Narrator:
0:01
Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased evidence, proven facts powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr. Michael Koren.
Dr. Michael Koren:
0:17
Hello, I'm Dr. Michael Koren, hosting our fourth and final session speaking about advanced lipid profiles for MedEvidence, with my dear friend and colleague, Dr. Al Lopez, DO. We've had some great conversations about how to use advanced lipid profile testing, and I wanted to wrap up our discussion by talking about some very famous people who died early and also talk about how we use this over the course of time. So before we get into that, though, there's a little trivia question that we like to ask people, and I think it'd be useful for the audience to hear the answer to that, and the trivia question is basically what's the most common symptom or presentation of heart disease? Is it arm pain, is it chest pain, is it shortness of breath, or is it sudden death?
Al Lopez, DO:
1:06
Sudden death.
Dr. Michael Koren:
1:07
That was quick, yeah, and that is true. So the most common presentation would be dying without a warning, which is a little bit scary, which also points out how important it is to be prepared to know about your family history, to look at things before it's too late.
Al Lopez, DO:
1:29
I think the data is much more voracious on men dying of sudden death than women, but women that have heart disease tend to progress even when treated progress along with cardiovascular disease and heart failure and don't do as well.
Dr. Michael Koren:
1:48
Yeah, men will typically die at a younger age of heart disease. They're much more likely to die suddenly of heart disease than women and they're more likely if they get past that stage of sudden death, they're more likely to have typical symptoms than women. So those are the things that we know about the difference between men and women. All right, so let's talk about some very famous people. We started this conversation by talking about our ties, our Jerry Garcia ties, and we talked about the fact that Jerry Garcia died of a heart attack at age 53. He was involved in drug rehab and didn't live the healthiest lifestyle and he'd gained a bunch of weight. His risk factors were not under control when he died and we both decided that, yes, we would have gotten an advanced lipid profile on Jerry Garcia before he was 53, and that could have saved his life. And we also talked about the fact that there are other people, like Keith Richards, who live the same lifestyle as Jerry Garcia but somehow make it into their 80s. But again, you don't know what their genetics are unless you check that advanced lipid profile. But let's talk about some other people.
Dr. Michael Koren:
2:52
Arthur Ashe, I think he died at age 38. I think he had bypass surgery. I actually met Arthur Ashe at New York Hospital and he had bypass surgery in his 30s and what was his deal? Would you have gotten an advanced lipid profile for him?
Al Lopez, DO:
3:06
You know we really didn't have that at that time. But if it was today and if he had a family history, yeah, I think in advanced lipid profile and looking at an Lp(a) would have been pivotal in treating him and seeing what his hidden risk was beyond a standard lipid profile.
Dr. Michael Koren:
3:22
Yeah, thin guy, incredibly thin guy. Muscular yeah, very, very so. Never been overweight, no, no. Incredible tennis player, right, yeah, and no lifestyle issues. No, he was a boy scout from when everybody, everybody's told me and unfortunately he needed bypass surgery done at New York Hospital and unfortunately he developed HIV disease during that hospitalization and ultimately died of AIDS.
Al Lopez, DO:
3:44
Yeah, and that was a blood transfusion.
Dr. Michael Koren:
3:45
No, it was not.
Al Lopez, DO:
3:46
It was not any other risk factor that he was an unfortunate recipient of bad blood.
Dr. Michael Koren:
3:51
And there are many other people. Okay, now let's see. We talked about Jerry Garcia. How about Jim Morrison? He famously died in a bathtub in Paris at age 27 or 28. And I think he quote died of heart failure. Did he need an advance lipid profile?
Al Lopez, DO:
4:06
Well, there's a big question on why he died of heart failure. So he was using heroin at the time. We know that causes.
Dr. Michael Koren:
4:14
Yeah, I would be less inclined to get an advance lipid profile in Jim Morrison, I think I'm not sure.
Al Lopez, DO:
4:19
And I think his dad was old, didn't have him very young, was older, so you know he doesn't have that family risk profile.
Dr. Michael Koren:
4:25
Yeah, I think we probably needed to get him away from the heroin and the alcohol and he probably would have been okay. I'm not sure the advance lipid profile would have helped him. How about Hank Williams? I think he died at age 29 or 30. Now we don't when he died in the 50s, but would you get an advance lipid profile on him?
Al Lopez, DO:
4:44
Again, you know again, substance abuse, alcohol and other drugs. Was that the exciting factor or was it really a heart attack? I think it's blurry in the 50s but if it was truly heart disease you know that he died of. Yeah, he probably would have benefited from and Lp(a) and advanced lipid profile.
Dr. Michael Koren:
5:01
Yeah, and he might have been tricky unless you knew a lot more about his. You know social history, but again, he's probably somebody that was more more affected by alcohol and smoking and other things. Jackie Robinson is another one. He died in his 50s, early 50s. Athlete, fit guy, also clean living, as far as we know.
Al Lopez, DO:
5:24
Yeah, good community person. So he did all the right things you know for himself and the community and I think he would have benefited. He probably did have either, you know, hyperlipidemia, high cholesterol and or had an elevated Lp(a), so he fit the risk profile of looking at an advanced lipid profile.
Dr. Michael Koren:
5:39
He could have had a familial hyperclestralemia.
Al Lopez, DO:
5:42
Absolutely.
Dr. Michael Koren:
5:43
Yeah, we didn't go into that specifically because that gets into genetic testing and cascade screening. What you'll learn from an advanced lipid profile is that you have a super high level of LDL and you have to dig into that a little bit more to determine if you have a genetic reason for that, such as familial hyperclestralemia. But there's a very, very good chance that people like Jackie Robinson in fact had that problem. Yeah, definitely. So let's say, let's say Jackie Robinson, for example, let's say that I know that you're a Yankees fan, so you know you probably were upset that Jackie Robinson played for the Dodgers.
Dr. Michael Koren:
6:22
But you know, let's assume that you're able to put that aside and were his treating physician and we brought you back to the 1950s. You got to meet him and you happened to have the technology available and you got his lipid profile and, lo and behold, you found out he had super high cholesterol, he had small dense LDL and lipoprotein-A. So and you know, obviously we didn't have much tools then. But let's say you did everything. You knew how. When would you check it again? Like, how would you use that to direct your therapy over the course of the next week, month, year?
Al Lopez, DO:
7:00
So you know you're not just looking at hidden risks when you're looking at advanced lipid profile on APOB. You also can hit therapeutic targets that will affect those more than just LDL, the triglycerides in and of itself. We know that small LDL or small dense LDL, which is kind of redundant if it's small it's dense, if it's dense it's probably small is more athrogenic than plain LDL. We know it tends to embed in the arterial wall much more easily, oxidizes much more easily and stays a lot longer in a vascular bed.
Dr. Michael Koren:
7:33
And you pick that up from the advanced lipid profile
Al Lopez, DO:
7:37
This you will find from an advanced lipid profile. So I think, looking at it initially and then, if you're trying to hit a target, knowing how long it takes for that therapeutic regimen to work so triglycerides really don't change easily, especially by diet and exercise you want to look at it again in nine months to a year. If you're using medications most medications like statins will in 30 days you pretty much have goal, but you can't buy insurance standards. Look at it, a lipid profile, if they want to pay for it.
Dr. Michael Koren:
8:03
Well, Jackie Robinson had money by that time. So let's see if you can pay for it out of pocket.
Al Lopez, DO:
8:06
I would look at it between a month and three months again as advanced lipid profile, see if we're at a therapeutic goal.
Dr. Michael Koren:
8:11
So you would if resources were not an issue. You would say you put them on a statin and look at it again using an advanced lipid profile within six weeks to two months.
Al Lopez, DO:
8:21
Yeah, and if, once he's at goal, then I can start pushing away from it, and then I can look at a standard lipid profile and then look at an advanced lipid profile, maybe two times a year, to make sure that he's staying with as many as two times a year.
Al Lopez, DO:
8:36
Yeah, once or twice a year thereafter, because people's habits, unless they have a roadmap, will go back to what they used to do. And that's what I found in 30 years of medicine. I don't care how great the person is, most people go back to their standard habits. So if you're not monitoring them, telling them look you're writing on the shoulder, look you're totally off road and your sugar's back up and your lipid profile's really off, yeah, you need to get back on game again. You kind of you stray too far. But yeah, that's what we do. We kind of pull them back into the road.
Dr. Michael Koren:
9:07
So, on this point, some advanced lipid profiles talk about the type of LDL small dense versus large LDL and some of them talk about particle numbers. Can you comment on one better than the other, or do some of the assays have both? How do you manage that?
Al Lopez, DO:
9:23
Some assays have both, I mean there's. I predominantly use two labs that I like, which I found have been very consistent on how they report their stuff. But you know, small dense LDL is not on an NMR profile which looks at LDL particles, VLDL, ILDL, the smaller particles, and then HDL and LDL size. That's an NMR and then on separate you can order on top of that oxidized LDL, small dense LDL you can measure, and then inflammatory markers as well, and those are separate panels that you can individually mark off or do it. But depending on what's off is what I'd look at and if they're both off they're looking both. So small dense LDL and LDL particles are not exactly the same but you may treat them similarly.
Dr. Michael Koren:
10:13
Okay, and how to triglycerides fit into that equation when you're trying to think of how to manipulate this lipid profile most favorably?
Al Lopez, DO:
10:22
Yeah. So you know, for a long time we've known that LDL is above 150 or athrogenic. That became semi-controversial for a while and some physicians were saying now, only over 400 is it athrogenic. The data's been there for 150 for a long time. The newer data is actually pushing that maybe 100 or 125 is where we should be. On people that are higher risk, so again, lower, lower, lower. But people with high triglycerides, on a standard lipid profile, usually LDL is inaccurate and then that inaccuracy can be anywhere from 20 to 60% depending on how high or high or low their triglycerides are. So that's pretty inaccurate. You know, if you knew your pregnancy test was only accurate, you know, in a small window, you probably wouldn't do it right so.
Al Lopez, DO:
11:09
So it's, it's the same concept. You know, this is a life or death issue.
Dr. Michael Koren:
11:12
Yeah. Now some people would argue that most of what you can get from an advanced lipid profile you can get from just a non-HDL cholesterol. How would you respond to that criticism?
Al Lopez, DO:
11:22
There's actually there's plenty of data done on APOB be just clarified.
Dr. Michael Koren:
11:26
Non HDL means the total cholesterol minus the HDL. The thinking is that only the HDL is good and all the other stuff is bad. So just put all the other stuff in the same bucket and just deal with that.
Al Lopez, DO:
11:39
It gives you a good ballpark look when you're looking at non HDL, but it's not quite as accurate as a APOB over A1 ratio or looking at an advanced lipid profile. W e talked about APOB in the first session being associated with the bad actors and is associated with the good actors, right, so APO A 1 is pretty accurate I'm being, you know, the good guys and APOB being five different atherogenic particles under one kind of oversight lab and that tends to be a little more accurate than non HDL and so I like that better and I think it gives me better accuracy.
Al Lopez, DO:
12:18
But when you're talking about LDL particles and subparticle analysis, that's very different than a non HDL and I don't think that's quite good enough. And it's broad paintbrush versus fine paintbrush. You know difference of just the carbonic and bigger bulk shelf and the guy who carves, you know beautiful scrolls into his, his artwork. Okay, you know very different both of woodworking but very different kinds of woodwork.
Dr. Michael Koren:
12:40
Fair enough, good analogy. So how about different types of HDL? Is that ready for prime time? Is that just academic, or do you ever use that? That's a can of worms.
Al Lopez, DO:
12:49
So for a long time everybody says, well, I have a great HDL and you know I'm safe. And we've kind of found that that may not be really true and we know that depends on whether your HDL is functional versus dysfunctional. So the analogy I use do you have special ops guys, or do you have keystone cops or HDL? And if you have a lot, there's actually some data showing that if your HDL is very high it's probably non-functional. And there's a lot of guys with their old bumping it themselves and not doing a whole lot of anything. So they're not really doing reverse cholesterol transport, taking bad cholesterol pulling out of your system. They're not really decreasing rombotic events and they're not really decreasing inflammation, they're just they're hanging out.
Al Lopez, DO:
13:29
And so there is one lab that does something called a functional HDL. It has another name as well and that's been correlated with coronary catheterizations. So it's a fairly accurate test and it's looking at reverse cholesterol transport, which is how HL works. It takes away bad cholesterol and gets it out into the liver yeah, to get rid of it. So we're still looking at better tests for that and kind of the jury's out whether HDL is really accurate and is even a normal HDL really that good. So yeah, that's been kind of a storm.
Dr. Michael Koren:
14:02
We know epidemiologically that higher HDLs are associated with less heart disease.
Al Lopez, DO:
14:07
Yes each.
Dr. Michael Koren:
14:07
Those are not, yeah, but the story isn't so clear compared to LDL.
Al Lopez, DO:
14:11
It's not right. It's not as clear. So clear that's. That's definitive. We know the lower you are, the better you go example, that is the APO a1 Milano story.
Dr. Michael Koren:
14:19
Yes that the families in Italy had actually very low HDLs but didn't get atherosclerosis because they have super HDLs.
Al Lopez, DO:
14:26
That's a really interesting story.
Dr. Michael Koren:
14:27
That's a fun thing.
Al Lopez, DO:
14:28
We should go into that story one day.
Dr. Michael Koren:
14:29
Yeah, that'll be our HDL podcast.
Al Lopez, DO:
14:31
Okay, that'll be fun.
Dr. Michael Koren:
14:33
But anyhow, alright, so I'm gonna. I'm gonna wrap things up with the big question. I'd call it the million dollar question. But a million dollars isn't that big anymore, but anyway, so we'll call it the billion dollar question. Do you need cholesterol in your circulation at all?
Dr. Michael Koren:
14:48
Of course, yeah, you do well before you jump in so fast. You know, some people argue that an LDL of zero is really the ultimate goal and we really don't need any cholesterol. Cholesterol in the circulation is just the stuff a body is trying to get rid of, because all of our cells can make cholesterol.
Al Lopez, DO:
15:07
Well you, I'm gonna be nitpicky. You said do you need cholesterol? You need cholesterol, that's sure, but when you're measuring, a cholesterol right, you're measuring it on a blood test.
Al Lopez, DO:
15:17
It's the stuff that you're not utilizing to make hormones, to make you know normal oils that you need for your skin and your hair, so you don't have straw for hair, etc. So do you need circulating cholesterol? I think that's been controversial and there is some data and some people that argue that you do need a certain amount for normal brain function because you need cholesterol for brain function for circulating cholesterol.
Dr. Michael Koren:
15:41
Circulate and then circulating cells can make cholesterol yeah.
Al Lopez, DO:
15:45
I'm actually not uncomfortable if we get down to single high single digits or low, low double digits. I'm just not really sure the data is very clear when we get the single digit lower than nine or so. And then I get a little uncomfortable and I and I have colleagues that tell me it doesn't really matter, you can bring it to zero and you're just fine. Mm-hmm, I'm okay with 20, I'm okay with 15 and we get lower.
Al Lopez, DO:
16:09
probably two versus 15 won't make that much, yeah, and it's not an accurate test at that point either, is it?
Dr. Michael Koren:
16:14
Well, again, if you do it directly, directly, but in the standard profiles probably not as well, and the reason we know bringing it up is one of the arguments for using advanced lipid profiles is when we're looking at the very low numbers, you probably need a direct measurement or advanced lipid profile help to really identify the lowest possible risk. So let's say you get a patient that says, doc, just get my risk down to close to zero as possible, you have my permission to do that and then you would probably lean on your direct LDL measurements to to be able to accomplish that.
Al Lopez, DO:
16:47
Well, we also know that if triglycerides are below 70, you have a 20% error rate on that calculated
Al Lopez, DO:
16:52
LDL if it's above 150 is the 20% error rate. It's above about 200. It's a 40% error rate and even higher it's like a 60% error rate if you're on hormones male or female hormones, females, people that are overweight, people are insulin resistance, people, high triglycerides all of those have it inaccurate LDL calculated LDL number. And so there's so many varriables on making the LDL calculated LDL for LDLC inaccurate. I question on a recurrent basis why are we even using it when it's not that expensive to do a direct LDL? So I'll do it on high-risk patients and if I have a question I'll do it on someone that's non-fasting. But there's also the argument how much fasting? You know how long should they be fasting? Eight hours, twelve hours, are you really fasting? And then the second argument is how long are you fasting during the day? It's only eight hours. So what is your cholesterol? You're not fasting. And if it's actually 250 after you've eaten, is that okay? So I think cop LDL C or LDL calculator LDL is very controversial at this point.
Dr. Michael Koren:
17:58
Yeah, and certainly the whole concept of what happens for non-fasting samples is something we know very, very little about extraordinary, little about, because everything we've done is based on fasting samples. But I think the people are moving towards this idea that LDL is as low as possible. Even down to the single digits is not a bad thing, because all of ourselves can make cholesterol for their own cellular functions and the stuff in the circulation is the extra stuff your body is trying to get rid of.
Al Lopez, DO:
18:26
Yeah.
Dr. Michael Koren:
18:27
So that's an argument. So it sounds like we're on the same page with regard to that.
Al Lopez, DO:
18:33
Yeah, I'm not worried when it's really low. In fact mine was normal when I had checked and I had actually put on a blood pressure medicine and my doc told me you know, you really need to be on a statin. I said why he goes? Because you have hypertension in your old Gee. Thanks a lot, buddy, but you start thinking about it.
Narrator:
18:51
You need a new doctor.
Al Lopez, DO:
18:52
Yeah, but you start thinking about it. You know, the older you get, the higher chance you are having heart disease. And is it a bad thought to really be on something that will prevent you from having something? So, again, primary prevention Is it aggressive? It's probably a little aggressive.
Dr. Michael Koren:
19:06
Well, Al, thank you for this journey through advanced lipid profiles. My pleasure it's been a fabulous conversation. I've learned a lot, as always from my guests, and hopefully the audience has learned something along the way as well. And with that we conclude another session of MedEvidence.
Narrator:
19:21
Thank you. Thanks for joining the MedEvidence podcast. To learn more, head over to MedEvidence. com or subscribe to our podcast on your favorite podcast platform.
