Welcome everyone to another edition of the Doctor’s Note where we talk about what’s on our minds when it comes to your health. This week I had the opportunity to visit once again with Dr. Daniel O’Roark and Nolan Hensley, PA-C of Trinity Heart and Vascular. Their cash only cardiology practice is in two locations: Johnson City and Greenville, TN.
As you know, I went cash only 17 years ago, which in my opinion makes you a better doctor. You have more time to spend with your patients, more time to enjoy your practice, more time to stay current in medicine. It’s a win/win for both. Patients love going to a doctor who is fulfilled and happy with his/her practice and trust me, Dr. O’Roark and Nolan Hensley, PA-C love their practice!
Since they’ve gone cash only, their satisfaction is through the roof.
- They are able to pass the savings to their patients. Note: when third parties are removed from the equation, it lowers a practice’s overhead.
- They are able to offer extended appointment times.
- They can focus more on nutrition and diet, which are the cornerstones of cardiovascular health.
In this Note, I will share some of our question/answer time around modern cardiology, statins, colchicine, CT angiograms, and more.
Let’s get started.
Modern Cardiology
Modern cardiology is going back to the basics and shifting paradigms. When I asked Dr. O’Roark about what’s new in cardiology, his answer surprised me. They’re going back to the basics, and I LOVE IT!
Dr. O’Roark:
If you would have talked to us 5 years ago, we would’ve known nothing about inflammation, nothing about dietary management, and nothing about how to promote a patient’s body to burn fat instead of glycogen. We’re still learning!
When I became familiar with the Cleveland Heart Panel, I had to educate myself on some of the tests, because it wasn’t part of our paradigm. Going back to the basics, we now focus on what you eat, which is foundational to life. That is our starting point. We view diet as a therapy for cardiovascular disease.
A Different Approach To Statins
In my practice, I’ve seen many patients be put on statins by their cardiologist that (in my opinion) didn’t need a statin. These patients come to my office with a total cholesterol of 80! No wonder they have Low T! Testosterone comes from cholesterol! A lot of cardiologists like to drive cholesterol down real low, but there are side effects to consider. I asked Nolan about Trinity’s approach to putting patients on a statin.
Nolan Hensley, PA-C:
In former practices, the knee jerk reaction was OK. A patient would come in with an elevated cholesterol level and the guidelines would say put them on a statin. That is not the case at Trinity Heart and Vascular. We have the medical freedom to treat each patient individually. If a patient has an elevated cholesterol level, I go over diet, exercise, and lifestyle changes that can help lower their cholesterol, versus just putting them on a medication that I know has side effects.
It’s true that in cardiology, what we’re looking for is prevention. We want to prevent that heart attack. That’s why I love their philosophy. They know about nutrition and they have time to spend with you!
Use of Colchicine
The use of Colchicine has now been approved by the FDA. I asked Dr. O’Roark what they thought about Colchicine.
Dr. O’Roark:
We’ve been using it for years, even in our old practice. I came across some data three or four years ago where they were doing studies on secondary prevention (people who’ve had stents, myocardial infarction, or had bypass surgery) and the number needed to treat was fairly robust. Colchicine is very simple, very safe and very well tolerated. It’s also getting cheaper. I take it myself. I can get a 90 day supply now for under $50, and it’s going to continue to get cheaper.
That gets to the other paradigm. Is it all inflammation? Is it inflammation, plus cholesterol? People can debate those things, but inflammation now has a seat at the table. It is undeniable that inflammation of the vasculature promotes atherosclerosis.
Do you think it’s an adjunct to a low dose statin in some people, or in place of a statin?
Dr. O’Roark:
The most robust data is with people for secondary prevention. But let’s say we had a patient who had a coronary calcium score of 400, they’ve never had a clinical event, and non-invasive testing shows no high risk findings. Obviously that patient is interested in trying to prevent adverse cardiac events down the road. We do talk about low dose statins and colchicine. LIFESTYLE is our primary recommendation, because a lot of what we eat (especially in the processed food department) is highly inflammatory.
Coronary Calcium Scorings vs. CT Angiograms
I get a CT calcium score on most of my patients over 40 years old. When do you need a CT Angiogram? A lot of people are talking about that now and how more accurate that is. Of course, that’s going to involve a contrast dye. Give me your general feeling about who should get a CT Calcium versus a CT Angiogram.
Dr. O’Roark:
We’re more selective with that because of the higher cost, and many of our patients either have high deductibles, or they’re cash payers. If we have someone who has known coronary disease and stable symptoms (no high risk findings), sometimes we will do a CT Angiogram to rule out unknown high risk anatomy. You want to make sure there’s no left main disease or three vessel disease. We’ve done some of that. An example is: you have a young lady that comes in who has some risk factors, has some atypical chest pain, has a negative workup, but still has the discomfort. You’re not terribly convinced that those middle aged people with lower amounts of cardiovascular risk are good candidates for the CTA. But generally, to answer your question, it’s largely symptoms driven and then we put that into the entire context.
The way they utilize the CT Coronary Angiogram is mostly patient to patient. Here is what Nolan added.
Nolan Hensley, PA-C:
What does a patient want out of their health? Some patients that come into our office are adamant about not wanting surgeries. They don’t want stents, but we need to rule out that they don’t have high risk blockage. So in that case, sending them for the CT Coronary Angiogram would assure us that they don’t have bad left main disease or multi-vessel disease that would ultimately benefit from surgery or stenting. Take that off the table first. Then we can move forward with medications, lifestyle modifications, and all of the outpatient options for treatment. At Trinity, we want the best option for what is going on in their bodies.
Baseline preventative is their lifestyle.
81mg Aspirin
What about taking an 81mg aspirin, which I’ve been doing since I was 40? It gets controversial. Note: I had to ask them this question! When I recommend it to most of my patients, they will say they heard that it was bad or not useful.
Nolan Hensley, PA-C:
Almost everyone that comes into the office, no matter what they are there to see me for, we usually end up talking about aspirin in some aspect. Aspirin for cardiovascular health is a wonderful medication. Aspirin kind of got a bad rap in the past few years just because it seemed like everyone was taking aspirin, and maybe there was an increase in GI bleed, but I think that goes back to lack of education on the behalf of the providers. Maybe they were telling their patients to take baby aspirin, and that didn’t correspond with the 81 milligrams. A lot of people that come and see us, they’ll say they take an aspirin from time to time just to help with their heart. I will ask, “what dosage?” They will answer they don’t really know. I tell them to go home and look. They will call me back and tell me they have the 325 mg dose!
So you take people that are taking a 325mg aspirin every day, and maybe on top of that they’re also taking their ibuprofen or their Aleve to combat joint pain, they’re going to get an ulcer in their stomach. It is important to educate your patients about aspirin: a baby aspirin, 81 milligrams a day, is good medicinal help to the body, preventing cardiovascular disease as well as other health benefits.
Omega 3’s
I recommend a lot of Omega 3’s and have heard recently that there’s some controversy. Can Omega 3’s cause atrial fibrillation?
Dr. O’Roark:
I have not looked at it in great detail. I’ve skimmed over some of the papers, but they’re not very robust. You have to control for the other factors, you know?
They’re saying this patient has atrial fibrillation and they took Omega 3’s, but the patient is 80 pounds overweight, has type two diabetes, has untreated sleep apnea, high triglycerides, and uncontrolled hypertension. It’s really hard to just blame an Omega 3 in that context. Those are the things that have to be known when you look at this data.
Individualized Medicine
That’s what I like about Dr. O’Roark and Nolan Hensley, PA-C. They have common sense! It’s individual medicine, not cookbook medicine.
In my opinion, medicine is a shared decision process. As doctors, we’re here to give you our opinion and best advice. I want to work with the patient. It’s their ultimate decision as to whether they want to take something or undergo a procedure. I don’t blame them for not wanting to. I had an 85 year old lady last week who was told she needed a bisphosphonate for her osteoporosis. I looked at her stand and she did have some risk, of course, but I said do you want to take this? Here are the side effects. She said no, and I said fine. You don’t have to take it.
Final Thoughts
I love the fact that Trinity Heart and Vascular is a cash only practice that is very affordable and AVAILABLE. It’s difficult to get into a cardiologist these days. With a cash only cardiologist, you can often get seen the same day. Access is such a big deal, especially when you’re dealing with the heart. You don’t have time to waste when it comes to heart disease.
Trinity Heart and Vascular Group has offices in Greenville and Johnson City, Tennessee. They do stress testing, echocardiograms, carotid ultrasounds, abdominal aortic ultrasounds, and a host of other things. I highly recommend this group if you are in need of a cardiologist.
If you want to learn more from Trinity Heart and Vascular, here is a conversation we had on cash only cardiology, and a second conversation on preventative cardiology.
Stay educated. Stay healthy.
Till next week.