CardiOhio Podcast
CardiOhio Podcast
Beyond Statins: A Practical Plan to Incorporate the New Lipid Agents
Please join our special guest, Dr. Benjamin Romer from Ohio State University, as we address the current state of lipid therapy in both primary and secondary prevention patients. He addresses a practical approach to the issue of statin intolerance, then reviews the newer agents including ezetimide and bempedoic acid, as well as the newer percutaneous agents, with a focus on practical tips for implementation. We wrap up with a discussion on the role of coronary calcium scoring to guide therapeutic decisions in select patients.
For more information, see the 2022 ACC Expert Consensus Pathway on the role of Nonstatin Therapies.
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So welcome back to the CardioHow podcast. We're really excited today to have a discussion on lipid lowering therapy, a topic we haven't addressed in a while, and we're really going to focus on some of the newer non statin agents that have been released in the last few years and talk about some practical tips on how to use them in our cardiac patients as well as for primary prevention. I'm really excited to have a guest today, who's a colleague here in Columbus, just like myself, and is a lipid specialist. So I'd like to welcome Dr. Benjamin Romer, who is on the faculty at The Ohio State University as a clinical cardiologist and a lipid specialist. And I assume that's a place that's in celebration mode today, since we're recording this podcast less than 24 hours after the Buckeyes. Dr. Romer. Uh, won the national championship last night. So Won the national championship last night. So Ben welcome to the show.
Ben:Yes, thank you very much, Kenny. It's good to be here. Yes, last night was a very fun, fun night, fun game, fun run so good celebration today on, on campus. It was good to talk with you at the Ohio ACC meeting a few months ago. We can kind of keep that conversation going today.
Kanny:Yeah, thank you very much. Yeah, as you just alluded to, you did give a very nice talk at our annual meeting about lipid lowering therapy. So Ben, I know, I know you're a graduate of OSU Med School. I, I see that you did most of your training in Chicago at University of Illinois. But we do have a lot of fellows in training who listen to this podcast. And so we always like to start just by hearing a little bit about your journey to your current position. And I guess what I would be most curious about is, as you pursued a career in cardiology, what kind of led you to focus on, on cardiac prevention and then eventually, specializing in lipid therapy as well.
Ben:Yeah, certainly. So, like you said, I I graduated medical school from Ohio State and then I did my residency and training six years, or residency and fellowship, rather six years in Chicago, University of Illinois, Chicago. And you know, I, I sort of knew relatively early on that I didn't want to be a procedural based specialist within cardiology, but I really didn't have much, that much of an interest in prevention during fellowship, mainly because I found that it wasn't, it wasn't stressed a whole lot. I mean, when you're in fellowship, you have to learn ECHO, you have to be in the cath lab you have to learn EP. It just seems like there are much bigger priorities with a steeper learning curve. And so it wasn't until I returned to Ohio State as as faculty in 2020, and it wasn't until about a year in until I realized that I kind of had a little bit of a relative blind spot in my knowledge. I just feel like as a general cardiologist, I, I, I should develop skills and prevention much, much sharper. So I, I, I kind of just had an interest. I, as I was learning more and more about prevention and about the newer agents that are out to me, it just felt like a very natural fit. To immerse my role as a non invasive cardiologist to also focus on prevention because that's what a lot of patients these days want to come in and talk about. They want to come in and talk about calcium score. They want to talk about lipoprotein A. I think nowadays a lot of people are focusing on prevention. So it was a, it was a very natural progression, which I'm very happy to be a part of now at Ohio State in a very a very excellent lipid and prevention clinic. So so, you know, as time goes on, I think, you know, the role for prevention in cardiology just continues to grow. Within the prevention clinic, a lot of patients are, are motivated to help themselves through lifestyle modifications, but also with the newer lipid lowering agents, they also come in and they, you know, they're, they're very interested in what options are available outside of statins in order to reduce their risk.
Kanny:Well, speaking of statins, I thought, even though we really want to focus on some of the newer agents, I don't think there's a lot to say about statins. You know, we have three decades of data and personal experience, using statins to reduce risk. But one topic I wanted to ask about statins before we move on to the other agents is the issue of statin intolerance. All of us in clinical cardiology, of course, we prescribe statins, we see patients being treated, and I think every clinician, really, who takes care of cardiac patients has to deal with the issue of statins. Statin either intolerance or what I would call statin reluctance. And we all know, of course, that in the literature, you know, the incidence is not particularly high, but we also know in the real world we do. So I'm just curious, if you could summarize, when a patient who maybe is already on a drug comes to you and notices some intolerance or complaints, like, what is your overall strategy to try to. maintain statin therapy and then, get into the decision making and maybe about, an alternate agent at some point.
Ben:Yeah. I mean, certainly within the lipid and prevention clinic I see multiple patients every time I'm in clinic that, that have statin intolerance. And, and as you said, whether that's a true adverse reaction or it's just an unwillingness, a reluctance, You know, the end result is that we have to come up with strategies to try to encourage them to try another one or a different one, or maybe remedies for their statin associated side effects or consider another alternate agent. So in general I primarily prescribe hydrophilic statins, especially rosuvastatin. And I find that a lot of patients come in on atorvastatin or simvastatin, if just switching them from those type of lipophilic statins to hydrophilic one, especially rosuvastatin, they do okay. And I also think it's very important to remind patients that even a low dose of rosuvastatin, maybe every other day, you know, just five milligrams of Crestor every other day can lower LDL by a considerable amount, you know, 25%, 30%. And that's, you know, convincing a patient, Hey, you only have to take this once every other day. So, you know, I, my, my go to statin is, is, is rosuvastatin. But if they don't tolerate that, then pravastatin or patavastatin even are, are other options that, maybe they'll tolerate it. Checking vitamin D is also important and, TSH, I, you know, there's, there's some, there's some literature that suggests that that low vitamin D can decrease HDL can increase LDL and triglycerides. So, that's something that we'll check, especially in these winter months. A lot of people are vitamin D, D deficient. As for something like Coenzyme Q10, you know, the guidelines do not recommend supplementing with Coenzyme Q10s to prevent statin associated. muscle symptoms, but I have no problem prescribing it myself simply because, you never know if somebody has a placebo effect even from Coen's MQ 10 to wipe away their symptoms. So, those are some of the, those are some of my initial reactions to statin and tolerances. It's important to check for for drug interactions. Having pharmacists on board in our lipid clinic is invaluable to, you know, to help check for drug interactions and potentially reduce the dose of a statin if an interaction makes it such that the level of statin will be too high. So those are kind of my, you know, my, my, that's my checklist sort of when patients come in, but as you said, it can just be challenging sometimes and sometimes people will come in and they'll just be very stubborn and hard nose and you can give them all the data and talk about it, you know, the lipid or the LDL lowering and the anti inflammatory effects of statins. And, you know, you just can't really budge them. So it's a, it's a battle that we're going to keep fighting. And, you know, sometimes you can make headway with patients, Because it is important to have them on statins, but every once in a while, you know, they just, that's not the case.
Kanny:Yeah, yeah, thanks. I wasn't aware of that link with, potential link with vitamin D deficiency. I think that's definitely worth keeping in mind in many of our patients, especially in this climate. So that's good to know. And I've had similar experience with, you know, the kind of microdosing of rosuvastatin, and patients, like you said, do really tend to tolerate that really small dose even when they've had other issues, and it's pretty striking the LDL reduction you can get. So, one other general question I had before we talk about some of the agents specifically, because this does come up in day to day practice as well, I know the guidelines still, focus on using a standard, lipid profile, or perhaps using, non HDL cholesterol as kind of a practical parameter to monitor, therapy. But we also understand, that calculated LDLs can be prone to issues. So in your patients, not necessarily, your highest risk patients, but in the day to day general clinical, patients for secondary prevention do you think a standard profile is enough for serial monitoring or do you tend to, do direct LDLs or consider measuring ApoB serially?
Ben:Yeah. I mean, in my patients that just in my, in my general cardiology Clinic where I have patients that I'm following for hypertension or Even just kind of risk factors if they're not complicated heart failure, for example I will get a lipid profile with an indirect LDL and I'll get it when they're not fasting. I mean, just the routine screening I have no problem following the guidelines to, in that regard, to get a non fasting indirect LDL profile. A. And so, you know, the, the, the calculated LDL is unreliable when triglycerides are quite high. So above 400 or, or, you know, if LDL is very low, if it's less than 70, and really this is with very high risk patients where you're aiming for LDL is that low, that that's when the calculated LDL can be unreliable. So in patients that I have on, on multiple lipid lowering agents, especially something like PCSK9 inhibitor in patients that have triglycerides that are, that are really, really high, then. Then I will jump straight to doing the direct LDL and make that lipid profile be fasting. But in general I think it's just fine to kind of get the general lipid profile in, in patients that you Either aren't worried too much, too worried about, or maybe you just haven't unveiled what their true underlying lipid abnormalities are.
Kanny:Great, great. So, you know, assuming you do have a patient who's either tolerating statin therapy, but not getting their LDL to target, or is having, some degree of intolerance, I guess I want to just go over kind of your practical strategy for how you would then incorporate additional agents. So, Is it safe to say that ezetimibe is still kind of the first choice nowadays for a non statin or a second drug given that it has, some outcome data that we've been, seeing for several years? Yeah, I
Ben:think that is safe to say. It's safe to say most importantly from, as you mentioned, outcomes data improvements in, in in major adverse cardiovascular events for secondary prevention patients. Thank you. Mortality benefit, everything like that. So it's important from that regard, first and foremost, but it's also important because insurance companies won't cover some of the other agents unless you've tried a zetamide. So there are some patients where if you have them on high intensity statin and then you add a zetamide that they'll, they'll be, they will have an excellent response to, the 10 milligram addition of a zetamide. Some patients, it lowers their LDL by a, by a considerable amount. Some other patients, it doesn't really budget that much, you know, 10, 15%. But, you know, in, in theory, ezetimibe should lower LDL by, maybe 15, 20 percent as monotherapy. But when you combine it with statin, more like 25 to 30%. So, there are a lot of patients that we have, especially secondary prevention patients, where the target LDL is below 70, or if they're very high risk, below 55. And let's say the LDL is, you know, 5, 10, 15, 20 points higher than what you target, that's when ezetimibe can achieve your goal, and you're sort of, you're good to go in that regard. So, yes, ezetimibe certainly is my first go to. But in the realm of genetic dyslipidemia as familial hypercholesterolemia patients with really high LDL levels and, and multiple manifestations of atherosclerotic disease, if their, if their LDL is over 100 on stat, already on statin therapy, and if you're trying to get them below 70 or below 55, Addition of azetamide alone isn't going to cut it. So it sort of depends on what their risk is, what risk you've established, and then just how much lower you need to target their LDL as to whether the addition of azetamide will be enough with statin already on board.
Kanny:Sure, sure. And then assuming you have to go beyond azetamide then, I know one of the newer agents that's garnished a lot of attention the last few years since it was approved is bempedoic acid. Can you say a little bit about how you use that agent now in a clinical sense and in what settings?
Ben:Yes, certainly. So bempedoic acid is It may lower LDL by 15 to 20 percent alone. I think it's maybe closer to a third if you combine it with a zetamibe and there's a, there's a combination form of, a zetamibe and bempidoic acid. So in the trial, in the clear trial the effect of bempidoic acid as far as from a prevention standpoint was more pronounced in patients that were primary prevention. And so I generally use bempidoc acid in those patients who who, who are primary prevention, who might be moderate risk that certainly that aren't high risk or very high risk where, where you're trying to lower their LDL again, by, by by a modest amount, 20 to 30%. And if you can combine it with a zetamine, that's the best bang for the buck. I mean, usually these are patients who come in. and they're statin intolerant. So they're statin intolerant, their primary prevention. And those are the ones where you say, well, benpidioic acid may be a good idea. Now you have to be careful about gout. Check uric acid levels before starting benpidioic acid. I ask older patients above the age of 60 if they have had any, tendon issues in the past because there's a very, very small risk of tendon rupture without that would obviously be a catastrophic event. So generally speaking, I use it in primary prevention patients who are statin intolerant that are maybe moderate risk and you need kind of moderate LDL lowering. I just think there are better options out there for patients who are secondary prevention or you need You know, much more aggressive LDL lowering.
Kanny:Sure, sure. And one final word about benpedoic acid. I mean, I know azetamide, of course, is generic. Do you have any issues with approval or cost issues for, cost or access issues for the patient at this point in time?
Ben:Yeah, certainly. I mean, usually in order to get it covered you have to document statin intolerance. So both bempidoxic acid alone and the combination you know, can require a prior authorization or can be costly to patients. So that's why, you know, it's not an agent that I would just jump to as monotherapy if a patient hasn't tried multiple statins. So usually it's, you know, they're statin intolerant, you try a zetamide, they're either intolerant of a zetamide or they need additional LDL lowering and maybe they're, they're, you know, they want to avoid taking multiple medications. So you can say, well, we can just. Do this additive to azetamide, but you're still only taking one pill. And so that's, that's kind of a way to convince those patients that, that bempedoc acid is a good idea.
Kanny:Yeah, that makes sense. That makes sense. So then kind of moving on to some of the other therapies I mean we have you know about a decade of or more data with the PCSK9 inhibitors You know, I still feel like and tell me if this is the case in your in your practice at Ohio State Is that, are those generally still administered through your lipid clinic or do you see some general cardiac providers getting more comfortable giving those and then where do they fit in, in the stepwise approach to the helping patients get to target?
Ben:Yeah, so for, for a long while I, I think that a, a, a common reason for referral to the Lipid and Prevention Clinic was to consider PCSK nine and administer. But really over the past six months or so, we're making much more of an effort to educate general cardiologists and primary care physicians, internal medicine, family medicine, that prescribing PCSK nine inhibitors. Is is a very safe thing to do. The risk profile is very low. The efficacy is is very high. You know, we're trying to make PCSK9 inhibitors more mainstream and have providers be more comfortable prescribing them simply because, as I said, they are so effective. They're very effective and they're safe. The main thing is just patient education. And so, you know, administering PCSK9 inhibitors is quite easy. It's just like, sort of like an insulin pen. I mean, I've had very little pushback from patients about using PSCSK9 inhibitors or even the side effects associated with them. And so we're trying to certainly make it more mainstream with all different providers who might who might be prescribing those, you know, including endocrinologists even. So as for, when we, jumped to them I think, I, I, as a. Just as a cardiologist, I always try to establish the patient's risk. And so, the first thing is to determine whether that patient is primary prevention or secondary prevention. And if they're secondary prevention with a history of heart attack or stroke or, you know, peripheral arterial disease, then automatically, at the very least, you're going to aim for an LDL target of less than 70. And if they have other additional risk factors or multiple prior events, then it's an LDL of less than 55. And, you know, the truth of the matter is that these patients that are secondary prevention, they had LDLs that were quite high for a long period of time. And PCSK nine inhibitors are just so effective at lowering LDL and non HDL, I mean 60% in the trials for Repatha. and for preluant. So that's just that's an incredible lowering on top of statin therapy alone. So in those trials, the baseline LDL for these patients was maybe around 90 or so because they were already on statin therapy. And addition of PCSK9 inhibitors brought them, you know, 60 percent below that baseline of 90. So I, you know, I can't talk enough about just how important it is to administer PCSK9 inhibitors. In secondary prevention patients or in high risk primary prevention patients, especially those that have familial hypercholesterolemia. And then if you tell them that, you know, there's a med out there that's more effective and you can get rid of another one. Oftentimes, they're very open to that idea,
Kanny:but you will typically continue the statin if they were tolerating it,
Ben:absolutely. The statins are here to stay. If the patient is tolerating without a doubt.
Kanny:Yeah, 1 thing I was just thinking about when you talked about acceptance of the, percutaneous agents is that maybe with the proliferation of some aglutide and trizepatide which it seems like, about half our patients are taking now, maybe that's made these these agents more acceptable too. Yeah, I
Ben:think that's a great point. And a lot of patients, will have, you know, Great cardiovascular benefits from those GLP 1 agonists as you mentioned. So I that that makes it sort of sort of easier That you can tell them. Hey, it's just another injection Instead of losing a lot of weight like those meds you mentioned, well this is going to lower your cholesterol levels and you'll be in good shape, so that's definitely a good point.
Kanny:So in your in your clinic, who typically does that initial education to the patient about getting started on the PCSK9 in terms of the injections? Some education about any side effects? Is that, would that be a pharmacist typically, or? Or a nurse practitioner and how do you think that could then translate to like a general cardio clinic?
Ben:Yeah, so, in our lipid and prevention clinic, you know I'm i'm paired with with a pharmacist and we go and see the patient together and do the visit together, which is just excellent from a multidisciplinary standpoint, very comprehensive way of evaluating the patient. And it's usually the pharmacist that, that will then, you know, grab a dummy pen and do the education. And truthfully it, it, that education lasts for less than a minute. So I, I think from from a general practitioner standpoint it doesn't take much time to educate the patient about administering that. I mean, it's, it, it's, Quite honestly, it's easier than doing insulin injections because you don't have to set, you don't have to set the dose but to be honest, even if you were to have a nurse or, or, you know, a mid level provider, I would feel completely comfortable with a nurse in my general cardiology clinic educating a patient how to administer a subcutaneous injection just because it is that easy.
Kanny:Yeah, I agree, and I think a lot of us in general cardiology are finally getting to the point where it's kind of a routine part of our practice because obviously Not everyone has access to a the resources of a lipid clinic are limited even in a setting when you have it You know at least that's that's the case for us as well Well, I guess just to finish up in the last few minutes five minutes or so. I wanna ask you a little bit about Enli, but just briefly, I know there's another agent, another PCSK nine agent in umab which my understanding is limited to, you know, homozygous fh. So is that an agent that would be less common in a general cardio practice at this point in time?
Ben:Yeah, I think, I think so. I mean, umab is, is, is very effective, but it is only approved for homozygous fh. So those are patients, that's an agent that really should be only prescribed by a lipid specialist. After a patient has undergone genetic testing with, with confirmed homozygous FH.
Kanny:Okay. So then I guess that brings us to Inclisiran, which has also been approved in the last few years. And my understanding for that is that it is indicated. For secondary prevention C. A. D. In addition to a familial hyperlipidemia. So how is that agent, you know differ from the more established P. C. S. C. 9 inhibitors. And then how do you. Incorporate that versus the other agents.
Ben:Yeah. So in glycerin and PCSK9 inhibitors, they work very similarly. A PCSK9 inhibitor will, it's a monoclonal antibody that attaches to the PCSK9 protein and prevent that protein from eventually down the road causing, causing breakdown of the LDL receptor. And glycerin is a small interfering RNA that prevents translation of the PCSK9 protein. So it just prevents PCSK9 protein from from even being produced. So the net effect is that you have more LDL receptors to bind LDL and take it out of the bloodstream between glycerin and PCSK9 inhibitors that we discussed. So in glycerin is a very effective way to at lowering LDL. In the Orion trials, I think it reduced LDL by around 50 percent or so, which is, which is an excellent reduction in, in LDL. So, there are some benefits to the benefits to in glycerin is that you only have to administer it. You administer it day one. And then three months later, and then at six months, and then after that, it's every six months. So after the first couple of doses Inclistrin is only administered twice a year, which for some patients is a very, very attractive way to have a medicine administered. Now, it is administered in an infusion clinic. So you would have to go into a clinic to receive the to receive the medication. But that also means that that's not charged to insurance. Inclisirin is not charged as a medication. It's, it's charged as kind of a as a clinic visit. So, for patients that are worried about cost of medication or at the end of the year being in the donut hole and they're paying an arm and a leg for whatever, you know, their DOAC and their SGLT2 inhibitor and their PCSK9 inhibitor, You can kind of circumvent that cost in some, in some ways by having Inclisirin be administered in, in, in the clinic setting, in an infusion clinic. So, you know, the, the one, the one point to make about Inclisirin is that we, we don't have outcomes data yet. That's scheduled to come out over the next couple of years. All signs point to certainly a positive outcome. result from from those studies. But I would just like to make the point that we have a lot more data with the PCSK9 inhibitors and, you know, generally speaking, they lower LDL by 60 percent compared to 50%.
Kanny:Yeah, great. Great. Well, that's good to know about the fact that, it's a clinic based treatment rather than, you know, considered a pharmaceutical because I do think that makes a big difference the way some patients reimbursement works Well, it's amazing how much this field has changed in the last decade or so. with these new agents and these new outcome studies. One final thing I want to ask before we wrap up in a couple minutes is, being an imager myself, I'm always, been interested in the way we can use imaging to kind of guide therapy and patient management. And of course, you know, if you think more about primary prevention, not so much secondary prevention, but for the primary patient, which of course we see many more of these in our general clinics now. How do you tend to use imaging technique like calcium scoring in some of those borderline patients to make a decision, to either initiate therapy or in some cases to convince a patient. That they need to be on therapy.
Ben:Yeah, certainly. I mean, you know from from the most recent guidelines the guidelines And I I think a lot of us within internal medicine family medicine no matter how you're trained or are aware of the pooled cohort equation where you know You just type in ascvd risk calculator and then you put in the patient's name Age, gender, ethnicity, their lipid levels, do they have diabetes, hypertension, etc. And then it'll give you a 10 year risk of atherosclerotic event or lifetime risk as well. You know, for certain age groups. And so then that'll categorize patients in low borderline intermediate or high risk of an event over the next 10 years. And per the guidelines, they say that if you, if you have patients that are borderline or in immediate risk, then to strongly consider doing coronary artery calcium score. And I completely agree with that. I, I tend to use coronary artery calcium score a bit outside of that because I think that In addition to, to refining a patient's risk in a better way with coronary artery calcium score. As, as to whether or not you should utilize a statin, I find that if a patient, if a, if a patient knows that they have some degree of coronary artery calcification, if, if you can sort of prove to them that they're already having subclinical manifestations of. of coronary disease, then they are oftentimes they're more inclined to take those lifestyle modifications more seriously, in addition to being more open about aggressive lipid lowering targets with statins, ezetimi, PCSK9 inhibitors, all the agents that we said. So, you know, if a patient is, is, is very low risk, then no, there's no reason to get a calcium score. I mean, if somebody is 32 with no family history, no risk factors. There's no reason to get a coronary costume score, but you know in that pooled cohort equation It doesn't take much to get patients to intermediate or borderline risk as they get older So once you approach the age of 60 you only throw in another risk factor in there And maybe the LDL is just a bit high and you get to borderline or intermediate or even high risk And so obviously at that point you should strongly consider statin therapy But what's also true about coronary artery calcium score is that it can really help determine which patients would benefit from being on aspirin. I mean, as we know, over the last five years, the pendulum has swung away from aspirin use routinely for primary prevention. But if you have a calcium score above per the most recent National Lipid Association guidelines on coronary calcium. That's an indication to start 81 milligrams of aspirin. Now you have to be a little bit careful as patients get older. I And the last point that I'll make is that, you know, a lot of patients, they may come in and they may have risk factors, they may have smoked for 30 years and hypertension, And you get a calcium score and it's zero and a calcium score of zero, the negative predictive value of a calcium score of zero over, the next five years or so is quite high. So it can be very reassuring to patients as well. So I can't speak highly enough about utilization of coronary artery calcium score. I tend to utilize it outside of what the guidelines say, unless they're very low risk or if they're secondary prevention. It should really only be used in primary prevention. There's no role for it in secondary prevention, but I just think it gives you a lot of information about where the patient is and what their, what, what their, however long, how many years or decades they've been on, they've had certain risk factors, you know, how that's all added up to affect their coronary arteries.
Kanny:Yeah, yeah. Well, I'm really glad to hear you say that because I agree completely. I feel like, as you mentioned, there's a lot of power in zero as well, sometimes you see, them get prematurely put on a statin by a primary care provider, you know, based on a single profile or very unclear risk. So I think that score is zero. It couldn't really be reassuring as well. Well, Ben, I think we covered a lot of material. It's such a changing field with so much data and prevention so much that we've learned in the last few years. But I think you were able to kind of succinctly give our listeners some practical advice on how we, you know, Approach these agents. So I do want to thank you for taking time to talk and also for presenting at the State of ohio meeting, a few months back and Perhaps down the road we can have you back to give us some updates on on some of these studies you alluded to
Ben:Yeah. Well, thanks very much, Kenny. It was, I mean, I think I, I'm very grateful to be on the podcast. I've, I've really enjoyed, you know, being part of, of, of today, this podcast, and i, I just think it's an exciting time to be in the field of prevention cardiology. And, and, the, the whole reason is to improve people's lives, and there's no better way to do that than prevent them from having really, poor outcomes from heart attack or stroke, is the best part in all that we do.
Kanny:Yeah, absolutely. And I guess the final thing I'll say, you did allude to the guidelines and I just want to remind the listeners that there is an ACC expert consensus document that just came out in 2022 that specifically addresses, non statin therapies. And it's a great reference document. It's very practical as well. So it's really written, you know, with an eye towards day to day practice. So we will put a link to that actually in the notes for our podcast. So I want to thank Ben and I want to thank our listeners and until next time, thank you all.
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