Evolution of Cardiac Diagnostics: A New Era with AI-Powered FFR-CT

So plaques are dangerous for two reasons: one, they narrow the artery and can cause angina, but the second, which is more important, is that it actually cracks when the plaque cracks and you all know that I give my talks on why why the plates crack. inflammation in plaque plaque is almost like an apple and it bursts inside the artery so you need an anti-inflammatory lifestyle you need an anti-inflammatory diet so your plaques don't crack and cause a heart attack so when plaques form in the arteries, you definitely want to stabilize them, you want to follow an anti-inflammatory diet, an anti-inflammatory lifestyle which we'll talk about, that's a whole separate talk, but if this artery narrows and now let's say this plaque healed itself, the Dude didn't even know it, but now you have a blockage here, at what point does it reduce blood flow?

Because today's talk is about ffr, when this blockage on average reduces by more than 75%, that's when the blood here will reduce. may decrease now when the blood starts to decrease, p patients will have chest pain, pressure tightness, heaviness when walking, climbing stairs, exercising, feel pressure tightness or may be short of breath when walking or may feel palpitations . everything or worse, you may not feel anything. The worst part is that 80% of people who have a blockage over 75 don't even have chest paint, so not having chest pain or pressure doesn't mean anything, it just means that we don't have a Proper angina alert system, it's the guy who gets chest pain when he exercises.

You are lucky because you will go to the doctor complaining of chest pain and this will attract attention. The tragedy we have in America today is that many people have this. blockage, but they don't have chest pain, so they go unnoticed, go unnoticed, and then one day when it shuts down completely, they have a heart attack. the plate should not break. The plaque should not be growing. It may have a license plate. We can stop them. If we move forward we can stabilize them and if the plaque is over 75% it restricts flow, why would I care if you don't have chest pain?

Why would you care if he doesn't have chest pain? So what's the deal with this piece of muscle? here, when you don't get enough blood supply, you can get an arrhythmia and the muscle won't work very well either, so if it's an arrhythmia, let's say this patient runs up the stairs, you can get an A arrhythmia because the muscle doesn't get enough blood supply. blood supply is so sudden that your heart goes into ventricular arrest and you pass out, that is sudden death, you don't wake up until the doctors arrive and even then you may not come out of ventricular fibrillation, so we consider it a number arrhythmia two, muscle damage that when this ejection fraction the pump weakens patients may complain of shortness of breath they may be suffering from congestive heart failure because that muscle is not getting enough blood supply, which is why we see a lot of patients that come here, we have shortness of breath and ejection fractions are not as good the heart is weak it is not damaged it is not dead all it is is a blockage and we improve the blockage and the muscle starts working again and then they are fine so we worry about blockages because We don't want you to have an arrhythmia and we don't want your heart muscle to weaken over time, so it's important to know if you have what's known as a flow-limiting injury.

This is an injury. Do you want to know if it limits the flow? limiting my flow, you should know that, so I do calcium scores on patients and if I see calcification building up, then I want to know if it's doing this thing that narrates it or it's just sitting on the wall, how do I do that? do a stress test, that's traditionally been what we do, so when you do a stress test, then you can tell by the EKG, so all of a sudden you get a check on your EKG, it says, ah, you're not getting blood supply. blood to your heart. muscle, you put in your stress test, you need more tests, that's one way to do it, the other is a nuclear test, so when you do a nuclear test, what you do is you inject the radioactive material and you can show on the stress test that this artery is not getting enough blood supply, but this artery on the side here is getting enough blood supply and the one on the back is getting enough blood supply, so you can see that in the core, that's how you can tell if someone has a block or not. so they have calcium, it may be in the wall or it may be narrowing the artery, you don't know, you want to know if the artery is narrowing inside or not, the dangerous things you need to do a stress test, you look at the EKG part and you do a nuclear stress test right now, that's how we were doing it until a few years ago, now we do angiography and CT geography, so now I'm going to get to that, so in the heart C the artery is injected . but that's an invasive test and if we see an obstruction and it's a strong obstruction you usually know that this is causing a problem these days we also do CT scans so now let me introduce you to angiography okay angiography angiography means you're taking a picture of the artery how you can go in from your arm or from your leg and shoot the dye into the arteries and see the blockages so now there's a problem so here's an artery like before and I'm putting dye inside , so I bring my catheter here and I'm injecting the dye into the artery.

Will I be able to see what's out here? No, I'm just looking at the inside, so it comes here and it could narrow like this. narrowed so it's on the angiogram and I look at it and I say aha, this is about 60% narrow and I might want to put a stent in to open up that blockage, but is it an accurate measurement, is it an accurate measurement on the angiogram? and my answer is no, unless it is very very tight, it is very difficult to tell if this is limiting flow or not on the angiogram, you just see that there is a blockage, but you can't tell if it is actually limiting flow or not, you need a functional. test to tell you if it's actually limiting blood flow or not, that's why before we do an angiogram we always do functional testing, that's a good Golden Roll, you should know if the blockages are just there and maybe they're not obstructing the flow, maybe it's only 60% maybe it's 70% you have to do a stress test or you have to do some other form of testing to know what a flow-limiting leon is, the angiograms don't tell you if it's flow-limiting. flow or not, that just tells you that you have a blockage and that is the tragedy because what is happening today is that we do neography without functional tests in three arteries, he has a blockage in all three, oh yes, bypass surgery for disease of three vessels, but of those three arteries, two of them may not have a flow-limiting lesion.

How would you know that? How do you know? Because look, there are many of my patients who have three blocked blood vessels in all three Aries. You have to know which one is causing a problem and which one isn't. Otherwise, you're going to take a photograph and find three blockages, one in each artery, and say, "Okay, you need three postures or you need bypass surgery" and that happens all the time, then a patient comes in, let's say A diabetic patient who feels a little discomfort comes to the doctor. says you know what you have all these risk factors, let's go straight to C, you limit the patient, you will find blockages and the next thing you know they are going to do an anoplasty or a Bast surgery without having known if those arteries are reducing the blood flow or not, then you could say well, now the blockages are being avoided, so he will live a long time, not necessarily because if the blood flow wasn't being reduced in the first place, putting him on a bypass that will make you feel better if you already have it.

It stops blood from flowing through that artery and now you put a bypass or put a stent in here, what benefit did you get from that? You're still getting enough blood flow through it. What did you do now? That is the question. that's the problem we have, you see, Coryan disease is very widespread, it's there, people have it, it's a completely different topic that we will also talk about in my future lectures and the ones that have already done it about why people suffer blockages. But the problem is that those who have blockages are not being properly diagnosed as to who really needs revascularization, who doesn't, whose arteries are really cloudy and whose arteries are not cloudy, and all they need is a prevention program, a prevention program to prevent cracking. and get worse if it doesn't limit your stroke, leave it alone, putting a stent in a device that doesn't restrict blood doesn't make sense so I have studies to show you that it does and I'll show you in a minute if you do it. put a stent in a blockage that's not really FL, you know it's necessary because there's a lot of blood going down there, but oh, let's get rid of it, it's there, let's stun it, that patient is going to live longer, in fact, he's going to live less. because now you are going to have the complications of stent thrombosis, which can occur in one to 2% of patients, tent restenosis, which is scarring within the support, which can occur in up to 5 to 6% of patients. patients, even with drug-eluting STS, so you have I took someone who this was not causing any flow limitation and you put him on a St and made him worse than he was before, there is no benefit, so just because there is a Blockage doesn't mean you have to go in and revascularize it either. surgically or percutaneously using angop plastic, you need to know if it's really causing flow limitation or not and that's why we need better testing, so in the cath lab, when we do angiography, when I do angiography, let's say you came to the cath lab. catheterization in the The hospital came to see me because you have chest pain and they told me that you need a hard placement of the cat POS support.

I will do the angram and I don't have any stress test to do it. All I have is the anagram, so this is what I'll do well here's your anagram here's your right coronary artery this is your circumflex artery going back this is the artery in the front and I bring my catheter from the arm normally now I bring it here like this and inject the D and then bring it here and inject the die, so I'm going to see where the locks are. Now I told you it might have a lock, so let's give it a lock, it's right here, it has a lock, oh my gosh, maybe it has a lock.

This is a blockage issue, so this is where I do an Invasive Fractional Flow Reserve in the cath lab. How am I going to do this? Too easy. Those who are all engineers here should know that I take a wire, a very thin wire. a pressure wire measures the pressure and I carry it on my catheter I slide it here and I slide it through the blockage and I put the wire there I have it and I'm measuring the pressure difference here versus here it makes sense if there is a difference in pressure here versus here it means that this Legion is capable of decreasing blood flow, so we don't have this technology, but now we have this and we've really perfected it, it's called Fractional Flow Reserve, so we're looking to add the ratio of the pressure here versus here I'm going to maximally dilate this muscle, which I don't think you should get involved with those terms, but basically I'm giving adenosine to maximally dilate the arteries here and then I'm looking to see if I can. create a gradient across that Legion so if I'm creating a gradient the pressure here is higher than here and if my ffr is less than 0 8 1.0 it's normal now I know I'm restricting my blood flow now I know yes, this lion needs to have a stent because it is capable of decreasing blood flow if the ffr is greater than 0.8 that blockage does not limit the flow.

I mean, it has a lock. I can see it but it doesn't limit the flow. I'm getting a physiological d L, see then because the other alternative would be to stop sending him for a stress test and bring him back if he doesn't pass the stress test so that this way we can do the ffr in the cath lab like in the place, that's how the ffr started in the cat. lab, so in the plaster lab I can determine if you have a blockage, what your ffr is and let's say you have another blockage here and maybe you have one here.

I can do the F power for each one, so I take that wire and slide it in. Discuss each one now, why is this so important? Let's say this gentleman had one, two, three blockages, if I didn't do the ffr, I'm going to say he has three vessel disease, call the surgeon, let's operate, do you understand and a lot of that is happening, you must have accurate data without data you can't just do things, this is this, I told you, if I put a St here and here and they're not needed, the stent can thrombose, you might get a bleeding complication from drugs you're supposed to get or you may have restenosis restenosis is a scar inside theSten, so he could have continued and actually what happened is he just ate something bad and got indigestion, that's what landed him in the hospital and you end up getting a St.

Do you see the danger here? That's why ffr is so fantastic. You take the time to place it in each Legion and you're fine. Studies have been done to show that if you follow the direction. from the ffr and then to the stent, so placing a stent directed by the ffr leads to better results than if you just look at it angiographically and extend it. There have been studies done, so in those studies they took patients who had angiographic data like these three blocks. and compared them and their results with those who hadblockages, but they only got a posture according to the ffr, so placing a stent versus targeted ffr versus geographic direction, which had better results, better results of those who had ffr because you're just making the lesion that was actually blocking and restricting the flow so that data There are very solid data now so we know this data so having this knowledge now I will take you to the cast lab every time to place that wire inside your artery .

It's invasive. So is there another way we can do it? Is there another way? I told you about the stress test, the stress test doesn't tell you about that particular Legion, it just tells you that this portion of the heart does not receive blood supply, so patients often tell me well what my percentage of blocking. stress test all I can tell you is that the front of the heart is not getting enough blood supply, it could be due to a blockage here, here, here or here, I don't know and how tight it is, I don't know everything.

It's probably more than 75%, it could be 80, it could be 90, it could be 95, it could even be 100% with guarantees. All I know is that the front doesn't fit into our Blom, so you still need an angiogram. You got a positive result. stress test, you still need an angram, you need anatomical data to see where the blockage is and what to do with it, okay, there you go, this is useful in the casting lab when I'm inside the casting lab, that's very useful because I'm already there, I'm going to do ffr, is there another way? Let's look at CT scans so everyone knows we're doing CT scans right now, so let's talk a little bit about CT scans and how that has changed what's happening.

In a ctel, you're injecting dye into a vein and it goes to the arteries and once again it goes to each artery, the dye goes there, you're doing a CT scan and you can actually see the blockages, but we have a problem. I have a problem here's the artery and I'm going to draw a little bit of plaque here we have some calcium explode a big chunk of calcium here okay look it's on the outside a little bit goes to the inside too let's give it a little bit more let's give it like 30% blockage, okay, so the CT scan shows this, but the problem is that when the x-rays pass through the calcium, it feels a shadow, so you overestimate the blockage, so when you look at the engine computed tomography.

GRS you say ah this guy has a 50 to 60% block, well what is it? So we've noticed that with CT angiograms it tells you there's a blockage it tells you there's calcium it doesn't tell you precisely what the percentage is and if you read your CT scan and the reports it will be between 40 and 60, 60 to 70%. , but they are never that precise because it is a visual estimate. That's okay, it's a visual estimate and can give you an over-reading of the stenosis. It's called blooming artifacts. It doesn't really tell you functionally what's going on in that artery, so don't you need more valuable information to know?

City scans are extremely harmful, first of all, if your city scan shows that you don't have calcium, you don't have corn disease, that's why I like city scans, that's why I like cheesy scores from calcium, so what I do is I look at Cory's calcium, so let's say you came to see me and you have some problems and you're worried that I have Harding of the arteries, my father had a heart. attack my brother just had bypass surgery do I have a problem? I'll wear calcium scum. That's the first thing I'll put on because it's so easy to do.

It's a low-level city scan for calcium in the walls of Aries. If your score is zero, do you have heart disease? You know you're going home, stop eating that crap because that's what gives you heart, but follow my videos, that's why I like calcium levels now if your calciums test positive, yes, you have it. calcium 0 to 100 is mild 100 to 400 is moderate more than 400 is severe so I'm going to say: okay, you know this is a problem, we can go do a stress test to see if these blockages are really causing you a problem or we can do a CT angiography, so we do the CT angram and the report comes back saying aha, 50 to 60% blockage right there, well 60 could be 70 for this could be 40, so it's too much desire Washi.

I need to know if that is actually capable of reducing blood flow or not so now once again it comes ffr so we didn't have this technology the technology is now there where you can take the anagram CT and send it to California and take a look at it . AI has a few uses. after all, and that report can come back and say this is a flow limiting Legion, the ffr in this Legion is 0.6, that's abnormal, right, totally no6, which means yes, this lion needs to be fixed, you should refer to this one but this other R3 that was here Branch big br Big Branch also here and also had a lock and the ffr looked like it was around 50% but the power on this one was 0.9 and then the right cor also had a problem, there was a 50% blockage there too because remember cor arri disease is a systemic disease, it's not just a focal disease, you have a blockage in one artery, you have a blockage in another and all your arteries will have some degree of PL , there is no such thing as single vessel disease.

If you look hard enough it's all three arteries so this report would come back saying 50% here 50% here 50 to 60% here but the ffr is only abnormal here so what does that mean? It means you go in and fix this blockage. If you can fix it with a stent and you get rid of that blockage, now the flow will be restored, you've done a good thing; otherwise you'll say well these other blocks you know you better do them. step back surgery, so focus on the block, which is functionally important. Bar F functional fractional flow. The reserve has to be the main state of the future.

We have to analyze the functional tests. Whether you're going to do a core thesis or you're going to do a CT scan that's going to tell you what's going on, so the way we're working with our patients right now is we're still doing a lot of stress testing as well, so I'll just give you a little background on the physiology of what happens here is the muscle when you're exercising your Vaso dilates all these little blood vessels that open up and when you're running jogging when you're doing any type of exercise so in rest there can be a lot of blood coming in, but when this vessel dilates, that's how more blood comes down because your vessels dilate when you exercise your dilated Vessel, so you get more blood that's needed because your Vessel dilates here, so that you are drawing more blood into the heart muscle and this is how we measure the ffr in the catha, we apply a baso dilator in the artery, baso dilates all of this and then a gradient is created, a pressure difference between this and this, so By doing ffr on these patients we are going to be able to identify injuries that really need to be repaired and injuries that need to be left alone, so my particular interest is in leaving V leaving the blood vessels alone, that is highlighted if you have a legion that limits the flow in ffr, I will intervene but I only want to put in what is necessary, only the minimum needs to be done because the biggest problem is all these other plates, why do I tell you that they are the problem?

Because in all my experience I have seen the rule of 70. I am going to explain the rule of 7. 70% of heart attacks occur in blockages that are less than 70%. I mean, suddenly this thing breaks and it became 100, so it was less than 70. The day before yesterday he was able to climb Mount Dora that he had. No problem, how come today he is having a heart attack because the plate ruptured? So I'm more interested in removing blockages and stabilizing them. I try to make sure they don't get worse in the future. Keep them stable and you can shrink them too.

These are a little bit, you can't get rid of them if your calcium hits 1,800, it's not going to go down to 500, but what you can do through an anti-inflammatory diet and an anti-inflammatory lifestyle is make sure that doesn't happen. it gets worse and number two it doesn't break UC if it breaks it will form a blood clot so that's the point the point of doing that ffr is to tell you to fix just this one leave the rest alone the rest are to be managed systemically physically diet sleep stress toxins nutrition fix your hormones fix your gut microbiome that's what's going to take care of these blockages not a stent because these days what's happening is most people think you have a blockage and then you go a get a stent and then they'll give you aspirin and maybe some Plavix and then they'll give you a stat and that's it, and I'm telling you you might need the St, but what?

What you really need is a lot of work to determine why you have the plate and what you are going to do to stabilize it. What did you do? What did you do? But you should know what made the plates happen in the first place and more. plaques occur due to inflammation inflammation and this inflammation comes from what is inflammation when you are attacking something foreign what are you attacking what is foreign is all yours how can you develop a pump inside the artery that is full of inflammatory materials here ? there are T cells here, there are B cells there and there are macros that are dying there and releasing calcium and that's all that calcium in there, what it is is inflammatory and no one has really found a solution or answers as to where that information is.

It actually comes from, they will say it is inflammation but they don't know where it comes from and tonight I will tell you what I believe. I think most of that inflammation comes from your gut because your gut is the difference between what's outside. you and what you actually see, you could understand why your body is mounting an immune response against what, so that's a separate topic, but these days I look for sources of intestinal inflammation where you have what is known as intestinal permeability problems because you have food sensitivities or you have a dysfunctional microbiome, you have microbiome, the bacteria in your gut is not right and I see this over and over again that these patients, if you sit down and talk to them long enough, you will find out that they all have a gut problem. and this is what causes the translocation of lipopolysaccharides from the intestine into the bloodstream which are then absorbed by the LDL molecules, the bad cholesterol molecule as everyone knows them, and create what are known as small dense particles, these small and dense LDL particles.

I tell you the information that happens in the body and these molecules are absorbed by the macrophases and then the macrophases engulf them all and of course these particles also activate the endothelium, so they activate the endothelium, so the endothelium is weakens and the gluco Kix becomes destroyed and then these molecules come here and the white blood cells come here the macrophases and they get stuck to that area here and then they come in and die on the wall and now you have a plaque right there, it's all got to do with inflammation, so looking for sources of inflammation is very important, it starts with the gut, it also starts with your lifestyle, it starts with how much you sleep, how you stress, whether you have sympathetic or parasympathetic nervous system activation, whether you have heavy metals in your body, all these things cause these formations, so once they drop, then you need to know if it really limits the flow or not, and if it limits the flow, then you do an intervention so you can put a stent or a B surgery, but if you reverse engineer every patient, you have to reverse engineer every CHD patient, otherwise you just take care of the stent or the bypass and just leave it. come back you have to reverse engineer it reverse engineering is very important okay so he has the blockage why does he have it let's go back let's look at this guy he has hyperinsulinemia what does that do that causes nitric oxide depletion promotes aerosis promotes obesity promotes fatty liver so you have pre diabetes you have a very high insulin level wow that causes the formation of eosc disease right there it causes high blood pressure and all that strips the endothelium that causes problems in the arteries, so it is called Sugars high in insulin, of course, high sugar also destroys the lining of the arteries because they glyat and destroys theI give too much lead or Mercury right now, your body is going to mount a reaction or change. uh, Redux potential and that's going to change a lot of your body's physiology, so it's complicated CU.

We only think of inflammation as infectious things that cause inflammation like pneumonia or a big boil on the skin, but inflammation is also due to your own physiology. it's changing because you have toxins or your hormones, so inflammation is a trap for many things, it's not just bacteria or bacterial products, it's also your hormones, toxins and you can also develop an inflammatory disease if you don't have enough nutrition. or incorrect nutrition, for example, if you have many deficiencies in your body, your homeostasis will not be normal, so it is a complicated question. One day I'll give you a separate talk on that, yes, but it's a complicated topic, but most of what's actionable is checking your gut, checking your hormones, particularly insulin and sugar, making sure it's not toxic, making sure to have no toxins and B forms, not just lead, and all these things with toxins are made with plastics.

I'm talking about your makeup and your creams and all those estrogen receptor agonists your soap your shampoo I don't need it because I don't have hair or shampoo left but these are all plasticizers that enter your body antibiotics are a toxin they are killing the bacteria in your gut artificial sweeteners colorants emulsifiers preservatives they are all toxins that are not supposed to be in you and they act through the microbial microbiome they are going to know all these things they are going to check all these toxins in your system and get rid of them and then your nutrition or 40 sudden nutrients are depleted, we don't have enough nutrition in our body because of the type of foods we eat, so we replenish our nutrition, get rid of toxins, fix our hormones and fix our gut, that of things.

It's going a little complicated, yes, that's a big question so far. I would say I can't give you an exact number, but based on the experience I've had and everything I'm reading, it's at least 80 to 90%. precise because like I told you just my cable is so precise that I can move it 4mm and 5mm and I will get a different FF all so it is very precise and tells me exactly the location of the lock. um, it's not as precise with ffr with CTS, it gives you more information about that segment, look and it's an

evolution

. technology too, we're still learning about it, but the bottom line is that if you have an abnormal ffr on your CT angiography, it will go and look at the entire artery anyway so you can see all those parts and just the ones that look geographically tight but it is also corroborated with an invasive ffr, technology is changing because the AI ​​we have today will be different in four years, it is changing very very quickly so I think it will be better. and better over time and it is a C of learning for doctors also for all of us in terms of how we interpret these results, but it is another thing that you see, the fundamental thing is that studies have been carried out that if you observe the patients and do the ctfr and it's not bad, but they have a disease, they got kicked out and you just follow them for 15 years.

How many 15 years the results are good because they did not have a very significant ctfr, so a negative ctfr is very useful for me because it says that the studies tell me that I can leave that patient I do not have to heal him he has a lot of calcium he has many locks everywhere but none of them are tight and if I just do my prevention program they will do better and by the way in those studies you know what the prevention program was. They weren't giving them a lot of statins, basically, and they were getting a little bit of a beta blocker and a little bit of an acetylcholine inhibitor or something like that, whereas today's prevention program that I do is much more than that, so I can expect even better results. than that, so sometimes it's not a positive factor that will help you, it's a negative factor if you don't have problems, so leave it alone now, we're going to get very aggressive. therapy, you should try it anyway now that the technology I'm going to explain to you why I'm going to explain to you why a patient who has blockages in all three arteries, the right cor artery, the circumflex artery and the LED, here is the heart, right? how can this patient who has let's say he has 80% here 80% here 80% here now all of this is significant, am I right or not, but he doesn't have any chest pain because I told him that 80% of patients never do you feel it? chest pain, so let's say you have this now.

I inject radioactivity into your stress test. You're going to have a decreased flow here, here and here, so when I look at the image it's smooth, but let's say you didn't have this one here. and here there was only 10%, you would see decreased flow here, good circulation here, decreased flow here in the picture, you say ah, you failed your stress test because you have decreased flow here, but when all three arteries are down , you will become uniform. decrease in flux, so you will see what I call a homogeneous decrease in the absorption of radioactivity, there is no heterogeneity because the way you interpret a nuclear stress test is that you look for heterogeneity.

Heterogeneity means that one part of the heart receives a lot of radioactivity. Some of it doesn't, but how come this person doesn't? you have a blockage there, but if all three are one blockage there is no disparity, you have it, so it is very important for patients to realize that if your calcium score is very high and if you have blockages in all three arteries, you can get a false negative nuclear stress test. That patient, if they're young, the calcium score is very high, just do the CTA on them because you don't want to get caught with someone who has very high-grade blockages in all three arteries. that gave you a false negative core, so a lot of judgment is needed there too, but with such a high negative score, it's probably okay because your functionality still matters.

You can move around Dora's clan and back, no problem, just do It feels better that I should do a CTA with e now that we send these studies for evaluation. Some segments, if the vessels are too small or too thin, cannot be analyzed properly, so it is not always the case that all of them are obtained. segment of your artery analyzed, sometimes they can't analyze some POS, so there are also some technical problems, but generally speaking, most of the time you get a pretty good reading, you can't see everything, yeah, it's another tool in our arsenal for H, below, about who the problem kid on the block is.

I don't need to worry about these guys, but that guy over there I need to worry about. Put it in there. You might even choose it. He becomes more aggressive. More information. The more I can concentrate. that guy, like I said, if the ffr is fine in that other patient, even though he has a high castom score and has been stable for three or four years, I can sit, my data shows me that he will do fine . to do it right, look, all those studies have been done, we know that a negative ffr is a good thing, yeah, okay, thank you for coming tonight, thank you and if you liked this video, here's one that I would recommend and if you want.

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