Ischemic cardiomyopathy is probably seen more often in elderly patients, compared with idiopathic cardiomyopathy or hypertrophic cardiomyopathy. Or do all these groups completely overlap? Dr. Anton Titov, MD. I think cardiomyopathy groups overlap. Patients with ischemic cardiomyopathy that we have here for heart transplantation are pretty young. I think there is an overlap between ischemic, idiopathic. Hypertrophic cardiomyopathy. Dr. Pascal Leprince, Transplant Surgeon. We see patients with idiopathic cardiomyopathy around the age of 50 to 60. Some of the ischemic cardiomyopathy patients are even younger, 40 to 50 years old. They have bad coronary artery disease. Medical second opinion is important. Bad coronary disease in 40 to 50-year-old patients. Do you think there is a significant genetic influence on ischemic cardiomyopathy? Dr. Anton Titov, MD. Or do you think it is the sedentary lifestyle and never controlling cholesterol levels when they are in their 30s and 40s. Then they have an "oops" moment when they are 50 years old. Then it is too late. The arteries are already laden with cholesterol plaques. I think it is not easy to answer this question. Because we think that we know all risk factors for coronary disease, for atheroma, it is high cholesterol, sedentary lifestyle, male gender, aging, hypertension tobacco. All those risks for coronary artery disease are known. What amazes me is that we see some patients coming to the clinic. They never smoked, they have normal cholesterol; they do not have diabetes. They are maybe too strict with their lifestyle. They do have bad coronary artery disease. On the other hand, we know that some patients abuse their health. They smoke, they eat a high cholesterol diet, they don't take good care of themselves. But they don't have coronary artery disease. So, on the one hand, I think that some patients get coronary artery disease because they have heart disease risk factors. But for me, this is not the only story of how patients get coronary artery disease. Some doctors do work on unknown risks for heart disease. Dr. Axel Haverich is a Chief cardiac surgeon in Hannover. He is working on a different concept of coronary artery disease. Maybe it would be interesting for you to interview Dr. Axel Haverich. He's a great man. The vascularization of the wall of the coronary artery with the vasa vasorum can make the difference for coronary artery disease. [Vasa vasorum are small blood vessels that provide blood to larger blood vessels]. I will not go through more than that because I don't have enough knowledge about that. But I'm pretty sure there are other explanations to coronary artery disease apart from lifestyle. Of course. The risk factors are very important. Sometimes you have a high cholesterol, it is very important to lower the cholesterol. There are many clinical trials confirming that. I'm not saying that we should not look very efficiently for risk factors found in those clinical trials. It is very important you have a low blood pressure. Patient has to control blood pressure, to control cholesterol, to control diabetes. Physical activity every day is very important. To lower all these risk factors is very important. But, again, this might be not the whole story with coronary artery disease. This is why we sometimes see patients with no risk factors but who have coronary artery disease. I'm sure in those situations you probably look in their family history. Do they have early coronary disease running across generations? Dr. Anton Titov, MD. This would point out to the genetic cause. Yes, yes. I agree. Dr. Pascal Leprince, Transplant Surgeon. We know that heredity is a very important risk factor for coronary artery disease. But some patients with coronary artery disease don't have any relatives with known coronary disease. Dr. Pascal Leprince, Transplant Surgeon. We still understand only the upper part of the iceberg. But not the deeper part of the of the iceberg. It is very important to look at that deeper part in detail. Hopefully in the next 50 or 100 years we will know better about causes of coronary artery disease in patients with low risk factors.