Preventive Cardiology (13 Apr 2026)

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Dr Marilena Giannoudi (MG): Hello everyone, and welcome to another episode of Clinical Conversations, brought to you by the Royal College of Physicians of Edinburgh trainee and members committee. My name is Doctor Marilena Giannoudi and I am on the T&MC. And today I'm delighted to be joined by Doctor Heeraj Bulluck, who is an interventional cardiologist at Leeds Teaching Hospitals and has recently developed an interest in preventive cardiology. And we'll be talking a bit about why that's important and why we need to be thinking about a shift from treatment to prevention. So, Doctor Bullock, good morning. Welcome and thank you for joining me.

Dr Heeraj Bulluck (HB): Thank you Marilena. I'm delighted to be here. Thanks for the invite and looking forward to our chat.

MG: Me too. So, I guess let's get straight into it. For me, the best place to start is, as I mentioned to our audience, you are known as an interventional cardiologist. So, on the front-line treating heart attacks in the cath lab. But you've recently developed this interest in preventive cardiology. So, can I ask, how did that come about and why do you think that this is important?

HB: Thank you. Yeah, that's a very important question to me actually. So, over the years, having treated heart attacks in the cath lab, nowadays, I'm seeing patients presenting at a younger age and some of them younger than me in my forties. We work very hard in the cath lab, you know, to patch the artery and then afterwards reinforcing all the secondary prevention measures. And then it made me realize a lot of resources are invested after the damage is done, and maybe moving the treatment and prevention strategies upstream before disease manifests would be a better strategy. And that led me to think about optimizing my heart health myself. And along the way, I thought I should spread the message. What can we do about optimizing our heart health, especially in midlife in our late thirties? 40s and 50s. This led to me writing the book Hard Reset forty.

MG: Okay. Thank you. So, is preventative cardiology about optimizing risk factors? And if so, how do we know what our risk factors are?

HB: Thank you. So, probably coming from me being an interventional cardiology probably I will call preventive cardiology being an early intervention cardiology. So, it's more about intervening before disease manifests itself clinically. And this can be quite challenging because a lot of us we feel fine most of the time and we don't realize something is happening. The first sign is usually the symptoms of a heart attack, but usually this is the last chapter of the book. When someone presents with a heart attack or angina disease gradually progress over time. So, to answer your question, preventive cardiology is more about identifying risk factors Early and acting on them early. With lifestyle changes, small habits we can easily implement and compound, and then eventually that can change the trajectory of disease in the future. And the second part of the question is how do we know what our risk factors are? This, again, when we're in our twenties and 30s, we don't really think too much about it. But usually once we are in our forties and beyond, suddenly there's this shift in our, for example, energy levels, our sleep patterns are disrupted a bit more stressed, our waistline starts to creep. The GP might tell us our numbers are borderline in terms of blood pressure, cholesterol and glucose, or hba1 C as we call it. So, this is the time when we can truly identify certain, as we call it, risk factors or certain parameters we can act on early before they become irreversible. and that eventually leads to irreversible damage in terms of plaque formation, inflammation, plaque rupture, heart failure, stroke.

MG: And so, what is the best way of identifying them? Because you said the GP might tell us something, but lots of people may not go to the GP. Do you think we need to increase opportunistic screening? Do you think we just need to get education out there because there's so much on the internet or with smart devices, whether it's your watch or your phone, we should be tracking our kind of risk factors through that.

HB: Yeah. So, this is the basis of the contents of my book Heart Reset forty. So, the idea is not only the patients we see but ourselves. If we're in our mid-thirties, 40s and beyond is first of all to know our numbers. Education is important. What are those numbers and what do they mean? And there are simple things like blood pressure, for example. So, a lot of people don't know what the blood pressure is until they present to A&E. So simple things, you know, I wouldn't say you need to start worrying about it in your twenties and 30s, but once you are in your late thirties and beyond, it's important to start knowing what's your blood pressure like? What is your lipid profile? Normally in the UK you have a NHS health check it for men in their forties and women in the fifties. They will get a free health check. So, it's important to probably attend those and get a baseline idea of your numbers. Those would be your lipids, your specifically your HDL or and your hba1 C. So already there are three numbers their blood pressure, your LDL and your Hba1 C. So, there are certain normal range which I mentioned in the book. So, if your numbers are okay, it's a good chance to maintain what you're doing and make sure that doesn't go in the right direction. If the numbers are borderline, then it's time to act. Now, early, before you have symptoms to improve those parameters with time and as you say, tracking. So, if you have borderline numbers now it's important to implement some lifestyle changes now and then eventually recheck them at certain time intervals depending which parameters we are talking about.

MG: And would I be right in saying that actually the European Society of Cardiology, the ESC, has got quite good guidelines in what we should be advising targets to be, depending on age and pre-existing risk factors that we can refer back to as well.

HB: Yes, definitely. So, there are various guidelines out there. Yeah. One of them is the European Society of Cardiology. So, there are cut offs even for healthy individuals stratified by age, gender and ethnicity in some cases. And yeah, that would be a good resource to refer back to. And one other parameter I haven't mentioned would be it's your waist circumference. So that's a good marker of your metabolic risk. Above and beyond your BMI. So that's another number. And what is your normal range or should be. There are reference range out there depending on gender ethnicity. And that's a good number to track as well because that indirectly will indicate how much fats are on your vital organ. The visceral fats, which are usually the active form of fats. And those are the ones that lead to metabolic syndrome or insulin resistance and the downstream consequences.

MG: Okay. And for our listeners, I'll put a couple of those kind of risk stratification profile guidelines in the footnotes of this podcast. I think you've already alluded to this, but when should we start making these lifestyle changes? You mentioned something about, you know, you need to be aware of it in your early forties, is that when we have to be strict with ourselves, or does their work start before then?

HB: Yeah. So I think you're right. The work should ideally start before then. In an ideal world, the earlier we start, you know, as a kid, you know, teenage developing those healthy lifestyle as part of normal habits that would have been ideal. But this is not the case in real life. We tend to drift into, say, unhealthy lifestyle in the twenties and 30s. Usually our body is more forgiving and can adapt, but it's in midlife, so it may be mid to late thirties to start with. When the metabolic shift that happens, hormonal shifts in our body when the implications are more important. So, I would say if you had to choose now, it would be in your late thirties, but it's not too late to start in your forties and 50s if anyone listening to us are in that age group or even the sixties, it's never too late. But the idea is that decade of opportunity, which is in your forties and 50s depending for men and women is when those small micro habits. We can talk about that can compound. And the potential benefit is much higher in that decade compared to doing the same intervention the ten years or twenty years later. So yeah, to answer your question, the earlier we start, the better. Atherosclerosis does not begin in midlife. Usually, they start in our twenties. There has been studies looking at autopsy of young adults involved in road traffic accidents. For example, one in five of them would have signs of early plaque formation like those fatty streaks in the vessel. And so usually it accelerates when our health routines erode, as I mentioned in the late thirties and 40s, when our work intensity increases, sleep becomes irregular, movement declines and stress becomes chronic. So, from a clinical perspective, the trigger is not age. It's a change in pattern. And when patient says they feel fine but tired when blood pressure or lipids are borderline, when weight has crept slowly over the years. This is the moment of highest leverage. And those are the years when small sustainable change compound. Waiting for symptoms often means we miss that window.

MG: And obviously these are all to an extent, I guess, modifiable risk factors. But how can we manage or is there a way to manage genetic risk factors, such as family history? Because I think we'll have all come into contact with patients who said, you know, I'm so healthy, I watch what I eat, I do this, I do that. And actually, the big risk factor that pops out when you're taking a history from them is, oh, yes, my father had a heart attack in their fifties and my grandfather had one in their sixties. And you think it probably is just all family history without having, you know, a formal diagnosis of familial high cholesterol or, you know, something similar to that. So how important do you think our family history actually is?

HB: Yes, so I think family history is very important, partly because it depends on what mindset those patients would take. Some would say, oh, I've got strong family history. I'm doomed. So, no matter what I do, I will have a heart attack or a stroke. Others might say it's an opportunity to start early, so family history sets based on risk, but it doesn't decide an outcome on its own. So genetic influences such as cholesterol handling, blood pressure regulation, insulin sensitivity and inflammation. So those can be decided by genetic influence. But those genetic risks express themselves within an environment we live in. So, what we see clinically is a patient with strong family history often benefit the most from early prevention because their risk is identifiable early, much earlier than the general population, and can be modified over time. So, a helpful way to frame it is that family history. Explain why risks may be higher, but our lifestyle, behaviour, environment and early intervention largely decide whether it becomes disease. In the book, there is a sentence I use which says Gene loads the gun, but lifestyle pulls the trigger. So, we may have the genetic risk factors, but what we do in our lifestyle habits may influence whether we take the path of, you know, to thrive in the future or decline and deal with the crisis afterwards.

MG: You obviously mentioned the factors of LDL hba1, C, and waist circumference is the big things that we need to be targeting. What lifestyle changes do you think are the most effective at optimizing these risk factors?

HB: Yeah. Thanks. So yeah, you're right. The easy parameters, as you mentioned, would be LDL Hba1 C your waist circumference and blood pressure doesn't require you buying an expensive gadget. You just need a blood test from your GP. And if tape measurement and BP cuff at home in terms of lifestyle changes. So, the most effective changes are not extreme. They are usually the ones that can be sustained. They are repeatable and can be sustained and compound with time. So, from a cardiovascular standpoint, the highest yield intervention are first of all, I would say regular low intensity movements, for example, brisk walking. Even if you manage to do twenty minutes a day, that's an effective way of improving our blood pressure, our insulin sensitivity, it reduces the triglyceride, improves our HDL, and eventually reduces apob, which some of the audience might be familiar with, which is the atherogenic particles, which eventually impacts on atherosclerosis. So that would be one intervention, you know, brisk walking every day, and he doesn't need to be a dedicated time. He can always be small interventions such as park a bit further away from work or the supermarket. It gets you to do a few steps, take the stairs instead of the elevator. So that's another way to add these micro movements eventually compound at the end of the day. Secondly, I would say sleep consistency rather than sleep optimization. So, setting set bedtime routines to go to bed at a particular time, no screen for an hour before bedtime, ideal room temperature, which I mentioned in the book. So, these are certain things that make sure our sleep consistency is there. Although I understand as doctors, we have shift patterns and this is not always possible. Hence are not focusing on sleep optimization but at least being consistent with it and aiming when we can at least, you know, seven hours, which is not always possible, but that's usually what's recommended. So that's something to bear in mind. I mentioned walking sleep. And thirdly, we'll be what we put on our plate. So, the main culprits, as we've heard in the news and everywhere else, is to reduce the amount of ultra processed food we eat. So that's a big factor. If we can reduce what's in our plate, ultra processed food, sugary drinks and things like cured meats, which is rich in sugar and in salt and adding things, usually I would advocate the pattern of diet, which is more like Mediterranean style diet. So, lots of fresh fruits and vegetables, beans and legumes, olive oil, avocado, olive oil, fish. So, if by adding those, good food eventually, naturally makes us avoid the unhealthy side of foods, which I mentioned ultra processed foods, sugary drinks, cured meats, and even alcohol. So, this will be the third intervention, the fourth and final one, I would say, which is, you know, the easy lifestyle change we could do is not eliminating stress. You know, we can't avoid having stress in our life, but finding ways to manage stress better, to prevent it from having any biological impact on our health. So, for example, make sure we have dedicated time to do some activities where we can, it can help us to wind down, for example, just going for a walk. Again, it ties down. Make sure we have a good night's sleep. May help with stress as well. It ties up to the other measures I mentioned, or sometimes just doing a few minutes of breathing exercises. So, there's box breathing or breathing exercises you can do. So, if you take a pause and just do some breathing exercises or mindfulness, sometimes that can have an impact on how we cope with stress better. So, these would be the lifestyle changes I would say can make the most difference with the limited time we have. So, these behaviours after multiple systems are notoriously. So, it will improve blood pressure, insulin resistance, inflammation and autonomic tone will all shift together. And what matters most is not intensity. It's more about consistency that compounds over time. And it is. Whether this change can fit into our busy lives is what matters. Hence, I suggest these small things that we can easily incorporate that eventually compounds with time.

MG: Perfect. I guess the only thing that's in the back of my mind and is probably the only thing that really left to cover. Not that preventative cardiology is such a small topic, but at what point do we say, I've tried everything? I'm doing as much exercise as I can. You know, I'm trying to get my sleep. I'm trying to drink my water. I'm having my Mediterranean diet. But those risk factors are still through the roof. So, you know, your blood pressure is still uncontrolled. Your LDL is still high. You're not losing weight. At what point do we need to turn to medical therapy as a form of prevention? Because I think some people say, okay, go away, do diet and lifestyle for six weeks, for eight weeks and come back and we'll reassess. Is there a set timeline that we need to be reassessing these risk factors?

HB: Yeah, that's a very important point actually. So, medication should not be framed as a failure of lifestyle. It usually works together. It is risk reduction. So, lifestyle will change the risk factors gradually over time. Whereas medications will lower risk usually quite much more quicker. So, medication therapy becomes appropriate when risk remains elevated despite reasonable lifestyle we've mentioned. Or for example there's a strong family history. Then in those situations we have to start medication quite early because lifestyle alone will not impact Biology or when markers are drifting upwards over time. So you see at what time, I would probably say over six months, one year, if your markers are still drifting in the wrong direction, or when you've had imaging or risk assessment showing subclinical disease, or whether someone had a coronary calcium score or they've done a Q risk, and that is advocating use of medication, I think that would be a good time to add it. On top of lifestyle used early and appropriately medications reduces lifetime exposure to harm and often prevents the need for invasive treatment later. So, the most effective strategy is not always lifestyle or medication. It is sometimes a combination of the two introduced in the right order in the right time.

MG: Yeah, we are doctors. We sometimes need to give medications, don't we? Yeah, indeed. Great. And very quickly, without wanting to open a can of worms. What is your take on weight optimization through injectable therapies? And do you think that this is needed as a way of optimizing prevention?

HB: So, I think that would be a good example of what we've just talked about. When is medication required. So, I think there is a role for these injectables for certain patients. If they've tried all the lifestyle measures and if their weight is still in the red zone or not going in the right direction, then there is a role to complement lifestyle for a short time, I would say and then reassess. It's not a long-term solution on its own. It should work together with lifestyle intervention after having tried it. There is a cost implication, but for some patients I think it will be beneficial. It needs to be individualized, and you need to reassess and it should be considered a short-term bridging therapy rather than long term solution.

MG: Thank you. I'm glad you said that. And maybe that's because it's my own personal opinion as well. But I think when we are coming into contact with these patients and having these discussions with them, it is important to focus on the fact that this is short term, because I think a lot of patients then, you know, think they don't need to carry on with all their lifestyle measures because the injectable therapy will just do what they haven't been able to do themselves.

HB: Indeed. Yeah, I agree with that. And also, one thing to mention is this is a relatively new therapy. And there's not the long-term data of the implications. What happened in people stayed on the long term. So, it's still a space to watch. And as you said, it's a short-term bridge to eventually doing something more sustainable for the long term.

MG: Perfect. So, before we close, what would be your advice to any doctor listening to us. Medical student who is coming into contact with patients with high cardiovascular risk. How can we start the discussions and the advice about optimizing the kind of prevention therapy?

HB: Yeah. So, I think that's something maybe we all can improve on. I have to admit; I was not really paying attention to this before I developed an interest in this recently. So, I think the ideal candidates, what I see in clinic, I'll just tell you my own experience, are someone in their forties. They've come to see me with non-cardiac chest pain, so I've kind of reassured them. It's not kind of, but they have certain risk factors that borderline blood pressure. Their HBA one C is in the pre-diabetic zone. The LDL is not optimal. So usually, I will have a brief chat with them. It's not usually one intervention that fits everything. Sometimes they will say they are doing everything right, but when you probe them or the sleep is not great, or they got, you know, quite a lot of stress in their life and the coping mechanisms are not there. Some of them may be exercising, but it's not about the volume of exercise. For example, they can't just exercise an hour in the morning and then you sit at the desk for eight hours. So sometimes you have to every hour you sit. Ideally, you should walk around for a couple of minutes and break that down. So those kind of things actually, I've summarized that nicely in my book, Hard Reset forty. Usually, I would advise them on these various aspects on their sleep eating, on their stress management movement. The idea is to develop a routine so that it becomes part of your daily life, rather than something you need motivation to go and do. And if you don't have motivation, you drop off it, so it becomes part of your daily life. It's small changes and then tracking. As you mentioned at the beginning, tracking is important because we can't drive a car without a dashboard to know what speed we're going, how much fuel we got left. So tracking is important where we stand now. It shouldn't become like an obsession, but it's a guidance of which direction we're going and what we need to change to kind of improve those parameters. So that's all summarized in the hard reset forty, which is a good resource, but you don't need to get that. What I've just mentioned, it's a multifaceted approach to eventually improve the parameters. Now that compounds of it's on and change the trajectory of disease.

MG: Great. I think that's the best place for us to end it, to be honest. So, thank you so much for your time. Thank you for your knowledge, and thank you for giving us tips that we should not only take forward for our patients, but for ourselves, slightly worrying about how important sleep is, I think for anybody working on an uncle rotor, but I guess it just means that it's a wakeup call that we should all be looking after ourselves because it will have implications on our health kind of later down the line.

HB: Yeah, that's a good closing line. I agree with you. And yeah, it's not only for the patient, but also looking at our own heart health. And eventually that can help to prevent burnout, which we see a lot in the NHS. Yeah. Perfect.

MG: So, Doctor Bullock, thank you so much for joining me. To our listeners thank you for joining me yet again. For more episodes of both clinical and career conversations. Please visit your usual streaming site. I will make sure that footnotes are present for this episode for both guidelines, Doctor Bullock's book, and any other resources which may help you with preventative cardiology. Thank you for joining me today.