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 and I'm delighted to host another session of MedEvidence, and we have a very special guest today, Dr. Al Lopez, DO. Al is a colleague of mine, a fabulous internist and a real expert in lipids, and he's going to talk to us today about advanced lipid profile. Hey, Al, how you doing? So how'd you get interested in lipid profiles?
Albert Lopez, DO: 0:41
So about 20 years ago I tried to hit all the data sets to keep people from having heart disease or vascular disease, and no matter how much I got them to go, there were still a large percentage of patients that seemed to still have an event, another stent, another peripheral vascular intervention done and that really frustrated me. So I kept on thinking there's got to be more than just lowering blood pressure, checking sugars and making sure those are at goal, or getting them on a statin or getting their lipids to a certain goal. At that time it's quite different than today's. So I started reading more on advanced lipids and inflammatory markers, and that's kind of how I got here.
Dr. Michael Koren: 1:24
Interesting. Al and I have known each other for a while and we worked together on clinical trials and he's a delight to work with and I happen to know that he loves Geri Garcia ties. So I actually went to my closet and there was some dust there, I have to admit, but I pulled out an old Geri Garcia tie and Al, why don't you show yours? And I think this is actually apropos, and the reason I say that is because Geri Garcia may have some relationship to advanced lipid profiles. Let's face it, the guy died at age 53. So when somebody dies of age 53, of a heart attack, you've got to wonder what's going on. So what are your thoughts about that, Al?
Albert Lopez, DO: 2:06
You know I think a lot of people put a finger on his history of drug use, but at that time he was in rehab and over the last preceding prior five or 10 years, he gained a lot of weight.
Dr. Michael Koren: 2:18
His risk factors were probably not under any type of control.
Albert Lopez, DO: 2:21
Yeah, so I think you could point it to drugs, but I don't really think so. I think there's something else cooking in there. We know other high profile people that have had the same issue.
Dr. Michael Koren: 2:33
So one of the questions I have is why does Geri Garcia die at age 53? And another rock star with a similar history of debauchery, like Keith Richards, lives to his 80s. So there's got to be something genetic about that, wouldn't you agree?
Albert Lopez, DO: 2:48
I think there's hidden risks that we're not really looked at and a number of people, and I think they're starting to come more to the surface and being looked at more aggressively.
Dr. Michael Koren: 2:56
Yeah, and it's interesting, particularly in the music scene in the 60s and 70s, where a lot of people died way too early. There's some very interesting stories. One of my favorites is actually a guy named Tom Wilson who was a record producer for Simon and Garfunkel and Bob Dillion and others. He was actually the guy responsible for making the song Sounds of Silence a big hit. Just a quick historical note is that Sounds of Silence was originally released in 64. It was a bit of a flop and then this guy, Tom Wilson, who was an African-American guy that graduated Harvard, got into the record business and he became the producer for Simon and Garfunkel. And when Simon and Garfunkel were actually broken up and had given up on music, he changed the whole arrangement of the song, electrified it and became a huge hit. And unfortunately this guy, tom Wilson, died at age 47 of unknown reasons, of a heart attack, probably because of some sort of genetic dyslipidemia.
Albert Lopez, DO: 3:52
Yeah, I think we can talk about other things. We think of athletes always being the superheroes and never becoming ill and not dying early either, and we have several of those as well. Is that not true, Mike?
Dr. Michael Koren: 4:02
Yeah, absolutely. Some of them are probably arrhythmic deaths, but some of these others that kind of out of the blue die at a young age, often have dyslipidemia or some sort of cholesterol or lipid issue. So we're going to jump into that a little bit. So, Al, just start us off by telling us what is an advanced lipid profile.
Albert Lopez, DO: 4:22
The advanced lipid profile is a blood test that gives us a lot more information than a standard lipid profile. It'll include things like Lp (a), LDL, particle numbers, ILDL, VLDL, size of LDL, small dense LDL and there's other markers in there and so there's better markers to look at ApoB is one
Dr. Michael Koren: 4:50
Yeah, explain ApoB to the audience in terms of the difference between a lipoprotein and the proteinaceous part of it.
Albert Lopez, DO: 4:56
So Apo B is a protein that's attached to many of the atherogenic particles, including LDL, Lp(a), VLDL, ILDL and LDL particles, and so when you look at LDL it looks like a raspberry or a blackberry and in total piece of the raspberry is called an LDL, but the bumps on it are just as atherogenic. So the more bumps you have, the more atherogenic you are. Even if Mrs Jones has the same LDL as Mrs Smith, if Mrs Jones has a lot of particles, thousands of particles, she's more prone to have cardiovascular issues than the other person that has less, though.
Dr. Michael Koren: 5:37
And some people are probably more genetically predisposed to have higher levels of apolipoprotein B.
Albert Lopez, DO: 5:43
This is true. I think it's. Also we're seeing that it's mediated by anethyla dysfunction or metabolic syndrome. So people that are overweight or obese, people that are diabetic and some resistant patients also have hidden dyslipidemias.
Dr. Michael Koren: 5:58
So APOB is a particle that runs with a bad crowd. In fact, it may define a bad crowd.
Albert Lopez, DO: 6:06
Maybe that's why it's called B.
Dr. Michael Koren: 6:09
And this is one of the things you look at in advanced lipid profiles. So getting back to a further definition of that, so just tell the audience a little bit more about what to expect from an advanced lipid profile and, while that differs from what your physician usually orders, when you get standard labs.
Albert Lopez, DO
So I will look for risk on patients when I'm ordering an advanced lipid and so initially I may just do a standard lipid profile the people with strong family history people that have early vascular disease or whether it's arterial or carotid or cardiac or peripheral vascular disease I will order and advance lipid peripheral on those diabetics typically and if you look at the standard lipid profile and diabetic LDL is usually not elevated it's usually triglycerides and then these sub-particles as well
Dr. Michael Koren: 6:55
So just to break it down for our audience, not of all of whom are versed in this kind of thing so do you get a total cholesterol as part of a standard package or only in an advanced lipid profile?
Albert Lopez, DO: 7:06
Total cholesterol,DL Lldl triglycerides and HDL. The standard standard guess g the best of maybe 1970 lipid profiles and there's not much we do in current medicine that's from 1970, except the stethoscope. Well, that goes way before the 1970s. That's true, that's true.
Dr. Michael Koren: 7:25
Okay, so you mentioned the things that are part of the standard lipid profile. So now give us examples of an apolipoprotein B that you look for in this advanced lipid profile, and you may get into the different types of LDL when you have that discussion.
Albert Lopez, DO: 7:38
Right. So I'll look at LDL particle number to see what that is If it's elevated. We're looking at mitigating that risk. We're looking VLD ILDL. We're also looking at HDL size. Ldl size we know that small, dense LDL is much more athrogenic than standard LDL in of itself, and the larger LDL and then when we're looking at inflammatory markers, that's a whole nother story, but we're looking at I'm looking at several inflammatory markers.
Dr. Michael Koren: 8:10
Yeah, and we'll hold that for a second. I don't want to bring too many things on board at once. So what about lipoprotein-lil-a? Where does that fit in? Is that part of a standard profile? Advanced profile.
Albert Lopez, DO: 8:19
For a long time. We've, you know we've clumped in LP-lil-a with LDL and in the standard lipoprofile and they're starting to take that out now, and so we've known that this has been a bad actor for over 20-something years. But there's not much we could do with. You know a lot of people using vitamin C which had single-digit changes yeah. Really Hydro-vitamin C. They were trying niacin. We've kind of vilified niacin and it only dropped it maybe 12 to 18%.
Dr. Michael Koren: 8:48
It works. Yeah, I used to use niacin quite a bit, but yeah, I did too for a while, unless they were red-headed and green-eyed. And then they hated you because they flushed or developed atrial fibrillation? Yeah, that's another story.
Albert Lopez, DO: 9:02
But for the most part, you know there was nothing there for LP-lil-a patients so they kind of was put in the back of the bookshelf and nobody would look at it anymore. And it's been an interest of mine for a long time because I've noted in a number of cases of patients and then hoping to change dietary lifestyle, exercise et cetera, which we know doesn't really affect it very much but is the best we had and that story's changing.
Dr. Michael Koren: 9:25
Yeah, and we'll get into LPA in a little bit more detail later on in the broadcast. But anyhow, just to get to the other things that are just in the advance of the profile, how about remnant cholesterol? Do you look at that?
Albert Lopez, DO: 9:36
There's a couple of interesting articles by Peter Libby and Dan Ray. They're talking about remnant LDL and you know those are another way to look at, can misnomer it as APOB or some of these other particles. But remnant lipid profiles are the ones we possibly don't look at and but they're.
Dr. Michael Koren: 9:57
And just for the audience, that's kind of what's left over when you take all the other categories out.
Albert Lopez, DO: 10:01
Right, and so they tend to be really plaque-producing bad particles, so they're bad actors as well, and so these remnant particles are really important in certain subclass of patients.
Dr. Michael Koren: 10:12
Now we also talk about oxidized LDL. Is that part of a standard lipid profile? Is that part of an advanced lipid?
Albert Lopez, DO: 10:18
profile. That is not. How do you?
Dr. Michael Koren: 10:19
learn about that.
Albert Lopez, DO: 10:20
Oxidized LDL is fascinating. So you know, when I was in medical 100 years ago, you know we talked about foam cells and so how LDL you look good for your state of age. Hyperbaric chamber works well Me and Michael Jackson. It's very interesting because we talked about foam cells and almost the reaction of, like Coca-Cola and Mentos, where you get this foam reaction or inflammatory reaction. When LDL enters the vascular bed or the vascular wall, the arterial wall, in certain cases it will oxidize and if it's oxidizing you're making plaque.
Dr. Michael Koren: 10:59
But you can't measure that easily with the tools that we have as clinicians.
Albert Lopez, DO: 11:03
It can be done. In an advanced lipid profile you can measure oxidized phospholipid or oxidized LDL and I've been using that for about 15, 20 years and if I know oxidized LDLs up then I'm starting to look for where it's embedding itself. Is it in the legs and the carotids in the heart? So now I'm really doing it like this major search Interesting.
Dr. Michael Koren: 11:21
Well, al, we've covered a lot of ground, so we're going to take a pause and we're going to jump back in by talking specifically about lipoprotein.
Narrator: 11:29
Little a Thanks for joining the MedEvidence podcast. To learn more, head over to medevidence.com or subscribe to our podcast on your favorite podcast platform.
