This Q&A Session occurred on 11/18/2020.
How does our platform test the microvascular system?
“The ABI is more of a macrovascular test. The microvascular portion is where the money is at. It is where we save people’s lives. There are two tests. There’s the sudomotor test where patients will put their hands and feet on a glass plate. And that looks at the smallest blood vessels in the entire body. [It determines if there is a blockage in these small blood vessels.] That test looks at sweat glands.
Sweat glands are an interesting phenomenon because two things happen to sweat glands. Number one, they are innervated by the smallest nerve fibers in the body. The small nerve fibers course through them. Secondly, the blood vessels feed those sweat glands to sweat. In order to sweat you need to have a blood supply. If that blood supply is somewhat fragmented or compromised then we know there is an issue with the smallest blood vessels.
If you think about a stream, [rocks in the stream create turbulance]. The water diverts around or over the rock. Right before the water hits the rock is the highest pressure and then downstream of the rock is low pressure. It’s no different than with our arteries and blood vessels. That blockage signifies that there is something going on.
The last portion of the test is the ANS. How our body adapts to certain phases of our lives. Today I went to one of our larger new clinics in New Jersey. I was explaining to the lead physician who owns the practice…” think about our body as an adaptable organism. If I ask you to wear a 10 lbs weight vest you would be a lot more fatigued than you are today. Your body would have to compensate, mainly your heart and circulatory system. The microvascular portion of your body would have to compensate. And the easiest way to compensate is to increase the amount of blood throughout the body.
We call that stroke volume and stroke volume times heart rate is called your cardiac output. So that adaptability is one of the things we look at on that test. We can map the way patients move through space and time. The way they take deep breaths and the way that it compresses the heart. We can measure heart-rate variability. That tells us if there is an autonomic nervous system problem. There is an adaptability problem. So we should be able to run up the stairs without running out of breath. In order to do that our heart rate needs to pick up as well as the amount of blood flowing throughout our body with each heartbeat.
We have other things happening in the smallest minute blood vessels in our body, the vascular endothelium and we can see resistance patterns through the autonomic nervous system testing and cardiac impedance. We can estimate what the injection fraction is. We can estimate what the cardiac output is. More importantly, we can estimate what the cardiac index is based on body size and we can estimate the resistance patterns we are seeing inside the vascular endothelium.
All of that has been woven into an algorithm. We are able to tell what degree of microvascular disease a patient has. Let’s say someone has a system vascular resistance that is quite high. And think about system vascular resistance this way.
It’s like water flowing in a garden hose. Do you don’t want things banging against the walls of the endothelium because that creates microtears and leads to microvascular disease? High blood pressure and high cholesterol can create tears in the vascular endothelium. So now we have a way of measuring that with our ANS test through a cardiac impedance.
Think about that and the resistance patterns in the smallest blood vessels because we want things free-flowing. If you think about putting your thumb over the hose nozzle what happens? Water is sprayed everywhere. The same is true with pulse pressure. We know that for people over the age of 65 high pulse wave pressure leads to dementia. A simple exercise is a great remedy.
Think about the power of measuring these asymptomatic patients whether they’re 40,50,60 or 70. Amino acids like L-Arginine will vasodilate the vas and help those patients become much more healthy.
How do we compare to Life Screen?
Nothing wrong with the Life Screen except that insurance doesn’t pay for it and we are a much better platform. We can simply help rule out Atrial fibrillation, sleep apnea, Cardiac arrhythmia. Life Screenwill test for Osteoporosis, which we won’t. We are a complete cardiovascular wellness platform. What I explained to him and he didn’t realize is how powerful our platform is. We can diagnose Atrial fibrillation, sleep apnea, Carotid disease, disease of the lower extremities, mapping out pressures within the vascular endothelium.
I want to get to a point where this is so ingrained in society, so ingrained in the medical community that medical providers will wonder “whatever happened to the EKG?” It’s not that the EKG is not a good tool, but it’s one tool but it can not allow us to see dynamic vascular endothelium pressures far exceed the EKG. We now have a tool that is incredible to identify asymptomatic disease.
What are some new developments you are working on for 2021?
There is another test that we are beta testing. It’s an EKG that gives you a 3-dimensional view of the heart. It will be incorporated into the algorithm of our platform. Imagine the power of showing someone they have a microvascular disease here and no microvascular disease here. We don’t want them to progress to macrovascular disease.
Those disease processes are thick as thieves and birds of a feather flock together. So if the patient has high cholesterol, kidney disease, hypertension or diabetes, or smoking their going to have the microvascular disease. We want to prevent the progression of microvascular disease. You are able to see an incredible picture of the entire body with parts that are green and red, yellow for lack of blood flow. We’ve got the entire spectrum of both micro and macrovascular disease incorporated.
Recently, I had a gentleman come in. We couldn’t figure out what was wrong with him. His stress test was normal. He was scheduled for a cardiac cath but didn’t want to go and then COVID hit. And so we did a 3d EKG and also did the ANS testing.
His EKG at baseline shows a “right pulmogram splat (sp?)” and right ventricular pressures. He’s got pulmonary hypertension. So, to be expected so it looks like I would expect to have, but I can’t see the picture of his blood flow, and so that same EKG but we can now see blood flow was grossly abnormal in his right ventricle.
So I call his cardiologist who is a good friend of mine and tell him, “I did this 3d EKG disperging mapping on him and this guy needs to go for a cath.” I sent it over to him and we were both shocked at the level of difference between being just a voltage meter and a picture of our heart and low and behold he went to cath and he had the significant right ventricular disease and had a bypass. And so without that 3d EKG, we wouldn’t have pushed as hard to have the catheterization.
I think that his next year is going to be amazing and incredibly needed in medicine.
What would you say to someone who says “Medicare doesn’t pay for preventative medicine”.
Medicare and Obamacare placed a high emphasis on preventative medicine. The bigger issue today is what patients can expect as far as deductibles. As you know several years ago, Medicare didn’t have a deductible. Last year the deductible was up to 185. And it’s all value-based right? It comes back to you as a value-based assessment. For the practices that we are in, allow us to work with their EHR, we are able to screen the patients. Medicare is moving towards preventative medicine.
What would you say to an internal medicine practice that already has an ultrasound device?
My guess is that they are using the device for ABI only and macrovascular disease unless they are looking at the coratids. They certainly aren’t doing arterial doppler ultrasound. We offer a complete cardiovascular wellness platform. In the end, the money is not on the macrovascular disease, the money is on the microvascular disease. We want to get to these patients before they have macrovascular disease. Our specialty is identifying disease before it gets chaotic.
How would you respond to a pain management physician who asks, “how does diagnosing peripheral neuropathy affect treatment?”
This is a great question. Peripheral neuropathy comes in many shapes and forms People always want to put it in this box. “Peripheral neuropathy is diabetes, B12 deficiency, Cervical radiculopathy. Each patient is unique and has their own experience with pain and so one of the things that we do really well. Let’s make sure that this peripheral neuropathy is sudomotor dysfunction and not organic disease.
Sometimes you misdiagnose it. I had a patient who was a nurse and I misdiagnosed her for a year before we did a test on her. She had an abnormal sudomotor test because she has peripheral neuropathy and she was seeing a pain management physician, but when we did her ABI’s he ABI’s were grossly abnormal. And she was a smoker, but nobody including me for a year refused to consider that her pain was anything other than peripheral neuropathy. Peripheral neuropathy is a spectrum and not a one size fits all. It’s helpful to identify any other type of organic disease.
How would you respond to a physician who says, “Sympathetic skin response is not a reliable measure of sudomotor function?
It’s frequently inaccurate with the older population” I would like to see that article? In the older population, yes, sometimes it is true that it is absent, but the other testing modalities and results that we use and surrogate markers we use are above and beyond the sudomotor portion of that test. I can show you data on diabetics that you can refute with that physician.
What is the best pitch to a cardiologist?
Great question. Krista said today, “cardiologists are difficult.” And they can be. We want to find a cardiologist that speaks our language. We just signed a large cardiology group out of New Jersey who said “where have you been my whole life? This is what I have been looking for. This is so important.”
We’re looking at vascular resistance and it’s so important. What I’m trying to tell my colleagues is that we are trying to identify microvascular disease. If we don’t change our treatment algorithm or our treatment paradigm they’re going to continue that macrovascular disease.
The best pitch to cardiologists is what a cardiologist told me “Let’s stop treating macrovascular disease and start to find where the microvascular issues are coming from and treat that.”
He’s a new school cardiologist, he’s got a very open mind and he understands that the best way to decrease microvascular disease is to decrease free oxygen radicals and oxidative stress. Nitric oxide is one of the huge things we can add to someone’s regimen.
So you can do those several ways through medicine or through alternative medicine. One is a naturally occurring amino acid called l-arginine. And we can certainly give that. The best pitch to my cardiologist friends “listen, I’m not trying to take business away from you. I’m not saying that there is not macrovascular disease. There is. But why are we waiting until we get macrovascular disease? Let’s treat microvascular disease.
I can tell you every patient that has ever had a heart attack, microvascular disease doesn’t end because they had a heart attack. That part of the heart just died from the macrovascular disease standpoint. You can’t be that obtuse to think that just because they had a heart attack in that part of the heart that they don’t have microvascular disease. Cortid, legs, and the super mesotecic (sp?) artery. The best pitch to cardiologists is to identify and treat microvascular disease.
Can our platform diagnose sleep apnea?
We had multiple podiatry groups who asked us “how do you guys diagnose sleep apnea?” There are several clues. There are changes in the right ventricular strain pattern that we see on autonomic nervous system testing. C1, C2 systemic vascular resistance. Cardiac output, stroke volume. There are a few others. When these are cross-referenced you get a very good idea that there is a right ventricular strain (RVS). RVS comes from obesity, and sleep apnea. We are adept at being able to predict who has sleep apnea and who doesn’t. Hospital groups like this because they can self-refer patients identified with sleep apnea to other services. It means better patient care and more money for them.
Does the algorithm use AI?
We continue to look at all the numbers that are coming in. What we try to do is stratify it to the practice. For example, the patient population of an orthopedic group is different than that of internal medicine practice. For orthopedics, they’ve got sports injury, smokers, spinal fusions. We are constantly making adjustments and improvements to the algorithm based on what our data shows. There is a new enhancement coming out including the algorithm and summary sheet. The ultimate prize will be red, yellow, and green. The summary page will still be one page but will be more precise and tailored to each individual practice population. This is new-year-matieral. A four to five-week timeline. It will also include the Greenhar Technology, 3D dispersion EKG mapping. The power of that is to be able to show the macrovascular status.
What’s the best pitch to use for beginners?
Ask the physician, how much do you trust the EKG? Do you trust it enough to be able to tell them that they are going to be healthy for the next year? Everybody does it? We all do it? Patients all want EKG’s when they go to the doctor’s office. But how much do you trust that? That is a static picture. What if we could take that EKG and show you the story behind it? My trust level of the EKG is not very high. I”ve seen EKG’s come and go and patients then have events. Imagine, a 60-year man comes in with a health EKG but his systemic vascular resistance is 2100, there is a problem. THat’s microvascular disease. My question is why is it so high? Is he eating too much salt? does he have blockages? high cholesterol? diabetes? We have a dynamic platform while the EKG is static.
Is our platform a full-body vascular scan?
No. A full-body vascular scan would also include the brain. Ours includes the coratid on down. There is a neural scan. There is a neural vascular health platform that is not announced yet that will be coming at some point perhaps 2nd quarter next year. At some point, there will be a brain scan that will be coming.