In this Q&A, our plant-based doctors welcome Dr. Kim Scheuer to the team. Guest speaker Dr. Nicole Harkin joins us as we answer your questions, discuss heart disease, and the effects of your diet on your cardiovascular health. You can learn more about Dr. Nicole Harkin at: https://www.wholeheartcardiology.com/
Questions Answered
- (00:03) – Welcoming Dr. Kim Scheuer
- (01:22) – Introducing Dr. Nicole Harkin
- (02:54) – How much fat that you recommend for someone who is trying to reverse their cardiovascular disease?
- (05:02) – Have we reached a point where we can't live a normal lifespan without inhibiting cholesterol synthesis?
- (07:38) – What is the recommended LDL cholesterol level for those with a family history of heart disease?
- (09:09) – Does drinking coffee negatively affect cholesterol, HDL, LDL, or triglycerides?
- (10:22) – How are carotid arteries cleaned up by lowering LDL, and how long does it take to see changes?
- (14:52) – What is the optimal number for triglycerides?
- (14:59) – What should I do if the whole food, plant-based diet is not reducing my cholesterol?
- (18:15) – What do you recommend for elevated levels of LP little A?
- (21:08) – My blood pressure remains elevated while I'm on a plant-based without salt, any suggestions?
- (23:27) – Should I avoid oil?
- (25:45) – Do you use amla or Indian gooseberry for cholesterol?
- (27:05) – What does an elevated calcium score indicate?
- (30:35) – What is considered to be a moderate CAC score?
- (30:41) – Are the inflammatory markers on blood tests a good indication of soft plaques?
- (31:28) – Can you test for soft plaque without an interventional angioplasty?
- (34:33) – How can I contact Dr. Nicole Harkin?
Complete Transcript
Dr. Laurie Marbas
(00:03)
And today we want to welcome two amazing doctors first, Dr. Kim Scheuer who's our new plant-based doctor on Plant Based TeleHealth. Hey, Kim, can you say hi and tell us a little bit about you?
Dr. Kim Scheuer
(00:14)
Hi, everybody. I'm so happy to be here. I'm boarded in family practice and in lifestyle medicine, and I am just joining the Plant Based TeleHealth group and I'm so excited. I did traditional family practice for years and years and years, and then about nine, 10 years ago, I decided to improve my health. And when I did, I found out how to improve my patient's health and here I am.
Dr. Laurie Marbas
(00:39)
Fantastic. And she is quite the athlete too. So she likes to run up the Rocky Mountains, so you guys are in for a treat. And Kim will be starting pretty shortly, hopefully the next few weeks, and you guys keep an eye out for that, and we're super excited and we'll be getting her on the podcast and sharing everything. And now we have Dr. Nicole Harkin who is our Plant-Based cardiologist and our special guest. Hey, Nicole, how are you?
Dr. Nicole Harkin
(01:04)
Hi, how are you?
Dr. Laurie Marbas
(01:06)
Great. We are so excited to have your expertise on here because we get a lot of questions about this.
Dr. Nicole Harkin
(01:11)
About the heart? Yeah.
Dr. Laurie Marbas
(01:12)
Yes.
Dr. Nicole Harkin
(01:12)
Not an important organ, people still want to know about it.
Dr. Laurie Marbas
(01:17)
Just a little. So can you tell us a little bit about you where people can connect with you and everything there?
Dr. Nicole Harkin
(01:22)
Yeah, of course. So Dr. Nicole Harkin, I am a cardiologist and actually a clinical lipidologist as well, so I do a lot of cholesterol stuff and I'm physically located in San Francisco, California, but did most of my training in New York and was in New York for several years in private practice. And then on moving to San Francisco, I decided to start my own thing. So I have a preventive telecardiology practice called Whole Heart Cardiology where I see patients and help optimize their heart health and do a lot of complex cholesterol disorders and all that good stuff.
Dr. Nicole Harkin
(02:01)
And I love using, obviously, the major cornerstone of my practice is lifestyle medicine to optimize heart health. So that's my deal. I see patients in New York City, virtually in New York, California, and Florida.
Dr. Laurie Marbas
(02:15)
Fantastic. So Nicole's been amazing. I've already sent patients to her, I text her, things like that and so she's great. So if you guys have any questions, if you're in the webinar side, please put that in the Q&A box. And then on the Plant Based TeleHealth page, if you could please just put the comments there, I'll be monitoring that and I'll bring those up to Dr. Harkin. But do any of our plant-based doctors, including, Hey, Dr. Pierce, joined us, Dr. Klaper is here. Dr. Miller. So any of you guys have any questions, please feel free. We'll start with some of our questions that we like to ask Plant Based cardiologist.
Dr. Chris Miller
(02:54)
Yeah. I have some questions. I just want to know the basic question, where do you stand on the how much fat that you recommend for someone who already has cardiovascular disease and is trying to reverse the process and they're plant-based already. How much fat would you recommend to that person in form of nuts and seeds and avocado?
Dr. Nicole Harkin
(03:15)
That's a really good question. That's a really good question. And I think it does depend on patient to patient established cardiovascular and sort of where their cholesterol levels are all that good stuff. But definitely we know that we want to reduce obviously saturated fat and trans fat as low as possible. So trans fat, we can get out of the way because it's eliminated for the most part from our dietary supply. And then saturated fat, obviously, if they're already on a plant-based diet, they're hopefully not consuming too much of it although we know that it's in certain plant-based products as well.
Dr. Nicole Harkin
(03:55)
So I do allow some mono and polyunsaturated fats in the diet and I think this is where it's very helpful to sort of speak with the patient in terms of where they're at satiety, meal planning, family considerations. All of these go into the mix as well and sort of what all their risk factors are going. So I don't have a set percent, I just kind of look at the overall diet and work with them on getting obviously the saturated fat out as much as possible.
Dr. Nicole Harkin
(04:33)
But there's definitely in terms of… And I'm sure we can get into all of this, but there's some data in terms of the poly and the monounsaturated fat, when those get introduced that we do see lower cardiovascular endpoints as well. So I'd much rather make sure they're not eating a lot of processed stuff, that kind of things before I get too strict on other things. So I know that's kind of a pop out of an answer, but it really is patient to patient specific for me.
Dr. Michael Klaper
(05:02)
Nicole, many of your colleagues in cardiology are very enthusiastic about class of drug called statins so much so that everybody should be on statin, we should put it in the water supply, it's so beneficial. And I'm thinking, have we homo sapien developed the body that cannot live a normal lifespan without inhibiting an enzyme in our liver that synthesizes cholesterol?
Dr. Michael Klaper
(05:29)
That seems so unnatural that we need to shut down HMG-CoA reductase in order to live a normal life with healthy arteries. Do you find any problems with that stance and how do you feel in general about statins?
Dr. Nicole Harkin
(05:47)
So I am a cardiologist, so I do use statins, full disclosure here, but certainly, I analyze the situation very, very differently. So I think that the current ACCA J calculator particularly when it comes to age really can overestimate cardiovascular risk in certain individuals and mandate or recommend statin treatment in individuals who may not need it, particularly those who are on say a whole food, plant-based diet or some other sort of plant predominant diet.
Dr. Nicole Harkin
(06:21)
So I think that we definitely have situations in which we use statins in primary prevention way too often, and in many individuals who might not need it. And so I think in those sort of situations where say the ACCA J calculator is recommending a statin, but based on your clinical expertise, you don't believe that they would benefit from it, there's other tests that we can do to sort of help us make that decision and convince ourselves that this patient would not benefit from a statin, something like carotid ultrasound or coronary artery calcifications, or you just have that, that conversation with the patient.
Dr. Nicole Harkin
(07:04)
Certainly the guidelines are there as guidelines and us as specialists can really enter into those more nuanced conversations with our patients based on their risk. So I have plenty of patients who, as you know, we can get our cholesterol down quite low with whole food, plant-based diets.
Dr. Nicole Harkin
(07:23)
Sometimes because of genetic considerations, patients can't get there and so then that becomes that conversation with a patient. This is where your cholesterol is at, this is where we probably prefer it to be, where should we go from here?
Dr. Laurie Marbas
(07:38)
Right. Anybody other plant-based docs have any questions? Dr. Kim, Dr. Jeff? Okay. So I have some other questions from the lots of questions actually have been popping up. So what is the LDL cholesterol recommended now especially with those having a family history?
Dr. Nicole Harkin
(07:57)
So I like cholesterol really low. I'm super strict on that. And luckily with whole food, plant-based diets, we can get it really low. I mean, I'm sure you all have had fantastic results with it as well. So in sort of no other risk factors, I'm okay with an LDL cholesterol below 100. My preference is below 70 and honestly, in the 50s is great because that's where we really see virtually no cholesterol buildup in the arteries. So we keep moving the bar a little bit further and further along, but really kind of the lower, the better in terms of cholesterol buildup.
Dr. Nicole Harkin
(08:40)
Now, again, this is patient to patient dependent. It really depends on other risk factors and things like that. But I do like to see it quite low, and we know that the low is safe. There's plenty of populations out there that have fairly low cholesterols and have no adverse cardiovascular events. Now, do we need to artificially push it that low in everybody? Probably not, and it just depends, again, going back to risk assessment and patient preferences.
Dr. Laurie Marbas
(09:09)
Absolutely. So additional questions. Does drinking coffee negatively affect cholesterol, HDL, LDL, or triglycerides, et cetera?
Dr. Nicole Harkin
(09:18)
That's a good question. So we found actually that cholesterol is probably affected adversely by non-filtered coffee. So French press, which I actually used to really enjoy, can in some people actually raise LDL cholesterol [inaudible 00:09:40]. So some people filter coffee is a better option. So basically. Other than that-
Dr. Laurie Marbas
(09:52)
So you cut out just a little bit. So you were just saying the French press, you cut out just a second. Something about the French press coffee that you used to drink, sorry.
Dr. Nicole Harkin
(09:56)
Yeah. So the French press coffee, actually, there's some compound in coffee that if you don't filter it through a drip, through a filter, then you get an elevated LDL cholesterol. So actually drip coffee, or some sort of filtering of your coffee is probably best for LDL cholesterol. Not everyone's affected by it, so this is when you're getting into the nitty gritty of things, but some of these things add up, right? So.
Dr. Laurie Marbas
(10:22)
Yeah, absolutely. And then we had another question from here on the webinar. It says when you've lowered your LDL to 70 to 74 with the whole food, plant-based diet after one year, can you please explain how the carotid arteries are cleaned up and how does it feel to the patient? She says, “FYI, I had a stroke in December, 2016 with 100% occluded right carotid artery.” So any thoughts on how long that takes or do you see some changes?
Dr. Nicole Harkin
(10:48)
Yeah. So it's really highly variable. So more often than not, you won't feel anything and it's sort of the cholesterol, as long as it's not causing events. You're unaware that that blockage is there. And so from a blockage cholesterol standpoint, you won't fill anything. Now you'll feel all the other fantastic effects of the whole food, plant-based diet, obviously, but there's no change that you'll feel if that plaque changes.
Dr. Nicole Harkin
(11:25)
Now, plaque regression is an interesting one, which I'm sure everyone has very different opinions on and it's quite controversial at the moment, but most of our therapies, statins medication, things like that cannot reverse plaque and [inaudible 00:11:42] it. Now there's some evidence with the whole food, plant-based diet that we do you can see improvement. So the good thing about the carotid arteries is you can kind of easily monitor that without radiation, you can get a simple ultrasound or an MRI or something like that so they can check up on that.
Dr. Nicole Harkin
(12:04)
But I would say that in general, with some of these sort of blockages, we focus a little bit too much on the known blockages rather than the systemic issue at play, right? Which is a lot of what we're trying to do with lifestyle change is prevent any other blockages, right? Because if you have one big blockage, likely you have lots of other blockages in other arteries of the heart as well.
Dr. Nicole Harkin
(12:29)
And so rather than hyper-focusing on the one which probably has already caused issues, I would be focused on all the fantastic things that you're doing to sort of help your body overall and really improve the blockages elsewhere.
Dr. Laurie Marbas
(12:44)
Excellent. And someone just had a few questions regarding, do you have any suggestions on the… Let's see here, did anyone here give a suggestion for HDL triglycerides and total cholesterol? Are there specific numbers or do you just focus mainly on LDL or are there other optimal numbers for these other readings?
Dr. Nicole Harkin
(13:04)
Yeah, I focus mostly on LDL. That's really our target. In terms of HDL, it's a marker. So higher HDL or the good cholesterol is a marker for improved cardiovascular outcomes, but we don't have a lot of data that shows that actually artificially focusing on raising it, certainly not with any medications does any good. So I don't hyper focus on it too much. That said, exercise and not smoking are the two great things you should be doing anyway and that improves your HDL.
Dr. Nicole Harkin
(13:37)
And again, for the same reason, total cholesterol, I don't pay that much attention. HDL is really high which is a good thing, the total cholesterol can be higher. Triglycerides is an interesting one, that's certainly something I start to focus on as well and definitely with the epidemic of insulin resistance and metabolic syndrome and obesity. We're seeing issues with triglycerides and they certainly are linked to adverse cardiovascular outcomes. So that's another target in terms of lifestyle changes.
Dr. Nicole Harkin
(14:10)
Thankfully, when people switch to a whole food, plant-based diet, we see those numbers come down really pretty dramatically. Refined grains and things like that is the one place where people can get into trouble, so really working on lowering kind of those sort of products certainly, but again, that's part of sort of all of this.
Dr. Nicole Harkin
(14:28)
I mean, that's the great thing about working on sort of a comprehensive lifestyle plan that includes a whole food, plant-based diet is that a lot of these things you see lower lowering of blood pressure, you see lowering of LDL, you see lowering of triglycerides. So often we don't have to focus too much on each one, although sometimes we do still see certain things that are still elevated and then there's little tricks here and that you can do, but…
Dr. Laurie Marbas
(14:52)
What would you say the optimal number for the triglycerides is then?
Dr. Nicole Harkin
(14:55)
So definitely below 150 milligrams per deciliter is where we like to see it.
Dr. Laurie Marbas
(14:59)
Perfect. And this is the question we get a lot, any suggestions if the whole food, plant-based diet is not naturally reducing cholesterol, let's make it some caveats here, maybe money who has no known cardiac disease and never had diabetes, hypertension. They're like the plan either that just has some genetic issues or then there's the ones that were sick, reversed it, lost all the weight and now what should they do? And then of course, there's those ones that are the transitioning. So let's start with that first one because that's a lot of questions we get.
Dr. Nicole Harkin
(15:30)
Yeah. And obviously, other people, feel free to jump in. I'd love to hear everybody else's thoughts on all of these cases as well. I'm sure we'll all have sort of different approaches and things like that and this is where the art of medicine comes in and I love this sort of stuff. But for patients who have continued elevations in their cholesterol despite sort of an optimal lifestyle therapy, those are some of the toughest cases, I think. And so because all of our data is on populations, right? It's not on individuals, and so then you have to apply that data to a specific individual situation.
Dr. Nicole Harkin
(16:08)
And so that's where I do use other testing and family history and all that kind of stuff, and to have that conversation with the patient and decide what to do from there. So it depends, if they have a very strong family history or their inflammatory markers are still elevated, or something along those lines, then often I will… Or maybe say a pregnancy history of gestational hypertension or a preeclampsia, some other sort of risk enhancing feature, that's when I use other testing, so like a carotid IMT or a coronary artery calcification score to sort of see where they're at and then that gives you data about their body.
Dr. Nicole Harkin
(16:56)
And then you can kind of go from there in terms of making decisions about whether or not to add therapy or not. Certainly if their LDL cholesterol is quite elevated, meaning greater than 190 milligrams per deciliter, that's when I have the conversation with them about potentially something which is called FH, familial hyperlipidemia, which is a genetic cholesterol disorder. And in those people, we do have good data that they are at much higher risk of cardiovascular events simply because they've had an elevated cholesterol throughout their lifetime, and that ranges somewhere between 100 and 200 people to 250 people.
Dr. Nicole Harkin
(17:36)
And so those people are sort of in a different class altogether in a different conversation. But for your average run of the mill person, try to gather as much data, present to them what we know and what we don't know and then let them decide what to do. Certainly, if the coronary artery calcification score is zero, I feel very comfortable saying “I think you're one of those people that we can wait on and let's just see,” and then I let patients make a decision. I'm all about getting as much data as I can, giving them my opinion. And then having patients be able to make an informed decision.
Dr. Laurie Marbas
(18:10)
That's excellent. Any of our docs have other questions or do you want me to go on to the next…?
Dr. Chris Miller
(18:15)
I have a question if it's okay. Do you guys mind? Thank you, Dr. Harkin. So my question is about LP little a and the genetic risk that that adds. And so if people have family history or they already have cardiovascular disease, you check them LP little a and it's elevated, what do you recommend at that time? And they are already, let's say, plant-based.
Dr. Nicole Harkin
(18:40)
That is the question of the day, my friend, I love that topic. So for the listeners, LP little a is a type of a cholesterol particle that is atherogenic like LDL cholesterol meaning it's a vehicle to transport cholesterol, and unfortunately, it does transport it into our arteries. It also has a little protein that is also similar to plasminogen which is the clotting factor. And so it does increase our risk of clotting disorders.
Dr. Nicole Harkin
(19:15)
And so individuals who have an elevated LP little a have an increased risk of heart attack and also aortic stenosis which is when the main valve in our heart that goes between our heart and our body gets thickened. And so this is a huge area of research right now. It is genetically determined, unfortunately. So this is the other disorder that I see not uncommonly that is very frustrating. And as alluded to, it's a risk-enhancing feature and is recognized at this point in our primary prevention guidelines.
Dr. Nicole Harkin
(19:49)
And so unfortunately, it is one of those things that really responds very suboptimally to anything that we try to do, and really it's pretty resistant to diet. The only time we really see it elevate anymore and another time to maybe check it is after menopause in women, it does go up a little bit at that point as well, but it's really unresponsive to diet. Medications for the most part don't lower it. In fact, statins increase it. The new PCSK9 inhibitors, they do lower it modestly like 20%.
Dr. Nicole Harkin
(20:24)
So right now there's not a lot to do other than knowing that it's there and it's a really good motivator to get patients to make major changes, right? Particularly my patients that want to get serious about it, but they're not quite sure and then I present a lot of this to them. It's a really good motivator to help them get serious about the whole food, plant-based diet or what other lifestyle changes we're trying to implement.
Dr. Nicole Harkin
(20:49)
So my approach at this point is to use it as a risk enhancing feature, help patients lower their risk in all other ways including their cholesterol. There's trials right now for medications at some point, but right now it's all about all the other.
Dr. Laurie Marbas
(21:08)
That's fantastic. Any other questions from the docs? Nope. Okay. So we have a few questions about hypertension. Can you talk to us a little bit about salt and hypertension? And let's say someone is on a plant-based diet, not consuming salt, but their blood pressure remains elevated or continues to be moving upwards instead of downwards. Any suggestions or thoughts there?
Dr. Nicole Harkin
(21:30)
Yeah, so blood pressure is another big risk factor for heart disease and so certainly we do know that the whole food, plant-based diet or DASH style diet, predominant diets can lower blood pressure. Certainly, some people are very salt responsive, and some aren't. I see dramatic reductions in some people when they stop consuming salt and then other people don't respond as much as well. So certainly getting out any of the processed foods, even the plant processed foods, freezer stable things, all that kind of stuff, unfortunately, that makes our life easier, but it's just…
Dr. Nicole Harkin
(22:14)
And it's hard because in patients that are trying to transition over, those are the things that also sort of make it harder to get the blood pressure down. And I'm sure you guys have seen this as well, it's just incredible. I'll have patients that come to me on three blood pressure medication and I start them on a whole food, plant-based diet and I'm like, “Okay, now call me if you get at all lightheaded so we can stop. And in some people, you have to stop it within a week or two, and then in other patients, we just still see this blood pressure that just won't budge and it's really frustrating.
Dr. Nicole Harkin
(22:45)
So I do work on definitely the salt reduction, so definitely less than 2000 milligrams a day, ideally less than 1500 in some people. Some people that does a lot for, and some people, it just doesn't. And then certainly focusing on some foods that we know that can lower blood pressure, things that are very high in potassium and magnesium, really making sure we get in the leafy greens, all that kind of stuff.
Dr. Nicole Harkin
(23:10)
So there's little tweaks we can do. I'm sure you guys have other suggestions as well about how you tweak it once you really get someone to try [inaudible 00:23:19] but it can be really frustrating and I've certainly had some patients that I just couldn't get them off their last blood pressure medicine for whatever reason.
Dr. Laurie Marbas
(23:27)
Absolutely. Okay. And then we just have a question also, we get a lot of questions about oils, olive oil, coconut oil. What are your thoughts on oil? Should it be avoided at certain cases or is it okay a little bit? We do get a lot of those questions.
Dr. Nicole Harkin
(23:42)
I know, and this is another area of huge controversy and I'm sure we all would have very different opinions on oils and things like that because of the data with PREDIMED which is the large randomized controlled trial that did show reductions in cardiovascular endpoints when nuts and olive oil were added into a Mediterranean diet, I do feel like small quantities of extra virgin olive oil are probably reasonable.
Dr. Nicole Harkin
(24:12)
So I don't necessarily restrict that, although it depends on some of my patients. There is saturated fed in olive oil, right? So I think it just is patient to patient dependent and depends. I do encourage cooking with veggie broth or just water, whenever possible, so not like this dredging of the olive of oil, and it's very caloric as well. So I do allow small quantities here and there. Some people I know are much more strict and prefer no oil. I don't think there's a perfect approach, and I don't think we've got enough data to say whether it's strictly none at all or some.
Dr. Nicole Harkin
(24:49)
But I think I don't say no way for most of my patients. Coconut oil is very high in saturated fat, that's a whole nother story and I try to. I know it's gotten this huge health halo out there because of the medium trait, this whole thing, but really the data we have indicates that it behaves like most other saturated fats and raises our LDL cholesterol. So I try to limit coconut oil for sure.
Dr. Laurie Marbas
(25:17)
I like your saying, health halo. That's great.
Dr. Nicole Harkin
(25:20)
I learned that from one of my RD friends and I was like, “I love this.” Same with the sugars, the different sugars that are out there and stuff like that. So there's a lot of things that have got all these processed foods that have these health halos around them because they don't have this, but it's still a processed food, right? So that's my new favorite term.
Dr. Laurie Marbas
(25:40)
Absolutely. Fantastic. Any of the other docs, any other questions, I guess?
Dr. Kim Scheuer
(25:45)
I was wondering if you use amla or Indian gooseberry at all for cholesterol?
Dr. Nicole Harkin
(25:50)
Good question. I actually haven't. I would love to hear your guys' thoughts on that and how you use it because I actually haven't yet. So I would love to learn from you.
Dr. Laurie Marbas
(25:59)
Yeah. I actually use it a lot, especially with the cholesterol. It also helps with blood sugars for diabetics. So I've seen it drop, and granted these are anecdotal cases, but 30 to 40 points.
Dr. Nicole Harkin
(26:12)
Really?
Dr. Laurie Marbas
(26:13)
Yeah. So it's definitely worth a shot. It's a bit tart, but they only need about half a teaspoon to a teaspoon a day. So we come up with creative ways to use it, but anybody else use the animal powders seen any changes or?
Dr. Chris Miller
(26:26)
I use it for inflammation as well and it has helped lower some of my patients with stubborn CRPs that are just still a little bit high. So we put a little bit in a smoothie. So like Lori trying to hide that bitter flavor, so that helps, but yeah. So it seems to have some benefits.
Dr. Nicole Harkin
(26:44)
Oh, that's really interesting, because I do have a couple of patients who have that persistently elevated hs-CRP so I like that. Okay. Interesting.
Dr. Jeffrey Pierce
(26:52)
I don't have much experience with it, but I've seen that it can lower production of uric acid so it might be helpful for people with gout.
Dr. Laurie Marbas
(27:01)
That's cool. I didn't hear about that.
Dr. Nicole Harkin
(27:03)
I didn't know that either. Good to know.
Dr. Laurie Marbas
(27:04)
Dr. K?
Dr. Michael Klaper
(27:05)
Nicole, I'm curious what the calcium score really means to you in your cardiologist head when you see a mildly or moderately elevated. To me it's evidence of the battle past in the artery wall maybe years ago, but I don't know how much is telling me about what's happening right now in the arteries, I'm more interested in their inflammatory markers in their hs-CRP and their oxide cholesterol, et cetera. Someone here has a cholesterol calcium score of 2000, what do you do with those numbers, the calcium score?
Dr. Nicole Harkin
(27:41)
A great point. Excellent, excellent point. So that is entirely correct. So the coronary artery calcifications for you listeners is essentially a specialized CAT scan that we get that looks at the arteries of the heart and specifically measures how much calcium is in the arteries. And so then it quantifies that, tells us sort of where they are as well, and then gives you a score. And then it also ranks you or scores you based on other individuals you are same age and gender.
Dr. Nicole Harkin
(28:13)
And so there's a lot of decent chunk of data at this point showing correlation with elevated calcium scores and cardiovascular events. So certainly very high coronary artery classification scores over 400, they're actually considered at the same risk as someone with established coronary disease who's had an event based on sort of the event rates they see. But to your point-
Dr. Michael Klaper
(28:38)
Although, excuse me.
Dr. Nicole Harkin
(28:38)
Go ahead.
Dr. Michael Klaper
(28:41)
They're high risk for myocardial infarction, et cetera, if they continue eating meat and cheese and the standard American diet.
Dr. Nicole Harkin
(28:49)
100% true.
Dr. Michael Klaper
(28:50)
All these studies are in that population. If I've got a plant eating person who has a high calcium score, what is it really telling me?
Dr. Nicole Harkin
(28:59)
100%. So that's exactly right. So what that score is telling us is what has happened in the past. So that calcified plaque is actually a plaque that has had an issue ruptured and then was healed. And then so these are old plaques and which is why just as a side note, coronary artery calcification scores in young people that are zero are not necessarily reassuring because we would really hope they wouldn't have calcified block. So if you see a CAC score in a very young person, that's alarm bells going off.
Dr. Nicole Harkin
(29:35)
But anyway, to your point, what it's not showing is the soft plaque, right, which is the stuff we really care about. What they've shown is that individuals with high coronary artery calcification scores why they're at higher risk is actually because they tend to have a much higher burden of the soft plaque as well.
Dr. Nicole Harkin
(29:53)
Okay. So it's that stuff, that's what we're caring about, and what's the stuff that's going to cause their events. So to your point, what do we do about it? And certainly a very aggressive lifestyle approach is an intervention, right? So to your point, they can't stay on just their standard diet and not do nothing, we have to do something, and certainly putting them in a very aggressive lifestyle approach is one solid approach. And in fact, we don't have strong data to be honest, that adding statins to individuals with elevated coronary artery calcifications scores in that moderate territory prevents offense.
Dr. Laurie Marbas
(30:35)
So what is considered moderate territory and numbers of the CAC score?
Dr. Nicole Harkin
(30:38)
100 to 400.
Dr. Laurie Marbas
(30:41)
Okay. And then are the inflammatory markers on the blood tests actually a good indication that they have soft plaque? What if they are low, are they still at risk for having this soft plaque?
Dr. Nicole Harkin
(30:54)
Yeah. So to my knowledge and that's a really good question. I'll have to look and see if say they've done studies to try to figure that out, and I don't know that they have because then you'd have to do an angiogram to identify the soft plaque, right? So I'm not sure that that study has been done, that would be a very interesting study to figure it out.
Dr. Nicole Harkin
(31:12)
But yes, I think that inflammatory markers can be helpful. What else is going on? Is there rippering, uncontrolled insulin resistance? All these other things play into how high risk this person is and what are you going to do about it, right?
Dr. Laurie Marbas
(31:28)
Sure. I interviewed Dr. Williams, I interviewed actually three of you guys that are Plant-Based cardiologists. They haven't come out on my podcast yet, but he also mentioned just diving a little bit deeper into imaging to look at the soft plaque. I can't remember exactly what he said, but is there anything there, any testing there that someone could do without interventional angioplasty?
Dr. Nicole Harkin
(31:48)
So to look at the actual soft plaque in the coronary arteries, if you did the CAT scan with dye, so a CT angiogram, which we used to not do in the absence of symptoms but are now increasingly doing simply for that reason because you then can identify more of the soft plaque which is really what we're caring about. So that's one option. The other option I like in young people is actually looking at their carotids because it's an ultrasound, there's no radiation. And we've got good validation in terms of how thick their… It's called the carotid intima which is basically the lining of the vessel wall, how thick that should be, and certainly if you're seeing soft plaque there, and particularly in a younger person, that's of concern.
Dr. Nicole Harkin
(32:35)
And I like that because it's an ultrasound, right? And so you can kind of keep an eye on it without… It's very, very noninvasive. So I think that's another good approach. Obviously, that's the arteries in the neck, not the heart, but all of this is a systemic issue, right? So if these are clean or they have something, that's a pretty good indication of what's happening in the heart as well.
Dr. Laurie Marbas
(32:54)
That's excellent. And any other final questions for Dr. Harkin? We're hitting our half hour mark. Anybody?
Dr. Chris Miller
(33:01)
I want to make one point. That was awesome, Nicole, thank you for sharing all that information with us. But one point to all the participants out there, and I just want to say that it's hard to ask these tough numbers about a random patient because every patient is different and it really does matter. And so for everyone out there with all your questions, it really is helpful to know your own personal risk factors and your numbers and your level of inflammation because I see all the time, one person with let's say total cholesterol of 170 LDL of 80 has no plaque has beautiful clean arteries, no family history, so that's awesome.
Dr. Chris Miller
(33:40)
And the next patient will have the exact same numbers, 170 and LDL of 80, and now they have plaque and they're high risk and they have family history. So we're going to have to treat that person more aggressively than this person, same diet, same numbers. So it's hard for us to give one number. And when we're all asking Nicole or hammering her with questions, this has been awesome. We really appreciate it. We really appreciate answering all of our questions, but I just want everyone to understand that it is unique in individuals, it's hard to give answers so.
Dr. Nicole Harkin
(34:09)
That is an excellent, excellent point. I'm really glad you summarized that there, and then that's what it comes down to. And that's why we're all doing what we do and we love seeing patients because as I said, all of this data is on populations at large, and then it's our job in that doctor-patient relationship to then refine it for that individual patient sitting in front of you and figuring out what going to be the most beneficial plan for them.
Dr. Laurie Marbas
(34:33)
Dr. Harkin, you were amazing. Thank you so much. And we do have people asking again, how do they get hold of you and where can you see them?
Dr. Nicole Harkin
(34:41)
Yeah, of course. So on Instagram is where I'm most active, Nicole Harkin MD. I post what I'm cooking for my littles and different heart healthy tips, all kinds of cardiovascular prevention information. And then I also can be found on my website, www.wholeheartcardiology.com. I have a newsletter to get more info, and then also if you live or can drive to and be located at the time of our appointment, New York, Florida, or California, you can also figure out how to become a patient of mine as well.
Dr. Laurie Marbas
(35:19)
Excellent. So I would highly recommend anyone who needs of plant-based cardiologist to check out Dr. Harkin or at least drive to a state of New York.
Dr. Nicole Harkin
(35:28)
I've had patients do it so
Dr. Laurie Marbas
(35:30)
Yes, it's a very common think in this virtual world that we do. But any final words from other Plant-Based doc? Anything you'd like to say?
Dr. Kim Scheuer
(35:42)
It's great to learn from you. Thank you.
Dr. Jeffrey Pierce
(35:43)
Yeah, it was a pleasure.
Dr. Michael Klaper
(35:43)
Absolutely. Well done.
Dr. Nicole Harkin
(35:47)
Thank you guys so much. I really appreciate you guys having me here and I love learning from you as well and collaborating. I just think it's so awesome that so many people are really using medicine in this way and it's just great.
Dr. Laurie Marbas
(36:01)
Yes, absolutely.
Dr. Michael Klaper
(36:01)
The fact that you exist as a plant-based cardiologist at your age is so wonderful, it does my heart good.
Dr. Chris Miller
(36:10)
Ha-ha. Good one.
Dr. Laurie Marbas
(36:13)
Dr. Klaper is very punny so.
Dr. Nicole Harkin
(36:15)
I love it. I love the dad jokes, they're always the best.
Dr. Laurie Marbas
(36:21)
Excellent. Well, thanks, everyone. This is definitely going to be one of our more popular videos, I am confident in that. So we appreciate your time, Dr. Harkin, and again, thank you everyone. And guys check us out at plant-basedtelehealth.com. We have Dr. Jeff Pierce, we have Dr. Kim Scheuer who's our new doc joining Dr. Miller and myself and Dr. Klaper who needs no introduction as always. So thank you again, everyone. And we'll see you in two weeks and we'll go from there. Talk to you later. Bye.
Dr. Jeffrey Pierce
(36:48)
Bye-bye.
Dr. Michael Klaper
(36:49)
Bye.
Dr. Nicole Harkin
(36:49)
Bye.
*Recorded on 2.21.21