Ep. 37: How Do You HeartWell? When Risk Scores Miss the Mark — with Dr. Regina Druz, MD, MBA, FACC, FMCP-M, integrative cardiologist

Standard cardiovascular risk calculators — Framingham, MESA, and the rest — are built from large populations. They tell you which group you resemble, but not who you actually are. In this solo episode, recorded for American Heart Month, Dr. Regina Druz argues that population risk scores are the floor, not the ceiling, and walks through a beta tool her team built at Holistic Heart Centers, Heartwell AI, that layers your genetics, imaging, and advanced biomarkers on top of validated risk models — then simulates what different treatments (or supplements) might do. Framed by her own daily question as a breast cancer survivor taking Tamoxifen — ‘will this work for me?’ — she demonstrates the idea with two de-identified patient cases and explains the ‘fire and forget’ debate, the roughly 30% ceiling of medication risk reduction, and the residual risk that personalization is meant to address. This is an educational overview, not medical advice; Heartwell AI is a decision-support tool whose outputs are statistical projections, not guarantees.

Watch on YouTube: A video version of this episode is available on the Own Your Heart Health YouTube channel. Subscribe to be notified of new episodes.

Episode Chapters

[00:00] Welcome & the Most Exciting Episode of 2026
[03:00] ‘Fire and Forget’ vs. Personalization
[06:30] Why I Ask ‘Will This Work for Me?’
[12:30] Risk as a Concept: Beyond Cholesterol Numbers
[16:30] The Floor, Not the Ceiling: Population Models vs. You
[22:30] Introducing Heartwell AI (heartwell.ai)
[28:30] How It Works: Validated Models + Real-Time Research (Not a Black Box)
[32:30] Case 1 — The Worried Woman With ‘High’ Cholesterol
[40:30] Case 2 — Early Menopause & a Calcium Score of 644
[48:30] Residual Risk, the 30% Ceiling & Your Next Step

Transcript

[00:00] Welcome & the Most Exciting Episode of 2026

Dr. Regina Druz (00:02): Welcome to Own Your Heart Health. I’m Dr. Regina Druz, your holistic cardiologist. This week we’ll dive into common heart health concerns, uncovering root causes and unpacking scientific discoveries and controversies. The information provided does not constitute medical advice. Please contact your healthcare practitioner before making any changes that may impact your health.

Dr. Regina Druz (00:45): Hello everyone. This is probably going to be the most exciting episode of 2026 — certainly for me; you can disagree, and at the end of the year we’ll compare notes. It’s exciting because I’m about to show you something truly extraordinary, inspired by hundreds of patients, thousands of questions, and the real need for personalized care. I recently read an article — I wrote about it in my Substack newsletter, Vital Signs and Bottom Lines — from the European Heart Journal, about the strategies cardiologists use for adults found to have elevated cholesterol, so we can help them avoid heart attacks, strokes, and cardiac death.

[03:00] ‘Fire and Forget’ vs. Personalization

Dr. Regina Druz (03:00): The article was structured as a debate. One group argued for what they called a ‘fire and forget’ approach — in my Substack I called my response the ‘Fire and Forget Rebellion.’ Their point: don’t over-discuss, because medications work. We use them to reduce major adverse cardiac events — MACE. They do work, sometimes with side effects, and where resources are limited and the burden of heart disease is enormous, you deploy what you have: prescribe the medication, and even if the patient doesn’t follow up, so be it.

Dr. Regina Druz (05:00): The other side — argued by a friend and local preventive cardiologist, Dr. Eugenia Gianos — was that patients increasingly ask for personalization: for genetic data, for a comprehensive understanding of how to lower their risk. That’s exactly the gap I want to bridge. The patients who come to Holistic Heart Centers usually already have the prescription from their own doctor; what they’re looking for is a comprehensive, personalized deep dive into their situation — what they should or shouldn’t be doing. Across more than a thousand patients, the same questions come up every day. And they’re the same questions I ask myself.

[06:30] Why I Ask ‘Will This Work for Me?’

Dr. Regina Druz (06:30): They’re my questions because I’m not only a physician — I’m a patient too. As I shared in a previous episode, about two years ago I was diagnosed with early-stage breast cancer, found early, essentially curable; it was removed, I had radiation, and I was placed on Tamoxifen, a common medication used even in low-risk cases. Every single day I pick up that bottle and ask myself: will this work for me? Clinical trials show women like me get a substantial risk reduction — but that’s a group. I don’t actually know how closely I resemble those women, or how I differ.

Dr. Regina Druz (08:30): And I know that’s exactly the question you’re asking. If you’ve been prescribed something for high cholesterol — a statin, an injectable like Repatha, a non-statin alternative — you ask yourself every day: will this work for me? Does it mean I won’t have a heart attack? That I won’t have a recurrence? That I’ll have a life full of energy and vitality, able to do everything I want as I age? And the second question we all ask: what else should I be doing to reduce my risk of this disease?

Dr. Regina Druz (10:30): Most of you already know medication alone isn’t enough. It’s powerful and it plays a role, but there’s more you can and probably should be doing. If you’ve listened before, you know we’ve covered fasting strategies, anti-inflammatory strategies, hormone-replacement strategies — and we’re just scratching the surface, because this year we’ll talk about measuring your immune age, your inflammation age, and using deeper biomarkers to forecast risk. You and I are asking the same questions, because we’ve each been marked by a condition — coronary disease, high cholesterol, high blood pressure, early-stage breast cancer like me — and placed in a category. Within that category, we need to understand what we can do beyond the common trials and population metrics to truly affect our health span and lifespan.

[12:30] Risk as a Concept: Beyond Cholesterol Numbers

Dr. Regina Druz (12:30): Cardiovascular disease remains the number-one killer of both men and women, in developed and many developing countries — leading in mortality and translating into enormous morbidity. Some of the fastest-expanding forms in women go beyond coronary artery disease into heart-failure syndromes and conditions whose physiology is less understood and where standard medications may not help as much. Women often spend years struggling to get diagnosed — with conditions like spontaneous coronary artery dissection (SCAD), which can be found on an angiogram when everyone assumes a classic heart attack, or Takotsubo cardiomyopathy, related to the heart-muscle weakness we also see around pregnancy and childbirth, the so-called peripartum cardiomyopathy.

Dr. Regina Druz (14:30): One of the most important questions people don’t ask about heart health is simply: what is my cardiac risk? People ask what their cholesterol is, what their blood pressure is, what their weight should be — but all of these combine and compound into something called cardiovascular risk. We have whole prior episodes on it, including on the calcium score. Traditional risk factors — high blood pressure, diabetes, elevated cholesterol, obesity, family history — are powerful because they predict a certain risk of major adverse cardiac events: non-fatal heart attack, stroke, or cardiac death. From large studies like Framingham, the Framingham Offspring Study, and the Multi-Ethnic Study of Atherosclerosis (MESA, which used imaging like the calcium score), cardiology built standardized, deterministic risk equations.

[16:30] The Floor, Not the Ceiling: Population Models vs. You

Dr. Regina Druz (16:30): Here’s the problem: none of these models is comprehensive enough to give a truly powerful individual estimate. They give a group-level estimate — low, intermediate, or high risk — and then make you think that’s all there is. I argue that the population-based estimate is only the floor; the ceiling hasn’t been determined yet. On top of that floor we have to add your individual predispositions: genetic information, the current status of your blood vessels, your vascular age, your imaging data. It’s still a statistical projection, but it’s far better than forcing you into a group you may or may not belong to.

Dr. Regina Druz (18:30): Just as my own doctor tries to fit me into a group of similar women without accounting for my individual characteristics — because that information mostly doesn’t exist yet — the same crude fitting happens in coronary disease. Someone has to collect the individual information, analyze it, and refine a crude statistical probability into something applicable to a real person. That’s the major gap in cardiology right now — and in oncology and neurodegenerative disease. On one side is research data from large, long, expensive studies and registries; on the other are people living with these diseases every day, doing individual things those datasets never captured.

Dr. Regina Druz (20:30): So one of the things we pioneered at Holistic Heart Centers is structured programs that begin to close that gap — looking at advanced biomarkers, comprehensive genetic panels, imaging that grounds your vascular age and atherosclerosis progression, even digital biomarkers like body composition, heart rate, and HRV — and pulling it together into a personalized interpretation of your unique risk. We don’t throw away the population metrics; that’s the floor, where we start. When you ask ‘should I take this drug or not?’, the answer isn’t a flat yes or no — it depends on what we can determine about your personalized risk versus the burden and side effects of treatment, so you can make the best decision: medication, less medication plus supplements, supplements alone, and what lifestyle changes to execute.

[22:30] Introducing Heartwell AI (heartwell.ai)

Dr. Regina Druz (22:30): So in 2026, in honor of American Heart Month, we’re releasing the beta version of your personalized cardiovascular risk estimator. It’s called Heartwell AI — the website is heartwell.ai — and I’ll show it in a few minutes. It crystallizes hundreds of data points from our patients’ histories and journeys to help fill the gap between the population metrics traditional cardiology and primary care rely on and the individual who may not fit those categories.

Dr. Regina Druz (24:30): The tool is highly actionable. You can use it during visits with us, or invite your own physician to use it with you. In honor of American Heart Month, we’re making access free for all patients we see in February — it’ll come as part of your visit, and you’ll get a report. This part is a little technical: if you’re listening on a podcast platform, keep listening, but if you have even a few minutes, hop onto YouTube, because this is visual and I want you to see exactly how it works.

Dr. Regina Druz (26:30): It’s currently a professional version only. If you’re a patient, go to heartwell.ai and click ‘invite your doctor’ — send them a link, or enter their details and we’ll reach out on your behalf and let them know you’re interested. Your doctor can then start free assessments — they get a set of free assessments to test-drive with your information, with your consent, so there’s no cost to them. I built this because I didn’t want patients left with random numbers from population equations. Those are our floor — the best of what decades of research gave us — but I wanted to add personalization and the ability to simulate an intervention, because so many patients say, ‘I don’t want to be on a statin, or on Repatha — is it too much, too little?’

[28:30] How It Works: Validated Models + Real-Time Research (Not a Black Box)

Dr. Regina Druz (28:30): Since it’s called Heartwell AI, much of it is AI-driven — AI is what made it possible for me to build this at all — but the information does not come from a black box. We use a solid methodology: validated risk models (the same equations your doctor uses for the population-based metric), and on top of them we pull in the constantly accruing research — genetic risk, imaging risk, intervention modeling — to give you, first, what your personalized risk estimate may be, and second, what you can actually do about it. That closes the critical gap. It requires a National Provider Identifier (NPI) to sign in, which is how the system verifies clinicians — physicians, registered dietitians, nurse practitioners, physician assistants.

Dr. Regina Druz (30:30): When the tool generates an AI-assisted summary, it’s doing real-time research using an academic mode from Perplexity — real research with citations — so it’s not a black box: it’s a synthesis of information pulled quickly, drawn from a curated knowledge base of highly regarded cardiovascular publications that we update regularly, plus a real-time clinical search. Importantly, I’m still the human in the loop and the human driver. I used to do all this research on my own time; now I’m leveraging the technology to get that level of insight in real time, which is what my patient actually needs.

[32:30] Case 1 — The Worried Woman With ‘High’ Cholesterol

Dr. Regina Druz (32:30): Let me walk through a couple of de-identified demo cases — based on real people, shown with permission as teaching examples. The first is a woman in her 60s on bioidentical hormone replacement who tends to run higher lipids: LDL around 126, a very reasonable HDL of 75, good triglycerides, and a hemoglobin A1c that sometimes drifts into the pre-diabetic range. She’s lean — not someone with weight to lose — and I suspect she may be a lean ‘hyper-absorber’ who takes in too much cholesterol from food, or has mild tissue-level insulin resistance, since she could stand to build more muscle. She’s very worried about those cholesterol numbers.

Dr. Regina Druz (34:30): On standard assessment she doesn’t have high-risk features — great blood pressure — but she wants her LDL and ApoB as low as possible. If you’ve listened before, you know an LDL around 70 and ApoB around 80 are widely considered optimal, and for higher-risk patients we aim lower — LDL under 55, with European colleagues publishing in August 2025 that under 45 may do even more. Those are population targets. Her real question is: does she personally need to be that low? She has a few wrinkles — a slightly elevated high-sensitivity C-reactive protein and a little carotid plaque, not unusual in her 60s — so some markers suggest her cholesterol could matter.

Dr. Regina Druz (36:30): She also gave us her genetic data, so we go beyond standard computations — bringing in polygenic risk scores and her possible susceptibility to statin side effects, because we don’t want to fix one thing and harm another. When we run the simulations, her genetics actually shift her risk down by about 25%, because she carries some important protective variants. So even though her lipids run high, she doesn’t compute to high risk, and she could potentially manage this with supplements rather than a statin. There’s still uncertainty — her last coronary calcium score was zero a couple of years ago, and given her mild inflammation we might repeat it sooner than the usual five years.

Dr. Regina Druz (38:30): Looking only through the population lens, depending on the calculator she lands anywhere from low to intermediate — the zone where we’d normally open a discussion about more workup or medication. But she’s already doing a great deal for herself; she doesn’t fit the ‘lose 20 pounds or stop smoking’ boxes. Because her polygenic risk scores put her in the lowest category versus the biobank population, her adjusted risk drops. This isn’t a perfect calculation — it’s a model, a construct — but it gives the patient and physician a path forward. Here that path is not a statin; we loaded a preset of two supplements, adjusted doses, and saved the simulation to share with her, projecting her LDL into a more optimal range. If new information comes in — say a coronary CT angiography revealing more about her vascular age — we can revisit.

[40:30] Case 2 — Early Menopause & a Calcium Score of 644

Dr. Regina Druz (40:30): The second case, a patient I saw recently: a lovely 70-year-old woman, not overweight, not a smoker or drinker. Both happen to be women here, but the tool isn’t limited to women — these are simply the cases that came through. The concerning part: she went into menopause early, in her late 40s, and never received systemic hormone replacement — because 20-some years ago the approach was different from today’s. She’s run elevated cholesterol — LDL 146, ApoB 112 — not off the charts, with no signs of inflammation. Because of her age and those mildly elevated numbers, her doctor ordered a coronary artery calcium score.

Dr. Regina Druz (42:30): That score came back a whopper: almost 644, placing her in the 90th percentile for age and gender — the top 10%, a competition no one wants to win, because it reflects accelerated atherosclerosis. When I looked at her genetics, she had a perfect storm: variants predisposing to endothelial dysfunction (we test for these in our Heartwell Toolkits, or with a standalone genetic panel), plus rarer ‘tier-three’ variants that essentially turn her good cholesterol bad — tied to a concept called reverse cholesterol transport, which I’ll devote an upcoming episode to (‘when your good cholesterol turns bad’).

Dr. Regina Druz (44:30): Her primary care doctor had already started a low dose of rosuvastatin, five milligrams, and they were at a crossroads about whether that’s enough. The standardized estimators put her at intermediate risk on the surface. But this is just statistics — telling us a 70-year-old has the arteries of a 100-year-old: longevity in the wrong place. Because genetic data isn’t usually included in risk estimators, and many patients never even get a calcium score, a case like hers can look deceptively mild. When we factor in her genetics, her scores quadruple; add the imaging, and her 30-year risk is very high — which makes sense, because she already has coronary artery disease.

Dr. Regina Druz (46:30): So a low dose of one statin won’t get her there. Modeling shows rosuvastatin 5 mg gives only a modest LDL and ApoB reduction — not enough for her level of risk, where we’d want LDL under 45 and ApoB as low as possible. I worked with her to understand that a higher rosuvastatin dose, plus ezetimibe — and, given her risk, a PCSK9 inhibitor as triple therapy — begins to approach levels where we might see disease stabilization or even some plaque reversal (the jury is still out). I also modeled supplements — bergamot and berberine — which lower LDL and ApoB somewhat but, for her, don’t bring risk low enough. Some cardiologists would call aggressive medication ‘fire and forget’; but I’m not firing and forgetting — I’m in shared decision-making with her to actually make a difference.

[48:30] Residual Risk, the 30% Ceiling & Your Next Step

Dr. Regina Druz (48:30): Where we’re heading with Heartwell AI is collecting outcomes from clinicians who practice this way, so we can give each patient a sense of their own trajectory — what’s sometimes called a digital twin. As new information comes in, we adjust the scenario. This is proactive, hands-on management — not ‘here’s a population, here’s your forecast, deal with it.’ It’s the difference between handing someone an umbrella for today’s rain and actually understanding their long-term climate.

Dr. Regina Druz (50:30): Here’s why personalization matters so much. Even with the best medical therapy for coronary heart disease, we typically achieve about a 30% relative risk reduction. If your 10-year risk is 10%, good therapy might bring it to roughly 6.5–7% — meaningful, but most of the risk is still there. In cardiology we call that residual risk. So the best therapies leave roughly 70% of your personal risk untouched — and that’s not me saying it, that’s the data. Unless you understand what’s driving that residual risk — and today, with advanced biomarkers, genetics, and imaging that are clinical-grade, not just research tools — you can’t address it.

Dr. Regina Druz (52:30): If you tell me, ‘Doc, I’m going to exercise, eat well, fix my sleep, stop smoking’ — wonderful, you absolutely should. But there’s real value in additional testing, because it turns a weather forecast into a climate forecast for one specific area: you. How else do you know how much to exercise, which diet, which medications or supplements? If you’re still hanging your hat on population metrics alone, you may be missing two-thirds of what could actually affect you.

Dr. Regina Druz (54:30): So this American Heart Month, take advantage of the opportunity. If you’re not seeing my team, you can invite your own doctor to heartwell.ai and have them run it with you. If you’d like to work with us, you can schedule on our website, and for all of February, Heartwell AI is a free add-on to our consults. Be grateful to yourself and to your heart, and understand that you have options and solutions — in 2026 there are more than ever. But the person most responsible for your success is you, because if you don’t take the next step, change isn’t likely to happen.

Dr. Regina Druz (56:00): Thank you for tuning in to Own Your Heart Health with Dr. Regina Druz. This podcast is powered by Holistic Heart Centers. If you enjoyed the show, please rate and review us on your favorite platform. To learn more about our services, visit holisticheartcenters.com and subscribe to our YouTube channel — the link is in the show notes. See you next week.

Frequently Asked Questions

What is Heartwell AI, and who is it for?

Heartwell AI (at heartwell.ai) is a beta cardiovascular risk tool built by Dr. Druz’s team at Holistic Heart Centers. It starts from validated, population-based risk models — the same equations clinicians already use — and then layers on an individual’s genetics (including polygenic risk scores), imaging (such as a coronary calcium score), and advanced biomarkers to produce a more personalized risk estimate, along with a simulation of how different treatments or supplements might change that risk. It’s currently a professional-use tool that requires a clinician’s National Provider Identifier (NPI); patients can use an ‘invite your doctor’ feature so their own physician can run it. Dr. Druz emphasizes the outputs are statistical projections, not guarantees, and that a clinician remains ‘the human in the loop.’ This is an educational overview, not medical advice.

Why aren’t standard risk scores like Framingham or MESA enough?

Because, as Dr. Druz puts it, they’re the floor, not the ceiling. Standardized estimators are built from large populations and place you into a broad category — low, intermediate, or high risk — but they can’t capture what’s unique about you: your genetic variants, the current state of your blood vessels, your vascular age, or your imaging findings. Two of her case examples illustrate the point: one woman’s high-looking cholesterol was offset by protective genetics (lowering her estimated risk), while another woman’s ‘mild’ cholesterol masked a coronary calcium score of 644 and high-risk genetic variants (dramatically raising hers). Population scores are a useful starting point, but individual data can move the estimate substantially in either direction. None of this replaces evaluation by your own clinician.

What is the ‘fire and forget’ debate?

It comes from a European Heart Journal debate Dr. Druz discussed in her Substack newsletter (Vital Signs and Bottom Lines), where she titled her response the ‘Fire and Forget Rebellion.’ One side argues that since lipid-lowering medications clearly reduce major adverse cardiac events, clinicians should simply prescribe them broadly and not over-discuss — ‘fire and forget’ — especially where resources are limited. The other side, which Dr. Druz favors, argues for personalization and shared decision-making: patients increasingly want to understand their individual risk and the full range of strategies (genetic, imaging, lifestyle, and medication) available to them. Heartwell AI is her attempt to bridge the two. This is a summary of a professional debate, not a treatment recommendation.

What is ‘residual risk,’ and why does it matter?

Residual risk is the portion of cardiovascular risk that remains even after effective treatment. Dr. Druz notes that even the best medical therapy for coronary heart disease typically delivers about a 30% relative risk reduction — so if your 10-year risk were 10%, good therapy might bring it to roughly 6.5–7%. That’s meaningful, but it leaves the majority of your personal risk untouched. Her argument is that understanding and addressing residual risk requires going beyond population metrics to individual data — advanced biomarkers, genetics, and imaging — which are now clinical-grade rather than research-only. As always, decisions about how to act on that information should be made with your own clinician.

Show Notes & Resources

Host: Dr. Regina Druz, MD, FACC

Dr. Regina Druz is a holistic and integrative cardiologist, the host of Own Your Heart Health, and the founder of Holistic Heart Centers. Board-certified in cardiology and nuclear cardiology, she blends conventional cardiology with functional and longevity medicine and a strong emphasis on personalized, data-driven cardiovascular risk assessment. In this solo episode she introduces Heartwell AI, a beta tool her team built to layer genetics, imaging, and advanced biomarkers on top of standard risk models — and frames it through her own perspective as both a physician and a breast cancer survivor.

Resources Mentioned in This Episode

Heartwell AI — heartwell.ai — beta personalized cardiovascular risk tool (professional version; requires a clinician NPI). Patients can use ‘invite your doctor.’ Noted as a free add-on to Holistic Heart Centers consults during February (American Heart Month) — this promotion is time-bound; confirm current availability.
Vital Signs and Bottom Lines — Dr. Druz’s Substack newsletter; her article ‘Fire and Forget Rebellion’ responds to a European Heart Journal debate on lipid management
HeartWell Toolkits — advanced biomarkers, comprehensive genetic panels (including endothelial-dysfunction and lipid-related variants), and imaging-based vascular-age assessment
Coronary artery calcium (CAC) score & coronary CT angiography — imaging that can dramatically refine an individual’s risk estimate
Polygenic risk scores — genetic risk modeling layered on top of standard estimators
Prior OYHH episodes on cardiovascular risk and the coronary calcium score
Coming soon — an episode on ‘when your good cholesterol turns bad’ (dysfunctional HDL and reverse cholesterol transport)
Schedule a consult with Holistic Heart Centers — holisticheartcenters.com (or go.holisticheartcenters.com/apply)

Holistic Heart Centers

holisticheartcenters.com
HeartWell.ai — AI-powered cardiovascular risk assessment
Address: 55 Bryant Avenue, Suite #6, Roslyn, NY 11576
Phone: 877-511-5166
YouTube: @reginadruzmd
Instagram: @dr.reginadruz
Podcast: Own Your Heart Health — available on Apple Podcasts, Spotify, and all major platforms

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