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 here with our third session of Advanced Lipid Profiles with my dear friend and colleague, Dr. Al Lopez, DO. Al and I have dug into some of the nerdy stuff in the last section and now we're going to get into the clinical stuff. Talking about how we treat our patients. Al this what you do for a living. This is what you do day to day. Let's walk our audience through your thinking. When you have a 50-year-old fellow, he comes into your office and he says, doc, I am so scared. My first cousin just dropped dead of a heart attack at age 51 and my birthday is next week. I know I haven't been the best 30 pounds overweight. I used to smoke, but now I just smoke cigars when I play golf on the weekend. I don't really exercise like I should. I know my cholesterol is high, but I haven't checked it for a while. What should I do? I don't want to end up in the same place as my first cousin. Walk us through how you would approach somebody like that.
Al Lopez, DO:
1:17
I think we can start with basics with this gentleman. He's a low-hanging fruit, he's a smoker and I don't care if it's a cigar once a month. We know that cigars are pro-thrombotic and pro-athrogenic. We know that they help progress plaque and actually increase clotting. Once a cigar once in a while or cigarette every day. Obviously, the more you smoke, the more risk you have, but it's still a risk factor. Stopping smoking is number one. We know he's overweight, so we can talk about lifestyle changes. I start with this conversation like what's your why? Why do you want to live longer and how do you want to live if you live longer? I think that's an unspoken conversation and people have all the time. They don't really say how do I live longer in a better form? Nobody says I want to live to 90 and be in bed with a stroke. I have that conversation on let's change your lifestyle. You're eating McDonald's every day. You're eating only fried foods.
Dr. Michael Koren:
2:18
We're not prejudicing against any particular restaurant chain.
Al Lopez, DO:
2:22
Maybe we can at this point talk to them about reducing red meat consumption, using plant-based meals a couple times a week, eating the rainbow, six to eight servings of fruits and vegetables a day, and then exercise. They don't have to run a marathon tomorrow, let's just walk. Let's start with a six-minute walk every day and then every week let's augment that by a minute, and then getting eventually to goal and then adding high-intensity training. Eventually, and then slowly they'll cut. As they cut carbohydrates, fats down and exercise, they will lose the weight, which is a goal. And then I give them short and long-term weight goals. You tell somebody you got to lose 100 pounds by next week. It's not going to happen. You tell them they're going to lose 100 pounds in a year. It's probably not going to happen either. If you give them a 2D view window and say this is minimally what I want you to lose per month and this is what you want you to lose in three months, six months, a year, and then, if you can lose more than that, we can dance a jig together. I think when you give them those goals, then you set them up for success.
Al Lopez, DO:
3:23
The scary thing is the hidden risks. Those are the easy ones right. Then we can check his blood pressure. Is he really a goal? You really want him in the one teens and one twenties? What is his heart rate? We know people with very high heart rates don't last as long the maybe you'll consider a medication to drop heart rate down if he really has a high heart rate and then looking at other screening things at that point. Then now is the hidden risks. You have a cousin or a family member that died in an early age. Once you've got the lipid profile and make sure they're not pre-diabetic or insensitive?
Dr. Michael Koren:
3:56
Just to drill into that, would you just get a standard lipid profile on a start, or would you just jump right into the advanced lipid profile.
Al Lopez, DO:
4:02
With this gentleman, he says he has high lipid profile, and high for some people is a lot higher than what I'm comfortable with. Some people is way higher than I'm comfortable with. I tend to be very aggressive on lipids.
Dr. Michael Koren:
4:17
You would get an advanced lipid profile.
Al Lopez, DO:
4:18
I would get an advanced lipid on this person because his family member died at a young age, to include an Lp(a) and include a direct LDL. If his triglycerides had been high before or if he had a high sugar in the past above 90 or 88 or 90, then I would get a direct LDL on him. I would do it in layers. If those were abnormal then I would look at other advanced lipid profiles. But I would do an NMR profile.
Dr. Michael Koren:
4:45
He has enough risk right off the bat that you would not mess around with the standard stuff you want to dig in.
Al Lopez, DO:
4:50
I want to dig in a little bit more. I would get an oxidized LDL right off the bat? Not unless he has symptoms that worry me if he told me you know I'm really short of breath when I exert myself, but I'm not short of breath at rest, but it's even, you know, if I run I'm really, you know. That's one thing. But even going up a flight of stairs most people shouldn't be that short of breath going up a flight of stairs, right, unless they have asthma or big, big, big smokers.
Dr. Michael Koren:
5:15
So let's assume that he doesn't have any symptoms other than being scared to death.
Al Lopez, DO:
5:19
I would do an advanced lipid profile with direct LDL on him, looking at Lp(a) fasting look at Fasting sugar and then, you know, check his blood pressure heart rate. I would look at it, but I'm again fairly aggressive. There's other tests that look a little more sensitive than an A1C. You can look at in insulin resistance score. You can calculate your own insulin resistance score or you can do a one or two hour glucose tolerance test, which is real pain to do because people got to be there for two to three hours.
Dr. Michael Koren:
5:51
They got to drink this kind of well, you have his attention At this point.
Al Lopez, DO:
5:55
Anything you want him to yeah, usually if he's coming and saying that he's pretty scared.
Dr. Michael Koren:
5:59
So so he's. He's scared, but he's completely asymptomatic. You're convinced of that. You get the advanced lipid profile. Any other, any other ways of looking at him? Do you get a cat scan to look at his current calcium crown? Do you put him on a treadmill, what? What are your other thoughts about doing?
Al Lopez, DO:
6:15
I think, if he's you know, if he doesn't have an abnormal EKG is asymptomatic. Doing an exercise stress test look at functionality is worthwhile to do a nuclear. I don't think that's the way to go right, because they're looking at functionality and seeing what he's doing. I don't think he needs an echo unless you hear a new heart murmur. If you hear a heart murmur and it's not been identified before, then yes, we probably want to do an echo at that point, which is an ultrasound of the other heart.
Dr. Michael Koren:
6:41
Yeah, and again he was. He's fine again. We're just gonna keep this. You know, on the internal medicine level that he doesn't have any cardiac symptoms at all and it's just purely screening.
Al Lopez, DO:
6:50
Yeah, so I think I could do that. Coronary calcium score. I think is has huge, huge value and it's probably underutilized right now and that will give us a base layer if he has disease. And so when you do a coronary calcium scores, you have a cat scan of your chest done and then they read calcium deposition in the arterial wall. So what that reads is that it's hot plaque that's cooled down and you've left, instead of lava, pumice stone and the arterial walls and that's what you're measuring so to speak, the pumice stone.
Dr. Michael Koren:
7:23
Actually a little triva, you get what's called an Agaston score of the amount of calcium in the coronary arteries. And we think Agaston is famous for creating that CAG score, but everybody else knows him for the South Beach diet Right.
Al Lopez, DO:
7:35
He's actually a very interesting gentleman. He's still working today and he's quite amazing to hear speak and to meet.
Dr. Michael Koren:
7:41
Neat guy.
Al Lopez, DO:
7:42
He's really neat. So if you have the Agaston score, if it's zero, then your chance of having coronary disease is very, very low. It's like one, two, three percent.
Dr. Michael Koren:
7:56
And most places that you send patients for this type of test will have a nomogram that tells you what you expect at different ages. Right, so you can put people into a percentile rank of risk, which can be very helpful, right.
Al Lopez, DO:
8:09
Again, if it's over 400, then you have very, very high risk of having probably ischemic coronary disease or pretty significant coronary disease. But the controversy is when do you repeat it and then who do you do it on? So I don't think I would do it on a 30-year-old person. There's no data on 30-year-olds in doing it unless everybody died at 32. Yeah, Right, but I think someone that's 50, the gist of it is it's worthwhile doing it because that would also might convince him, if it's high, to put him on a statin.
Dr. Michael Koren:
8:37
Okay. He's asymptomatic, you'll get an advanced profile to see what his lipid risk is, but if that turns out to be clean, you're going to just work on his lifestyle.
Al Lopez, DO:
8:48
Heavily work on his lifestyle.
Dr. Michael Koren:
8:49
And you would make the argument about a standard stress test, not an imaging stress test based on just defining parameters for an exercise program.
Al Lopez, DO:
8:58
Well, and I might argue, if it was his brother or his dad at a young age, I might argue that he probably should be on a statin for prevention right, looking at primary prevention, preventing from ever having heart disease, and so there is data on that. That's kind of heated at times, but I would say so. let's do a few what-ifs here.
Dr. Michael Koren:
9:16
Let's do a few more what-its"Okay, so now this guy is a 30-year-old guy and his 51-year-old first cousin died. Do you change any recommendations?
Al Lopez, DO:
9:25
I think you still look at respect to hypertension, high sugars. We know that you can develop plaque in your 20s. At puberty, you can start developing plaques, maybe sooner than I think very, very high lipids.
Dr. Michael Koren:
9:38
Not that much different. Maybe a CAG score at 50, but not necessarily at 30.
Al Lopez, DO:
9:41
Not at 30. I don't know if I do the stress test, but I would definitely look at lipid profile, sugars, blood pressure, heart rate and look at those things, but he's seven years old and he as a family member who dies at 50. So we know with age that there's a higher risk and higher chance of having coronary disease. But it sounds unfair. But if he's a very I've had 70-year-olds that would I would exercise 30-year-olds.
Al Lopez, DO:
10:08
They're really in incredible shape. So it's partly that I think everybody deserves a chance and there is data on treatment in 70-year-olds for prevention. So, yeah, I think I would look at a coronary calcium score.
Dr. Michael Koren:
10:20
So you get that advanced lipid profile in the 70-year-old and not so much.
Al Lopez, DO:
10:24
Yeah, I would.
Dr. Michael Koren:
10:25
I probably would. How about a 90-year-old?
Al Lopez, DO:
10:26
90-year-old probably not.
Dr. Michael Koren:
10:28
So somewhere between 70 and 90. If you make it past 80, you're probably going to do okay.
Al Lopez, DO:
10:33
Yeah, well, probably, and at that point there's other things that are going to get you, that are going to slow you down, right, right.
Dr. Michael Koren:
10:39
Okay, now it's a 50-year-old woman, not a 50-year-old man. Do you change anything?
Al Lopez, DO:
10:45
So women present differently and if you listen to Martha Gulotta, who does a wonderful talk on women in heart disease, if you look at women and Google and chest pain, you'll get a woman in a bikini. She argues that we're not just women in bikinis, we have hearts too. We have something underneath our bras and our breasts. There's a heart in there. I think women are undervalued in heart disease and they present differently than men. They may present with dizziness, weakness, shortness of breath and not necessarily chest pain. I think the work up in women should be just as important.
Dr. Michael Koren:
11:21
What do you want to change anything between the 50-year-old woman and a 50-year-old man, but hormone analysis would that be part of it?
Al Lopez, DO:
11:26
There is some data that hormones will help improve. I think it's more symptomatology and how they feel with hormones, but I don't think I would check it as my first line 30-year-old woman would that matter? 30-year-old woman unlikely unless she has an elevated Lp(a) of the line she had family members, family members that had a very early age, had aortic valve lube disease or cardiovascular disease at an early age, then I would look at Lp(a) in that woman.
Dr. Michael Koren:
11:50
I guess, just for the audience, we don't use statins during pregnancy so that you have to be aware of that in younger women.
Al Lopez, DO:
11:57
Pregnancy is a stress test because the whole lipid profile goes crazy, hormones go crazy. You're supporting another being. Things augment and change in order to feed this embryo, to make it viable. It's a beating.
Dr. Michael Koren:
12:13
How about the 50-year-old guy now brings in his 15-year-old son and asks you the same questions? Any differences in your approach?
Al Lopez, DO:
12:23
I don't think I do much unless I know that they have a family has a Lp(a). I would look at an Lp(a) in those people because now you look at what we call cascade screening, we're looking at family members that have early cardiovascular disease and we would look at an Lp(a). I think cholesterol screening should be done at a young age every five years, three to five years depending on how bad it is.
Dr. Michael Koren:
12:45
The 50-year-old guy brought in his 15-year-old son and he said I want my son to be screened. You would ask have you been screened yet?
Al Lopez, DO:
12:53
Right, that was the first thing is has he been screened and what's your risks? What are the family members have been screened and what risks they have? I do a very strong family. I do it from grandparents to parents, to aunts and uncles and then make the assessment on this young adult. I think if there's a strong family history, I would look at an Lp(a) and liquid profile for sure.
Dr. Michael Koren:
13:12
Okay, so now let's change the race of the patient coming in. Does that matter? Does it matter if it was a white person or a black person, or Asian or Hispanic?
Al Lopez, DO:
13:22
We know that certain subpopulations have higher risk for heterozygous familial hyperlipidemia as high genetic cholesterol and also for Lp(a). We know that it's higher propensity, especially in Southeast Asians, and need to be treated quite differently.
Dr. Michael Koren:
13:38
Does that influence your willingness or threshold for getting an advanced lipid profile?
Al Lopez, DO:
13:42
Yes, so Southeast Asians higher risk.
Dr. Michael Koren:
13:49
So you would order more advanced lipid profiles in somebody from India, for example.
Al Lopez, DO:
13:53
India, Pakistan, South Pacific. What has not been studied is Filipinos. Filipinos are very high metabolic syndrome, high diabetes rate. I think I would look at those patients as well. Black patients from African-Americans to Africa. High propensity of Lp(a).
Dr. Michael Koren:
14:13
So you might be more likely to order an advanced lipid profile in African-American versus Caucasian.
Al Lopez, DO:
14:20
Depending on the scenario, okay, all right, fair enough. Yeah, it's nobody's that clear cut right. There's very few very clear cut things. If not, everybody would have been diagnosed early and everybody would live to 100.
Dr. Michael Koren:
14:31
Right, okay. Now obviously these are all what we call primary prevention scenarios. So now how about secondary prevention scenarios, where somebody has already been diagnosed with some degree of coroner disease, whether it's say they had a stent. The same person came in. Hey, doc, you know I need a good internist. I had a stent when I was 40 years old. I haven't had any symptoms. My cardiologist says I'm perfect and I'll just go see my internist. And now just my cousin, my first cousin, just dropped dead at 51. Am I doing everything I need to do?
Dr. Michael Koren:
15:07
So has that changed your approach, particularly with regard to the advanced lipid profile, let's say that he's been good. He's on 40 of a torvastatin, he's taking his aspirin a day and he's on a low dose of an ARB, and he said his blood pressure is always perfect.
Al Lopez, DO:
15:26
So it sounds like this person who's had, you know, vascular disease and is on anti-aquagulant and aspirin, supposedly on the right medication, sounds like he's in a good regimen. The question is, what is his hidden risk and does he have any risk factors right? So this patient you know they already have coronary disease that would not do a coronary counseling score. I don't think that's worthwhile because that really kind of aligns risk with you. Should or should not be on a statin? Should you do more aggressive treatment? And so the assumption is that they have calcium.
Dr. Michael Koren:
15:55
In terms of the advanced lipid profile.
Al Lopez, DO:
15:58
I think in the advanced lipid profile. I think if they have young family members, yes, Lp(a) with those people, and we know that the recurrence rate in people with coronary disease is almost 70% if you're not on the right medications, or if not higher, and so you know they need to have a very low LDL. I've been very aggressively treating patients with low LDLs that have disease and diabetics at 55, like the Europeans have, and an American heart is very wisely lower those standards as well. So I think this is gonna be a big change. So this person, I would look at their lipid profile and make sure they're very low on that. I would do an advanced lipid profile. If they have high triglycerides, if they have an LDL of 40 and triglycerides are 70, do they really need you know if the Lp(a) was normal? Do I need to look farther than that? Probably not, unless they have symptoms.
Dr. Michael Koren:
16:51
Okay, so we're gonna take a pause here. But I'm gonna be really curious in our next segment about how you use advanced lipid profiles over time. Is once enough, or is there information to be had when you look at them over time, and how often do you check? If you get one, you do something. Do you check it again in three months, six months or a year? So we're gonna jump into that discussion in our next segment.
Narrator:
17:14
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