Season 2, Episode 4: Optimizing Heart Health Through Prevention and Early Detection with Dr. Michael Twyman

Evelyne: I’m so excited. Dr. Michael Twyman is a heart attack prevention expert, the founder of Apollo Cardiology, and a board certified cardiologist. A decorated veteran, he served as a Medical Corps physician in the Navy and was appointed department head of internal medicine, while simultaneously earning his MBA. Following his military career, he continued his path in cardiovascular medicine, which led him back to his hometown of St. Louis. After several years in a hospital setting, Dr. Twyman recognized his passion for prevention. He now integrates the best of both conventional and functional medicine to get to the root cause of his patient’s cardiovascular issues. He serves in the role of cardiovascular director for the Institute of Muscle-Centric Medicine.

He’s recognized nationally as a speaker in the areas of cardiovascular risk reduction, mitochondrial health, and circadian biology. I’m excited to talk about that. We haven’t talked about that that much on the podcast. Having worked with world-class athletes and high performing entrepreneurial influencers, his mission is to educate his patients on how to live better and longer by optimizing their mitochondrial function to become heart attack proof.

Wow. Dr. Twyman, can you tell me a little bit more about your journey from practicing more on the conventional side to now more of the integrative and functional side?

Michael Twyman: Sure. So after I completed my active duty career in the Navy, I went back and did my cardiovascular training here in St. Louis, and was an invasive cardiologist for many years. But at some point, really got bitten by the idea that maybe there’s a better way of doing things instead of just doing pills and procedures. And found functional medicine through some patients that were bringing me information from primary care doctors that they were working with. And eventually, that piqued my interest enough to attend some conferences, and eventually came upon the work of Dr. Mark Houston, who I know you guys have interviewed before, and was inspired by some of the talks that he had given talking about endothelial health. And then, just kept putting that in back of mind of, “Okay, how do I keep implementing this into my practice?” And then back in 2017, I stumbled upon the circadian biology world accidentally. I was trying to mitigate jet lag and got a pair of these blue blocking glasses, and the jet lag wasn’t that bad.

So I just kept integrating these things that my patients would sleep better, their lipids would be better doing the things that we were doing that were not just stent-based. And four years ago, I decided this is what I wanted to dedicate my career to and launched my own practice, Apollo cardiology. And that’s what we do with patients is get to the root cause of their cardiovascular concerns.

Evelyne: That’s amazing. I love that you found out about functional medicine through your patients. That’s really cool. I definitely see that trend more on social media and people are asking and demanding from their conventional doctors to listen to their issues and to get educated on some of these things that we know in our world. So that’s amazing. In a nutshell, how do you help your patients become heart attack proof, like high level overview?

Michael Twyman: It’s a test, don’t guess philosophy because just looking at somebody from the outside, you really have no idea how healthy their arteries are, and you have nearly 60,000 miles of blood vessels and the blood vessel can start becoming dysfunctional in your teens and twenties. So you have a long time to intervene before somebody starts having a heart attack in their fifties, sixties, or seventies. And it’s mostly about helping that endothelial function be healthy. And then I know today we’re going to be talking about the glycocalyx and just how do you support the body’s ability to prevent the vascular disease from taking hold? Because it’s a lot easier to prevent it than it is to treat it at the end stages.

Evelyne: And I do think that most people in their twenties and thirties, we’re not thinking about our cardiovascular health 20, 30, 40 years down the road. How do you think that we could reach the 20-year olds? And I’m still in my thirties. How do we start to care about our cardiovascular health?

Michael Twyman: I think it’s just starting to ask better questions. Look at your family history. If your mom, dad are doing well and aren’t on a bunch of blood pressure medicines and lipid medicines, maybe you do just the conventional screenings in your thirties and such. But if you have family history, and I had a strong family history on my mom’s side, everybody should start getting screened earlier. And you can check your lipoproteins when you’re in your teens and know if you have high lipoprotein A or high ApoB. You can monitor your blood pressure at any time. Blood pressure is still the number one thing that damages your arteries.

And so if you start noticing that those things are creeping up, you probably need to do something about it. But I do understand, people in their twenties, they think they’re invincible and they can run on pizza and beer and they just keep going. But eventually, that does catch up with you and most of the time it starts catching up right around when you’re 40.

Evelyne: Yeah. And for the practitioners listening, is cardiovascular health something that we should be testing in every patient? I think it gets overwhelming, right? Because a lot of practitioners focus on say, gut health or hormones. We know they’re all interrelated, and of course those are connected to cardiovascular health, but I think we’re not always necessarily doing advanced cardiovascular testing or even… Well, I guess you get your blood pressure measured when you go to the doctor. But how do you think as practitioners, we can incorporate this without maybe overwhelming patients or clients?

Michael Twyman: No, it’s a very good point, but I always start with that vascular disease is still the number one thing that kills people. And every 40 seconds, somebody has a heart attack. And so yes, it’s important to focus on their nutrition and their exercise and their gut health. But if people are dying of heart attacks, that’s kind of a challenge. So you have to go looking at the root cause and figure out did this person have endothelial dysfunction and start trying to repair that. And there’s some very simple lifestyle things you can do first. And then yes, if you’re getting into doing some of the testing, we can talk about that, but it’s not as complicated as people think. My practice is very niched down where that’s what people are coming to me for and they have all the toys to be able to do things, but there’s always kind of like a starter pack and it’s blood pressure, nitric oxide availability with oral test strips, a few labs, and just get the ball rolling.

Evelyne: Great. I actually have more of a question around that. So who is your typical patient? And then you mentioned the nitric oxide strips. What other tests do you run on? Pretty much every patient who walks through your door?

Michael Twyman: So my practice is still a growing practice and it’s skews just a little bit younger than a traditional cardiology practice because most patients are coming to see me have not already had events. They have not had a heart attack, stroke stents or bypass surgery. They’re trying to stop having one or prevent one I should say. So my average patient is probably about 56 years old. A little bit skewed more men versus women. But that’s a good point that many times men don’t seek care until they have symptoms. And women, they don’t always seek cardiovascular care because it’s not top of mind that cardiovascular disease is still the number one thing that’s going to take them out early. They’re very concerned about breast cancer, which is important, but eight times more likely you’re going to die of heart disease than you are of breast cancer. And so I skew about 50-50 on the sexes, but the ideal patient is really anybody who cares about their cardiovascular system.

So we have people in their twenties that work with us. They have very strong family histories and they just want to know what genetically did they inherit from their parents. We can do some of the starter test to tell us how healthy the endothelium is. They don’t need advanced testing where you’re looking at the coronary arteries of that age usually, and then we just follow them serially.

But typically, somebody in the 35 range really should start thinking about like, I probably should get a baseline and see what’s going on with my cardiovascular system. And most of the time you’re going to not find a whole lot and that’s good. You’re in the low risk bucket, stay there. But I recently saw a gentleman who was 36 years old and was incidentally picked up on a CT scan that he had a bunch of calcium in his coronary arteries. He ended up getting a CT coronary calcium scan and his score was almost 1400, which is a very, very high finding for anybody, especially for somebody under the age of 40.

And so he wouldn’t have known that he had that unless he got that test. Fortunately, he’s asymptomatic and we’re going to figure out the root cause of what’s driving that plaque in his arteries and stabilize it. But those are the things that we try to do here is just looking at somebody from the outside again. You have no idea what’s going on on their inside. And that is the story of Bob Harper, the guy from the biggest loser. Very, very fit individual, but in his early fifties had near fatal heart attack in the gym. And people were like, how could this possibly be? He looks very fit. He must eat clean. Well, he had lipoprotein little A and he had a widowmaker plaque rupture. So fortunately the medical teams were able to save him, but if he had advanced testing before that, and I don’t know any of his backstory if he ever did or not, he would have at least known he had been in that higher risk category and maybe could have done something to try to mitigate those risks.

Evelyne: So with the testing, can you tell us a little bit more about which tests you are running?

Michael Twyman: So it does depend a little bit on what the patient’s coming in with. But a traditional patient who’s just screaming head to toe, what is my vascular health? Starting up high, we would do an oral salivary nitric oxide test, and there’s various vendors that make the test strips. If it’s white, you don’t make a lot of nitric oxide through that salivary pathway. If it’s bright red, you do. And mostly that’s about having a healthy oral microbiome and having the inputs, the nitrates to be able to make that happen, that reaction happen. So that’s dark green leafy vegetables and beets for the most part.

Then we do testing that looks at pulse wave velocity, essentially how fast do the arteries expand and contract? It looks like a pulse oximeter and the arteries should be very elastic, will be a type one artery. The artery is expanding and attracting very quickly. If the arteries a type six or seven, the artery is like a lead pipe, it doesn’t relax well. That’s often an issue with nitric oxide.

We have a device that looks at blood pressure, which is a surrogate for how healthy your arteries are, especially the central blood pressures, which is what this device is calibrated towards. The central blood pressure is the blood pressure that comes out of your heart and the blood pressure that goes down the heart arteries, the brain arteries, and your vital organs. That blood pressure really should be less than 120 over 80 and ideally 110 over 70.

We have a device called the EndoPAT. This is a little bit more of a niche device, so not a lot of cities will always have this device. But this device is basically like a stress test for the arteries and tells you how much, percentage wise, the arteries can dilate with a vascular stressor. So a 15-minute noninvasive test that there’s a blood pressure cuff involved where you pump up the blood pressure cuff higher than their systolic blood pressure. So you temporarily cut the flow off to their one side of their arm and there’s probes on each fingertip. After five minutes, you open up the stopcock, the blood rushes back down into the arm, and they you have what’s known as reactive hyperemia. So the reactive hyperemia causes nitric oxide to dilate the smooth muscle in the artery wall, and then the flow rushes back down to the hand and the person’s hand wakes back up.

The device calibrates a score called the reactive hyperemia index, and a normal score should be greater than 2.1, which means that the artery is at least double in size when there’s this vascular stressor. But optimal is a three to four. So if you’re not at three to four, you got to figure out what’s in their blood or in their lifestyle that’s not allowing them make sufficient levels of nitric oxide. Because I tell patients this test is sort of like the force field test. Is your force field up, I should say you’re less likely that the cholesterol particles are going to be sticking to your arteries in your developing plaque, but if your force field’s down and this can happen in your teens and twenties, you have to intervene because otherwise, they’re set up that things are going to go along, well, eventually they’ll start developing vascular inflammation and plaque in their arteries. So those are kind of the starting points. And then there’s a whole battery of blood tests that we do.

Evelyne: Okay. And you mentioned the EndoPAT, which Dr. Mark Houston also mentioned when we did our interview. What were the other two devices I think people will want to know?

Michael Twyman: The one that we use is called the Max Pulse, but there’s some various vendors that have this pulse wave velocity testing, and then we have a device that measures your central aortic blood pressure and that device is called the ATCOR device.

Evelyne: Okay. Great. Thank you. So I’ve been reading more about nitric oxide and really trying to wrap my head around understanding this and the pathways by which it’s produced. Can you tell us more about those?

Michael Twyman: So nitric oxide is a critical signaling molecule that in the vascular system helps vasodilate the arteries, but it also acts somewhat like a Teflon coating that the higher the levels, the nitric oxide you have, the more it can repel the cholesterol particles from sticking to the artery in the first place. And the main place that nitric oxide is produced is on the endothelial lining. The endothelium is the one cell thick layer that lines entire luminal surface of the blood vessels. And if the endothelium is impaired and nitric oxide is low, that is when the cascade where plaque may start building in the system.

After the age of 40, there’s an enzyme called endothelial nitric oxide synthase that tends not to work as well as before. As everybody ages, their enzymes slow down on how fast the reactions happen. And so there’s a backup pathway, inter salivary pathway where nitric oxide can be produced. So with dietary nitrates, which are mostly in the green leafy vegetables and beets, if you have a healthy oral microbiome, the nitrate reducing bacteria in the saliva will break down those nitrates. You swallow them and they become nitrites in that process. And as long as you have stomach acid, the conversion will happen where you ultimately will make nitric oxide.

So this is one of the cases where many times when people have low salivary nitric oxide, it’s removing things from their environment so that the oral microbiome can be recovered. So if people are using antiseptic mouthwash, they destroy the oral microbiome. You don’t have the nitrate reducing bacteria, so you can eat all the beets and the greens you want. You’re not going to make nitric oxide through that pathway.

And the second thing is if you’re blocking stomach acid with proton pump inhibitors or H2 blockers, you’re not going to be able to make enzymes as efficiently. You can’t break down proteins well without acid. So you will often want to try to remove certain things from their environment to try to get those pathways back online.

Evelyne: That’s really interesting about the stomach acid because I think sometimes when we’re thinking about cardiovascular health, we’re maybe forgetting about gut health. Do you use digestive enzymes in your patients to help with that?

Michael Twyman: At times I will. Many patients we’re working with other function medicine practitioners who are doing the gut optimization part of it, and so I will often recommend it if they can’t… I probably have a little bit different take on how to optimize your protein intake. But if you don’t have enough stomach acid, then you’re probably going to have to use some digestive enzymes to help that process along.

Evelyne: Okay. I want to talk more about the oral microbiome because I find this really, really interesting. So I was doing a little more reading. I know that smokers, especially, their oral microbiome, I don’t know if I should say it gets destroyed, but smoking impacts nitric oxide production, right? And so I’m curious about vaping. And so I did a little search on it. I don’t know if you probably don’t see people who vape because of the types of people you attract. And I think generally it’s not something we’re probably around, but I see people in their twenties, especially, just out and about vaping. And so interestingly, I actually did find some articles that show there’s a correlation, which was very interesting to me. So I think this is a huge problem. I was wondering if you’ve done any research on this or have anything to add to that.

Michael Twyman: I haven’t done any particular research on it, but it’s back to the traditional smoking cigarettes. That’s one of the worst things that you can do to damage the glycocalyx and the endothelium. Now it’s the heavy metals and everything else that comes along with it. And that’s probably one of the ways that the vaping also causes is an issue. It’s not going to be the nicotine, it’s the other inhalants that are coming with it. And often there’s some heavy metals that you might get exposed to. And so anything that disrupts the oral microbiome, fluoride, mouthwash, are something that some people just have chronic abscesses or oral infections that are dysregulating the oral microbiome. So there are companies that are very close to developing consumer facing products where you could actually test your saliva and figure out do you have these nitrate reducing bacteria? And if the answer is no, there’s going to be probiotic type of gums and other things that can try to repopulate the good guys.

Evelyne: Very, very interesting. Yeah, the article I saw was based on two articles that were published in the Journal of Arteriosclerosis Thrombosis and Vascular Biology, so we can link those. I thought it was interesting because even though we might not see these patients in our practice, I know a lot of practitioners are on social media and I feel like we need to spread the word. Just like you were saying, we need to pay attention to this in our twenties and thirties. And I think people think that vaping is somehow better, but obviously, it’s not.

Michael Twyman: No.

Evelyne: So from my understanding… Well, you talked about beets already and I think that’s the traditional way that we think of increasing nitric oxide in the body. But then, what are some of the other supplements or some of the other nutrients that we can use to increase nitric oxide production?

Michael Twyman: So before we even go down the supplement or the medication route, it’s the other lifestyle things. It’s exercise. That’s the number one antiaging drug. And it’s because that reactive hyperemia occurs with exercises. You increase your heart rate and had to pump more blood to the muscles, you force the blood across the glycocalyx and it’s going to cause more nitric oxide to be released from the endothelium. And then you start upgrading certain enzymes because the body’s like he’s probably going to exercise and run again, so let’s get ready for when he does it again.

And then the other one is sunlight. It’s the UVA spectrum of sunlight when it hits your skin, liberates nitric oxide from the blood vessels. This is one of the reasons when you’re out in the sun, your skin starts turning pink. It’s not necessarily that you’re burning, it’s that the blood vessels are coming to the surface and they’re dilating with the nitric oxide release.

Evelyne: Very cool. Okay. Let’s do a little segue into the circadian rhythm here before we go back to the supplements.

Michael Twyman: Sure.

Evelyne: So tell me more about this relationship between our circadian rhythms and nitric oxide production and cardiovascular health. How can we optimize this to have downstream effects on our cardiovascular health?

Michael Twyman: So I often talk with patients that there’s four main levers to optimize your health. And nutrition and exercise are important, but I often will start with stress mitigation because we’re all under stress. That’s not necessarily a bad thing, but it’s how do we manage it? And then the part that’s usually not as sexy to discuss is like how well people are sleeping. Because if you don’t sleep well, you will not age well. Now behind me is a mitochondria. The mitochondria, the organism, your cells that make energy for you. They repair themselves while you sleep. They’re the engines that are going to be combusting the fuels, the organic healthy foods that you’re putting in the system. If you don’t sleep well, it’d be like you never took care of your car, you never change the spark plugs, and then you expect that car to go 200 miles an hour the next day when you’re putting in premium gas.

If you don’t tune up the engine, nothing’s going to go well long-term. And one of the biggest drivers to your circadian rhythms are the light environment you decide to live under. And so for those that are watching video, I’m wearing the blue blocking glasses because I want to protect my melanopsin receptors in my eye so my body knows what time of day it is. Your body’s always trying to seek out what time of day it is by cues. Light cues, food cues, foods coming into the system, the body’s like person must be awake, they’re eating now.

So the light one is the biggest zeitgeber, or time giver. And so in an optimal day, the first light that would hit your back of your eye would be sunlight. And then throughout the day you’d be taking sun breaks and your body would be sampling what color blue the sky is. And your body would know, oh, it’s noontime, it’s 3:00 PM. And then when the sun sets, no more blue light hits the back of the eye and the body realizes, oh, it must be nighttime. And then three to four hours later you should be asleep.

But people today, they get stuck to their devices and their devices basically are set at the exact same color temperature as solar noon. So the body keeps getting hit at noontime every time they’re looking at their phone at 10 o’clock at night. And that’s the time when your body’s going to pop up more and more cortisol. Cortisol is an alertness hormone, but the cortisol directly damages the glycocalyx, raises your blood sugar. Patient’s like, I’m not eating any carbs. Well, how much cortisol do you have? How much blue light do you have? That has a big driver of your blood sugar is the cortisol load. So if you’re not sleeping well, you’re not repairing the cells. I don’t think it has so much of impact on your nitric oxide production per se, but it is one of the things where I’m talking about that first and then we go down to the vascular health profiles because sleep is tied to everything else.

Evelyne: So I have two follow up questions for you. One of them is, so I already have f.lux On my computer, so it does dim the brightness over the course of the evening or night. And I told you before we started that I tend to stay up very late and then I turn my phone down pretty much all the way in brightness by the end of the day. But is that still blue light if there’s no sort of orange blocker on?

Michael Twyman: It still is. Correct. It has to be a physical blocker for the most part. Those softwares are good. They’re cutting it down. Downside of being maybe like a fire hose of blue photons in your eyes, it’s kind of like a garden hose, but there’s still photons of blue light that are hitting that receptor. And so those devices are great to kind of help with eye fatigue, having the software that filters it out. But unless the screen is red, red, you’re still going to potentially be affecting your circadian biology with that.

Evelyne: And then, I really haven’t been good with wearing glasses, my blue blocking glasses even at home in front of the computer. But I’m curious, you’re wearing them during the day right now. But what’s the idea behind wearing them during the day if you’re trying to tell your body to still be awake? Why would you not use them later on in the day?

Michael Twyman: The key time to be wearing them is post sunset when the body would’ve just seen darkness. So until they invented the light bulbs in the late 1800s. It was dark or you had fire, you had red light. So if you have the red light bulbs at home, you don’t necessarily need to be wearing these things. But the reason I wear them during the daytime is when I’m in front of computers. The computers are set at 5,500 kelvin, and so it’s past noon where I’m at currently, so I don’t want my body to think that it’s still high noon. And so these particular lenses, they block about 40% of the blue light. So you don’t want to block all blue light because the blue light by itself is not necessarily bad. The sky is blue to give you energy and information to your body. But it’s how much blue light is being sensed by the melanocyte receptors in the eye.

So I wanted to kind of mitigate a little bit of it, and I’ve been pretty circadian trained since 2017, so I don’t necessarily need to wear these to sleep well. But when I track my sleep, which I don’t always do, the sleep tends to be better when I do this, so I keep doing it. But in the evening, there are lenses that are much darker than this, the red super biohacker ones, I will literally be unconscious in half an hour if I put those things on. So I rarely would need to use those. I only really use them for jet lag mitigation.

Evelyne: Very interesting. Thank you for explaining that and expanding on that. And since we’re on the topic, I was reading that one of your areas of expertise is on photo biomodulation, which I had to look up that used to be called low level laser therapy. So I see this promoted by biohackers. I see it a lot on Instagram. Everybody’s buying red light panels and doing red light face masks. So I guess to me… Because these are not inexpensive generally, I kind of think if your diet, lifestyle, stress management, sleep is not optimized first, then maybe don’t bother with it. But do you agree or disagree with that? And when do you recommend it with patients?

Michael Twyman: So it depends on how large of a panel or wrap or other type of device they want. But there’s some devices that are outstanding that are $200. You don’t need a hundred thousand dollars red light bed to get benefits.

And so start with, what is it? Photo BI modulation? It’s using light therapy to change your biology. So this was discovered accidentally in the sixties. They were doing research in cancer on mice and they shaved these mice’s abdomens and they were trying to use this red ruby laser to induce cancer in these animals. And what they actually shown was that the wounds healed quicker with the light therapy and the fur on the animal grew back faster, and they didn’t know why.

And then eventually, when they worked out the science, it was that the red spectrum of light was stimulating the mitochondria and the mitochondria is making more energy with that light therapy. And so most of the research was in Russia and in Europe. And because of the Cold War, a lot of that literature wasn’t translated over here until the nineties. But it was NASA that really kind of got the big ball rolling in the US because they were trying to develop different lights for the space station for growing food up there.

And then they realized that the red light therapy was more beneficial at helping musculoskeletal injuries heal. And that’s the general best use case for these panels is to speed up wound healing, speed up musculoskeletal injuries. And last time I think I looked, there’s like four or 5,000 articles on PubMed about photo bowel modulation. So it’s not new, it’s not a fad and it’s probably here to stay. It’s just the use cases are going to continue to expand.

So how do I tend to use in my practice, it’s mostly to show people how it can be used to help… If you sprain your ankle, how do you get the ankle healed faster so they can get back to exercising. There are some novel cardiovascular use cases for it. There’s studies that were done in Israel that showed patients had smaller heart attacks when they were treated with light therapy at the time of their heart attack.

It was a pilot trial, and it hasn’t been duplicated yet, but it showed that at least it was safe in the instances of myocardial infarction. So how did it actually work? It was actually that it was stimulating mesenchymal stem cells and those stem cells were going to repair the damage of the areas that were ischemic. And so you can activate your stem cells that are in your sternum or in your tibia with these type of devices. And so, that is often how I recommend patients choose them as they shine the light on their sternum or their tibias and let the stem cells go to work to wherever they need to be repaired.

Evelyne: Fascinating. So do you recommend the handheld devices? Do you recommend panels?

Michael Twyman: This is where it kind of is still the wild west out there because it is challenging to know what you’re looking for because there’s a couple of variables. It’s like cooking is why I tell people. First, you need to know the wavelengths. So the colors of the light, they’re generally going to be red and infrared light. The infrared penetrates it a little bit deeper. You’re going to see where it’s like nanometers. So 660 nanometers is red, 810 nanometers is infrared. And there’s some different use cases, but generally it’s going to be some type of red and plus, minus you’ll have infrared with it. Then there’s going to be something called the irradiance or the power density. That’s essentially how many photons of light are coming out of the device. It’s be measured so called milliwatts per centimeter squared. And so higher power does not necessarily mean better device.

This would be like cooking a turkey in boiling oil. You can do it, but is that the best way to do it? Not really. It’s kind of low and slow. And then it’s like if the power of the device is too low, then that’d be like trying to cook the turkey with a flashlight. It’s just not going to work. So you need certain power density to work. And then it’s the time. Again, you could cook something for three seconds, probably going to burn it. Or you’re going to try to cook something for 24 hours, maybe it’s going to work, but there’s a sweet spot.

And so, that’s why I get asked a lot like, “Well, how often do I use this device?” It depends exactly what the specifics on the device are, how much you use it. It’s the dose that you’re looking for. So it is a little bit challenging. So you do have to work with somebody who has some experience with this, or if you’re buying a device from a company, look at the specs of their device and see what are their use cases for that device. But for the most part, most people should not be using these devices hours a day. These are like five to twenty minute type sessions.

Evelyne: Gotcha. And for practitioners listening, are there any resources you recommend for how to get better trained in this and how to use it with patients?

Michael Twyman: So there’s an organization, the ISLA, the International Society of Laser Administration, they have training courses. I personally did a course with Floor Medical. They’re out of the UK. It’s an outstanding eight-hour course, and they go from the basics to the advanced, and then you really understand what is the potential use cases for this. My mind was spinning when I was sitting through that when I was like, oh, they’ve already been researching this for treating myocardial infarction. They’ve already been researching this for trying to treat high blood pressure. The data’s just not firm enough yet to have this be a strong use case.

But it’s something where you should start educating yourself about this particular one because this one is not going to go away. There’s just going to be better and better devices. And you had asked me about what is the best type… Honestly, it’s not going to be the panels because you can’t really control for the dose with the panel per se. It’s going to be eventually they’re going to have more topical devices where you can actually modulate the exact dose the person receives.

Evelyne: Very interesting. Thank you for sharing that. I want to go back to the supplements-

Michael Twyman: Sure.

Evelyne: Because now we covered the diet and lifestyle. And what are some of the supplements, I know most people are familiar with beets for raising nitric oxide. What are some of the other ingredients that we can look for?

Michael Twyman: So the one challenge with the beets is you have to know where the beets are grown. Dr. Nathan Bryan did some research a few years ago where they sampled beets from, I believe five different cities, and there’s a completely variability of the amount of nitrates that are in the products based off the soil conditions. And the other thing that is not as much of a fun fact is that… Or I should say it is a fun fact, is that most people would like to probably eat organic foods to avoid the pesticides and the other things, but organically grown food has less nitrates in it because they can’t add nitrates to the soil. So you might not be able to eat enough organic beets to get a true dose of nitrates through your diet. You have to get 300 milligrams of nitrates to kick off that pathway. There are some commercially available products.

There is a Beet It juice that’s often used in Europe and that come like a little shot glasses and shoot back 300, 400 milligrams of nitrates. That’s something people can do. It does taste a little bit earthy, but it works. And then there’s other companies that have developed oral dissolving lozenges. There’s companies that have developed longer acting capsules. And so, you can just supplement with people can’t get it through their diet or they can’t withdraw the things that they’re doing, like they can’t get off the proton pump inhibitor, or they just don’t have the OR microbiome, then you can give them products that help their body actually make nitric oxide then. There is a product from a company Calroy, called Vascanox. Vascanox is a nitric oxide promoter. It has a long use case where the effective of nitric oxide will be around for at least 24 hours. It’s two capsules once a day.

But one of its things that makes it a little bit unique is that it does also promote the release of hydrogen sulfide. And the hydrogen sulfide is vasoactive, dilating the arteries, but it also acts like a phosphodiesterase inhibitor. So the Viagra type medications. So your nitric oxide is coming in through the food stuff that you eat, exercise, the other components of Vascanox, and then the hydrogen sulfide is basically keeping the nitric oxide around longer. So you think of, you’re filling the funnel up with nitric oxide and then it just can last longer.

Evelyne: Interesting.

Michael Twyman: The quick side note is this is the reason why 50% of the time that guys who take medications like Sildenafil don’t get an effect from it. Those medications don’t actually give you nitric oxide. They just help keep the nitric oxide around longer. And so if you can’t make it, they’re not going to work. So the Vascanox has something that gives you nitric oxide and then helps keep it around longer.

Evelyne: Interesting. And so that hydrogen sulfide is coming from the black garlic extract, right?

Michael Twyman: Correct. Correct.

Evelyne: And usually, I’ve thought of black garlic extract, like the H black garlic extract in cardiovascular health, but not necessarily in this application. So that’s really interesting. So I spoke with Dr. Mark Houston, who was one of the…. Well, he was the principal investigator right on the Vascanox trial. And so one thing we didn’t discuss was how to take it and when to take it. And I noticed the recommendation is to take it in the morning. Why is that?

Michael Twyman: Just that I think it’s probably just ease of use. I personally take the product, I’ll disclose that, and that’s the time I take is two tablets in the morning time. You can take it with food and it does have over a 24-hour effect where the nitric oxide levels will be high enough. Some of those other products on the market do work well, but sometimes you have to take them twice a day. So I think it’s just a kind of a compliance, just make it easier to have it first thing in the morning.

Evelyne: And since you’ve used this product in your patients for a while, I’m curious, what are some of the effects that you’ve seen? I know that, obviously, we always want clinical trials, right? But I feel like what this podcast, what practitioners love to hear is what did you see in your practice? How did it change things in your practice versus maybe other things that you were using before? Do you have any stories that you can share with us?

Michael Twyman: Sure. So in my practice, I have all the toys in my office to be able to test vascular health. And so often when patients use products like Vascanox, the first thing that will improve is going to be the pulse wave velocity. So they’ll see the RDS going from stiffer to more elastic, and that can be within just a couple of days.

Evelyne: Wow.

Michael Twyman: That can change from a type three to four to a one to two. Now it takes a little bit longer for the blood pressure to kick in, but usually within a couple of weeks their blood pressure should be decreasing as well, if they already were hypertensive. If you’re normal tensive, it’s not going to get you hypertensive and get you dizzy. But from Dr. Houston’s study, it would generally lower your systolic blood pressure by about 10 points. And so that’s about the same equivalent as a calcium channel blocker ace inhibitor medication. So you’ll see the blood pressure.

One thing that works a little bit more nuanced, and I don’t see it always, is that I don’t always see the oral test strips go from white to red with these types of products because it may just be that oral microbiome is still dysfunctional. So you’re just kind of bypassing that pathway and the nitric oxides working directly on the endothelium. So I don’t get terribly concerned if somebody’s taking Vascanox or these other nitric oxide promoters and their salivary test strips don’t light up. It just may be a marker of they still have a poor oral microbiome. And like I said, there’s companies in development that are going to be able to test your saliva sometime this year and tell you like, okay, you’re one of these people. There’ll be other products eventually that’ll be like a prebiotic that hopefully can kind of bring back those nitrate reducing bacteria then.

Evelyne: Interesting. And I know we talked about things that are bad for oral microbiome like the smoking, but how do you address the oral microbiome in your patients?

Michael Twyman: So yes, first, always try to do no harm. Try to remove the things that are doing the damage. So yes, if somebody who’s smoking or vaping, they got to quit. There’s nothing healthy about it. We talked a little bit about it was using antiseptic mouthwash. You don’t want it to be disrupting the oral microbiome. You don’t know what you’re doing when you’re using them. And I get that question often, what about this organic or this that? And don’t know.

You have to be your own kind of Guinea pig. So test with the salivary nitric oxide strips. Your levels are bright red, use whatever product. All of a sudden you’re white, then you know disrupted that oral microbiome. Again, that test will come out hopefully soon that can tell you are you at risk for it with your product actually damaging the oral microbiome fluoride. So however you get fluoride, so if it’s in your water or toothpaste that can disrupt the oral microbiomes. We would like to try to avoid that. And then, we talked about the stomach acid. So you got to have stomach acid to digest your protein. So trying to do things that help with digestion is always key as well.

Evelyne: Great, thank you. And you’ve mentioned the endothelial glycocalyx a couple times and endothelial function, we’ve brought it up quite a few times on the show in the context of long COVID. Every cardiologist we’ve had on, we’ve talked about it. So because it’s a sort of newer concept in our field, I’m curious how your practice has changed now that you’re focusing on this versus maybe some of the things that you were doing before.

Michael Twyman: So I think it was more of an iteration than it was a major shift because I’ve been looking at the endothelial function since I first learned about it from Dr. Houston, Nathan Bryant back in 2013 or so. And so the glycocalyx was just kind of a natural, oh, okay, this what’s protecting the endothelium. So the patients, I tell them like the glycocalyx is like a protective gel coat. It’s Teflon. It’s protecting the endothelium. And they struggle, like what does that mean? Well, if you took a fish out of water and it’s slimy, that slime is essentially the glycocalyx of the fish. That’s what’s coating your arteries. And if that glycocalyx is healthy, it’s going to be heavily negatively charged. And that negatively charged glycocalyx is going to repel or push away the lipoproteins, push away the white blood cells from sticking to the arteries in the first place.

So yes, lipids are important for atherosclerosis. But if you have a healthy glycocalyx and endothelium, you don’t have to be as concerned about the lipoproteins. It’s going to be repelled most likely. And so you can tell that by doing these non-invasive tests. This person’s arteries are very elastic. I’ve looked at their carotid with the carotid intima-media thickness scan. I’ve done a CT scan that looked at the coronary arteries. They don’t have any demonstratable plaque. They must have a good glycocalyx. Stay the course. But if you see a lot of plaque in the person’s arteries, you know their glycocalyx has been damaged at some point, and then you may need to do some more regeneration for it to put the force fields back up.

Evelyne: Interesting. And since you’ve been working more on supporting the endothelial glycocalyx, do you have any cool patient success stories of maybe somebody where you weren’t seeing a difference in plaque and then all of a sudden you started working on this incorporating endothelial glycocalyx support and then noticed significant changes?

Michael Twyman: So plaque regression is definitely possible, and I definitely have seen it in my practice, but it’s always… I tell patients first you got to find it that you have plaque because if you’re waiting to have symptoms or you’re waiting to have an abnormal stress test, it’s really late. You have severe plaque at that point. So the first goal is find it. Second is stabilize it, prevent it from progressing on to the point where the plaques rupture. And that’s often the best win. Even if you can’t get the plaque to regress, you still win as long as the plaque doesn’t get vulnerable, inflamed, and rupture. So we have a lot of those types of wins where we find these people with these five alarm fires on their blood work, add the appropriate nitric oxide promoters and glycocalyx promoters and put the force fields back up and let the body go to work at repairing the underlying damage.

And sometimes it’s kind of a long game, but sometimes it’s kind of the happy accidents is like you talked earlier about COVID. That’s definitely not my area of focus, but I’ve had a lot of patients with COVID, and we realized that was an endothelial disease essentially. It’s like, oh, I have all the tools to help support that.

And so, when these patients will come in and they had long haul type of symptoms, they often had abnormal pulse wave velocities and abnormal central blood pressures and abnormal EndoPATs. Like, okay, we’ve got to support you with nitric oxide promoters. And then we would do that and then it’s more anecdotal, but you get the people come back like, “Hey, I can smell again. My taste came back. It’s been gone for a long time.” Yeah, the microcirculation of your olfactory nerve came back online. So if it’s improving there, it’s probably going to be improving in your heart arteries as well.

Evelyne: That’s amazing. This might be sort of a repetitive question, but I’m just trying to understand it better. Tell me more about the relationship between the endothelium and nitric oxide, because I’ve sort of thought of them as separate things.

Michael Twyman: So the endothelium is one cell thick. It lines the entire luminal surface of the arteries, and one of its jobs is to secrete nitric oxide. Nitric oxide is a signaling molecule. Now, it causes the arteries di vasodilate. It causes the smooth muscle in the artery to relax. Nitric oxide also is kind of a chemo repellent. Then the white blood cells and the cholesterol particles don’t stick to the artery wall.

It’s a conversion of arginine to citraline with the enzyme endothelial nitric oxide synthase. Now the person is not low in arginine and they’re not low in citraline, it’s that enzyme doesn’t crank as well once you continue to age. And so that’s why if you’re just taking a arginine supplement, they’re often not going to work. It’s not that you lack arginine, you can’t get that enzyme to work. So that is one of the things. Now endothelium does other things, but one of the most important is that it’s that secretion of nitric oxide.

Evelyne: Interesting. Okay. Thank you. And something you said triggered a thought in me, and I might be totally going on a limb here, but so you said that a lot of times your patients come in and they don’t necessarily have this plaque yet, which is great. So would you ever recommend taking a product like Arterosil kind of preventatively or yeah, how do you determine when you actually use that if maybe there’s not plaque present?

Michael Twyman: Correct. That’s the kind of slam dunk case is somebody already has significant plaque in their arteries and you’re just trying to support them at that point. But as a complete preventative, I probably wouldn’t. But if I saw evidence of that the artery stiffness were high, that endothelial dysfunction, if their blood pressure was not 120 over 80, I’d be considering it. While I was doing the workup to figure out like, okay, why is this not optimal? Is it high homocysteine? Is it high uric acid? Is it high asymmetric dimethylarginine? Or something else that’s driving oxidative stress? So trying to find the root cause and shutting it off. But sometimes you don’t necessarily need something for lifetime. You want it to support the body when you need to.

Evelyne: I’d love to talk about an area of cardiovascular health that we have not discussed on the podcast before and that’s erectile dysfunction. And I know that the incidents drastically goes up when men get into their sixties and seventies. And last year in San Diego, I actually hosted a talk for practitioners with a local doctor whose specialty is ED, erectile dysfunction. And the title of the talk was Erectile Dysfunction as the Canary in the Coal Mine for Heart Disease. And he uses supplementation to support the endothelial glycocalyx as part of his treatment. And I’m curious, when you’re treating ED, do you find that when a patient comes to you with symptoms of this, that you see in their labs that they’re having issues or do you more take it as a warning? I guess it depends on their age, right? Because obviously, if you’re older it’s more likely that you have cardiovascular issues. But I’m curious what your experience is in practice around this.

Michael Twyman: So that is an area that I definitely focus on because it’s important to men’s health and it is… I’ve definitely used that terminology. It’s the canary in the coal mine. Most guys come and see me directly. That’s not their main concern, but we’ll bring it up and they’re like, “Oh, I didn’t realize they were connected.” I often use the analogy and I learned it from somebody else. I’m sure ED equals ED. So erectile dysfunction equals endothelial dysfunction until proven otherwise. And then, since it does go up as your age, because vascular disease tends to go up as your age, and it’s roughly percentage wise by your age. So if you’re 40, there’s a 40% risk that you’ve had ED at some point. And when you’re 70 years old, there’s about a 70% chance and you have to figure out, okay, is it vascular or not?

So if somebody comes in complaining of those symptoms, you want to try to remove the low hanging fruit. So if they’re drinking too much alcohol, if they’re potentially on a beta blocker. Beta blockers often have that kind of side effect and make sure it’s not a psychological issue. So if somebody has performance anxiety or depression… Okay, well they need a counselor behavioral therapy and then the sexual function might improve.

But it is one of those things where it’s like if that’s something that’s high in the guy’s mind, so it’s probably something that’s the primary care doctors or the urologists are probably seeing a lot of it. They probably need to go get a vascular work up and say, “Okay, nope, the vascular system checks out okay.”

Evelyne: Very interesting. So tell me a little bit more about your treatment. Any clinical pearls when it comes to erectile dysfunction?

Michael Twyman: So the big thing is it’s the microcirculation is the problem. The microcirculation is smaller than the human hair and 99% of your blood vessels are that size. And so you’re doing things that support the glycocalyx such as Arterosil, and if you need nitric oxide support, products like Vascanox will help with that. There are other ones, but those are the ones I tend to use most in my practice.

And you will see that if their arterial elasticity scores on the max pulse are improving or their endopap scores are improving, they’ll often anecdotally going to be telling you like, “Hey, my erectile issues are a little bit better.” And I said it earlier, saying I’m not opposed to people using the medications like Sildenafil or Tadalafil , but sometimes you’ll actually see it… If you give these nitric oxide promoters and then add that, they get a much better robust response.

Evelyne: Interesting. Thank you. I also noticed that you use the Cleerly Scan, which also came up in that talk that I did with a practitioner here last year, and I thought the technology was really interesting, but I haven’t heard you mention it today, so I’m curious about it.

Michael Twyman: Yeah, the Cleerly Scan is a fascinating use case of AI. So coronary disease, non-invasively, you can assess for it a couple of different ways, but kind of the most novel way and the way that you get the most data is using a CT coronary angiogram. So requires an IV, requires IV contrast, so you need to have normal kidneys. You often need to be on a beta blocker right before the test so that the heart rate is slow. So it decreases motion artifacts. So you can’t be bradycardic that you couldn’t get it. Or if you’re already bradycardic, they’re probably not going to use a beta blockers. You should probably not worry about that part. But you can’t be allergic to beta blockers. You can’t be allergic to nitrates because there’s a couple of things they got to do to be able to get the high quality scan.

But the CT angiogram is mostly a test to look at stenosis, how much blockage you have in your arteries. And so that’s interesting. If you’re symptomatic, it’s going to tell you, okay, well then this person will probably have less symptoms if you optimize their medications and potentially stick that blockage. But what you really want to know about is the plaque that you wouldn’t know is there normally, and that’s what the Cleerly Scan does. So they take a CT angiogram and then the Cleerly Scan is using AI to interpret those images. And voxel by voxel, they basically slice the artery and they look at the wall of the artery. And so much like an iceberg, it’s quantifying how much plaque is in the wall of the artery. Guesses can tell you how much plaque is pushing up and occluding the blood flow, but you really want to know what’s in the wall of the artery.

So it gives a score that’s called the total plaque volume. And the higher that total plaque volume, the higher the risk. And they came up with their own scoring algorithm that there’s stage 0, 1, 2, and 3, much like a cancer score would be. And stage zero, I’ve honestly only seen two people with a score of zero, and they’ve always been women and they’re always younger women. Every single man I’ve every scanned is abnormal. It’s just a very sensitive test. And often, you will only find soft plaque in those people. And the soft plaque is the plaque that you’re more concerned about because it’s the soft plaque that can potentially be more vulnerable and go on plaque rupture and the blood clots. Often the hard calcified plaques are like scars in the artery and they’re not going anywhere. But if they build up to a great enough degree, 70%, then you may have chest pain, shortness of breath with exercise, but they’re not the ones that often rupture. It’s the soft plaques. And that’s what you’re going to look for with that Cleerly Scan.

And so if you see a high total plaque volume and it’s mostly salt, then you want to start pulling out all the bells and whistles to try to put out that fire. And often that’s going to be promoting nitric oxide with products like Vascanox. Using Arterosil to potentially help shrink that soft plaque, which hasn’t been shown yet in the coronary arteries. But they do have studies with MRIs that have shown soft plaques progressing with products like Arterosil. Statins have been shown to regress plaques, so statins would be used in this case most often. And then there’s some other things that you would want to look at blood work wise. Why does this person have such a high soft plaque burden?

Evelyne: Interesting. Thank you. And I don’t know how long it’s been out, because I only found out about it last year, but is this something that you’ve recently incorporated and are you using it with everybody?

Michael Twyman: So I’ve been using it for about two and a half years.

Evelyne: Nice.

Michael Twyman: I think it’s probably been out about three and a half maybe. And it’s not for everybody. So if you’ve already had an event, meaning heart attack, stroke, stents, bypass, you’re already high risk and you should be treated as such. So this is more for people who are going to be in that intermediate range. So it’s not for 18-year-old guy with a little bit of chest pain when he exercises, they’re going to work that up differently.

But if you’re 35 and your dad had a heart attack at 50, this might be a good test to tell you are you going down that same pathway? Because doing just a traditional stress test and EKG is not going to tell you how much plaque you have in your arteries for the most part when you’re young. You have to have advanced plaques to really fail those type of tests. So that test is kind of individualized the person in front of you.

But generally, if you’re over 35, it’s a test you can at least put in the back of your mind, am I a candidate for it to then talk to somebody who has some experience using that test.

Evelyne: Great, thank you. What else are you currently excited about in the field of cardiovascular medicine?

Michael Twyman: I think it’s just that it’s all going to be wearable technology in the future where people are going to be able to do more and more of this type of testing at home. So I was recently at a conference in Las Vegas talking about cardiovascular health and endothelial function, and I brought a lot of my wearables, and I call them toys, that can test your arteries at home. I don’t think any of them are ready for primetime for mass distribution, but I think the companies are getting closer and closer to do that. You can always start with blood pressure at home, but there’s companies that are developing watches that are pretty sensitive to measuring your blood pressure. There’s devices that you can measure your glucose at home, but eventually they’ll probably test that can measure your insulin levels and lactate levels and all these other biomarkers.

We didn’t go into lipids today, but Apolipoprotein B, there’s a test that you can do that at home now. And so I think people are going to be able to be more empowered getting this data at home. And then, likely with the use case of AI is you can dump all this data into it and get a better picture of what’s truly going on in you at real time. So I think that’s the thing I’m most excited about is that AI is going to be kind of the copilot for the doctors to be able to understand all this information that’s coming at them.

Evelyne: Yeah, I love how you put that. That it’s the copilot for the doctors. That’s amazing. What is something that you’ve changed your mind about in all of your years of practice?

Michael Twyman: That things would stay the same. You do the training and you think that this is the way you’re always going to do it, and I thought I was going to be an invasive cardiologist for many years, but you eventually go down different rabbit holes and you’re like, oh, it might be a little bit more about the endothelial function. And then, oh, it might be a little bit about you look at circadian biology. So I think it’s just that… I don’t think I underestimated that how much of a lifelong learner you’d have to be, but how rapidly things would change. I never expected AI to be here and how much it’s actually going to impact my practice going forward. So I think that’s the biggest thing that I’ve been surprised by.

Evelyne: Yeah, that’s great. I think it’s super exciting. Keeps us on our toes all the time. And then some other questions that I always ask our guests, what are your three favorite supplements for yourself?

Michael Twyman: Myself personally and full disclosure, sometimes I do speak for Calroy, but I do take Arterosil. I do take Vascanox. I’m a board certified cardiologist and I want to have healthy arteries. I got to lead by example. So those would pick up two of the spots. And the third one, for myself, it would probably be Berberine. Berberine just has a lot of use cases. It helps with glucose regulation, it helps with lipoprotein management. It supports the LD receptor to plug these ApoBs out of circulation. Antioxidants, so it can kind of help prevent some of the damage to the glycocalyx. So Berberine is something that I frequently use with patients.

Evelyne: Great. And then the final one, and I think I know at least part of the answer, what are your favorite health practices that keep you healthy and resilient?

Michael Twyman: The first one is try not to miss any sunrises because the sunrise is when your circadian biology and your sugar and clock gets set every day. So it’s also just a very relaxing type of practice. It just helps your body start making the hormones and neurotransmitters that it needs for the day.

Second would be just focusing on high quality sleep. I think it’s my superpower. I’ve always been a good sleeper except in times when I was on call in the hospital every third night, but I eventually got out of that system and because I wanted to lead by example. I don’t want to be up in the middle of the night treating heart attacks anymore. It’s useful for patients to have a doctor that can do that, but that is at a health toll to the doctor who’s doing it. I don’t think they’re going to be able to do it before they will break down. So I just wanted to sleep like it’s a superpower.

And the third thing, most likely it would just be that I pretty much meditate every single day. That’s the first thing I do in the morning, and I think that just really helps ground me and how I kind of face the world.

Evelyne: I love that. That’s great. You made me think of something else. So I don’t catch sunrises generally unless I maybe have to catch a flight. That’ll get me up. But so there are different types of people. I just thrive more at night. Do you think that’s necessarily a bad thing or do you think that we are sort of wired differently and maybe fall into types and that’s okay?

Michael Twyman: There definitely are different chronotypes, but I think there’s less night owls than people really think. If people really got into sun gazing in the morning time and limiting the artificial light at night, they probably would find that they probably are going to bed earlier. I’m a perfect example. When I was in the military, my average bedtime was usually 11:30, midnight. I’d get up 7:30, 8:00, roll into work and just start going. And then once I really started getting into this kind of circadian entrainment, my average bedtime is maybe 9, 9:30 at the latest, and I’m up by five every single day and I can’t stay in bed any longer.

And so I think it’s just that if you train with that sunlight in the morning, your body’s going to get on that rhythm. You’re not going to jump from like 9:00 AM to 5:00 AM immediately, but you can start backing it up. And if you really start mitigating your light at night, or if you wear the dark lenses, the red lenses, see how much you can actually stay up and actually do something. Because people think like, well, I got the second wind. I have a lot of energy. That’s cortisol. And so, that’s good to keep you awake, but it doesn’t necessarily mean that’s the optimal thing to improve your sleep.

Evelyne: Yeah. I have some work to do on my sleep for sure this year. Well, thank you for sharing all that. It was a pleasure having you on today. I really appreciate your expertise and check out the show notes for any resources that we shared on today’s show.

Thank you for tuning in, and please share this podcast with your colleagues. Follow, rate, or leave a review wherever you listen. Thank you for designing a well world with us, and thank you so much, Michael.

Michael Twyman: You’re very welcome. Thank you.

Voiceover: This is Conversations for Health with Evelyne Lambrecht dedicated to engaging discussions with industry experts exploring evidence-based, cutting edge research, and practical tips.