Cardiovascular disease & why we should change the way we assess risk | The Peter Attia Drive Podcast

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

[villamartignoni]

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.

[AZ]

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!!!

[BrandonSchmit]

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.

[tracyfoust]

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

[jlundberg]

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.

[rliao]

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

[gantte]

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.

[wanmay]

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!

[filmovia]

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.

[carolinefenton]

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.

[tg]

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.

[thiagobartolo]

This conversation should have millions of views. Thankfully this brilliant men are advocating for awareness on intelligent preventive medicine.

[cheddarpuff]

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.

[allfusionx]

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

[GerardCantor]

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.

[lindaw]

Best guest ever best medical researcher w superior thinking and humility

[brucepugh]

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.

[TheTonynoble]

:) 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.

[lucycooper]

He’s 80 ??? Wow. Glad he agreed to do the podcast with you ! Thanks for the video Dr. Attia