Kerry 0:28

All right. Hi, everybody. Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller, and today we have Dr. Monica Esposito. Welcome to the podcast

Monica 0:38

Thank you so much for having me. It's great to be here.

Kerry 0:41

Tell us a little bit about who you are and what you do. Yeah

Monica 0:45

so I am also a board-certified family medicine physician. But my practice is out in North Tampa, and I founded Ascend Concierge Medicine, which is kind of a mix

Welcome & Dr. Monica Esposito

Monica 0:56

between direct primary care and concierge medicine out here, so a little bit of a different model than the traditional fee-for-service. But it's been an adventure. It's been wonderful. My patients have loved it, and it's definitely been filling my cup in terms of working in the primary care realm

Kerry 1:11

That's awesome. I think it, when you have a different background, which I would like you to share, and how you get into concierge medicine, I think it really is, treating, having the time to treat the whole person and really dive into things. And d- tell us where you came from so you, we understand, why you did what you did

Monica 1:29

Sure, of course. So I've been working in primary care. I, I graduated from residency back in 2018, 2019. And I have been doing primarily kind of the HMO Medicare side of things. So worked with a lot of medically complex patients, a lot of elderly, and, dealt with a lot of, really in- intense kind of workups and everything for my patients. The issue that I contended with was the fact that I constantly found myself

Why she started concierge medicine

Monica 1:57

fighting with the clock, fighting with insurance companies dealing with not really being able to practice in my full capacity the way I wanted to, and devoting so much of my time towards the paperwork and nonsense and red tape versus spending all my time devoted to actual patient care. And getting a little disillusioned with that, especially in combination when I ended up having kids. I'm a mom of two. So I decided, it's time for me to make an adjustment and a change, and I founded Ascend Concierge Medicine, and we opened our doors in March of 2025. So we just passed our one-year mark not that long ago.

Kerry 2:32

Yay. Congratulations.

Monica 2:34

Yeah, big milestone. But in this model, instead of going through the insurance side, we treat people completely based on a membership fee, so they pay a monthly, quarterly, yearly, depending on preference, and they don't require insurance. So I have a mixture of payers from people that, own small businesses and choose not to carry insurance at all and use my services in lieu of dealing with the insurance side. And then I have other people, and the other probably two-thirds of my patients, that carry insurance but want having, that longer connection, that accessibility, the direct relationship where they always see specifically me when they come in and the ability to get more, hands-on immediate care if something does come up. 'Cause, with traditional fee-for-service, it can be a challenge, and I know any of us physicians working really in family medicine or across the board, we're always dealing with the clock and feel like there's never enough time in the day. And, we inherently want to spend more time with our patients and have those sit-downs and one-on-ones. And it's been really nice 'cause, my standard appointments are 60 minutes. My intakes are 90 minutes, and that's like a pipe dream outside of this model. So it's been really fun being able to have those connections and really have the time to do some of these more complicated workups for my patients when they're needed.

Kerry 3:52

Yeah, it's interesting, what topic that we're going to discuss today considering that we talk about, the red tape and the dealing with insurance companies and guidelines kind of things like that and recommendations. And that leads me to, the screening tests and all that stuff that we're supposed to do for patients, and we still should in no matter what model that we're doing. But you're in a unique position that you could maybe offer a little bit more screening tests or more detailed things. So I think

Today's topic: preventive screening

Kerry 4:20

think, we can talk about the basic ones too, but also maybe those advanced screening things. I don't know if that'd be fun to start with, but we were just talking before we were recording, what kind of things that maybe are becoming maybe down the pipeline with new guidelines of things. So for instance, maybe we're gonna talk about cardiovascular screening. Can you tell me what what you do in your practice, what maybe you couldn't do before, and what is recommended really?

Monica 4:46

Sure. Some of the more recent guidelines are evolving to include a little bit more advanced testing in terms of the labs and even at times I think we're working towards including imaging as well in that element. But I think that's gonna be a little bit more in the years to come. The, the guidelines always take a little while to catch up with the research, of course. That's how it goes. But so in my practice, I do include the basic lipid screening on my patients. But

Advanced cardiovascular testing (ApoB, Lp(a), hs-CRP)

Monica 5:14

in order to help risk stratify, we also typically will include an apolipoprotein B, which basically tells us a little bit of, it's a specific type of high-risk element within the lipid panel, a type of LDL as well as a lipoprotein A, which is more of a hereditary thing, and then a high sensitivity CRP, which is something specific that you can see with inflammatory changes within the heart. Now these are simple because all it is a blood test. So when I draw labs on my patients, typically I'll get that as one of the introductory things and include that 'cause it, it helps us get an idea of if they're borderline, we might say, "Okay, your apolipoprotein B was high, and even though your LDL was a mild elevation, we might be a little bit more concerned about the potential progression towards cardiovascular disease in your future." So you know, they also updated one of the calculators, the PREVENT calculator, instead of the, the traditional ASCVD So we do have the different calculators that we can use to help assess the cardiovascular risk. But one of my new kind of favorite tests that I've been using a lot especially in my patients that are borderline on what they should do in terms of risk management, is the coronary CTA with Cleerly ideally. And what this does is instead of just testing a coronary calcium level, which is one of the things that I think historically was used quite frequently this test is gonna evaluate both types of plaques that you see in the cardiovascular structure. So you have your soft plaques, which are primarily made from the actual, the, the LDL and these bad particles that are floating around, and then you have your calcific plaques. And the coronary calcium testing that was used historically will evaluate specifically for those calcific plaques. So although it was useful in a way, it didn't give the full picture. Now, when you get the coronary CTA, that's gonna evaluate both types of plaques. It's gonna show you a breakdown of not only where your plaques are within your cardiac vessels, but it's also gonna show you if you're getting stenosis, so a narrowing of those vessels, how severe it is, and how much of it is calcific plaque versus non-calcific plaque. And the ones that we can typically impact the most with our treatments and guided therapies are gonna be those non-calcific plaques. So if I have a patient, say I literally just had somebody that came in and, did one of these tests, and he had, 25% stenosis in his RCA, which is one of the big vessels, and then 50% in his LAD. And that's another one of the dominant vessels that we always hear about, "Oh, it's the widow-maker." The one that if you have a big, bad heart attack it tends to be one of the big ones that we see. And in light of that, I was like our numbers are not great, and I know we've wanted to avoid medications a lot in the past." He historically wasn't on, on pills really. It's like, "But I think that given the fact that you're such a healthy guy, we know if you have a major event, a heart attack or a stroke, you're the person that it's gonna absolutely knock you down from where you are. You're not gonna be able to maintain your current active lifestyle, and it's really gonna have huge negative implications l- probably on the long term." So to me, this patient that, he was on the fence about it, this helped me convince him, "Hey, I think it's time that we go ahead and initiate statin therapy. And, it's time that we get a little bit more aggressive, and we can use this test and actually repeat to evaluate the efficacy of the treatment." So in his case, he really likes being, actively involved and seeing and, visualizing what's going on and if things are working. And this is one of those tests that can help us to do that because we can get a before, and then we can repeat this test in a year or two down the line and see if his vessels have actually legitimately improved with lesser stenosis. So it helps with that visibility, and it helps with those patients that are maybe borderline or that may have some inherent risk but their numbers are not that impressive to better catch those patients that are early in the process and need the preventative element. I remember I was speaking with one of my colleagues that's a preventative cardiologist, and he told me some numbers that I thought were fairly staggering. He said 50% of people that go in and have a major heart attack, that's the first sign or symptom that they had. So they don't always get those prodromal, that angina, the where you feel like you have a little tightness when you're walking or moving or doing things. Sometimes the first time that they get a symptom, it's the big one. It's going in with a heart attack. And if we could capture more of those patients with doing some of the advanced testing in the early phases and, mayb- maybe managing their risk factors versus waiting until we have a major event and then treating and having to go backtrack and they already have damaged tissue, how many patients could we help really positively impact on a long-term basis and maybe m- minimize their risk factors before it's a major issue? So it's like a proactive versus reactive medicine.

Kerry 10:30

Wow, you said so much good things there. I think going back to how we, risk stratify and things like that, so you mentioned this ASCVD calculator. That's something we use, looking at blood pressure, the cholesterol profile that you mentioned that you get, and then, that would give us a percent of whether they're moderate to high risk or something like that. And now they have this new prevent calculator that has something similar, but they also changed the LDL guidelines, right? So the LDL guidelines used to be, like,

New prevention guidelines & coronary CTA

Kerry 10:58

less than 100, and now they moved it to less than 70, which is really crazy, and I'm having difficulty having that conversation with my patients, and trying to convince them when I was, maybe borderline whether they should take a medicine or not, right? But kinda going through the same steps that you are. So we do this advanced imaging if possible. Now, you're in a practice where you're able to order the actual CTA with Cleerly, where I'm like, "Okay we can maybe get, the coronary calcium score." It's 100 bucks, right? We're talking about 100 versus 1,800. So very different discrepancies, and like you said, they aren't for-- they're not for everybody yet or not recommended or covered by insurance yet because they haven't decided that's a cost-effective method to do, prevent heart attacks or anything like that. So hopefully one day that'll be more, streamlined, but right now it's me having that conversation and then maybe convincing them just to do that. But then you mentioned once again why the-- what the limitations of are the study that I usually order, right? And that's because we only see the that calcified plaque, right? So when I have that explanation, I'm usually saying something like this is the stable plaque, but sometimes we think maybe that stable plaque shows that correlation to the unstable plaque," right? "So if you already have stable plaque, you're probably gonna have some unstable plaque too, but I can't prove it to you, but maybe we should do an intervention at this time by taking a medication," or something like that. So similar, but you get this much better, more advanced study that shows actually the unstable plaque too. That could be the kind that I usually say flick off and cause the heart attack or stroke or something like that, right? So that is so good that you're, being able to use these new, more advanced technology and studies to make that proactive, decision-making pro- like, to help the patient. I-- that's a staggering number. If 50% of, the people who have a heart attack is that big heart an- like you said, for a symptom, so that's staggering. So being able to practice that preventative medicine is, really exciting, and it's exciting to see what is gonna come down the line too. But there's so many patients that don't wanna take statins, so-

Monica 13:10

I know.

Kerry 13:11

These are... and I get it, and, unfortunately we do see the benefit of them, and they have all these new medications coming out. Our practice is actually part of a, a study right now on intervention in a primary care practice to do- improve our screening and methods like that. So basically, yeah. It's, it... but it's still hard to have the discussion with the patient, right? Statins are one thing, but you mentioned the CTA, and the LP little A, so we, like the lipoprotein A. So that, like you mentioned, do you have any more, like expanding on that? You said it was a genetic risk factor, and do you... How do you manage it, 'cause sometimes it's high, and what do you do?

Monica 13:53

So with LPA, we typically only test that one once because it's not something that is gonna change. Ultimately, it's their genetic risk. But it generally helps to give us a guide of, okay, is this person somebody that is going to inherently have bad numbers? And it's not true genetic testing, which we can actually touch on as well. But it gives us that idea of, okay, this is a person that even if they really do the work on their side

Lipoprotein(a), genetics & who benefits

Monica 14:21

and try to modulate their risk with lifestyle modification, they may not be hitting their numbers because of the fact that the genetics are gonna work against them. And so it gives us kind of an added numerical just to say, "Hey, listen, this is going to be a struggle, and we know this." I've had marathon runners that ended up needing statin therapy because although they may be as thin as a rail and super fit and eat all the right things, their numbers are still terrible, and they're like, "I don't understand. I do everything right." And I'm like, "Yeah, unfortunately, the, the gene pool comes into play here, and it does work against you sometimes." Oh, and just an FYI so the CTAs, the ones that I order, typically they run around $700. So although it's expensive, it's a little more attainable, and they do get covered by insurance with certain symptoms. So anybody who's had issues with some of like the anginal type symptoms in the past or coronary artery disease, oftentimes you can get it covered. So it's something that potentially maybe you could integrate, at least in those cases. For people that would have to cash pay completely, it's, it can be unattainable for a lot of people, unfortunately, and I'm hoping that will change as the guidelines catch up and, they're finding plaques on people in their 30s. People that, are our age or things like that where we're healthy, and then they look at it and they're like actually," i'm hoping that will evolve, but

Kerry 15:41

Yeah, I think it's the clearly that is the 1800 part of it. But anyway, that is really good to know because I didn't know that insurance would ever cover it so that's helpful for

Monica 15:51

Yeah, it's nice.

Kerry 15:52

Cool. Okay, great. The other thing you mentioned was, like the APOB and the HSCRP. Are there... How can ma- patients maybe improve those numbers?

Monica 16:03

So it's not so much that you're gonna automatically improve it. Oftentimes we see that the ApoB will correlate to some degree with your LDL numbers. But the ApoB gives us a little bit more indication on how high risk your LDL itself is. Because although LDL inherently we always kinda vilify as it's the bad cholesterol some of it can be worse than others, the c- certain type of particles. We talk about obviously on our side with

ApoB, hs-CRP & treatment decisions

Monica 16:31

family medicine, lifestyle modification, so incorporating routine cardiovascular exercise. We want people to be getting at least 150 minutes a week if possible. Incorporating healthier diets, so limiting the amount of the animal fats and stuff that they're getting in their diet. Making sure that they're not eating a lot of the, the greasy foods and things that tend to love sticking to your blood vessels and clogging everything up. But ultimately, in some cases we do still end up needing people to end up on either the statin therapies or in, some cases where it's more severe, the Repathas to help bring these things down. Now, apolipoprotein B is one of those more specific things where, if your LDL Is kind of borderline and, it's a little bit high but not terrible. And, with our old number systems, if somebody had an LDL of 115 and they didn't really have other risk factors, we might be hesitant to be really pushing the medication. But if they've got a sky-high ApoB, we'd be like, "Listen, your LDL's not great, and by the new guidelines you're recommended to get this. But we're looking at this number right here, and your ApoB is off the charts. And automatically, this is putting you at a, a high risk category for a cardiovascular event." And so knowing that and having those additional details can help basically to set people in the different categories of, okay you're borderline, but maybe we can start out with doing some of the lifestyle modifications versus, hey, this is a little bit more of a ticking time bomb. This is something that is more serious, and it's more critical that we really push to get these numbers down quickly. So I think it's more so to help kinda categorize these patients as say, "Hey, we really need to push this," versus, "Okay, let's try the lesser, less aggressive methods, and we can see where we're at and repeat, in three to six months." It's And it can be a challenge 'cause like anybody else, even for you and I, we're, we don't want to be on medications. Nobody wants to take extra pills. But ultimately it's a which is the lesser of evils. If you're high enough risk that, your doc is saying, "Hey, you're at high risk for a heart attack, and if we don't do something, then I'm afraid that we're gonna end up having a major event," versus, "Oh, hey, your cholesterol's a little elevated, maybe we should take a pill," one versus the other, the approach makes a difference. And patients definitely respond to having that additional data in front of them. Same thing with the high-sensitivity CRP. It, it can give us an idea of if there's inflammatory changes and basically assess the risk of having plaque. And oftentimes those inflammatory plaques can be more prone to breaking off and stuff with the soft plaques, so we worry about those being more mobile and causing the heart attack. So all of these different numbers together create a little bit more of a full picture of the overall risk and can help if people are wavering on one side versus the other and saying, "Hey let's be a little more aggressive right now and give this a try."

Kerry 19:26

And I think it's really important for, listeners to know that maybe they're not seeing you or not seeing me and they're not getting these tests ordered to maybe ask their doctor, or provider or whatever to order them for them so they can assess further whether it is recommended that they take another medicine or take a medicine to be treating it too, right? So I happen to order it in my practice, but I always am like I'm not 100% sure if this panel's gonna be covered by your insurance, but, let's see." So unfortunately, that caveat comes out of my mouth a lot. But it's an ex- those are excellent tests. It's my favorite panel on Quest and, I think it's great that it's definitely being used more do you have any more things to say on that? And I know there's some other cardiovascular screeners that sometimes we don't see or hear as much or maybe even remember to do.

Monica 20:16

Think, I think those are the main ones in terms of the regular cardiovascular screenings. I do include EKGs on all my patients because I do like having that baseline on file 'cause I've found that sometimes we catch, incidental things that maybe wouldn't have been caught otherwise. 'Cause people can have, like AFib and be completely asymptomatic or things like that. But it also gives us that baseline that if they ever were to have some sort of symptoms and, they didn't wanna go to the ER, it wasn't that severe, but something felt off,

EKGs, genetic testing & personalized prevention

Monica 20:44

we can check and we can say, "Hey you've got a new left bundle branch block," or you're suddenly really bradycardic, or you've got a lot of extra, random beats or something, and it would give us an idea of this is different from your baseline. We sometimes will include, if patients are interested, the genetic screenings related to cardiovascular health. So there's a panel that, includes some information about your ability to process some of the different statins 'cause some people do have that as a big concern with the myopathies and things. And then it also will evaluate for like the, the familial hyperlipidemias or things along those lines. And mostly it's just so we know definitively on those patients that, hey, this is a genetic issue. This is not necessarily a dietary issue. We understand that you're doing what you're supposed to be doing, and you're gonna fight this, and it's gonna be a losing battle unfortunately because your numbers are gonna be sky high because of this genetic predisposition. And it does still increase your risk the same way that it would even if it weren't genetic, so we still need to treat it accordingly.

Kerry 21:45

I definitely don't do much genetic testing, so that would be, a little bit outside what I have knowledge of. So it's good to hear, from you that what you do. I- some of those like the Cleveland Clinic lab that some concierge medica- medi- providers, doctors use, they have some other tests on there. I don't know if you use those or if consider them like cardiovascular screening tests or... What I was alluding to earlier, by the way, was like abdominal aortic aneurysm, but we can go there in a second. But do you use any of those Cl- Cleveland

Cardiovascular genetic panels

Kerry 22:13

Clinic lab tests?

Monica 22:15

I don't specifically use Cleveland Clinic. There are some panels for like more of the cancer side that I use for Natera. And that's more like the cancer screening type things. And then Helix is the one that I work with some. They have the different ones for the cardiovascular stuff Some of the cardiomyopathy panels even, so for people that are high risk. So hypertrophic cardiomyopathy or some of these other genetic elements that you can have risk factors with if we're concerned. And they have things i- in the depression realm too, in terms of like medication management and things that you can get. So there's some different elements that can be used in patients where it's indicated. It's not by any means something that I use across the board. But in those subsets or if we have questions or if there's been issues tolerating things in the past or if there's some gray areas with family history, it can be an added tool that we can incorporate. And usually the, the cost is relatively reasonable, and sometimes we can get coverage with insurance, although that's spotty.

23:13

Thank you for listening to the Get Healthy Tampa Bay podcast. A special thanks to Dr. Monica Esposito for sharing her expertise on cardiovascular prevention and advanced screening tools. If you found this episode helpful, please subscribe, leave a review, and share it with someone who wants to be proactive about their health. And be sure to join us for part two of this conversation, where we'll dive into cancer screening, aneurysm detection, colon cancer prevention, and other important tests that can help detect serious disease before symptoms

Preview of Part 2 & closing

23:41

appear. Until next time, stay healthy, Tampa Bay