Saw a cardiologist to make sense of my lipids

[Avies48]

LDL wasn't that bad. Apob was >100. CT-CAC was 43. My aunt had an MI in her 40s with plaque in the LAD. Mine is also in the LAD.

And so... I'm running a 5 year experiment to see how low I can get LDL and ApoB with the goal of possibly reversing the calcified plaque.

I started with diet and exercise, then supplements like psyllium and a very high dose of EPA, which had me at 112mg/dL ApoB. Then I added in ezetimibe. After about a year I was hanging with a friend who is metabolically unhealthy, never exercises, shit diet etc.. He showed me his lipids and they were better than mine. He was on 20mg Rosuvastatin, and so that sealed it for me. I tried Rosuvastatin at 10mg/day after learning about the dose response curve, which goddamn it, I'll write about in an article shortly, but most of the efficacy comes from 25% of the max dose. Here:

View attachment 300384

I ran that for quite some time watching for adverse side effects. Seeing none, I moved on to bempedoic acid. In parallel with that, I was working on getting Repatha. The Rx was easy, but it's expensive as hell. I applied for a copay card which is easy to get, but found out my company's pharmaceutical benefit includes a special rider for "preventative" care and so Repatha was covered with no pre-auth.

After a year on all of that, my lipids are in good shape. Just in time to.... blast my face off, which is what I'm doing presently.

As for cholesterol in the brain, as @Ghoul pointed out, the brain makes its own cholesterol and it's best to run a statin that doesn't cross the blood brain barrier. Those would be hydrophilic statins like Rosuvastatin or Pravastatin.

Damn my insurance wanted a pre authorization and its blue cross… ppo… even the copay card wouldnt cover it and it was still $500

So i tried statins and they caused me to get a blood clot so the docs made me drop it quickly!

Zetia gave me horrible diarrhea…

My apob was 140… ldl 177-178 and total cholesterol was 258….

So yeah u have done ur homework and i hope u get the answers ur looken for

 

[deadbeef]

I use the Quest panel “CardioIQ advanced lipid panel”

It’s cheapest through walk-in labs, ~$135

For comparison, I paid $60 at fitomics for the Labcorp version of that (NMR LipoProfile).

 

[Mongo966]

This is quite problematic because it's hard to discern what's real and what's not. Is egg yolk truly a spectacular fat or is it destroying my lipids profile at an egg or 2 per day? Are seed oils really killing me bc I just got an update from Arnold's Pump club that canola oil is a healthy fat (based on the current research) whereas the guys eating 2 ribeyes per day covered with ghee tell you 2 tbsp of canola oil is killing you. IT'S SO CONFUSING.

I literally asked the cardiologist, "If I have the choice to eat salmon w/high healthy fats or white fish w/no fats which choice do I make?". Her reply, "we don't know."

If your head hurts from trying to figure this shit out it's probably because you have no business trying to figure it out in the first place. Let the doctors do your thinking for you. That's what they're for.
Let me put it this way: My dad had a quintuple bypass 10 years ago and he recently went for imaging to see how his disease had progressed, and the images showed that his disease hadn't progressed at all and that's thanks most certainly to lifestyle changes. Do you think he's been listening to his cardiologist/dietician for lifestyle advice or do you think he's been listening to joe fucking rogan?
Good on you for doing your reading and looking deeper into your own numbers. Now you know you aren't one of the lucky bastards who doesn't have to worry about plaque

 

[bigMoJo]

For comparison, I paid $60 at fitomics for the Labcorp version of that (NMR LipoProfile).

I don't think it's the same, for example doesn't look like it includes ApoB. Here is a comparison of the markers. One is from Fitomics showing what Labcorp tests, the other is a sample IQ test report from Quest. I couldn't find report for Labcorp to compare apples:

​

 

[bigMoJo]

If your head hurts from trying to figure this shit out it's probably because you have no business trying to figure it out in the first place. Let the doctors do your thinking for you. That's what they're for.
Let me put it this way: My dad had a quintuple bypass 10 years ago and he recently went for imaging to see how his disease had progressed, and the images showed that his disease hadn't progressed at all and that's thanks most certainly to lifestyle changes. Do you think he's been listening to his cardiologist/dietician for lifestyle advice or do you think he's been listening to joe fucking rogan?
Good on you for doing your reading and looking deeper into your own numbers. Now you know you aren't one of the lucky bastards who doesn't have to worry about plaque

How old is your dad bro?

 

[Mongo966]

How old is your dad bro?

74 years young now.

 

[bigMoJo]

Regarding that Quest report, it's actually this:
"Advanced Lipid Panel with Inflammation, Cardio IQ" Test Code: 94220
Includes:
Cardio IQ® Cholesterol, Total
Cardio IQ® HDL Cholesterol
Cardio IQ® Triglycerides
Cardio IQ® Non-HDL and Calculated Components
Cardio IQ® Lipoprotein Fractionation, Ion Mobility
Cardio IQ® Apolipoprotein B
Cardio IQ® Lipoprotein (a)
Cardio IQ® hs-CRP
Cardio IQ® Lp-PLA2 Activity

The other Quest panel is:
"Advanced Lipid Panel, Cardio IQ" Test Code: 92145
Includes:
Cardio IQ® Cholesterol, Total
Cardio IQ® HDL Cholesterol
Cardio IQ® Triglycerides
Cardio IQ® Non-HDL and Calculated Components
Cardio IQ® Lipoprotein Fractionation, Ion Mobility
Cardio IQ® Apolipoprotein B
Cardio IQ® Lipoprotein (a)
*This is the one offered through Fitomics for $133 with coupon.

I'll see if they can add the first one and the price.
At the same time, I'm just going to ask my PCP for the lab order because it's covered 100% through my insurance.

 

[bigMoJo]

74 years young now.

Yes, he's young. Glad to hear he's doing well. "Keep F-in Going Baby!"

 

[egruberman]

I don't think it's the same, for example doesn't look like it includes ApoB.

It's not. Here's a sample report:

https://files.labcorp.com/testmenu-d8/sample_reports/123810.pdf

Weird that they do an NMR test but don't offer ApoB and Lp(a). The one I use is the Quest 92145 you linked above. I get hs-CRP occasionally with a different panel.

Let the doctors do your thinking for you. That's what they're for.

Yeah.... no. Doctors follow the standard of care, hopefully. Few are well-informed on this topic, which baffles me. Even still, most cardiologists follow the guidelines of the American College of Cardiology who, maddeningly updated their guidelines in 2022 and still recommends using LDL-C rather than ApoB like the rest of the civilized world. They also continue to push statin mono-therapy at maximal doses before even considering non-statin ancillaries that have a better safety profile.

Atorvastatin is the "gorilla statin" in the words of Tom Dayspring typically prescribed at 40mg/day and above. It's lipophilic and crosses the blood-brain barrier just fine. At the maximal dose of 80mg/day, 1 in 3 patients will develop type 2 diabetes within 3 years.

They are the reason all the anti-statin bullshit exists. They've been pushing the same fucking protocol for two decades all the while mortalities from ASCVD have been increasing in the past decade.

The poly-pharma approach works perfectly fucking peachy. At low doses, statins are mostly harmless and move the needle a great deal in terms of reducing ApoB. Ezetimibe and bempedoic acid are wonderful add-ons each with their own complementary mechanism of action and reams of data on outcomes as well as side effects.

Hilariously, among the side effects for bempedoic acid is "tendon rupture" which scared the shit out of me because nobody wants to get wrecked in the gym, but an examination of the literature shows that this occurs exclusively when co-administered with a very high dose statin.

Finally, Repatha, or evolocumab if you like is a PCSK9 inhibitor, and one of the real kings of lipid management, mostly used for those that are statin intolerant because... It's ridiculously expensive. It also has a complementary mechanism of action.

One of the reasons we don't use ApoB is because the payers don't want to shell out for the test, which I can get for $35 at retail. They sure as hell don't want to shell out $1k/month for Repatha if they can avoid it. Your doctor knows this, because he's not working for you, he's working for the payer.

So, yeah, definitely don't take advice from Joe fucking Rogan or any of the carnivore twats. Ultimately, it's best to cultivate an ability to sift the bullshit from what isn't. I would use the word, "truth" but it's not the truth and anyone that purports to know the truth is lying. I can give you data which suggests something to a greater or lesser confidence. For myself, I tend to pay attention to people that flip flop on a topic. That is to say, they'll update their understanding as new data become available.

I like folks like Tom Dayspring or Allan Sniderman on this topic. I follow Peter Attia as well, who introduced me to those folks and the topic of lipidology as well with his epic 20k word 10 part blog post on cholesterol from 2012. I wouldn't take everything that comes out of him as gospel however, as he is known to shill, but is pretty transparent about it.

Speaking of Tom Dayspring, I just checked his twitter:



This is good as well and from 2022 while the ACC was publishing it's bullshit guidelines:



and the paper:

https://www.sciencedirect.com/science/article/pii/S2666667722000551?via%3Dihub

 

[egruberman]

So i tried statins and they caused me to get a blood clot so the docs made me drop it quickly!

Which statin and at what dose?

Pro tip: You can get bempedoic acid from one of the Indian pharmas here. HAB makes it, "Bempetol" or "Bempetol-EZ". The latter comes with ezetimibe.

I mean to lower ur ldl that low, im not sure thats healthy… but i dont know much… so there’s that

The only people that have suggested that LDL that low is unhealthy are the aforementioned nutjobs. There are theoretical concerns, possibly an increased incidence of stroke and some other potential downstream effects, like the production of hormones, vitamin D deficiency, and cognitive effects.

These risks, however are theoretical. I supplement vitamin D and oh, hey, I also supplement testosterone. I've got cognition to spare, and if a stroke takes me out, that's not a bad way to go.

I'm not suggesting that everyone replicate what I'm doing. It's a calculated risk. I do suggest that low/no risk folks get their ApoB under 80mg/dL and people with 1 or more risk factors, get it under 60mg/dL. Use the lipid management interventions that work, keep statin doses low and stick to hydrophilic ones.

 

[Avies48]

Which statin and at what dose?

Pro tip: You can get bempedoic acid from one of the Indian pharmas here. HAB makes it, "Bempetol" or "Bempetol-EZ". The latter comes with ezetimibe.



The only people that have suggested that LDL that low is unhealthy are the aforementioned nutjobs. There are theoretical concerns, possibly an increased incidence of stroke and some other potential downstream effects, like the production of hormones, vitamin D deficiency, and cognitive effects.

These risks, however are theoretical. I supplement vitamin D and oh, hey, I also supplement testosterone. I've got cognition to spare, and if a stroke takes me out, that's not a bad way to go.

I'm not suggesting that everyone replicate what I'm doing. It's a calculated risk. I do suggest that low/no risk folks get their ApoB under 80mg/dL and people with 1 or more risk factors, get it under 60mg/dL. Use the lipid management interventions that work, keep statin doses low and stick to hydrophilic ones.

I tried crestor 5 mlg per day for 2 weeks and then blamo left calf tibial oclusive dvt blood clot

Bempetol-EZ Is this the one that comes with ezetimibe? Or Bempetol, sorry which one was the later?

Id be willing to try zetia again especially if my script for repatha is turned down

 

[jtmarlin]

If your head hurts from trying to figure this shit out it's probably because you have no business trying to figure it out in the first place. Let the doctors do your thinking for you. That's what they're for.
Let me put it this way: My dad had a quintuple bypass 10 years ago and he recently went for imaging to see how his disease had progressed, and the images showed that his disease hadn't progressed at all and that's thanks most certainly to lifestyle changes. Do you think he's been listening to his cardiologist/dietician for lifestyle advice or do you think he's been listening to joe fucking rogan?
Good on you for doing your reading and looking deeper into your own numbers. Now you know you aren't one of the lucky bastards who doesn't have to worry about plaque

I think you missed the part where I asked the cardiologist if I should eat salmon or white fish and she said "we don't really know"

 

[jtmarlin]

From his post it seems his Dr is much more concerned with the BP then the cholesterol just don't see what is being done to address it though.

Keep in mind this was my FIRST appointment with her and I haven't seen her again since the results of the CAC score. It's only been the weekend.

I can tell you what I have started doing already. I've dropped my testosterone dose from 30 to 20mg per day (hoping this helps my BP) and have even considering ditching TRT completely - or going down to 15mg per day. I want to talk to her the cardiologist first. This will cause me to lose 20 pounds over the next couple months which will 100 percent bring down my BP. I had to stop TRT 3 years ago to get my wife pregnant and I went from 195 to 165 at 5'8. I just don't know if I can live with low T forever or if those health risks outweigh this one.

I have a theory here on my situation. About 15 -18 years ago in my late 20s I cycled for 3 years or so with minimal breaks. Never more than a gram total really but I didn't take many breaks. I was natty for the next 10 years then began TRT at 39. I have cycled with primo and nandrolone a bit during that time but mostly as TRT+. I'm wondering if I did a bunch of damage years ago and have been stable since then or this has been progressing. Judging by my lipids probably the latter.

Like I have said before I have had yearly primary care appointments like a robot, I visit my urologist every 6 months (he prescribes the T) and there has never been a mention about my BP being too high or me having a lipids issue that needed serious tackling outside of the bullshit (get more exercise and eat more vegetables - I resistance training 4 days a week and do 20k steps per day). Just feels like everyone has me sleep walking to a MACE in 10 years until I decided on my own to go to the cardiologist after pulling my own own labs multiple times. Seems like such a system failure.

 

[bigMoJo]

It's not. Here's a sample report:​

https://files.labcorp.com/testmenu-d8/sample_reports/123810.pdf

Weird that they do an NMR test but don't offer ApoB and Lp(a). The one I use is the Quest 92145 you linked above. I get hs-CRP occasionally with a different panel.

Here it is if you add ApoB & Lp(a) a la cart:

 

[Mongo966]

It's not. Here's a sample report:

https://files.labcorp.com/testmenu-d8/sample_reports/123810.pdf

Weird that they do an NMR test but don't offer ApoB and Lp(a). The one I use is the Quest 92145 you linked above. I get hs-CRP occasionally with a different panel.



Yeah.... no. Doctors follow the standard of care, hopefully. Few are well-informed on this topic, which baffles me. Even still, most cardiologists follow the guidelines of the American College of Cardiology who, maddeningly updated their guidelines in 2022 and still recommends using LDL-C rather than ApoB like the rest of the civilized world. They also continue to push statin mono-therapy at maximal doses before even considering non-statin ancillaries that have a better safety profile.

Atorvastatin is the "gorilla statin" in the words of Tom Dayspring typically prescribed at 40mg/day and above. It's lipophilic and crosses the blood-brain barrier just fine. At the maximal dose of 80mg/day, 1 in 3 patients will develop type 2 diabetes within 3 years.

They are the reason all the anti-statin bullshit exists. They've been pushing the same fucking protocol for two decades all the while mortalities from ASCVD have been increasing in the past decade.

The poly-pharma approach works perfectly fucking peachy. At low doses, statins are mostly harmless and move the needle a great deal in terms of reducing ApoB. Ezetimibe and bempedoic acid are wonderful add-ons each with their own complementary mechanism of action and reams of data on outcomes as well as side effects.

Hilariously, among the side effects for bempedoic acid is "tendon rupture" which scared the shit out of me because nobody wants to get wrecked in the gym, but an examination of the literature shows that this occurs exclusively when co-administered with a very high dose statin.

Finally, Repatha, or evolocumab if you like is a PCSK9 inhibitor, and one of the real kings of lipid management, mostly used for those that are statin intolerant because... It's ridiculously expensive. It also has a complementary mechanism of action.

One of the reasons we don't use ApoB is because the payers don't want to shell out for the test, which I can get for $35 at retail. They sure as hell don't want to shell out $1k/month for Repatha if they can avoid it. Your doctor knows this, because he's not working for you, he's working for the payer.

So, yeah, definitely don't take advice from Joe fucking Rogan or any of the carnivore twats. Ultimately, it's best to cultivate an ability to sift the bullshit from what isn't. I would use the word, "truth" but it's not the truth and anyone that purports to know the truth is lying. I can give you data which suggests something to a greater or lesser confidence. For myself, I tend to pay attention to people that flip flop on a topic. That is to say, they'll update their understanding as new data become available.

I like folks like Tom Dayspring or Allan Sniderman on this topic. I follow Peter Attia as well, who introduced me to those folks and the topic of lipidology as well with his epic 20k word 10 part blog post on cholesterol from 2012. I wouldn't take everything that comes out of him as gospel however, as he is known to shill, but is pretty transparent about it.

Speaking of Tom Dayspring, I just checked his twitter:

View attachment 300406

This is good as well and from 2022 while the ACC was publishing it's bullshit guidelines:
View attachment 300407


and the paper:

https://www.sciencedirect.com/science/article/pii/S2666667722000551?via%3Dihub

The point of telling my dad's story was basically to say that the medical community has the meta. Prevention isn't their focus but that doesn't mean they don't know anything about it. There's no need for OP to be confused by the internet when he can go see specialists who know what they're doing when it comes to this stuff. They'll tell him what to do and he will be better off.

 

[Mongo966]

I think you missed the part where I asked the cardiologist if I should eat salmon or white fish and she said "we don't really know"

Wtf does this even mean?
I'm telling you to follow what they say because it works and it's been proven to work time and time again. I even told you a story about my dad but you're like "uhhh were you even paying attention? they don't know which kind of fish i should eat."
I am out.

 

[egruberman]

Bempetol-EZ Is this the one that comes with ezetimibe? Or Bempetol, sorry which one was the later?

Bempetol-EZ is the one with ezetimibe. Maybe try one and then the other to tease apart any potential side effects. If you can tolerate both, that’d be optimal.

There was an outcomes trial on bempedoic acid completed in 2023z. The CLEAR outcomes trial. It showed a significant reduction in MACE in statin intolerant patients.

Also, keep plugging away at that Repatha prescription. I’m hoping we might see UGL evolocumab soon. It’s a monoclonal antibody. Who knows whether UGL labs can synthesize if.

 

[Sampei]

@Millard why I have got all the icons in the post a reply greyed out, can't post pictures and if I try to attach a file it doesn't let me attach anything : /

 

[buck]

"Keep an eye on it" is one of the most common prescriptions for hypertension, in my experience, and most of the time, doesn't get addressed until it's much higher.

I am in charge of my health not my Dr. He just gives an opinion. Most people don't want to deal with health issues from my experience and prefer to hide their head in the sand. If a patient doesn't ask about something Dr's often let it go. as their job is to make people feel better. And bad news doesn't make people feel better. In the end i blame people for where there health is. Knowledge is easy to get these days.

 

[egruberman]

Prevention isn't their focus but that doesn't mean they don't know anything about it

This is where we disagree. I have a pretty dim view of cardiologists, at least the ones that I have any experience with. From my perspective, the entire cardiology community seems to be focused on treating MACE rather than treating the disease itself.

In my experience, oncologists tend to stay more up to date with emerging treatments than cardiologists in spite of cancer being the second leading cause of death in the US over ASCVD.