MedEvidence! Truth Behind the Data

Cholesterol & the Cardiologist: A Real Patient's Numbers & What They Mean

• Dr. Michael Koren • Episode 355

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Cardiologist Dr. Michael Koren is joined by a 35-year-old patient "Tucker" to walk through his cardiovascular numbers and explain what it all means. The doctor explores a lipid profile and an advanced lipid profile from top to bottom, explaining everything from how LDL is calculated to what hs-CRP measures. Along the way, they discuss how diet, exercise, supplements, and medications can affect these numbers, how the numbers relate to your risk of a cardiovascular event (like a heart attack or stroke) and what, if any, interventions should be taken. This real-world-example shows how complex the world of cardiology and lipids is and gives helpful, actionable information based on the numbers you might see. 

This podcast is not medical advice, and all personal situations should be discussed with your physician.

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Have a question for Dr. Koren? Email him at askDrKoren@MedEvidence.com

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Music: Storyblocks - Corporate Inspired

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Announcement:

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts, hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Michael Koren, MD:

Hello, I'm Dr. Michael Koren, the executive editor of MedEvidence! And we're going to do something a little bit different today. And this came out of a meeting, actually a business meeting, with my friend and colleague here, Tucker, who just started running his cholesterol results by me. It was funny. It has nothing to do with medicine, but he knew that I was a cardiologist and he knew that I'm very active in the lipid field. And he started asking me questions about his personal circumstances. And it got me thinking, you know, an intelligent guy like Tucker, who's truly interested in his health and doing the best for himself and his family, had these questions, and it brought up some misconceptions that people have, and also the fact that there's a lot of information out there that sometimes is tricky to discern. So, Tucker, welcome to MedEvidence and tell everybody a little bit about yourself and why you got a series of cholesterol and other tests that may be of interest to everybody.

Tucker:

Yeah, absolutely. And thanks for having me here, Dr. Koren, and and uh happy just to have this conversation and and really educate myself and others that are in the same shoes as I that you know really care about their health but want to go next the next step or go a little further in in their journey and and making sure that they're doing the best they can for not just themselves but their family. Um, you know, I have a unique family story. I lost my father uh to a stroke heart attack, and and uh, you know, it it really put in perspective-

Michael Koren, MD:

How old was he when when he passed?

Tucker:

He was 56, I want to say. The stroke happened, and then, you know, progressively got worse over time. Um so you know, it was in 2008 that he had had a stroke, and um it really just opened up my eyes for my health journey and and now being a father of three kids, three boys, and and uh you know, wanting to be a grandfather one day and and and see them live out their lives as well.

Michael Koren, MD:

How old are your kids now?

Tucker:

So I have a six-year-old, a four-year-old, and a one-year-old.

Michael Koren, MD:

It's a busy household, my friends.

Tucker:

It is, it is indeed. It is. Hearts are full and hands are full for sure.

Michael Koren, MD:

Absolutely. So you mentioned about your dad. Any other members of your family die of a heart attack or stroke, say before the age of 60?

Tucker:

No.

Michael Koren, MD:

Okay.

Tucker:

No. My my mother's mom had passed away from cancer, but not of any heart issues.

Michael Koren, MD:

And are you having any specific symptoms that make you worry about a heart attack or a stroke?

Tucker:

No, honestly, no, nothing in particular. Just wanting to be more educated.

Michael Koren, MD:

Great. And I'm just gonna ask you some basic questions that a cardiologist would ask a patient. Uh, if any of these are not understandable or or you ask me why I'm asking them, that's fine. Please ask me. But uh we usually ask people about a series of cardiovascular risk factors because we're trying to get a sense for what your actual risk is and whether or not your history is more or less likely to reproduce your father's history in terms of having a major cardiovascular event at a relatively young age. So with that in mind, uh the things we'd ask is one, do you smoke?

Tucker:

No.

Michael Koren, MD:

Never smoked. No smoke.

Tucker:

Uh I I've smoked a cigarette before, but not consistently smoked, right?

Michael Koren, MD:

Yeah, gotcha. Yeah, the uh it's funny. The definition of somebody that may have smoked is a hundred cigarettes in your life. Although, quite frankly, uh most people in college will get to that number, just go going to bars on the weekends. Right, exactly. But uh but you never smoked habitually on a regular basis.

Tucker:

No.

Michael Koren, MD:

Uh any history of diabetes?

Tucker:

No.

Michael Koren, MD:

Okay. Um do you have high blood pressure or are you being treated for high blood pressure?

Tucker:

I have high blood pressure. I'm not being treated for it. Um, it's not to the point where I feel it you know needed to be treated for. Um, but yes, I'd say I have the white coat syndrome, you know. Every time I get it tested, there is-

Michael Koren, MD:

Give us a range for what that blood pressure is when it's at its high and when it's at its low.

Tucker:

I have no idea. To be completely honest with you, because it's, you know, they'll come back and take it and they'll be like, you're fine.

Michael Koren, MD:

So has anybody told you your your top number, your systolic blood pressure is more than 160?

Tucker:

No.

Michael Koren, MD:

Okay. Has anybody told you that your bottom number, your diastolic blood pressure, is more than 90?

Tucker:

No.

Michael Koren, MD:

Okay. Um, have you been told that your blood pressure actually did, in fact, normalize when you're outside of the doctor setting? Yes. Okay. So so what you know about your blood pressure is that when you're stressed, it may go up a little bit, but other times it's normal, which by the way is a normal thing.

Tucker:

Right.

Michael Koren, MD:

Blood pressure naturally goes up when you're exercising, etc. So getting back to the cardiovascular risk factors, uh, I understand you do exercise regularly. You look very fit.

Tucker:

I Try, yes.

Michael Koren, MD:

Tell us, tell us about your exercise routine.

Tucker:

Yeah, so I typically four to five times a week, more on the five times. Um, and it's a mixture of, you know, weightlifting to higher heart rate cardio hit stuff. Um so you know, a good combination of weight lifting and high heart rate.

Michael Koren, MD:

Nice. And never get any kind of cardiovascular symptoms like chest pain or tightness or breathing issues while you're doing your exercise.

Tucker:

No, no.

Michael Koren, MD:

Fabulous. Now there's some cardiovascular risk factors that are obvious. Uh being a male puts you at higher risk than a female. You're a male. And your age, you want to state your age for everybody? 35. Okay, so you're you're a young man, so that actually puts you in a lower risk group. And by the way, age of all the standard cardiovascular risk factors is the one most predictive of who's gonna have trouble. So even if everything is perfect at age 80 in terms of your cholesterol and your blood pressure and your sugar status, your risk is still higher than somebody at 35 that has a lot of problems with these numbers. So I always like to bring that into perspective that age is the most predictive thing that we have, which is actually sobering for doctors, is that um quite frankly, if you know somebody's age, you're gonna know more about their prognosis over the next 10 years than anything else. But that's a little bit different than what you're here for. You're here to maximize the likelihood of a good outcome for yourself over the next 10 years. And then when you're 45, you're gonna come back and say, I want to maximize that likelihood for the next 10 years, et cetera. So while age is the most potent cardiovascular risk factor, there's a relative concept here, is that you want to reduce your relative risk at your age. Is that a fair statement?

Tucker:

That is very accurate. Okay. Yes.

Michael Koren, MD:

All right. So now we're we're gonna jump into a little bit more. Um, you know, you mentioned that you did go online because of your concerns about your family history, and that you got some extensive lab testing. So just tell us a little bit about that story.

Tucker:

Yeah, it's always something that, you know, like you had said, given family history that I've I've wanted to do, and and uh, you know, this was very user-friendly. Um, the platform that I used to gather all this data and um, you know, went to my wife and she wanted to do it as well. And uh, you know, the numbers were that-

Michael Koren, MD:

and we'll go through some of the numbers, right? But you got a you got a lot of data. Did you feel like you understood everything or did it uh tell me a little bit about that?

Tucker:

No, I and and that's you know one of the conversations or the what what led me to you uh in in our business meeting and and saying, Dr. Koren, can you can you please look at this and break this down for me? Because you know, I have it, I don't know what to do with it.

Michael Koren, MD:

Got it.

Tucker:

And that's why that's why we're here today.

Michael Koren, MD:

Sounds great. Okay. Well, if it's okay with you, we're gonna just kind of jump right into stuff.

Tucker:

Absolutely.

Michael Koren, MD:

And you and I can look at the numbers and people in the audience, either the viewers or listeners, can get this information. You give us permission to show this online.

Tucker:

Yes, sir.

Michael Koren, MD:

You okay with that?

Tucker:

Oh, yeah. That's why we're here.

Michael Koren, MD:

Okay. Well, we'll cross out your name so they can't see that other than other than Tucker. But just this is the old HIPAA thing. We want to make sure that your privacy is protected. Obviously, coming on this program shows that you you're okay being out there a little bit, but we still want to protect your privacy as much as much as possible.

Tucker:

My goal is to help others.

Michael Koren, MD:

Terrific. So starting with your cholesterol profile, we call this lipid profile quote standard, which literally millions and millions and millions of people get every year. And I I have family members and friends, et cetera, that are constantly calling me and you know, what does this all mean? And typically in this lipid panel, you see total cholesterol, HDL cholesterol, triglycerides, and LDL cholesterol. And then below that you have the ratio, which is the proportion of things, uh cholesterol to the HDL, and the non-HDL cholesterol um total number. So does that make sense to you? When you look at this, do you have a do you have an intrinsic a sense of I know what's going on or not so much?

Tucker:

I know I have some things out of range and and you know, some things I need to work on, but aside from that, my my knowledge is very, very small low about this. Yeah.

Michael Koren, MD:

So just let's just start with uh a basic concept, which is the difference between total cholesterol and LDL. Cholesterol is a lipid, it's a fat molecule. Cholesterol is actually a really, really important molecule in our bodies. Every cell in our body needs cholesterol to function. And because cholesterol is so important to cellular function, every cell in our body makes cholesterol from basic materials. So our cells make cholesterol. This is the thing that most people don't understand, which is that because the cells are making cholesterol and pushing it out when there's extra, by and large, what we measure in the bloodstream is the extra stuff our body's trying to get rid of. So there's a big misconception, even among some physicians, that somehow we need dietary sources of cholesterol to function and have normal lives. Well, cholesterol is actually a product of animal cells. So if you're a vegetarian, you're not gonna eat a lot of cholesterol in your diet. But that's okay because your body makes it.

Tucker:

Right.

Michael Koren, MD:

But vegetarians can still have a high level of cholesterol in their circulation because of genetic factors. So again, think about cholesterol as something that all your cells need, all your cells can make, and the stuff that you're measuring in the bloodstream is the extra stuff. But as I mentioned, cholesterol is also a fat, and your blood is mostly aqueous or water-based. Do fats and waters mix? You ever put uh fats in a cup of water?

Tucker:

It's like oil and water.

Michael Koren, MD:

Exactly. They don't mix. Right. So, how do you get this to move in your circulation and eventually get out of your bloodstream? Well, the way you do that is by forming lipoproteins. Your body forms lipoproteins, and we'll show a picture of that. But lipoproteins are these much larger molecules, typically shown as spherical molecules, that have a combination of fat and protein, which can be soluble in the blood and then eventually get delivered to different places, most commonly the liver, to get rid of them.

Tucker:

Interesting.

Michael Koren, MD:

So HDL and LDL are two quote lipoproteins, high density lipoprotein and low density lipoprotein.

Tucker:

Understood.

Michael Koren, MD:

High density lipoprotein is epidemiologically linked with better outcomes, meaning that if you have higher levels of HDL, you're less likely to have cardiovascular disease. LDL is the opposite. If you have high levels of LDL, you're more likely to have bad cardiovascular outcomes. Now, because of this epidemiological association, we talk about HDL as the good cholesterol, quote unquote, even though it's more than just cholesterol. And we talk about LDL as the bad cholesterol, even though it's more than just bad cholesterol. And more recently, there's another particle that's become something we talk a lot about, which is called lipoprotein(a), which we like to say here, at MedEvidence, is the really, really, really, really bad cholesterol four really bads. And the reason for that, and we'll show it structurally, is it has an extra little uh component to it called an apolipoprotein that makes that particular particle more difficult to get rid of, to get out of your bloodstream. And because of that, there's a much stronger epidemiological link between high LPA and bad cardiovascular outcomes. And I mentioned this because you may have a little bit of an LPA problem here. Right.

Tucker:

We'll get to that. And that's something I can control or not control?

Michael Koren, MD:

Well, we'll get to that.

Tucker:

Okay.

Michael Koren, MD:

We'll getting into that. But I just want to give everybody the basics because even simple things like this, I find most people don't really understand exactly what they are.

Tucker:

Right.

Michael Koren, MD:

But that does it all make sense so far.

Tucker:

It does. Yeah. No, it helps a lot.

Michael Koren, MD:

And then uh finally, you have another type of blood fat called triglycerides, which is really about energy. Triglycerides are one of the energy stores for your body, and it's actually needed for energy. But it's different than cholesterol, which is also structural. So cholesterol is the foundation of hormones, cholesterol is the foundation of cellular walls of the cells. But uh triglycerides is really an energy store.

Tucker:

Okay.

Michael Koren, MD:

Okay. So we have all those things here, and I'm gonna you'll be able to see it from the audience that Tucker's total cholesterol is 261, which is a little bit high. And it's listed as the reference range is less than 200 milligrams per deciliter. But again, we're gonna talk about the fact that if that cholesterol is in HDL, it's not as bad as if it's in LDL. And moving down, your HDL is 67, which is actually pretty good. Um they're saying the reference range is above 40. Above 60 is even better. So that's a that's a positive. You have a high HDL, probably in part due to the fact that um you you're physically active. Physical activity in exercise, particularly intense exercise, will raise your HDL. Another thing that can raise HDL, I didn't ask you about this yet, is alcohol use. What's your typical alcohol use?

Tucker:

Yeah, I would say weekly, I guess you could base it off of, you know, probably four cocktails a week.

Michael Koren, MD:

Okay.

Tucker:

Or four alcoholic beverages.

Michael Koren, MD:

You don't drink every night.

Tucker:

No.

Michael Koren, MD:

Okay. So you go out for dinner on the weekend and a glass of wine, okay. So four alcoholic beverages um per week. So that's not a big driver, but um, that's certainly not something that I would consider unhealthy from a heart standpoint. There's some debate about whether or not um alcohol use at moderate to low levels may have some negative effects on your GI tract and GI systems, but from a cardiovascular standpoint, I'm perfectly okay with that.

Tucker:

Yeah. And and you know, there was a time that it was a lot higher than that. I'll preface the audience with that, you know, and and since doing you know these panels and really dialing in, you know, where I want to be, it, you know, I've been cognizant of intake.

Michael Koren, MD:

Yeah, and the other thing, by the way, is when you drink a lot of alcohol, your triglycerides may go up. That's one of the things that can drive higher triglyceride levels. And yours turn out to be very normal, 73. Uh, they say that for the reference range that it should be less than 150, but in fact, I love seeing them less than 100. So you get you get a fist pump for that.

Tucker:

Love it.

Michael Koren, MD:

So your triglycerides, you're you're kicking butt onto the triglycerides.

Tucker:

Good.

Michael Koren, MD:

But this is a little concerning. Your LDL is 177. Right. Okay. And they don't even give a reference range from that. And they also put something interesting in it that says calculated, which I like to make sure people understand, is that LDL for most of the assays that are done is not directly measured, but is actually calculated based on your total cholesterol, HDL, and triglycerides. And for somebody like you that has numbers kind of in mid-range, that's not a big problem. It's usually pretty accurate calculation. But if you have particularly high triglycerides or a low LDL that you're trying to get really low, for example, patients of mine that have very bad cardiovascular disease, that calculated measurement may not be as accurate as a direct measurement.

Tucker:

And you can get a direct measurement.

Michael Koren, MD:

You can get a direct measurement. It's a little more expensive, and doctors have to ask for it specifically, but it is obtainable. I'm not going to go into all the different ways of calculating LDL, but I assume this is the what we call the Friedelwald equation, which is the most commonly used way of calculating your LDL.

Tucker:

You're exactly right. It says, yep.

Michael Koren, MD:

And that would typically be the total cholesterol minus the HDL minus the triglycerides divided by five. So you can check to see if their math is correct now that I gave you the formulas.

Tucker:

Thank you. I will.

Michael Koren, MD:

All right. And then moving down, you have your cholesterol to HDL ratio at 3.9. They say less than five is is what you want to see. And that's in part because you have a nice HDL cholesterol. And then your non-HDL cholesterol, which is all the stuff other than HDL, is 194, which again is high. So just looking at this, we would say that this lipid profile is not exactly where we would want it. And the first question that comes up is what's going on with your diet? Um, are you eating a lot of meat? Are you eating a lot of uh saturated fats? As I mentioned, your body can make cholesterol, but your dietary sources of fats and cholesterol also drive this. And remember, it's not just cholesterol when you're consuming, but fats. In fact, saturated fats are more likely to drive higher cholesterol than ingesting cholesterol itself.

Tucker:

Right.

Michael Koren, MD:

So tell us a little bit about that part of your life.

Tucker:

Yeah, you know, I I do eat a lot of red meat and and you know, meat in general, I guess you could say, as far as you know, chicken, and you know, I try to stay away from pork. Um my fish intake is is lower than what it probably should be, uh, in my opinion. Um so you know, primarily every meal it's either chicken or steak. Um now that you know I've gotten these results, I've kind of gone more to chicken, but yes, this and then dairy too, right? You know, and and cheeses and you know eggs and and different things like that. But um pretty bland for the most part. I do have some some rice mixed in or some grains mixed in, but um that is something I try to be cognizant of and then work in some fasting as well just to to you know help cellular repair.

Michael Koren, MD:

Would you say that you eat meat during every meal during your day?

Tucker:

I wouldn't say every, I would say you know, one to two times a day. Okay. So leave out breakfast and just you know have the dairy as far as you know, or or you know, eggs and and then probably lunch and dinner. Yeah, that's a fair assessment.

Michael Koren, MD:

Yeah. So obviously bringing that meat consumption and dairy consumption and egg yolk consumption, obviously the whites of the egg don't have cholesterol in it, but the yolk does, that would help drive down your LDL. But the truth is, is that as I mentioned, because so much of cholesterol may come from your body itself, it's very variable how much reduction in LDL cholesterol you get when you change your diet. And I've had people that have changed to vegetarian diets or even vegan diets, and they have a dramatic lowering, but other people that do it and they are very disappointed that they don't have more of a lowering. And that tells me that their bodies are intrinsically making cholesterol that's being put into the circulation. But the truth is it's very hard to know that without having a patient try it. So often we'll take somebody like you and say, okay, well, you're a young guy, you're not having any symptoms, you have a cholesterol profile that's a mixed bag, good HDL, but not great LDL. And maybe you should go on a much stricter diet where maybe you eat red meat once a week. Maybe you eat fish uh five or seven times a week, which I tend to do. Um my main protein in my diet would be fish. Okay. Uh and try to cut back on the cheese and maybe instead of doing regular omelets, do egg white omelets and put these things into your diet and then recheck in a few months and see if you put a dent in that.

Tucker:

I was gonna say, how long is it typically that you would have to do that trial, so to speak, to see results?

Michael Koren, MD:

Typically you want to see about two or three months. Okay. Um that's usually what what you want to see for triglycerides, by the way. If you have high triglycerides and you change your diet, that'll change very quickly.

Tucker:

Okay.

Michael Koren, MD:

But the LDL may take a little bit longer before you're gonna have an impact on it. And again, nutritional elements of this are a whole podcast in of itself, because there's a lot, a lot of nuance in in all these things. But as I mentioned, saturated fats and the ingestion, ingestion of cholesterol will drive this, uh, will drive your LDL levels up. But saturated fat's even more than cholesterol. And the reason I bring that piece up is that shellfish often becomes a discussion. Shellfish is high in cholesterol, but very low in saturated fat. So that's not a bad place to go if you need to replace certain things.

Tucker:

So shrimp aren't bad.

Michael Koren, MD:

They're not as bad as um really fatty meats or eating the skin of chicken, even. But um uh I personally will eat shellfish, and I consider that part of my diet that pulls out from the meats and the fats and is using a lower fat, but something that's not super low in cholesterol. Good to know. Okay, so hopefully that makes sense. So getting back to um uh these types of interventions, the other thing is that there are certain foods like oatmeal, for example, that make it more difficult for your gut to absorb cholesterol. And if that's not in your diet, you may want to think about things like that. So grains and other things that uh we often eat in the mornings, but not necessarily, are important. And also bananas, um, other things that have roughage, et cetera, are good things for us to consider in terms of diet. And again, this is not an extensive podcast on that. Right. And but there's lists online where you can see how all these different foods can actually affect cholesterol absorption and and their glycemic index, which is a whole other conversation.

Tucker:

Is there a way it, you know, let's say you do go through with a meal plan for three to six months. Do you notice any difference in your body as far as if your cholesterol levels change, as far as energy or anything like that, or is that strictly felt off of or captured off of a blood test only?

Michael Koren, MD:

Well, it's interesting. Uh it it is different for different people, but there's no doubt that the type of food you eat does affect your mood. It affects uh neurohormones that affect your brain, it affects your appetite. So there's a lot of factors that go in, and everybody's not exactly the same. So, in general, um, when you eat high protein things, people feel a little bit brighter. Um, when you eat some things that are high in sugar, sometimes that raises certain hormonal levels that make you feel sluggish. Although other people have an immediate rush when they have sugar. So, again, these are competing hormonal levels. I'll tell you for myself, if I have something that's very, very sweet, I want to take a nap in 15 minutes. Whereas other people kind of get that sugar rush from but these are how different hormones are balanced in your bloodstream and how they affect you. So there's no doubt that foods affect your mood and affect your function, but it's it's very individual. And uh we'll definitely look at that for a future podcast about some of these details. But do you have any observations for yourself when you eat high protein versus low protein?

Tucker:

No, honestly not. Um I mean, I do it's more the fasting versus not fasting for me, really. You know, I notice energy levels and whatnot when I haven't eaten and I've done a moderate to severe workout versus when I've eaten before and done a

Michael Koren, MD:

you feel more energetic with fasting or less energetic with fasting?

Tucker:

I would say less. Okay. Um just you know, given the type of workout dependent upon what I'm doing. Sure. You know, if I'm going on a run, then you know, fasting, I seem to feel a little bit better than you know, if I'm going to lift weight.

Michael Koren, MD:

Yeah, it's interesting. Uh again, in my vast experience with people like yourself and asking these questions, I'm not sure there's anything that's a formula for any individual. It's just a little bit trial and error what works best for you.

Tucker:

Gotcha.

Michael Koren, MD:

So let's move on to the rest of these numbers. And some of these are less related to vascular disease. I'm going to kind of skip over those. But the one the next one on your page is actually homocysteine, which is one of these super interesting uh concepts that people talk about. And homocysteine is an amino acid, it's it's in the protein class. And we know that people that had higher levels of homocysteine have a relationship with higher incidence of cardiovascular disease. But there's not that much talk about homocysteine uh for the reason that we don't have as much data that intervening makes a difference. So the reason we talk so much about LDL cholesterol is that the association with higher LDL cholesterol and bad cardiovascular outcomes is is strong, but not super strong. There are a lot of people that have high LDLs that live completely normal lives don't get atherosclerosis, and other people that have lower LDLs that have tons of atherosclerosis. So there's a correlation, but not a perfect one. But what we do know is that lowering LDL with treatment makes a huge difference. And time and time and time again in studies, we show that lowering LDL makes a difference, particularly when you're at high risk. But something like homocysteine that also has that relationship with bad outcomes when it gets higher, has never been shown to be the same in terms of the lowering it. Plus, the neat thing about homocysteine is that it's something that reflects B vitamin metabolism. And there's a relatively easy way to treat high levels of homocysteine, which is with B complex vitamins.

Tucker:

Okay.

Michael Koren, MD:

And a lot of people take multivitamins or B complex vitamins, and that will have the maximal effect on lowering homocysteine. So outside of using B complex vitamins, there's not a whole lot out there to show us that lowering homocysteine is going to make a difference, even for somebody like you with a family history. Okay. But that covers that. And then you have some of these things. These are things that an endocrinologist might look at. Uh you have the zinc level, which is kind of interesting. So the the general sense is that zinc is protective. Some people call it an antioxidant. And your levels are 105, which is completely normal. But this comes up a lot. And there's also something called the zinc-copper ratio. You want your zinc-copper ratio to be higher rather than lower. Uh, copper is complex in terms of how it's correlated with cardiovascular disease. Both low levels and high levels are not good. But there's a general sense that your zinc-copper ratio should be favorable. And uh one of the interesting places where that was looked at was actually in the country of Finland. Finland historically had a very high rate of cardiovascular disease. And it turned out in particular that there were areas in Finland where there was more copper versus zinc in the drinking water that had the highest rates of cardiovascular disease. So some of the epidemiological insights came from that particular study looking at a country and how different parts of the country were affected in terms of epidemiological rates of cardiovascular disease. Now, again, um, do you recommend zinc supplements? No, unless you have profoundly low levels. And nor would I recommend copper supplements. But um it's something that if you're really out of whack one way or another, you want to talk to a physician about, probably an endocrinologist.

Tucker:

Are you getting those already in your multivitamin that you know?

Michael Koren, MD:

Yeah, I honestly I don't I personally do not routinely check this in my patients. Okay. But it it is uh it it it's an eat interesting thing from an epidemiological standpoint. And if you have a good diet and you take uh multivitamin once a day, you're probably doing what you need to do for if you're dealing with these issues. And then um I'll skip some of these others because they're a little esoteric. And um, but I'll just mention for interest's sake is that they measured your leptin. Are you familiar with with that?

Tucker:

Not at all.

Michael Koren, MD:

Okay. So leptin is actually something that suppresses your appetite.

Tucker:

Oh wow.

Michael Koren, MD:

And there's a lot of research going right now with the GLP1 agonists about how it affects leptin levels and other things. And there's a belief, and we are actually doing a lot of research on this particular area, that maybe we can use changes in leptin levels to reduce somebody's appetite. So they did check that yours is within a reasonable normal range for what you expect for a 35-year-old man. So nothing to worry about there. But uh it's just interesting that that was checked. Then you had some tests of what we call inflammation. Your rheumatoid factor was negative, your antinuclear antibody screen was positive, though. And um this is a nonspecific test that can be associated with some immune diseases like lupus. And generally, this is something your physician should follow up on and do some further testing to see if you have other elements of inflammation. Now, some of that testing was done, but not all of it as we go into subsequent things. But that's uh something that's reasonable to follow up because we know, for example, that patients who have lupus have higher rates of cardiovascular disease. And maybe that's the threat in your family history. Maybe that's what um was something that affected your dad. And so I would definitely follow up on the positive antinuclear antibody test, and we'd get other types of testing to see if you have the diagnosis of lupus. Although you haven't mentioned any symptoms, that would make me think of

Tucker:

Right, I was going to say, what would be a-

Michael Koren, MD:

arthritic type simple symptoms are typical, rashes are typical, and there's other things. But um, again, that's a little thread, but it's also a very nonspecific test. So just because it was quote positive doesn't mean that you have any illness related to it.

Tucker:

Got it.

Michael Koren, MD:

But it they did order that and it it is of interest. And uh I'm gonna skip some of these other things um in the interest of time, but um I want to get to um one other thing that I noticed that was super interesting, which was your Lp(a) level. And let's see if I can find that here. So, yeah, here we go. So you have what's called an advanced lipid profile. So the first thing we talked about was the standard lipid profile. But there are a lot of other ways you can look at your your lipids, your lipoproteins, to get insights. So, one of the things that uh we do in the advanced lipids. Profile is actually look at the number of particles. So when you measure something like uh LDL, low density lipoprotein, you can look at it in two ways. You can look at it based on the mass or the weight, or you can look at it at the number of particles, which we call concentration. And so when you think about it, if you have fewer particles that are of heavier weight, that's going to be a little bit different profile than people that have more particles of a lighter weight. So in the extremes, people that have more particles with a lighter weight may have the same overall lipid levels as somebody that have fewer particles at a heavier weight, but their prognosis is different. So if you have more particles that are small particles, that's actually worse than somebody that has fewer particles that are big, more buoyant particles. And you do, in fact, have an excess number of LDL particles. So that's something we don't like to see. And you have above what you would want to see in terms of small LDL and medium LDL. So I would point out the fact that when you look at this statistically, that's another small reason why you would want to consider getting that LDL level down, or maybe even ultimately using a statin drug, which we'll talk about in a second. Okay. So I think that's a uh something that's important. And then um they looked at your omega-check, they called it, which was uh looking at a panel of your omega-3 fatty acids, and that came in a little bit low. Um, I I think this this is a proprietary uh assay, and we'll show this on the screen. But it goes into all uh multiple different omega-3 fatty acids, which are very important in terms of number of cellular functions. But the thing about the omega-3 fatty acids that's tricky and and even difficult for physicians is that the interventional studies for some of these things have been a little bit all over the place, quite frankly. So, what we know is that when you supplement with omega-3 fatty acids, you may have some benefits. Uh, there's some information, for example, that it may help mood disorders, it may help people with depression. But when we've used it to look at reducing cardiovascular disease or particularly cardiovascular outcomes, it's been a little bit of a mixed bag. Some studies have shown positive results, other studies have shown not great results. And so, because of that, we don't necessarily focus on that. But it's interesting that's a part of your panel. The flip side is that this is another one of those things that may be relatively easy to take care of. So, in somebody like you, we talked about the fact that you don't eat that much fish, which is rich in omega-3 fatty acids. Right. And you may want to consider that. So, an easy intervention would be for you to just eat more fish and replace some of the other proteins with that. And I imagine that that would help your omega-3s go up. But there are supplements out there.

Tucker:

So Yeah, I've started to supplement with salmon oil and and cod liver oil. Okay. Um there you go.

Michael Koren, MD:

We'll rerun these numbers in six months and see. Yeah, and you and you'll you'll probably see them higher. But again, this is one of those reflections of uh your du how you get your your diet can change the numbers. But you have to be a little bit careful because I can't really tell you the diet's gonna change your outcomes.

Tucker:

Right.

Michael Koren, MD:

But nonetheless, and there's no downside, especially if you like fish, right?

Tucker:

Right.

Michael Koren, MD:

Or if it's no big deal to take a fish oil capsule a day, then there's really not any significant risk to that. Sometimes people talk about the mercury risk of of some of these things.

Tucker:

Which they test for already, and that was fine, right?

Michael Koren, MD:

So exactly. And there are products out there that are refined products that don't have mercury in it. But um, quite frankly, a fish oil capsule a day, a thousand milligrams or one gram, I don't think is gonna hurt you from a mercury standpoint. But uh interesting that they did that. So I want to touch on your lipoprotein(a). We we alluded to that earlier, and that's that really, really, really, really bad cholesterol, as I mentioned. And your level here is 151. That's the concentration, it's in nanomoles per liter. And that's high. And that's super interesting because high Lp(a) levels run in families. Okay. And maybe that's what put but that's what affected your dad.

Tucker:

Right. Triggered this.

Michael Koren, MD:

Yeah. And you mentioned you didn't have any other family members, but have you had other family members have their Lp(a) checked? By do you know of?

Tucker:

I I I'm sure they have.

Michael Koren, MD:

Brothers, sisters, or your mom, or or- I'm sure my mother has. Um, you know, my wife has, but I don't I haven't asked about it. Or anybody on your dad's side of the family, um uh aunts or uncles on his side of the family?

Tucker:

Yeah, not that I've asked.

Michael Koren, MD:

The reason I asked that is because there's a genetic inheritance pattern for uh lipoprotein(a). It's it's called what we call autosomal dominant. And that number is really determined by your genes.

Tucker:

Okay.

Michael Koren, MD:

So your overall LDL, as I mentioned, is a combination of your genetic predisposition and your diet. But Lp(a) is almost all genetics. And it's interesting for somebody like you that has an Lp(a) level that's elevated to see what their genetics are, and you can kind of figure it out because you got one or both genes from your parents, and it's discernible once you can figure that out. Obviously, your father's deceased, so we can't get that now. But by looking at other of his family members, you may be able to figure that out.

Tucker:

Or just his history. If my mom doesn't have it, then he would have had to have it.

Michael Koren, MD:

Exactly. That's right. So exactly. So the deduction, right? Deductive reasoning,

Tucker:

right

Michael Koren, MD:

That's right.

Tucker:

And and I guess to that point, you know, for my kids' sake, um, you know, since I have it, and if my wife had it, they all by trait will have it. Is that a safe assumption?

Michael Koren, MD:

Probably so, but not necessarily. Because remember, uh an autosomal dominant gene is something that hides recessive gene. So let's say that they both got recessive genes that don't code for LPA at high levels, then they would have normal Lp(a)s. I probably confuse you with that.

Tucker:

But No, I I mean I I I can understand.

Michael Koren, MD:

Just like two brown-eyed people can have a blue-eyed baby.

Tucker:

Right.

Michael Koren, MD:

Makes sense.

Tucker:

Right.

Michael Koren, MD:

So, anyhow, um, but your lipoprotein(a) is is high. And so that is something that would be a risk factor. And as I mentioned, that's actually a stronger risk factor than LDL itself. So, because of that, um, uh you would be somebody that I would want to explore a little bit more where you stand in terms of atherosclerosis. Okay, and I'll get to that in a second. The flip side is that you also got what's called an hs-CRP, which is a look at your vascular inflammation, and that was beautiful at point two.

Tucker:

Great.

Michael Koren, MD:

Okay. So uh generally we want that to be less than one, and yours is optimal at less than one. And there's some data that's showing of all these markers, we call these biomarkers. Of all these biomarkers, the hs-CRP may be the one that's most highly correlated with bad cardiovascular outcomes in the future. There's some debate whether or not Lp(a) or uh hs-CRP are better. My personal opinion is that uh Lp(a) identifies certain subgroups that are particularly high risk.

Tucker:

Okay.

Michael Koren, MD:

And hs-CRP is more of a general sense of vascular inflammation. But nonetheless, uh it's good news that your CRP is low. And that's becoming more and more studied in terms of how inflammation and the identification of inflammation leads to bad cardiovascular outcomes. And we've had some podcasts on that. So I'd uh if you like this discussion, I invite you to look at some of the other podcasts we do in particular. I did a podcast with my classmate, Dr. Paul Ridker, is considered the international guru on CRP and inflammation, and and you'll learn a lot more about this.

Tucker:

Love it.

Michael Koren, MD:

But yours is good, so that's good.

Tucker:

Great.

Michael Koren, MD:

All right, so we cover a lot of ground here. Any questions before I get into maybe some recommendations?

Tucker:

Yeah, I guess you know, one thing that I I've done within the last two years, just before getting all of this done, and curious to see what your thoughts are. You mentioned Finland earlier in the podcast, and and uh I have a sauna in my backyard

Michael Koren, MD:

OK

Tucker:

And uh, you know, uh in the fitness side of things, it's obviously very common to do and and becoming more and more common nowadays um or or more accessible. And uh just curious to get your intake on you know sauna usage and and higher temperatures for an extended period of time.

Michael Koren, MD:

So there's a lot of these things we just don't know the answer to. So the when we when we do look at things scientifically, we have to do a randomized trial. And a randomized trial means that we randomly choose you to one thing or another. So a randomized trial of sauna use would be to randomly put people in saunas or to do something else and and compare the results over a period of time or based on a biomarker or based on something. So we just don't have those kind of studies for sauna. But if it makes you feel good, there's not a whole lot of downside. Just be careful because it can lower your blood pressure, and if you get out too quickly, you can hit your head and do some damage that way. Yeah. But um, I certainly you know, there's some things in life that you should just enjoy, and uh sauna is one of those things. But to have to do it compulsively for your health, I don't necessarily would don't need to recommend that.

Tucker:

Okay.

Michael Koren, MD:

But I don't see anything wrong with it either. Good to know. So this gets into some of um the things that what we uh we would do is uh if you're in a patient setting with me, what we do in terms of our plan, what how we're gonna move forward with all this information. We've got a ton of information, we cover a lot of stuff. So what do you do next? Well, obviously you're very concerned with your risk, and you have some factors here that will need to be followed up, like your ANA, and we talked about your LDL and your Lp(a). But what do you do to look at your risk? And one of the things that I would recommend for you is what we call a coronary artery calcium score or CAC score. And what we're learning is that CAC score gives you good insight into whether or not you're prone to atherosclerosis. And if you remember, uh, we first uh became more aware that young people can have pretty bad atherosclerosis based on autopsy autopsy studies that were done during the Vietnam War. And these were young men, you know, 18 to 24-year-old men that were killed in battle, unfortunately. And during their autopsies, it showed that some of them were already developing atherosclerosis on their aorta. And uh as technology has progressed, we can now uh uh determine whether or not you have atherosclerosis without doing an autopsy, fortunately. And the easiest way of doing that, and uh it's a cheap, effective way, is looking at the amount of calcium in your coronary arteries.

Tucker:

Okay.

Michael Koren, MD:

And calcium is the way our bodies heal atherosclerosis. So if you have some atherosclerosis that develops, your body's gonna try to heal that, and it'll typically calcify that plaque, and that'll show up in a CAT scan. CAT scanning is a very good way of looking at calcium. And so, somebody like you at age 35, you would hopefully have a zero CAC score. You wouldn't have any calcium. So if you had a zero CAC score, I'd feel a lot better about using diet and exercise to try to continue to work on that LDL. But if you had a CAC score that was above zero, any number above zero, I would say, hmm, at your age, Tucker, um, this means that your body is starting to already develop some atherosclerosis. And I would actually recommend a statin for you. Now, the reason I wouldn't recommend it without the CAC score is that we probably wouldn't make a difference in the next 10 years if you had a zero CAC score. But if you had any positive CAC score, then I think the statin would. And statins are one of these drugs that um unfortunately have a mixed reputation, even though they should be like the mother's milk of cardiology and treating people. Because unlike some of these other things I mentioned, every time we study statins, we get a positive outcome. So lowering the LDL with statins has uniformly led to better outcomes. But of course, that's dependent upon your risk. So if you're 35 years old and you have virtually no risk of having an event for the next 10 years, will statins make a difference? No, they won't make a difference because there's nothing to prevent. On the other hand, if you're 60 and you have the same profile, then they're much more likely to actually make a difference. So if if I saw this, these numbers in somebody age 60 with everybody else the same, I'd absolutely put them on a statin.

Tucker:

And what's the what's the scaling range for CAC scores, I guess?

Michael Koren, MD:

Is it uh zero to over thousands.

Tucker:

Okay. Yeah.

Michael Koren, MD:

So again, and it's very age dependent.

Tucker:

I was gonna say, so you know, a person in their sixties probably definitely has a some that they're not at zero.

Michael Koren, MD:

That's right. Most people, it's it's would be relatively unusual for somebody in their 60s to have zero, but some do.

Tucker:

Wow.

Michael Koren, MD:

And some people in their 70s have zero. So I've had actually patients, many patients, that come to me freaking out about their Lp(a). And they'll have the same Lp(a) as you, they'll be 72 years old. I'll do a CAC score and it's zero. And I have the great pleasure to tell me to tell them, well, you know, nothing's perfect in in medicine, but your risk is really super low. So I wouldn't worry too much about your Lp(a). Thank God there's something that's protecting you. And we may not even understand what's protecting you. Hopefully in the future we will. But despite the fact that your Lp(a) is high, I wouldn't freak out about it. On the other hand, we have people who are in a similar situation that are zealots and diet and exercise, and they have CAC score in the thousands. They'll say, Doc, I'm doing everything. I I eat a vegetarian diet, um, I run 50 miles a week. Why do I have a CAC score of a thousand? Well, as we know from a number of very high profile people that have died despite their fitness, um, there's stuff that can happen that we can't control.

Tucker:

Right.

Michael Koren, MD:

And that's where you need medicine.

Tucker:

Right.

Michael Koren, MD:

So yeah, the CAC score is something I would recommend in you.

Tucker:

Okay.

Michael Koren, MD:

And uh then we look at that and we see okay, are you somebody that can continue doing diet and exercise to treat these issues, or you're somebody that I would start a statin on? And I would look at that as a determining factor in somebody like you.

Tucker:

Good to know. Yep. Excellent.

Michael Koren, MD:

And then um the other thing that came up is uh we kind of covered it already. Uh, should you take some supplements? Doesn't hurt to take some fish oils, but you would accomplish pretty much the same thing by eating more fish.

Tucker:

Right.

Michael Koren, MD:

But again, nothing wrong with insurance policy as long as you don't mind burping up fish every once in a while.

Tucker:

Yeah.

Michael Koren, MD:

The secret there is yeah, keep the keep the capsules in the freezer and they they tend to slide down better.

Tucker:

Good to know.

Michael Koren, MD:

Yeah. All right. And um they they they tend to, in my experience, cause less burping and um you know you know sometimes it could be a little embarrassing in a meeting if you if you smell like salmon.

Tucker:

Yeah, yeah, yeah, yeah. Yeah. That's you're the last person in the office that that anybody wants to be around.

Michael Koren, MD:

But I you know I I don't I don't see any harm in that. And a multivitamin, especially multivitamin with vitamin B complex vitamins in it is certainly something that uh I seem to do little harm.

Tucker:

Okay.

Michael Koren, MD:

But then some of these other things that are out there, I would talk to a doctor before you do them because you know I have a lot of patients come in and there are on a list of 15 supplements that they were told were quote good for them,

Tucker:

Right

Michael Koren, MD:

But they don't necessarily have a good reason for them.

Tucker:

Right.

Michael Koren, MD:

And unfortunately, supplements can do bad things, especially if you take too much of them. So I'll give you a personal example. You know, when I finished my cardiology training over 30 years ago, I recommended vitamin E based on epidemiological data showing that there seemed to be a correlation with vitamin E and its antioxidant effects and better outcomes. But then there were interventional studies were done where you actually randomized people to vitamin E or not. And three major interventional studies were done, and two of the three actually showed a tendency towards harm of vitamin E supplements.

Tucker:

Wow.

Michael Koren, MD:

So you never know until you do the testing what these things are going to look like. And because of the fact that supplements are not supported by pharmaceutical companies and they're just sort of considered part of your diet, they're not tested to the same degree as things that are pharmaceuticals, which go through incredible testing. You know, the scrutiny around those pharmaceuticals is intense. And as consumers, people can benefit from that knowledge by either participating in clinical trials or by reading the results.

Tucker:

Right.

Michael Koren, MD:

So in your case, certainly I see no harm in a fish oil supplement. I would wouldn't necessarily recommend more than a thousand milligrams a day and a multivitamin with B complex in it. But other than that, I'm not sure there's anything else that would jump to the fore.

Tucker:

Cool. Yeah, we'll keep we'll keep the regular regularly scheduled program with uh, and you know, my kids don't eat fish, right? You know, you can make it put in front of them, they won't touch it. So that's you know more or less why I we can disguise tuna in different ways.

Michael Koren, MD:

Right. That's a good point.

Tucker:

They will eat raw tuna, but you know, any salmon or anything like that, it's a different story.

Michael Koren, MD:

If it looks like a fish, they won't eat it.

Tucker:

Right. Exactly. Exactly right. No.

Michael Koren, MD:

Well, in any event, um, do you have any other questions?

Tucker:

Um no, obviously a lot to unpack, and I appreciate you know you taking the time to review this and and um you know have a follow-up in another couple months just to see where I am now. I'd love to get the CAC and and you know really see where I am in that.

Michael Koren, MD:

Let's do that for our audience. Okay. So we'll we'll get your CAC score. Yeah, and we'll have you come back after some of maybe these dietary interventions and even your sauna, and you can tell us how you do with that. Yeah, and we'll see uh how the numbers look.

Tucker:

Yeah, I would love that. I would love that. Thanks for having me.

Michael Koren, MD:

Tucker, thank you for being part of MedEvidence.

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