Preventative Cardiology with Dr. Mathew Budoff: Rational Wellness Podcast 398

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Dr. Mathew Budoff discusses Preventative Cardiology with Dr. Ben Weitz.

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Podcast Highlights

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Dr. Mathew Budoff, MD is a professor of medicine at the David Geffen School of Medicine at UCLA, Program Director and Director of Cardiac-CT, Division of Cardiology, Harbor-UCLA Medical Center and he is an investigator with The Lundquist Institute https://lundquist.org/matthew-budoff-md.  Dr. Budoff’s research is devoted to advancing procedures that can help doctors identify patients early that are at high-risk for cardiac events and progression of atherosclerosis. This early detection can lead to patients being placed on the correct therapeutic path to prevent a heart attack. Additionally, Dr. Budoff’s research focuses on determining the effect of different therapies on atherosclerosis and determine if heart disease can be reversed. His office is in Torrance, California and his office number is 310-222-2773.

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Podcast Transcript

Dr. Weitz:  Rational Wellness Podcasters. Very excited today to be having a discussion about preventative cardiology and we’ll be talking about how to better understand how to detect, prevent, and possibly reverse coronary artery disease and prevent heart attacks. Today we’ll be having a discussion with Dr. Matthew Budoff, a professor of medicine at the David Geffen, School of Medicine at UCLA, Program Director and Director of Cardiac CT, Division of Cardiology, Harbor UCLA Medical Center. He’s also an investigator, researcher with the Lundquist Institute, and he’s published over 100 studies. Dr. Budoff’s research is devoted to advancing procedures that can help doctors identify patients early that are at high risk for cardiac events and progression of atherosclerosis.  This early detection can lead to patients being placed on the correct therapeutic path to prevent a heart attack. Dr. Budoff, thank you so much for joining us.

Dr. Budoff: Oh, it’s a pleasure to be here.

Dr. Weitz: Great. So, maybe you can start the discussion by giving us a little better understanding of what is atherosclerosis and why do cholesterol plaques form in our arteries?

Dr. Budoff: Yeah. So, you know, atherosclerosis or literally hardening of the arteries is a buildup driven by things like diabetes and cholesterol. And then ultimately it develops calcification as part of the Process. And that’s where we can kind of get a glimpse at it non-invasively when it, when we see those calcific.

Dr. Weitz: Let, lemme just, let me just stop you there. One second is atherosclerosis. The, is the forming of plaque, is atherosclerosis the forming of the plaques or the hardening of the arteries? Are those two separate things part of the same process?

Dr. Budoff: We kind of think of them as the same process. It’s kind of an [00:02:00] extension going from the beginning of the plaque formation and then again, the hardening of the arteries. The word atherosclerosis is hardening of the arteries, but we kind of consider that term to be the entire spectrum of the disease, right?

Dr. Weitz:  But those are actually two related but slightly different things, right?

Dr. Budoff:  Absolutely.  Yeah. Yeah. I mean, the the, the formal atherosclerosis or hardening of the arteries is when they develop calcifications and they become brittle.

Dr. Weitz: Okay. So, we have the coronary calcium scan, which you are a recognized expert at and published a lot about tell us about the benefits of doing this scan.  For the most part, most people go to their doctor and get a biomarker testing through serum. So they look at cholesterol and things like that, but the coronary calcium scan is the direct measurement of whether or not they have calcified plaque in their  arteries.

Dr. Budoff: Absolutely. And, you know, when we talk about high cholesterol or having diabetes or smoking, those are what we call population based risk factors.  That means that in a large population, some people may be more prone to developing disease, but we have no idea about the individual and not, not all of us behave exactly the same. So the calcium score allows us to look into the individual and say, Do you have disease? Are your arteries starting to get clogged?  And then we can address that more directly. So it’s personalized medicine rather than population based medicine. And that’s why we’ve moved away from C reactive protein and biomarkers and ApoB as the diagnosis. Those might help us with treatment, but to diagnose the disease, we have to look into the heart and we need a calcium scan to do that.

Dr. Weitz: When should somebody first get a coronary calcium scan?

Dr. Budoff: So generally men over 40, women at over 50 are at increased risk of heart disease. It might come earlier in some people have a bad family history or have other risk factors, but generally men over 40 and women over 50 is kind of the The the sweet spot for for detection.

Dr. Weitz: Now, haven’t we learned that from some of the autopsies of soldiers in Vietnam that atherosclerotic process often starts in each The twenties or even teenage years. So is there an argument for doing a scan like that even earlier?

Dr. Budoff: Yeah. I mean, the problem is that those type of plaques that form that they found in those, in those young men and women who died from other diseases, they have just have what’s called fatty streaks.  They have little bit of like a, a depth, a very mild deposition in the aorta. So we can’t see that with a CT scan. Oh, okay. And we know that doesn’t often or always progress into the real heart disease that we talk [00:05:00] about. But again, if somebody has bad risk factors or really, you know, a high cholesterol or diabetes, certainly earlier testing would be warranted than the ages I gave earlier.

Dr. Weitz: So for a patient, say, in his 30s or 40s who have hyperlipidemia, they have really high levels of ApoB or small dense LDL or whatever marker you feel is the most important for risk of heart disease should they have a calcium score And if they get a calcium score and it’s not zero, but it’s low what is it?  What is the key numbers to look at?

Dr. Budoff: Yeah. So, you know, once people have a positive calcium score, they have that hardening of the arteries. They have that. That deposition in the arteries that we know is represents atherosclerosis

Dr. Weitz: and positive. It’s anything over zero, right?

Dr. Budoff: Basically, anything over zero.  Absolutely. So if you have some plaque, then we already have the disease. And that’s when I [00:06:00] like to start getting involved with the patient. And it might be mild things like just checking their cholesterol and looking at their heart. blood sugar, making sure they don’t have a cult diabetes. And if they have a lot of disease, then I go further and I do more advanced testing to say what’s going on.  Why do you have so much heart disease at your age? We need to really figure this out and treat that exact cause.

Dr. Weitz: Now, what is the score? Let’s say I got a 40 year old guy who has high cholesterol and he has a 5 or a 10 or what is the number that we really are concerned about?

Dr. Budoff: Yeah, so, you know, we look at it based on age and gender.  So, a 40 year old person with any plaque is abnormal. So that would already be a trigger. Let’s say you’re, you’re, you know, you’re 60 and you have a score of 5. That’s fine. You have trivial plaque and you have less than what we expect. So we look at it based on age and gender and say is your, is your score high or low or normal?  Zero. And that’s, that’s [00:07:00] how we can then kind of risk stratify and decide how aggressive to be.

Dr. Weitz: So let’s say you had a guy who had a five, how aggressive do you need to be and when do you need to rescan for that?

Dr. Budoff: Right. So a young person with a score of five, I would start being aggressive. I would think about some therapies to to start just because they’re ahead of the curve as far as their other peers go.  And 65 year old with a score of five, I would dismiss it or say that you’re doing great. Whatever you’re doing, keep doing it. So it is a little bit relative on age and gender, but I would say if they have a little bit of plaque. I would start thinking about at least some therapies I like to use aged garlic therapy in some of the patients that slows plaque progression there’s obviously a lot of different therapies that we can apply that have some benefits for atherosclerosis especially when we catch it at such an early stage, the score goes into the thousands.  So a score of five is still a trivial number relatively and doesn’t lead to it, heart attacks in the short run, but we want to think about the long run in those patients.

Dr. Weitz: And can you address the concern that some people have about radiation? Because I think everybody’s heard that a typical cat scan can have the amount of radiation equivalent to 30 to 50 x rays.

Dr. Budoff: Absolutely. And, and you need to be selective here. Unfortunately, not all scanners are created the same and we have a. big divergence in how these are done. So if you get an old scanner and you do these CT NGOs, you’re going to get a pretty good dose of radiation. If you get a if you get on a new 256 scanner in a center that does a lot of cardiac CT, you’re going to get less than the background radiation that you would get just for being alive.  For a year, so it really depends on the location and the scanner and I would definitely recommend if anyone’s interested in [00:09:00] either a calcium score or a CTA that they shop around a little bit and ask them what kind of scanner they have. And again, you’re you’re want to hear something like 256. you want to hear that.  It’s a more advanced scanner or a newer scanner rather than the old 64 is because they did afford a good dose of radiation. Unfortunately, and they’re still being used a lot today. Okay.

Dr. Weitz: When should a patient let’s say a patient has a very low or even a zero calcium score. Can it be that they still have soft plaque and they should get a CT angiogram with artificial intelligence?

Dr. Budoff: Yeah. So, you know, I believe that if they’re over those ages, I mentioned over age 40 and men and over age 50 and women, and they have a score of zero, they’re doing great. And I, I don’t think they need to go for further testing in the short run. Okay. I think if they are young. Then, or if they have a low score and they’re, they’re worried about, you know, the, the, how much soft plaque do they have, then I would, then I would think about going for an advanced test.  Like you [00:10:00] mentioned the CT angiogram where we have to put in a little bit of dye. And then use that artificial intelligence to see exactly what level of plaque they have.

Dr. Weitz: Can you tell us a little more about those scans? Because this is the latest technology for visualizing atherosclerosis.

Dr. Budoff: Absolutely. And you know, it really has changed the way we all practice. So Basically what we’ve been doing for a long time is starting with the calcium score. And if that looked good, we just said, you know, you’re doing great. Don’t worry about it. You have no plaque. Then we started to get these more advanced CT angiograms where we can put dye in the arteries and we can see even a small amount of non calcified or what we call soft plaque, the earlier stages of plaque.  And, and that becomes very important in a younger person where they might not have calcified their plaque yet and have a score of zero. But it’s a false zero. They don’t, they have, they have some soft plaque. So I think for selective people, I definitely go beyond the [00:11:00] calcium score. And if they have a high score, I definitely go on to get that CT angiogram.  Cause now I’m worried about how bad are the blockages? Do they have like severe blockages that we may need to be even more aggressive with if their score is elevated.

Dr. Weitz: Can you explain the significance of soft plaque versus hard plaque?

Dr. Budoff: Oh, absolutely. So, you know, soft plaque is the earlier stage. That’s what those young men and women had in Vietnam and Korea when they, when they did autopsies that’s the earlier stage of disease and it’s a little bit less dangerous, but it’s the earliest nidus of disease.  And once it gets embedded in your arteries, it’s going to start to grow. So if you want to go even earlier for detection, we go beyond the calcium score and do that CT angiogram with AI or what they call the clearly test.

Dr. Weitz: Now, isn’t soft plaque more unstable and more likely to cause an event? Isn’t it the case that the [00:12:00] majority of heart attacks are not caused by the artery progressively getting clogged, but by a soft plaque that ruptures creating a clot?

Dr. Budoff: No, absolutely. So, the. Pure soft plaque. So if there’s no calcification and it’s just very mild soft plaque, they usually don’t rupture and we don’t worry about those. It’s the ones that get kind of the mixed plaques or the more advanced plaques. So there are stages of atherosclerosis and the very earliest stages, the very early fatty streaks, as we used to call them, the little bit of just a little bit of soft plaque is really not a dangerous thing at all, but it is the beginning of the process and it would be a good time to intervene.  You know, a guy named Machiavelli in the 19 in the 1400s said that the best time to intervene is when the disease is early, but it’s much easier to detect the disease when it’s more advanced. And that’s what we’ve been doing for so long is waiting for people to have positive stress tests and [00:13:00] blockages in their arteries to say, oh, you have heart disease.  Let’s start treatment. And that’s far too late. So this gives us the earliest opportunity to intervene.

Dr. Weitz: How do we distinguish the unstable plaque, the soft plaque that’s vulnerable rather than the soft plaque that’s in the early stage?

Dr. Budoff: Yeah, I mean, there are definitely very easy to discern, images on the scan when we read the CT scan at least anybody who’s been doing this for some period of time They can look at a plaque and say that looks more stable Based on where the plaque is and what it looks like as compared to what we call vulnerable where it has certain features That are very obvious to us that that plaque is is not so so stable and and may be more problematic for the patient

Dr. Weitz: So calcified plaque, even though it’s scary, tends to be stable and puts us it makes it less likely that it’s going to rupture leading to a heart [00:14:00] attack, correct?

Dr. Budoff: Yeah, but think of calcified plaque as the tip of the iceberg. So if you have calcified plaque on a calcium score, you have soft plaque as well. So it’s the easier to detect first line of defense that we use in our widespread guidelines that says start with a calcium score. If it’s negative, maybe you’re probably good.

If you want to go further, you can do the clearly test if it’s high. You’ve definitely got a problem because if you have a lot of calcified plaque, you have a lot of non calcified soft plaque, and that’s the stuff that can rupture. So it’s kind of the, the tip of the iceberg or what we call the vulnerable patient, the patient who has a lot of plaque, not necessarily doesn’t tell us which plaque is going to rupture.

Dr. Weitz: Okay. So you’ve explained to us that we have patients who may have high cholesterol, but they don’t have plaque. Now, what is it that increases the likelihood that the cholesterol will penetrate through the [00:15:00] endothelium and form plaque in the arteries? Is it simply the presence of a lot of cholesterol, a lot of LDL cholesterol?

Is it inflammation? Is it that the LDL is oxidized is as have more to do with the health of the endothelial lining of the arteries? What is, what is, what are the most significant factors that end up resulting in plaque formation?

Dr. Budoff: Yeah, and you know, unfortunately, it could be any or all of those that you mentioned, and I think everybody’s a little bit different, and that’s where once you get diagnosed with atherosclerosis or even early plaque in the arteries, you know, you really need to work with your doctor.  With your physician to determine what the next best steps are and that might be looking at treating the inflammation in a person with high inflammation, or that might be treating the LDL cholesterol, or the oxidized cholesterol in a [00:16:00] person, but it did once you have the plaque. We have to then go backwards and say, now let’s do those diagnostic tests.  Why do you have the plaque? What’s our treatment target? And it might be different in everybody. So it’s, unfortunately, it’s just not one size fits all. And that’s why I’m not just a type of doctor that says, you know what? You have plaque, here’s a stat and have a good day. I think everybody’s a little bit different and needs to be treated individually.

Dr. Weitz: Right. Or a homocysteine could be a big factor, or even omega 3 levels could be a a factor. 

Dr. Budoff:  And, and it’s very multifactorial. There’s a lot of different things that can lead us down this road of early heart disease and even advanced heart disease. And, you know, a little bit of blood sugar abnormalities.  I think, you know, there’s just so many nuances that we have to think about.

Dr. Weitz: So, there’s lots of controversies about the link between LDL cholesterol and coronary artery [00:17:00] disease, especially in the integrative functional medicine community that I tend to live in. The majority of mainstream conventional cardiology believes that it’s mostly about LDL leading to coronary artery disease. And some claim that we should lower LDL as low as possible, even LDL C below 40. And on the other hand, a number of studies have found that the link between coronary artery disease and LDL cholesterol is not as clear as we have thought. Including the recent KIPP study published in British Medical Journal in March of 2024 is LDL cholesterol associated with long term mortality among primary prevention adults, which found that among patients age 50 to 89 without diabetes, not on statins.  The lowest risk for long term mortality appeared to be [00:18:00] with an LDL C range of 100 to 189, not below 100.

Dr. Budoff: Yeah, no, I think there’s a lot of different, different ways of looking at the disease. And certainly if your LDL is above 190 I would say that you have familial hypercholesterolemia. That means that.

You have a genetic component. You probably got it from mom or dad. And you, you might want to think about that a little more, more carefully, but you’re right. It’s not always the lowest number that wins with cholesterol. And I think we need to, again, individualized therapy. But if somebody has abnormal cholesterol and they’ve had a heart attack or somebody’s abnormal LDL, and they have a lot of plaque on their coronaries, I do address that as well, because I think that that could be a contributing factor.  So, I don’t just ignore cholesterol, but I think it needs to be individually assessed. And in some people, I do address it more aggressively than others.

Dr. Weitz: Should it be that rather than [00:19:00] look at LDL C, we should look at small dense LDL, or LDL particle number some of these other biomarkers we see on an advanced lipid profile, which I would argue should be the state of the art, rather than the basic lipid profile, which is still what’s being ordered most of the time.  Probably partially due to insurance coverage.

Dr. Budoff: No, absolutely. I agree with you. I think if you want a cheap way to at least get an insight into this is look at your non HDL cholesterol that gives us some insights into what’s going on much better than LDL. So the concept being that all of the bad particles would be the not HDL is the good stuff.  Not HDL means all the bad. Bad stuff. And that’s at least a cheap and easy way from the basic panel to get an insight into whether or not there’s something going on. If that’s abnormal or high, then I would [00:20:00] go further and do those advanced lipid testing.

Dr. Weitz: So by non HDL, you mean the APO B marker?

Dr. Budoff: Well, it’s, it’s LD, it’s total cholesterol minus HDL.  So it’s literally from those, the basic panel, you can at least get a quick calculation. And if that’s elevated, that’s a much better predictor than LDL because that incorporates triglycerides and remnants and APOB and LP little a all into one kind of gross measurement. Then you can go on and do further testing.  So if you don’t have that ability to get the advanced lipid test, like you described, start at least by, Calculating your non HDL cholesterol. Some of the labs already do that, right?

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Dr. Weitz:  What about L. P. little a, which is a significant type of LDL particle that puts the person more at risk? And there are there is currently drug development to develop drugs to lower Lp(a) however, currently there’s no FDA approved medications for LP little a and and I find often doctors don’t want to test for it and they say it’s hereditary and there’s nothing we can do. So why should we test for it?

Dr. Budoff: Yeah, no you know, I think that that that’s a place where we definitely have great data that lp little a is bad that lp little a can cause heart disease and it’s hereditary.  As you mentioned, it’s it’s genetic. But it is true that we don’t yet have treatments. So, There are, you know, there are some mixed recommendations. Some guidelines say definitely measure it in everybody and know what it is. It doesn’t change in your lifetime without, without specific therapy. So you, once you have one measure, you don’t have to keep measuring it over time.  And everybody deserves at least one measurement of LP little a, the counter argument is that. We can’t treat it yet. So knowing it doesn’t really help direct our therapies as much as knowing other values. So I think there is a split group out there [00:22:00] on, on LP little egg.

Dr. Weitz: Well, I would argue that there are some treatments, maybe they’re not specifically FDA approved for LP little a, but niacin has been shown to help in 30 to 40 percent reduction in patients.  And it’s a. It’s a safe I would argue it’s a safe intervention when used in a modest dosage, say 500 milligrams PCSK9 inhibitors have been shown to lower LP, little a, there’s a few other nutrients like L carnitine, coenzyme Q10, flax seeds have all been shown to lower LP, little a, 10 to 20%.

Dr. Budoff: Yeah, no, I’m, I’m a big fan of niacin.  I think it got. A bad rap by a couple of poorly done studies and I still use it in my practice and I agree with you. It definitely helps lower LP little a the statins have no effect though on LP little a and you’re right. Sometimes raise

Dr. Weitz: it. Actually.

Dr. Budoff: Yeah. Yeah. So they definitely [00:23:00] aren’t aren’t the treatment for LP little a and then the.  The PCSK9s lower it by about 30%. So you could do that. The problem is you can’t get PCSK9s just for LP little a. That’s the problem.

Dr. Weitz: Right, and they’re expensive.

Dr. Budoff: Yeah, and they’re expensive. So that wouldn’t be, I don’t think a common treatment for LP little a. But, but you’re right. I totally agree with you.  I think it’s very important to, to to know that number. And if it’s abnormal, at least you can do things like niacin and carnitine and other things that might be beneficial to lower that until we have more definitive therapies, which are under a lot of there’s 3 big ones under investigation. And we’ll know within the next year or 2.  If they work and how well they work.

Dr. Weitz: You mentioned HDL as the good cholesterol. And yet we’re still trying to figure out more about HDL and when it’s beneficial and when it’s not, and some data shows that. Higher HDL is not [00:24:00] protective and may actually be harmful or not beneficial. So some labs have broken down HDL into smaller and bigger particles.  Cleveland has looked at HDL functionality. Where do you think we are with HDL?

Dr. Budoff: Yeah, I think a lot of that, unfortunately, is still not panned out as much as we would like. I, I’d like to see better data. We’ve been our, our former chair of medicine here at UCLA spent his whole career trying to look at HDL functionality and really could never develop a good a good.  Marker or good assay that was widely and re widely usable and reproducible. So I think we still need better measures of HDL function, but if HDL is low I’m still a fan of, of niacin as a way of getting it up that I think is healthy and has some good evidence behind it especially the earlier trials that showed it reverses [00:25:00] plaque.  It improves outcomes. So there was some great evidence with, with the early studies with niacin. And it kind of got undone a little bit by some studies where they, I think they, they studied the wrong population and got the wrong answer.

Dr. Weitz: Yeah, one of those studies, they used a a drug included with niacin to reduce flushing and that drug was known to have side effects.

Dr. Budoff: Yeah. And they studied people with normal or high HDL, not low HDL. And I think that the sweet spot for niacin is low HDL or high Lpa, as you mentioned earlier.

Dr. Weitz: So when it comes to diet for heart disease, there’s a lot of controversy. And one of the big factors that’s been discussed for many years now is the role of saturated fat as a dietary factor that increases the risk of atherosclerosis.  We have the original seven country study of Ancel [00:26:00] Keys. That was the first one that really claimed that we could tell that Saturated fat was a cause of atherosclerosis. But that study has been criticized quite a bit. And then we have some observational studies in the sixties that seem to provide much of the link between saturated fat and heart disease.  And there’ve been a lot of critics of those studies and we have had Some meta analyses have found no link between saturated fat and coronary artery disease, and, and some who criticize the saturated fat link argue that it’s more metabolic health and sugar consumption, so we have people recommending different types of dietary approaches based on those what do you think about saturated fat and do we even know how saturated fat is?  Physiologically could even affect cholesterol since, you know, the cholesterol for the [00:27:00] most part is being produced by the liver and it doesn’t make it out of saturated fat. So do we really understand how this is linked?

Dr. Budoff: Yeah, no, I think as you as you kind of outlined, there’s a lot of divergent data and I think that that poses a big problem for us in medicine is, you can grab bits and pieces and take the one that sounds like something that you want to hear.  But I really don’t think we understand saturated fat very well. And I think, honestly, the dietary studies in general are really lacking the same level of evidence that we have with other therapies. And I think it’s a big deficiency in our health care. And I’ve tried to do some. Get some funding for dietary studies and it’s very hard.  So I think we still don’t have all the answers that, that we would like to see overall and I agree with you. I think the, the answer, the story for saturated fat is still open and needs further evaluation.

Dr. Weitz: Yeah, unfortunately who wants to pay for dietary studies and be [00:28:00] the model for a good, valid scientific study is based on how we test drugs.  So you simply give the drug in a placebo, you don’t change anything else and. Changing diet is much more complicated. You can’t just give people one thing to eat and then you give them some sort of survey and people invariably don’t fill them out very well. So it’s very hard to do a scientifically valid dietary study and certainly we can’t use the model of the randomized clinical trial based on the way we test drugs.

Dr. Budoff: Absolutely. Absolutely. And, and I was hoping to do some with the CT NGO and looking at plaque progression over time. And we’ve done some work with keto, but we haven’t been able to do like nice comparison studies, comparing one diet to another. And you could, I think, I think you’re right. There’s a lot of problem [00:29:00] with food recall and how we measure Fats, but I think you could go to extremes and study some of the diets, you know, the people who are vegan versus keto or you know, right, Ornish versus american heart association rather than just studying high saturated fat versus low saturated fat But I think we can get some of the answers But you’re right.

Nobody wants to fund it. There’s no money in it. There’s no industry behind it. At least no big funders. And, and the NIH, the National Institutes of Health has been reluctant to do dietary studies of any magnitude.

Dr. Weitz: Yeah, that would be great. If you could do that. We really appreciate that. There’s been a lot of talk in recent years about the lining of the arteries, the endothelium.  And when that health of the endothelium is not as good, what we call endothelial dysfunction. And then we have the innermost lining called the glycocalyx and we have nitric [00:30:00] oxide production. Can you talk about the importance of that? for coronary artery disease.

Dr. Budoff: Yeah. And I think that’s huge. I think, I think nitric oxide, we’re still learning quite a bit about, but I think that’s a huge opportunity for, for vascular health.  We know that it feeds the arteries, that it protects the arteries, that it improves their elasticity. Think of the normal artery as more like a garden hose. That can expand when there’s pressure in it and go down when there’s no, no pressure as compared to a lead pipe, which is what we get with atherosclerosis where the water just shoots out super fast because it’s such a stiff pipe.

And we really want that elasticity. We want that endothelial function to be working well and that’s things like nitric oxide and that’s things like exercise that can really improve the vascular health. Of the of the patient and that’s very important, especially when we start talking about Microvascular or small vessel disease that’s all about [00:31:00] endothelial function and spasm and things like that that we can’t see On a ct scan or on an invasive angiogram, but can cause a lot of damage

Dr. Weitz: What do you think about some of the natural methods to boost nitric oxide production, including the use of of certain amino acids, the use of beetroot extracts, and even potassium nitrate?

Dr. Budoff: Yeah, I’m a big fan. I’ve done some research with beetroot extracts and for that specific reason to look at nitric oxide. There is nice ways now of measuring nitric oxide at least from a research perspective with these salivary tests to look at nitric oxide. It’s a little bit hard to measure in the blood because it’s transient, but we can measure it in the saliva.  And you definitely see differences in people who have a good diet with, with a lot of things like, like, some of the superfoods and people who have a much, a poor diet and you’d see a big difference in [00:32:00] nitric oxide levels. And I think that plays a role in long term vascular health.

Dr. Weitz: What do you think about ADMA as a marker?

Dr. Budoff: I haven’t used it as much to be honest, but, but I have some colleagues who, who really stand behind it. So I think there are definitely some better biomarkers that we’re learning about now that we can use as surrogates for nitric oxide since it’s hard to measure.

Dr. Weitz: Can plaque be reversed with natural, Methods or with medications?

Dr. Budoff: Absolutely. I’ve done studies with garlic and randomized placebo controlled trials with garlic supplements, and we’ve seen reversal of the soft plaque. The calcified plaque is old scar tissue, but the soft the vulnerable plaques the plaques that we talked about earlier with the lipid laden plaques, those are the ones that are reversible and we’ve seen reversal.  There for sure. 

Dr. Weitz: And you’re talking about the aged Kyolic garlic.

Dr. Budoff: Exactly. Yeah, that’s the one that I studied. I looked at. We looked at a number of [00:33:00] trials with what’s called aged garlic extract or Kyolic, and we’ve seen reversal of the soft plaque, not the calcified plaque. We’ve also done. 

Dr. Weitz: And what, what dosage do you think is, is beneficial for garlic?

Dr. Budoff: Yeah, sorry. So for age garlic, I the recommended dose on the package is 1200 milligrams a day. The we studied up to 2400 milligrams a day and saw a plaque reversal. So I think, I think 2400 milligrams a day of that specific formulation is very helpful for plaque reversal, especially that soft plaque that we can see on those, on those AI tests.

Dr. Weitz: Okay. You were going to mention some other nutrients that you think are beneficial. Yeah.

Dr. Budoff: So fish oil we’ve studied also and icosapent ethyl or EPA and EPA also reverse black. So I’ve studied those two in prospective randomized trials. Nobody can criticize the, you know, the methodology.  It’s a very well, you know, very, [00:34:00] very double blinded trial where nobody knew what they were taking. And we saw plaque regression with, with fish oil as well, EPA. So, and that’s one of the reasons why I get nervous when my patients are vegan. Because it’s really hard to get good levels of EPA. I agree.

Dr. Weitz: Yeah, we measure omega 3s in our patients. Yeah,

Dr. Budoff: I do too. And I think it’s very helpful to show them that they’re not getting their necessary omega 3s when they’re in the mode of being a pure vegan. Because even krill oil. doesn’t have a lot of omegas in it.

Dr. Weitz: No, no. Yeah. I’ve had patients bring in their krill oil and you see that they has like a hundred milligrams of EPA and THA and I tell them, well, that’s fine, but you need to take 25 of these a day.

Dr. Budoff: Right, right. It’s a handful or the whole bottle at a time to get the sufficient dose you would need.

Dr. Weitz: I see some data on berberine reversing plaque.

Dr. Budoff: Yes. Yeah. So, I, I’ve, I’ve, I’ve seen some really nice data with berberine [00:35:00] and bergamot are two different things that are both been shown to have some, some evidence of plaque reversal.  And again, I wish the science was a little better. But, but yeah, I think both of those are very promising and I do use them in my, in my practice for patients who have more advanced plaque.

Dr. Weitz: And at worst, you’re not going to do any harm by taking some berberine or some citrus bergamot.

Dr. Budoff: Absolutely.  Absolutely. Can’t, can’t be bad for you. Just like, you know, almost all of our vitamins, as long as you don’t take them in too much excess, they’re either good for you or at least not bad for you.

Dr. Weitz: What do you think about some of the seaweed extracts for improving glycocalyx and the health of the endothelium?

Dr. Budoff: Yeah, you know, I think again some really nice data, smaller studies definitely suggest a benefit there. And, and again, I remain optimistic that those are, those are definitely a reasonable approaches for people to look at to, for that endothelial health. [00:36:00]

Dr. Weitz: Now, when women have heart attacks there’s some controversy over whether or not they are more likely to have a heart attack different than men.  My friend, Dr. Felice Gersh, who’s an integrative gynecologist, has written a couple of papers about this, and she argues that women generally have Microvascular disease of the small vessels versus disease of the coronary artery vessels and that there is a spasm or there is a dysfunction of these vessels.  And I’ve talked to some integrative cardiologists about this, and of course they were men and they tended to dismiss it and told me that basically women’s heart disease is the same as men’s. What do you think?

Dr. Budoff: So, yeah, I think there’s definitely two schools of thought out there and both of them, I think you outlined nicely.  I would say that women definitely have, when they have a heart [00:37:00] attack the plaque is different. It erodes rather than ruptures. So there’s definitely differences between men and women. Everybody would agree from a vascular biology standpoint their heart disease progresses differently.

Yeah. Many the I think the problem with the microvascular argument when you see when you can’t see it when we can’t test for it really and we just say, oh, if women have chest pain, it must be real. If men have chest pain, and we don’t find anything, we call it, we call it non cardiac chest pain is a little bit problematic.

And if you talk to some of these people, they say the only people who can get microvascular angina are women. Okay. And then the problem is, is that nobody has a false positive stress test anymore. Every stress test is correct with women, because if it’s positive and they have blockages, you call it coronary artery disease.

If it’s positive and it’s negative, you call it microvascular angina. Where in men, we know that there are false [00:38:00] positive stress tests, where sometimes it’s just wrong. And every test is wrong sometimes. So I have some problems with just telling, saying every time a woman has chest pain, it must be from their coronaries and it must be real.  I think there are other causes of chest pain.

Dr. Weitz: Is there any way to reconfigure the scans to image the microvasculature?

Dr. Budoff: No, we really can’t see the microvasculature. You have to really go to something like an MRI and look to see if under stress, the vasculature behaves normally or not. And that’s, I think the only really reliable way to do it.

Dr. Weitz: Is that currently available? How do you put the person under stress cardiac MRIs are

Dr. Budoff: available. No, absolutely. You can do a cardiac MRI. 

Dr. Weitz: But how do you do that with the person under stress?

Dr. Budoff: So they give them stressors. They give them things that

Dr. Weitz: would

Dr. Budoff: stress them out. Not medications run on a bike, right on a run or bike.

Dr. Weitz: And what have we seen from that? Is that [00:39:00] starting to be done or

Dr. Budoff: yeah, I mean here locally, they do them here at Cedar Sinai a lot, they, they have a women’s health clinic and they work women up and that they help try to distinguish between. The woman who has chest pain where it might be reflux, or it might be musculoskeletal versus microvascular disease, where it could be from abnormal endothelial function, because I think you have to distinguish, you have to try to figure it out one way or the other.  And I think we’re still learning the best ways to do that. I think MRI is the best so far at doing that.

Dr. Weitz: Another question related to women’s heart health. What about the relationship between hormone replacement therapy and cardiovascular disease? Once again, this is another controversial area and we know that.  For most of their lives until menopause, women tend to have much lower risk of heart [00:40:00] disease. And we know that’s because estrogen is protective. And yet after menopause, that heart disease risk increases. And that’s obviously because they don’t have estrogen. And then When we add the estrogen back in, we’re being told, Oh no, that’s really harmful based on the women’s health initiative, which I think was a poorly done study and gave people the wrong idea.  But there’s still controversy. How can it be that natural hormone estrogen, which for 50 years is protective against heart disease. And then when put back after menopause suddenly is harmful.

Dr. Budoff: Yeah, no, I agree with you. I think the studies were done incorrectly, and I think we got the wrong answer by doing the wrong study.  The women’s heart study, the average age in those trials were women in their 60s and 70s. And clearly, waiting 20 years after menopause to then say, let’s [00:41:00] restore you to how you were at the time of menopause is not when you want to do supplementation. So I, I believe in the timing hypothesis that if you give women Estrogen and hormone replacement therapy perimenopausally, when they’re going through menopause to maintain the normal levels of estrogen, you have a much better effect than trying to give it 20 years later.  And I think that’s been part of the problem is we’ve done again, the right study in the wrong people and got the wrong answer. 

Dr. Weitz: So I got to think the formulation plays a role as well. I mean, there’s a big difference between giving Premarin, which is estrogen from horses urine. And we know that the body is very, very specific when it comes to hormones and giving horse hormones to women is not the same as giving bioidentical estrogen and the same thing with synthetic progestins versus natural progesterone.

Dr. Budoff: Absolutely.  Absolutely. I think that the formulation, the timing, the population you study all have all play a major role in what the right answer is with hormones.

Dr. Weitz: And we also know that when estrogen is given as a patch or topically, it has a lower risk of clotting than when estrogen is given orally, as in the Women’s Health Initiative.

Dr. Budoff: Right. So I, I agree with you. I think there’s a lot of, a lot, a lot of problems with how we’ve done the studies and unfortunately they’re not being really revisited to be done correctly, even though these problems have been pointed out over and over again.

Dr. Weitz: That’s great. I, yeah, I prepared a bunch of questions and I thought there was no way we would get through all of them. And I pretty much we’ve gotten through all of them because your answers have been so clear and succinct. So I really appreciate that. You warned me in

Dr. Budoff: advance. There was a lot of questions, so I tried to keep the , the, the tried to keep the [00:43:00] answers brief so we get through ’em, but it’s, it’s been no really great to, to go through the spectrum of of all of these different topics and, and you know, I think there’s just so much that we all need to keep learning about, and I keep learning every.

And you know, it’s just been wonderful to see so many different scientists and so many different thought leaders you know, helping us move things forward and hopefully we’ll get, you know, more and more of the answers that you asked that we don’t have the perfect question, the perfect answers for yet and get, you know, better answers for your, for all of us to be able to, to treat our patients better and as patients to treat ourselves better.

Dr. Weitz: And I think one of the messages people should get from this talk is the importance of screening your patients for direct evidence of coronary artery disease when there looks like there’s risk based on biomarkers. It’s one of the few diseases that we tend to treat primarily just by looking at biomarkers, which [00:44:00] are evidence that the patient may have risk.  But yeah, we have these. Direct scans like the coronary calcium scan and the CT angiogram with artificial intelligence can tell us specifically whether they actually have the disease and we should be making more use of these tests to find out not just whether or not the patient may have disease, but whether or not they do and what stage they’re at.

Dr. Budoff: Absolutely. Absolutely. And, and I think we’ll, we’ll continue to. Do a lot of research in that area to, again, personalize, individualize therapy, and hopefully answer some of these questions about once you have the disease in a certain amount or distribution, you know, what the best treatments are for you as an individual.  Because I think everybody needs that individual approach and I’ve never been a fan of one size fits all.

Dr. Weitz: How can practitioners and patients find out more about [00:45:00] you and your research? And you also have a center that offers these scans and can tell us more about your contact information.

Dr. Budoff: Absolutely. So they’re very simple. We’ve always called these because they look for coronary calcium. We’ve called them calcium scans. So my website is just calcium scan, all one word. Calcium scan dot com and it has some of the science. It has the contact information. It has a way if you wanted to get a scan, we there’s a way to contact the center and get in the queue.  You know, for the CT angiograms, we largely are able to do this with insurance. The clearly might be the AI analysis, maybe a little bit extra the. Yeah. But we’ve tried to do our best to keep our prices down so that it’s more available to more people. And I did mention the scanners. We do have really, I’ve been a very big advocate of trying to get the radiation doses down.  I don’t want to expose people to more than they need. And we’ve been very cognizant [00:46:00] about radiation exposure at our center. So we do have probably among the lowest that you can get to get good images with our equipment that we have in our, in our scanner.

Dr. Weitz: And where is your center and how do people contact it?

Dr. Budoff: Yes. I’m in Torrance, California. I’m in Southern California, pretty close to L. A. X. We do have some people who fly in, but if they want to contact the center, just the easiest is 310-222-2773 again, 310-222-2773 and they, they can, they can get you scheduled or get you more information and send you out information if you want to learn more about it.

Dr. Weitz: And the CT angiogram with artificial intelligence I thought it was largely not paid for by insurance. You say you’re getting some insurance coverage for it.

Dr. Budoff: Yeah, so, Medicare just started paying for it as of December 8th. So literally last week and some, some payers may be covering it.  So we’re trying to work with the payors to get it covered more, but Medicare already covers it. The AI.

Dr. Weitz: Really? Wow. Yeah. That’s a new thing.

Dr. Budoff: Literally December 8th. We got coverage.

Dr. Weitz: That’s great. And if patients do have to pay cash, it’s what, like $1,500 or so? 

Dr. Budoff: Yeah, I think it’s right around $1,500 for, for if you’re completely cash out of pocket, it would be a $1,500 expense total.

Dr. Weitz: That’s great. Well, thank you so much, Dr. Budoff.

Dr. Budoff: No, it’s great. It’s really nice talking with you and everybody have a wonderful holiday season.

Dr. Weitz: And same to you. Take care.

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Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would very much appreciate it if you could go to Apple Podcasts or Spotify and give us a five star ratings and review.  As you may know, I continue to accept a limited number of new patients per month for functional medicine. If you would like help overcoming a gut or other chronic health condition and want to prevent chronic problems and want to promote longevity, Please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111.  And we can set you up for a consultation for functional medicine. And I will talk to everybody next week.