Raphael Sirtoli

Joel Jamieson did everything right and was still walking around with a 50% blockage in his widowmaker artery. He’s a world-renowned cardiovascular expert who doesn't smoke, doesn't drink, sleeps well, manages stress, trains consistently, and has a VO2 max probably north of 55. He got screened at 40 and found it. He had zero symptoms the entire time. This is the core problem with cardiovascular disease in well-trained individuals — it doesn't announce itself the way we expect it to. The markers we typically use to flag risk don't apply. No excess body weight, no poor lifestyle habits, no reason to think anything is wrong. What actually predicted Joel's risk was his family history. His mom had a stroke at 60. His dad and uncle died early. His brother had a triple bypass before 50. Every signal was there, just not one he could feel. If that kind of history exists in your family, get screened. The CT angiogram runs around $1,200 out of pocket — not cheap, and hopefully that comes down over time. But if you can justify it, it's worth it.

Worth noting for everyone interested in the Keto-CTA and LMHR research (I include myself in this group and am staying curious). Are QAngio, Cleerly or Heartflow validated in asymptomatic subjects with sub-clinical atherosclerosis? Short answer: no — not in a true subclinical-atherosclerosis cohort. All three platforms have published head-to-head IVUS comparisons, but every one of those studies enrolled patients who were clinically referred for invasive coronary imaging (i.e. known or suspected CAD), because you can't ethically push an IVUS catheter into an asymptomatic person just to validate a CT algorithm. This means they have not been compared to gold standard for people with minimal plaque where there is likely much more measurement noise. Each of the three has IVUS-validated its plaque quantification, but only in symptomatic / known-CAD patients undergoing invasive imaging — none has a published head-to-head IVUS validation in a true subclinical-atherosclerosis cohort, and that gap is fundamentally ethical (you don't IVUS asymptomatic people) rather than something likely to be filled. Why the gap matters: in subclinical disease the plaques are typically smaller, more often non-calcified, and located in less-stenotic segments — exactly the regime where CCTA's spatial resolution is most stretched. Algorithms tuned and validated on bulky, stenotic, IVUS-imaged plaques may not perform identically on a CAC-zero, mildly diseased asymptomatic vessel. To be clear this isn't an argument for or against the KETO-CTA study results. It's a question - are we using the right tool to determine risk? The answer is ... a tool is being used that's not validated in asymptomatic people with sub-clinical atherosclerosis. Therefore we need to be really careful what we make of the results and how it's used to patient recommendations. I'll be digging much deeper into the Pre-print from this group and AI analysis of plaque in asymptomatic subclinical atherosclerosis in the coming weeks with several esteemed guests.