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Ethan Weiss is a preventative cardiologist at UCSF, an entrepreneur-in-residence at Third Rock Ventures, where he is working on a project related to cardiometabolic disease, and a previous guest on The Drive. In this episode, Ethan compares and contrasts the diagnostic imaging tools, CAC (coronary artery calcium score) and CTA (CT angiography), used to image plaque—including the latest in CTA software—and how these tools inform our understanding of ASCVD risk and guide clinical decision-making. Ethan discusses the types of plaque that cause events and the data that make a case for optimal medical therapy over stenting outside of particular cases. He explains why high blood pressure is problematic and walks through the data from clinical trials testing aggressive treatment. He talks about the best way to actually measure blood pressure, why we shouldn’t simply accept that blood pressure rises with age, and how he uses different pharmaceutical agents to treat hypertension. Additionally, Ethan explains our current, but limited, understanding of the role of metabolic health in ASCVD. He discusses the impact of fat storage capacity and the location of fat storage and explains how and why there is still a residual risk, even in people who have seemingly normal lipids, don't smoke, and have normal blood pressure.

We discuss:

• Ethan’s entrepreneurial work in the cardiometabolic disease space [4:30];
• Calcium scans (CAC scores) and CT angiography (CTA), and how it informs us about ASCVD risk [6:00];
• Peter’s historical CAC scores, CTA results, and how one can be misled [10:45];
• How Peter’s CTA results prompted him to lower his apoB [14:45];
• Calcium scans vs. CT angiogram (CTA) [21:15];
• How Ethan makes clinical decisions based on CTA results and plaque burden, and the importance of starting treatment early to prevent ASCVD [28:15];
• Improved methods of CTA to grade plaque lesions and how it’s shaped medical decisions such as stenting [33:45];
• Why Ethan favors optimal medical therapy over stenting outside of particular situations [41:45];
• The need for FFR CTA, and the potential for medical therapy to eliminate ASCVD [54:00];
• The fat attenuation index (FAI) and other ways to measure inflammation in a plaque [57:30];
• Statins and exercise may increase the risk of calcification, but what does this mean for risk? [59:45];
• The root cause of statin hesitation despite evidence that statins are a profoundly important intervention [1:05:30];
• Importance of keeping blood pressure in check, defining what’s normal, and whether we should just accept higher blood pressure with age [1:10:45];
• Blood pressure variability, how to best measure it, and data suggesting the enormous impact of keeping blood pressure down [1:21:00];
• Drugs for treating high blood pressure recommended by the ALLHAT trial [1:35:15];
• What the SPRINT trial says about the aggressive treatment of hypertension, and the risks of such treatment [1:38:15];
• Confirmatory results in the STEP trial for blood pressure, and how Ethan uses the various pharmacological agents to lower blood pressure in patients [1:43:15];
• The role metabolic health in ASCVD: what we do and don’t know [1:51:00];
• The impact of fat storage capacity and the location of fat storage on metabolic health and coronary artery disease [1:56:15]; and
• More.

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