Lifestyle Or Tech: What’s Best For Your Heart?

Kavitha Chinnaiyan, MD, FACC, MSCCT

Thank you so much for having me.

Joel Kahn, MD, FACC

It is a pleasure to know you. I think around 20 years ago, you were a fellow at William Beaumont Hospital in Royal Oak, Michigan, now known as Corewel. Well, before that, in St. Joseph of Mercy Hospital in Ann Arbor, as a resident and chief resident. Before that, your medical training was in India. But you have had one of the most remarkable careers, and like, we could do three interviews and people would not know it was the same person because you have so many different aspects to talk about, but you are one of the world’s experts. I think you are a master from the Society of Cardiac CT Imaging, where there is a very high level of academic distinction. You know a lot about the topic we are talking about. You cannot reverse our disease if you cannot measure it. You are an expert at measuring it. We are talking to Dr. James Earls from Cleerly Health in a different interview, but it was a lot of case studies. We did not talk about the big picture. I still do not get why in 2024, people are recommended to get a colonoscopy and mammography, prostate exams, and cervical cancer exams. However, it is not recommended to get a heart screening. What are your thoughts, let us start with coronary artery, calcium screening. A technology that is over 30 years old, inexpensive, and available in almost every hospital. Some people call calcium scoring, or CACs. But everybody listening hopefully knows that at their local hospital, for about $100, they could find out if they have silent atherosclerosis. Do you think it is time? Is there a calculator that tells us who needs one, or do you just think everybody should get one? Like everybody gets recommended to get the other cancer screening.

Kavitha Chinnaiyan, MD, FACC, MSCCT

Yes, I think it is important that time. When you look at the timeline of cardiovascular medicine and its history. We are, in my opinion, we are at the threshold of something big, and that something big has to do with pulling together not just the individual patient but also treating the degree of blockage they have in their coronary arteries, which is all extremely important. A lot of our work over the last, I would say, 50 or 60 years has gone into that, which is understanding the history of coronary artery disease. 

But now, with where we are in world history and the evolution of imaging and big data, we are at that point where this knowledge that we have accumulated from population studies and from individual patients and everything that we have garnered in terms of our knowledge bank, in terms of interventional cardiology, drug development, or biomarkers, we are at the threshold where it needs to be disseminated, not into large communities and populations. We do that through screening. The fear has always been that there is not enough data. This is where I think this question of, Do you think everybody should get it? The naysayers will say, Well, show me the data that screening people will prevent events that will make a difference in their natural history of the disease as well as the impact it has on populations about decreasing mortality, decreasing morbidity, decreasing all of the effects such as heart failure and admissions, and so on, and of course, costs. We now have enough data to study those topics in the long run. But we studied that by disseminating that screening test to a larger population. The answer is yes. 

Joel Kahn, MD, FACC

Good.

Kavitha Chinnaiyan, MD, FACC, MSCCT

It is time to screen people for coronary artery disease. The issue with calcium scoring is: Who do we select? How do we select people for calcium scoring, CT? If you screen everybody, then, before a certain age, say, age 40, you may be missing non-calcified plaque and not getting all the information that you need. I go by, in answer to the question you asked, how do you select people? Well, in 2006, Don Lloyd-Jones published this impactful paper on the calculation of lifetime risk. If, by age 50, you do not have any coronary artery disease and you do not have any significant risk factors for coronary artery disease, then your risk of developing coronary artery disease or dying from it is quite low compared to somebody who has the risk or has coronary artery disease. Age 50 seems to be a good threshold for screening for coronary artery disease, and it may be lower if you have risk factors and so on. But if it is too young, it is not going to be useful, and then, beyond age 50, again, if you are asymptomatic, I think it makes sense to do screening calcium scoring.

Joel Kahn, MD, FACC

Well, I could not agree more. I have been an advocate for the wide use of coronary artery calcium scoring due to its ease, low cost, very low radiation, and no radiation below it. Nobody’s allergic to the calcium score. Nobody has to have a perfect low heart rate, and it is just accessible. It may not be perfect, but it is accessible. There is a statement in medicine that, on average, it takes 17 years for a new technology to permeate into practice. Calcium scoring was described in 1990, and it became available in Michigan in 1995 and 1996, and it sure was very expensive back then. But there is no financial obstacle anymore. You can drive to the University Hospital in Cleveland and get it for free if you are in Detroit or you live in Cleveland. It is just a nice aspect that that university has done for years and years. 

I point out what you saw because there is always literature. You, of course, have contributed several hundred articles to the medical literature, and we will stick to a medical topic right now. 

We are going to transition to the other magical part of your life in a minute. But, from the Intermountain Heart Institute, which is in Salt Lake City, they took patients who presented with heart attacks and looked for what they called Smurf’s modifiable risk factors. The high blood pressure, the high cholesterol, the high blood sugar, the smoking, the mom, dad, brother, sister—were there heart diseases? They reported that about a quarter of people who have heart attacks have no standard risk factors that a doctor would have warned them about six months earlier. You are at risk for a heart attack, but they found coronary calcium in all those people. Of course, they were a group that had heart attacks. I guess that is the untested hypothesis: when you find a patient with a calcium score of 130, 290, or 84 and they are young, will they make lifestyle changes? Will they, if appropriate, take an aspirin and exercise more, and if needed, use pharmacology to deal with their numbers and their pathology? But I am glad to hear you say, yes.

Kavitha Chinnaiyan, MD, FACC, MSCCT

I feel that the calcium score is such a good test for not just yet. It is such a good test for risk reclassification. It is not just starting people on medications; it is also a grading risk because if you do not have calcium and if you do not have coronary artery disease, then numerous studies have shown that statins are not going to help you. It is not going to do anything more to your already predictably good prognosis. It is both downgrading the risk, upgrading the risk when needed, and trying to decide how to deal with your risk now, which is powerful when you know you have something and can do something about it. So, yes, I agree that it is time for increased uptake of these tests.

Joel Kahn, MD, FACC

I am glad you pointed out the use of calcium scoring – CT imaging to deny the need to be on medication because a lot of listeners to this summit prefer natural approaches, diet, supplements, and lifestyles like exercise. That is certainly what we are teaching and promoting. But yes, there is no data when you have a calcium score of zero or very close to zero from which lifelong statins will benefit. It is unclear where that trade-off is. If it is at a calcium score of 100 or somewhere near 100 and above, statins may become more impactful. But even the American Heart Association in 2019 finally joined the statement that a calcium score of zero can be a consideration for not using statins. In my practice, maybe it is a reason to sometimes take people off statins; they are relieved that they had no justification to take a drug all those years, except for some diabetics. Yes, they will not give up smoking where their risk seems to be quite concerning. But yeah, hallelujah. We can confidently stop medication and still have low-risk patients. That is wonderful. Now you have a patient in your clinic. I know you have cut back on your practice. We are going to talk about why in a minute, because you are a wonderful group of patients that love you so much, of course. But you have a page with a calcium score of zero. You tell them the good news. How long might you wait to consider doing another one?

Kavitha Chinnaiyan, MD, FACC, MSCCT

Yes, it depends on the bulk of their risk factors. I would say. I am not averse to repeating that calcium score maybe in about three or four years and seeing if there is now a change. If not, then we continue with the same plan, or if something changes in their clinical picture, then I might go directly into a corner CT angiogram if they start developing symptoms. Things like that.

Joel Kahn, MD, FACC

Great. That is where we are going to go in a minute. In my case, I had access to a coronary calcium CT scanner at age 40 because my medical building in Troy, Michigan, at the time, had installed a new one. I did not need it. I came out of zero. I did it at 50, and I did it at 60, and I remained a zero, which is happy news. I have gone on and done a coronary CT angiogram just because I am a guinea pig, and I like to be involved with new technologies. I can talk about that, too. But now I think for the low-risk patient, for whom I would have qualified, that is probably the upper limit. 

I am telling you, my wife went about 12 years from her last scan, which was a zero, and this year went back 12 years later and remained a zero, which is wonderful. But she has a good friend who was also a zero 12 years ago, and we have not defined why she has lipoprotein. Her little-age genetic inheritance went from 0 to 200 in 12 years. We are dealing with that asymptomatic atherosclerosis, and probably in retrospect, knowing she had inherited lipoprotein, I could have moved it up a little sooner, but I kind of lost track of her from a medical standpoint. Now, my wife, I did not lose track of my wife. But I mean, I lost track of her acquaintance. We are using everything. We are talking about the summit. Then there is this test. I do not know when the first coronary CT angiogram was done. We have been ordering them at Beaumont Hospital through the E.R. for a good 15 years. Maybe this was identified earlier than that, but it certainly exploded lately. Why do you not tell the group the critical short-form differences between having a coronary CT angiogram and the simple coronary calcium score?

Kavitha Chinnaiyan, MD, FACC, MSCCT

Yes, incidentally, the first coronary CT angiogram, the case report, was published in the New England Journal of Medicine in 1978 but often talked about.

Joel Kahn, MD, FACC

Wow!

Kavitha Chinnaiyan, MD, FACC, MSCCT

Says we can detect stenosis. I think it was 1978 or somewhere around then. It has been a while, I know. I am sorry, maybe.

Joel Kahn, MD, FACC

What does a patient go through when they have a coordinated CT angiogram that is different than a calcium score?

Kavitha Chinnaiyan, MD, FACC, MSCCT

Yes. The difference is that with a coronary CT angiogram, we use intravascular contrast. We give contrast to IV dye through a vein in the arm. It is the same dye that we would use with a cardiac catheterization, where we take in, put in these catheters that go all the way to the heart, and inject dye into the arteries directly to take a look at the coronary arteries. We get the same kind of information—more information with a C.T. angiogram. But then we give that contrast through a vein in the arm. The equipment is the same. The difference between a calcium score and a CTA is that in a calcium score, there is no contrast. With the C. T. angiogram, there is a contrast. With a calcium score, we do not worry too much about breath-hold, heart rate, and things like that, but with a CT angiogram, the images need to be more controlled. The heart rate has to be nice and low. The patient needs to be able to follow breathing instructions. Those are some of the distinctions. But more importantly, a calcium score only gives you a visualization of atherosclerotic plaque, or these plaques in the arteries that are already calcified. Whereas in a coronary city angiogram, we can see plaques that are both calcified and not yet calcified. That is important because a lot of heart attacks and a lot of sudden deaths, for instance, would happen in the presence of plaques that are not yet calcified.

Joel Kahn, MD, FACC

It is a little more complex. People are listening who may know they have an iodine contrast allergy. 

Kavitha Chinnaiyan, MD, FACC, MSCCT

Yes.

Joel Kahn, MD, FACC

A bit severe. It can be a real roadblock to getting a coronary CT angiogram. Some people run a high rate of 90 and need medication, and sometimes it does not work, and we cannot get their heart rate down to a magical 55, 60, or less. The study may be canceled. I have had people show up and go home because sometimes they cannot get IV access to tiny little veins and sometimes they cannot achieve a low heart rate. Maybe they are anxious, maybe they are claustrophobic, or maybe they have autonomic neuropathy in their heart rates, and they are frustrated that, at present, they cannot do the test. Tell us a little bit. I mean, in 2024 and beyond, I know there is a family of CT standards called Photon-counting scanners. How soon do you think our mutual hospital Corewell will have one? What is the difference to a patient? If you cannot get a Photon-counting scanner, this is the technology. Now, you would not know. The difference is a patient. You are inside a circle, but the circle has improved in all of that. What else? What is the second-best state-of-the-art scanner that reduces the radiation dose, the breath hold, and all the rest?

Kavitha Chinnaiyan, MD, FACC, MSCCT

Well, the Poton-counting CT scanner, the plan for us is to have it soon. Hopefully, within the next few months, we will have one of these scanners. It is a very new and exciting technology, and the main thing for our purposes in our discussion here is that it can look into the artery in finer detail. If you have calcium, for instance, ordinarily it is hard to see into an artery when there is a lot of calcium because it obstructs our ability to look into the artery. These newer scanners, minimize the effects of such things as calcium. We can look into the artery a little bit more clearly and tell, look into it, visualize the artery, and see if something is going on within it. Because of its technology, it is inherently associated with low radiation. Now, about what’s the next best thing, there are many scanners out there with different types of technologies using a single heartbeat acquisition and so on, which are inherently associated with low radiation doses. However, the thing to know is that scanner technology is one thing, but imaging protocols are another. You can have a scanner that has low radiation, but if you do not know how to image on that, then you will still have high radiation. It is important to go to centers that pay attention to their imaging protocols, lower the radiation dose, and use the scanner as it is supposed to be used.

Joel Kahn, MD, FACC

But a well-done coronary CT angiogram could be as short as a five-minute test with a Band-Aid go-home. Has been compared to what I trained in. You trained in but did not continue with invasive coronary angiography. The famous heart cath radiation is done way more than a million times a year in the United States alone. It is holding up well. In a recent meta-analysis, I read, the real reason was that three-quarters of patients were referred to as outpatients, not the sick patients in the coronary care unit. They are probably going to go to the catheterization lab at the outpatient who may have flunked the stress test or had some chest pain. Three-quarters of the time, you can do a coronary CT angiogram and avoid an invasive procedure that has some risk and is much more expensive than a coronary angiogram. 

I agree with you. I think the future is not necessarily good for invasive cardiologists, but it is good for patients that they can find out the same information. It may be even more accurate. Maybe in the last couple of minutes on this topic, I have had the pleasure of working with healthy people, and I know there are a few other companies now that are doing quantitative and plaque characterization, fancy words for the listeners, but we are learning things about heart arteries, how much shock, like how much-calcified plaque, and how much the gnosis. That is being measured with artificial intelligence. I have ordered these now for hundreds and hundreds of patients, but very often they pay out of pocket 1500 dollars to get the highest quality evaluation. I am not ready to tell most people or skip the calcium score for $75. We are going right to a 1500-dollar test with an iodine die and a little higher dose of radiation. Some people out there are recommending you go straight to the coronary CT Angiogram. How do you feel about that? Do you think that should be selected? A little bit more limited than a calcium score or a free lunch? Everybody goes for one.

Kavitha Chinnaiyan, MD, FACC, MSCCT

Well, again, it depends on what the risk is, what we are looking for, and what we are trying to accomplish with that. If you have somebody who is diabetic, who has a very strong family history, who has seven deaths in the family, and you have all at once a stacking up of the risk factors and you are not sure if this person has reliable symptoms, for instance. Then a CTA, with contrast, I think is a better tool because, especially when they are younger, the calcium score may not be useful. I think more studies are needed to see what the population effect of doing a CTA instead of a calcium score would be. The general argument and the general data show that it does not have incremental value for calcium scoring. When the calcium score is done well, then the CT does not add as much in population studies. Until we have that data, I think it is necessarily going to be limited because of its cost, because of the risks of contrast, and because of the higher radiation dose. Also, there is a lot more scope to do a CTA wrong than a calcium score wrong or improperly.

Joel Kahn, MD, FACC

Right. I do think the future, though, is so bright for this technology. The follow-up is what I went over with. Dr. Jay Earls and a different summit interview were watching plaque shrink. Watching, measuring, and documenting the reversal of heart disease in the coronary arteries. It is exciting. I did go for it.

Kavitha Chinnaiyan, MD, FACC, MSCCT

Not only that, it is because now, as I was saying, we are at this threshold where we can see atherosclerosis. We can measure and quantify the natural history of coronary disease, which is super important for upcoming therapeutic applications. Whether it is drug delivery, newer drugs, immunotherapy, or whatever, new technologies are emerging, and they are going to depend on imaging. You cannot cap a whole population, but you can do CTs on a whole population. It is going to be driven by imaging and even biomarker discovery. It is going to be correlated with imaging. I think imaging is now at the center of many different innovations in cardiology.

Joel Kahn, MD, FACC

I think people have gotten a lot out of this because there are listeners who are over 40, 45, or 50 and have not had a coronary calcium score. You have to go to your primary care doctor or your specialist to get a prescription and schedule it. Then some of you might want to consider these more advanced coronary CT angiograms. Be sure you do check out that interview I did with Dr. Jay Earls from the company called Cleerly Health. You will see how it complements this. Do not go anywhere, Dr. Chinnaiyan, and we are going to hang on for a couple more minutes. We have been talking to a world expert in so many different things, a mother, a wife, and a dog mother, the author of several hundred amazing research papers. I want to point out the author of four special books: Shakti Rising, Heart of Wellness, Fractals of Reality, and Glorious Alchemy. You can get those from the big booksellers, and please go over to her website. You will be just mystified by the rest of her life. I am going to spell it out as S-V-A-T-A-N-T-R-A dot Institute. Svatantra Institute and I probably messed that up.

Kavitha Chinnaiyan, MD, FACC, MSCCT

But that is correct.

Joel Kahn, MD, FACC

Wonderfully, we are going to come back after this brief break for the premium members and talk a little bit about how you pivoted to a second and just remarkable career. Then we should spend the third section talking about your husband’s career. You just have to look up the rest of the Chinnaiyan family because it is pretty amazing, too. Hang on. Do not go anywhere. We will be right back. All right. We are back with the world-famous, wonderful, multi-talented Dr. Chinnaiyan, here for the second year in a row, and hopefully, we will be doing this for many more years. She will probably have five more careers by then: TV shows, movie stars, and the rest. But, you were a world-famous cardiologist, and I am going to say that seven, eight, nine, or 10 years ago we talked about you wanting to write a book, and that gave you a little push. It did not take much pushing, like the baby eagle about to fly. You have broken some glass, but you have cut back your cardiology, clinical, and academic career to half-time.

Kavitha Chinnaiyan, MD, FACC, MSCCT

Yes, a half-time or less, because I am doing other things, teaching spiritual disciplines and different Eastern traditions, traveling the world, leading retreats and workshops on various topics, and taking people on pilgrimages and challenging things where you understand your limits and how to overcome them. Yes, having a good time.

Joel Kahn, MD, FACC

I can tell by following you on Instagram that you go to some of the most exotic, distant, and spiritual places and sometimes show up in front of the Colosseum in Rome, too, with your husband. I mean, did you know that you always have this in you in cardiology? Was it just phase one? Or did this kind of slowly grow upon you that you were going to pivot and take a risk? It is always risk-taking.

Kavitha Chinnaiyan, MD, FACC, MSCCT

Yes, I have been inspired by you. You taught me when I was a fellow how to follow your heart. I do not know anyone who follows their heart the way you do. You have inspired me so much, not just in writing a book but in being fearless. No, I do not know. When I came into cardiology, I thought I was going to be like anyone else—just work, retire, and have this career. It was my spiritual journey that kind of propelled me in this direction, of teaching. I led a program at the hospital for seven years called Heal Your Heart, which was a free program for the community. Where I was teaching yoga, I was teaching the principles of lifestyle medicine to patients and their families, and so on. That became the book The Heart of Wellness. which led to more openings to teaching other things from the Yogic literature and philosophy. Whatever I was going through in my inner journey, I was bringing it into my cardiology practice. Then, as I wrote more books and started teaching more, I realized that it is one thing to be an armchair philosopher—to sit in one place and talk about your limitations. It is another way to leap off the cliff and see what you are made of. I had to leap off the cliff. It was not an easy decision. It was hard because I was at the peak of my career when I decided to take a step back, as I was at the peak of my academic career, publishing, leadership positions, and so on. But ultimately, the thing that comes from your inner journey is to realize that life is very short. You have not been given endless chances. I realized I cannot wait until I retire to do something because I may not be around. Whatever I want to do, I need to do it now. I just took the leap of faith, and yes, so here I am.

Joel Kahn, MD, FACC

I did not expect the beginning of your answer. I humbly say, Great, I am glad I played a little role

Kavitha Chinnaiyan, MD, FACC, MSCCT

No, you inspired so many people. You have inspired me. I know how you fearlessly come into your life, and that is beautiful.

Joel Kahn, MD, FACC

Thank you. You are very kind. Some people would say, a wandering and chaotic path. But as many people post on Instagram, what looks like a straight line is

Kavitha Chinnaiyan, MD, FACC, MSCCT

Exactly.

Joel Kahn, MD, FACC

Circuitous route and challenges and questioning, and, were there moments, are there still moments? You question what you are doing. I think you are in a pretty good groove right now, with a pretty good following. But I mean, the reason I am asking about that is that there are people who are listening who have to make lifestyle changes, lose weight, change their diet, deal with negative family members, and all the rest, but it is friction to get to where they want to be. You have had some friction where your colleagues are supportive, or do they not have a clue what you are doing?

Kavitha Chinnaiyan, MD, FACC, MSCCT

Yes, I have had supportive colleagues. I mean, an incredibly amazing group of colleagues who may not understand my decisions, but they support them. That is critical not only in the workplace but also at home. I am supported by a family that, again, may not understand why I am doing it or why I would put aside a very successful career to kind of follow a path that has no guarantees. About following, following is fickle. Today you have a tomorrow you do not. You cannot do anything for a following. You have to do everything because you are following your essence. As people come, people go. So what? I want to walk this path. If people want to come with me, great. If they do not, fine. I am still walking my path.

Joel Kahn, MD, FACC

Well, I give you credit for that, and I deal with that almost every day, even on something as relatively unimportant as social media. I mean, 

Kavitha Chinnaiyan, MD, FACC, MSCCT

Yes, it is. 

Joel Kahn, MD, FACC

I speak my peace, and I have been a little bit irritating to some of my other plant-based physicians for not speaking out on some social topics because they might lose followers, and I share with you that attitude. If you are so fickle as a follower that you will not acknowledge it, it is not all broccoli in life. There is more than broccoli in life. The only debate in life is whether olive oil is good or bad. That is a debate, but it is not the debate. Big issues are going on in the world, and people are usually not hurting about olive oil. They are usually hurting about much, much deeper topics, whether they be political, family, isolation, trauma, or child. You are dealing with these.

Kavitha Chinnaiyan, MD, FACC, MSCCT

Yes, and being in the public eye, you are much more in that realm than I am. But one of the things that has become clear to me, particularly in the last year, is that to be truly authentic to myself, I do not have to portray an image of not making mistakes or of not slipping or falling. That is not at all the case. I slip and fall, and I make mistakes. I get up, and then I share what I learned from that fall. It is when we feel like, even with the city and geography. If I feel like I am an expert, then I stop learning. But if I am always in the mode of, well, there is so much I do not know, then I am going to keep growing. It does take a particular mindset to allow that of somebody with a public persona. To allow people to fall and fail and still be okay with that and not because if you seek perfection, that is when things go wrong in this whole public space.

Joel Kahn, MD, FACC

Well, I am going to honor your time and honor your time with your family, your dog, and your beautiful daughters and say, Thank you so much. I want people to go over if I can end with a quote from a famous doctor named Kavitha Chinnaiyan; And that the true gift of the journey to radical gratitude is that we can look upon the entirety of our lives with awe and wonder. I do want people to find your Instagram site Svatantra Institute, and you can find an entire article about the Bology of Gratitude there. I mean, again, you go to PubMed, and you will see Dr. Kavitha Chinnaiyan, the professor of medicine. There is a lot to explore there; that was the first part of our discussion. But the second half of your life is so interesting, and I know I am going to enjoy trying to understand 10% of it and learning with you. Again, there are all these books over it, the Svatantra Institute as S-V-A-T-A-N-T-R-A dot Institute. Maybe I would recommend to people listening that they start with The Heart of Wellness. It is probably closest to the theme of this Reversing Heart Disease Summit. If beyond that, you want to read a deeply philosophical work by Dr. Chinnaiyan. God bless you, and Good luck. I have read them. I think I wrote some introductions to at least one of them. 

Kavitha Chinnaiyan, MD, FACC, MSCCT

You did. Yes.

Joel Kahn, MD, FACC

Which is, again, they are kind of you, but you are looking forward to the next five, or 10 years?

Kavitha Chinnaiyan, MD, FACC, MSCCT

I am so much, and I am looking forward to five or 10 years with you.

Joel Kahn, MD, FACC

Well, God bless you.

Kavitha Chinnaiyan, MD, FACC, MSCCT

You are my friend and mentor.

Joel Kahn, MD, FACC

So kind. Well, hopefully, we will see each other, not just electronically, since we only live 25 minutes apart, but see each other over. Maybe good food soon with your remarkable husband, who is already on his path. many research awards, and maybe many more are coming soon. You guys are where? When was the last year or two years ago you were in Sweden?

Kavitha Chinnaiyan, MD, FACC, MSCCT

Yes, last year. 

Joel Kahn, MD, FACC

The big Sweden Medical Prize is the second biggest Swedish medical prize. But you never know, with the Chinnaiyan family, what is coming next. Thank you so much for your time here.

Kavitha Chinnaiyan, MD, FACC, MSCCT

Thank you very much.

Joel Kahn, MD, FACC

Bye bye.