Qualy #121 - The "art" of longevity: the challenge of preventative medicine and understanding risk

**Peter Attia** (0:11)
Welcome to a special bonus episode of The Peter Attia Qualys, a member exclusive podcast. The Qualys is just a shorthand slang for qualification round, which is something you do prior to the race, just much quicker. The Qualys highlight the best of the questions, topics and tactics that are discussed in previous episodes of The Drive. So if you enjoy the Qualy, you can access dozens more of them through our membership program.
Without further delay, I hope you enjoy today's Qualy.
I want you to give us a quick, or reasonably quick primer on other things that tend to confuse patients, such as calcium scores versus CT angiograms. And I even want to touch on heart flow in a minute, because that comes back to it. So I think the listeners know what a calcium score is and a CT angiogram is. So just give us the quickest sense of that, because what I'm much more interested in is, what do the results tell us?

**Ethan Weiss** (1:05)
As a cardiologist practicing in 2019, I struggle with the question of whether I'm gonna help you or hurt you. That I feel this tremendous sense of uncertainty about whether I should be as aggressive as I can, picking up every rock and looking under everything, and trying to optimize, to the best of my extent, my ability, versus whether that, maybe the best thing I can do is leave you alone. And you've probably seen examples too where, I mean, I remember, again, as a cardiology fellow, maybe even as a resident where somebody would come in from an outside hospital, sick as shit, just absolutely on death's door, and all we did was just turn off everything, and the patient got better, because they were just over-managed. And I think I struggle a little bit with this, sort of where I want to be in that spectrum, and how aggressive I should be in looking for, say, occult coronary disease, which I think is a question you get a lot, and I get a lot, right? One of the major reasons somebody comes to see me as a preventive cardiologist is they say, am I gonna die of a heart attack? And what's my risk of dying from a heart attack?
My brother died of a heart attack at 44 What should I do?
And I still don't have an answer about how aggressive I should be in trying to understand it. But a lot of these tests we'll talk about, I think, feed into that. And I think ultimately what we're missing, and I hope we can eventually refine it and make it better, is a good way to predict disease risk in these chronic diseases, these common chronic diseases like cardiovascular disease, metabolic disease, that we just don't now yet have the tools to be able to say, you know, Peter, well, your risk is X, Y, or Z, and so therefore we should do this or this or this in terms of prevention, understanding that there's gonna be risk in each one of these things that we do, and there may be risk in even part of the process of getting from here to here, point A to point B.

**Peter Attia** (2:52)
I'm glad you brought that up, because it illustrates the challenge that frankly can't be explained or rationalized or described on Twitter. Not to pick on Twitter, but just to...
So there's this idea which you've said, which is I don't know sometimes how aggressive to be or not to be. And what you're really saying is at the individual level, with you as my patient sitting in front of me, I don't know how aggressive to be or not to be. You're not asking the question on average. And yet, what tool are you given to guide you? You are given a tool called a clinical trial, which is by its very nature all about averages.
And so, therein lies the mismatch of what I've described as Medicine 2.0. When I say described, meaning I'm writing about it in this book I'm working on that hopefully I'll have finished by the time I'm alive or not alive. And the idea is, it's not to poo poo clinical trials, it's just to acknowledge that clinical trials give us great information on averages, and the larger and more robust the trial, generally the more heterogeneous the data.
But you've asked a question that comes down to judgment. You know what it means to be aggressive, and you know what it means to be conservative, and you know what the corners of that box look like. What you're asking is, I could have two people in front of me that superficially look similar, but actually one of them is probably going to have a better outcome if I behave aggressively, and the other one might have a better outcome if I behave conservatively. It's the challenge to figure out which one's which. If you're a hammer and everything's a nail, even if you're acting as a hammer and nail in accordance with clinical trials, I suspect you are still acting in a very blunt manner.