Announcer:
0:00
Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts Hosted by cardiologist and top medical researcher, Dr. Michael Koren.
Dr. Michael Koren:
0:24
' Dr. Michael Koren and I'm here with Dr n hello I'm Dr Michael oren and I'm here with Dr. Christopher Labos in our second session of discussions about clinical evidence uh and really most importantly is what we discussed uh previously was this concept of concept of Bayesian versus frequentist ways of looking at the world. And the reason this is a great conversation, Christopher, is because you wrote this fabulous book where you look at some of these concepts and how easy it is to misconstrue things. Thank you for that plug. We love that. How easy it is to misconstrue things because of your frame of reference and the way you're thinking about looking at data and you made some fabulous points about that and I want to drive those points home with specific examples in our second opportunity to discuss these things. So first let me start with a very simple question, and this can lead into this important conversation Is salt good or bad? For you, Just answer the question. I don't want to hear a bunch of stuff Is salt good or bad? Can you answer that question? Is salt good or bad?
Dr. Christopher Labos:
1:20
Yes, I can, in the same way that you answer most questions in medicine. It depends,.
Dr. Christopher Labos:
1:51
After being there, it's like we do consume too much sodium in Western civilization as a whole. Okay, and the thing about sodium is that if you eat too much of it, you retain water, it increases your blood pressure, it puts you at higher risk for heart disease and if you have heart failure or kidney failure, that is very problematic. And one of the best ways for somebody who has heart failure, kidney failure, to maintain fluid balance, not become volume overloaded, is to minimize the amount of sodium you take, because the more you take in, the more you have to get rid of to maintain fluid balance. So overall, we should be consuming less sodium. And part of the issue because one of the book chapters is about salt, one of the issues is really to sort of push back against this attempt in recent years to rehabilitate salt, to pretend that, oh, some salt is good for you, and I get into some of the findings from the PURE study and all of that, which were you know it needed some caveats. That being said, you obviously need some degree of sodium to be alive. It's just that most of us are going to get enough sodium from the food that we eat without adding table salt to it, and an important point here is that when you look at North American populations, most of the sodium that we consume is not the sodium that's present in food, and it's not even the sodium that we add at the dinner table, although that is an important contribution. Most of the sodium that we eat is added to our food by somebody else, because we eat a lot of processed food or we eat out at restaurants, right, and I think the issue with sodium and with salt is a public health one, not dissimilar from the issue with trans fats, which is the government or FDA uh uh has to really get involved to reduce the amount of sodium that is added to our food, and they've sort of taken they've already started to take steps in that, because they are trying to replace sodium with potassium and sort of pass legislation that will allow food companies to replace sodium with potassium and still call it salt. So we'll require label changes and I think there is quite a bit of evidence that substituting sodium for potassium is better, right, it reduces blood pressure. It improves cardiovascular outcomes. We've seen, you know, studies in China on that. So I think that's where we have to get forward.
Dr. Christopher Labos:
4:14
And so we have to make a distinction between the macro public health implications of having less salt in our diet from processed foods, but also realizing that some people need salt. I mean I have, you know, young patients, uh, you know, very low blood pressure. They have multiple syncopes. You know, they do need some salt just to get their blood pressure up. Right, elite athletes who need to rehydrate, like if you were to run a marathon. I've run. I haven't run a lot of marathons, I've run two in my entire life, congratulations, yeah, yeah.
Dr. Christopher Labos:
4:46
But what they tell you is you can't just drink water when you're running a marathon. You will eventually become hyponatremic, right. And you know, when people die during marathons, there is, you know, at least one of the contributing factors. It probably is hyponatremia. You do need to replace some of those electrolytes Why was . gatorade You're in Florida. invented? It was invented to be an electric replacement for, uh, the gators, right? So you need electrolyte replacement if you're an elite athlete. But what's true for an elite athlete is not true for the vast majority of the general population and sort of that nuance is, I think, important to realize that you can have multiple parallel conversations. You can acknowledge that athletes need to rehydrate and replenish electrolytes while at the same time applauding the FDA for taking steps to limit the amount of sodium in the food we eat, because it is starting to become a bit excessive.
Dr. Michael Koren:
5:45
Right and it gets complicated, in fairness, for the average patient with congestive heart failure. For example, you mentioned replacing sodium with potassium, which in general is a good thing, unless your kidneys don't work that well, yes. And then it gets even trickier when you have a heart failure patient that you want to have a certain baseline level of pharmacological therapy that lowers blood pressure and you need something to lift blood pressure a little bit. So there's even be a subgroup of heart failure patients that we have to tell well, you need to take a little bit extra salt. So this is the tricky part of medicine in general, of medicine in general. But conceptually, just to make it very clear for the audience, is that for the average person that is dealing with high blood pressure or has a tendency to develop swelling or a fluid overload, salt is not a good thing. But in certain circumstances, for example athletes or people that have POTS or autonomic dysfunction, salt could be a lifesaver.
Dr. Michael Koren:
6:50
So again, it's circumstantial and should be geared towards individual patients and don't fall into the trap that say everything is good or everything is bad. And we see this for the COVID vaccines. People say, oh, the COVID vaccines are terrible, you're going to get pericarditis, or COVID vaccines are lifesaving. You're an idiot if you don't get it. Well, it depends on who you are and your circumstances. So thank you for your book that helps people understand some of these issues. It's super important for people to read things that people like you put out to help explain these very interesting, complex but really tangible issue. If you take the time to understand why we say what we say.
Dr. Michael Koren:
7:35
So, let's switch gears just a little bit. Let's talk about cardiac inflammation. Yeah, and as a cardiologist, give me what you're telling your patients these days about it. And some of the data to generate information about Colchicine, which is a drug that we use to treat vascular inflammation, came out of Canada. So I don't know if you're a part of that or not, but just talk to us a little bit about your experience, your thoughts in the inflammation hypothesis.
Dr. Christopher Labos:
8:04
Yeah. So I sort of have two sort of minds on the inflammation hypothesis. The reason why the word inflammation makes me nervous is that it is so often used by people you know who are trying to sell junk cures, right, like a series of alternative medicine. People who are like inflammation is the cause of everything. Yes, but also no right.
Dr. Christopher Labos:
8:28
So if you have arthritis, yes, it's a problem of inflammation in the joints, right, there's ways to treat it. It doesn't mean go buy my herbal supplement for $80 off the internet and I think that's where I like. So I always try to tell people is like, yes, inflammation is a problem, but one of the best things you could do to reduce inflammation is quit smoking. Please, for the love of God, quit smoking, sir you know. So it's like inflammation is a problem.
Dr. Christopher Labos:
8:52
The issue is that we don't actually have very good targeted therapies to suppress inflammation. That being said, if you can get somebody to quit smoking, start exercising, lose weight, eat healthier, their inflammatory markers will come down right. So you can affect inflammation just by being healthier. And so the question becomes is it a marker of disease or is it an independent causative agent? I think it probably is to some degree causative, and if you had a good medication that could lower inflammation, then that would actually make a difference. Right now we are sort of limited in that we can't attack inflammation directly. We just control blood pressure, control cholesterol, treat diabetes, get people to quit smoking, get them to exercise, and that does quite a bit, but there is still some residual risk there and so and it's not as if people haven't tried right there were two major trials like Paul Ritker.
Dr. Michael Koren:
9:45
Paul Ritker yeah, Canakinumab, the , the Cantos study yeah.
Dr. Christopher Labos:
9:50
Yeah, and you know there were two right. One didn't work and then there was a new investigational agent that did actually lower the risk of cardiovascular disease but was never brought to market because there were more infections and more deaths associated. So that's always the issue, right If you have a medication that's very good at suppressing inflammation, it's also going to suppress your immune system and put you at higher risk of infection. So you know, the Colchicine thing is interesting because the data is certainly positive in that trend. It's not uniformly positive and the trials were very different. Some were in acute MI, some were in chronic CAD patients. And colchicine is, you know, has its side effects right at high doses it can cause diarrhea, , it can cause neuropathy.
Dr. Michael Koren:
10:33
What percentage of your patients can tolerate 0.6 milligrams BID of colchicine?
Dr. Christopher Labos:
10:40
Not many, even the patients who get it for pericarditis. When they have pericarditis they don't 50%.
Dr. Christopher Labos:
10:46
Yeah, I don't know, it's hard, it's easy. Not all of them can tolerate it, and so that's the thing. I think, if you're going to make the argument that there's a role for targeting inflammation in heart disease, I think that's fair. Is colchicine the drug that's going to get us there? I think if we have this conversation 10 years from now and there's a new drug, we're going to look back and be like it's sort of like imagine if we were having this conversation in the late 70s or early 80s and we were talking about cholesterol and we were talking about the cholesterol hypothesis and we were talking about giving patients like cholesteramine right, which was the drug used in the coronary primary, coronary primary prevention trial, right?
Dr. Christopher Labos:
11:25
All these debates about cholesterol in the 70s and 80s and into 90s people arguing is cholesterol true or not, was largely driven by the fact that we just didn't have very good medications to lower cholesterol, and then statins, and PCSK9's the come in and it's like well, what you know? There's no argument anymore, right? Exactly, driving cholesterol down to near zero levels, right? Huge benefits, right, the? You know the debate is largely over.
Dr. Michael Koren:
11:48
people still debate it.
Dr. Christopher Labos:
11:49
Yeah, there's a few fringe people out there. Let's be fair, some of them are cardiologists, which is worrisome, but that's the thing it's like when people are arguing about inflammation. I think part of the reason why we can't come to a consensus is that we don't have a very good therapy. If you had a good drug that was a really powerful inhibitor of inflammation that you could test in a trial, then you would get an answer and we would be good.
Dr. Christopher Labos:
12:14
I think the problem is now is that you look at the Colchicine data and it's like you know, is it the first medication I start? No, because the reality is we have so many different targets and especially if you're managing patients, you know you got to control their blood pressure, got to get their cholesterol down, you're going to do their diabetes, you got to get them to quit smoking. You have so many, I think, so many more important targets first, that it's sort of at the lower end of the spectrum. And a lot of patients, what do they say to me? I'm taking too many medications, right, right, so what's the highest priority? Obviously the antiplatelet. Obviously the cholesterol, obviously the blood pressure stuff. Right, sglt2 inhibitors if you have diabetes. So you know.
Dr. Michael Koren:
12:54
Or not. Obviously, sglt2 inhibitors are very helpful in heart failure. Just to make sure people understand, with or without diabetes. But sorry to interrupt.
Dr. Christopher Labos:
13:03
Yes, yes, yes, absolutely. And so that's the thing. It's. Like you know, sometimes the practical has to give way to the ideal. In an ideal world, would you want to add on colchicine to somebody who has stable CAD? Yeah, in the practical world, where cost is an issue, there are practical considerations, there's polypharmacy, there's side effects. Sure, I don't know that we're there yet. But then again, 10 years from now, maybe we're going to have a specific, you know, interleukin inhibitor and we're going to be like, wow, that was a silly thing we said 10 years ago. Obviously, inflammation is a big deal, and I really do see a lot of parallels between inflammation and the cholesterol debates of the 70s, 80s and 90s.
Dr. Michael Koren:
13:41
Well, as you know, we're working on that.
Dr. Michael Koren:
13:42
As a clinical trialist.
Dr. Michael Koren:
13:43
I'm involved in a lot of trials as we speak, looking at different markers of inflammation and how to suppress those markers and whether or not they result in cardiovascular benefits.
Dr. Michael Koren:
13:52
So to your point, in five or ten years we'll have a really good read on these things and understand if blocking a certain interleukin specifically is the answer to this question. And it's fascinating and from our standpoint here in Florida and other sites around the country that we work with, there's opportunities for patients to get involved in these clinical trials and they may or may not get some individual benefit, but they'll be part of this process of really helping to understand really the next frontier in reducing cardiovascular morbidity and mortality. So, as we know, we've done a really good job over the last 30, 40 years of reducing heart disease death rates by 50% or more, but there's still a fair amount. It's still the number one killer of people in Canada and in the United States and most places around the world these days. So there's a lot more that can be done and maybe the inflammatory hypothesis is the way to achieve better results in the future.
Dr. Christopher Labos:
14:48
Yeah, yeah, agreed. It's going to be really interesting to see what pans out over the next five to 10 years.
Dr. Michael Koren:
14:52
Yeah, christopher, this was an amazing discussion. Thank you, I loved every minute of it. You're a wealth of knowledge. Show your book for everybody again, because I would recommend this book Again. It's a thinking person's book and it's something that it's worth reading and helps you understand the statistical knowledge that people like Christopher have and how you apply that in your day-to-day life. And, more broadly, the MedEvidence platform is to help people understand why these controversies pop up about is salt good or bad, is coffee good or bad? And usually the answer is just the answer that Christopher just gave, which depends.
Dr. Michael Koren:
15:31
It depends on who you are, what the circumstances are and again, from my perspective as a clinical trialist. The most fascinating thing that I do is, when we don't know the answer, we have a way of testing it.
Dr. Christopher Labos:
15:43
Yeah, and I'll just throw in one thing about the book, lest the Math Throw People Off. It's actually very similar to what this podcast is, because it's a conversation, right? The book is written as a narrative piece of fiction where the main character who is a doctor not based on me.
Dr. Michael Koren:
15:58
I keep claiming that, even though no one believes me, even though he looks just like you, he looks just like me.
Dr. Christopher Labos:
16:03
The main character is a doctor. He's actually attending a medical conference, and over the course of the weekend he bumps into a lot of people and he keeps having these conversations, and so each chapter is about a food, it's about a specific epidemiological concept and it's about all these controversies, but it's written like a conversation. So if you wanted a more lighthearted, easy read, that's what this book is about, and then, as a fun little twist, there's also a romantic subplot in there which I said I didn't get to that yeah, yeah, it's, it builds.
Dr. Christopher Labos:
16:34
It builds sort of midway through the book. And it happened because when I showed an early draft of it to a friend of mine, it was a doctor talking to a barista about coffee and my friend said, uh, oh, great, very interesting concept. But I kept expecting him to ask her out at the end. And the minute she she said that I was like I'm actually writing a romantic comedy and I didn't realize it, and so the whole thing sort of dovetails into a narrative.
Dr. Michael Koren:
16:57
Well, even better. That's fabulous. I love it Well. Thank you for sharing that information. Definitely, we support your efforts to hopefully sell lots of copies of this book and, most importantly, share the knowledge that's behind the book. Thank you very much for this really insightful discussion, and we'll do it again, and one of the things that I think a lot of people might be fascinated by is some of the differences between the US healthcare system and the Canadian healthcare system, and we can have a lot of fun having those discussions and how we can learn from each other.
Dr. Christopher Labos:
17:27
Yeah, absolutely, I'll be happy to come back anytime, thank you.
Announcer:
17:30
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