367. Technology to Uncover “Silent” Heart Disease with Dr. James Min

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Dr. James Min: 

Just because you live a healthy lifestyle doesn't necessarily mean you don't have heart disease.

Dr. Richard Shuster: 

Hello and welcome to The Daily Helping with Dr. Richard Shuster, food for the brain, knowledge from the experts, tools to win at life. I'm your host, Dr. Richard. Whoever you are, wherever you're from, and whatever you do, this is the show that is going to help you become the best version of yourself.

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Thanks for tuning into this episode of The Daily Helping Podcast. I'm your host, Dr. Richard. And our guest today is brilliant beyond description. His name is Dr. James Min. He is a former professor of radiology and medicine at Cornell. He's a board-certified cardiologist with a clinical focus on cardiovascular disease prevention and cardiovascular imaging. 

I could literally talk about his credentials for 25 minutes, but he has developed some remarkable technology that can help so many people. And we're going to talk about that and a number of things. Jim, welcome to The Daily Helping. I've been looking forward to this interview for a very long time. 

Dr. James Min: 

Thanks, Richard, for having us on the podcast. Like, really happy to be here. 

Dr. Richard Shuster: 

Absolutely. So as I said, there was a laundry list of things that I could have talked about with respect to your academic achievements and some of the things you've done. But let's go back in time a bit, Jim. I'd love to hear kind of your superhero origin story and what puts you on the path you're on today.

Dr. James Min: 

Yeah. Well, I was -- I trained as a cardiology fellow at the University of Chicago and had planned to do interventional cardiology where you put in stents in arteries. The reason for that is I liked coronary heart disease. The cause of heart attacks was always my research interest and my clinical interest as well. 

At that time, there was a new thing coming out, a new technology called the 64 slice CT scanner which made it for the first time possible to image the heart in 3D. And I thought that this was, it allowed you to go inside the arteries and really visualize an individual person's plaque and build up and type of disease that they had. I thought that was going to radically change our understanding of coronary heart disease. And so I switched over into imaging and focused on that technology in order to use it as a tool to better understand heart disease. 

And so then after training, I ended up at the New York Presbyterian Hospital and Cornell Medical College on the Upper East Side of Manhattan, where we just use the tool mostly for research purposes. We ran a lot of large-scale outcomes trials where we try to understand what we're seeing on the image in terms of disease, how that impacted somebody's outcome, and whether we could influence the natural history of that outcome in a manner that would reduce heart attacks and strokes and death and other adverse consequences.

So we started a clinical program once we learned a lot of these lessons. And we applied a very different approach to prevention and precision heart care, where we would use imaging to practice end of one medicine. Right? So, the field of cardiology is replete with large scale, randomized control trials, which we firmly believe in. But when we're seeing a patient in the office, we don't have 80,000 people to look at, we only have one. And we need to treat that person as an individual. 

So we used imaging to do that and it was just quite a successful program in terms of our clinical outcomes. And so we said, this is great, but we can never scale this past the Cornell walls. And so we needed to solve a bunch of problems. The first problem was like, it was taking us 10 hours to analyze an individual's image that was never going to scale. And so we needed to automate that. Okay. The second is we need to educate people like the clinicians, primary care physicians, general cardiologists, on what we were seeing in the imaging. The third was we needed to empower the patients to make sure they understood the disease so that they knew what we were treating, why we're treating and so on. 

And we had to treat the disease and then ultimately, we had to track it. So the tracking of the disease also based on imaging. So what we did was we started a company about seven years ago called Cleerly with the intent really to not be an imaging company per se, or an AI company, but really to develop a comprehensive standardized and personalized care management platform for evaluation, education, treatment and tracking of heart disease. So hard to believe it, but we're seven years into the formation of this company. And really, we have a mission to try to create a world without heart attacks and try to replicate what we were doing at Cornell and New York Presbyterian.

Dr. Richard Shuster: 

Amazing. And I've seen some of the trends from a research standpoint, where not only the world, but in particular America is going in terms of cardiovascular health. So I want to talk more about Cleerly and how it can help people, but let's take a step back to a higher level, Jim. Can you give us cardiovascular health 101 and a little bit of do's and don'ts, because it is terrifying when you read the stats that are out there today? 

Dr. James Min: 

Yeah. So I mean I think the first question to answer for the audience is what is heart disease, right or coronary heart disease? There's many different kinds of heart disease. Coronary heart disease is the cause of heart attacks, and it is due to plaque that builds up silently within the walls of the heart arteries over time. Turns out, there's many, many different types of plaque that build up all which have very different functions and different prognoses and different risk. 

We didn't understand that until the last 10 years or so. And now I think we've come to understand it quite well through all of the research trials. The plaque builds up starting at a pretty early age. Like even when you looked at victims of death in the Vietnam and Korean war, like people were developing plaque buildup in their early twenties. It's an insidious phenomenon. Meaning it grows slowly and generally slowly, but quietly and silently over time. And then at some point, those plaques might rupture or erode and that then causes a heart attack. 

The problem with it, like with our current approach, is that we're reliant upon symptoms. So people think that chest pain and shortness of breath are a sign of heart disease. They can be but for 60 percent of the people who will die of a heart attack or suffer a heart attack, they will have no symptoms before their event. And I think everybody knows somebody like that, right? Somebody who went out for a run and never came back or somebody went to sleep and never woke up. And generally, the sudden coronary deaths are at a very early age. The average age is around 50 years of age.

And so we're trying to find those people, those at risk people to try to Prevent those heart attack and sudden death events from occurring. How can you prevent it? Well, our historical approaches have been to look at things like cholesterol levels, or inflammation levels, or diabetes status, or blood pressure. All of those things, if you think about it, aren't coronary heart disease, they're indirect markers of heart disease that do elevate risk of groups of people but not necessarily the individual. 

And so they're highly unreliable in identifying who's actually sick and who's not and who's actually at risk of a heart attack and who's not. Not to say that we shouldn't care about those factors because they're very important and we should treat them but really to couple those risk factors of heart disease with the actual heart disease itself, which is the plaque that builds up in the arteries. Maybe I stop there and see if I addressed your question, Richard.

Dr. Richard Shuster: 

You absolutely did. And I think for most people, and partially because we get educated by the jingles for the drug commercials on TV, right? Like we're told lower our A1C, and we're told have low cholesterol. And, I mean, Statins are the number one drug that is sold in the world, so  we're on that treadmill. But what I'm hearing from you is that, and of one that these are indicators and there may be correlations between them and the risk for heart disease, but you're trying to look at the individual in a different way with what you're doing. So, tell us how what you're doing at Cleerly looks at somebody's heart and creates essentially a treatment plan that's completely different to what medicine has been doing previously.

Dr. James Min: 

Yeah, it's a good point. Like you mentioned Statins, so let's take people with high cholesterol, which Statins treat. If you take a hundred thousand people who have high cholesterol and treat half of the people with Statins and the other half with not, you will definitely see an improvement in outcomes in patients taking Statins.

But there's two issues that people don't think about too much. Like if I tell you that this 50,000 people over on the left have high cholesterol and this 50,000 people on the right have low cholesterol, will there be more heart attack events in the people in the group with the high cholesterol? The answer is absolutely yes. However, when you take 50,000 people and then run them through a fancy analysis of their heart, turns out 70 percent of people with high cholesterol don't have a speck of disease. 

So we're just treating a lab test at that point in time. We're not treating a person. So those trials are really good for group-based comparisons, but that end of one concept means that I need to personalize my treatment for the individual who's sitting in front of me, not for a group of 100,000 people or 50,000 people and so on. 

And so I think, and then the second problem, I think that people don't talk about is that Statins are one of the most effective drugs that we have in lowering the risk of heart attack events. But it's about a 20 percent relative risk reduction, meaning that out of 100 people who are treated, 20 will benefit, but that means 80 aren't benefiting. And we don't know who those people are, right, because we've lowered their cholesterol, they're on the medication, and yet, four out of five people aren't benefiting.

So that's a concept called residual risk where you treat somebody's risk, but they still have residual risk that you haven't addressed. Who are those people? The only way that, in my mind, that you can actually find those people is to take a picture of each individual and make sure that they're free of heart disease, or if that they have heart disease to be able to effectively treat it and make sure that it's not progressing despite the therapies, given that it fails in four out of five people. 

So what are we doing? We're just trying to give a very comprehensive evaluation of actionable coronary artery disease measures, so I don't really care about things that I can't treat because I don't have anything to help that person, but I know, like, based on 60, 70 years of research that there are three major findings of coronary artery disease that are treatable. 

The first one is the primary disease process. That's the plaque. In the last 10 12 years, we've learned a lot through very large outcome studies of how to treat that plaque, what happens to that plaque over time to stabilize it, and what the therapeutic and clinical goals ought to be. And we've developed a software that helps support physicians in practicing that end of one approach, the personalized medicine approach. 

At some point, the plaque can narrow the artery. It can encroach upon the inside of the artery and start to narrow. That's called a blockage or stenosis. And at some point, that stenosis might cause a reduction in blood flow which may cause a patient chest pain or shortness of breath and that's a concept called ischemia. So we measure that too and compute that from our technology. 

So whether it's atherosclerosis, the primary disease process, stenosis, the narrowing in the artery, or ischemia, a reduction of the blood flow within that artery, our platform provides all of that detail to the practitioners. And then translates it in a way that you don't have to be an imager to understand. You can be a patient, primary care physician, general cardiologist, and you'll all be empowered by the data to understand how to approach a patient and optimize their heart health. 

Dr. Richard Shuster: 

It's pretty amazing because imaging has been around forever, but you're using imaging and AI in a way that takes something that was nebulous to many. And you are not only making it understandable, but easy to implement solutions for geared to the individual, which is spectacular. 

Dr. James Min: 

Yeah. I mean, as I talked about that stenosis and ischemia concept, those aren't heart disease, right? Those are consequences of heart disease. The heart disease itself is the plaque or the atherosclerosis build up in the walls of the arteries. So that was our primary emphasis is that heart doctors should measure heart disease, primary heart disease and we'd never done that before. We didn't understand it until we did the large-scale outcomes trials. We couldn't do it until there was a very safe non-invasive way to image. 

And for your listeners, like the test that we use is called a coronary CT angiogram done in -- when I left Cornell, we were slotting 10, 15-minute time slots to get this thing done. So patient would be in and out in 15 minutes. It's not a hard test. It's completely non-invasive. A CAT scan, which is what this is, is just a fancy X ray, very low dose radiation, very safe. 

So I think that we finally have a way that we can image primary disease similar to the way you screen with a MA mammogram or with a colonoscopy, right? You use those tools as an imaging tool for direct visualization of an individual's disease in a personalized fashion. I think it's time that the heart doctors start to follow in line with those kinds of really successful preventive measures. 

Dr. Richard Shuster: 

So you mentioned that generally, you start seeing heart attacks, young people in their 50s. You talked about the Korean war data that many of these people had plaque buildup as young as their 20s. When should somebody, at what age rather, should somebody start thinking about getting a test like this?

Dr. James Min: 

It's a great question. Like so right now, the coronary CT scan is reserved primarily for people who are symptomatic, right, who present with chest pain or shortness of breath. And we have two reimbursable CPT codes so that insurance can pay for this but primarily reserved again in the symptomatic population of people. 

That's the way we practice, right? We generally wait for people to have symptoms and then in most cases, not just cardiology, but other fields of medicine, and then we evaluate them. We believe that there's a time in the future where we should be more proactive about screening. And but in order to do that, we need to prove that. And so we actually launched a very large 7,500 patient randomized control trial called Transform. And Transform is testing the hypothesis that in completely asymptomatic high-risk individuals what works better. Does the standard of care of looking at risk factors of heart disease work well? Or does a Cleerly guided approach where treating an individual's actual disease as identified by imaging work better? 

And so that trial is ongoing right now and we're enrolling. We need that evidence in order to really espouse sort of public policy recommendations for universal screening. And we'll see what happens with this trial, but right now what we're doing is primarily offering our services in the symptomatic population of people.

Dr. Richard Shuster: 

Makes total sense. And can they get this through their regular doctor's office? Or do they have to go to a special center just for this?

Dr. James Min: 

Yeah, it's a good question. Like they can go to any center that has the ability to perform a coronary CT angiogram. If you look at the scanners across the country, that probably represents 95 percent of the CT scanners, the facilities that own CT scanner. So you can get it pretty much everywhere. 

It's easier if you're integrated with us, because then we auto extract images into our cloud and so on. So there's no manual work there. But if people are interested in, they can go to cleerlyhealth.com and they could type into info at cleerlyhealth.com and just we can point them to the nearest location.

Dr. Richard Shuster: 

Amazing. Before we transition, I would be remiss if I didn't ask you because of your expertise. So outside of just the standard, the diet and exercise kind of commentary, what are some things that people need to think about in terms of their overall heart health?

Dr. James Min: 

Yeah, I think a couple of things that one is that there are thousands of factors, many known, many unknown, that contribute to heart disease. So just because you live a healthy lifestyle, doesn't necessarily mean you don't have heart disease. Like we have a good collaborator and friend who was a very successful iron man triathlete, and he had a heart attack while running a triathlon. And he said something very poignant. He's like, at the end of the day, fitness isn't health. And he's absolutely right. You can be highly fit, eat very healthy, and yet still suffer a major catastrophic event. 

And so I think that's one thing that people should know, because you always hear people say, oh, I eat well and I eat fish and I exercise regularly. That does not mean that you don't have heart disease. There's thousands of things that can contribute, air pollution, anxiety, sleep apnea, a poor diet, genetics. There's just -- you can name, just keep going on and on naming all of the factors that contribute to heart disease, and many of them we don't know. Right. 

So like it's not something that we can say, oh, because we looked at these six or seven factors, you will not have heart disease. That's why we think that image-based analysis on a personalized level is the way to go. The second thing I think is to understand that fitness is not health, right? So that heart health is something that is an insidious silent phenomenon in the majority of people. 

But the third thing is that it's very treatable. And so whether it's through lifestyle modifications or non-invasive medical therapy, the heart disease is very treatable and it's easiest to treat at the earliest stages. If you look at all the studies of what is the biggest strongest predictor of who's going to progress significantly with disease, the baseline amount of disease is always the dominant factor that predicts the progression. So we've got to get the horse before it gets out of the barn at a very early stage for prevention, where maybe the therapeutic intervention is simply lifestyle modification changes and trying to really optimize the lifestyle towards promoting heart health.

Dr. Richard Shuster: 

I love this. This has been such an amazing conversation, Jim, as you know, I like to wrap up every episode by asking my guests a single question and that is, what is your biggest helping, that one most important piece of information you'd like somebody to walk away with after hearing our conversation today?

Dr. James Min: 

I think that heart disease remains, is, was, and remains the number one public health epidemic in the world. There's a heart attack. There's somebody who dies a heart attack or suffers a heart attack in the U.S. every 40 seconds. It's a preventable phenomenon. We have a heavy toolbox of tools. We just need to identify people at an early stage where we can get to them, treat them effectively and prevent all of these catastrophic events from occurring. 

It's a new paradigm, a new clinical paradigm, but I think it is the one that has been demonstrated in many other fields to be successful. And I think what we need to do is really introduce or transition our field into an era of precision heart care or personalized medicine. So easy to be proactive. It's harder to be reactive because an adverse event has already occurred. 

Dr. Richard Shuster: 

Well said. James, tell us again the URL where people can learn more about Cleerly and see if it can help them. 

Dr. James Min: 

Sure, it's Cleerlyhealth.com and Cleerly is with two Es. 

Dr. Richard Shuster: 

Perfect. And we'll have links to everything Cleerly in the show notes at drrichardshuster.com. Well, James, this has been an incredible conversation. I'm so grateful for your time. I know it's going to help a lot of people. Thank you so much for coming on the show today. 

Dr. James Min: 

Thanks for having me, Richard. 

Dr. Richard Shuster: 

Absolutely. And to each and every one of you who took time out of your day, if you liked it, if you're inspired, if you're going to start taking steps to manage your heart health, go give us a follow and a five-star review on your podcast app of choice, because this is what helps other people find the show. 

But most importantly, go out there today and do something nice for somebody else, even if you don't know who they are, and post in your social media feeds using the hashtag #MyDailyHelping because the happiest people are those that help others.