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Recorded May 26, 2022

Preventive Cardiac Imaging

Dr. Jonathan Forquer 

This transcript has been modified to improve reader experience, but the messaging remains unchanged.

Moderator  00:00

Well, today we’re going to have an opportunity to talk with a local cardiologist who really emphasizes his care on preventative as well as screening imaging and workup for patients with cardiac or heart problems. And so I’m very excited today to have this opportunity.

So, with that, I’ll have Dr. Forquer give us a brief introduction about himself, and kind of what his specialty is and what it entails.


Dr. Jonathan Forquer  00:41

All right. Well, thanks for having me. Appreciate it. I think there’s a good opportunity for hopefully a lot of people in the community and primary care doctors […] to understand what, you know, preventative medicine and cardiology really entails. We’ve got a lot of interesting technology and opportunities, hopefully, for people to see, you know, a chance to reduce that opportunity for a heart attack in the future.

I talk to my patients all the time about that. This is where we get to work on preventing that first heart attack from ever happening.

As a personal introduction, I’m John Forquer. I’m one of the general cardiologist and director of the echocardiogram lab, as well as the stress lab. I’m in charge of cardiac CT, and do most of my work through the office and working with patients for primary prevention.

So, I am actually born and raised in Lancaster, Ohio, so really dedicated to this community and hopefully helping people stay out of the hospital and enjoying full and healthy lives.


Moderator  02:06

Sure. Well, great to have you. Thanks for being here. So, diving right in then, when we talk about preventative heart care, a lot of times we’re talking about — when we talk about people coming in with heart problems, it’s emergencies and things like that. But we’re realizing more and more there’s a role for maintenance and prevention. And so beyond just a healthy lifestyle and say that you’re doing those things, or you’re already aware of those interventions. What does imaging — what studies do you do? What are common studies that are to be had around here?


Dr. Jonathan Forquer  02:39

Well, I think over the last six years, since we got the cardiac CT program up and running, we’ve had a lot of really good information to come from all of these tests. And we have been able to further refine how we approach all of this.

So, there’s a few things that kind of differentiate where we stand: It’s if a patient has symptoms, or if a patient is just coming in, kind of worried about their heart care, or their heart health.

The typical situation is like a 45-year-old guy, he’s otherwise healthy — but his dad had his first heart attack at the age of 52. And “Doc, I’m just worried about it. I don’t know, you know, I don’t want to be like my dad and have all this stuff going on. I just want to know up front.” And so that’s a great opportunity for a test called a coronary artery calcium score.

This is a very safe, quick test. You come in, it’s just one 15 second breath hold and down in the radiology department. It doesn’t require an IV, no other special preparation. And this test is very good at detecting even tiny amounts of calcium deposits within the heart arteries. That is sort of the signal that we have early plaque formation. And the best part about knowing early is now we can have those interventions set up and be really, really aggressive with their cholesterol control, and their blood pressure control and their diabetes control. Rather than just kind of, “Oh, you know, we have a heart healthy diet,” we’re going to be a lot more aggressive with those individuals.


On the flip side, for people who don’t have any calcium deposits in their heart arteries: That’s really good news. Those patients over the next five years have a very low chance of having any problems in terms of acute heart attacks or other, you know, symptom development. Which, that isn’t the signal that, “Oh, everything’s great. We don’t have to do anything, I’m good to go.” No, that’s actually kind of the opposite. That’s when I tell people, “This is excellent news. Now, you can exercise with impunity. You can be really, really aggressive. And you don’t have to worry any, you know, symptoms that you know that, oh, that was a little weird.” Well, I have great deal of confidence, it’s not your heart, and keep pressing on through is the way to maintain, you know, your overall health and prevention going forward.


Moderator  05:42

Sure. So, if I was that patient, and I had kind of a nagging suspicion that my dad had heart disease and that sort of thing, you’re telling me that it’s a pretty quick test to get done. And there’s a fair amount of confidence that if it doesn’t have calcium, I have nothing to worry about with regard to having a heart attack in the near future.


Dr. Jonathan Forquer  06:02

In the near future. Now, there’s other ways that we approach preventative cardiology, in the long term. And these are things like our ASCVD risk score, our atherosclerotic cardiovascular disease risk estimator plus from the American College of Cardiology: There’s an app for that. Which is great, you know, it’s 2022. There’s always an app for that. And this gives a really good predictive model over the next 10 years and a lifetime risk score.

There’s other scores out there that also do a good job with 30 year risk. And those can help point us in the right direction long term as well. But you know, if there’s even something in that intermediate category, maybe-maybe-not well, then maybe the calcium score can help us refine that. And say, “Yeah, we will go ahead and get you started on that statin” or “We will talk about aspirin.” And that’s a whole new hot button topic out there in the world of cardiology that we can maybe talk about a little bit.


Moderator  07:12

Sure. Sure. So that’s great. So, that’s just one study that that’s available to people that have curiosity. Say that there was calcium on the on the findings, what would be next steps?


Dr. Jonathan Forquer  07:27

So next steps is talking about your overall risk. And that’s looking at a lot of historical data: family history and personal history of, you know, things like diabetes.

Diabetes is one of the biggest risk factors. We even kind of associate it as a risk equivalent. So, if I have someone with diabetes, I kind of want to treat them as aggressively as I would someone who already had a heart attack or already has a stent, or has had open heart surgery, because it’s that closely associated in terms of their long-term risk.

And so, looking at cholesterol numbers, looking at their blood pressure numbers very, very closely. And talking more about some other higher level things. There’s a lot of discussion in the cardiology world about more than just your cholesterol. Every PCP orders cholesterol numbers, and what do we do with that information? Is there anything else that helps define that better? Should we be doing what’s called Apo-protein B (Apolipoprotein B) levels to help refine, you know, their overall risk of developing plaque over the next 5-10 years? So, that’s the next step. It’s history and a thorough lab evaluation.


Moderator  08:59

Okay, so that gets us a far ways into knowing more about my own heart health, without having a lot of invasive procedures done. So, say that I am one of those higher risk patients. Where does — where does, like you said, echocardiogram: What is that and when would that be used for me?


Dr. Jonathan Forquer  09:17

So, the echocardiogram is a — it’s an ultrasound of the heart, as the simplest way to look at it. Just like moms going in to get checks on baby, it’s the same technology. The only problem is we have all these ribs up here in between the skin and our heart. So, it’s a little bit more technical, but it’s actually very safe, generally pretty quick — you know, 30 to 45 minutes, you’re in and out. Some patients, you know, do require an IV, and we use some other advanced techniques and image enhancers, but most people are you know, don’t even need an IV.

The echocardiogram is looking a little bit different. So, I always use the analogy of, you know, someone building a house. You got a general contractor, you got your plumber, you got your electrician: That’s cardiology in a nutshell. The echocardiogram is looking at the general structure, the walls and roof and everything of the house.

When we’re looking at an echocardiogram, we’re seeing a variety of things in terms of how well the heart is squeezing as a pump, we’re looking at the thickness of those walls, we’re looking at the valves that help blood move in a single direction — the right way. And we can also estimate some of the pressures inside the heart. So, there’s a variety of other things. Generally, patients with symptoms, though, are going to get a full echo.

At FMC, we have a screening echo program. And so it’s actually pretty inexpensive. Don’t quote me on this, I think it’s like $25 or $30. And we can get a screening echo — just the basics — to look at the structure, look at your valves. And anyone can get one of these ordered, and you know, pay pretty quick and easy. And that way we can see, is there a major change in your heart function? If that all looks good, chances are low that you’ve had a major problem in the past.

If you have a family history of heart valve replacement, and someone wants to get checked out even though they don’t have any other signs or symptoms — heart murmur, shortness of breath, stuff like that — then we can get that very simple screening test for pretty much anyone. Again, very safe, usually pretty quick, and it’s a good way to look for those patients who, you know, are concerned, “Oh, my so and so loved one have this. I just want to get checked out.” — Yeah, we can, we can help out with all that.


Moderator  12:03

Sure. That’s great for a community center to be able to have screening programs like that. So, if I was — say, I’m a doc in the community, and I have a patient that I think probably should at least see a cardiologist or have some sort of workup done. How do we get plugged in? How do we — how do we see preventative cardiology here?


Dr. Jonathan Forquer  12:25

Yeah, so right now, a lot of these preventative tests are very easily ordered by any primary doc in the community. We have some who are, you know, very good about it: They already know great patient selection, this is going to be a good candidate for this kind of test. And they go ahead and order it themselves and I’ll end up reading it and get them information, you know, within just a few days.


For any primary care who doesn’t have the confidence in terms of you know, who’s the right patient for this? Is this a good one? Well, then we can easily refer over to our office, and we’re happy to see those patients and get them plugged in to the right pathway. Because sometimes you get these patients who, once you to ask them a few more questions, “Oh, you do have some symptoms that are a little concerning here. Maybe a screening test isn’t all you need, maybe we do need to go down this other pathway.” And that’s where other things like stress testing, or a coronary CT angiogram – this is the full CAT scan of the heart, if you will. This one is a little bit more involved, and this is a great screening tool so to speak, but it’s for patients with symptoms, who are at low to intermediate risk for significant coronary disease. And so that’s where the history comes in. And at this point, yeah, that’s probably you know, giving the cardiologist a call and send and referral over and we can talk about that.


This test does require a few other things. We give them to medicine to keep their heart rate nice and slow and regular. We give them some other medicine while they’re down in the CAT scan area to open up their blood vessels. But here again, in a very short, very safe test, we can get a ton of information about their heart or heart arteries, can even assess you know, if they have minor versus significant plaque. We can look at their aorta and their pulmonary vessels and all the structures of the chest. And so this is a ton of information and a very, you know, quick, safe test.

The only downside is if there is something significant that we find out, well, now you’re in the pipeline for doing some other significant testing in the hospital generally, so. But that all is on an individual basis.


Moderator  15:13

And the good thing is you may not have a heart attack because this has been discovered.


Dr. Jonathan Forquer  15:17

Absolutely. And so that’s really interesting. I believe it was in 2014, there was a study that came out. And this is, of course, like NBC Nightly News headline: Cardiac CT Saves Lives. Well, the truth is, passing X-rays through your chest does not prevent heart attacks. That’s not the case. But what it does is identify cardiac disease early. And when we do that, we have known therapies that are proven time and time again in 10s of 1000s of patients to prevent, you know, future heart attacks. And so, if we can get you on that early, we’re really doing you a great service, a great favor to prevent that first heart attack from ever happening. And that’s my goal.


Moderator 16:03

Awesome. It’s great to have you in the community. Is there anything else you’d like to add about preventative heart care and imaging options?


Dr. Jonathan Forquer  16:13

In terms of imaging, you know, just following up regularly with your physician or cardiologist, these are ongoing things. And we always talk about, you know, your three-year risk, your five-year risk, 10-year, 30-year, we can do all of these different things. But the truth is, it’s always changing. And so, if you have someone who, you know, is doing well today, but three years later, they haven’t really taken care of their diet the way they should, they haven’t been exercising — that can be significantly different. Or you have someone who was kind of on the borderline, and then has really taken control of their diet and exercise and stress reduction and sleep — all of those really important things. And we retest that, and we see your overall risk has dropped, you know, well below what it was before.

You know, I have plenty of patients who say they don’t want to be on medicine: Okay. I’m gonna give you six months, I’m gonna give you a year. If you can do this all the right way, we can always reassess, and we need to constantly be doing that — which means patients need to be seeing their primary care doc at least once a year, especially over the age of 40, having routine screening things – and that goes for everything, you know, colonoscopies and lipids and blood pressure checks and all the routine stuff that way.


Moderator 17:43

Sure. Awesome. Well, thanks for being with us today. I really enjoyed our conversation. I learned from it — probably just like so you guys will. We will go ahead and put information in at the end of this on how to contact the office and get plugged in if you have interest in seeking out preventative heart care.


Interested in learning more? 

Learn more about Jonathan Forquer, DO, and FHP Cardiology.
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