Hey everyone, welcome to today's webinar. I'm Joe Sasson, the Executive Vice President of MedAxium Ventures, and we're really thrilled about today's education. We're going to wait just a couple of minutes as more people are logging on to the system to get started. So just sit tight for a minute or two and then we'll begin. Thank you. Hello, if you've just joined us, we're just waiting another minute or two to begin the webinar. Thank you. Okay, I see a few more people have joined the webinar. So I think it's about time for us to get started. My name is Joe Sasson, I'm the Executive Vice President of MedAxium Ventures, and just thrilled to bring you today's webinar, AI Coronary CTA Analysis in the Modern Cardiology Practice. So thank you for being here. Before we get started, I just want to explain a little bit about what you see at the bottom of your screen. On the lower slightly left, you see a button that says chat. And in that chat, you will find a link to today's presentation that you will be able to download. Down center and a little bit to the right, there's a button that says Q&A. And if you can use that to ask your questions throughout today's presentation, we will answer those as we determine is appropriate, whether that means interrupting the speaker to have an answer during the presentation, which is a rarity, or holding all of those questions until the end, which is more commonplace. And then we will use those questions submitted to fuel our Q&A at the end of the session. And so you can see both of those buttons now on your screen, the chat and the Q&A. The chat will only be for downloading the presentation. It will not be a place to have dialogue about what the presenter is doing and saying. So it's really a read-only kind of position in this particular webinar. So what I'd like to do is introduce our two primary speakers today. We do have Dr. Joe Jasser with us. Dr. Jasser, prior to his joining CLEARLY, was the chief medical officer of Vesta Healthcare. And he was also the chief medical officer of Be Clinical, where he provided clinical consultative services for clinical delivery organizations and medical groups. Dr. Jasser earned his Bachelor of Science from The Ohio State University, as well as his medical degree from The Ohio State University College of Medicine, and an executive MBA from Washington State University. He completed his residency at Summa Health System, and he is board certified in internal medicine. And he is currently the chief operating officer of CLEARLY Health. So Dr. Jasser, thank you so much for being here with us today. And our second primary guest is Jason Cole. Dr. Cole is currently the governor of the American College of Cardiology for the state of Alabama. He's also an adjunct professor of medicine at the University of South Alabama. He is a native to Mobile, Alabama, and he completed his fellowship in cardiovascular medicine while also completing a Master of Science in clinical research at the Rollins School of Public Health at Emory University in Atlanta. He completed his residency and internship programs at Brigham and Women's Hospital and Harvard University School of Medicine in Boston. And Dr. Cole graduated medical school magna cum laude from the University of Alabama School of Medicine in Birmingham. So two very distinguished guests that are here to join us today and have discussion around AI and CT in diagnosing coronary artery disease. Before we kick off with Drs. Jasser and Cole, I also want to introduce MedAxium CEO and also a graduate of The Ohio State University, Dr. Jerry Blackwell. Dr. Blackwell will kick us off with some comments, and then we will turn it over to Dr. Jasser and Cole for today's presentation. And then we will, of course, as you submit questions through the Q&A button, we will either answer those throughout, or we will certainly get to those at the end of today's presentation. So I will turn it over to Dr. Blackwell for a few comments before he turns it to Dr. Jasser. Dr. Blackwell. Thanks, Joe. And thanks, everybody. Thrilled to have you here. Thrilled for the work that clearly is doing and what you're going to hear today. It's really exciting. I'm going to be very brief, but I can't stop, but say, go Buckeyes here since we, Dr. Jasser, from The Ohio State University. And the other interesting thing from my point of view here, personalizing this, is the other stop along my academic cardiovascular training track was at the University of Alabama at Birmingham. So between Joe and Jason, it's really going to be a delightful time. My final personal bias in this, again, as the President and CEO of Medaxium, and just loving the value of the education provided inside this network and our ability to learn from one another. My personal area of practice for the past 30 plus years in cardiology has been in advanced imaging. And as a founding member of both Society of Cardiovascular Magnetic Resonance and the Society of Cardiovascular CT, I've seen this discipline evolve and have seen the value to the common man, both in urban settings and in highly rural settings, Brian. So without further ado, again, on behalf of Medaxium, thank you for joining us. You're in for a real treat, taking the next steps in cardiovascular CT, combining these with AI and personalized analytics. It's a remarkable future ahead. So Joe, Jason, thank you so much. Thank you so much, Jared. Really appreciate the kind words. And I can't help it, but go Bucks. So it's one of those things. So you either bleed scarlet and gray or you don't. And I can appreciate that. So thank you so much, everyone. And thank you so much for making the time to join us today. What I'd like to do is I wanted to start us off with where we are and looking at cardiovascular disease and why this is such an important area for us to really put innovation and new thinking around, you know, when looking at cardiovascular disease, it is the leading cause of death and it's 40 percent more deaths than cancer, all cancers combined. And about 30 percent of the people who suffer from a heart attack develop lifelong heart failure. And unfortunately, the other the other 30 percent end up not making it through the entire episode. It is a significantly costly disease and overall it is treatable. So that's the call to action here is our opportunity to really take a look at a very major health epidemic around the world that is that is extremely costly to society, that creates a lot of morbidity and mortality, and to think differently about it and knowing that it's treatable makes it even more impactful for us. And looking at the history of the way that we've looked at coronary artery disease, it's we've looked at it differently than we have the other impactful diseases that we deal with in health care. You just heard me say about of cancer and how heart disease is causes more mortality than all the cancers combined. But we're very good at screening for cancer and we're very good at identifying cancer early in the course of disease. If you take a look in cancer care, we've moved away from manual breast exams. We're using newer technology with mammography, breast MRI and AI. We're moved away from people called blood testing and moving towards more visualization of the actual disease, leveraging colonoscopies and newer technologies around DNA screening. You take a look at lung cancer. We've moved away from the simple screening using an X-ray to more advanced screening with lung CT, low dosage lung CT. But if you take a look and compare that to where we are with coronary artery disease, we haven't made that significant that those significant strides or that progress as we have in other areas of medicine. We still look at risk factors, which are surrogates. When you when you look at true heart disease, we look at people who have high cholesterol, but unfortunately, 70 percent who suffer heart attacks have normal cholesterol. So are we really looking at the right things? We look at symptoms. We treat symptoms. And then you just heard me say about 30 percent of the patients who who present for their first heart attack don't make it through. So treating symptoms is a little bit too late. And then you also heard me talk about the sequela with severe morbidity downstream from a heart disease. And majority of heart attacks, heart attacks are missed by stress testing. So we've got to think about the new way, a new way of evaluating heart disease if we're going to be impactful in the way that we're identifying and treating the the actual cause. When you look at the way that we've done it, it's the system itself has is has created some of the fail points. The 90 percent of stress tests are normal. And I'll be asking that, Jason, here in a little bit on what he's seen in practice. But when you look at the literature, a majority of stress tests are normal. You've got a lot of false positives which lead to unnecessary invasive procedures, which also can create significant morbidity downstream. And then for those, the worst case scenario is those false negatives of those that don't have detectable disease that are discharged and end up having significant, either significant sequela or a heart attack after the fact. Alongside of that, you take a look at the catheterizations. About two out of every three catheterizations are normal. And, you know, in the more recent studies, we've we've seen that there's no clinical outcome benefit for ischemia guided coronary revascularization. All of these things that I've just talked through over the last 10 or so minutes is is is is highlighting the fact that we need to think about heart disease differently. We need to look at coronary artery disease differently. And we need to think about the way that we're treating it more aggressively and identifying it earlier in the course of progression. So in looking at it and putting all this stuff together, you know, if you take a look at the three faces across the screen and these are real cases, the pictures are Photoshopped, but they're not real. But the the cases that that I'm highlighting are. And if I were to take a quick poll on who, you know, who is the most obvious one to have heart disease or have a heart attack, you would you'd probably say Jeff or William. But in reality, it was Sarah. And it was identified severely as a severe heart disease, significant plaque and atherosclerosis that ended up in an intervention that saved her life. So the what I'm highlighting here is the paradigm of heart disease has changed. And and we need to think about it differently. I wanted to take a few moments and pause and ask Jason kind of in your practice, what have you seen and what have the other what have you seen and what are the pitfalls that you've observed in the workup of coronary artery disease? So I think that, you know, when you first of all, thanks, thanks a lot for the chance to to be here, I think, you know, with with cardiology practice and so I have a couple of words about myself. So I've been in practice of cardiology and general cardiology imaging practice since about 2005. And so that's that's been a time frame that has has has really had a lot of imaging. And we'll talk about some of the changes that develop. But one of the things that that you've really begun to understand is how we understand so much about biology and pathophysiology of coronary disease and how much our testing doesn't really look at that and doesn't really unfold that. So an example is the patient who comes in and we're seeing this less than we used to say 10, 15 years ago. But the standard concern was the patient says, you know, they go to their primary doctor and they say, you know, I've got a strong family history of heart disease and, you know, my, you know, I'm 45 years old and my dad had a heart attack at 48. And the primary doctor says, OK, well, I'm concerned, I'll check your cholesterol, I'll send you to the cardiologist. And the patient ends up with a treadmill stress test. You've got an active person who has no symptoms. And and at that point, I know we're talking about, you know, 10, 15 years ago, you're trying to make the argument that we're trying to answer a completely different question than what we're really being asked in terms of prevention of disease. And as we've started to make progress, that's been different. The number of patients who come in with stress testing and we say, well, you know, you had a normal stress test and you walk out and you're very happy that the stress test is normal. Well, all that means is that you've got with pretty good likelihood you don't have high grade obstructive disease in a proximal coronary artery. And that's pretty much all you know. And so the ability to shift from this functional testing to answer more of an anatomic and biological question, I think is one of the things that that that that we have seen evolve and develop. And obviously, we'll talk about further developments on that today. Yeah, that's great. And thank you for that, Jason. You know, I think we graduated awful close to each other and have seen the evolution of of stress testing and all that sort of stuff. And, you know, from your perspective, what has been the most impactful changes of stress? You know, the history of stress testing and or the diagnosis of heart disease. I mean, I remember back in the day of nuclear stress test used to take four or five days to get done. Now they're done in the same day. And if we could possibly make it any quicker, we would. And stress testing was the leading thing. So we've seen evolution. And what have you seen in history kind of that you can highlight that you've seen evolve and kind of leading us towards where we're headed now? Yeah. So I think that so what so, you know, so if you go back and you say, well, why, you know, why did we add imaging to treadmill stress testing? It's because the accuracy, as I think you highlighted earlier, was very, very poor. And so all we did when we add, say, stress echo imaging or stress nuclear imaging to stress testing is we're trying to get a slightly better, a slightly more accurate answer to the question of is there potentially a flow limiting lesion? The development of of of nuclear imaging has has been a massive change. And what we've seen in our practice is a shift away from SPECT imaging to cardiac PET imaging, which is really doing a much better job of answering that very specific question of how much ischemia is there, quantifying the level of ischemia and trying to help help answer, you know, some specific questions. And when you do cardiac PET, you do generally today do PET CT. And so you have this little bit of a hint of a little bit of a hint when you can look at the images to see when you look at attenuation correction images, you know, is there coronary calcium? And so you can get a little bit of a sense since there. But stress testing, even when it's pretty accurate when we talk about cardiac PET, is still answering a very different question than the sort of person who's sent over. And so the answer is not you have an asymptomatic 45 year old. I'm just going to do a better stress test. It's the question of, well, how do you how do you how do you try to answer their question a little bit better? Although, yes, certainly I would grieve you completely that that imaging has has improved. Yeah, and that's kind of that's a great, great observation and interesting to see how that is that is continuing to evolve and how CCTA and how CT in and of itself has changed, changed the way we think about it. You know, I've highlighted a couple of pitfalls in regards to the negative, should say the false negatives and that sort of stuff in your in your career, Jason. You know, I'd like to hear from you on the way that we're looking at heart disease. You know, there's a lot of pitfalls. I'd like to see if you had if you had a magic wand, what would you change and what would you like to see happen? So, you know, as as we talked to and it's it's it's a it's a question that sort of answer, you know, how would I how would I as as be as parsimonious as possible? How could I how could I try to answer questions directly? And I think the the answer is that you need to get accurate information. You need to get functional information and you need to know the patient's underlying biological status. And so, you know, as we talked through, I said, you know, if you gave me. If you gave me a treadmill and a CT scanner, I think I could I could answer the vast majority of the questions that we have and, you know, saving some of the nuclear imaging for people with known complex prior revascularization issues along those along those lines. And so, you know, my my history has been that pretty much as I started, we started doing cardiac CT. And so we've sort of built that up. And so I've kind of kind of grown up with and, you know, been involved in some of the some of the first, you know, large scale clinical trials on that. And so we've been trying to figure out we figured out pretty quickly that CT was accurate. And so by 2008, 2009, the question was not, is coronary CT accurate? The question was, how do you choose the right person for the right test? Who's who is the who's the individual that we need to do this on? And who is who is it not? Because, you know, we took three or four years to do studies that said, yeah, for the most part, it has a high negative predictive value and not a very good positive predictive value if you've got a lot of calcium. But we can improve that some. And how do you pick the right people? And so and so I think as we've been able to do that, we were stuck, you know, as as imaging moved to coronary CT. We could make that diagnosis. We could rule out disease. But we we're still sort of on the brink of being able to really take that next leap and figure out, OK, who has really concerning disease and who has less concerning. That's awesome. That's great. I'm thinking through this standing CT scanner with a treadmill, and I just can't visualize that concept. But I appreciate what you know. And to that point, Jason, you know, I think I think it's a good time for us to talk about what is CCTA and how it's actually changing the landscape for us. And to your point, as imaging continues to advance, we're learning more and more on what it can show us overall in the disease progression. In CCTA, most recently, it's the only non-invasive method for the evaluation of coronary artery disease. And what you're seeing here on the screen in regards to the images, this is the same patient. This is the same vessel on the same patient. On the left, you see the gold standard, which is the invasive angiography, and it's no diseases seen. When you look at it on the CCTA and you really analyze the data, you can see that there still is a significant disease burden that's taking up a good portion of the lumen of the vessel. Over the course of time, studies have shown that CCTA is well endorsed. It has received level 1A recommendation by the AHA and ACC in 2021 in the chest pain guidelines. It is effective, as Jason has kind of highlighted for us. It's safe because the radiation dosages are extremely low, and it's very quick. Only thing we can't do is we can't do a CCTA at the same time on a treadmill yet, but we'll eventually get there. But overall, when you look at the opportunity here in CCTA and looking at the images and the ability to see disease we haven't seen before, and in a way we haven't seen before, I think we're marching very quickly towards that. Digging a little bit deeper on CCTA use, the clinical outcomes support it significantly. You heard me just say it is the only test that's endorsed, but it also has the highest diagnostic performance for coronary artery disease that was seen in three different studies. It's also the strongest prognosticator for future risk that was articulated in the Scott Hart trial as well as documented and confirmed to and promote. And the interesting thing is it's also the only test that is able to guide care to help reduce heart attacks and death by 40%, and that's what you're seeing on the chart to the left is the overall incidence of patients treated conservatively after a CCTA as compared to the standard of care. With all the evidence, I think it's upon us as clinicians and as healthcare leaders to really start thinking differently about coronary artery disease and how we leverage the newer technology. And that's where CLEARLY comes in. I mean, take a look at what CLEARLY can do. CLEARLY is post-processing of the CCTA data, and it is able to identify the type of plaque, the morphology of plaque, and then the phenotype of plaque. And then we can also identify the, by identifying the density, we're also able to highlight which is the highest risk plaque. Through all of that, we can create personalized treatment algorithms that can transform the plaque morphology over the course of time. And CLEARLY is also able to track disease progression over the course of time and looking at sequential imaging. So using the CCTA data and adding another layer of AI and post-processing analytics gives us the opportunity to see things in ways that we haven't seen before. And Dr. Cole has been very involved in the overall utilization and has been an early adopter of CLEARLY. And I wanted to take this opportunity to ask him some really important questions around how has it changed your practice? We've talked about the progression of imaging. We've talked about the advancement of the overall way we're looking at heart disease. But I'd really like to know, you know, since you just mentioned about the use of CCTA, how you see CCTA fitting in your course of practice and how CLEARLY has helped you in a new way. Yeah, so I think, so the way that I have come to think about CLEARLY, having had the chance to use it for a bit over the last year or so, is if you back up for a second and you think of the value of coronary CT. So coronary CT, which we have worked on, you know, as I said, I've been involved in it now for over 15 years as we've seen it and we've talked about the promise and what's coming next and what it's going to be able to do. And it really wasn't until just a couple of years ago that finally we had chest pain guidelines that caught up and said, yes, it's really an acceptable and in many cases preferred first-line evaluation. And I think there's two real reasons that coronary CT is very helpful. One is it's accurate. It has a very high negative predictive value if you compare it to other testing. It is a really, it is a very accurate, quick, non-invasive way of evaluating the patient. The second thing is it lets us actually see biology. It lets us see what is going on, the anatomy that is there, and we can see, we can see inside of it. So for example, you referenced the Scott Hart study there before. Well, the reason, so if you, in the study there, the patients who had this, who had usual care versus the CT guided care, they had better outcomes. They had better outcomes because they were treated more aggressively because they recognized who had disease. The patients didn't just have stress tests or clinical evaluation that they said, well, you don't have obstructive disease. They recognized that they had disease. So it allowed us to treat it. Well, in my practice, what I've seen with using CLEARLY has really been an assistance in both of those ways. The simple way is that I think there's going to be more and more value in helping to standardize readings. One of the challenges that we have with CT is that it's not, I've told every single person, we have cardiology fellows that we train every year. I've taught in courses. It's not a hard technology to learn, but there are a few things you absolutely have to learn to get it right, and there can be a lot of variation. So having another tool to help standardize reporting is going to be useful. I think that's an exciting, we would have a five-minute discussion on that if that was the main thing that we were offered, but it's a real value. But the second thing is it takes that second part of it and just really explodes it onto the scene and really allows us to answer the first question of, do you have obstructive disease? How do I feel like this is playing into your symptoms? But what do I know about your risk? And remember that the risk that it's talking about are, first of all, things that we've been talking about in cardiac CT. These risk markers were not originally created here. We've talked about these things, low attenuation plaque, spotty calcification. There are certain things that we knew were high risk plaques, but there was simply no way. I could see these on occasion. We could point out, I could teach with the fellow that would come through and say, yeah, that's not a good one. That's a high, but I had no way to quantify it. I had no way to say it. And in fact, I had no way to even be sure that I was going to reliably be able to detect it. I didn't even really know that if I pulled it up the next time, I'd be able to spend the 25 minutes looking through the scan to find the exact spot that I had seen before looking at it. And so now I have a standardized tool to help me try to identify the exact things that we'd been looking for in a way that I can get it to roll back. So that's been the single biggest value. And I think that that certainly, in my mind, even takes that first advantage of standardization and just blows beyond it because that's the thing that makes me excited about using it and about using the technology. That's awesome. Thanks, Jason. I appreciate that. Standardization is really important so that we're all reading things the same way and identifying things the same way. So I appreciate all of that. And when looking at that, it's hard to argue with a system that looks at things objectively with zero emotion. The AI engine data is data and there's no emotion attached to that data. So do I have to overread it or underread it? Or am I concerned about the medical legal liability and that sort of stuff? All of that gets thrown to the wayside when you start feeding the data to a computer and an algorithm. And we've seen that as well in some of the studies as readers tend to overcall things. And I think that's the tendency from our health care society as a whole because of the fear of the medical liability. So I really appreciate all your comments there. The one thing I want to ask you is, why is it so important? Currently, we treat symptoms. But there's a different way to look at heart disease. And why in your practice or in your thoughts and what you've seen is it important for us to identify it before we see symptoms and really think about more like a cancer type of treatment methodology than our current process? Well, it's pretty simple. Now, certainly as a practicing cardiologist, symptoms are important because patients come in and often seek you out because of symptoms and you want to make the person feel better. But I think that what we often do is we get a little sloppy in our thinking intentionally. We mix up the idea of symptoms and risk. And even though we've had some pretty clear evidence that except under rare circumstances, you know, the level of ischemia is probably not telling us a tremendous amount about the level of risk except under very carefully controlled circumstances. So we want to make the patient feel better. If the patient is symptomatic, if the patient is limited, I need to know if that's being caused by a significant stenosis because then I can get them on the right anti-anginal therapy or perform a coronary intervention and make them feel better. But we're mixing that up a little bit because we then kind of pat ourselves on the back. And how many times have we seen it when the patient, you know, does come in, does have a real lesion, gets treated, and then comes back and says something to the effect of, well, I'm glad that's taken care of. You know, everything is, everything is fixed because we spent so much energy talking about the symptoms. We said, no, no, no. All we've really done is we've identified that you're somebody who's at really high risk for things happening bad in the future. And now we've got to tighten up. Well, if I can separate that, if I can identify those patients separate from the symptoms, if I can identify people before they have symptoms, then I'm going to be able to get to that 30 to 50% of people that you were referencing on your first slides who the first time we ever encounter them is when they have a heart attack. And so, and so if we can identify who those people are, that's going to be the question because the answer doesn't appear to be to treat everybody in the population for, for lots of reasons, but we need to try to figure out who they are. And so I think we, we have to, and patients, there are some patients who intuitively do understand this and they, obviously they come, they understand often it's family history. It's other issues where they, they do come and they proactively seek out and we need to be able to give them really the best answer because for a long time, we just didn't have great answers to give them. And so that's why they ended up with those treadmill stress tests 20 years ago when they were told they were okay, because the doctor, that's the only tool he had. And so I think trying to identify and make that, make that separation in our, in our way of thinking as well as patients is going to be important. That's great. That's great. And thank you for that. The, the one, the one thing is you're kind of alluding to here is, is how, how do we look, how do we, how, how do we look at disease over the course of time? And have, you know, and looking at clearly the opportunity in CCTA, the opportunity to observe the plaque progression or regression over the course of time can help us see things that we haven't seen before. I wanted to kind of see, how do you see that evolving over the course of time and are you using it in your practice now, or is it something that you're looking to? Yeah, that's, we had, I've had a lot of conversations about that. And, and I think here is one of those situations where very honestly, I think there's a tremendous amount of potential. I don't have enough experience using it to actually have time, time unfold, but boy, do we need a tool to be able to do this? And boy, can you not see, I actually had a patient just within the last couple of days that actually had this exact conversation with, there is a, a very hunger to, to, to track patients. And my, a number of the referring doctors who I, I think had finally come along to the idea of calcium scoring have gotten involved in, understand calcium score and understand the idea behind it. And they see, they see the patient and we get everybody treated and, and we were there on their statin and they're labeled up, but the patient wants to know what's going on. So they go to their primary care doctor who orders a follow-up calcium score on them, because they say, Oh, it's been four or five years. And boy, you know, you had a score of 150 and now I've got you on calcification, you know, you're in, you know, everything's fine. And then immediately I get a consult back because the patient's calcium score is now 350. And, Oh my God, what have we been doing to this patient? And so then I have to have a conversation about the fact that statins increase calcium scores, and then that blows people's minds. And it turns into that issue because if your calcium score goes up, I don't know if it's going up because you've simply got more disease, which is a bad thing. Or if you're going up because you're stabilizing plaque that was unstable and now it's calcified, and that's a good thing. And boy, wouldn't it be great if we had a tool that it could actually look at the things like the higher risk plaque and see that plaque, you know, that volume of addressing. And so you certainly would have to say that, that that is that you can easily see that as a potential role that is, that is out there. I think to be honest, that's going to be something we're going to have to see there's going to be for the, for, you know, more, more work to be done as we try to figure out exactly how we incorporate that. But I can say that for the first time, I actually see the concept of a tool that I can use from that. Previously, the only way I could have done that is to recast the patient and do, do an intravascular ultrasound. I mean, you know, or, you know, OCT or IBIS is really all I'd be able to do to do to really look at the plaque that I'm concerned about. So at least now I have, I have a non-invasive way that can do it. And as you pointed out without emotion, standardize, measure, you know, completely agnostic to patient or the story is, or whether they've been behaving themselves or not behaving themselves, you know, the truth is what it is. So I think that's an exciting, exciting potential. That's awesome. Yeah. And you, and you brought forth one of the other questions. It's like, you're reading my mind over here. It's interesting. It's the patient experience. And one of the things that I've learned in my practice is when I was practicing is showing patients their images or showing patients their actual disease process changes the conversation in a very dramatic way where they now feel ownership over their disease. And, and the, and the us as physicians, our ability to influence behavior or medication adherence changes and wanted to see if you've, if you've encountered that in your practices, you've been using clearly and what the patient experience is and, or any insights that you have on leveraging that. Yeah. I think that's so, yeah, there's always been a hunger to show patients pictures and images. I mean, you know, I mean, and certainly there's a, there's a long history of that with, you know, with, with cardiology, everybody, you know, would get often little, you know, pictures, you know, from the cath lab. And I've been talking about trying to, you know, the idea of calcium scoring, we tried to try to show people calcium scores and, and the idea is it's really there. You really need to take your medicine because it's, you know, we, we really see it, but it's, it's not overly rewarding. Basically you have to, you have to, when you show somebody a calcium score, I have to say, yes, this is white and it's not supposed to be white and you need to do something about it. And I will have to say that there is definitely definitely a greater level of understanding when you can, you can show them not just pictures of images, but, but some, you know, explanation that's there. And yes, I am more and more going. I had a patient yesterday that I actually actually pulled out as opposed to, you know, we give a, we give a PDF to the patient, you know, on the, it's a very nice automated report that they, that they get about the analysis. But I actually had one yesterday I pulled out and started, you know, actually went interactively through the, through the, the images. And, and, you know, this is, this is, you know, you don't have the plaque here that I'd really be concerned about. So, you know, we're going to stick with, we're going to stick with you know, with statin and aspirin and I think you're doing the right, the right stuff. And so, yeah, I think that that's another potential role. That's great. That's great. Yeah. And it's interesting that, I mean, I've personally had mine done. I mean, you see the images and your eyes open up. It's like, wow, I did not realize that. I guess dinner plans are changed for this evening is what ends up happening, but it's that constant repetitive nature of, of, of engaging with the patient on a different level. I think there's value to be had there. On the other side of that is the physician workflows. And, you know, and as I've learned in my career, managing physician organizations is you just don't mess with the physician's workflow. You don't add extra work to a physician's workflow and wanted to see how you're leveraging CCTA and clearly in your current workflow and how you see that evolving over the course of time. So would love to hear. I can simply tell you what my experience is and I don't really claim that it's gonna, that it's the answer for everybody or the way that it works because I've been kind of playing around with it a little bit and figuring out who it, you know, how it helps me when it doesn't. You are gonna get some different information. You're going to have an extraordinarily low number of patients who are ever normal. If you send clearly, you're gonna find some level of plaque. You will, and you will very often find that the level of stenosis is less than your eye had expected. And so, and so certainly patients who have a burden of disease will tend to do that. And so, and so basically I begin my interpretation of the case in exactly the way as I have typically. And my day is always separated into multiple different parts. I don't have a period of time where I sit down and read 15 scans, you know, at the end of the day or, you know, at noontime or something like that. I usually am trying to constantly keep up, you know, between patients and working. And then when I've got, you know, we've got teaching, we've got people coming in and you pull those aside. So it's, there's never a single manner. So what I do is I will simply start, I will do a routine reading just as I do before. And then honestly, we will, you know, very often obtain clearly. You do choose to obtain clearly the way that we are set up. It is not, it is not being ordered by default on every patient. It's certainly something we're doing and the ways we're choosing to do it are really twofold. One is if there is a moderate level of disease, it's just a decision I make in terms of reading it. And I think that there's, you know, some concern of the level of plaque that I'm going to, I'm going to do it. Those, you know, really the CADRADS two, three, four type of patients. And those, that's our scoring system for CT that tells you kind of a level of stenosis, if you know, getting up there. And the other are patients who are actually referred specifically with the idea of doing it. As a number of my partners who do not do cardiac CT, but as they've learned about it and I've shown them and I've shown them, you know, the results and I've shown them, you know, what I can give them for, I can give them a PDF for the physician, I can give them a PDF for the patient. And they have started to pick out patients that they feel like it's going to be useful for. If they request it upfront, even if we don't see anything, we're going to order the clergy. So those are the two groups of patients that we'll do it on. And basically I order it and then I do not finalize that report until I have the clearly, because I think, you know, ultimately, no matter how good the AI is, you know, ultimately I'm responsible for providing that report. And so it's a tool that I'm using. And so I don't want contradictory results or things like that in the chart. So I wait until I get it back. I mean, and I finalize it. From a pure workflow standpoint, the turnaround is pretty fast. I've learned that the late evening ones often do not get back until the next day. But if I do it, I'm in central time. And if I send one before about 4.30 to 5 o'clock, I will get it back that day. Sometimes as soon as an hour, sometimes it may be two or three hours. And otherwise, and they pop back to me about 4.30 a.m. in the morning. And so they're all ready for the next morning. But from a workflow standpoint, that's it. The other thing that's worth saying is, again, this is a process we're ongoing with. I'm in a group of about 30 cardiologists. And I think there's about five, six that read Cardiac CT. And I'm using this very regularly. And for some practical reasons and not wanting to overflow some of the back channels, we haven't just opened it up for everybody doing it. And so the other people, when they want it, they kind of more select, they're even a little bit more selective than I am. They all have access to it, but it goes through and we make a point of ordering it. And then it just kind of adds into their results too. So we're still, it's still a moving target. And again, the way we're doing it now may not be the way that we're doing it in another 12 to 18 months. But right now that's kind of our workflow. Awesome. No, that's great to hear. Thanks, Jason. And along those same lines, how do you see the benefits downstream for organizations? When you look at it, preventing disease is one thing, but then also identifying the right people to go into a cath lab is another. So I'd like to- I think our entire, yeah, our entire, the entire idea of our non-invasive, when I'm trying to run our non-invasive program, and again, we do SPECT imaging, we do PET imaging, we do cardiac CT, we add clearly to the cardiac CT. My objective means that we need to get the right patients in the cath lab. And if I've imaged a patient and they have a normal, or a normal cath, but a not intervention cath, I kind of feel like I've failed. I mean, I kind of feel like, you know, a false negative, you know, or a cath, you know, or a, you know, unnecessary cath, false negative, you know, false positive, you know, how you're looking at it, but basically a pembe with a negative cath who you sent to the lab is really kind of a failure of your non-invasive imaging. Now, there are times that it's obviously, that it's not reportable and you can't, and if you truly hit zero, you may have a few people that you left out that needed to go. So of course I'm realistic on that, but ultimately that's the way I feel, is that we need to be sending the right patients to the cath lab with all the information necessary. And so, for example, with CLEARLY, I've absolutely had patients who have had very concerning, so say they've got a 60% proximal LAD lesion, but it's got low attenuation plaque, pathology does not look good. I am very concerned about this area. There's a part of me that thinks that that's the person who really needs a stent put in that area, and somebody who has an 80% mid-right with a little bit of angina, I could put them on nitrates and they'd be fine. I don't have data for that at this point, and so we don't, but absolutely, I have told the interventionalist when they go to the lab, this patient needs an IVUS of their LAD, and we need to be very aggressive in looking, and if there's anything to look at that. So we are definitely targeting specific areas of interest in the cath lab based on what we have seen non-invasively. We were trying to do that beforehand, and I think CLEARLY has really just kind of accelerated that to another level. That's great, that's music to my ears. That's awesome. That's what this is all about. So I've been picking on you quite a bit. I wanted to see, Joe, I wanted to kind of turn it over to the audience and see if there's any questions out there from the folks out in the audience that either myself or Jason can take on. I appreciate that. Gentlemen, thank you so much for sharing all of those insights and that wonderful conversation over the last almost hour now. So thank you for that. I want to prompt everybody again that in the lower center right of your screen, there is a Q&A button, and as you enter any questions that you have there, they will come to me, and I will be able to address those as they come in. So just a reminder on that. I do have a couple that have come in, and so let me bring those back to you guys. There's no indication on which one of this is for, so it'll be both of you is my assumption. But the question is, why do we need to detect heart disease before the visible or physical symptoms are present? I'll answer, I'll come at this from a primary care physician's perspective. Until a patient presents with symptoms, they have to look at the disease they have, and that's the biggest challenge with it. And you heard me kind of start at the very beginning and looking at the landscape is more about a third of the patients who present with their first symptoms is mortality. So it's unsettling, Joe, when you look at it. So for us to kind of look at things differently, we have to see it before the symptoms present themselves if we're gonna be impactful. Dr. Tobias, I'd love to hear from Jason and kind of what your thoughts are. I mean, I think that the simple answer is that we are attempting to do that, but the tools that we have are not adequate. And so the reason that we need to make some better effort at doing it is because we're already doing it, we're just not doing it very well. We're using things like pool risk calculators based on risk factors, based on databases that are possibly relevant to the individuals that we're looking at. And so we know that our tools are not very good. And so in order to put somebody in an appropriate treatment, we need to do it. A patient does not necessarily have to be on a statin because they've got high cholesterol. A patient needs to be on a statin because they've got atherosclerosis and that's one of our modifiable risk factors, whether or not that's their biggest one, we can still get benefits. So we need to know who to treat and our tools are not very good. So we're trying to get them better. Thank you. Thank you both for that. I have another question that is here and it's for you, Dr. Cole, although Dr. Jess or maybe your experience with the programs, you'll also be able to comment on this. And it is about how your practice and your choice of care pathway has changed since implementing clearly, Dr. Cole. So I think that we had already, I certainly personally, as well as what we've been trying to put in place as much as we can uniformly, I think had moved to the idea that as a first line test for chest pain, that anatomic imaging with CT is really an ideal test. And so I think in that sense, clearly has only strengthened that. It has not fundamentally changed the approach that we already were moving to. That basically, because again, if I can know whether or not somebody has atherosclerosis, that's gonna help me to treat them a lot better than whether I just know whether or not they've got angina pain from a stress test and clearly does that better. The other realm and the realm that we're only just starting to scratch the surface off is the question of true prevention of the patients who have that family history, have other risk factors, don't have a lot of obvious risk factors, but still have concern and trying to tease those patients out. I think having a tool like this as opposed to simply having basically a calcium score, which is what you had before has provided an alternative. And I think that clearly for people who are on the borderline of do I stress test? Do I do CTs? I think having this type technology is only gonna push them more in accordance with most recent chest pain guidelines of anatomic testing. Excellent. I appreciate that. And let me just ask very quickly, Dr. Jasser, you've seen clearly implemented across a number of programs. Is there anything you would add to Dr. Cole's view? No, I've learned that the guys out there in the field are at the tip of it all. And what he's seeing is spot on. And I'm seeing similar across the landscape, Joe. Nothing to add there. Okay. So I've got one more question that's come in. And just as a reminder, everybody down at the center right is the Q&A button and feel free to use that to submit your questions to us. Are there patients that you would choose not to do a clearly on? And what factors would you look at? So I guess in terms of what would make you say they're probably not a candidate. I would defer that one to Jason 100%. I think that, well, I think, so I think it is most so clearly is the same answer as you have for cardiac CT in general, just more broadly expanded. And that it's most useful in an intermediate risk patient population. So one easy people that I very often will not do it on is a patient who has previous stents. Because first of all, you can't see the area of the stents. Now you can see other areas. It's just excludes that area. But again, this person is already treated, perhaps being treated maximally as much as possible. It may not be answering the question. Now I could back up and say that I also often try to say that maybe cardiac CT is not the best test for somebody who has previous stents as well. But there are times you order it. A, because I order it, I'm just stuck reading it. And B, because there may be a specific case. So that would be a sort of patient who I would be reluctant to think that I'm gonna get added value, at least with the technology that I have today. And then the other patients are the patients where it looks normal. And this is, I anticipate that we're gonna get more data and we're gonna start looking. And I think we will need some data at that point for the normal, for the truly normal. The calcium score is zero and there's no evident plaque because I can probably run clearly and get some little plaque identified. But let's be honest, I don't know what that means. Nobody really knows what that means. And it's probably not gonna change my therapy if it's just a patient came in with intermediate risk chest pain. Now, again, if it's a patient with a really strong family history, their doctor has specifically requested it, 100% I'd get clearly in that patient. But it may not be somebody that I would just add it on as an extra. So those two extremes would be the first ones that I'd be more skeptical. Got it. Anything to add to that, Dr. Jasser? No, I would agree with that. And that's the similar perspective that we have, Joe and Jason, in looking at it. It's the clipping off of the extremes, those without any disease and those that have such significant or substantial disease that it doesn't make any sense. So totally agree. And that's what we're hearing from other cardiologists as we're working with folks across the country. Wonderful. I've got another question that's come in. And it's on, the question is, any reflections on the blurring of the nomenclature between primary and secondary prevention? And does that change your clinical approach? I mean, I think it depends on what we're, yeah, I mean, I think to answer that question, you have to get into what you're trying to, what you're preventing when you talk about primary prevention and secondary prevention. You know, is it, are you preventing events? Are you preventing, are you actually preventing disease? You know, what are you trying to do? Or simply, you know, and do you treat them differently? So, I mean, the one thing you have to be honest about is that again, and it's one of the reasons I did not necessarily say I'm gonna do this for the most minimal of disease is you simply don't know what you're going to try to do from there. But it's a tough, you know, I think it's a tough scenario. But on the other hand, the alternative to it is if you've got patients in that intermediate range, and they fit in so beautifully in terms of treating them aggressively, however you define prevention, I think it works well. I agree with that. I agree with that. I think going back to what we were talking about earlier, Jason, and then layering in the disease progression or regression and looking at it over the course of time helps clear that line up a little bit more, but it may also create a little bit more blurriness, Joe. It's good, to Jason's point, to kind of blend together. And do you think that there's then implications looking to the future if we take a look at things and call them primary versus secondary from an insurance perspective? Is this going to then have some influence on reimbursement, maybe not in this moment, but looking out two years, three years, four years, do you think that changes based on how we classify things? Awesome. You stumped me on that one. Well- My crystal ball. I'll pull up my crystal ball. It'll show me everything I need to know. Yeah, well, I appreciate it. I know we only have two minutes left and we do like to end on time. I'll turn it to both of you for any final thoughts for our audience today. I just want to say thank you so much, Jason, for taking the time and having the conversation with us and MedAxium for having us here. So I really greatly appreciate it. Nothing more to add. I thank you everybody for your time and attention. Yeah, I mean, it's been fun. This has been fun using this technology. I think we're being helpful for patients and people that hear about it are always interested in asking questions. So I appreciate the chance to talk. Yeah, well, I appreciate both of you lending your time and expertise to the community today. We really appreciate it. For those of you that have dialed in and been a part of the webinar, we will send out a link so you'll be able to review any pieces that you want, as well as any future questions that come up that you would like answered, you can reply to those emails and we will forward them on to the presenters today and do our best to get you an answer in short order. So thanks everybody for joining us. We really appreciate it. Dr. Jasser, Dr. Cole, and of course, clearly for helping to bring this education to the community. And with that, we will conclude today's webinar and we hope to see you on a future webinar soon. So thank you all very much. Thank you.

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