June 21, 2024

This transcript has been edited for clarity.

Robert A. Harrington, MD: Hi. I’m Bob Harrington, and I’m here at the American College of Cardiology (ACC) meetings in Atlanta. I always love to use these meetings as an opportunity to catch up with friends and colleagues to talk about what they’re working on.

For those of you who have listened to the podcast for a long time, you know that one of the things I really like to do is to talk to physician writers. Sometimes, it’s fiction; sometimes, it’s nonfiction. Today, we’re going to talk to a colleague from Stanford who has written a new book on heart disease and cancer. We’ll get into that in a moment.

I’m here with my good friend and colleague, Mike McConnell. Mike is the chief health officer at Toku and is also a clinical professor of medicine at Stanford — and still seeing patients and reading images.

Michael V. McConnell, MD, MSEE: Yes.

Harrington: Excellent.

McConnell: Great to be here.

Harrington: Mike, you sent me a copy of the book, and I really enjoyed reading it. It’s a nice read with a provocative title. Tell us what the title is.

McConnell: The title is Fight Heart Disease Like Cancer.

Sudden Cardiac Death on My Watch

Harrington: That grabs your attention. You’re a preventive cardiologist. You’re also an engineer. We’re going to unravel both of those as to how you came to this. One thing I really like is that you use both stories and evidence.

As I would expect from a clinical scientist, it’s heavy on the evidence. You’re not saying anything that’s not based in the literature, but you’re telling stories. There are some pretty powerful stories. One of the early stories is the unfortunate death of your father-in-law. That seems like it profoundly affected how you think about this.

McConnell: I would say that was the first time I thought that I needed to write a book someday. My daughters were only 10 and 13. My father-in-law was a very prominent scientist who actually developed many cancer detection blood tests and was quite interested in doing the same for heart disease. Unfortunately, he was not particularly good about seeing the doctor.

He gave a big talk and was on a van back from the talk. When everybody got off the van, he was still sitting there. He had sudden cardiac death.

People take cancer quite seriously. Heart disease kills more people than cancer, yet we don’t seem to take it as seriously as we should. That happened on my watch in many ways.

Harrington: You bring that up with your wife, his daughter, obviously, and your daughters. You bring up this notion that it happened on your watch. I think you used that phrase.

McConnell: Yes. In the book, I talk about some of the things I’ve tried to do. On the other hand, it reinforced that we have to give tougher talk to our patients, that taking a few more extra steps or dropping a donut here and there from your diet is not really enough, for many people, to prevent this catastrophic disease.

Harrington: Speaking to talking tough or making changes, you ask your patients whether they would rather have heart disease or cancer. Uniformly, people pick heart disease. You started talking to people in the language of the cancer diagnosis. Talk a little bit about that.

McConnell: I think that’s a great example of where the science and the stories came together. As I started my research career, much of it was trying to develop new tools to image stenoses in coronary arteries. I think we now recognize that that’s really late-stage disease. As the field was evolving, my research was evolving toward whether we can pick up earlier plaque, and then, as you know, whether a plaque is biologically active or inflamed became more important.

We shifted more toward molecular imaging. Then, I started realizing I was imaging more like an oncologist doing a PET-CT because yes, there’ll be a tumor there, but is it growing? How active is it? We should shift everybody’s focus more toward early disease detection and how to reverse the biology so that it never becomes late-stage disease and so we don’t have your father or your father-in-law having a sudden myocardial infarction.

We know some people are lucky. They get the symptoms. We’ve got great stents and surgery for when people come in acutely. As you know, half of the people don’t make it to the hospital with a heart attack. We really want to be much more upstream by thinking of it as biologic disease and learning from cancer and how it is much more about early screening, detection. Then, if you find something, reversing the biology and make it benign.

My discussions with patients convey that a coronary calcium scan is very similar to a mammogram. There is a story in the book that when a patient had a high calcium score, we started them on a statin, and they came back a few months later and said, “I stopped it. I thought if I did a little bit more physical activity, a little bit healthier diet, I’d be fine.”

Maybe I overreacted, but it was very impactful where I said that you have to think of this as cancer growing in your coronaries.

Harrington: You told that story.

Atheroma vs Plaque

McConnell: He had a very strong visceral reaction. That’s part of the reason cancer is called the C-word, right? People don’t even want to use the whole word because of its impact. In many ways, I’m trying to up level people’s understanding of heart disease and really empower them that there’s much more we can do for early detection and to stop it in its tracks if we find it.

Harrington: That’s how you talk about it. You break it up, and you talk about early detection, prevention, and treatment. It all rolls together from a parallel to cancer, which I found really interesting. The way that you use the language about a tumor growing in your artery grabs you.

McConnell: Maybe it’s unfortunate that we switched our medical term from atheroma, with -oma for tumor, which is how it was initially described, to plaque, which more sounds like what accumulates on your teeth.

Harrington: It sounds like you should be able to scrub that away.

McConnell: Right, exactly. The American Heart Association (AHA), the ACC, and the cardiology community, I think, have really tried to educate public around prevention.

One of the things I do to try to reinforce prevention is to highlight that almost everything you do to help prevent heart disease is on the American Cancer Society (ACS) website to also help prevent cancer, including physical activity, healthy diet, and avoiding cigarettes and excess alcohol. Maybe that helps with the motivation to think that you’re helping to prevent both. Screening and therapies are where I think heart disease can learn more from cancer.

Harrington: Let’s unpack some of these things. Just the other day on CNN, the lead story was the growing detection of cancer in young people. You’ve seen this. Colon cancer is getting detected at younger and younger ages. These are very aggressive cancers that have been detected.

The lead story was about the potential biologic reasons. One of the things people talk about is inflammation. They talk about inflammation from the perspective of metabolic disorder, obesity, and diabetes, and it all seems to track. As you said, you’ve started listing off the AHA’s essential eight, and the ACS talks about the same things.

McConnell: Yes. One of the big overlaps as to why they think healthy diet, physical activity, and obesity are strong risk factors for both is that they promote more of a systemic inflammation. The more we understand inflammation in the immune system, the more awareness of the impact of inflammation in cancer and cancer therapy there will be. We’re just at the beginning of more immune therapy–based targeting of inflammation for heart disease.

Harrington: People like Paul Ridker and Peter Libby have been talking about this for years.

McConnell: Right. I worked closely with them when I was at Brigham and Women’s Hospital. There is a large amount of untapped potential there.

Precision Medicine

Harrington: Let me ask you a question that I was thinking about as I was reading it. Cancer care is getting more and more precise, meaning that we’re finding more and more of the biologic pathways, including checking the tumor genetics, to then decide what therapy is going to be used. Cardiac disease and atherosclerosis are a little more complicated.

McConnell: It is.

Harrington: Do you think the analogy falls apart over that or do you think that the analogy still has relevance?

McConnell: I think it’s a great question where there’s interest in more precision medicine.

Harrington: In fact, it’s not even like breast cancer or lung cancer anymore. This is pathway cancer.

McConnell: Yes. Even within individual cancers, you’re looking at the genetic drivers of those and then there are the targeted therapies for those.

Harrington: The clinical trials are being done that way.

McConnell: Yes. It’s interesting, but certainly we have the challenge or maybe opportunity — interventional colleagues like yourself maybe have more opportunity to do this. We rarely access the underlying tissue of atherosclerosis to make some of those determinants. There are aspects, say, around diabetes and obesity where they’re trying to learn different genotypes and phenotypes or the drivers so that you can optimize therapy.

On the flip side, I would say one of the drivers of writing this book is that we have a long way to go to just getting people with the basic broad guidelines that we have. Yes, there’s some additional benefit of more precision, but we still have to raise the boat.

Harrington: Let’s start on the detection piece because you talk about how we need to have cardiac assessment detection and learn from public health around cancer, whether it’s a mammogram or some other imaging, such as CT for former smokers. We do colonoscopy. We do a large amount of screening for cancer.

McConnell: Yes.

Harrington: What should we do for the heart and at what age? It’s recommended you get low-density lipoprotein cholesterol checked in childhood, repeat it when you’re a young adult, and then repeat it every 10 years thereafter. What else should we do?

McConnell: I really try to hone-in on what I’d say the first step a preventive cardiologist does, which is doing the AHA/ACC risk score. As many folks know, there’s a newer version based on larger data called PREVENT. I describe that as the first step in a self-exam because I’m really trying to empower patients and unfortunately, many have never really heard about the cardiovascular risk score. It’s not something that their doctor has mentioned to them. There are websites that most people now have access to their health records data, so that’s a great place to start.

We’ve made it a bit more complicated for heart disease than for cancer. It isn’t just a simple, “at this age, you get this.” We have a bevy of factors that go into your risk score. We have these risk-enhancing features. The goal is that at some point, as you cross into potential risk, you have that shared conversation. If your risk is high enough, often, that step is then statin preventive therapy. Many people fall into this intermediate-risk zone where the data are quite powerful that a coronary calcium scan…

Harrington: The 10-year risk between like 5% and 10%, where it’s that mid zone. If you’re over 10%, you should absolutely.

McConnell: Yes.

Harrington: Even over 8% probably. If you’re talking about 3%, 4%, or 5%, that’s not trivial.

McConnell: The current is 7.5%. Particularly, the US Preventive Services Task Force will say there’s some benefit there. There’s more benefit after 10%. We know there are people down in the 5% range who will have early disease, particularly if they have risk-enhancing features. Some people may want to start therapy then, and some people can be quite resistant to therapy. That, to me, is how you personalize the therapy. Do all your numbers add up to these plaque tumors starting to grow in your heart?

Calcium scan is the main tool we have. Obviously, with a large amount of the work being shown here at the ACC conference over this weekend, CT angiograms and artificial intelligence (AI) analysis to quantify plaque volume and characteristics is an emerging area. Even just the basic, “once your score is above zero, you have atherosclerosis in your coronaries,” I think for many of us and in most of the guideline pathways, that’s the stage to say we can stop it or even reverse atherosclerosis.

Harrington: It’s interesting. Our mutual colleagues at Stanford, people like Fatima Rodriguez and David Maron, are actually trying to extract information from noncardiac imaging. If you’ve had a CT or a chest x-ray, how do you extract that information using AI to basically assemble a calcium score?

McConnell: Dr Topol just had a post on opportunistic AI. Obviously, the disclaimer I already made about working at Toku, productizing research that I had been part of at Google, which was AI for retinal imaging. There was an AHA presentation in the 1960s about how cardiovascular disease causes change in the retina. It’s really AI that allowed us to automate that so we can do basically a risk score prediction from your retina from CT scans. I talk about mammograms; there’s breast artery calcification. There are companies developing the AI tools to pick that up.

Harrington: We’re going to be able to figure out more and more from a population perspective who may have atherosclerosis and then go to decision-making with the patient. Do you want to get on a statin? Do you think you need more imaging? Can you evolve your lifestyle?

Let’s go back to the specifics about the book because you’re a busy guy. I’ve worked with you for years. How did you find time to write a book?

McConnell: It took a while.

Harrington: Tell us how long it took. For people listening, it’s always informative that a book didn’t just appear. It took time.

McConnell: It was over a decade ago that my father-in-law had his heart attack and sudden cardiac death. I think most of that was these ideas that go around in your head, and I’d periodically write some things down on a piece of paper.

I’d say it was about 4 years ago or so when I got serious about trying to figure out how to publish it and putting together a 30% draft of the book to get feedback. Then, I tried to lock myself in the back office in the house, dedicating a few hours a day at an off-peak time to try to make progress.

Harrington: It’s a labor of love. It really did take you a long time. I know you thought about it. We would talk about it at various things you and I were doing together. It shows because it’s very thoughtfully written. As I said, I love the combination of story and data. I think it does tell a story. How has it been received?

McConnell: It just came out at the end of January.

Harrington: I was lucky enough to get my copy earlier.

McConnell: I got a few advance copies, and I think I gave you one early on. What’s great is that I’ve had a number of patients who’ve come in and said they read it, they really enjoyed reading it, and it really helped them learn. Both from colleagues and patients, I’ve gotten positive feedback, which I’m very appreciative of.

Harrington: Any feedback from the cancer community? Have they felt like, hey, wait a minute, you’re in our space? Or have they been grateful because it calls attention to them as well?

McConnell: Maybe I’ll get some feedback from them, but I haven’t. Hopefully it will be positive feedback. The proceeds from the book will go to the AHA and ACS.

Harrington: Thank you for doing that. I should have noted at the beginning. You say on the cover that all the proceeds are going to the AHA and the ACS.

McConnell: I wanted this really to be about getting the word out, empowering people to have a more modern understanding of heart disease, and giving them tools that they can do themselves and to work with their doctors around.

Harrington: And their families. You also take a lesson from the cancer playbook, if you will, of support. For cancer patients, it’s a big deal to get family support. We don’t see that with heart disease, do we?

McConnell: Right. That was the corollary in the beginning: If you wanted to get diagnosed with heart disease vs cancer, most people would choose heart disease even though it kills more people than cancer. If you wanted high-quality care, people associate that much more with cancer where there are friends and family and there is a much stronger support system. We can learn from cancer how to get more people to help you if you do get an unfortunate diagnosis of heart disease.

You and I have worked in the digital health space. One of the things that really has opened our minds is how behavior change is key. When you try to directly reach the consumer and engage people in their health, that’s an area where people are often more motivated to do things when it’s for their friends, family, or loved ones than just doing it for themselves. That’s, I think, another way that a broader care team and involvement can help people.

Harrington: I’ve heard it described by our colleague Kevin Schulman at Stanford. He says there are emotional diseases and nonemotional diseases. Cancer is an emotional disease. Heart disease, largely, is a nonemotional disease. Do we have to change that societally to really be able to go aggressively after heart disease?

McConnell: I think that would be tremendous. Part of the message here is we need to start thinking about it as a growth inside our blood vessels that can grow and spread in scarier ways than cancer. It can be asymptomatic one day, and like with my father-in-law, you could be dead the next. If we approached it more like that, I think, there would be a stronger buy in from both the healthcare community and patients in treating it more aggressively.

Harrington: That’s the message we are going to leave with. What we need is to mobilize the public health around this question of atherosclerosis.

McConnell: Yes.

Harrington: And be able to treat it aggressively like we think about treating cancer.

McConnell: Early.

Harrington: Not when the disease appears but right long before that.

McConnell: Exactly.

Harrington: I want to thank you, Mike, for joining me here on Medscape Cardiology | theHeart.org. It’s been a pleasure to talk with you.

For those of you listening and watching, let’s put the book up here. Fight Heart Disease Like Cancer, by Mike McConnell at Stanford University. As Mike said, all the proceeds from the book are going to the American Heart Association and the American Cancer Society. Mike, thanks for joining me.

McConnell: Thanks, Bob.

Robert A. Harrington, MD, is chair of medicine at Stanford University and former president of the American Heart Association. (The opinions expressed here are his and not those of the American Heart Association.) He cares deeply about the generation of evidence to guide clinical practice. He’s also an over-the-top Boston Red Sox fan.


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