The One Test That You Want To Fail

Joel Kahn, MD, FACC

Thank you very much. I’m excited to be here with you, but I’m also excited to share with your dynamic and great audience.

Jennifer Simmons, MD

Yes. Why don’t we start by just giving everyone a little background on where you started and where you are now so that they can get a sense of who is talking to them?

Joel Kahn, MD, FACC

I’m just about to turn 64, and I started, and I’m ending about a mile apart because I grew up a mile down the road.

Jennifer Simmons, MD

Isn’t that funny?

Joel Kahn, MD, FACC

I’m in suburban Detroit, grew up here, attended the University of Michigan in Ann Arbor, and figured out I was a pretty good student because I ended up graduating number one from medical school, and I guess I’m not going into the family furniture business.

Jennifer Simmons, MD

Definitely not.

Joel Kahn, MD, FACC

I wanted to be a cardiologist even before that. Just a random few things, like a heart murmur I had as a child. I stayed in Ann Arbor for a while, wandered to Dallas, Texas, and the University of Texas at Southwestern, and then I became a cath lab guru. I spent a year in Kansas City, and in 1990, I came out as just ready to take on the world if I had a blockage. I was ready to balloon it and later stent it. I did that for getting close to 30 years. But the only other quirk in my life is that I adopted a Whole Foods plant-based diet when I was 18 years old. Very honestly, I hated the dorm food. They had a great salad bar. It wasn’t a real ethical or global environmental decision. It was just surviving. I had a girlfriend with me who made the same move. She’s been married to me for 42 years and tolerates me. We discovered a few years later that we were in Ann Arbor, and I guess we were vegan. Around then, I heard of various doctors like Dean Ornish and the Prediction Center, and I realized there was something to this odd nutrition pattern, which I was following in my colleagues’ work. Just to end my intro, I’ve had a dual-track standard hospital, standard cardiology, aggressive what’s called interventional cath lab cardiology, and a real curiosity into prevention, nutrition, and early diagnosis, believing you could reverse atheroma growth as you could identify it early. About eight years ago, I stopped doing hospital cath lab work just like you did with your surgical career and said, There’s a lot of surgeons out there, and there’s a lot of cardiologists out there. But there sure is not an overwhelming number of preventive and integrated ones. That’s all I do now for people all across the United States. To some degree, the world is trying to teach them, test them, and get them on a better path because we are dealing with that big elephant as you said, the number one killer of men and women. It’s a serious disease. I mean.

Jennifer Simmons, MD

Yes, it is now.

Joel Kahn, MD, FACC

A thousand people a day—a little more than a thousand a day—just drop dead suddenly of heart disease. When you’re dying of cancer, it’s tragic. But your family has a little time to be around you. Hopefully, when you drop dead of heart disease, nobody says goodbye. It rocks people’s lives. They’re never the same and back again. Yes, we can drop that number. Half of them are women, and some of them are women with breast cancer. There’s lots to talk about here.

Jennifer Simmons, MD

Yes, for sure. The reason that there’s an 800-pound gorilla in the room is because people are not talking about it. I mean, that number—a thousand people a day—that’s astounding. In every decade of a woman’s life from 30 on, and correct me if I’m wrong, heart disease is exponentially more of a threat to life.

Joel Kahn, MD, FACC

Right?

Jennifer Simmons, MD

Right.

Joel Kahn, MD, FACC

I estimate that the number of women, decade by decade after about age 45, who die of heart disease is ten times more than those who die of breast cancer. Now, we don’t want anybody to die of breast cancer, and we don’t want anybody to die of heart disease. But when you think about all the attention given to breast cancer detection, early treatment, and long-term survival, where’s the ten-time focus? The occasional effort is on now, checking your breast and checking your colon, and you have this organ between your colon and your breast called your heart; maybe I have to check it too. It’s very simple to do that. Nobody should walk around unaware that they have silent heart disease. It’s just one test away from knowing the reality.

Jennifer Simmons, MD

Let me ask you this because everyone is aware of the breast cancer statistics. Everyone knows one in eight people over someone’s lifetime. Everyone knows that there’s a 12% chance of breast cancer. However, the number of heart disease cases and deaths from heart disease dwarf breast cancer. Where are the red ribbons? I mean, we are swimming in a sea of pink ribbons. Where are the red ribbons?

Joel Kahn, MD, FACC

Some of those numbers in the last cut I saw were 20 and 21. 700,000 people in the United States died of heart disease. A thousand people per day die unexpectedly, with no warning, no goodbye, and no kiss. I love you. Just dead in the bathroom, in the bedroom, on the sofa at work. Tragic stuff, but all those people could have been detected ahead of time, and most of them could have made efforts to prevent that and certainly at least delay that. Half of that is women. About a third of women will die of heart disease, and that’s ahead of every cancer combined; it is number two. Briefly, in 2020, COVID was number three or 2021, but that’s dropped off. We have a whole lot of other tragic conditions. But let’s not go there. There’s a woman who’s concerned about her breasts. They should be concerned about their heart health. There are a lot of overlapping risk factors. As age increases, breast cancer risk goes up. As age increases, heart disease risk goes up as the diet is off-western. The process—the ultra-fast food diet that so many people eat either because of stress, finances, their urban situation, and such—well, it’s the same diet that feeds heart disease and breast cancer. There’s some data about alcohol intake and breast cancer, and lately, there’s been a trend away from endorsing alcohol intake and heart disease. Obesity would be the last one I mentioned. It’s not body shaming; it’s just science that increases the risk of cancer, obesity, and heart disease. If you just think about it for a minute, this is the single most important statement I’m going to make: when people are about 45 to 50, they’re going to start hearing, and you ought to get their mammograms scheduled. You ought to get that colonoscopy scheduled; maybe you’ll do the poop test called cologuard. A guy is going to get a digital rectal or PSA blood test for prostate cancer. A woman’s going to see her gynecologist and get a gynecologic exam for cervical cancer screening over there. I just listed every formal screening for serious diseases that takes place during a physical exam with your internist, family doctor, nurse practitioner, or gynecologist. Where is the heart screening test? There’s this giant deficit in Western medicine and a giant deficit in the United States, specifically, and there’s no discussion. Sally or Mary or Jane or Theresa, pick your name. The number one risk to you is heart disease. We have a program here to screen you for heart disease. Maybe around age 45, it will start every 5 to 7 years. We’re going to do a test that was developed in 1998. The University of California, San Francisco, called a heart calcium CT scan. we’re going to do that.

Comes back to zero. We’re going to celebrate with a nice big salad with sunflower seeds, pumpkin seeds, and balsamic on it. If it doesn’t come back zero, we’re going to focus all our efforts on identifying why you aren’t a coronary artery calcium CD score of zero, and we’re going to try and prevent it from accelerating over time. Should you run into breast cancer disease issues, we’re going to have to overlap the supportive care for your breast cancer issue and your silent heart disease issue. This was a CT scan developed in 1990. At the time it was introduced in the United States, it was about 1500 dollars out of pocket. The insurance companies weren’t sure what to do with it. Functionally, you’re on a stretcher. You go into a circle CT scanner—no I.D., no injection, no iodine. You hold your breath, and you go home about 5 seconds later, without a Band-Aid or any claustrophobia. The radiation exposure is less than a mammogram. It’s a CT scan, but it’s a very quick on-and-off CT scan. There’s software that says there’s no calcium in your heart’s arteries. You have an incredibly good prognosis for probably a decade, but you might want to repeat that test in five to seven years. If you are anything over a zero from one to 11 to 142, and there’s just no way, of course, everybody should know blood pressure, blood sugar, blood cholesterol, smoking history, diet history, grandparents, parents, brothers, sisters, the whole gamut. Put those all into calculators, and you come up with the prediction that you might have heart disease. When you do the CT scan, you change two-thirds of those numbers. Some people judged to be low-risk way up, and some people judged to be high-risk come out of perfect zero. It’s an enormous peace of mind not to go off and eat donuts and sit on the couch, but to celebrate. I’m not getting heart disease. I’m 64. I’m a zero. I want to stay at zero. I’ll periodically retest, and a lot of my lifestyle is about keeping the healthiest arteries I can because there’s probably no better metric for your overall health and aging. There are all kinds of aging tests. Now, there’s another doctor out there. I’m 20 years old, 20 years younger than my birthdate, and it’s because of all that I’ve done well that they all missed the boat because if their calcium score is zero, they’re young. If their calcium score is outside of the range, they’re not young. I don’t care what your epigenetic or your glycan test and your telomerase test are.

Jennifer Simmons, MD

Oh, yes.

Joel Kahn, MD, FACC

You need a heart-artery aging test. get a coronary artery, a calcium CT scan, or a heart artery calcium CT scan. In my city, it costs between 50 and 99 bucks to pay out of pocket every five to seven years. Everybody can afford that. It’s just a glaring, missing piece of the puzzle. If you go back to the thousand people a day that drop dead without a chance to kiss their loved one goodbye, at least 80% of them could have been picked up. This is known data on a CT scan for three months, six months, and three years, and they could have had a program with aspirin, diet, exercise, and medication. In a recent study out of Copenhagen, Denmark, they took healthy people, men and women. Half of the study was women, which I love to see. 9500 elements are unusual.

50% had a calcium score over zero. That’s pretty much the cut. You’re 50% likely right now to have silent heart disease. Over the years ahead, it was eight, nine, or ten times the risk of having a heart attack if you weren’t a zero. You just got to get it done, and you got to take care of your heart the way you get screened for other important, usually cancer-based situations.

Jennifer Simmons, MD

What’s the false negative rate with that test? Meaning,, how many zeros ever end up having cardiac events?

Joel Kahn, MD, FACC

Has studied a lot of it out of the same city of Copenhagen, but in other places, ten years, probably less than 1%. You get your 99% likely ten years after a zero score to say, I’ve never been in an emergency room, I exercise and feel great, and I’ve never had a stent or a heart attack. Whereas if you come back with 100, 300, 500, or whatever, it’s a much different number. It might be 20% rather than under 1%. These are scientifically studied numbers. The American Heart Association took a long time, but they’re pretty much on board to say this is a screening test for the masses. The two immediate implications are that somebody is listening right now. Their gynecologist and their internist said, Your cholesterol is 235. You ought to go on Lipitor at 20 milligrams. The science is overwhelming. If you come back with a calcium score of zero, you have no benefit from statin prescription medications like Crestor and Lipitor. Even the American Heart Association, a very stodgy group, says a calcium score of zero doesn’t need prescription drugs for cholesterol needs. Eat a few sunflower seeds, pumpkin seeds, a little organic tofu, and a big salad every day with oatmeal for breakfast. Just manage it.

Jennifer Simmons, MD

Let me ask you something. The test has been on the market for 30 years. It is 50 to $99. It is incredibly sensitive and specific.

Joel Kahn, MD, FACC

Right.

Jennifer Simmons, MD

Why isn’t it being universally done?

Joel Kahn, MD, FACC

Good question.

Jennifer Simmons, MD

What am I missing?

Joel Kahn, MD, FACC

After watching your entire summit and learning, everybody should go over to Netflix and watch a documentary called The Widowmaker. It’s probably now about five years old. It’s the history of this CT scan and a little bit of a conspiracy theory, as you have to imply, follow the money. Well, there’s no money in this test. You’re not going to get anybody from hospital marketing? I’ve seen it on billboards at times. It’s just tragic. The health care system. I’m not a big basher of the healthcare system. God knows I’m outside of it, and I’m not part of it. I’m proud to have a different view of it all. But they’re going to promote the proton beam scanner that you use to treat prostate cancer and the new robotic surgery for heart surgery. I mean, that’s what you’re going to see promoted. Sadly, there’s just nobody but 50 of us in the country who talk about this nonstop and get it done, and none of us don’t own a CT scanner. I have zero conflict when talking about this.

Jennifer Simmons, MD

Yes, so this is my cynical side saying: the issue is that if you do that, you will eliminate a large part of the population. That would be consumers of surgery, consumers of statin, and consumers spending. Forget what the number is. Is it $8 billion? $8 million to bring a drug to market, but an $8 billion return on investment, or something like that.

Joel Kahn, MD, FACC

By about $800 million to bring a new cardiac drug to market and open.

Jennifer Simmons, MD

Eight billion in return.

Joel Kahn, MD, FACC

It worked well for OxyContin. They’re all trying to get the same scope. The real evil is, again, that there are a lot of good doctors and a lot of good medicine. If you’re 50 years old and you ask your internist, no, dad had a bypass at age 54. What should I do? All right, you ask your friend, the cardiologist, and they’re going to say, Yes, let’s go schedule a stress test for you. I used to have a specialty called a nuclear cardiologist. You’re on the treadmill, and you have an IV, and you get injected with something we used to call thallium, and now we call it cardiolite. It’s radioactive. You get the good news, Bob or Jane; your stress test looks good. You can still have a horrible calcium score and miss that. You have silent heart disease because your arteries are aging, but they’re not severely narrowed. That is a $2,000 test. Here we have a $50 test. Which one is going to be used more by some clinics, some hospitals, and some administrators? Finally, the radiation dose of that stress nuclear test is 15 times higher than the CT scan. You can get one every five years for 75 years and have the same radiation in your body, which we all should be concerned about. This is a stress nuclear treadmill test. I don’t order a stress nuclear treadmill test. I used to be the author of multiple well-known papers on it. I just say no to abusive radiation doses, and I don’t consider the heart CT to be at all abusive. The levels are dropping so low with modern CT scanners, so it’s fantastic that we can do this so safely.

Jennifer Simmons, MD

Yes, that’s amazing. I have long since said that the mammographic screening program that started in 1970 with the best of intentions, was predicated on an understanding that breast cancer grows linearly and reaches some critical size, at which time, if you found it before that size, you could treat it early and prevent metastasis. We’ve had several iterations of what the mammogram is; unfortunately, that premise is incorrect. Breast cancer is a biological disease that behaves biologically. It is what it is from the beginning. Its growth is not linear or predictable. Well, as we’ve had these different iterations of mammograms, we’ve become more and more sensitive. But we’ve also become more and more radiation-delivering. The original studies from 1970 that were considered a safe amount of radiation exposure error are no longer true. With the 3D mammogram or the CT thermography, we are delivering three times the amount of radiation to women year after year after year, and a lot of these women are getting radiation twice a year now. Setting that issue aside, we are picking up lesions that are smaller and smaller, and we’re treating these women aggressively. We’re treating them all aggressively. We’re treating them with surgery; we’re treating them with radiation. We’re treating them with chemotherapy. We’re treating them with a hormonal blockade. For a lot of these women who were already probably going to get heart disease if they continued on the same trajectory, we have accelerated that process for people, and so I’ve long argued that the medical system is contributing to cardiac deaths in the way that we treat breast cancer. I’d like you to address that a little bit, talk about the effects of radiation on the heart, talk about the effects of chemotherapy on the heart, and talk about the effects of hormone blockade.

Joel Kahn, MD, FACC

This is an excellent topic. I want to add one pearl to the idea of women listening to the summit and the idea that I’ve never heard of or never had a heart calcium CT scan. I’m going to go ask my internist; most states require a prescription. I ordered so many of them. I have a pre-stamped prescription pad (CT Calci—contrast), and I’ve ordered tens of thousands of these. My wife’s hairdresser has had it done. Her husband had it done; the nail ladies had it done. The nail ladies’ husbands have it done. I’ll give these out to anybody.

Jennifer Simmons, MD

Well, and quite frankly, I mean, while we’re talking about that, a mammogram costs $150 if you’re paying for it out of pocket. a mammogram, which people wouldn’t think of not getting, and yet the exponential threat to life is cardiac disease. 

Joel Kahn, MD, FACC

The pearl I wanted to share before your very good question about the risk of radiation and chemotherapy is that many women listening might already have encountered the breast cancer diagnosis, and they may have had a chest CT scan, which is very common. Or maybe they had a chest CT scan because they had COVID or their chest scan. After all, they had an abnormal x-ray, a nodule, if not a chest x-ray. But if you’ve had a chest CT scan in the last two or three years, a good radiology expert should have said so on the report. A competent, up-to-date radiologist noted no coronary artery calcification, moderate coronary artery calcification, or severe coronary artery calcification. It’s the same heart in the same blood vessels that we’re doing on the special, dedicated heart. I found this free information by going through my new patient’s hospital records. If I see CD., I’m going to read the report. if the report doesn’t mention how or if I have the capability of getting the CD to look at the heart part of it. Very often, we don’t have to order that special CD. I can say, ma’am, great news. Trust me, I’ve looked at thousands of these. You had no calcium in your heart arteries three months ago. We don’t have to order the $75 test, and we save them radiation. That’s a little tidbit for everybody to consider.

Jennifer Simmons, MD

If they have had that study and it is not mentioned, can they go back to the radiologist and ask them to re-review it?

Joel Kahn, MD, FACC

Challenging thing to do, but absolutely. I wouldn’t do it if it’s five years old. But if you’ve had a CT scan in the last two or three months, yes, absolutely, you can. You might have to go through the hospital operator. I can do it easier than the patient, and I can pick up the phone. Sometimes I can’t get my hands on the disk. I have to do that. I have to leave an email to somebody at the Mayo Clinic and say, Could you please come? I’d rather do that than expose a woman or a man to another dose of radiation, for the heck of it. You bring up a great topic. Let’s just start with radiation, because here’s a woman diagnosed with left breast cancer, and after maybe surgery and maybe some chemotherapy, the idea is that we’re going to finish this off with radiotherapy, and you’re talking to an expert, and I emphasize that I picked the left breast. It turns out that even with the best shielding and care under your left breast, it’s your heart. On top of your heart are your three heart arteries; coronary artery disease. That’s where people get atherosclerosis, stents, and bypasses. There’s unequivocal evidence that a woman undergoes typical left breast radiation therapy as a post-cancer treatment. Not immediately, but months to years. Statistically, every woman should live until 90 without a problem. However, according to statistics, there’s more disease in the left and tiered ascending arteries, particularly the front widowmaker artery, that can develop. You might get by without it. There’s an innovation to try and prevent it. Many women during their breast cancer treatment are doing very deep breath holds, trying to lower the breathing muscle, the diaphragm, to also lower the heart and get it out of the way of the radiation therapy. It’s something that is challenging but can be done, and it’s safe. It’s just a breath. Not only would it be wise for any woman to get a heart calcium CT scan once and maybe every five to seven years after, but a woman diagnosed with breast cancer recently is probably going to get a CT scan of the chest. Get somebody to read it. But a year or two after completing all the therapy, if it involved left breast radiation, it might be wise to talk to somebody and get another calcium score down the road. I wouldn’t think it takes a while for atherosclerosis to develop hardening arteries, but there’s study after study about higher-risk heart disease, and the consequences are heart disease. Like heart attacks and all. That’s one thing. Then you mentioned therapy.

Jennifer Simmons, MD

Before we leave that topic, I want to mention that last month there was a study published, and I can’t remember which journal it was in. They looked at radiation, and there may be a difference. There is a statistical difference in local recurrence, but there is no difference in survival between women that get radiation and women that don’t get radiation. Given the fact that we know that radiation will accelerate heart disease, I do think that as a medical community, we may need to rethink the appropriateness of radiation, especially for older women. If there’s no survival advantage, it just doesn’t make sense.

Joel Kahn, MD, FACC

Okay. I agree.

Jennifer Simmons, MD

I also wanted to ask you: if someone did have radiation, don’t you think that would automatically happen, especially lopsided radiation? Don’t you think that would automatically warrant a cardiac evaluation just because of the possible damage?

Joel Kahn, MD, FACC

Cardiology is called into breast cancer management issues. Number one, sometimes it’s just standard, what we call surgical clearance. Maybe that woman is older and has a history of heart disease, bypass stents, congestive heart failure, or arrhythmia on a blood thinner. We will be called in at times, like for a gallbladder or hip replacement surgery. Number two is the one you just mentioned: radiation therapy. Number three is chemotherapy and hormonal modulation therapy. I wanted to be sure to say this, and I’ll say it now. A specialty has evolved in the last ten years—an authentic specialty called cardio-oncology. There is a tremendous overlap between cancer diagnosis, cancer therapy, and heart complications. If you go to the Mayo Clinic, Cleveland Clinic, University of Michigan, or Johns Hopkins, wherever you mention it, they’ll have a division of cardio-oncology, usually a group effort, a team that involves a gynecologist, a gynecologic oncologist, oncology and hematology, and cardiologists that have dedicated their knowledge and experience to this. It’s not necessarily every cardiologist. I’ve attended several national meetings called the first annual Cardio Oncology American College of Cardiology Conference, and now it’s more than the first annual they’re progressing on. There are many of them. That’s exciting and good, and I don’t think it’s super well-known. I still end up educating my patients. You probably would benefit from contacting the University of Michigan Cardio-Oncology Clinic, and they go up there and get expert opinions. Why is that important? We talked about radiation therapy. We talk about the fact that probably a woman undergoing cancer evaluation therapy should get some cardiovascular risk assessment before, during, and certainly in the long term after the cancer therapy. But the therapy itself, besides radiation, and I’ll just run through this just for time, there’s been a famous chemotherapy class of drugs called anthracyclines, daunorubicin, and doxorubicin, and they’re dosed very carefully, but they’re very effective in various breast cancers.

We know that at higher doses, they can cause a weakening of the heart muscle. We’ve shifted from talking about heart arteries to the very measurement of the V-8 engine function of the heart. I’m in Detroit, so we have to make car analogies. The V-8 engine and anthracycline chemotherapy like Doxorubicin can weaken the heart, and it’s a permanent weakening. that leads to a condition called congestive heart failure. We monitor women getting that class of chemotherapy with ultrasounds of the heart that are called echocardiograms, maybe with blood tests, a hormone called BNP, and heart enzymes called troponin. We like to pick up the problem as early as possible. There’s some, and the dosing is the main thing. There’s some interest in certain medications that are heart failure medicines that are pretty widely available and safe to help prevent the permanent damage that occurs. But there have been some women who are permanently impaired and have even died from a weakening of the heart called cardiomyopathy from the chemotherapy they’re getting. There’s a popular group of chemotherapy-related drugs called receptor antagonists, like Herceptin, which are very commonly used. They can cause the same weakening of the heart. But it’s not irreversible, and it’s not permanent for the majority of women. It’s not fortunate that it happens at all. We go through the same process of monitoring the heart and educating women about shortness of breath, ankle swelling, and sudden weight fluctuations—all classic signs and symptoms of congestive heart failure—but hopefully, by picking up a very subtle drop in heart function early, that woman might mean lowering or eliminating the dose of that drug. Then we get to, in a very brief overview, hormonal therapy. A woman completes her breast cancer therapy and gets told she’s going to spend five years on Tamoxifen or other agents in that class. There are some implications for interfering with estrogen pathways in terms of cholesterol levels and normal artery function. That woman just needs to adhere to a healthier cardiovascular support lifestyle—the diet, the sleep, the weight, the blood pressure, the blood sugar, the exercise, and all. Then some are called aromatase inhibitors, like Arimidex or Anastrozole. They are commonly used after breast cancer therapy, which is longer-term for postmenopausal women, and they may slightly increase the risk of a heart attack. If your calcium score is zero, your cholesterol is not 350, and you have taken some other measurements, your risk for all those therapies is probably very low, but you want to walk into these treatments with as much cardiovascular information as possible. I will wait to know what you have in your clinic, but we do have some naturopathic doctors in Detroit. They’re not MDs; they are ND’s and have gotten board-certified in oncology. and are of great assistance to women in diet and supplement sense, sleep, and stress management. I also refer to them as part of a team to wraps a whole lot of attention around women going through this traumatic period in their lives.

Jennifer Simmons, MD

Yes. Along with the aromatase inhibitors, we talked a little bit about metabolic health, and I have long said that cancer—not all cancers, but most cancers, and certainly breast cancer—is a metabolic disease. In the same vein, so is heart disease. We see the risk factors. You started to say this in the beginning; the risk factors are the same. For the same people who are getting a breast cancer diagnosis and are then in a position to have declining heart health because of exposure, how much is their metabolic state coming into play for you, and what are your recommendations around that?

Joel Kahn, MD, FACC

Yes, it’s a big deal, of course. Hopefully, the cancer diagnosis, the cancer therapy, and the follow-up therapies have been successful, as they are for the majority of women.

Jennifer Simmons, MD

I mean, for 90% of women who get breast cancer diagnoses, they survive that diagnosis, unfortunately, only to go on and die of heart disease.

Joel Kahn, MD, FACC

There’s that risk. There’s a very shocking observation in several papers that seems to be true. Okay. You got the good news. You ring the bell at the end of your therapy—maybe a ring as the bell at the end of five years—you’re coming off your Tamoxifen, and the team you’re dealing with gives you a very optimistic long-term look at your breast cancer outcome. Some women experience a heart attack in the follow-up after completing breast cancer therapy and suddenly spike their risk of having a recurrence of breast cancer. They’re on this very low recurrence curve that spikes up. There’s been quite a bit of talk about heart attacks, the immune system, things like macrophage white blood cells and neutrophils, white blood cells, and natural killer cells, and all these fancy names. There is altered immune function after a heart attack, and it may alter the actual surveillance going on in the body for a strange cell. It’s around, and it may allow one to sneak through the system and start to grow. That’s not to scare people, but it is scary data. A woman surviving breast cancer ought to have the attitude that, “Okay, I survived that one, but a cat has nine lives and most humans don’t. I’m going to get control.” Now this cardio-oncology approach has been described very succinctly, as women should follow A, B, C, D, and E, and A is aware of the risk of heart disease in breast cancer survivors. The other A is aspirin. We talked about aspirin the other day, but aspirin is for women with a high calcium score on the CT scan; not all women need aspirin. If your calcium score is zero, it’s been shown you don’t need it. B is blood pressure is high, get a home blood pressure unit. Don’t put it in the closet. Put it on the end table and use your home blood pressure unit. C is two things.

Jennifer Simmons, MD

I just ask you, how often should people be checking their blood pressure? Because we don’t want them to check too much because that alone can probably raise blood pressure.

Joel Kahn, MD, FACC

I would say to do it frequently for two weeks. The best way to check blood pressure is to sit relaxed three times in a row. Even physicians sit down to check my blood pressure, the velcro, the noise, and the pressure. Blood pressure, number one, is higher. The number two is higher than the number three. You do it about a minute apart, and you pay attention. number three, and if you do that about ten times in a row, ten days, any time of the day, and they’re 120 over 70, okay, maybe once a month. Remember, once a month, the first of every month. Check your blood pressure. That’s the B, and the C is cholesterol and cigarettes. Don’t smoke. Not everybody needs to be on a cholesterol-lowering medicine. I want to tell you a little tidbit that I just saw in the news today. But if your calcium score isn’t zero, you can be rather relaxed in your attitude about your cholesterol, according to data, again, often out of Copenhagen. But if your calcium score is anything over zero, you want to work through diet, fitness, supplements, and maybe even medication. Get your cholesterol under control; don’t smoke. There are a bunch of things. Diet and eat healthily. I’m a whole-food, plant-based advocate. It’s the best diet for breast cancer. I’m a big advocate and friend of Christy Funk in Los Angeles and her approach to Whole Foods, which is land-based, and I’m sure you favor a whole lot of brightly colored, whole food choices. D is for the dose of chemotherapy. Just being aware that while we talked about anthracycline and chemotherapy, and then finally D is for diabetes, we are aware that we are having a legitimate epidemic. We overuse the word epidemic, but an epidemic of pre-diabetes and diabetes. Ask your doctor if I can get fasting blood sugar or fasting insulin. I’m fasting hemoglobin A1C three-month blood sugar and eating to avoid diabetes.

Jennifer Simmons, MD

Can I ask you about that? Because fasting insulins are not routinely checked. Why is that?

Joel Kahn, MD, FACC

An abnormal fasting glucose is not followed up on, and a bad thing is that a glucose level of 112 is not normal, and it might be overt diabetes or pre-diabetes. If you check the hemoglobin A1C criteria, it just depends on precedence, and maybe it hasn’t been proven financially that if you take a thousand people and go beyond their fasting glucose and also check their fancy, then, of course, the idea is that you might have a mild elevation in fasting glucose, but your fast insulin is quite high because your body is like a little duck in the water paddling.

Jennifer Simmons, MD

And trying to keep up with it. Right?

Joel Kahn, MD, FACC

Keep up and try to keep your fasting glucose reasonably close to normal. Less than 85 would be an ideal fasting blood sugar. If your insulin is high, you are insulin-resistant. That’s one definition of it. If your hemoglobin C is over 5.6% on a simple blood test, you’re undoubtedly insulin-resistant, like so many people. It’s all reversible with fitness, diet, and supplements.

Jennifer Simmons, MD

I’m truly reversible on days when these things don’t take a long time to reverse. But you can do the same thing over and over and over again and expect a different outcome.

Joel Kahn, MD, FACC

Stop putting that butter in your coffee and that cheese in your sample; then your insulin resistance will rise pretty quickly. In the last two hours, we went through ABCD. E stands for exercise, which of course benefits every aspect of your life, and E stands for that technical test called an echocardiogram, which is what you do during the chemotherapy phase to monitor the heart. Now, if I were to redo this American Heart Association, I would have three C’s: cholesterol, cigarettes, and CT scans, and maybe when they’re updated, they’ll listen to me and include that in the strategy to identify the earliest form of asymptomatic, silent heart disease. There is an interesting report this week in our medical literature. There’s new stuff that says that patients getting these anthracycline chemotherapy treatments like daunorubicin and doxorubicin who happen to be on a statin have better heart function than those not on a statin. It’s an observation about less inflammation and less oxidative stress. We’ll have to have trials in the future. We took women undergoing chemotherapy, and we put some low-dose statin and some not on low. I’m not the biggest advocate of using statins, but it was in the news today, and we got to keep open-minded about new and innovative ways to.

Jennifer Simmons, MD

Sure.

Joel Kahn, MD, FACC

The health of women, even if it runs contrary to what we might do in some or other practice patterns.

Jennifer Simmons, MD

We know that statins do have an anti-inflammatory effect, which is largely why we see some benefit from them. But there are a lot less harmful things that have an anti-inflammatory effect that we could probably accomplish the same thing.

Joel Kahn, MD, FACC

Broccoli. Broccoli would be on.

Jennifer Simmons, MD

Yes, exactly. Or turmeric. Let’s say that you are someone who is out of treatment. Is that the same person who should be getting a calcium score? They were treated ten years ago, or is that where they started?

Joel Kahn, MD, FACC

Yes, living life without a calcium score is like living life without a seatbelt or texting while you’re driving. Yes, you might get through. Okay. But when we’re talking, 50% of people in well-done prospective studies without symptoms of silent heart disease are not optimal. I mean, you should plan your life. Okay. I got through that breast cancer scare. I feel good. I look good. I’m back in the game alive, thank God. But you should plan for number two. I don’t want to be a heart victim. Wouldn’t that be a sad state of affairs? We’ve outlined it; it’s not all about that test, but I’m trying to be efficient. If you have that test and it comes back zero, most of your metabolism is working well for you. If you have that test and it comes back 268, you need to see a preventive doctor and get advanced labs. I’m telling you again, it’s not about how you look outside. I have husbands and wives that come to my clinic. He came here from McDonald’s carrying the bag and hadn’t seen the inside of a gym. She’s the Pilates, yoga, and fitness expert of the world, and her size 4 dress. She has a high calcium score, and he’s got a zero. You could bet on a roulette wheel that that was going to happen. You have to test. I use a hashtag every time you mention social media. Test, not guess. You target heart disease. We’re not looking for rare and obscure diagnoses. We’re talking about the core risk that we all have, whether we have breast cancer or not. Husbands of women’s significant others; others are women’s partners. Women with breast cancer should get a heart calcium CT scan. They’re going to be under a lot of stress during their period, according to me.

Jennifer Simmons, MD

Let’s just review again for anyone who has a calcium score greater than zero. Is anyone greater than zero? What kinds of things? It is reversible, right? There is a chance they will get it.

Joel Kahn, MD, FACC

Calcium scored down, but you can stop the plaque from building up. Yes.

Jennifer Simmons, MD

What are those measures that you are talking to people about that work to stop heart disease and maybe even reverse it? I mean, we do talk about that all the time over the reversal of heart disease.

Joel Kahn, MD, FACC

Science is there. You can reverse heart disease. Number one, you want to get the blood pressure cuff. I just want to give that a shout-out again. 80 to 100 million Americans are walking around with high blood pressure. Another silent disease, a silent killer. You want to get treatment. Number two, you want extensive labs. You want to get the ones your internist or family doctor does if your calcium score is not zero; you want to know about the diabetes aspect; fasting insulin; hemoglobin; A1C; inflammation; your C-reactive protein blood test; the special one called the high-sensitivity C-reactive protein; and you want to know a panel of some genetic tests. The most important one is a version of cholesterol called lipoprotein little A, or LP little A, which is inherited by 20 to 25% of all the women listening to this summit from mom, dad, or both. It’s enough. We make one in excess. We don’t need to do it. The second one is called lipoprotein little A. You haven’t heard much about it because you haven’t read my book, and there are no pharmaceuticals to educate your doctor to check it routinely for $30. But you probably want to get it checked to see if your calcium score isn’t zero and to find out if you have inherited it from the moment you were conceived. A double-whammy ability to make too much cholesterol and too much lipoprotein-A cholesterol. 

Jennifer Simmons, MD

Is that something that is also improved with diet and lifestyle, or is that what it is?

Joel Kahn, MD, FACC

It may take supplements, particularly niacin, but it’s not a statin. Things like Lipitor increase are lower routine cholesterol. They don’t lower lipoprotein-A cholesterol, which is why there are a lot of ongoing studies right now, and we’re close to two to three years away from having pharmaceutical agents, but I can get lipoprotein-A cholesterol down. It turns out a woman is finishing menopause and adopting hormone replacement therapy. If she’s a woman who inherited lipoprotein-A, it keeps the levels low. If she adopts bioidentical or more standard hormone replacement therapy, that’s scientifically proven. That’s not the same woman who’s had breast cancer. She’s got to work on hormonal therapy with her team. It may be the opposite. Estrogen blocking may potentially raise lipoprotein-A levels.

Jennifer Simmons, MD

Which is usually what happens. For anyone who’s had breast cancer, there is an excellent book written by Avrum Bluming called Estrogen Matters.

Joel Kahn, MD, FACC

I love that book. It’s sitting five feet from me, and I show it all the time.

Jennifer Simmons, MD

Yes, it’s an amazing book. It is a must-read for any woman. He addresses the issue of hormone replacement in the breast cancer population. because I don’t know about you, but I finished my training in 2002, the year that the Women’s Health Initiative was released. In the entirety of my career, until I read that book, I was under the impression that having had a history of breast cancer was an absolute contraindication to hormone replacement. Even without a history of breast cancer, when we gave people hormone replacement, we gave them the least amount for the shortest time. Since 2002, we have gone from almost 50% of women being on hormone replacement in the postmenopausal setting to somewhere around 6%. I wonder what impact that has had on cardiac disease because it is protective.

Joel Kahn, MD, FACC

Right. I am a fan of advising my patients to get excellent evaluations and excellent counseling on the topic, and that is the same book Estrogen Matters about 2018. You’ll find it in paperback at a low cost, and everybody who reads it couldn’t agree more.

Jennifer Simmons, MD

Yes. What have you seen in terms of practice? Has that increased the amount of cardiac disease, or are we seeing it at an average younger age because women aren’t going on hormone replacement?

Joel Kahn, MD, FACC

It’s a component. We’re talking about women aged 50, 55, and up, and at the same time, we’ve got more pressure on our diet. We have dealt with smoking pretty well. We haven’t dealt with blood pressure. We haven’t dealt with early detection. It’s a component, but we’re still dealing with so many people who are uninformed or not choosing to eat well or exercise well. The data shows that less than 5% of Americans eat according to hard prevention protocols. We got that big thing. We’ve got the hormonal thing. We’ve got a lot to work on.

Jennifer Simmons, MD

You’re talking to people who have a calcium score greater than zero and are checking their blood pressure and their labs. You’re talking to them about, and there are some genetic variations with LP little A, but they do get better when you put all these other dietary and lifestyle things into place.

Joel Kahn, MD, FACC

In 1990, Dean Ornish, M.D., published a book called Doctor Ornish’s Plan for Reversing Heart Disease. He didn’t have an acid trip, even though he was living in San Francisco. There was a lot of that going on. He had done research in randomized studies and was careful with geography before the time we had there, like sneaking some broccoli and doing work in your life using fasting protocols. I’m a big fan of the L-Nutra five-day fasting-mimicking diet called ProLon. We use a lot of that in my clinic. People can deal with five days of fasting programs and then enjoy the rest of the month, which helps them manage their weight very quickly.

Jennifer Simmons, MD

I think you froze for a little bit when you started to talk about Dean Ornish. Will you just back up a little bit and talk about why you were saying that? It’s not as if he didn’t have technology available to him. Yet he came up with this protocol.

Joel Kahn, MD, FACC

I made a little joke about the fact that he was close to Haight-Ashbury, and it wasn’t an acid trip that he wrote a book called Reversing Heart Disease. It was through carefully and well-done randomized clinical trials in humans that he was such a pioneer, along with Nathan Friedkin and others. We know you can shrink. Well, you don’t get worse. We can get better. We may not take diseased arteries and make them perfectly normal again, but you can. It’s managing your diet, and it’s a whole-food, plant-based diet. It’s about managing your fitness. It’s about managing your sleep. We now know that sleep apnea, which causes fragmented and short sleep, significantly contributes to heart disease. Finally, we’re learning more and more that I like science-based fasting protocols like Dr. Valter Longo’s five-day fasting-mimicking diet. I’m doing that right now. This week I’m on day two and feel wonderful.

Jennifer Simmons, MD

It’s amazing. His research was in breast cancer and women undergoing chemotherapy, and so I employ that with all of my patients going through treatment because it makes a huge difference in terms of not only the response to treatment but also the protection of the normal cells. They don’t need as many factors, and they have energy, feel great, and all of that. His work has been important in this arena. But I love ProLon, and I love the five-day fast. It’s remarkable how great you feel when you give your body a rest from food.

Joel Kahn, MD, FACC

Right concept because we eat two to four times a day, day after day. It takes discipline. But Dr. Longo has given us this. I call it a gift. Just open the box and follow the instructions; don’t negotiate it or break it. You’ll probably lose four, five, six, seven, and eight pounds in five days, feel good, and promote self-renewal and regeneration at a cellular level. Quite remarkable.

Jennifer Simmons, MD

It is amazing. Is there anything else that you want to say before we wrap up? What we’ve covered here is so important: the fact that cardiac disease starting in the thirties is at least twice the threat to women’s lives. Then, when you get up to 70, it’s like seven times the amount. We are losing more lives to cardiac disease than we are to breast cancer, and yet we’re not talking about it in the same way, it needs to be a part of the conversation, not only because cardiac disease is a threat to life, but because once you go through breast cancer, the treatments for breast cancer accelerate cardiac disease. It’s the same thing at the root of both diseases.

Joel Kahn, MD, FACC

Dietary stress, mental drama, sleep issues, and inflammation. There’s a lot of commonality. The good news is to get your lifestyle in order, figure it out, get a good doctor like you, and work with them. You can tackle many illnesses at once and prevent many illnesses with one game plan. Broccoli and turmeric.

Jennifer Simmons, MD

At the end of the day, just like I’m sure you say, heart health is heart health and breast health is health, and we’re all one system. So the things that you do to protect one system protect the entire system, and the things that you talk about are the whole plant-based diet and movement, prioritizing sleep, managing stress, and making sure that you are being proactive about your health because, at the end of the day, no doctor’s going to be able to save you. The only person who could save you is you.

Joel Kahn, MD, FACC

Agree. Well said.

Jennifer Simmons, MD

Yes. It was wonderful to have you here. I appreciate your time and your experience.

Joel Kahn, MD, FACC

Your persistence. 

Jennifer Simmons, MD

I can’t say no. I am persistent, and I will continue to stalk you on social media because I love what you have to say. Thank you so much for sharing your gift with the world. It’s so important. People need to hear voices like yours.

Joel Kahn, MD, FACC

Thank you so much. Appreciate it. Good luck.

Jennifer Simmons, MD

Thank you. Bye for now.