Good afternoon. This is Dr. Thomas Nero, and welcome to Patient Pulse. Today, I have the honor of speaking with Dr. Matthew Boudoff.
Dr. Boudoff is Professor of Medicine at the David Geffen School of Medicine at UCLA and the Program Director and Director of Cardiac CT at the Harbor UCLA Medical Center.
Dr. Boudoff has been a national leader in primary and secondary prevention trials, as well as lipid lowering trials. , but today we're going to be focusing on his work in cardiovascular diagnostic imaging. Dr. Budoff, you've been one of the leaders in the development of , coronary calcium scoring and CT coronary angiography.
Can you please just give us a little bit of background on where this came from and where you see this as, , being helpful for the average patient?
Yeah, so just very simply, a coronary artery calcium score is a noninvasive test. No needles, no injections, , no dye or contrast. It just affords us an opportunity to look at the arteries and see if there are plaques. in the form of calcification building up and if there are, we can then approach that with things like aspirin, cholesterol, medication, blood pressure control, diet and exercise, what I call the ABCs to treat those patients before they ever have their first heart attack.
So as a what we call the mammogram of the heart, identify the plaque early. Get the right people on the right treatments. CT angiography is a little more involved. It requires dye, it requires an IV. It gives us more information though. Soft plaque, stenosis blockage. We get a lot more information from that.
And I think that's the next step depending on the results of the calcium
Would you limit using calcium scoring in patients with high risk, or do you think this is something that really helps all patients to better assess what their risks are?
I think it's informative across the spectrum. I think the return on investment is probably the highest. in the high risk people because it does two things. One, it tells us, not only are you high risk, you're very, very high risk. And there's a lot of therapies that we can add, but also it helps with compliance and adherence.
It makes patients better patients because they understand that they have a problem. I saw a guy , this morning. Calcium score was 1935, crazy high score, tons of plaque in every artery, his LDL was not well controlled, his blood pressure was pretty good, but he's overweight, he wasn't eating, uh, as well as he could, and he's changed just from finding out that score , he's lost 10 pounds, he's changed his diet, does We intensified his therapy and I think he's going to live longer because of it.
So I think even the patients who you would deem high risk would benefit by knowing that there's something even more going on. And sometimes we're surprised we call people high risk. And they have no plaque at all. And we're like, you're not that high a risk, right? So, so we can maybe then, you know, worry about other things in those
Yeah, certainly looking at the disease itself in the arteries is really where the money is, right? , we can talk about risk stratification, looking at the Framingham risk factors or whatever , , and they're good. , but certainly there's gotta be something that we're going to add on top of that to be able To gild the lily here a little bit and , , to better understand, , where it is for each individual patient, , are you also utilizing this technology in order to determine whether , you've been successful with your therapy?
So I do, , I believe that a follow up time point and to see what the slope of the change in calcium is still helpful. It's not been incorporated, , strongly in any of the guidelines, , other than maybe getting it every five years to see what's going on. But I believe that if you're rapidly progressing, That you're on a slippery slope and that we can add new therapies to your mix.
And there's so many great therapies out there now that we need to know who, who to put on these treatments. And as you said, you know, a picture is worth a thousand words. It, it's so much more informative than telling somebody they have high blood pressure is to say, not only do you have high blood pressure, but you're getting a lot of plaques in your arteries.
And we got to do more than just lower your blood
One of the controversies that's been happening in cardiology over the last 10 years, or has been the question of utilization of LDL goals. We've put back goals into our guidelines , but are you changing what your goals are depending on what you're seeing in the arteries and either what your coronary calcium scores are or the amount of soft plaque that you're seeing and the CT angiographies?
Absolutely. I use it explicitly for should I start aspirin or not? And how low should I go with my LDL cholesterol? Um, I push LDL further down, uh, with each increment of of calcium score. So above 100 high risk, I get their LDL below 70 above 300. Secondary risk or same risk as if they suffered a heart attack, I get their LDL below 55 crazy high scores over 1000.
I try to get their LDL below 40. So I use it explicitly to help me direct my care. Same with blood pressure. I'm much more diligent with hypertension. , if their scores are
And certainly some of the newest data on the hypertension front is interesting that we really should be pushing everyone down to 120 over 70. I do believe, , but that's a, that's a different topic for a different day. , it's quite interesting that , a lot of people who are doing primary prevention, myself included, um, are really moving down our lipid goals.
And, , the old goals that we used to have of , less than 70, I think we really need to start, uh, throwing out. Um, I've asked this question to a number of people over the years, uh, What do you think the perfect LDL cholesterol is?
Uh, I, I believe it's less than 40. I, I don't think you need to get to 10 or six or two. I think we need some cholesterol. We're born with LDLs of in the twenties or thirties, and I think that's probably a good physiological place to be. So I, I try to get LDLs below 40 when I'm very worried about a patient or when a patient's very worried about themselves.
you don't, you don't need to answer this, or I'll at least I can edit it out if, if, if you, if you don't want anybody to know, but what's your LDL? I've asked this to a couple of other lipid specialists offline. And, um, and I was interested and I was surprised to find out of the four that three of the four had LDLs in the thirties.
Yeah, mine's in the fifties. My calcium score is negative. So I'm monostatin, but I haven't intensified therapy further just because I haven't seen any plaque development. But if I do, I think I would get my LDL into the thirties and start taking a second agent beyond statin monotherapy.
My doctor is going to be starting me on a statin as of January 1st. I had to talk her into letting me do that because again, I have no coronary calcium and no, , athroma in my, uh, CTA, uh, although there is some evidence of inflammation in the perivascular, , space.
But, , I'm getting older too. So it's, , it's that time, I believe.
No, I, I think it's, it's always going to be better to know personalized medicine rather than population based. Not everybody with high blood pressure and high cholesterol develop heart disease and conversely, some people with low blood pressure and low cholesterol do develop heart disease. And the only way you're going to sort those people out is by looking into the heart itself.
And, and that's where CT angiogram are going to come into play and help us personalize the approach to each individual that we
Well, you've certainly been at the forefront of developing this information. And , for all of us, I thank you for all the work that you've done. It really has been groundbreaking and so important and informative in the way that we're looking at coronary artery disease and our ability to evaluate and treat the patients
before they start having events, and now that we know that it's really about prevention and plaque stabilization rather than just putting in a stent in order to open up arteries , to save people's lives, it's really about the primary and secondary prevention, the medical management that you've been at the forefront of that's going to change outcomes for our patients.
So thank you.
It's been a pleasure and thank you for having me on.
