Dr. Jorge Gonzalez discusses using coronary artery calcium scores as they relate to risk of death, development of coronary artery disease, and cardiovascular outcomes.
I am I'm very excited for for our next speaker, DR JORGE Gonzalez. He uh for many years our group here at scripts and search for just the right person to come in and create a new program for cardiovascular imaging. In the answer was Dr Gonzalez. He seems to have this motor that just won't quit. In addition to a full time clinical practice, doctor Gonzalez has created from scratch our scripts clinic advanced cardiovascular imaging program which includes both cardiac cT and cardiac MRI. And in addition to that, he has spearheaded the hypertrophic cardiomyopathy and Air to air to programs. He was also our first cardiologist at scripts to bridge the cardiology and radiology divide. Successfully becoming a member of both groups. Doctor Gonzalez has been very busy publishing in the field of cardiovascular imaging and is quickly becoming a national force on the topic. So it is with great honor that I introduce our next speaker, Dr Jorge Gonzalez who was speaking on evolution of subclinical coronary atherosclerosis, coronary CT A and coronary calcium score. So Dr Gonzalez welcome and thank you. Thank you chris thank you for the introduction and thank you for having me and thank you and David for inviting me. I apologize for the background but uh I was hesitant to go to the office in La Hoya. Like you guys did mostly because my computer was still not working after our famous glitch and the men in the month of May. And so um and my background right now is basically my office is a mess at home with some remodeling. So um so thank you for inviting me. This is a topic that is uh I actually loved and uh it's something that I actually used the parts of clinical trying to diagnose atherosclerosis and uh and uh in the clinic on on a daily basis and uh I love to talk about this topic. And uh, I usually like to show a lot of the things I usually think more than the evidence itself because in evidence, most of us we all know about, you know what we uh we have been doing in terms of trials lately over the last like five years. And like most of you have heard the schema trial which heavily used also cardiac ct. But sometimes from the perspective of the image is nice to be able to show you where our brain goes, which is way different sometimes than people in and lipid clinics because we're usually more about like visualization of disease. And so these closures, I have none from the atherosclerosis perspective. Uh, you know, every time we talk about atherosclerosis, this comes to my head and he's always the subclinical and clinical differentiation and uh, you know, coming from a line of physicians, I'm the third generation in my family. I remember the picture and the right vividly with. My grandfather gave me the nod to as a gift when I was a medical student back in Venezuela. And uh, and I remember that picture like if it was yesterday, also, it comes to my man because I would not understand, you know, uh, what winter was until I moved to Boston in 2006. And so, uh, for this gentleman in here is basically on the picture on the right. I always thought myself when I was going to training, How can I get to try to avoid the clinical part? When you try to define coronary artery disease? I always have that differentiation between subclinical and clinical. And so, uh, the coronary artery disease definition uh, for years has always been the one on the right side. Especially when you read all the trials that have been done over the last 20 years since I was a med school. They all talk about when people have coronary artery disease. The inclusion criteria always involved patient with angina, Q. Ways of NSG myocardial infarction, a person with prior history of PCF stance or a patient with prior cabbage. But the subclinical part usually sometimes uh you know, uh not thought well and we didn't never have very good tools and trying to look at them because in on none of our tests, including stress tests in the catheterization, were able to see them. And so we know that from the political standpoint after this course is the stars very early in life. Uh and the likelihood of happening or the progression of happening usually goes all the, you know, it's modified by all the risk factors that you guys have mentioned at the start of the talk from someone with very high LDL, genetics, smoking hypertension, and other risk factors. And so from the image of perspective, I wanted to have a tool in which I can I'm able to see them mostly the subclinical par try to avoid what everybody talks about. So sometimes even when I see patients and they have a very high calcium score a ct with unobstructed the disease, I always always put an assessment and in the in the problems coronary artery disease. And I always have this debate with one of my good friends and colleagues, uh which I love to have discussions in the clinical perspective is Evan muse, because we always have deferring what we call coronary artery disease. And so his point of view is usually more on the right side from the clinical standpoint, and my point of view usually is most likely that the clinical part which usually is the process that happens in the intimate of the coronary disease. So thinking about Evan, I found this picture that resembles of amused when he was Children Or a child. And this is the way I look every time I think about the two components of the coronary artery diseases. That should I call it? If if the cast of course 2000, but the patient doesn't have any demand ischemia or should I wait for the person to have a Q wave of Marc Karlin fraction to be able to call it. And so the conundrum from the image in perspective, always put me in the pathologist point of view and I think all of us the images we usually think this way. And so people who tend to read Kartik cities, we see a very young when some of my colleagues order tested and sometimes and people in their forties and most of them are usually non obstructive. But you can still see that the scan is not normal, especially when we do coronary ct. So from the point of view from the pathologist, this process that starts very early. So for me as an image, I want to provide you with the tools that will allow me to diagnose this disease. When you are actually helpful, you are helpful with all the markers that you see here in the screen that you guys all use, uh, to be able to try to provide a risk certification. You guys to really incentivize and modify that occurred of mortality that you guys have shown. And dr griffin has shown. So when I started looking at risk, I remember for him in massachusetts. So uh, you know, I was in medical, in Venezuela, we talk about Framingham risk score is what I used to use from all the patients back then. And then I moved to boston and uh, when I was in boston doing research actually in fish oil, uh, you know, we used to live in Brookline, which is not far from framing him and then suddenly my wife was from massachusetts from boston herself. Uh, you used to go all the time to framing him to the shopping plaza and then, you know, and there are realizing that was the framing him that the Framingham heart study used to talk about all the time. And in that population is very different. The population that I was there and 15 years ago and the population when the trial started in 1940s. And so it started around 1948 and the population was almost 95% Caucasian. The population to diet. You can see on the right is the last census in 2019. You can see the population today is encompassed more than 16% Latinos, or 7% of African Americans and a very big population of Brazilians, for example. And so whoever has been in framing him or boston or lives in boston, they will understand what I'm talking about is not asking. Diversity used to be and those who studies now, they're being recognized in their multiple studies more updated from the frame. But the real Framingham, we all know that has their flaws and multiple people have been trying to improve how we are able to risk stratify patient. Because if you only use this calculator, you will miss a lot of disease sometimes. You know, when I use these calculators, this is the way I feel. You know, they're they're they're basically they're trying to, every time there are residents from the clinic rotating with me and I remember, you know, seeing uh dr griffin and dr Grey, they all have these calculators in their in their progress notes. And I the residents always asked me why I don't use one, and sometimes it's like I haven't been able to found which one is the is the best calculator for me. For my patients, I have patients who are completely different and sometimes they're like bad, they have bad disease and but they never have risk factors or they have risk factors and they never developed disease. So, I always felt at this point that I was trying to that the patient that was in front of me that it was, it was kind of trying to find Waldo and and basically calculators were trying to make me fit all these people and like calculator. But what I wanted to know what was the risk of Waldo and for those who you are trying to find her. Like chris was looking in a second is he's here. So so and the reason for it is because of this. And so if I and the guy on the left bob harper, amazing guy super healthy. His LDL was like 50 and uh he was the guy in the biggest loser program. And then you know if we have gone with Framingham risk score or even the A. C. C. Cardiovascular risk or I would have probably missing the way his doctors missed that he had coronary disease and had an acute coronary syndrome. And then uh sometimes there are some people who are super high risk, high risk and still the Framingham risk says Joe. This person's gonna have a heart attack in less than 10 years and the person is smoking or drinking in their 90s. So how do we tell this patient? How can we can differentiate those patients? Is usually one of my biggest conundrums in life. And the whole point remember is trying to avoid wild oh to end up here. So we're trying to avoid our patients to end up in the catholic. So when I usually tell my fellows or the residents is like, you know when I'm in the outpatient, my whole goal or passion as an imager is that I want to avoid the diagnostic cath if I'm sending somebody there is because I am certain that the patient's going to get a stint. There's nothing more of a failure for me as a cardiologist to send someone for a for a diagnostic angiogram and missed it. And so usually that's my biggest passion. But we kind of, you kind of lose like the track of like this is the real goal. So we know that message study most of you guys are aware and you guys all recognize the message. Study a mason study that started in the early two thousands now in most of the places and participant uh That when you put a patient to a counselor score, especially the databases starting at age 45. Um we we know that patients who have tend to have more calls intend to have more events. And this was all that related to coronary Events. And so the persons with more than 300 and 400, their higher risk they'll have more events. And the person who has zero or less than 300. We also know more contemporary from my friend taught the lines that from the walter reed. Now you? Ve a that also the same thing happens with incidents of stroke, maze and end up in mortality. So uh major mortality, cardiovascular mortality. So again, no surprise if you have a calcium score the longer the higher the custom sport you have, the higher your mortality and uh incidents of mark carl infarction, stroke and stroke. So when we tried to compare, there's a lot of the states and dr griffin refers to them like the character I. M. T. And there's so many of them that usually here in san Diego, they're popular. Some patients that will pay for like an entire packages that include the calcium score the karate and uh interesting enough for me, you know, I usually try to stay, you know, I don't do as many. I just tried to have the one that is going to give you the most like opening view of what that patients uh cardiovascular risk is and over and over and over in the literature when they are compared. Usually when you use any calculator Framingham risk score. Or like the newer contractors from the A. C. D. D. Plus the calcium score usually tends to be the most accurate to provide you with that risk. Uh The only importance of the calcium score especially from images like me is we always ask ourselves, you know it's like well it's going to have any impact in you when you do a coronary artery calcium score. And the answer to that is yes. And I will show you a picture a case at the end of a very very impactful. That really does make a difference in a lot of our patient because sometimes we we we have a lot of our patients depending upon the cycle that you practiced mostly. Uh they will need some a little bit more convincing to start medical therapy initially, especially in statin. And so the Eisner study uh when it was published Back in 2011, if they tried to answer that question and I think it did in my mind it's the slide on the left side is a little bit uh too much for an image or like me. And since that many image, I'm going to simplify it to you. They randomized that people to not scan and a scan basically. Okay. And so the people who were in scan with the council score after the end of the trial, they basically show that they decrease their systolic blood pressure, decrease their LDL cholesterol. They were starting a new blood pressure medications, lipid medications and aspirin. They have better lipid medication adherence because we're all talking here about medications and the new drugs. But in reality, a lot of patients, they usually tolerate more medications and uh they have side effects from the medications and it tends to be difficult. Um and so I think this shows you Also not only in real life but also in trials. That is also the patients stay on their medication is longer. And so uh surprisingly shows there is no more procedures. So no more stress test. Credit authorization between the two arms and most of the most of the people who are below 400 on that calcium score. They did not get more tests. And of course, as the guidelines suggest, any person with the above 400 calcium score threshold, they get stress testing. So when you divide that, when you compare that with the people who didn't go through this known scan, there were no significant differences. There's also a similar costs between the two arms. And surprisingly enough, the the issue is that the cost of of the calcium score. So I mean chris and I were like I think crusaders and trying to always keep the calcium score low in both of the size of the five. And we're fighting on the on the on the back. And uh but if you look at the sea and the city, even in San Diego, the prices go from $99 to $200. This test the average price in this test and this was 2,011 was $150. Um and so you know as long as the test is taste below 200, this probably still is a cost effective situation and and very very very interesting because the price is also they are different in each region of the country. Uh The other important part is that we know the power of zero, like dr Matt Budanov who uh it's a mentor also a friend and who also uh one of the guys also based some of my talks in the past, you'll see kind of like the same topic always talks about the calcium. The power of zero. And the power of zero is when you when you do a A patient and has shown in the original trial, the people with the Castle Score zero. There was no more procedures of course because actually saved sometimes from procedures because if you uh do any type of testing from all the markers that you see here mentioned. From the alpaca to the abbey to the family history, the pro Bmp two high sensitivity crp to karate black. Uh If you have a calcium score zero. And uh and some of the studies, even the calcium score below 10 in some sort of population That would have caught off ages 65. The probability of developing coronary heart disease actually is pretty low. And so it was one of the most powerful predictors. So it it works in a lot of patients of mine. I have for example 80 years old Who's 70 years old, they want to be in a statin and they have uh SDL of 180 and you do a council screen surprise and leaving with an LDL of 1 80. And uh and they have a council score zero and uh they don't tend to be on statin therapy and you are able to also stop some of their medications. So it actually helped a lot, especially to take that as a home home point that your risk when you have a council score in the low risk category is very low. And that takes us to the next topic, which is basically, well, when do you stop medications? And when do you use medications? And this is actually kind of like the things that the cardiac CT world has been pushing, which is basically the number of 100. So you can see on the graphic on the right when they when they grab all the people with the Castle score above zero, you know that there was a difference in patients with statin statin, but when they basically divide that in a subgroup, The people that real difference why, when the person, the patients had a calcium score above 100. And so if you have a patient with a calcium score above 100 is also data to place the patient on staten an aspirin. And so this is actually a good study and it was not published a long time ago. It was around 2018. And so more interestingly recently caught my attention. A lot of other fellows too. Because I get this question is also asked all the time. How often do we get a calcium score? I would say probably one patient every two weeks asked me this question. And the interesting enough, they did a very good study in which they see the baselines can when the patient has zero and they follow them all over the years. They not only that they divided by the amount of calcium score bit 0 10 or more than 100. But also they divided in terms of their uh ethnicity, which I thought it was super interesting and diabetes as well. And so you're probably safe or you're not going to be run if you repeat a calcium score in those patients after 3-7 years is the conclusion of the study? Usually the median is five years. So that's why I usually tell patients and the reason for that is it will depend also if the patient has diabetes or no diabetes. And also uh taking into account that asian americans, chinese they tend to have less calcium score build up. And that's why uh seven years old. But I think by you telling a patient around probably five years it will be probably not wrong after after you do a calcium score. There's also in terms of the cost is also very interesting studying which you know they divided the in terms of what's most cost effective because everybody talks usually about the price of this testing especially for images like me is always about the cost and uh the family history of premature C. A. D. And patients between 40 and 70 and basically well well divided by the known Gilliland risk calculators. And if the patient has an elevated risk we put them in StateN. And if you do cancel casting score guided if the council is more than 100 Putin statins when they do analysis in both pathways. The calcium score guided is usually more cost effective. And and basically before we get into the city, the uh you know the other component here remember when you get a coronary CT angiogram? Uh It's an added test is more complex. They have more time to be able to perform this test especially because involved more radiation and also contrast agents. But also the coronary CT provides you part of the calcium score data that we just discussed. But it also gives you all the analysis of the vessels themselves. And so when we talk about non invasive functional testing, prior to the angiogram we cardiology, we always think Uh you know that we're like unbelievable of sending patients to the to the diagnostic table. And uh the reality of it is like we're not that good at it. And uh regardless of what tests we use, even if we do is the classic Forrester criteria from the 1960s, which with by people in the typical angina, atypical pneumonia and not typical angina. We failed miserably and uh usually also using the non invasive methods that I like a lot. But still we we are we are not sending the right people. We tend not to find the seas. And so this article is being probably quoted by images like me a million times and from anecdotal from the Duke group um In the early 2000s. And they show that the going straight also from the diagnostic angiogram standpoint basin and all the predictors. We always talk about diabetes cholesterol being male. And uh we usually also uh we're not that good and sending them clinically to there. So you know, what do we do? Well, you know uh cardiac CT for sure is not the answer. A 100%. It's another adjustment in the in the specific population. And uh but I can tell you in that specific population were usually more the intermediate risk category because we tend to send to catherization like that shown in the picture on the right for those patients who are high risk category. But in the left is a low risk story. In the left you can see the cT angiogram which will help you to try to tell that patient, you know, listen, you have no instruction, There's no need for a stent. But definitely we need uh we have to put uh medical therapy and a star medical therapy which is very important in those patients. And that's what the power of seti. I think it is in the right population. And so our old plaques are saying, no, this is the real, this is the reason why we fail in cardiac CT sometimes because nor all the plots are the same. You can see here. There's a soft black, very straightforward, looks like at 80%. And when you play the picture, you can see there's approximately a deletion, pretty clear cut. When the real problem is when patients have tend to have tongue of calcifications, calcium scores 3000 or 4000. This looks bad because the blooming artifact of this lesion, it will show you that, oh my God, this is probably severe when, when you do, the calf is non obstructive. And this is the real reason of the weakness In which city is extremely powerful and sensitivities. I would say it's 95, Like in recent trials, We miss very distant disease and vessels of 22 million less than two. But it's very good at telling you calcify and not calcify whatever you have in terms of lesions, but it's not very good at being able to uh sometimes differentiated in some of the lesions like this if it's truly obstructive. Uh, before I jump into the case is uh, you know, I think everybody heard from the schema trial, so I would not talk about it here. But not many people have heard her from the scott hard trial and it's probably one of the trials that I actually uh talked to most. And usually this is an example of what I tend to do in my clinic and his patients basically randomized between who are stable chest pain patients come to see you in the outpatient clinic and randomized the standard care plus city or a standard care alone. So when basically uh 50 year old patient because we do with chest pain, we tend to usually have a functional testing all the time because we know the treadmills and were trained. The treadmills are the best uh you know, to determine the real functional capacity. And I'm, you know, we're not debating that topic. I still put people depending upon the risk factors on the trembling or not. But I tend to do use a lot of patients were higher risk or you know, they tend to have more convincing stories, diabetes smokers, family history of premature CED elevator, L. D. L. S. A. Little L. P. A. I tend to go into more of the city category. And in these trials if when you guys look at it carefully, the C. T. A. Was much more powerful and preventing nonfatal myocardial factions and death from coronary heart disease. Um And then the standard care alone and the whole reason uh in my mind when you really look at the study and read the end, which to me is that if you read the appendix it's usually where you find kind of like the greedy media of all those details. It's because the big difference not because the idea was better on the nuclear echo or anything like that. It was mostly because these patients were able you to show you the plaque and be able to start medical therapy. If you see the difference between the two groups of how many of them were started on medical therapy. Like what I showed you in the eyes near trial in new blood pressure meds, new cholesterol meds and aspirin those and patients and be able to convince them that you have plaque and be able to make them exercise and lose weight. That's I think in reality that it was overwhelming. The difference between the two groups that make that possible. And I'll show you some couple examples. And again this is just basically to show you uh clinical efficacy to in those patients with suspected engineer that come to you on a regular basis and your clinic. Um So there is also a good editorial from 2000 and 18 and I'll put my bias in there is written by Tod the lines who is also a part of you via. I know him since it was that uh walter reed Medical center past President S. E. C. T. With a friend of ours and who has also talked to our fellows. The power of C. T. Uh He wrote uh it's basically encompassing this three in which you do any type of stress testing and you don't get to see the coronaries. You're just seeing a functional testing which is negative done deal done. The city usually tries to help you and visualize also the non obstructive portion. And so the non obstructive disease component, the early atherosclerosis, subclinical atherosclerosis that I was talking about. And uh and being able to tell you that that patient show them and be able to make changes therapeutic life of changes that we all would like to do. Um you know and and you can see on the right side. I don't talk that today because there's too much of a topic. But the high risk plaque features is what's coming next in the cardiac ct world in the analysis and the artificial intelligence. To be able to predict which ones of those like the napkin ring sign are going to be able to be higher risk than any other type of plaque. Which we know that in patients with stemming and A. C. S. More than like half of them they are presenting from Brookshire plaques from blacks. The ones that look like this were non obstructive. So it's kind of like catching them earlier without having to do a functional testing which will not provide that type of information. And you know the coronary City strategy for the bottom studies that you can see the promise and the scott hard. The coronary city Australia was more accurate finding those diseases and the standard of care stress testing alone And again since I tell you my bias, I'm going to tell you also to read the con part which was written by DR handle which is a nuclear cardiology which is actually pretty good. And also puts in perspective the criticism of city or the weakness of City that I told you before in the accuracy when there's high calcium disease and and the technicalities of the test Because it's easier to talk about 250 sexually CT. That's Chris Memorial compared to a 64 slice CT which is 90% of the scans that we have in our country. There's a complete different ballgame and different accuracy and test in that in that regard. So to end, I'll show you some few clinical cases to show you as an example what I usually tend to see in clinic. You have a 46 year old male with no histories, have family history of premature C. A. D. Who is overweight with the M. I. 29 blood pressure is pre hypertensive and LDL 1 32. Atypical chest pain. Normally CG at baseline. Typically you know on this patient uh we will we'll ask you what will you order next? And so you were the stress ccgs stress echo will be them in stress spect pet and MRI Ct caf. You have all the flavors they're written and I would say probably suspected the first four uh will be probably the first one in the list of a lot of patients. Uh Since it's 46 I would like to imagine people would like to order the first press three First. The reality is sometimes its prior practices where there's an economic incentive. Probably the fourth one is order as well but it probably would have not been in contact C. T. A sum of some for some people the first option but I tend to differ and make you think differently. And I'm gonna show you that that patient, for example was a patient in my clinic and uh the C. T. Showed non obstructive disease. So definitely I was able to answer the question but it was able to show that the plaque, the coronary calcium support for a 46 year old remind you was about 400 which was really not not normal. It was in the severe range and his LDL was 1 32. So instead of telling him after a stress CCG or a stress echo that he was a good pat on the back you know try to you know eat healthier and I'll see you in six months. You know we're talking about complete different ball game when you have the evidence of the council score. And I get that question all the time about patients telling me well what changed you now? You want me to put statins when the doctor told me 1 30 or 1 25 was normal. The evidence that showed me to put you on statins and tried to aim now for 70 was actually the CT. And so and I think that's usually very helpful from as an imager perspective like me So 63 year old female with history of hypertension, high cholesterol, former smoker complaining of chest pain normally CG the cardiology one sec ta. Because they have heard me talking and they said well let's try what this guy says. But the company denies the C. C. T. A. They read the nuclear as A. T. I. D. And I cannot you know differ from my colleagues. You know it was suspicion for T. I. D. And uh a city was ordered and the patient had non obstructive disease. This is very typical. I see this almost on a five cities or 10 cities a week. And the outcome is medical therapy. And a lot of people tell me well what's the cost analysis and well when you do a cross analysis against the stress packed which is reimbursed probably three times higher than what Medicare paid for. Uh average for C. T. Which is around $428. I can tell you that definitely you will be saving. And in terms of radiation which is the other question that I get the most radiation in cardiff city. In a scanner. Again like the one we have a memorial. The latest technology is usually not no more than 2-3 million receivers. And we even do a scan for one millisecond or less. And so third cases a 64 year old male with hypertension, high cholesterol. He was an injectable testosterone due to low levels, comes with sort of a breath, had abnormal calcium score of 400 years prior. Um He did a stress test and uh it was a good stress test and I put all the parameters for for those who are no cardiologist, like you can see that they're all good parameters. The target hardware, the double product function, the mets, the exercise. And this is a real patient. Again, there's a patient from my clinic uh and to remove the bias. The stress test was not read by me. It was one of my colleagues and I completely agree with it. I could have not even seen any of this being abnormal, but the patient continue to have the symptoms. They pushed me to put a further test and I did a ct and he had a significant L. A. D. Lesion. I was so now convinced about it that we even did uh F F. R. C. T. And the F F. R. C. T. Came back positive. And again the patient went for coronary angiogram and ended. I would stand. So this is also the use in times of C. T. In in cases in which also even the stress test might not be convincing data and it's a provocative topic for a lot of patients, a lot of people in my field, especially for non images. Another common case, 65 year old male with end stage liver going for evaluation for liver transplant. He's complaining of Disney in exertion. The typical new reaction in in this country in many places is the vitamin echo in the East Coast or West coast. Now here I tend to see more nuclear expect. And the patient goes for that. He had a CT chest from 2017. I know that when I saw him uh ton of calcium, his in his in his arteries his nuclear scan came back actually positive abnormal. And again you cannot argue also with some uh proficient abnormalities understand their highlighted there. But the patient ended up with the council score 500 it was non obstructive disease. And also the patient ended up with no characterization. Someone who could have been managed also by C. T. Uh FFR City was also negative. And the patient because it's a liver transplant candidate, they also go for angiogram when there is any of this debate. And most of them they still even go for angiogram. And they actually correlated with the CT also has a negative case. The last case, I'll talk to you about showing you what how to stick to the medical therapy works when you show to the patient is a 67 year old male with past medical history of hypertension, high cholesterol. No family history of C. A. D. Is a former smoker until age 30. He's originally from Galicia spain, which is the northwest part of spain on top of Portugal. Uh He used to be very active, play soccer but not active to knee injury for the last two years. His you go by the typical calculators is still an intermediate risk score. You know, you will put on medical therapy. He's treated for his hypertension. Uh He takes his meds sometimes on Dustin. Doesn't want to take aspirin. Doesn't want to take statuses. BME is not that bad. Uh it's in the 25 26 region and you know uh is doing good with no symptoms. You do a calcium score and the calcium scores 2035. And uh you know those patients they they you know they are reluctantly. But once they see this data is very powerful. This this data shows you that listen, you do have coronary artery disease. And even though you didn't have coronary in your family history, family history doesn't matter because the reality, these are facts. This this is not something subjective like a level of an LDL at that time. Or like you can bury amongst the month. This is not gonna bury. They're just going to go up. And so just to show you here on that show of the what the Eisner trials showed, increases blood pressure on the L and new medications and adherence. The patient was started asked that the new blood pressure men's an aggressive lifestyle changes and despite you know, I can tell you, the patient adhere to medical therapy for the first time in decades and I can guarantee you that I know that patient very well because that happens to be my dad. And so and the only way I could get this guy to get started medication was being able to show him the scan and having to prove to him that it was time to really pay attention to his life. And with that I would like to say And thank Buddha because he once told me that all truth passes through the tree stages. First is ridicule. 2nd is violently opposed and third is accepted as being self evident. And uh he sure that's live with me and I stuck with me that since I, since I know him when I was a fellow back in philadelphia and visited to give a talk impacted me in many ways and happy that he's in the roasted later today to talk. But matt uh, that that comment is really has gotten to, you know, my career here because at the beginning, when you come as a, as an image, you know, I always said to him is that ridicule on the opposition stage at the beginning when people are like a skeptical about the testing and I think numbers do not lie and obviously now is an accepted uh strategy. And these are just the belgians of cardiac ct uh, at the Memorial Hospital. And this is Projections, after after COVID-19 and uh, and after a hacker attack. So hopefully hopefully they're not far from reality, but that's the current stage and it will be the future stage, which I guarantee the cardiac cT will be a very useful tool in their mandatory in most cardiologists and primary care doctors, which now I tend to see at least five of them ordering per week. End up getting approved in the help of trying to identify these patients even before we get they get to see a cardiologist. Hopefully, well before in that clinical stage and more in the subclinical stage. So that Trayvon's the sewers, the quirks and the grace of the world, they're able to treat us, the people like me who have high cholesterol in our family. Okay, thank you for inviting me and thank you for listening, wow! That that is that was an amazing cock doctor Gonzalez. You brought a really fun approach to it, very enlightening and I really love how your case is kind of summarized and wrapped it all up and really made it real as far as how to incorporate cT in clinical practice. I think that that's I think that's very helpful for a lot of the viewers for this talk. So, again, thank you very much. That was great.