yeah. And we'll do an advanced lipid panel, which goes beyond our traditional lipid panel, which has really been there for decades.
Ben: Right. So, you're actually looking at lipid particle size, particle count.
Ram: Yeah. I'd like to do that for you because we've seen that observation that just standard lipids alone can underestimate risk. This is where we pair it with things like the calcium score, endothelial function, and we can get a great composite of risk above it.
Ram: And there's some fascinating things in the advanced lipid panel, things like Lp little A, TMAO, the particles that we can deep dive when we get your results.
Ben: Yeah. These days, a lot of walking. I'd probably walk anywhere from five to seven miles a day just while talking on the phone, or consulting with people, or recording. And typically, sauna four or five times a week, some kind of a cold soak after anywhere from two to five minutes. And often, I had another cold shower, jump into a cold river, cold tub later on in the day. And then, about four times a week, I'll do around a 45-minute long kettlebell, or strength training session, or a high-intensity interval training session, or something that's a little bit more of a difficult workout. And then, aside from that, some tennis with the family, usually a hike on the weekends. And I'd say the hardest thing I do is those four sessions a week, like a Monday, Tuesday, Thursday, Friday, I'll go to the garage and crush the kettlebells or do a lot of sandbags, unwieldy objects, carries. I quit racing professionally last year, and so I do a lot less of the extremely hard, voluminous, intense training.
Ben: Yeah. There was a time when I was probably getting close to about 16 to 18 hours a week though when I was racing triathlon, for example. But yeah. No. Now, it's primarily walking, some kettlebells, some sauna, some cold, and then just a little bit of sports here and there in between, tennis, paddle boarding, hiking, things like that.
Ram: Okay. Take a deep breath in for me. Good. And blow it out. Good. Okay. Alright. So, that is test one complete.
Ben: One thing that I thought might be cool once we've done all of this, and whether it's a week from now or whenever we've got all the results in and we're ready for a summary is I was thinking I'll do a lot of like recorded podcasts where I can Skype you or call you and we can do like a 15, 20-minute debrief. It's kind of like a track on the audio at the end. I'll put a little bow on everything for people.
Ram: Yeah. That would be great. There'll be a lot done–
Michael: Go ahead and lay on your back.
Michael: Great. So, what we're going to be doing here is called a carotid duplex. This is an ultrasound of the two large arteries in your neck, taking blood flow up to the brain.
Ben: I don't have a lot of blood flow to my brain.
Ram: You'll find out.
Michael: What's great about this test is the carotid artery is extremely superficial.
Ben: So, it's easy to see.
Michael: Mm-hmm. Yeah. And we're able to really get an early look of any buildup on the arterial walls. And then, again, same type of parameters with the echocardiogram that we did. We have the color. So, we can see the blood flow actually going through the artery, and then we have the Doppler. So, we're going to actually get to hear the blood flow going through.
Ben: I have a carotid and a heart. So far I'm two for two.
Michael: Two for two.
Ben: Are there certain populations that you found to either be surprisingly healthy from a cardiovascular standpoint, or unhealthier than would be expected from a cardiovascular standpoint, doctor?
Ram: It's a good question. I think what's nice about being in L.A. is that we see such a diverse population of folks. What's interesting is that some of the folks that have family history that come in, and we deep dive and look at some of these parameters, we find that truly there is a significant genetic component with some of the lab work that we see. And then, we start to do some of the tests, the ultrasounds and so forth, and we can start to see early disease. So, that is somewhere where we can definitely alter the trajectory. If we can get to the disease five, ten years earlier, we could make a huge downstream difference.
Ram: But it's interesting. I do see certain folks that have done very hardcore ketogenic diets, which I know is your area of expertise for you. And interestingly, their lipids can be very alarming. So, there's a balance on that that we should certainly discuss and something like–
Ben: And the people who I've worked with and helped out with their lab panels who are following a ketogenic diet, I'll often see pretty rampant triglycerides, some amount of inflammation, coupled with high LDL, which I don't think is sufficient for heart disease, but definitely a necessary component. And a lot of times, I'll find that these are the people who are not necessarily achieving ketosis via, say, carbohydrate mitigation, some amount of fasting, good plant intake, and not an appreciable intake of saturated fat, but instead people who are doing the coconut oil bombs and the half a stick of butter on their coffee and just rampant amounts of particularly saturated fats with the absence of much plant matter. And I think there's kind of two flavors of a ketogenic diet. One that is favorable for heart health potentially, and one that seems to accumulate a lot of risk factors for heart disease.
Ram: Yeah. I tend to agree. I think there's a certain diet type that is optimized to the individual and interplay between that microbiome, and TMAO is an emerging risk factor. So, I think it's really fascinating and I think there's still a lot of unknowns.
Ben: Yeah. You can fast, you can eat fish, you can have eggs, you can drench some of your vegetables and extra virgin olive oil and still maintain low blood glucose, low glycemic variability, and somewhat high levels of circulating ketones and have good health. And then, you can also, like I mentioned, just dip a giant spoon in nut butter and coconut oil and butter all day and do it that way. I think you'll see two different outcomes. Do you have any opinions on this new trendy carnivore diet a lot of people are following now?
Ram: Well, I try to take a balanced viewpoint on all these issues, but I do see some problems that run into. Again, I see people are able to keep their inflammation levels down and keep their lipids under control and certain things. I suppose they've adapted–like we talked about, there's some adaptation to that type of diet, but my personal feeling is that it's a little bit extreme. But again, there really hasn't been really controlled data on that, and these studies are obviously hard to do.
Ben: Yeah. Again, I tend to see the same thing. It could be done right or done wrong. I think there's people eating ribeye steaks from Costco for breakfast, lunch, and dinner, and then there's people consuming bone broth, and liver, and lots of glycine-rich organ meats and kind of taking an entirely different approach. I think the latter is if you were going to use that type of approach just from a nutrient density standpoint, and you're also limiting the massive amounts of methionine intake you get from just eating muscle meat all day long. And there's some definite linkages between methionine and constant mTOR activation to the extent where you might be eliminating longevity to a certain extent.
Ben: Yeah, yeah. So, I think for that diet, more of a so-called nose-to-tail approach seems to be favorable. It's a very socially limiting diet. No plants at all. It's difficult to follow. I see it being of some utility for someone who just wants to eliminate all problematic plant compounds from an autoimmune standpoint short-term, but I don't see it being a long-term–
Ram: Strategy, no.
Ben: At least a strategy that I personally could sustain just because I love our vegetable garden and plant foraging and having a little bit more expansive diet. The same could be said of like a vegan approach, too, right?
Ben: You could be vegan and have granola and bread all day long or you could be fermenting, and soaking, and sprouting, and doing greens, and shoots, and sprouts.
Ram: I mean, we always say, “Listen, potato chips are vegan.” And there a lot of trouble with vegan diets. It's between the nutritional deficiencies we've talked about, but certainly having that base of whole food plant-based eating is good. I think everyone agrees on that.
Ben: Yeah. Nearly everyone.
Ram: Nearly everyone.
Ben: Yeah. Except the carnivore population. And I don't think through a certain extent, the paleo diet crowd issues a lot of things that we know could be metabolically favorable like legumes or grains, certain things that I don't necessarily have a problem with if they've been prepared properly.
Ram: How do you recommend young folks that are interested in nutrition, what is the way to start? Because it's very confusing and there's a lot of choices out there. How do people find their pathway on this?
Ben: Well, it's confusing as dogmatic. If someone were interested in it as a career, then I think the very best thing to do is to tackle it from a standpoint of–if you look at the education rather than focusing on nutrition courses or dietetics courses, which are always going to be biased, what you do is that you instead take chem, biochem, ochem, microbiology, and you essentially equip yourself to be able to understand the underlying building blocks of what it is you're talking about. And if you start there, even physics to a certain extent just to understand some of the energetic equations, then you're able to step back and look at any diet right, especially if you pair that with some type of education anatomy and physiology rather than simply learning about, whatever, carbs, protein, fat, the Mediterranean versus the paleo versus the vegan. I think instead of deep underlying knowledge of the science is going to set you up to foundationally understand any diet, if it's something you want to pursue from a professional standpoint.
Ben: Yeah. I think that's the key missing component is a lot of people just don't –they don't understand the science behind the actual molecules we're talking about.
Ben: Yeah. That's the issue with nutrition is no matter which route you go from an educational standpoint, there is going to be a certain amount of bias.
Ram: And I think in medical school, just thinking back, we had maybe a handful of lectures on nutrition that's more geared towards nutritional deficiencies, scurvies, and things like that that we don't really encounter in just modern society. But the true practical nutrition training was really not there.
Ben: Yeah. Yeah. There's a few orders. I think the Institute for Integrative Nutrition is one that does a decent job, the IIN. They have a good certification that seems to be a little bit more well-rounded and holistic. Then there are places like the–
Ram: Okay. We'll break here.
Ram: Good. So far so good.
Ben: Awesome. The Institute for Functional Medicine, they put out some good resources and there are guys like Chris Kresser, who have good training programs, Paul Chek, who's a little bit more of a fitness trainer. He has some really good programs as well based on an education that's more addressing each person individually, and also looking at things from a more ancestral standpoint.
Ben: But a lot of the university courses, they're steeped in essentially this same food philosophy that is sparked from government subsidy of grain, corn, and soy, monocropping of agriculture, this idea that fats are largely vilified, just all lumped into one category. It's still very kind of like old-school food pyramid-esque, a lot of the education, shockingly enough. Alright.
Ram: Alright. So, as we've talked about looking and identifying areas where there's risk in the heart with the valves, heart enlargement, cardiomyopathies, and cardiomegaly, et cetera, is that we look at for with the echocardiograms. We looked at the carotid. So, looking for plaque and disease. So, the other big one that we like to do is looking at the abdominal aorta. That's where we unfortunately hear about aneurysms in elderly folk who've not been able to survive it because if it doesn't really happen in the parking lot of the hospital, it's a tough one. So, Medicare has a great privilege that anybody over the age of 65 can actually go get a one-time only abdominal ultrasound if they've ever had one in their family, if they've ever been a smoker, if they've had high blood pressure. And there's about seven or eight parameters that Medicare will actually gift you one at the age of 65, which is great because it really is truly one of those silent killers. But it's nice again here that we have that as part of our packages looking at [00:31:46] _____.
Ben: Yeah. That's interesting. That's not one that a lot of people talk about is the [00:31:49] _____.
Ram: Not one that a lot of people talk about. And again, it is a silent killer.
Ram: So, it is important to have that evaluated. So, again, and the great part about all of this and everything that we'll be doing to you today is it's all non-invasive. It's all done with ultrasound or pneumatics.
Ben: Mm-hmm. And no radiation.
Ram: And no radiation.
Ben: Oh, that's fantastic.
Ram: So, you're getting a lot of testing with little, essentially, to no risk. The highest risk is the treadmill.
Ben: Yeah. I'm not afraid of treadmills, but too many time on those things.
Michael: It's not the treadmill you have to worry about, it's the guy operating it.
Ben: Yeah, exactly. Although I just interviewed someone on my podcast who swears by the hormetic benefits to low amounts of radiation.
Ram: Oh, wow. What was his thesis?
Ben: Her name was Jane Goldberg and she was talking about everything from radon exposure to the fact that in rodent models living around Chernobyl, you're seeing extended lifespan to UVA and UVB radiation from the sunlight and low amounts having a hormetic effect. And there might be something to that low-level natural radiation we get from the earth or the sun.
Ram: And what's the idea that would stimulate your innate mechanisms and your DNA.
Ben: Yeah. Innate endogenous antioxidant production, some amount of DNA repair upregulation, et cetera. I don't necessarily plan on–she does in her book in certain places issuing the benefits of, say, the atomic bomb or something like that, but I think there's something to be said for these. I think they're called geothermal hotspots, or in alternative medicine they're called energy vortices, these areas on the planet where there's natural radiation emitted by rocks and geological formations, and you'll find a lot of Native American hot springs and healing spots actually built up around those locations like in Sedona or Big Sur. And then, also, some of this idea, there are certain rocks and stones that emit low levels of radon, for example. She'll find a lot of rocks that they would harvest from, say, King Solomon's mines over in Israel. She got some interesting data on increased lifespan or at least increased cellular resilience in response to some of that. I generally try to limit my exposure to radiation from a lot of more modern sources, or wear my EMF blocking underwear on the airplane and all that good stuff.
Ram: Hopefully, they're still not red.
Ben: The underwear?
Ram: Yeah. All the EMF stuff's always red. It's like always the most [00:34:51] _____.
Ben: Yeah. Mine are blue. And then, some company out of Germany actually sent me this slick travel suit that's essentially comprised of almost like Faraday cage material.
Ram: Like a full body–
Ben: Yeah, yeah, but it's not unsightly, it just looks like some nice slacks and the shirt.
Ram: Very cool.
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Ram: We're going to launch the endothelial function test now, which as you may know that endothelium is many consider that the biggest organ of your body, it's like the super organ, it's the layer of cells that line all your blood vessels, 60,000 miles of your blood vessels. So, understanding endothelial function is really critical. It's been thought to be sort of that canary in a coal mine sort of thing with 10-year risk prediction 10 years ahead of time before even atherosclerosis can appear. So, there's great data that's been validated and it's also FDA approved. So, it's a good baseline assessment.
Ram: And also, with nitric oxide production, which is really what it's all about.
Ben: Yeah. We'll find out if all that walking outside in the sunshine is helping with the endothelial nitric oxide function.
Ben: I'm convinced that's one of the best things you can do right now is a lot of good sunshine. You see some data on even like the sauna and the cold thermogenesis. It's going to be an increase in nitric oxide for me as well.
Ram: Yeah. And then, L-arginine supplementation for some folks tends to be helpful through diet. So, I don't know what your thoughts are on that.
Ben: Yeah. I just take a Viagra every morning and I don't mess around with the L-arginine. How to hack your cardiovascular function test? Just take sildenafil beforehand. You'll feel you look great.
Ram: So, this next test is called an EndoPAT. So, it looks like I've heard you already say it three or four times at least, arterial stiffening. So, this is looking at nitric oxide.
Ram: So, it's fine that you talk about Cialis. Yeah. Cialis is a heavy nitric oxide. We all know exercise products and stuff like that always boost nitric oxide. So, we're actually able to measure it. It's actually a medically award-winning formula. As you will probably know, there's a Nobel prize behind the diagnosis of nitrogen oxide. So, very important cool tests.
Ben: Okay. And this one's called the EndoPAT?
Ram: This is called the EndoPAT.
Ben: Okay. Not the Endopath, the EndoPAT?
Ram: Correct, P-A-T. So, Endo standing for endothelial lining, and the PAT standing for peripheral arterial tone. And that's going to be these guys right here. So, very cool little device has a pneumatics inside of it. So, your finger will go in there. Are you right-handed or left-handed?
Ben: I'm right-handed.
Ram: Okay. Here, and it's got here.
Ben: Okay. Index finger goes in.
Ram: Put it in there just like that.
Ben: Looks like a little finger condom.
Ram: Thumb from bumping into that sensor.
Ben: Okay. That's what those are for.
Ram: This keeps the stability of the test. [00:41:20] _____. This is kind of a cool and unique test in the respect that we actually put your arm to sleep for this guy.
Ben: You put my arm to sleep?
Ram: Put your arms to sleep.
Ram: So, for our lovely viewers, they're going to get to miss out on the boring component of a test that's also conducted over 15 minutes where the patient is not allowed to move and is not allowed to speak.
Ram: So, we'll have a couple portions of some control in the test where I'll be doing some talking, but again you're going to be a good boy.
Ben: That's fine. Yeah. I can go [00:42:15] _____.
Ram: That's a great ADD checker as well. Alright. I know. Just like that.
Ben: And if you have warned me, I would have headphones at an audiobook in. Now, I'll just have to go inside my head.
Michael: I'll try to be like one since I do about three a month.
Ben: That's right. Tell me stories.
Michael: I don't know if you'd like the one that I'm listening to now.
Brenda: [00:42:41] _____ Ben's head's like an audiobook.
Ben: Yeah, that's right.
Ram: Well, it's funny. Sometimes you listen to them, you can't remember if they're a movie, or if it was an audiobook. Like, something will pop in your head, “Oh, my god, I remember that great scene.” Like, that wasn't a scene, that was an audiobook.
Ben: Especially the really good one.
Ram: Alright, perfect. So, fingers go all the way down. You're going to stay just like that. And I'm going to take the air out of those in just a second. And we said 6″2′, right?
Ram: And then, I hear 185.
Ben: About 180, actually.
Ben: I quit eating as many ribeyes.
Ram: Alright. So, fingers should all the way be down, don't move, hold nice and still. Perfect. Okay. So, we're going to go ahead and put you into the testing position, which is exactly like that and exactly like that. Alright. So, we have good signals, good strength. You ready to go?
Ram: Here we go. So, 15 minutes, no moving, no talking. Alright. So, we have begun, as I said, 15 minutes no talking, no moving. The test is broken up into three five-minute segments. The first five-minutes is called the baseline, and that's why the two probes up on your fingertips there are capturing your pulse data which we see represented over here on this screen. And we're going to maintain this measure for five minutes, and then we'll enter into the second stage, which is called the occlusion. And that's going to be where I pump up the blood pressure cuff and put that left arm to sleep. Through the science, they found out that is the non-dominant arm that we like to test. And so, again, we'll maintain that for five minutes.
And then, the last five minutes is called the dilation, and that's when we're going to watch as the blood is returned back into the artery, and that revascularization process. So, since we're looking at pulse in terms of amplitude, the higher the amplitude–so we should be watching that amplitude increase after we release the blood pressure cuff. And in their proprietary software, they're able to give us the measure of nitric oxide through the voltage, so how tall it is and how long it lasts it. And so, based off of those parameters, I will be able to get that score for you today. So, 3 minutes, 25 seconds left of the baseline. Okay. 2:40. Doing good. So, when you release the blood pressure cuff in 2 minutes and 25 seconds, you'll just feel a normal rush of blood going back down your arm, no discomfort. Two minutes, doing good. And 45 seconds, doing good, 10 seconds. We'll let that air out. Alright. So, five minutes, still no moving, no talking. Alright.
Great. So, what we're seeing here is a response in the artery. So, as we reintroduce the blood flow back, we see that the pulsatility on our screen is actually higher than it was when we began, which is exactly what we expect to see happen.
Ben: This is the reactive hyperemia we're talking about?
Ram: Absolutely, absolutely. Well, what's so great about this test is we can actually see it in the form of the high amplitude pulse.
Ben: Mm-hmm. And the machine will take this data and apply calculations and normalize it to its database.
Ben: And then, we'll get the RHI number, which is the key number that we're looking at to get an indicator of arterial health and endothelial function.
Ram: And what I love about this test specifically is that we get the results now. Some of the tests that we talk about, even our favorite tests that we like, sometimes we have to send that out. Sometimes we're dependent on getting those test results back. Sometimes that could be a day, sometimes that could be a couple days. What's great about this and the practice is that you get that rapid results.
Ben: It's a real-time number.
Ram: It's a real-time number. Two minutes, 20 seconds left. Doing good. And coming up on two minutes, two minutes left, and then we'll be done with this test, and then we'll go ahead and transition over to the stress echo. Doing great. Homestretch, 1:20, 50 seconds, doing good. Alright. So, in 15 seconds, we'll go ahead and stop all of our recordings. I'll let you know when you're safe to talk and safe to move. And then, we'll initiate the program to go ahead and give us those rapid results. You can talk, you can move. How did you do?
Ben: Oh, lull in Lalaland. I could hear your voice droning in the background, but I was so deep into meditation [00:48:51] _____ planet.
Ram: Got some good data here.
Ben: I have to admit, I'll probably need to take a leak then before I get on the treadmill.
Ram: For sure. We'll pause for station identification.
Ram: And good to just unhooked here.
Ben: Station identification. I don't know that in a long time.
Ram: I'm glad that at least one person in the room got it.
Ben: Yeah, yeah. Somebody's heard the radio before. That was an interesting test.
Ram: I really wanted to see what you thought about it, yeah.
Ben: Very cool. It fell asleep then.
Ram: Well, yeah. I've done a lot of blood flow restriction training before where I'm pretty used to having the arteries occluded even while training. So, that wasn't too crazy of a sensation for me.
Ben: So, what are you doing here, doc?
Ram: Alright. This is one of our most fundamental tests and cardiology. We're doing a 12-lead electrocardiogram. So, Brenda is putting these leads on. So, we're going to be recording electrical signals from your heart.
Ben: So, this is essentially like a resting EKG?
Ram: Resting EKG. So, we can ascertain your heart rhythm, we can see if there's any kind of athletic heart pattern, chamber enlargement, and so forth. So, it's our fundamental test. So, we'll get–
Ben: This is the one I'll let you look at the QRS wave.
Ben: Uh-huh. The rhythm of the heart.
Ram: That's right. We'll look at the QRS waveform and the other waveforms. So, absolutely.
Ben: Now, explain to people who might be wondering why you can't just put an electron, say, over the heart for this, why the electrodes go in so many locations.
Ram: Well, we're looking at vectors. So, think about when we talk about a 12-lead EKG, we're looking at the heart from 12 different angles, so we can localize certain disease patterns. As you probably know, there are some consumer devices that are really pretty cool that you can record your own heart rhythm at home, and that attaches to a smart device. So, those are good for–
Ben: I use one for that to measure heart rate variability called NatureBeat.
Ram: Yeah. And so, those are good for rhythm analysis. This is good for not only rhythm analysis, but really looking at again the heart and all these different leads and localizing any other issues. So, it's a little bit more detailed.
Ben: Mm-hmm. And what would be an example of an issue you might find on an EKG, electrical abnormality, like an arrhythmia, tachycardia?
Ram: Yeah, arrhythmias, tachycardia. In older folks, atrial fibrillation is a common thing that's picked up on an EKG. We could see left ventricular hypertrophy. We could see left atrial issues with the atria as well. So, different chamber abnormalities. Sometimes you can pick up electrolyte abnormalities also. So, some really interesting things on the EKG, and then of course vagal tone. I suspect you'll have a low resting heart rate, so we'll just see what your resting heart rate is on the EKG. So, yeah. We can pick up all of that.
Ben: So, will this also pick up heart rate variability?
Ram: Traditional 12-lead EKG does not, but my sense on heart rate variability is that you can see that on some of the devices, the Oura rings, and so forth where you can get more of a consistent day-to-day measure of that. That's probably the most useful to develop a pattern. I think isolated measurements on that can be a little bit hard to interpret. So, it hasn't quite made it into the traditional cardiology world, but I think it's going to be fascinating when we have wearables and sensors where we're just gathering data on a continuous basis for folks to be able to aggregate this data and see what this all means. Great. Thank you. So, as predicted, heart rate of 42, so high vagal tone, pretty impressive. And otherwise, looks like a good EKG, no major red flags here. So, we'll review this a little bit more in detail, but this is overall good.
Ram: So, your resting heart rate, usually, do you track that?
Ben: Yeah. Usually if I'm asleep, I'm kind of upper 30s, low 40s.
Ram: Yeah, fantastic.
Ram: Excellent. So, this part looks good.
Ben: Depends on what I'm up to during the day, whether, I don't know, my mother-in-law is visiting or not. Hopefully, she doesn't listen to this podcast now.
Ram: Okay. Excellent. Alright. So, resting heart rate, 42.
Ben: So, that was accurate?
Ram: Yeah. So, on for your home stretch here. I think we're going to get you on the treadmill.
Ben: Homestretch, yeah.
Ram: Alright. So, yes. So, we've hooked you up like a standard resting electrocardiogram. Again, as we discussed earlier, a little bit different electrodes because again this is a stress, so you're expecting to be bouncing on the treadmill, exercising, sweating, et cetera. So, the electrodes have a little bit bigger surface area and are designed to stay on you during those phases of your test. And then, what's cool is we will then use the ultrasound machine again in conjunction with the treadmill. So, what we do is we take pictures of your heart at rest. So, we look at the regional wall motion. So, the heart should look like a bellow. So, the heart is going to contract like a bellow with a base that moves up.
So, that's essentially what the ventricle should look like. Well, each area around that bellow essentially are a segment, and our coronary arteries feed various segments of those walls. So, we do the resting images of the heart, then we bring you over to the treadmill and exercise you, get that heart rate up. Now, what's different from a traditional treadmill is normally of course or at the gym, as soon as you're done, you generally cool down. We don't have a cool downstage. We go from maximum exercise back over to this table as quick as we can back into our imaging position and we take those pictures again. And that's so we can see that heart beating extremely fast and obviously looking for any type of blockages along those walls.
Ben: Got it.
Ram: So, back into your titanic pose.
Ben: Okay. That's actually one movie I never want.
Ram: Left on left side. Well, that's why you don't know how to come over on your side. The most famous scene in the movie is this pose right here. And I think she got a dime or a nickel for that.
Ben: Many others I never watched, [00:56:40] _____ hard time for people. I've never been in the movies. I read a lot of books though. That's not jam.
Ram: Well, that's good. You can get a lot more from a book in most cases than movies. Alright. Let's see who we have.
Ben: The only time I'll watch a movie is if I'm stuck on an international flight.
Ram: So, really on this test, it's patient preparation. You spend that extra couple minutes getting the electrodes and getting the right pictures. It really goes such a long way to get a good quality study. So, we don't always get great windows like yours to look into the heart. So, we just have to do everything we can with the patient prep.
Ben: Makes sense. It was going to be fascinating to compare all this data we're getting and have it all in one place. Now, in terms of this workup that we're doing, is it common for someone, whether it's an executive, or an athlete, or someone like that to come into your clinic and for you to do this battery of tests?
Ben: Called it a full cardiac workup.
Ram: It's a full kind of cardiac preventive workup. And again, we're always looking at new technologies and tools to put into the mix. Part of it is that there's a lot of technology but just hasn't been quite validated with some of the data, but this is a good representative set of things that really does have good data. So, we like to look at it.
Ben: So, I'm more interested in doing this same panel, they would just be able to contact Atelier Health and say they want the full cardiac workup.
Ram: Preventative cardiac workup.
Ben: We're going to call it the Ben Greenfield Specials.
Ram: That's right.
Ben: Then people get dependent and they'll start to see if they can beat our results, see who's got the biggest heart. I was reading an article the other day about how broken heart syndrome is becoming increasingly common in an era where loneliness and depression is increasing dramatically with this idea of impaired cardiovascular function due to the emotional and stress component.
Ram: Fascinating, yeah.
Ben: Yeah. It is fascinating that you can actually have broken heart syndrome very similar to some of my experiences there to lose a loved one.
Ram: Yeah, yeah. This has been–
Ben: [00:59:07] _____ get the same thing through loneliness, through depression, through losing a job to like COVID.
Ram: Yes. The emotional impact, the stress that's created during those types of events, there's varying theories, but it can really create a catecholamine, flood the heart with catecholamines and that can create a stressed cardiomyopathy. I think the other term has been a takotsubo cardiomyopathy that they've called before. Yeah. So, here we're just getting some good baseline pictures and a couple different angles. This is called a parasternal lung axis view. And then, Michael will switch over to a few other views as well.
Michael: So, just like a film editor or capturing snapshots and they loop, and the software on the machine, and plus the software that Dr. Dandillaya uses post-test to evaluate all your images. It puts them side by side so you can actually compare the walls as we had discussed earlier. Go ahead and lean back a little bit more. Stop right there.
Ram: So, these, Michael, are obviously terrific images. So, we have a really clear view of all the segments and we're going to compare these resting to what we call the post-stress images, and we can see if there's any differences or abnormalities. And if there's coronary artery disease, there would be a segmental well-motion abnormality on stress. So, that's the rationale behind doing this.
Michael: Perfect. Okay. So, we're ready to go ahead and transition to the walking portion of this test.
Michael: Alright. Arm forward. So, we're going to go ahead and start okay? Here we go. So, just go ahead and begin walking. Great. So, the way that this test works is every three minutes, it goes higher and faster. It's on a predetermined course if you will. We use something called Bruce protocol. Bruce protocol is pretty standard throughout the United States. It's what most cardiology office–
Ben: [01:01:21] _____ Screen TV.
Ram: That's over here.
Michael: And typically, we will do this. We have a couple goals we like to achieve. Of course, maximum heart rate is one of them. When we of course [01:01:35] _____, 220 minus your age is your maximum heart rate. So, we're looking to get to that, and most of our healthy patients don't have significant amount of orthopedic issues or were going to cause more harm than good, but we like to get everybody up there that we can to a minimum of 85% though. So, for you today, because I do believe we're doing online betting on how long you go, we have to take you all the way.
Ben: Yesterday was full of days. We'll see how that goes.
Ram: What is our target heart rate?
Michael: 182 or 154.
Michael: Remember, 100% is going to be that 182. And then, we said 85% was good. So that'll be that 154.
Michael: Yeah. Did you have the device over your mouth like you do now when you did that?
Ram: Yeah. Do you want to come over and just come–[01:02:38] ____, do you have the address?
Ben: That's right. Yes, yeah.
Michael: Doing good, doing good. So, four minutes 35 seconds on the belt. Heart rate's still 94. Great. So, in about 30 seconds, we'll go ahead and transition to the next stage, and it'll turn into a little bit more work. Young healthy guys, the EndoPAT is torture on you, your stress tests are torture on us. Good. So, here we go. We're going to transition to that next stage. Good. Doing good. Seven minutes. Heart rate's finally up to 125. Superman is unbreakable. We're in good shape. Doing good. Heart rate going up. Great. Doing good. So, next stage is, either, going to be a very long stride or a low run.
Ram: How are you, guys, doing? Do you, guys, have a study [01:03:55] ______?
Brenda: Yeah we have three.
Michael: Just to make sure, thumbs up, doing okay. Yeah, perfect. Good job. Don't want you talking. I want you just doing what you're doing, concentrating on that breathing. 160. So, we have them at our 85% mark. Again, trying to get closer to 182 as possible. Alright. So, in 15 seconds, do you feel comfortable going into the next stage for, let's say, a minute?
Ben: Maybe, just a little bit.
Michael: Okay. Give me a minute, okay?
Ben: Go ahead.
Ram: We're at 170.
Michael: He’s going to recover really quickly.
Ram: Yeah. So, we got to get him–
Michael: So, that's the other part that we see with the stress test. And then, remember, right back over to the table. If you have to stop, just simply say, “stop.” It takes me a second. Doing good. Try to give me 40 seconds and we will stop. Anything sooner, just need to hear from you. Doing good. Keep it up.
Ram: Just keep going.
Michael: 30 seconds. Doing great. 171, going for 182, less than 30.
Ben: Just–Okay, there we go. Alright.
Michael: Awesome. Good. Left arm, left side.
Ram: Alright. We'll get the lights.
Michael: Okay. Blow it out. Good. On the outs just try to slow it down for me a little bit. Good. Breathe. Out. Hold. Breathe. Good. Keep it going. Out. Good job. Good job. Good job.
Ram: Good, really good.
Michael: We love those outs. Out. Perfect. Your rate is coming down.
Ram: Coming down nicely.
Michael: Everything is normalizing. Doing good. On a side note, you probably have a very good discussion on mask and full-on feelings and unbiased opinion on–
Ben: You might feel a little bit of a resistance.
Michael: Listen, you did it, but you're here. You're not green. You're not blue.
Ram: It's not easy.
Michael: I consider it to be more labored. It's harder. It's almost like a little bit of a weight on your lung. But, essentially, you're still moving oxygen. You're still moving everything.
Ben: This whole mask thing, it's great for everybody's cardiovascular function. They'll get a little bit of hypoxia.
Ram: That's right.
Michael: But, you've already turned back to normal, yes?
Michael: Good. Heart rate's already back down to 78.
Michael: And, we're just not even two minutes in post.
Michael: Good. So, we monitor you for about five minutes afterwards, just to make sure that everything is good and returns back to normal.
Ben: So, still Titanic position?
Michael: Do you want, you can go ahead and lay on your back.
Ben: Okay. It's kind of like a little good luck you put people through. Don't eat. No coffee. Come in. Put a bunch of wires on. Get on treadmill. Don't say anything for 15 minutes and don't move. You can advertise this as sort of like a little Navy SEAL training thing.
Michael: And I expect five-star Yelp reviews. So, I don't think it's a total request.
Ben: That’s right.
Michael: You had me at hello.
Ben: Give me a glass of wine on my way out the door.
Ram: You did good.
Michael: Alright. So, we're three minutes, 20 in post. You're doing good.
Ben: When do we do the bench press test?
Ram: That's next.
Michael: Alright. You can go ahead and sit up.
Michael: I promise I have no pleasure from that.
Ben: No, that's okay. I'm not a hairy guy. So, it's not too bad.
Michael: I do have some people that would ask me to do two at a time. Yes. Alright. And, perfect. Thank you for the assistance.
Ram: Just watch this too. Here we go.
Michael: No pressure, you’re on camera.
Ram: Oh, Amy, is the treadmill patient ready?
Ram: Okay, Michael we just need to—
Amy: Do it?
Ram: Yeah, he'll do it now.
Amy: Charlotte is going to out here.
Ram: Yeah, she’s drawing him.
Amy: I’m going to go with Diana.
Amy: We’re going to do the IV.
Ram: Oh, perfect.
Michael: Alright. Off we go. I think that was our last procedure here, yeah?
Ram: Alright, Ben. Ben, this is Amy.
Ben: Hi, Amy. Good to meet you.
Amy: My name is Amy.
Ram: This is Ben Greenfield, the biohacking.
Amy: I listen to your podcast.
Ben: Cool, amazing.
Ram: We got your blood. So, I think.
Ben: So, what we'll do–is the video on?
Male 1: Yeah. You want me to turn it off?
Ben: No, no, you can keep it on. I'll tell the doctor real quick. Alright. So, that was a whole battery of tests. Now, what you guys are going to see next is we're going to go one other facility for one more test. Do you know the name of the test that we're—
Ram: The coronary calcium scan.
Ben: It’s going to be the coronary calcium scan. And then, after that, once you've seen the coronary calcium scan, you will be subjected to an executive summary with me and the doc about the results of everything that you've just seen me go through. And again, shownotes for all this are going to be at BenGreenfieldFitness.com/heartpodcast.
Alright. Now it’s time for the cool stuff. We got a SOMATOM calcium scan here, and this is actually going to scan my arteries for any amount of calcification or calcium buildup which itself can be a cardiovascular risk factor. If you ever read the work of folks like Dr. William Davis who's been on my podcast, we actually talked about this test on that show. And, it can be a really good indicator of a cardiovascular risk potential. So, we're going to find out if I've got too much calcium in my arteries, which could be a result of everything from inflammation to atherosclerosis to shockingly even excess vitamin D intake or excess calcium intake. So, it's going to be interesting to see what results look like.
Ram: All the white stuff is calcium.
Ben: So, the large white, that's all calcium deposits.
Ram: That's a huge score. This person has a score in the thousands.
Ram: And a stent at 44, okay. So, they're not doing so well. You have calcium also in an artery over here. This is the left anterior descending artery territory.
Ben: Calcium in the descending artery.
Ram: Right here, small calcifications there. And then, on the right side, there’s calcification here. The score is 42. Now, that score isn't particularly high when we compare it with people who have obstructions in their coronary arteries.
Ram: Usually, they have quite high calcium scores in the hundreds or the thousands. On the other hand, at your age, 38, we typically don't see many people with calcium at all.
Ram: So, the takeaway here is it's not a huge amount of calcium, but it's showing up early. And, a lot of people would consider that bad news, and it depends on how you look at it. If you say, “Gee, I don't like it being there early,” I guess you could say that's bad. On the other hand, if you don't have a test this, you don't know that it's there. So, then you go along and you get to be 45, 50, maybe 55, 60, and then all of a sudden you got a lot of heart disease.
Ram: Whereas, by spotting this when you're 38 and saying, “Hey, this is starting early.” Then you work with your doctor to slow this down considerably, and it depends upon what's causing it. And in most cases, we don't know every reason why it happens. We know if you have high cholesterol it contributes to this, but inflammation usually kicks it off. You aren't obese. So, you probably don't have insulin resistance and elevated glucose. That's the most common reason we see.
Ben: Yeah, yeah.
Ram: But heredity has a great deal to do with this as well so we can't explain everything. What we do know is there is some component of inflammation that causes the endothelial, the inner lining of the blood vessel to get inflamed. And then, in conjunction with cholesterol in your body, there gets to be plaque, and that plaque, as it heals, becomes close calcified, okay.
Michael: You’re looking good.
Ben: A few little spots.
Michael: This is like the pregnancy rule. The pregnancy rule is you have plaque.
Michael: So, this is like knowing what the dealer’s holding. Ever played Blackjack?
Ben: I'm a little bit plaqued.
Michael: Yeah. How old are you?
Michael: Yeah, this is young. This is very young.
Ram: So, it’s early.
Michael: It’s early and do you have a family history of heart disease?
Ben: No. I would guess it's possible that some inflammation might be contributory due to about 20 years of competing in some pretty masochistic adventure sports, ultra-endurance sports, and lots of Ironman triathlons.
Michael: You know if you cholesterol's okay?
Ben: Along those lines. Yeah, quite well. HDL is somewhat high. LDL is fine. HDL triglyceride ratio is good. My LPA is low. CLP is low.
Michael: So, this tells you it's not low enough. There's no such thing as one number fits all. So, if you had no plaque I would say that–I don't know your numbers, but this says that whatever your cholesterol is, it's too high. At 38, you shouldn't have any plaque. What's the percentile for his age?
Ram: It's over the 95th yeah.
Michael: So, you have actually more plaque than 95% of people your age.
Ben: Wow. This is good to know.
Michael: Yeah. This why they intervene now because probably if you intervene now with cholesterol-lowering, what will happen, it probably will save you a lot of years of life.
Michael: So, I was surprised to see this actually. It's very unusual to see 38-year-olds with [01:15:05]_____.
Ben: I'm going to be headed off to do some research on calcium scan score lowering.
Michael: Yeah, yeah.
Ben: For sure.
Ram: I told them that it's actually good news to find this out when you're young.
Michael: Oh, yeah. Of course.
Ben: Yeah. Dr. William Davis is the guy I first learned about this scan from. And, I might pick his brain a little bit too about some recommendations he may have.
Michael: Well, these are very underutilized. If everyone had the scan done, you would be running a lot of harder task.
Ben: Yeah, simple and quick too.
Ben: Now, do you guys send me the results or do you release these through the doc?
Michael: Well, if you leave your docs, we can release it to both.
Michael: So, if you–
Ben: And, what's the best way to do?
Michael: Just make sure you give the name of your doctor and then your contact information and we could send them–
Ben: Oh, at the front desk?
Michael: Yeah, with Ruby.
Michael: Interesting. It is what it is.
Michael: The devil you know, they say, is better than a devil you don't know.
Ben: Oh yeah, absolutely. No, I'm glad to have found this. This is actually surprising to me but at the same time I like to find. This is why I'm doing these tests to find some information of it.
Michael: Yes, exactly. This is really important for heart health. And, it's a really important prevention examining. So, this is what we do that we take this information and you integrate it into your treatment and you mitigate risk.
Michael: So, this actually allows us to personalize your risk.
Michael: So, saying that at particular number is normal or good is actually not the way to look at it. What you have to do is you have to take the number, your goal, which is related to your risk. So, in your case, a lot of doctors will say, “Oh, your cholesterol is okay.” But, it may be okay for some but it's not okay for you. So, this doesn't save lives, it's the action you take with this actually saves lives.
Ben: Alright, cool.
Michael: Alright, good luck.
Ben: Well, thank you very much.
Michael: Thank you, you're welcome.
Michael: You're welcome, gentleman.
Ben: Alright. And so, how often does one typically retest for a protocol?
Michael: Once this is positive, you don't retest.
Ben: They don't retest.
Michael: What you may want to do at some point maybe three, four, five you're down the line, you may want to get what they call a coronary CT which is where they get contrasted.
Michael: Because this particular test only looks at calcified block.
Michael: So, a guy like you, this may be the tip of the iceberg.
Michael: So, what you may want to do is actually get the full coronary CT where we can look at not only the heart plaque, but we can actually look at the soft plaque, and then we can look along the entire arterial supply.
Michael: And, we can tell you if there's any soft plaque, which is actually the more dangerous plaque if it's located in the areas–
Ben: Fantastic. It'd be like three, four, five years down the road.
Michael: Yeah. I'd say about three years down the road. You can do a full coronary CT. That's where we get the contrast. And, it's a much more comprehensive exam. But, this exam, I think, will provide a lot of benefit to you because it really represents knowing exactly what the status of atherosclerosis.
Michael: That's something I would do for the coronary CT angiogram about three years ago.
Ben: Noted. Alright.
Michael: Good luck.
Ben: Cool, alright.
Well, folks, here we are, the smoke has cleared and I am actually on Skype right now. I'm back up in Spokane, but I've got Dr. Dandillaya who you met in the entirety of all of the audio that you just listened to in which I went through each of the tests. Well, he and I are now going to pull back the curtain and reveal what we found. And, he is of course affiliated with the Cedars-Sinai's Heart Institute extremely experienced in cardiology and internal medicine. So, he has a lot of experience kind of going through and interpreting these reports. So, he's going to reveal what we have found. And, what do you think Dr. Dandillaya? You ready to do this?
Ram: I'm ready.
Ben: Alright. So, where do you want to start?
Ram: Well first thanks for having me on. It's great to be here. So, Ben, as you recall, we put you through a battery of eight tests essentially. I'm going to go through each one, kind of describe it a little bit, and then go over your specific result. So, the first test we did was a 12-lead electrocardiogram or EKG, a very standard test in cardiology. My observation for you, you had a sinus rhythm with a rate of 42. And, again, an EKG looks at the sum of electrical activity in the heart.
So, just to step back, we find folks sometimes incidentally they're in another rhythm like atrial fibrillation. They sometimes can have chamber enlargement or what we call left ventricular hypertrophy. We see that in some of the athletes and we see these athletic heart patterns and it can be sometimes alarming if you don't know any history and you see an EKG, it can look someone's having an acute heart attack. So, we see these early repolarization changes in some folks. And, I think you may have some of that in some of the leads. So, again we'll send you copies so you can have some of the visual on this. But–
Ben: That's called an early repolarization.
Ram: Early repolarization pattern which we see in a lot of healthy young adults. And, it's an interesting anecdote. I remember I took care of a basketball player who had very severe early repolarization changes. And, he didn't have a copy of his baseline EKG and he ended up having some chest pain a few months later, went to an emergency room and they took him straight to the cath lab to get an angiogram because they were worried that he was having an acute heart attack. So, I always think for some of the high-level athletes that have these changes, they should keep a snapshot of their EKG with them just in case they end up with some chest discomfort and they see another physician. We have a baseline.
So, the theme that you're going to hear probably from me is just getting baseline data and being able to have a snapshot because things change over time and it's really helpful to track that over time.
Ben: Yeah. So, essentially you're saying there's a differentiation from a pathologic condition when you see early repolarization in an athlete.
Ram: Correct. So, that's very key to distinguish. And, many times that's why we follow up with some of the imaging studies. But, the other interesting thing again is that you have a resting heart rate of 42. And so, that tells me that you've had a high vagal tone. Again, we see that in the athletic population. I had a guy the other day that had a heart rate of 31, I think it was.
Ben: Yeah, I was going to say–
Ram: And, absolutely no symptoms.
Ben: –humblebrag. Mine's actually 34, but I was a little bit excited during that test.
Ram: That's right.
Ben: Yeah, same thing. It could be diagnosed as a pathologic condition of sinus bradycardia unless someone actually knew that this person had a history of aerobic exercise, for example.
Ram: Correct, correct. And, I remember anecdotally many years ago, I always read the Tour de France athletes. They had heart rates in the high 20s and it's just a marker of such robust cardiovascular function that they have such an efficient pump that they're getting all their body's needs through a less number of heartbeats. So, it's generally construed as a good sign. I think the problem sometimes you wonder is if you get a little dehydrated, anything like that, those conditions can lead to syncope like a vagal episode, vasovagal episode which is passing out.
Ben: Which has happened before in triathlons, for example. I believe that's one of the common causes of deaths in triathlons. You get a whole bunch of aerobic athletes in the water; they pass out due to that vasovagal syncope or syncope. And, I've always pronounced it syncope when I see it in writing. So, I have to get used to saying it as syncope. But, that basically is something that occurs in many cases because they're stressed out, they're mineral depleted, they're under stress and all of a sudden that bradycardia becomes an issue.
Ram: Yeah, yeah. Again, I think this is just going to be your pattern, but I think it's fine. You're not having any symptoms, no dizziness, no blacking out, that type of thing.
Ben: Yeah. And, by the way, related to the EKG, I know that atrial fibrillation, the irregular often rapid heart rate that occurs when the two chambers get these chaotic electrical signals, that's often seen in athletes as well. From what I understand, that would be diagnosed on an EKG but you don't see something like AFib.
Ram: Correct, correct. And, it's really interesting because we're moving into the era of just personalized monitors. So, you can literally have a six-lead EKG sort of in your pocket. There are companies that make that that syncs to your smartphone and just transforms your smartphone into pocket EKG. So, that's extremely helpful to have sometimes especially some folks have these little skipped beats and palpitations. And, you're really only as good as the data you get. So, you don't really know what that may represent unless you have a picture right there. So, atrial fibrillation in that athletic population is interesting and there's various theories about why that may happen, the effect of intense exercise on the electrical system and the role of inflammation and, of course, some genetics. So, yes that is an interesting population.
Ben: Interesting. Alright, cool.
So, EKG, no big issues there aside from the fact that I should keep a copy of that on me and I should also be sure that if I am participating in events where passing out could potentially kill me such as a swim, I should make sure I'm really, really well topped off as far as mineral levels, hydration, et cetera.
Ram: Exactly, exactly.
Ben: Got it.
Ram: And, I guess that's just a kind of a thing you have to customize for your own sort of body but absolutely.
Ben: Okay, got it.
Ram: So, yeah moving on, we then worked on the ultrasounds. You remember we did a battery of ultrasound tests that looked at your heart and vascular system. When we do an ultrasound of the heart, that's called an echocardiogram. And, an echocardiogram in real-time, it looks at heart function. So, we get a number called the ejection fraction, which is a measure of the heart's contractility we can visually look at the size of the different chambers of the heart and also the thickness. So, it's kind of a nice correlate to the EKG because the EKG, if it's sort of like the EKG is black and white TV, the echo takes it up to a color TV. And then, we have things cardiac MRI, which takes it up even more. But, the echo is really accessible in most doctors' offices. And, they can actually be pocket-sized.
So, on your echocardiogram very normal-looking ejection fraction. You had an injection fraction we calculated out of 63%. Normal is generally 50 plus percent. It doesn't go to 100%, but a typical EKG is like 66. EF is 60, 65%.
Ben: So, that's a percentage of blood that's leaving my heart every time it contracts, right?
Ram: Yeah, it is a measure of the stroke volume sort of the stroke volume that's coming out of the heart. There's a term you may have heard called congestive heart failure. Basically, in one subset of congestive heart failure called systolic congestive heart failure, those folks can have ejection fraction 40% and lower, and they are at risk for things sudden cardiac death and arrhythmias and things like that. And, they're obviously very symptomatic because they can't meet their body's metabolic needs. So, shortness of breath and swelling in their legs so forth. So, that's a pathologic sort of finding on the echocardiogram for example.
And, for you, we also looked at chamber sizes. I was very happy looking at wall thickness. You may have also heard of a term called hypertrophic cardiomyopathy, which is sometimes diagnosed in athletes. There have been some–
Ben: Yeah, the so-called athlete's heart. And, my wife does always tell me I have a big heart by the way.
Ram: Yeah, that's right. And so, that's an issue with kind of overgrowth of this, what we would call the septal wall of the heart. And so, it's very important to take those measurements. And, you had very normal measurements on the septal wall. Your posterior wall was slightly thickened at 1.1. And again, these are millimeter measurements. So, there's always a little bit of variability. But, again, when we see an athletic person we know that they can have a little bit of thickening of that muscle. I don't see any patterns because we do something called Doppler flow where we look at blood flow patterns across the chambers. I don't see any evidence that that's causing a problem because what happens in some folks, for example, when they get high blood pressure or hypertension, the wall starts to thicken out of proportion. It can get actually very dramatic and they get stiffening of the heart and they actually can get a type of congestive heart failure called diastolic heart failure. So, this is very good to see this kind of a normal pattern. So, you have normal flows across the valves, aortic, mitral valve. There's four valves of the heart. They all looked good. And, overall contractility looks great.
Ben: Got it. So, despite there being an enlarged musculature in the heart, you're not seeing any of the aortic abnormalities or valvular abnormalities that might accompany that in some cases.
Ram: Yeah. I see what we call normal systolic function, normal diastolic function. So, your heart is relaxing appropriately interestingly enough as cardiologists, we've always, in the past, we're focused on the contractility of the heart. But, there's a lot of activity in the resting part of the heart as well called diastole. And, that's actually very energy-dependent process. So, we're starting to focus more and more on that because we're seeing folks that have problems with that relaxation part because of high blood pressure and aging and so, forth. So, it's sort of kind of the next generation of our research is really focusing on how to treat that aging process of the heart, that stiffening of the heart called diastolic dysfunction. So, again, great baseline to have. So, very, very pleased with this.
Ben: Okay, good, good, me too.
Ram: Moving on. So, we then scanned with the ultrasound your carotid arteries. These are the arteries that go up to the brain. They come off of the aorta right and left carotid. And, again, it's interesting because, in some folks, you can pick up plaque that's starting to develop. It's a large artery. So, it's really nice to visualize the different layers of the artery. And, in some folks, they've had a lot of cigarette smoking in their life and so forth. You can see some calcified plaque and it's a warning sign. Again, we worry about stroke when we see plaque in the carotid arteries.
And, again, happy to report for you very normal-looking carotid arteries, really pristine. So, that's great. This is an easy test to do as a baseline and to look at every couple years because if you start seeing thickening of the carotid artery, you're going to potentially make some additional changes through your diet lifestyle, avoid exposures. We always think about air quality and being in LA. The role of air pollution and things that, smog, anything inflammatory that's going to affect that lining of the vessel, we'd want to take out of the picture. So, again that's where the carotids are really nice because they're easy to do. But, a good, good test.
Ben: Right. And, unlike X-ray imaging, there's really not a great deal of ionizing radiation exposure associated with ultrasound imaging. I know some of my listeners are concerned about that. But really, the radiation risk from that type of carotid ultrasound is pretty low and that's interesting. So, you said about how often do you think people should do a carotid if they decide they want to do a carotid ultrasound.
Ram: I think it's really a customized recommendation. I mean, it kind of depends on your viewpoints on early detection and prevention. Certainly with risk factors. I mean, I love getting a baseline sooner rather than later especially if people have been smoking and things like that just because we can suddenly show them, “Hey, listen, this is what's going on with your artery.” But, certainly, at age 40, I just to get a full baseline of data. And then, depending on the finding, you can kind of customize based on some of the other risk factors how often you want to follow up.
Ram: Annually may be aggressive, of course, but every couple of years it's good to periodically look at this.
Ben: Right, got it. Okay, cool. Well, that makes sense. I'm glad I don't have any type of stenosis. That's music to my ears.
Ram: Yeah, yeah. That is tremendous. And then, we did what's called an abdominal aorta ultrasound. When we put the probe, we put it right in your abdomen by your navel and so forth. This looks at the diameter and size of the aorta which is the long tube that comes off of the heart, the artery. All the branches feed the different organs and so forth. And, it's interesting because the aorta can become aneurysmal in some folks.
Again, there are some risk factors with cigarette smoking, some genetic risk factors, and so forth. But, it's like a three, four-minute test to screen for this, for an aneurysm. And, if there is some dilatation, then of course we want to aggressively look at underlying risk factors and then continue to follow that closely. Again, very happy to report that you had a very normal looking aorta, no atherosclerosis. And that term, I mean build-up of plaque that's the hardening of the artery. So, no atherosclerosclerotic changes, no dilatation.
Ram: So, again, an easy test to do, gives us a lot of confidence when we see that.
Ben: Got it. And just so you know as a listener, if you're not familiar with the term aneurysm, that's just if the aorta gets to a certain extent where the walls can become weak and balloon outwards and then you get the risk of a rupture. That's basically what an aneurysm is for those of you who are unfamiliar with that term. Okay. So, abdominal aorta ultrasound look good. And, sorry to interrupt you. What were you saying next?
Ram: The next thing we did, we did a stress test for you. We put you on the treadmill.
Ben: Right, my favorite one.
Ram: Yes, with the mask and all. So, again in the era of COVID, it's been really hard to do these in many places. We just almost don't do it because the aerosolization and all of that. But, on a case-by-case basis, there's just some data that's really helpful to see just by exercise. And so, on your treadmill test, again, just to give your readers a little overview, stress tests have a standard protocol. There's different ways to do stress test. A treadmill stress test as it implies, we put you on the treadmill generally every three minutes the grade gets increased as well as the speed of the treadmill. It's kind of what we call a standard Bruce protocol. And then we measure heart rate, blood pressure response, and we did a type of stress test where we actually did some baseline ultrasound pictures of your heart because what we want to do is compare your baseline to the peak stress images to see if there's any difference, and to see if there's a normal response.
In someone who has a blockage in a coronary artery, the stress test can be abnormal in many ways. The EKG, we're also doing a continuous EKG monitor. So, that EKG that we did for your rest, those leads are on, they're modified a little bit in position. But, if there's a problem, there would be different, there would be certain electrical signals that would alert us that your heart muscle is just not getting enough oxygen, what we call ischemia. And, apart from that clinically if you say, “Hey, listen, doc, I'm getting chest pain and it's three minutes,” that's a bad sign. And, what's interesting is I've had some women that have put on the treadmill and they came with sort of non-specific complaints of like heartburn.
And, I remember one lady, in particular, she said my throat is burning after three minutes on the treadmill. She said, “I feel my throat's burning.” And, I looked at the EKG part and there was what we call profound ST-segment depression, which basically on the EKG tells us that our heart muscle is not getting enough oxygen. So, we immediately stopped the treadmill and we sent her to the hospital for an angiogram. And, she had a 95% LED blockage. That's the widowmaker. So, she was very, very lucky but just again to let your listeners know that coronary disease can present in different ways and that atypical symptom of just even heartburn, we just want to get it checked out especially if there's an exertional component to it.
But, again, going back to your specific case, you had a phenomenal workload. I think you exercised to stage five of the Bruce protocol and you probably could have gone more. But, we got all the data we needed for over 14 METs.
Ben: I'm going to blame that by the way on squat day, the day prior.
Ram: Okay, yeah. So, that's again stage five. That's again with the mask. That's a tremendous workload again. And, we look to make sure there's no arrhythmias, any atrial fibrillation. Make sure that heart function increases appropriately on the stress response. And, you checked all the boxes. So, really phenomenal highly conditioned athletic performance on the treadmill. So, no red flags. So, again, excellent job on that.
Blood pressure response goes up, which is a normal kind of thing. So, again, no real concerns on my side there.
Ben: Fantastic. Cool. And, I'm glad I got done with that one. That was a painful one.
Ram: Yes, yes. We drew your blood and we did an advanced lipid panel for you through one of our specialty labs. And, again, the traditional lipid panel which everyone is familiar with, you come in, that's been around for 30, 40 years. It's a standard part of all our physical exams. The technology has advanced and there are more advanced ways to look at lipids. And, correspondingly these are essentially biomarkers of risk.
And so, beyond the lipid panel, we can look at what we call lipoprotein fractionation or lipid subfractions. Your cholesterol has good cholesterol, HDL, bad cholesterol which is LDL, and then triglycerides. And again, not to get too technical, but some of this is a calculated value. So, technology's advanced where technically in some labs you don't even have to go in fasting because you can get direct measured LDL cholesterol, which is your bad cholesterol. And, the other thing is you can break down these particles.
Ben: I wish they'd quit calling it bad cholesterol. I realize it's necessary but not sufficient for cardiovascular disease. And, I've seen LDL to be quite necessary and protective. And, if we didn't have LDL, we'd all be dead. I just don't know why people still call it bad cholesterol. Really, it's the particle size that's more important along with things like triglycerides, inflammation, blood glucose, et cetera.
Ram: Yeah. You're absolutely right. Cholesterol is an essential part of membranes and it's a backbone of hormones, testosterone, et cetera. So, it's very, very critical. And, I would say you're right. I think the truth is really nuanced in this area. You're only as good as the data that you have. Again, much of this, there aren't large scale trials on outcomes with certain patterns. But, we are seeing a lot of associations with certain things I'll give you an example and this is where this fractionation or breaking down the cholesterol in the particles can be very interesting. You can separate out. You can measure your LDL, which is traditionally that “bad cholesterol.” You can actually measure the size now. And, what we call smaller denser particles actually are more likely to create plaque.
So, in certain diabetic patients, we see this small dense pattern and it corresponds to the fact that these lipids accumulate in the vessel wall and they can get oxidized. And, when they get oxidized through the inflammatory response, they attract all sorts of bad players from the bloodstream, immune elements, and so forth that then kind of attack it and sort of create more of a plaque. That's how atherosclerosis starts. It starts off with probably in our teens when we have a little bit of this fatty streak. But, I do agree with you that I think there's been an over sort of emphasis on LDL cholesterol. I'll give you one more observation. There was one research series that looked at young people that had heart attacks. In young, we defined as in their late 40s, 50s kind of thing. They were actually hospitalized. And, when you look back at their cholesterol, a large proportion of them actually had “normal cholesterol.” They wouldn't even qualify for utilization of a statin. So, it sort of begged the question, how big of a risk factor is cholesterol? So, again, there are some good arguments that we need better biomarkers and that's where we have some of them.
So, again, looking at the size of the LDL particle, looking at this absolute number of the LDL particle is also helpful. Just to go back some basics here, your total cholesterol was 248. Again, HDL is the high-density lipoprotein. HDL which traditionally has been thought to be very protective form of cholesterol because it is involved in reverse cholesterol transport back to the liver and kind of scavenging the bad cholesterol and taking it back to the liver for disposal. So, HDL has a very interesting role that again is still being worked out. But, your HDL was 104, which is extremely high.
Traditionally, we've always thought that someone who's got such high HDLs is really well- protected. And, again, there's some disagreement in the cardiology community about that. There's a term called HDL functionality and so forth that there's a lot of research in. But, this is a great number. And, this is why your total cholesterol number is higher.
Ben: We shouldn't necessarily discount the fact of what you've just said in case that skips people's notice is that there is a paradox of high-density lipoprotein and elevated cardiovascular risk in some studies potentially due to the fact that HDL may play a role as an anti-inflammatory substance and potentially could indicate that there's some kind of chronic inflammatory condition going on. That's just one example. But, yeah, extremely high HDL. I think that one should look at things like fibrinogen and homocysteine, CRP, and other inflammatory markers to ensure that those aren't extremely elevated in the presence of a very high HDL at least in my opinion.
Ram: Yeah. No, I think it's all fair. And then, the other thing for you, your triglycerides were 82. Again, great number. And again, when we see metabolic syndrome and metabolic patterns, we see folks with low HDL, high triglycerides. Triglycerides were always seen as kind of a soft cardiac risk factor. But, I think there's going to be more importance in getting that optimized as a general sort of barometer of metabolic health.
Ben: Yeah. The so-called atherogenic index, right?
Ram: Yup. And so, one of the things I'll also mention. So, your C-reactive protein was essentially at the lowest number. It was less than 0.3. I think they don't even bother to sort of break it down further. So, that's really again quite phenomenal because, in our theory of atherosclerosis and probably most disease processes, it really is the chronic uncontrolled inflammation that's a problem. And so, that's great.
And, C-reactive protein, again, just a word about that, there's different viewpoints. You can alter your C-reactive protein. It can probably change, fluctuate many times a day. There's data about that, data about dietary patterns that can suddenly change a C-reactive protein, gut dysbiosis can suddenly alter a C-reactive protein number. But, when I see a track record of C-reactive protein that's well-controlled, that's a good thing.
Ram: So, that's good great for you again. One other marker we did, one other inflammatory biomarker we did was called Lp-PLA2 which is a type of inflammatory enzyme and usually we to see less than 123. The significance of Lp-PLA2 when it's elevated is that, it has been associated with heart attack and stroke risk. Part of the reason is that it's felt to be an inflammatory enzyme that is localizes to plaques, highly inflamed plaques in the coronary artery. And the hypothesis of a vulnerable plaque is that some folks have a lot of inflammation in their coronary arteries and these plaques get inflamed and they actually rupture because that plaque becomes unstable. The morphology or the form of the plaque is unstable and we don't have a great technology now to say, “Hey, listen, this person, you have two people, this person has a vulnerable plaque because they've got a lot of inflammation in this particular area.” We may be getting there with some of the advanced imaging with CT but it's not quite ready for prime time as they say.
Ben: Got you.
Ram: So, again Lp-PLA2 is an interesting marker. So, your marker was 154. So, it is a little–it is elevated. Again, something that we should, we would want to track and understand there could be some genetic sort of components to this, but again kind of creating that baseline set of data for you is going to, is something we have. So, we just want to note that.
Ben: Yeah, that's interesting. I wonder if there's any evidence that for example kind of like CRP working out in the days prior or something that might actually increase vascular inflammation acutely and cause something that to be elevated.
Ram: Certainly. I'm sure there is some role of that. And then the other thing I will point out. So, the other thing we did was a Lp little A, lipoprotein little A, which in many times there there's a lot of genetic and ethnic differences in this. But, an elevated lipoprotein “Little A”, it's basically a form of LDL cholesterol, it's a very atherogenic form of LDL cholesterol, maybe 10 times more atherogenic. Your level, the level ideally should be less than 75, your level was 16. So, in some folks I see a very high level and it's hard to get it down traditional statins, traditional therapies don't work well. We have a new class of medications called the PCSK9 Inhibitors and they may be able to lower that. But, fortunately, you've got a level that's well within normal limits there as they say. So, that's great.
Ben: Got you. And just a back pedal just briefly, when it comes to Lp-PLA which in my case was elevated, let's say that that it was not due to some type of lifestyle factor such as exercise leading into the test. I know that alpha-lipoic acid is one thing that's recommended, there's a potential antioxidant to lower that value. I believe some research has been done on fish oil as well in that respect. Anything else you recommend for decreasing Lp-PLA2?
Ram: Yeah. No, I think those are all good things. I mean, aspirin has been kind of fallen by the wayside a little bit for primary prevention for various reasons and large clinical trials. But I think looking at a just kind of focusing on the anti-inflammatory pathway through diet tends to be a really good way to counteract that.
Ram: But those are all good observations.
Ben: Okay. Got it.
Ram: The other interesting thing that I want to spend a minute on was TMAO. So, TMAO stands for trimethylamine-n-oxide. It is a biomarker and it has been associated with elevated levels of TMAO, has been associated with increased cardiovascular risk, independent cardiovascular risk. Published, it was discovered and essentially a lot of the research has been done at Cleveland Clinic. And it's interesting and I don't know what your viewpoints on TMAO are, but we're tracking this on a lot of folks and interestingly we see in some folks that they're eating very well, eating very clean, they have an elevated number on this. And, an optimal number is less than 6 on this reference range greater than 10 would be high.
And so, on your TMAO Ben, you had a level of 18.9. So, it's something where we need to look back a little bit at traditional thoughts is dietary patterns that can lead to high TMAO. Dairy, eggs certain types of red meat could be the carnitine, choline products that basically get transformed from the gut microbiome into this more of this inflammatory from TMA to TMAO.
Ben: Yeah. I mean, I think TMAO is really interesting because if you look at it, meat and choline and carnitine are vilified in respect to TMAO. But if you look at fish and vegetables you also see a steep rise in TMAO in response to–I mean, like fish, have 40 times more TMAO preformed in fish than you get from the choline and carnitine coming from meat and red meat. And so, I suspect that the elevated TMAO in people who eat a lot of let's say red meat could be due to a gut dysbiosis condition or some type of other inflammatory components such as burnt bits and carcinogens that might be present and coming into the diet as a part of that red meat. Or just the fact that people who eat a lot of red meat a lot of times are also not the healthiest folks on the planet. They're also watching football, drinking beer, and immersed in environmental pollutants and toxins. Not [01:51:29] ____ the too broad of brush. But I think there's a lot of confounding variables with TMAO.
Ram: There are. And what's interesting, what I've read is TMAO is really has been predominantly found in a lot of the deep-sea fish as I recall. And, the role of TMAO was thought to be almost like antifreeze for the fish, so that they could survive in that kind of a colder, deeper sort of water climate. So, as I recall, I don't believe freshwater fish have as much or have any TMAO. But, again, kind of depends on kind of what you're eating, where it's caught and so forth. So, I do agree there's a lot of confounding variables with some of this data.
Ben: Yeah, yeah. Interesting. Okay. Well, that's notable though. Okay. So, elevated TMAO, elevated Lp-PLA2. Got it.
Ram: So, moving on, we then did a test of your endothelial function. So, this is called the EndoPAT test. And this is an FDA-approved test that really looks at the function and the health of the lining of the arteries of your system and that's called the endothelium. Endothelium is a single layer of cells that goes to all the blood vessels, it's kind of considered a super organ, in many ways it's almost like an endocrine organ in some ways. Nitric oxide secreted by the endothelium really allows for good vascular health and dilatation when needed. So, that's why one of the schools of thought is that good endothelial function or bad endothelial function by that measure that can be predictive of things further down the line. But it's one of the earliest markers of cardiovascular issues that we sometimes see.
Again, a lot of confounding variables I've seen, diet, acute changes in diet, alter the, what we call the EndoPAT score, the RHI which is reactive hyperemic index. But, this test as you remember you were lying down for 15 minutes, you have basically probes on your fingertips to measure blood flow and then we have one arm is the control, and then one arm is the test arm. And then, we basically occlude the artery with the blood pressure cuff the brachial artery. And then, we do that for five minutes and then we release it. And what we're measuring is that the blood flow pattern when we release the cuff, there's a very characteristic normal pattern that we see that shows that endothelium is responding appropriately and essentially dilating and allowing good blood flow to the fingertip.
And so, they have databases of what's normal and what's abnormal. And again, this is something that based on what we see, we generally try to recommend increased foods that can produce nitric oxide and there's a–you're an expert on all that. But, your RHI which is reactive hyperemic index, a normal is 1.67, we got a number of 1.48, a little bit on the lower side. And, again, there are a lot of confounding variables on this. And again we try to have people in a fasting state when we're doing this caffeine and some things that, some other things can interfere with it. You're not really on any medication as I recall.
Ben: Yeah, yeah. It is–that is really interesting though also because I've actually done testing via a company called Stratagene which assesses a variety of different so-called “dirty genes.” My nitric oxide synthase pathway is actually are a little bit impaired genetically. And I actually, I go out of my way to use things like beetroot, I've been microdosed with sildenafil before the active component in Viagra. I do a lot of sauna, granted I came in fasted without having taken any of the type of things I'd normally use to support NO production. And so, it's possible that this just might be a genetic defect in NO production I just need to for life be sure I'm getting sunshine, sauna, beets, and other NO supportive compounds.
Ram: Absolutely. L-Arginine is another popular supplement to augment nitric oxide. So, yeah. So, this, that actually totally makes sense. So, that's interesting. So, yeah. So, that was the EndoPAT. And then, we did your calcium score, you went across the way and got that CT, it's a very low dose basically CT scan that looks for calcium in your coronary arteries. We get a score, score can go from zero to thousands, higher the score higher the risk. It's a tiny bit of radiation with this test, but it's a great test in the cardiology world because there's been a lot of data in the general population that higher scores correlate to higher risk.
Again, ideally, a score of zero and this is where you've got, you're a special case here kind of based on your athletics and performance and everything and we'll talk about that. But you did have a score of 40, 42, I believe. And that's actually in the highest, higher percentile for someone in the same age and gender. So, and what we should kind of review what that may represent. Because traditionally when we see a very high calcium score we say, “Hey, listen, this is a prognostically, from a prognostic standpoint, predictive standpoint there's some concern that this could lead to future coronary events or coronary obstruction. How do we mitigate that risk?” And that's where we should, but we should talk a little bit about some of the factors that go into this. Because when you look at the data there's been some recent data coming out of I think there was one good study coming out of the Cooper Clinic in Dallas in Texas, they do a lot of fitness studies. Where they looked at, they looked at the cohort of patients that were extremely high athletic performers. And they showed that not only did they have high calcium scores in many cases, sometimes the score was greater than 100. There wasn't an associated increased risk in cardiovascular mortality.
And so, there's various theories about why this calcium score becomes positive or starts to develop and it's possible it's the type of exercise creates a stress response. But, the observation is that calcium actually is a very stabilizing factor in some ways for the plaque. The reason why calcium scores are important is that we worry about uncontrolled inflammation in other parts of the coronary artery. But a calcified lesion itself is, in on one level it's stable. It's almost like is it a scar, is it just a stable kind of thing, it's not really bound to rupture, it's really the soft plaque.
Ram: What we worry is going to rupture. And so, again we didn't go through the full CT coronary angiogram because again there's radiation and there's some other considerations. But, again if we did a CT coronary angiogram we saw a bunch of soft plaque, that would be a question is, what should we do? What should we do differently?
Ram: But, really again with your background of activity. Again, I think we have to take that into consideration.
Ben: Yeah. I came across the same studies about how prevalent calcium scan scores being elevated is common especially in high volume endurance activity athletes, but zero long-term risks for mortality when present. And I found the same thing that it's the nature of the density and the kind of the tight packing of the calcium that doesn't appear to be a problem versus the soft loose stuff. So, kind of a corollary here that you could say it's kind of similar to having high cholesterol, but having it all be like big fluffy cholesterol versus small–
Ben: –small oxidized, cholesterol particles or small dense particles.
Ben: Yeah. So, it's super interesting. I think what I plan to do and what the doctor advised me to do is a repeat calcium scan score down the road just to see if any of that is growing so to speak. And, I'm really keeping my eyes on the literature too just to see what further studies come out on calcium scan scores, particularly in active populations.
Ram: Absolutely. So, I think it's, again in our regular population, we do calcium scores maybe every three to five years. And again, it's very interesting to track if there's progression. We just need more research and data to see what this means. But again, I think the data set really suggests that we're seeing this in a lot of the athletes and they're actually doing okay. Again, we do want to make sure that we do look at other traditional what we call Framingham Risk Factors and family history. But again, with everything I'm seeing here for you, this is just your pattern.
Ram: And, we just optimize everything else we can.
Ben: Yeah. Well, this has been absolutely fascinating and big takeaways here, for me personally is to keep my eyes on that LpPLA2 number and potentially even do a repeat test with an advanced lipid panel at some point. Continue to pay attention to the research on trimethylamine and also keep my nitric oxide levels topped off, keep taking all my Viagra. And keep my eyes on the calcium scan score data as well, although not, I'm not super alarmed at this point. And then, also, regarding the vascular inflammation potential for Lp-PLA2, look into things alpha-lipoic acid, fish oil, and just a diet that's rich in antioxidants.
And then, finally, even though I have a big heart, it doesn't appear to be a big issue. So, this has been super interesting, because the overall goal here was to just give people an insider view. If you were going to do the gold standard battery of tests for cardiovascular fitness or health what would it look like and I'm hoping that folks after hearing about the 12-lead EKG, the exercise EKG, the abdominal aorta, and the carotid ultrasounds. The ultrasound, echocardiogram, the advanced lipid panel, the calcium scan score, and of course the EndoPAT, are realizing how many things that we can look into. And I just think this is fascinating.
And I want to thank you too, I know your time is limited today because you have patients, I'm well aware of that. And I think we're even over time. So, I don't want to hold you too much longer. But I do want to thank you for just opening the eyes of my audience to all of these cool ways to test.
Ram: Yeah. No, my pleasure I think it's great. I'd love to hear feedback. I know there's, it's the technology is moving so quick. We didn't really even talk about some things with heart rate variability and things that. But, I think really we're going to come into an era where we're going to be able to collect all of this data on a continuous fashion through our smartphones and sensors and everything. And we can really create almost a threat matrix. And really, because still there's still a lot of folks dying of coronary disease and there are some people that just should be identified earlier and make right changes with lifestyle. So, we'd love to identify those folks and get them on the path quickly.
Ben: Yeah, yeah. Well, it's absolutely fascinating. And folks you can of course go and leave your comments in the shownotes over at bengreenfieldfitness.com/hearthealth. And, in the meantime, if you want to look up Dr. Dandillaya, I'll link to his website as well in the shownotes if you want to visit LA or Beverly Hills more specifically and go through a battery of tests with him similar to what I did. And, also shout out to the folks at Next Health who helped to organize this entire podcast and you can go listen to my podcast with Dr. Darshan Shah at Next Health if you want to learn more about them and what they do.
And, in the meantime, Dr. Dandillaya, thank you so much for coming on the show, man.
Ram: Absolutely. And yeah, I wanted to also give a quick shout out to Darshan who couldn't join us today, but we should do another one with all of us. But, I wanted to thank Darshan to connecting this and making this all happen, it was a real pleasure to do this with you.
Ben: Awesome, awesome, thanks. Well, folks until next time I'm Ben Greenfield along with Dr. Dandillaya signing out from BenGreenfieldfitnes.com. Have an amazing week.
Well, thanks for listening to today's show. You can grab all the shownotes, the resources, pretty much everything that I mentioned over at BenGreenfieldFitness.com, along with plenty of other goodies from me, including the highly helpful “Ben Recommends” page, which is a list of pretty much everything that I've ever recommended for hormone, sleep, digestion, fat loss, performance, and plenty more. Please, also, know that all the links, all the promo codes, that I mentioned during this and every episode, helped to make this podcast happen and to generate income that enables me to keep bringing you this content every single week. When you listen in, be sure to use the links in the shownotes, use the promo codes that I generate, because that helps to float this thing and keep it coming to you each and every week.
What is the best test to check for heart problems? To answer this question and take a deep dive into the health of my heart, I recently spent hours and hours at a medical facility in Los Angeles being put through the most advanced cardiac workup known to man—then packaged my entire experience into this special podcast episode that's complete with physician interview videos, deep dives into the state of the art equipment that was used, and much more.
So prepare to have your mind blown by this rare glimpse into the world of heart health and to learn everything you need to know about exactly what's going on with your ticker.
My guest on this episode, Dr. Ram Dandillaya, is a cardiologist in the Division of Cardiology at the Cedars-Sinai Heart Institute. He is board-certified in cardiovascular diseases, nuclear cardiology, cardiac computed tomography, echocardiography, and internal medicine.
Dr. Dandillaya has a clinical interest in preventative cardiology, peripheral vascular disease, and cardiopulmonary exercise testing (CPET). In addition to being a fellow of the American College of Cardiology, Dr. Dandillaya is a member of numerous societies, including the American Heart Association’s Council on Clinical Cardiology, the American Society of Nuclear Cardiology, the Society of Vascular Ultrasound, the Los Angeles and American Society of Echocardiography and the American College of Physicians. In 2009, Dr. Dandillaya was elected to a two-year term as Vice President of the Cedars-Sinai Alumni Association.
Dr. Dandillaya’s research has been published in major scientific journals and he has present abstracts at many national meetings, including annual sessions of the American College of Cardiology and American Heart Association. He is also actively involved in the teaching of fellows and residents at Cedars-Sinai Hospital.
Dr. Dandillaya’s more recent research interests include issues related to percutaneous aortic valve replacement, the role of 64-slice computed tomography and coronary calcium in coronary artery disease, and the prevention of atherosclerotic heart disease.
In this episode, you'll discover:
Part 1: Ben's Examination At The Clinic
-Ben's heart ultrasound…6:06
- Enlarged heart ventricle is common in ultrasounds (athlete's heart, or cardiomegaly)
- 50/50 on finding issues in “healthy” patients
- High-carb diet can be deleterious from lipid oxidation standpoint
- Polyunsaturated fats are huge culprits for diabetes
- Protocol: set of diagnostics on each valve of the heart
- Checking for function and chamber sizes
- Ben's health protocol:
- Article: Athletic heart syndrome
- Article: Echocardiography in the evaluation of athletes
-Carotid duplex scan…19:22
- Triglycerides, high LDL often found in keto practitioners
- Carnivore dietproblems:
- Too extreme
- Lack of controlled data
- Social problems with not eating plants
- How young people should begin their nutrition journey
- Study physiology, microbiology, to understand the building blocks of the body
- Bias often found in the educational route (dated knowledge)
- Institute for Integrative Nutrition
- Institute for Functional Medicine
- BGF podcast with Chris Kresser
- BGF podcast with Paul Chek
- Article: Carotid artery ultrasound: Should you have this test?
-Abdominal aorta ultrasound…30:43
- BGF podcast with Jane Goldberg
- EMF-blocking underwearBen wears (use code BEN to save 20%)
- Faraday full-body clothing(use code BENPROTECT to save 5%)
- Article: Abdominal Aorta Ultrasound
-Endothelial Peripheral Arterial Tone (Endo PAT) test…39:50
- Measuring nitric oxide levels
- 15 minutes no talk, no movement
- 5-minute baseline
- 5-minute occlusion
- 5-minute dilation
- Article: Assessing Endothelial Vasodilator Function with the Endo-PAT 2000
- Article: The 10 Best Foods to Boost Nitric Oxide Levels
-12 Lead EKG…50:00
- Multiple locations; vectors to examine the heart from multiple angles
- NatureBeat app for HRV
- The test they did on Ben does not track HRV
- Heart rate = 42 bpm
- The Electrocardiogram In Athletes Revisited
- Atrial Fibrillation in Competitive Athletes
-EKG while on treadmill…54:45
- Ultrasound of heart at rest, and while exercising
- Max exercise back into resting state to examine heart
- Harder and faster every 3 minutes
- Ben's heart rate returned to 72 bpm after 2 minutes
- Article: What is an exercise electrocardiogram?
- Article: Bruce protocol stress test
-Coronary calcium scan…1:09:45
- Ben's score is 42; small amounts of calcium
- Many men Ben's age do not have calcium at all
- Spotting calcium at a young age can prevent heart disease later in life
- BGF podcast with Dr. William Davis
- It appears that in active, endurance athletes, elevated CAC scores are not uncommon, and that metabolic fitness appears to be protective in this respect. For example:
- Article: Your athlete-patient has a high coronary artery calcification score – ‘Heart of Stone’. What should you advise? Is exercise safe?
- Article: Fitness, Exercise, and Coronary Calcification
- Article: Prevalent CAC common in high-volume endurance activity athletes, but no long-term risk for mortality
Part 2: Ben And Dr. Dandillaya Review The Results Of The Exam
- Ben's resting heart rate = 42 bpm
- Possible “early repolarization” pattern
- Keep copy of EKG handy to inform docs in the event of chest pain
- Heart rate is indicative of high vagal tone
- Tech is making EKG results more accessible via smartphone apps and the like
- Ensure minerallevels, hydration, etc. are topped off while performing in stressful situations (such as swimming where you can pass out and die)
-Vascular ultrasounds (echocardiogram)…1:25:00
- Ejection fraction – measure of heart's contractility
- Ben's ejection fraction = 63%
- Congestive heart failure; at risk for cardiac death, arrhythmia, etc.
- Hypertrophic cardiomyopathy (athlete's heart)
- Doppler flow: blood flow patterns across the heart's chambers
- Ben's levels and readings are all good across the board
-Carotid artery scan…1:29:40
- Ben's results are very good
- Thickening of carotid arteries occurs with pollution, toxicity in the air
- Ultrasound does not have the radiation levels of X-rays
- Customized recommendation on the frequency of being examined
-Abdominal aorta ultrasound…1:32:20
- Aorta can become aneurysmal due to lifestyle, genetics
- Not done often in the COVID-19 era; danger of exercising with a mask on
- Looking for arrhythmia, atrial fibrillation
-Advanced lipid panel…1:37:50
- Lipoprotein fractionation
- Good cholesterol (HDL) vs. bad cholesterol (LDL)
- LDL isn't bad per se; the size of the particles is what can be problematic
- Lipids become oxidized on vessel walls; how atherosclerosis starts
- Ben's results:
- Total cholesterol = 248
- HDL = 104 (extremely high)
- LDL = 126
- Triglycerides = 82
- C-reactive protein = <0.3 (very low)
- Lp-PLA2 = 154 (slightly elevated)
- Lipoprotein (a) = 16 (should be below 75)
- TMAO = 18.9 (should be between 6-10)
- Ways to decrease Lp-PLA2
- TMAO has higher levels in deep-sea fish; confounding variables on how to interpret the data
- Article: The Role of Advanced Lipid Testing in the Prediction of Cardiovascular Disease
- Article: Examining the paradox of high high-density lipoprotein and elevated cardiovascular risk
- Article: Atherogenic Index of Plasma and Triglyceride/ High-Density Lipoprotein Cholesterol Ratio Predict Mortality Risk Better Than Individual Cholesterol Risk Factors
- Article: Lp-PLA2, a new biomarker of vascular disorders in metabolic diseases
- Article: The Beneficial Effects of Alpha Lipoic Acid Supplementation on Lp-PLA2 Mass and Its Distribution between HDL and apoB-Containing Lipoproteins in Type 2 Diabetic Patients: A Randomized, Double-Blind, Placebo-Controlled Trial
- Article: 10 Things to Know About Lipoprotein(a)
- Article: Trimethylamine N-Oxide: The Good, the Bad and the Unknown
-Endo PAT test…1:52:23
- Endothelium is a single layer of cells that goes to the blood vessels; considered to be an organ of the body
- Nitric oxide (NO) secreted by the endothelium allows for good cardiovascular health
- Ben's RHI (reactive hyperemic index) = 1.48 (normal is 1.67)
- The Strategene report(via which Ben found out he has impaired nitric oxide synthase pathways)
- Beets, sunshine, etc. support NO levels
- Arginineto supplement NO levels
-Coronary calcium scan…1:56:05
- Higher the score, the higher the risk
- Ben's score = 42 (higher percentile for age and gender)
- Athletic training background is a factor in the score being higher than expected
– BGF podcasts:
- With Chris Kresser
- With Paul Chek
- With Jane Goldberg
- With Dr. William Davis
- With Darshan Shah of Next Health
- With Dr. Ben Lynch of Strategene
– Other resources:
- EMF-blocking Underwearby Lambs (use code BEN to save 20%)
- Faraday Full-body Clothingby NoChoice (use code BENPROTECT to save 5%)
- NatureBeat App for HRV
- Next Health
- Institute for Integrative Nutrition
- Institute for Functional Medicine
– 12 Lead EKG:
– Ultrasound Echocardiogram:
– Carotid Ultrasound:
– Abdominal Aorta Ultrasound:
– Exercise EKG:
– Advanced Lipid Panel:
- The Role of Advanced Lipid Testing in the Prediction of Cardiovascular Disease
- Examining the paradox of high high-density lipoprotein and elevated cardiovascular risk
- Atherogenic Index of Plasma and Triglyceride/ High-Density Lipoprotein Cholesterol Ratio Predict Mortality Risk Better Than Individual Cholesterol Risk Factors
- Lp-PLA2, a new biomarker of vascular disorders in metabolic diseases
- The Beneficial Effects of Alpha Lipoic Acid Supplementation on Lp-PLA2 Mass and Its Distribution between HDL and apoB-Containing Lipoproteins in Type 2 Diabetic Patients: A Randomized, Double-Blind, Placebo-Controlled Trial
- 10 Things to Know About Lipoprotein(a)
- Trimethylamine N-Oxide: The Good, the Bad and the Unknown
- Assessing Endothelial Vasodilator Function with the Endo-PAT 2000
- The Strategene report(via which Ben found out he has impaired nitric oxide synthase pathways)
- The 10 Best Foods to Boost Nitric Oxide Levels
– Calcium Scan:
- Your athlete-patient has a high coronary artery calcification score – ‘Heart of Stone’. What should you advise? Is exercise safe?
- Fitness, Exercise, and Coronary Calcification
- Prevalent CAC common in high-volume endurance activity athletes, but no long-term risk for mortality
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