Cardiovascular disease & why we should change the way we assess risk | The Peter Attia Drive Podcast
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- เผยแพร่เมื่อ 26 มิ.ย. 2024
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Allan Sniderman is a highly acclaimed Professor of Cardiology and Medicine at McGill University and a foremost expert in cardiovascular disease (CVD). In this episode, Allan explains the many risk factors used to predict atherosclerosis, including triglycerides, cholesterol, and lipoproteins, and he makes the case for apoB as a superior metric that is currently being underutilized. Allan expresses his frustration with the current scientific climate and its emphasis on consensus and unanimity over encouraging multiple viewpoints, thus holding back the advancement of metrics like apoB for assessing CVD risk, treatment, and prevention strategies. Finally, Allan illuminates his research that led to his 30-year causal model of risk and explains the potentially life-saving advantages of early intervention for the prevention of future disease.
We discuss:
00:00:00 - Intro
00:00:10 - Problems with the current 10-year risk assessment of cardiovascular disease (CVD) and the implications for prevention
00:14:32 - A primer on cholesterol, apoB, and plasma lipoproteins
00:22:07 - Pathophysiology of CVD and the impact of particle cholesterol concentration vs. number of particles
00:28:45 - Limitations of standard blood panels
00:33:10 - Remnant type III hyperlipoproteinemia-high cholesterol, low Apo B, high triglyceride
00:39:26 - Using apoB to estimate risk of CVD
00:42:57 - How Mendelian randomization is bolstering the case for ApoB as the superior metric for risk prediction
00:53:47 - Hypertension and CVD risk
01:05:49 - Factors influencing the decision to begin preventative intervention for CVD
01:11:37 - Using the coronary artery calcium (CAC) score as a predictive tool
01:23:27 - The challenge of motivating individuals to take early interventions
01:26:30 - How medical advancement is hindered by the lack of critical thinking once a “consensus” is reached
01:33:24 - PSK9 inhibitors and familial hypercholesterolemia: two examples of complex topics with differing interpretations of the science
01:39:49 - Defining risk and uncertainty in the guidelines
01:46:07 - Making clinical decisions in the face of uncertainty
01:51:58 - How the emphasis on consensus and unanimity has become a crucial weakness for science and medicine
01:59:58 - Factors holding back the advancement of apoB for assessing CVD risk, treatment, and prevention strategies
02:11:44 - Advantages of a 30-year risk assessment and early intervention
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About:
The Peter Attia Drive is a weekly, ultra-deep-dive podcast focusing on maximizing health, longevity, critical thinking…and a few other things. With over 35 million episodes downloaded, it features topics including fasting, ketosis, Alzheimer’s disease, cancer, mental health, and much more.
Peter is a physician focusing on the applied science of longevity. His practice deals extensively with nutritional interventions, exercise physiology, sleep physiology, emotional and mental health, and pharmacology to increase lifespan (delay the onset of chronic disease), while simultaneously improving healthspan (quality of life).
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In this episode, we discuss:
00:00:00 - Intro
00:00:10 - Problems with the current 10-year risk assessment of cardiovascular disease (CVD) and the implications for prevention
00:14:32 - A primer on cholesterol, apoB, and plasma lipoproteins
00:22:07 - Pathophysiology of CVD and the impact of particle cholesterol concentration vs. number of particles
00:28:45 - Limitations of standard blood panels
00:33:10 - Remnant type III hyperlipoproteinemia-high cholesterol, low Apo B, high triglyceride
00:39:26 - Using apoB to estimate risk of CVD
00:42:57 - How Mendelian randomization is bolstering the case for ApoB as the superior metric for risk prediction
00:53:47 - Hypertension and CVD risk
01:05:49 - Factors influencing the decision to begin preventative intervention for CVD
01:11:37 - Using the coronary artery calcium (CAC) score as a predictive tool
01:23:27 - The challenge of motivating individuals to take early interventions
01:26:30 - How medical advancement is hindered by the lack of critical thinking once a “consensus” is reached
01:33:24 - PSK9 inhibitors and familial hypercholesterolemia: two examples of complex topics with differing interpretations of the science
01:39:49 - Defining risk and uncertainty in the guidelines
01:46:07 - Making clinical decisions in the face of uncertainty
01:51:58 - How the emphasis on consensus and unanimity has become a crucial weakness for science and medicine
01:59:58 - Factors holding back the advancement of apoB for assessing CVD risk, treatment, and prevention strategies
02:11:44 - Advantages of a 30-year risk assessment and early intervention
Allan, oh my. I could listen to him for 2 hours and 25 minutes!
And I always forget that Peter is a great interviewer among all the other things he does so well.
I like to hear about particle size, and wish Allan would have taken us deeper through his thoughts on that.
Grateful to get stuff like this. What a gift.
Hi Peter , There have been a number of replies referencing Dr Malcolm Kendricks latest book "The clot thickens" which gives a more plausible hypothesis to CVD causation than just "APoB particles get stuck in the arterial walls" and infact does a great job of debunking this myth. Would be amazing if you and Alan could take a look into this , even better interview Malcolm so we can actually get to the truth of what is happening. I would love to hear your rebuttal to his hypothesis , so far he's just been ignored. Look forward to your reply.
@@davidblackford5193 excellent suggestion I agree 100%
Now let's talk about the significant increase of apoB in low/zero carb diets.. it's important to look at the context. Would be great if you can talk about it in the future. Thanks again for sharing.
Astounding that Magnesium is nowhere on the list.
I’m a cardiologist, MD, PhD; I didn’t go to Ivy League schools, but I felt I had very good training. This level of discussion is not found in medical school training. Thank you for the free CME. It’s the third time I hear this discussion and I am finishing his book to understand lipidology a little better.
I absolutely agree that the science was dumb down and that somehow we got stuck in the 1990s. But I feel that things are changing slowly.
How will you mow treat high APOB?
Your accuracy and honesty are refreshing. As a clinical pharmacist/drug info devotee, I've worked with residents who have a huge STATIC knowledge of general medicine. As they progress (especially into subspecialties) they don't really have the time to take a deep dive into many subjects, so they rely on associations to steer them. Personally I like following top notch resources (e.g. Allan Sniderman, Peter Attia, Tom Dayspring, Gil Carvalho) in specific areas.
May I ask the book you are reading ? I enjoy these conversations. I am a FNP . In family medicine these convos do not happen . I try to stay on the cutting edge of medicine. Thank you for your contribution
@@brucefranken4615😊
@@tammyglaude7266low carb and no saturated fat
Dr. Sniderman, I am a clinical pharmacist and I did a presentation for our patient centered medical home which houses approx 30 primary care doctors - the physicians and providers are likely going to make apoB standard of care within our institution and it’s due to your amazing work. We commend you! Knowledge is power and it’s helpful to step out of the echo chamber of the AHA/ACC guidelines and into the primary literature to critically evaluate the evidence and optimize care. Thank you for all you do!!!
Please apply this same rigor to HCQ, sir. Big Pharma has managed to demonize this PROVEN PROPHYLACTIC & CURE ( per American Frontline Doctors). They provide 2 examples : 1900 & 2300 patients- one hospitalization 0 deaths !
I requested a Lipoa and a Apob test be added to my blood tests. United Health Care would not cover the tests and the total of the two came to $118. My Apo b is high. My primary said she doesn’t really know what that means. I am going to try and get a consult from a cardiac care center. I appreciate the information this video provides! Keep fighting the fight!
This talk single handedly shows the problems with science acceptance in the US but also the reasons why we must to a better job of showing the power of science. What an amazing human being, Allan Sniderman. Wow. Privileged to have the opportunity to have listened to him talk and the medical community needs more of what he's done. Thanks Peter Attia for what you do and your thoughts in this arena. Spectacular talk.
agreed. even though there definitely are flaws, it's important it's also the scientific community and science itself that is the best tool to overcome those flaws in scientific acceptance.
I think it shows the power of consensus and how individuals outsource their cognition. A one-page executive summary is the final word for almost all doctors? The selection process for papers and conclusions drawn are committee decisions with an almost forced/DeFacto unanimity?
I feel that this conversation between these 2 brilliant men gives me the knowledge and credibility to advocate for myself with my own doctor. And I'll share the information with family and friends. Don't downplay the impact you have made. Thank you so much for this
I love how this conversation began with a thoughtful discussion of ApoB and migrated into a philosophical exploration of the systematic weaknesses of our current clinical guideline process and a rumination on the nature of uncertainty
Everything ends up in philosophy if the participants have adequate curiosity - start with the saltiness of salt and you could end up at epistemology! lol!
Shocking that this has only 246 thousand views given its significance. Profoundly helpful Peter. Thank you. I had an environmental exposure due to the stealth use of a diesel generator by a Crystal Geyser Bottling plant a block away over a 12 month period during lockdown that pushed me into dyslipidimia with adverse neurovascular outcomes that were only documented after admission for a TIA to Adventist Hospital in St. Helena I have not yet been properly diagnosed.at Stanford Medical after 12 months. I am on atoravastin and have begun to shift my dietary and supplemental intake based on watching your videos over time. Deeply appreciative to you.
Thank you! I have enjoyed this podcast tremendously. I've learned so much. what a pleasure it is to listen to two brilliant scholars who are offering pure knowledge, decency and common sense and serving it with so much humility. so rare. so desired. so appreciated.
New grad NP here and I ordered my first ApoB today. I am just going to start ordering ApoB on every lipid panel from now on.
FASCINATING! I've listened to this discussion twice - Drs Sniderman and Attia are refreshing voices. Both are deep thinkers, but what I like the most, they don't guess. Instead of curing or masking symptoms, they research and search for root cause.
Root cause is often gum disease
I’m a first year med student and we just wrapped up our lipo protein lectures and my professor was adamant LDL-C is the gold standard…. Despite the explanation that the apoB value gives a count of the atherogenic particles… it’s a bit defeating as a student I must admit.
Gentlemen, I don’t have the words to thank you for this wonderful episode. Great to see Peter in such awe of his guest (also a great show of respect). Beyond the specifics, there was just so much wisdom packed in this interaction (worth listening to multiple times). Again a huge thank you to both of you and teams behind the scenes who made this happen
Best guest ever best medical researcher w superior thinking and humility
Thank you so much for this. So courageous and so truthful. I first recognized that I had to do my own research and sometimes push back against what doctors advised when I was diagnosed with luminal a breast cancer. It is so frightening to stand on your own and choose your path based on your best assessment of all the information and your individual case. Now I learned that I have HDL of 125 mg/dl-- very high, very rare, and potentially dangerous and once again I am trying to figure out what to do on my own, in the face of clinicians who persist in telling me that high HDL is good, certainly nothing to worry about. I feel cursed by the lousy genetics but blessed to have the information in presentations like these. And, though my individual case details are rare, I feel now like I am not rare or alone in trying to figure out things myself, in the face of harried and uninformed clinicians.
Thank you Dr Attia for the guests and sharing the knowledge. My “KickAss100YrOld” self appreciates the information!
Amazing lecture! I have learned so much from this, a lot of information to digest, will watch this many times. Thank you.
This is pure gold. Thank you for sharing this with the world.
Thank you so much for sharing your knowledge with us.
Please kindly, would help us tremendously if you have podcast on hypertension.
God bless you all.
Snidermam has a wonderful philosophy on life and humanity
What a great discussion. I was on statins for 30 years. I am 64. I became pre-diabetic and in 2019 stepped into diabetes with an A1C of 6.6. I started a low carb diet and by late 2020 reversed my diabetes. Lowest A1C became 5.8 and all my liver and kidney values came back to normal after years of out of range. I wanted to stop the statins so doc ordered a CAC. My score was 1.something. Now my LDL and total cholesterol were high (trig. very low and HDL high) so doc ordered another CAC and now that score is 26. In only 3 years. I see my doc this week and after a TON of research on my part (both pre-treatment like this discussion and anti-statin) I think I will choose to go back on a statin (per my doc's recommendation). I will also ask about an APOb test. I have to convince myself that I can control my previous diabetes through diet, which I did. I may not want to live to 85 but 75 is certainly a goal.
Consult a physician and dietician who’s well versed in the whole food plant based nutrition.
Wow! To be so lucky! Most people would not have a CAC that low after 30yrs of being on a statin! I think I would just be on Linus Paulings Heart Protocol and a few other supplements and call it a day! My last CAC was 458 down from 660 which is a 30% reduction achieved in 20 months...think about that!
Are you still eating the low-carb diet?
Any gum issues ??,
@denzaharo9326 your right about gum issues. That would set off calcification for sure. It's very odd all those years, and a near zero CAC score doesn't make sense.
This conversation should have millions of views. Thankfully this brilliant men are advocating for awareness on intelligent preventive medicine.
:) When you get to 74 you will become very interested in living to 84…and the ‘’work” you are doing now will very likely give you good quality of life, even over 90.
Enjoyed that - Thanks for saying yes Allan - I have several of your papers and share your perspectives with students and colleagues to provoke discussion around the causes of ASCVD
Best conversation on TH-cam in 10 years !! Thank you!! My lpa is 267.😕
OMG what an incredibly insightful exposee! 👏 Thank you for this.
Thank You for the content and superlative interview. Reminds me of Atul Gawande's Better: A Surgeon's Notes on Performance, which candidly touched on shortcomings in medical care. Also, Moneyball by Mike Lewis - group think and entrenched consensus leading to glaring inefficiency. Such a good conversation! Thanks again.
After all is said . You got to reduce your carb intake. It's better than medicine.
The best comment IN THIS ENTIRE PODCAST!! 58::25
I learned a lot about what ask at my next physical but this brilliant comment completely sums up how we got to the disaster of COVID 😷. …
An amazingly valuable interview and discussion. Thank you!
It seems to me that the only way to change the way risk is assessed (which will never happen but should) is that for one week out of the year, doctors should go to a conference led by the leading scientists doing studies in their specialty to discuss the latest results and to figure out the best possible way to diagnose and treat diseases. Instead, we have doctors who are following what they learned in med school, their residency or read in a New England Journal of Medicine article years ago, along with whatever the pharmacological industry is currently pushing. Not the best recipe to prevent disease.
You'd hope so!! It used to be called CPD (continuing professional development), but whose scrutinising in out low regulation world? When its all market forces the only rubric is how much money the doctors and pharma can screw out of the public. Patients dying is not much of a feedback loop.
doctors do attend such conferences
@@annettestevens2260 i attended such a conference recently. They talked about LDL and statins and plant based diets. It was myopic and unsatisfying. I will not attend such a conference again. Much more information on TH-cam.
@@annettestevens2260 the conferences are more like sales pitches.
Pushing what the latest pharmacy rep is sellin
Cash price for calcium heart test is $125 here in Las Vegas. APoB is $25 at Quest Diagnostic.
Amazing podcast, the best I've seen so far. I have a new appreciation for the depth and complexity of the cardiovascular subject matter. WELL DONE !
What a wonderful person and intellect
Excellent Interview, and I really appreciate the timeline notes.
Vey , very well explained .Very much apppreciated 🙏🙏 Thank you for your time and knowledge 🍀🍀
Man these guys are scaring the living shit outta me !! I better start taking care of myself !
I had a stent placed in 2019 at age 46. I had 99% blockage in my LAD artery. By God's grace it was discovered before I had a heart attack. No family history, never had cholesterol at or above 200, not obese or diabetic, never drink or smoke. I ask my cardiologist why, he doesn't have an answer, just tells me to exercise, eat a plant based diet and take my cholesterol meds. For some reason I'm just not satisfied with that answer.
Also no high blood pressure. But as I listen to this I did have low gel numbers and higher triglicerides, so maybe that was the cause. I had never heard of the apob
@@tg3728 What are "gel" numbers? By the way, your high triglycerides would suggest your diet was too high in sugar and carbs, thereby provoking high insulin, thereby provoking arterial damage, thereby leading to a 99% blocked LAD. Ask your cardiologist whether he thinks it's possible that years of hyperinsulinemia may have had something to do with your heart disease and see what he says.
@@Malcolm-Achtman I'm not sure what you mean by 'gel numbers, but I will research it. Thank you for the info, I will do that! The main thing now I is to prevent it from happening again.
@@tg3728 you said low gel, did you mean low HDL? Inferring from context
@@thefisherking78 Yes lower HDL than LDL at the time. Numbers are much better now.
To say that he is brilliant is an understatement! He is not only brilliant but wise!
Engaging and informative … thank you for the enlightenment
Until I had accepted the immaturity of professional medical organizations, little surprised me more than the extent to which they were more about themselves; their agendas, their remuneration, their politics; than they were about the health and well-being of those they serve.
They rigidities of US medicine is there for those without blinders to see! Whether it is the unhealthfulness of the Standard American Diet, the support of American agri-business by the cancer, diabetes and heart associations, recognition of patient rights or the primacy of ApoB in cardiac risk assessment, much work on physician’s personal emotional growth is needed.
There is good reason here to see why it takes so long to get information that can save and enrich lives from the results of clinical trials to the doctor’s office and patients. Very useful podcast. Thank you!
Unbelievable content. Knowledge that I certainly share with clients, friends, and family.
This was extremely informative! Thank you, both!
Very informative discussion . Thank you !
Such an amazing exchange, congratulations
I need to study this far more to help advise correctly on the concerns many people often bring to conversation. This is really fascinating.
I loved this interview. I am not an educated person but he made it very understandable. He’s so real.
Don't sell yourself short! The fact that you are watching videos like this shows that you are an intelligent person and are seeking knowledge in order to educate yourself which a lot of people don't feel the need to do.
@@karimaogden3875 True! Thank you! (virtual hug) I have been watching and listening to podcasts and TH-cam videos about health for the past year. I have learned so much from these and I share the info with my husband and sons. Now, we as a family have changed the way we eat and make our food, which has improved the way we all feel. Thanks again.
Yes, utube medical videos are very educational, everyone should be doing their own research. I've learned how to reverse my Calcium Score and come to a consensus of who should I believe and lately it's sure not Cardiologists that will reverse my heart disease!
Excellent discussion!
Put this guy on the sales team for the test equipment for LDL particle measurement, NMR, etc. His whole time is spent pimping the more stringent testing. Salesman of The Year!
I love the idea of being able to read guidelines with mixed opinions. As a well educated patient, it makes my rang of options open to me.
It seems to me they should be more aware of 'Noise ' as described by Kahneman when they try to make guidelines.
Great show Dr Attia. CVD has shown itself to be a highly complex disease, and there's too many in the sci/med community perpetuating out dated models of CVD. Bottom line is lower the LDL-C/apoB the longer the better. That along with mitigating systemic inflammation - finally starting to get the traction and attention it should - are key to prevention of CVD.
EXCELLENT information!!
I am still catching up on all your contents. Thank you for all the great knowledge ❤
My bookmarks:
25:33 - Americans 10 years behind - my opinion
43:00 - Guest's opinion - Americans 2 years behind
26:00 - Non-HDL similar to Apo B test.
28:00 - Extra cash cost of Apo B test = $2.50
31:50 - VLDL-C is atherogenic
40:30 - Once on statins, typical values unlikely to normalize. If high triglycerides before, high triglycerides after treatment. But Apo B is a target for success.
Amazing lecture
Thank you so much
Following the discussion, I just calculated my apoB number that's lower than ADA/ACC goal and used the app as well. Thank you. I'm waiting for your book to come out and getting ready for it by walking 2 miles (3 times a week) at 20 mins./mile rate. Just can't do the level 5 yet.
lol, I'm used to hearing Peter's voice a LOT more on these podcasts. But he just lets Dr. Sniderman talk, because what he's saying is pure gold.
I got my doctor to start testing me for ApoB.. I've refused statins, and managed to lower my ApoB from 186 (on a strict keto diet) to 83 by adding 2 cans (~600 g) of legumes per day, cutting red meat and SFA and exercising even more. And by incorporating 50-50 salt (half potassium chloride, half NaCl), I've dropped BP to 110/69 in my early 60s.
That is great news you could do that with diet because my apo B ia over 232 mg/dL and I am on a keto diet eating SFA.
This is interesting. I feel like my lpa and apoB have only deteriorated since starting keto and low carb in 2017 to address elevated A1C. My A1C never got better. Lots of stress and I don't exercise, so I get that s perhaps a supercritical missing link at least on A1C, but I have been told by a cardiologist at Cornell studying lpa is that lpa is genetic and nothing can really be done to improve it (not diet or exercise). I am taking niacin on and off. Not a fan. Maybe I need to go back to my old life just lowish grain, lots of beans and cut back on dairy and finally commit to regular exercise.
@@nathalierey7663Yes to everything you say. But as to your last point, there's no "maybe" about it. The human body is designed to be active, every day. 10,000 steps is a good target. Exercise always bored me, until I realized I could binge watch all the shows while on my elliptical or spin bike. So now that's what I do. Every damn day.
My guess on blood pressure being a mechanical engineer I’m not a doctor or a medical person is that it’s as simple as the total resistance of the circulatory system. And the resistance of the circulatory system would be a function of the resistance of all the individual parts. And I’m guessing that this resistance increases with a variety of factors including athroscrelosis, inflammation, kidney function, sodium levels, hydration regulation, and the ability of blood vessels in general to allow blood flow. So we see that blood pressure goes down with BMI probably because a smaller body has less resistance. Muscle tone would be a big factor I’m guessing assuming higher muscle tone has better blood flow.
Thank you Doctors
Not discussed in the context of guidelines were the legal risk of departing from them, the demands of the health system employer to hew to the algo, the undisclosed pharma thumb on the guideline scale, the effect on younger, 9 to 5 physicians who bring up the guideline and apply it, and the looming monolith of CMS bean counters discouraging screening because in macro is saves real money while the micro might save two dozen lives over a physician’s career (eg the DRE). Thank you Peter for questioning any attempt to ignore ApoB based on aggregate lab cost.
As usual awesome Peter, many thanks
Thank you both for this excellent discussion!
Listening to this for the second time.
I lowered my blood pressure by going low carb. Also, at the same time, I ditched all industrial oils.
Hopefully, an anti inflammatory diet will extend my life. Most of my relatives on my dad's side (Scotch-Irish) died young of heart attacks.😢
He’s 80 ??? Wow. Glad he agreed to do the podcast with you ! Thanks for the video Dr. Attia
Dear Peter, I’m a fellow MD (with at least an above average knowledge of lipidology). I usually enjoy your podcast…. But this?!.
Myopic, pro-statin (“great therapy”? Really? show me a study with more than a absolute minimal effect) apoB/cholesterol-centric lecture, with next to nothing on metabolic health, micronutrient status, inflammation, type A and B lipoprotein pattern, oxidation, insulin resistance and so on, and I know you know a lot about this stuff. I know particle count is important, but I my opinion you left so many other important points. Cardiovascular disease (atherosclerosis) is an inflammatory condition (or so I’ve let myself convince), you dont mention the condition of either the Apo-B/cholesterol (healthy vs oxidized/rancid) or the state of the artery (healthy vs inflammed) as something of grave importance for the risk? Just that Apo-B get stuck in there and that’s the cause of AS. I simply don’t agree.
And the short part on hypertension was at best laughable. When you can reverse HT in patient after patient with almost the same therapy (NOT drugs, but with good sleep and overall lifestyle changes).. it gives you quite a good hint on what is at least a part of the pathophysiology (although of course multifactorial). I my opinion. When you reverse insulin resistance, optimize micronutrients, lower kortisol and catecholamines and lower chronic inflammatory most hypertension resolve itself. It’s absolutely not just “age”.
Maybe I’m suffering from a bit of cognitive dissonance here. But I was disappointed.
I can help I think! More than absolutely minimal effect: one example (there are many more) is 4S with which the NNT for all cause mortality was 30 and NNT to prevent major coronary event was 15 over 5.2 years? Idk about you but that is a great therapy - absolutely amazing! Especially in the era where apoB levels were not targeted, probably would have seen better outcomes if they were (based on Johanneson 2021)
It is never a good idea to "meet your heroes". Sometimes a lot of respect for a person restricts you...
I agree 100%. I am not a doctor, but a patient with high Total Cholesterol,(familial) and high LDL. But healthy-high HDL levels, Triglyceride: HDL ratio is .76, normal Homocysteine, HBA1C, CPR markers etc. My ApoB : APOA1 ratio is 0.7. The first thing my GP said: "Gotta get you on statins now!" I said: " And you want to kill off my mitochondrial functioning, and give me a very high risk for Alzheimer's, in the 'hopes' that this drug will lower my chances of a heart attack ( and it has statistically shown to NOT in any significant way), never!" How many cardiologists are even aware that when taking a statin, you MUST also take enzyme Co Q 10, to save your mitochondria? It is insanity....Willful ignorance and big-pharma pay-backs that are bordering on criminal negligence...The motto "Do No Harm", is a big joke.
I agree, it is disappointing not to consider the lack of good evidence for statins. If statins are so amazing, why haven’t we seen miraculous improvements in CVD?
@@scoggme0 Exactly!
I thought I understood this issue. I was wrong. Thanks for clarifying many points of my misunderstanding. Excellent discussion.
Great information. Love you Allen.
Given Peter's enthusiasm for rapamycin, it would have been nice if he discussed how risk for cardiovascular disease is impacted by rapamycin use. We know that three independent studies have shown that 6-10 weeks of rapamycin treatment is enough to cause a reversal of some of the key measures of heart function (EF, FS and E/A) in old mice back to about halfway to that of the young mice (that is, it takes a 60-65-year-old back to about a 30-year-old in a human equivalent approximation). Does it lower CVD risk also?
I doubt the guest would know anything about it.
Amazing. Would like to learn more. Do you publish videos about this?
Will rapamycin reverse insulin resistance?
Remove animal products from your diet, and you will get the same effect without drugs.
I hope he asks his plumber for advice on his race cars aero too
Thank you! 😊
I'm a 60 woman interested in this topic--So enjoyed the philosophical discussion of knowledge and also why ApoB is a better marker. Thanks for making the topic so accessible to us nonscientist/docs
56:00 pathogenesis of Systemic Hypertension:(SHT) We believe tbe loss of elasticity in the aorta to be causative for SHT in cats. I am in veterinary cardiology and we often see SHT in older cats, and a interesting feature of thus is what we call colloquially the "lazy aorta". On a lateral radiograph we can see the aorta displaced ventrally in the descending thoracic portion. Histopathologically, these aorta demonstrate more fibrous tissue than a younger aorta. Dr. Sniderman may well be onto something.
Superb discussion.
..very interesting discussion..your guest is a wise man.. an easy question that could close your discussion with Allan, who stated that he turns 80 would be for all of us very useful to know his lifestyle and what he eats to reach this old age and be so alive and sharp:)
thank you! I wonder when boston heart panel will be available in other countries (europe, australia)? and how we can possibly approach precise diagnostics without it?
I don't get how you can have a conversation that includes cholesterol and not mention that a higher cholesterol provides a survival advantage for older folks. Wish I could provide sources, but I only remember the data.
I think it is in the Framingham data
I've heard that also, but it's hard to grasp since it is not uncommon for cholesterol to drop in elderly people and very sick people, thus making it appear that those with high cholesterol live the longest. The whole correlation is not causation thing. So much we don't understand about this makes it so frustrating.
He's an Md. You're welcome 🙏
th-cam.com/video/BzTjPuikhQE/w-d-xo.html
When I was first diagnosed with cancer my cholesterol , iron and vitamin D was really low … now that I’m in remission all those numbers are within normal range or higher
Amazing conversation!
"APO-B is causal but it's necessary but not sufficient"
So with my familiar dyslipidemia i can focus on the other factors, on which a life style's approach has more influence..
By the way another factor belonging to the category "necessary but not sufficient": insuline resistance? Prevention simpler then than trying to lower Apo-B with pills..
I would argue with the point of necessary as we know that many with heart attacks do not have high cholesterol. Multi factorial for sure but necessary, no.
I love the video! It makes sense! On another note, love your watch! We’re did you get it from? Thanks
ApoB "sufficiency" is a wrong term. Modifiable is a better term. There are several factors that can modify the rate of transcytosis of ApoB particles. TNF-alpha. Estrogens. Genetic mutations. Blood glucose. What has to be done - is to quantify the modifiers. Then we will know the safe level of ApoB for a given person.
agreed, that's the kind of nuance missed in this talk
So interesting and clever interview !
Bottom line question. Do I understand that if ApoB is even slightly elevated, starting treatment with something like a statin, will slow the atherosclerosis process thereby reduce time to onset of Events?
Can we talk about this conversation when you’re here? Love this guy
Thanks for siccing me on Peter attia!!
As a practicing physician I am frustrated with the overall knowledge and training in lipidology. As you can notice, even very smart and well studied specialists are discordant in opinions! I hope that in the next 5-10 years we will get this down…
Thank you for this podcast!
Never knew there was a medical specialty called "Lipidology" until yesterday when I was watching another channel. How does anyone go about finding one? Doubt that there are many of them in the U.S. Assume most of them work at teaching hospitals or at The Cleveland Clinic.Even finding an Endocrinologist, Diabetologist or CDE in a lot of areas is very hard and if you do, there is a long wait. I see a Hepatologist at University of Louisville for NAFLD (doing much better) because that's the ONLY place within a 100 mile radius that does Fibroscans. Even though I am an established patient, I still have to make my follow-up appts one year in advance and if I miss or can't make that appt because something came up, I risk having to wait another 6 months because the doctor is only in-clinic on Mondays and the rest of the time, he is teaching and seeing Hepatitis patients and I am considered low risk by my doctor because I am not diabetic and my NAFLD has been reversed. That's what I was told last year when I couldn't make my yearly appt because I had a car accident (no injuries thankfully) but my car was totaled and was trying to reschedule.
@@karimaogden3875 Usually an endocrinologist may have specialized in training as a lipidologist. My PCP sent me to one back in 2016 once he raised concerns about my cholesterol level and family history of heart disease. He's actually been running blood work for Apo B since early 2016 once or twice a year. Good luck.
@@karimaogden3875 it’s not yet an accredited specialty. But it is a science that needs to be addressed! So, a cardiologist, endocrinologist, internist and I think family medicine can take the boards and get accredited. There is no need for a paper saying that you are accredited, like Attia has noticed, even accredited lipidologists can also get stuck in the 1990’s.
My so called Essential Hypertension is reducing dramatically since I switched to a very low carbohydrate diet. I was pre diabetic ( Now reversed ). I have never smoked. I am normal weight. I am 64 & have had very high blood pressure since my early 30’s. I also now have very low triglycerides. These used to be high. My HDL is high & always has been. My Non HDL is 50% higher than the maximum reference range. I have been referred to lipidology by the British NHS because the Dr suspects familial hypercholesterolemia. She didn’t know what pattern A or B or Apo B particle numbers are. I hope to God that lipidology test the subtractions. I am on a very long waiting list. Meanwhile I am frightened. I stopped taking Statins due to massive muscle loss. Anne
I noticed this too, that if I want to get a statin to lower my apob, I'd have to engage in bad health behavior (eat chicken skins, smoked, etc.) in order to better protect my future health. When I bring down my numbers through discipline and sacrifice (diet and exercise), I'm not given statins to bring me all the way down to where I need to be. I'm left in limbo/normal land until I begin to fall ill. It is stupid if the goal is disease prevention.
Very High methodological level.
@Peterattiamd Your articulation of dealing with uncertainty at the 1:46 mark was very deftly made. This particular observation is something that I see becoming a major issue as we see medical care move away from a vocational ethos to a retail/market reactive ethos. Evidence, statistical variation doesn't replace novel care within the context of a clinical environment.
Great interview!
Another *Outstanding* show!
What is the title of the Herbert Stary book you mention at the beginning of the show?
I haven't finished the video yet, but it seems to me that this discussion should include in-depth mention of D3 activation by K2 .....if you are talking about calcification.
Never gonna happen. Vitamins and minerals have nothing to do with heart health 🙏
YES! Doctors don’t want to talk about K2. They say stop it, go on aspirin.
@@wizardatmathyour loss my gain CAC Score 660 down to 458.
I took a CAC test and the results came back 0. I've just learned about CT coronary angiography. CAC score may not detect uncalcified plaque, whereas CT coronary angiography will better detect thinning of arteries. What's your opinion on these two methods?
What treatment? Not statins. Not manipulating HDL. my husband was on statins 12 years when he had a heart attack at 68. He required 4 stents, so damage was still happening.
Did you know that Statins are banned in Europe?
What about checking MPO (Myeloperoxidase) and LP-PLA2 (Lipoprotein-associated Phospholipase A2) and, or the CIMT Test?
33:22 - "high triglycerides, high cholesterol but low 'apo-B' in remnant type-3 dysliprotenemia: low LDL is for sure because the conversion of VLDL to LDL is low. Low apo-B makes sense with high chylomicron which contains apoB-48 that is excluded in the apo-B (100) test.
Amazing insights!
as a dietician in am wondering if there is any data on if a a diet high in saturated fats increases apoB as it (seems) to do with LDL-C (or P)?
Even the link with ith LDL-C (or P) doesn't apear as strong as once thought but still i wonder
Thanks in advance
What great men, how dedicated
I’m curious what transient receptor potential channels A1 and V1 play in the lipid apoB scenario. TRPV1 and TRPA1 are of essential importance in endothelial and cardiomyocyte function. Add inflammation to this and we’re getting quite close to the main culprits here.
It's a tragedy that I had to wait until I'd had an MI & CABG before I took an active interest in this.
What was the url for calculator ? Thank you
Hey young doctor here, absolute beginner. I kind of like the topic of prevention. This video is so very helpful. I can confirm that too much focus is on cholesterol. The scientific consensus is on LDL particles being the cause not cholesterol. Why does an 40 year old lean athletic men with a LDL cholesterol of 40, that’s under the lowest LDL-C target, get a MI and CAD?
Apo-B test in Chopo Mexico is $588 mx ($31 US, £25)