Imaging for Health Screening with Dr Andy Manganaro

One of the most important things is to identify our risk for these chronic diseases that shorten our life , and today we get to talk about the power of preventive medical imaging health screening , and we're joined by an expert in the field , dr Andy Mangonaro , who's the chief Medical Officer at Lifeline Screening . Hi , andy , welcome to this episode .

I did my training mostly at New York University Medical Center and did research at UCLA for a number of years in cardiac physiology and then went into private practice after I did some academia . I've been the chief medical officer for Lifeline screening for about 16 years now .

By trade I'm a cardiothoracic and vascular surgeon for more than 30 years and of course during that time I saw all the results of the ravages of atherosclerosis and vascular disease in general . I particularly had an interest in the prevention of stroke .

So much death and terrible disability could be avoided by identification of previously unknown disease and successful preventive measures . Preventative vascular screenings aim to identify those with subclinical disease at a time when lifestyle changes in medical management can make a difference .

So if we can get to folks who have abdominal aortic aneurysms before they rupture , the difference is that if they rupture and they make it to the hospital , the overall mortality is over 90% . On the other hand , if we get to them before the rupture , we can fix it with a mortality of 5% or less .

So think about that 90% mortality versus 5% mortality , if you can only know that you have it and fortunately you can do that with an ultrasound examination .

Yeah , so anyway , excuse me for the interruption .

So my point being that if you know about these otherwise unknown problems because there are no symptoms associated , for example , with abdominal aortic aneurysm before the rupture but if you can know about it , you can do something about it and in some cases , like with the AAA that's an abdominal aortic aneurysm , you can fix it surgically or with an endovascular graft

. Now there , for example , are other things like causes of stroke . You know your audience I'm sure all knows that when someone has a stroke it's terribly debilitating , and there are so many that occur through the United States with no warning . In general , the first sign of a stroke , in 80% of the occasions , is the stroke itself .

There are no symptoms or warnings , uh , except in a very few number of them , and there are a number of causes of stroke , for example , uh , hypertension , high blood pressure , uh , which everybody pretty much knows about and is getting cared for .

Some folks have an abnormal beating of the heart , a rhythm of the heart that doesn't belong there , and some may have heard about it . It's called atrial fibrillation and it's one in which the small chambers of the heart quiver instead of beating , and when they quiver , the body gets fooled into thinking that the blood is static . It's just sitting there .

And whenever blood sitsiver , the body gets fooled into thinking that the blood is static , it's just sitting there . And whenever blood sits still , it clots . And if it clots it just sits there like a big bowl of grape jelly . Unfortunately , then when the heart does beat properly in that chamber , it spits it off .

And the first place it generally goes is up the arteries in the neck to the brain . They're called the carotid arteries , and it blocks off the blood flow to the brain , causing generally a massive or fatal stroke . And once a stroke occurs , the only thing you can do really is to rehabilitate patients . So the idea is to prevent them in the first place .

And the third cause of stroke is what's called atherosclerosis . Folks call it hardening of the arteries or plaque formation inside arteries . It's calcium and cholesterol Builds up inside what are called the carotid arteries , one on each side of your neck that go up to the brain .

And this stuff , this plaque , is kind of like crumbly plaster , like you would find if you took the wallpaper off your wall and you can see where it would just spit off , little pieces of it go up and block arteries in the brain . Whenever it does that , it causes a stroke and how bad it is is dependent on how much gets spit off and the like .

It can actually close an artery down and if there isn't flow from the other side , that's generally a fatal stroke . So those are the things that we screen for In that case . Again , we look at the carotid arteries by ultrasound and we can see this plaque and if there's a little bit in there , well , folks can do simple things .

They can change their diet , they can change their exercise regimen , they can be on medications from their family doctors , like aspirin , which is a mild blood thinner , statins , which lower cholesterol , and so on , and it can be followed along then because it becomes progressive in some cases .

If we find cases where the blockage is severe 80 , 90% those folks sometimes need to have either a surgery or stent placed to prevent the same thing , to prevent that stroke . And that has a very low risk . I've done thousands of the endoterectomies and the risk is less than half of 1% . So the idea is to find this because you may not have any symptoms .

If you have no symptoms , but you have the disease and you do something about it . Your life is so much better .

But yeah , that what you , what you mentioned , the power of screening is such an important concept that , um , the idea that , uh , we , we look for the disease with a test before the symptoms occur and by detecting it earlier than we would normally , normally , if we wait for the symptoms we'll we'll have a better chance of controlling the disease or preventing a

catastrophic event like a stroke like you mentioned , which may be the first symptom , unfortunately .

You know , if you get in your car one day it's an older car and you look down and you see some rust in the floorboards , right , you can be pretty damn sure that that's not the only place it is . It's going to be everywhere in the car , because what caused the rust in the first place doesn't just pick and choose .

It'll attack the fenders , it'll attack under the motor , in the exhaust and so on . Well , atherosclerosis is the same way .

So if you find it in one place , for example in the peripheral arteries of the legs , which we look at as well , then there's a very high likelihood that you may well have the same disease atherosclerosis narrowing of the arteries , in the carotid arteries and even in the coronary arteries , which are the arteries that supply the blood to the heart muscle and which ,

if they close , cause what everybody knows as a heart attack . So the incidence of , for example , of folks having heart attacks if they have peripheral artery disease , that is , blockages in the arteries to the leg is eightfold higher than if they don't , so that's why it's important to know about what's going on in your legs and in your carotid and your aorta .

There's a misconception , I think , among some patients when they , you know , they have a heart attack and they go in and they get , they get revascularization either through stents or through a bypass and they go . Wow , I'm glad I took care of that .

And what they don't realize is the stents and the revascularization only only stops the immediate shortage of blood supply to the heart but does nothing for the overlying , the underlying atherosclerotic heart disease , underlying atherosclerotic vascular disease that's occurring throughout the body , in their brain , maybe a stroke coming , or their kidneys , their peripheral vessels

and all . And getting at the root cause , I think , is one of the things that we're stressing here . But your point is so good that you can do a screen of the carotid arteries and if you have vascular disease there , you need to look at your heart , and if you see it in your heart , you probably have it in your brain too .

We don't do screenings of the carotid arteries , but what we do look for are the risk factors associated with that very disease , and we're able to tell people , therefore , what their risk is for having heart disease whether it's low , whether it's medium , whether it's high based on these other screenings and also based on their history and based on laboratory tests

such as cholesterol levels and so on , that we also offer them Diabetics . For example , if your glucose levels are high and you're identified as a diabetic type 2 , your incidence of all of these diseases both heart disease and all atherosclerotic diseases is significantly higher than that of the non-diabetic general population .

So everything kind of hooks together , and that's why it's so important to think of this , as you said , as a kind of an underlying disease that's manifest in all these separate , different ways .

We may not cross the threshold into type 2 diabetes , but we're all creeping up there , so we're all at risk for these various diseases . We're all at risk for these various diseases . Maybe , before we talk about the specific screening , could you talk a little bit about , maybe , what the risk factors are for atherosclerotic heart disease and how that comes about .

There's no question but that obesity is associated with onset of diabetes . It's associated also with high blood pressure , hypertension , and hypertension itself is associated with the development of atherosclerosis , heart disease , renal failure and so on . So it's all hooked together .

Of course , there were many other risk factors , for example heredity and the genotype that you are .

So if your daddy died of a heart attack when he was 45 , you can be pretty certain that you're at risk and you can do something about it and be aware of that , and incidents in general of heart disease in your family should make you aware that you are potentially susceptible to that .

Of course , there are the factors that we all know about in our lifestyle , such as smoking . Smoking is a no , no , no , no , no , no . Cigarette smoking is associated with atherosclerosis across the board . I can count on one hand maybe two of the patients that I did revascularizations on that did not have either diabetes or history of smoking , or both .

Now you may not be able to avoid getting diabetes from a hereditary standpoint , but you can avoid it in terms of not letting yourself become obese , remain active and so on , and you can certainly not smoke . So those are very , very important risk factors , and associated with that , of course , is lifestyle lack of exercise , which leads to obesity . Obesity .

Those are the things , those are the principal things . Yeah , lousy diet doesn't help either . You know if you're eating , if you're eating trans fats all the time , you know you can be sure your cholesterol is going to go through the roof . So you want to keep an eye on that as well .

So let me tell you that first , in that when one is under stress , then the body secretes what are called catecholamines People know it as epinephrine or adrenaline , and drugs like not drugs , but substances like that in the body , and it's normal for the body to do that .

So , for example , if there's a bear running at you , right , you want a lot of adrenaline in your body so you can run fast and get away , and that's okay under that circumstance and it's also just transitory .

On the other hand , if you live a life in which stress is there all the time , then those catecholamines , adrenaline , epinephrine and so on are there all the time and they raise your blood pressure .

That's one thing , and we already talked about hypertension causing atherosclerosis , and they also , in a more direct way , have an effect on the kidneys , on end organs and so on . So stress is a very , very important risk factor for all of this stuff . Plus , it's a terrible way to live us .

Instead , the blood pressure gets so high throughout the body that includes the arteries of the brain and the small arteries of the brain that they can't tolerate it and one of them ruptures . So basically , the artery bleeds into the brain and there isn't any place for it to go in the brain except to destroy brain tissue .

That's called a hemorrhagic or a lacunar stroke and it can be devastating . So that's one of the reasons why the incidence of stroke is increasing , but also the incidence of atherosclerosis is increasing for all the reasons we've already talked about .

So it isn't surprising to me that strokes are increasing and we're trying our best at Lifeline Screening to interdict that by getting folks to come and get screened for those things which can lead to stroke . You know we've screened over 10 million people since the inception of lifeline screening .

We screen between 600,000 and 700,000 people a year and we find enough disease in that period of time to fill the Super Bowl stadium , think about that . The Superbowl stadium , think about that . So so it's a . It's a problem that it that stroke is increasing , as there are so many other diseases that are related to lifestyle .

It's a theme of of this program that we are now metabolically much less healthy than we were 20 years ago and , like you say , with obesity , type two diabetes , insulin resistance , the junk food that has replaced the normal food that we used to eat in our supermarkets and other lifestyle factors that are just increasing incidence of all these diseases , but including

cardiovascular disease and atherosclerosis , as you mentioned .

But I will tell you that , despite that , back 60 and 70 years ago , people were healthier . We just couldn't do as much to fix the things that became wrong , whether it was cancer , you know , heart disease , tuberculosis , polio . So all those things have been corrected , which have lengthened our lifespan .

that people die of , they were around 150 years ago , but a much lower rate of heart attack and stroke and these chronic diseases

.

You don't eat anything out of a can , and I think one of the problems we have here is that nearly everything we eat comes out of a can whether it's in season or not , but in Italy , if it's not in season and it hasn't come out of the ground that day , you don't get it .

Maybe you could educate us what's available through your program and what do they look for ?

We scan the carotid arteries by ultrasound to look for a plaque in the arteries and we do an electrocardiogram to look for that abnormal rhythm of atrial fibrillation which is associated with stroke . So we do those tests . We also do an ultrasound of the abdomen to look at the abdominal aorta to see if there is an aneurysm present or not .

We do a screening of the peripheral arteries and measuring the ankle brachial index . That's a way of telling whether there are blockages in the arteries going down to the feet , from the groin and so on . Again , these are all related , as I told you before , one to another . Again , these are all related , as I told you before , one to another .

Then we have an entire panel of laboratory examinations , that is to say blood tests , and those include , oh gosh , tests for cholesterol , in particular , for atherosclerosis , tests , for prostate cancer , tests for thyroid disease .

I don't have the list in front of me , but there are dozens and dozens and dozens of tests , of course glucose and hemoglobin A1c to check for diabetes and so on .

And one of the interesting things about the program , as I developed it as chief medical officer , is that when we find something that falls into what we call a critical realm , then the patient gets notified immediately . Screenings can tell a patient if they have , for example , a six centimeter abdominal aortic aneurysm .

They don't have to wait for the physician and I'll talk to you about that in a minute to get the screening , read it and hit the alarm button Right . Then , based on that size alone , they can tell the patient you need to go either see your family doctor now or to the emergency room now , because that patient is likely being the operating table a day later .

So , similarly for high-grade carotid stenosis 90 stenosis in a carotid artery and so on .

Now , once those screenings are done and , by the way , the same with some blood tests such as a very high glucose level that might be critically dangerous Once those screenings are done , then they are sent electronically to our panel of reading physicians and these are all board certified doctors radiologists , cardiologists , cardiovascular surgeons and vascular surgeons who

read this material and identify any of the abnormalities in the screenings and that is then used to send to the patient the results of all of the screenings that they've had done , in a paper form or on the web , you know whichever so that they can look at those .

And in that , what we call a results package , not only do we just send them the raw data , we send them a kind of format that shows by color what their risk factors are . In other words , are they in the green , are they in the warning yellow or are they in the red ?

And we send them a copy to bring to their physician , because what we encourage them to do is to take all of this to their family doctor , because it's their family doctors and any specialists they recommend who ultimately take care of the patients . We simply identify the abnormalities in screening so that they're aware of them and can then get treated appropriately .

So those are the things that we do . If anyone's interested , of course they can go to the site for lifeline screening and there are many , many , many packages that you can look at and purchase .

And , as I said , I'm the last one to ask about what things cost , but I can tell you this that the cost of getting these done at Lifeline compared to what it would cost you if you had to pay out of pocket for them on the outside at a hospital is tiny .

And it's a specific kind of test unrelated to these other things that we do , but which we do offer , and which a patient can be seen by a nurse practitioner and that is covered by Medicare , but that's a whole separate arm .

One of our uh one of our other speakers , I think in one of their programs , was talking about other other tests for screening for cardiovascular disease , specifically heart disease . He was mentioning a uh , ct , uh , computer tomography , calcium score for looking for calcium in the coronary arteries , or CTA . What , what's the , the , what are the differences ? Which ?

Are they basically looking at the same thing or their advantages to one or the other ? Uh , for that right .

After that came the realization that if you mimicked those things in a safe environment , such as having somebody walk on a treadmill with drop to an electrocardiogram so that you can see changes and that's called the stress test that somebody could be identified as having coronary artery disease even if they didn't have symptoms . So that was a step up Then .

The next step after that , of course , is if you flunked that one , then you had what was called coronary angiography , and that's a dye test in which the coronary arteries themselves are actually visualized . Cardiologists do that and you get a picture of what's going on in the coronary arteries .

Now , as a heart surgeon , that was the roadmap that I looked at on these patients prior to doing surgery . So , for example , I knew that there was a 90% blockage in the artery to the front of the heart and an 80% blockage in the artery to the inferior , the lower part of the heart . So when I did the surgery , those are the arteries I made bypasses to .

So that was true up to , oh gosh , probably 15 years ago , and of course it's still . The gold standard for finding out whether you have coronary artery disease , if you have symptoms , is to have a coronary cath , which is what I described the angiogram .

But to get closer to what you were discussing about , some time ago it was realized that a CT scanner , which is a device which is very good at looking at all sorts of parts of the body , either with dye or without dye .

So , for example , if you want to look at somebody's lungs to see if they have a tumor in them , you can get a CT or a CAT scan it's called and that will show that .

Now it was figured out that you could also look at the coronary arteries using CT , not to see the blockage so much , but to see whether there was calcium in the arteries , because calcium is radio dense , in other words , it shows up on an x-ray and if there's a lot of calcium in a coronary artery , the likelihood is that some of it is blocking the arteries .

Now , you don't know that for sure . You only know that the risk is that some of it is blocking the arteries . Now , you don't know that for sure . You only know that the risk is higher if you have calcium in your coronary arteries , but it's a very useful device for people to get who have risk factors , and we don't do that .

It requires ionizing radiation and none of our tests do that . None of our tests have radiation . They're all completely safe and do no harm . So someone can get a calcium score in that way . So I hope that answers your question .

And do you think , should everyone be screened for stroke and cardiovascular disease ? Who's a good candidate for this type of testing ?

Well , what has been determined , especially interestingly within the last two to three to five years , is that the incidence of atherosclerosis is going down in the age curve . So whereas it used to be 50 and above that were at risk , now we're finding that people 40 and above are at risk .

So we screen people who are no younger than 40 and who have risk factors , and the kinds of risk factors are the sorts of things that you and I have already described .

So if someone is completely healthy , even at age 40 , and they have no risk factors , well they probably don't need to be screened , and we don't want to be screening people and wasting their time and wasting their money .

So they can call in if they're concerned and the folks that they're talking to will go down the list of risk factors with them and help them determine whether they have any or not .

Now , if somebody is 50 years old wants to be screened , even if they don't have any risk factors , or they're 60 years old and they just want to feel better about knowing that they're okay . That's all right , we would do that so , and that's , by the way , that's a positive .

So if you get screened and what we find is that there's no problems , well , that's not a bad thing , that's a good thing . Yeah , yeah no absolutely Including in terms of decreasing your stress in life .

And that's an interesting question because if if I had to answer that , oh , 50 years ago , the answer would have been one thing , because there wasn't much you could do for people who are very elderly safely . But nowadays it's different .

So , for example , folks even in their 80s , if they're found to have high-grade blockages in the carotid arteries , can be treated with very , very low risk , a success rate of better than 99% , and prevent stroke . Because even in your 90s , especially in your 90s , a stroke is a horrible , horrible thing to have happen to you .

And the same with an anomaly or a canyons , if you find a triple A in somebody in their 80s . Well , in the past who might have said , well , you know , maybe they won't make it through the surgery ? Not so anymore , because the surgery is so much safer , safer and we have also the ability to use endovascular stenting , which is much easier on the patient .

Uh , in those folks , and in fact what we found is the risk of repair for that in folks in their 80s is no higher than anybody else's . So should you be screened if you're in your 70s and 80s and so on ? Yeah , you should .

If you have risk factors , if you're concerned and uh , we'll , we'll tell you what you got yeah , I think that's a very enlightened view and I wish more physicians had that .

One of my best friends is 10 years older than I . He's 86 . And he still flies aerobatic airplanes .

It'll give you the names of contact folks and all that sort of stuff .

We are on Facebook , I know that , and on social media in general , and I have no idea how to get to that because I am a Luddite and I need my 12-year-old granddaughter to help me get on . Facebook 12-year-old granddaughter to help me get on Facebook . But it's there and anybody can figure it out and get on it very easily .