New cardiologist not care about my cholesterol

[Aerides]

My cardio says that cholesterol is a data point, but only one of several, and they don't take that kneejerk of 200+ equals statin. If you are otherwise healthy, active, have a good echocardiogram, stress tests, etc., perhaps even get a calcium score, then cholesterol by itself isn't always a straight line to meds.

 

[tulak]

Yes, she is happy to note them in my record and congratulates me for staying on top of my health.

I share mine- never had a problem. I send them beforehand and most of the time they end up in my electronic records. I'd be concerned about a doc who had a problem with this. You're not seeing another doc, you're not taking prescriptions he/she doesn't know about and you're not getting invasive tests that carry risks of their own and are justified only by potential benefits (e.g., annual colonoscopies, cardiac catheterizations). You're just checking things more often than insurance will pay for and possibly different tests than insurance will cover.

I'm reading "Outlive" by Peter Attia and he talks about Medicine 3.0. Medicine 2.0 is still focused on treating what ails you. Medicine 3.0 is starting very early to monitor things that blow up when you're in your 60s or 70s and wreck the quality of your life in your last decade (whenever that is). In my case, a blood test in an Employee Wellness program showed high fasting glucose when I was 59. I changed my diet up a bit and started watching a1c. It started at 6.0 and is now around 5.4 12 years later. Still not great and I continue to test every 4-5 months. Somewhere in my medical records someone entered the diagnosis "pre-diabetic" back when it was higher.

No one told me. I suppose it was because I wasn't at the level that needed treatment, but where would I be now if I hadn't taken charge of my own testing?

Thank you for sharing.

I'm slowing reading Outlive and have listened to some of Peter Attia's podcasts. He's definitely a more proactive doctor than my PCP.

I had my annual checkup a few weeks ago and asked about getting my calcium score and he didn't see the benefit. His reasoning was that it's not actionable and if it comes back high, it could lead to unnecessary anxiety. And if it came back high, his recommendation would be the same, lower your LDL. My LDL is around 90, as is my HDL, and triglycerides in the low 40s, so my numbers are good.

He's more in the camp that if you do the right things (excercise, etc) and your bloodwork is good, then don't worry about it. I tend to lean towards Attia's Medicine 3.0 approach, where I'd like to know before something becomes major, especially since I'm still young enough to have a measurable impact on my quality of life 30+ years out. But that's hard to do without a PCP to guide you, or at least be supportive in your efforts.

 

[braumeister]

I had my annual checkup a few weeks ago and asked about getting my calcium score and he didn't see the benefit. His reasoning was that it's not actionable and if it comes back high, it could lead to unnecessary anxiety.

Another thing that was pointed out to me by my doc is that while you may think a higher calcium score reflects what you're doing lately, it could just as easily be calcification that occurred a great many years ago and has done no harm. There is no way to tell which it is.

 

[athena53]

I tend to lean towards Attia's Medicine 3.0 approach, where I'd like to know before something becomes major, especially since I'm still young enough to have a measurable impact on my quality of life 30+ years out. But that's hard to do without a PCP to guide you, or at least be supportive in your efforts.

Unfortunately, most docs are driven by what insurance will cover. Why get deep into the weeds of tests that would head off future issues but that most patients can't afford to pay for out-of-pocket? Attia gets colonoscopies every other year, for example. He's decided that's the optimal interval where the benefits of catching growths early outweigh the risks of the procedure. Of course he has to pay out of pocket for most of them. I'm perfectly willing to do extra bloodwork but follow the recommendations of my doc on colonoscopies.

 

[tulak]

Another thing that was pointed out to me by my doc is that while you may think a higher calcium score reflects what you're doing lately, it could just as easily be calcification that occurred a great many years ago and has done no harm. There is no way to tell which it is.

True. I would be curious to know what my baseline number is at though. I think it would be interesting to measure twice, with a delta of 10 or so years, to see how/if it changed.

Overall, this was my doctor's point. You get a higher calcium score, so then what? It's not a useful metric for him.

Unfortunately, most docs are driven by what insurance will cover. Why get deep into the weeds of tests that would head off future issues but that most patients can't afford to pay for out-of-pocket? Attia gets colonoscopies every other year, for example. He's decided that's the optimal interval where the benefits of catching growths early outweigh the risks of the procedure. Of course he has to pay out of pocket for most of them. I'm perfectly willing to do extra bloodwork but follow the recommendations of my doc on colonoscopies.

That is true and something my doctor said. Insurance doesn't cover it, so why get it if he isn't going to recommend any other course of action, except lower LDL which is what he says anyways.

Personally, I think there's a difference if you have an LDL of 90 with a high calcium score vs a low calcium score. If you've always been at ~90 LDL and your calcium score is low, then why worry about lowering that value? But if you've always been ~90 with a high calcium score, then maybe you should focus on lowering LDL?

As for Attia, yearly colonoscopies are a bit of overkill. He's also on the fringe with some of his recommendations (IMO). But I like his overall philosophy, to monitor the easy stuff while your still young and healthy in order to have better long-term outcomes.

 

[jmmec]

My BP has always been high and I've been on medication for 20+ years (lisinopril if that matters) and my BP in the morning is around 115/72 since I've taking medication. This is probably a good thing.

My cholesterol was always below threshold and recently went over and my doctor asked me if I would be interested in trying a statin. It was my choice as he said I'm not chronic but I am "qualified" to take it. I started on Atorvastatin/Lipitor and the results were positive and my numbers are now well inside the "good" range.

More recently my glucose numbers have been edging higher and likewise A1C is in the "prediabetes" range. He asked me if I wanted to try medication and prescribed Metformin and we shall see how that works.

Question: Now that I am firmly ensconced in the big pharma ecosystem is there much downside to ingesting meds and reaping the benefits of these bloodwork and blood pressure metrics being vastly improved vs not taking the meds and living with metrics that tend to indicate higher risk factors?

I've always felt that this is a game of statistics and the meds just tend to tilt the statistics to more favorable outcomes. Let's just say side effects in terms of comfort and quality of life are nil so the only risk is some long term damage to my body, I would guess.

I would urge caution as it is possible that your recent onset of increased A1C may be due to the statin. You may find yourself to eventually become T2D.

Consider:

Meta-analyses of clinical statin trials to lower cardiovascular events reported an increase in the risk of diabetes by 9-12% (24, 25, 27) whereas in large population studies the risk was substantially higher. In a meta-analysis of 15 observational studies the risk of incident T2D was 55% (44). In four individual studies the risk of incident T2D was from 36-48% (38, 40, 42, 43), and in the US Veterans study (39) 21-22% for low and median potency statins (pravastatin, fluvastatin), and 34% for high potency statins (simvastatin, atorvastatin, rosuvastatin). Clinical statin treatment trials have significantly underestimated the effects of statins on the risk of T2D. Additionally, the diagnosis of T2D has not performed according to internationally accepted criteria leading to underestimation of incident T2D. In the clinical trials the risk of T2D has been quite similar between different statins but in the population studies statin potency has been a significant factor increasing the risk of T2D.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10546337/

 

[athena53]

As for Attia, yearly colonoscopies are a bit of overkill. He's also on the fringe with some of his recommendations (IMO). But I like his overall philosophy, to monitor the easy stuff while your still young and healthy in order to have better long-term outcomes.

They're "only" every other year but I agree. He also takes rapamycin and Prevastatin for preventative purposes and he and his wife get annual whole-body scans. Not for everyone. He's a bit of a human experiment and it's too bad I'll be unlikely to know his results over the long run since I'm about 20 years older.

 

[MarieIG]

This was a discussion with Dr. Robert Lustig regarding interpretation of a cholesterol panel (with a bit of background about the different types of cholesterol and interaction with the liver).

 

[braumeister]

As for Attia, yearly colonoscopies are a bit of overkill. He's also on the fringe with some of his recommendations (IMO).

There is "on the fringe" and then there is ON THE FRINGE.

A 45-year-old biotech CEO may have reduced his biological age by at least 5 years through a rigorous medical program that can cost up to $2 million a year

 

[MarieIG]

There is "on the fringe" and then there is ON THE FRINGE.

A 45-year-old biotech CEO may have reduced his biological age by at least 5 years through a rigorous medical program that can cost up to $2 million a year

Yes, I have seen him before.

 

[razztazz]

They're "only" every other year but I agree. He also takes rapamycin and Prevastatin for preventative purposes and he and his wife get annual whole-body scans.

There is "on the fringe" and then there is ON THE FRINGE.

A 45-year-old biotech CEO may have reduced his biological age by at least 5 years through a rigorous medical program that can cost up to $2 million a year

I'm surprised they don't mention their therapists. Millions for physical health but not a penny for obsessive-compulsive disorder or Illness Anxiety Disorder?

 

[tulak]

On the plus side, all of these wacky experiments might yield results that we benefit from. Problem is that time is not on our side.

 

[steady saver]

My cholesterol levels were always high, up to the high 200's. For years my long-term MD said no worries, my ratios were good. But then when I got into my late 50's she said "OK we need to start dealing with this, let's start you on statins." I said "If you insist on statins, I get a new doctor." Then I sent her 3-4 studies and meta-analyses that showed statins didn't improve all-cause mortality at ALL. So she backed off.

(Studies also showed that the "get it below 200" mantra is flat wrong. For men the optimum all-cause survival is at about 250, and for women it's much higher. So they shouldn't even TRY to lower your chol unless you're around 300 or more.)

The next year she said "I know you don't want statins. Well I've found a natural supplement that lowers cholesterol. I want you to take it." I looked at the label and said "This is Red Yeast Rice. That's where statins COME from. Ain't takin' it."

The next year she said "OK, I'm really worried about your atherosclerosis. I'm bringing in a guy to do sonograms of your carotids. I want to find out how badly you're blocked." Great, I said, let's do it.

The results came back and said I had the arteries of a man half my age. ZERO occlusion. She never nagged me about cholesterol again.

I love this!

 

[Time2]

It can be frustrating to understand why cholesterol was vilified. But now, that idea is stuck in the minds of the public and most doctors and will probably never let it go.

Nina Teicholz's book The Big Fat Surprise (with full bibliography) can help fill in the back story. Long story short; it partially involves people trying to further their careers in the 1950's using bad/no science, as well as a powerful religious sect that spends lots of money pushing vegetarianism.

I read your first paragraph and I thought, "I should post info about Nina Teicholz! Then you mentioned her book. I have watched several of her videos on Youtube.

 

[Golden Mean]

I read your first paragraph and I thought, "I should post info about Nina Teicholz! Then you mentioned her book. I have watched several of her videos on Youtube.

?

Yeah, I'm a fan or her and a bunch of people on the Low Carb Down Under Youtube channel.

 

[bjorn2bwild]

I would like to highlight two recent posts by Dr Anthony Pearson, 'The Skeptical Cardiologist', that I think are relevant to this discussion.
I will separate the two for clarity.

The first one takes on Peter Attia's 'Medicine 3.0' position on aggressive treatment of blood lipids for prevention of ASCVD.
A couple bullet points -

Attia’s Super-Aggressive Recommendations Lack Scientific SupportAt this point, I would say that Attia moves from what has been definitely proven in this area and into a speculative zone.
To support his Medicine 3.0 thesis that we should be lowering the elevated apoB of a 45 year old man “as much as possible” he cites a 2019 article written by Peter Libby, an esteemed leader in the fields of vascular biology, atherosclerosis and preventive cardiology:

It must be pointed out that these are speculations. They are unproven. And I am unaware of any cardiologists who practice this approach. Despite Peter Libby’s musings on the value of low LDL-C levels, at no point does he suggest that we should be using multiple cholesterol-lowering drugs to achieve neonatal levels of LDL.

I have for some time been shooting for LDL-C and apoB levels/non HDL levels <60 in my patients with documented ASCVD (either by CAC, CCTA or ASCVD events)
I keep my own apoB and LDL-C levels in the 40s.
But an LDL-C goal of 10-20 mg/dl is really, really (almost unrealistically) low. To achieve levels <20 most individuals would require multiple cholesterol-lowering medications each with a potential for side effects and a significant cost.

I suggest reading the entire post for better context.
https://theskepticalcardiologist.co...0-and-primordial-prevention-of-heart-attacks/

 

[bjorn2bwild]

This one addresses the CAC (Coronary Artery Calcium) Scan.
Again, a couple of quotes -

I am aware that controversy (at least on the social medium formerly known as Twitter) is raging over the utility of the coronary artery calcium scan in preventive cardiology. Although I agree with the analyses of my esteemed former colleague John Mandrola on the vast majority of topics he reviews, I beg to differ when he criticizes CAC scoring.
To the majority of preventive cardiologists “in the trenches” like me who have decades of experience using the CAC to fine tune their patient’s risk of heart attack, stroke, and cardiovascular death, the value is obvious.

The arguments frequently presented by the anti-CAC side of the this topic—typically from doctors who consider themselves medical conservatives—involve pointing at perceived downsides of CAC testing plus the absence of RCT level data that shows cardiac outcomes are improved.
I consider myself a staunch medical conservative and I’ve written extensively on the lack of value of various interventional procedures and misguided screening tests.
But CAC differs substantially from these low value interventions and tests in a number of critical areas.
First, CAC performs wonderfully as a screening test because a) it directly measures the process we are concerned about b) it does this with very high accuracy and reproducibility. False positives occur but they are so rare as to warrant a case report publication c) it is highly predictive.

And the full text for proper context -
https://theskepticalcardiologist.co...-prevention-of-atherosclerotic-heart-disease/

 

[audreyh1]

They're "only" every other year but I agree. He also takes rapamycin and Prevastatin for preventative purposes and he and his wife get annual whole-body scans. Not for everyone. He's a bit of a human experiment and it's too bad I'll be unlikely to know his results over the long run since I'm about 20 years older.

I just can’t handle Attia. He is super aggressive about taking drugs and has as his major goal to live an extremely long life by today’s standards. I can’t identify with his attitude/goals plus I find him to be very obsessive and into extreme minutiae and that makes me mistrust him overall.

 

[braumeister]

I just can’t handle Attia. He is super aggressive about taking drugs and has as his major goal to live an extremely long life by today’s standards. I can’t identify with his attitude/goals plus I find him to be very obsessive and into extreme minutiae and that makes me mistrust him overall.

He certainly gets deep into the weeds at times, but his podcast guests do provide a lot of useful information. I subscribed for a few years and enjoyed reading many of the transcripts in full.

But I was also kind of turned off by his IMO excessive self-medication and insistence on controlling certain blood markers, so I dropped my subscription. Don't feel as if I lost anything, but I stay on the mailing list so I at least have an idea about what he's interested in lately.

 

[athena53]

He certainly gets deep into the weeds at times, but his podcast guests do provide a lot of useful information. I subscribed for a few years and enjoyed reading many of the transcripts in full.

But I was also kind of turned off by his IMO excessive self-medication and insistence on controlling certain blood markers, so I dropped my subscription. Don't feel as if I lost anything, but I stay on the mailing list so I at least have an idea about what he's interested in lately.

I'm more interested in his observations on exercise, maintaining muscle mass, the importance of diet, and the "Senior Decathlon"- the things you still want to be able to do in your last decade of life (get up off the floor unaided, carry 30 lbs. X feet, for example) so you can remain independent and keep up with grandchildren and great-grandchildren. Your last decade is a theoretical concept, of course- you don't know when it will be.

I'm also profoundly affected by his observations on cancer treatments- the ones that prolong life by 6 months on average, cost tens (or hundreds) of thousands of dollars, and result in your last 6 months being occupied by hospital visits and various types of extreme discomfort.

 

[audreyh1]

He certainly gets deep into the weeds at times, but his podcast guests do provide a lot of useful information. I subscribed for a few years and enjoyed reading many of the transcripts in full.

But I was also kind of turned off by his IMO excessive self-medication and insistence on controlling certain blood markers, so I dropped my subscription. Don't feel as if I lost anything, but I stay on the mailing list so I at least have an idea about what he's interested in lately.

I have listened to several of his podcasts over the years and discovered several medical people worth following like Dr. Richard Johnson. He interviews well.

Other health bloggers also interview these folks and these folks are generally on Twitter for tracking directly anyway. But I’m not listening to health podcasts much these days as I already did so much. I know where to go when I want to catch up.

 

[braumeister]

My cholesterol was always below threshold and recently went over and my doctor asked me if I would be interested in trying a statin. It was my choice as he said I'm not chronic but I am "qualified" to take it. I started on Atorvastatin/Lipitor and the results were positive and my numbers are now well inside the "good" range.

Just a data point here. Atorvastatin (Lipitor) has truly been a blockbuster drug, having earned over $160 billion since it was introduced in 1997 (despite being off patent since 2011). Nothing wrong with that, of course, but it helps explain all the advertising.

It's also interesting to note this in the patient information sheet that comes with it:

If you are older than 70 years [along with a number of other conditions] ..., your doctor will need to carry out a blood test before and possibly during your Lipitor treatment to predict your risk of muscle related side effects.

 

[wildbilly]

I'm similar. Cholesterol has been 200-240 most of my life. One time it was 180 when I ate a LOT of garlic regularly. It went back up even though I was still eating garlic. In 2018 I paid $100 for a high powered CT calcium scan. They said I had some calcium build up starting in my aorta. A couple years later I had a weird almost pass out like situation. The neurologist ordered a angiogram. The only thing they found was one of the main arteries going up the back of my neck was completely occluded. Not a problem as the other smaller arteries pick up the slack. The next year 10 people I know ages 55-65, all in good (some very great) shape, all had heart attacks. So I decided to finally go on a Statin. Started off with 10mg Rosuvastatin and it went down to 180 right away. Then just like the garlic it years ago, it went back up. So they increased the dose to 20mg and it's been fairly steady around 180. My cardiologist would ideally like to see it lower due to the calcium in my aorta. However, I have been in the pre-diabetic range for the last 20 years and statins can increase your insulin resistance/blood sugar. So that's where I am at today at a quite healthy (exercise and eating) 59 FIRE YO.

I never wanted to go on a statin. Mainly due to the muscle pain/deterioration possibility. My sister who is two years older has been on a statin for a good 10+ years.

 

[KarenF]

…
I should have asked him about the local research study trying to get people to get their LP(a) checked but I didn't. I don't really want to know mine as there is nothing I can do about it. Figured mine would suck and I'd just worry. Not worth at $45 gift card.

FYI You can do something about Lp(a) these days. A combination of statins and PCSK9 inhibitors to keep your APOB below 60 is the new approach. Peter Attia has a lot of info on this. Everyone should know their Lp(a) level. You only need to get it tested once.

 

[imnontrad]

My cholesterol has been high for years - and this could be an indicator of pre-diabetes.
But no, I am not on any drugs for this. I have done a heart scan that had an excellent result and my HDL is slowly rising so my doc is not worried.
I have read that research has shown that the cholesterol in our body does NOT come from food - our body manufactures it. It is the main "food" for brain cells.