Decoding the Risk: What New Cholesterol Guidelines Mean for Women with Dr. Harpreet Tsui

The number-one cause of death in women is still heart disease — and perimenopause is where your cardiovascular risk starts to quietly climb. This week, Dr. Komal sits down with Dr. Harpreet Tsui, an internist, obesity medicine specialist, and founder of Coronado Health (a direct primary care practice in Nevada), to break down the 2026 ACC/AHA Dyslipidemia Guidelines — the biggest update to cholesterol guidelines in years.

This is a personal episode. Both physicians are Southeast Asian women with significant family histories of heart disease. Both are managing their own cardiometabolic health in real time. And neither of them is willing to accept "your numbers look fine" as the end of the conversation.

They cover what's changed in the guidelines, which genetic cholesterol markers your doctor may not be ordering, why perimenopause can flip your lipid panel overnight, and the exact language to use at your next appointment to get the full picture.

Guest

Dr. Harpreet Tsui, MD Internist | Obesity Medicine Specialist | Founder, Coronado Health (Direct Primary Care, Henderson, NV)

📍 coronadohealthdpc.com 📱 Instagram & TikTok: @drharpreet.tsui

Timestamps

[0:00] — Podcast intro and medical disclaimer

[1:03] — Meet Dr. Harpreet Tsui: internist, obesity medicine specialist, founder of Coronado Health in Nevada — and why both she and Dr. Komal wanted to have this conversation as Southeast Asian women with significant family histories of heart disease

[2:48] — Why direct primary care: Dr. Tsui on leaving the 15-minute appointment model to build a practice centered on women's health, obesity medicine, and actually having enough time to talk

[4:42] — Guidelines confusion and statins: from the clear LDL targets of residency training to the ambiguous "lower it if you feel like it" era — and why statins have gotten an unfair reputation despite data showing they reduce heart disease, stroke risk, and even drive plaque regression

[7:01] — Mistrust and culture around medications: immigrant family attitudes toward asking for help, the "I can do it on my own" mentality, and how even physicians absorb enough noise to hesitate — including Dr. Tsui, who prescribed herself a statin and left it on her nightstand for two weeks before she could take it

[12:14] — Key update: risk-based treatment replaces number-chasing. The new PREVENT ASCVD calculator factors in HDL, triglycerides, family history, ethnicity, and even zip code — and gives you both a 10-year and 30-year cardiovascular risk estimate, not just a snapshot of today

[16:11] — Perimenopause and lipid shifts: why cholesterol can change dramatically when estrogen drops, even when lifestyle hasn't. Dr. Tsui's LDL went from 77 to 177 in perimenopause. Dr. Komal's Lp(a) was normal before — and then it wasn't. Neither of them did anything differently.

[20:59] — ApoB and Lp(a) explained: the two genetic cholesterol markers now in the 2026 guidelines as independent cardiac risk factors. Your standard lipid panel can look stone-cold normal while these are quietly elevated — and why both physicians now check them routinely on midlife women

[23:28] — Female-specific risk factors are finally in the guidelines: menopause, PCOS, gestational diabetes, and preeclampsia are now formally recognized as independent cardiovascular risk factors. The gestational diabetes gap — including the postpartum glucose tolerance test that routinely gets missed — and why preeclampsia has lifelong cardiovascular implications

[29:32] — Lower LDL targets and the case for being more aggressive: below 70 for high-risk patients, below 55 for very high-risk — and why vascular specialists have been pushing for LDL at or below 50 for years ahead of these guidelines

[31:33] — Beyond statins: PCSK9 inhibitors, ezetimibe, omega-3s, and emerging Lp(a)-targeted therapies in the pipeline — what your options are if you genuinely can't tolerate statins

[32:06] — Why guidelines change — and why that's not the same as being lied to: the science evolves, the tools get better, and the recommendations follow

[33:13] — Pandemic messaging lessons: Dr. Komal on "flatten the curve," what it actually meant, and how the gap between what medicine knows and what gets communicated to the public continues to fuel mistrust

[34:31] — Rebuilding trust in science: Dr. Komal's experience at her Washington hospital during the first COVID deaths in the country, the CDC arriving to learn rather than lead, and why uncertainty in medicine is not the same as deception

[38:33] — Midlife women and heart risk: why cardiometabolic risk isn't discussed nearly enough in the context of menopause, and what Dr. Komal is doing in her own practice to screen every midlife woman proactively — before anything on the standard panel looks alarming

[40:04] — Estrogen loss and metabolic shift: the mechanism behind why visceral fat increases, muscle mass drops, insulin resistance develops, and cholesterol climbs when estrogen declines — and why this is biology, not a lifestyle failure

[41:09] — Inflammation markers and hsCRP: why both physicians check high-sensitivity CRP routinely, what Dr. Komal found when hers came back elevated despite well-controlled autoimmune disease, and the vicious cycle of visceral fat and cardiovascular inflammation

[43:26] — Personal plans, statins, and GLP-1s: Dr. Tsui shares her own treatment journey — transdermal estrogen, a statin, and adding back a GLP-1/GIP combination — and how her LDL dropped back below 70 and her hsCRP normalized. The reminder that everyone's genetics are different, and so is the plan.

[45:22] — Lifestyle first, medication timing: how Dr. Tsui structures the first conversation with patients — a deep dive on diet, body composition, schedule, and food access — and her three-month reassessment framework before deciding on pharmacologic intervention

[47:47] — Calcium scores and hidden disease: the coronary artery calcium (CAC) score as a window into subclinical atherosclerosis — including Dr. Tsui's own score of 214 at age 43, discovered while trying to prove her heart was healthier than her husband's

[50:12] — Statin side effects and PCSK9 inhibitors: managing myopathy, dosing strategies for women (who metabolize statins differently), and how Dr. Tsui gets about 75% of patients who need a PCSK9 inhibitor to actually commit to it

[51:37] — Insurance barriers to care: prior authorization requirements for PCSK9 inhibitors, the specialist referral runaround, and what happens to patients when the system gets in the way of evidence-based treatment

[52:31] — What to ask your doctor: specific language and specific tests — family history, the PREVENT ASCVD calculator, Lp(a), ApoB, fasting insulin, ferritin, GLP-1 conversations, and the "skinny fat" discussion that Southeast Asian patients in particular deserve to have

[55:19] — Family history, kids, and screening: when to start checking cholesterol in children (as early as age two with significant family history), why puberty brings new risk considerations, and a message to primary care physicians and their own patients — including the data on female physician mortality that should make all of us pause

[57:24] — Closing thanks and where to find Dr. Harpreet Tsui: Coronado Health in Henderson, NV | coronadohealthdpc.com | @drharpreet.tsui on Instagram and TikTok

Resources Mentioned

• 2026 ACC/AHA Dyslipidemia Guidelines
• PREVENT ASCVD Risk Calculator (American Heart Association)
• MASALA Trial (South Asian cardiovascular health research)
• Coronado Health: coronadohealthdpc.com
• Clearly Hormonal Episode with Dr. Ambreen Mohamed (CT coronary angiogram and women's heart disease — coming soon)

Connect

Dr. Komal Patil-Sisodia Endocrinologist | Internist | Obesity Medicine | Menopause Society Certified Practitioner 📍 Eastside Menopause & Metabolism — Kirkland, WA | eastsidemm.com 📱 Instagram & TikTok: @drpatilsisodia

Dr. Harpreet Tsui Internist | Obesity Medicine Specialist | Founder, Coronado Health 📍 Henderson, NV | coronadohealthdpc.com 📱 Instagram & TikTok: @drharpreet.tsui

Thanks for listening. Find more info about Clearly Hormonal on the website or Instagram.

Transcript

Dr. Komal Patil-Sisodia 0:01

Welcome to Clearly Hormonal, the podcast where we stop googling our symptoms at midnight and actually start understanding what's going on in our bodies. I'm Dr. Komal Patil-Sisodia, an endocrinologist, internist, obesity medicine specialist, and a Menopause Society certified practitioner, which is really just a whole lot of words to say hormones are kind of my jam. I've spent 17 years watching women try to navigate their hormonal health without ever having been taught the language for what's happening in their own bodies, and then meeting clinicians who want nothing more than to help them figure it out, but are up against 10-minute appointments and a system that just wasn't built for it. This podcast is my answer to that gap. We'll cover menopause, metabolism, hormones, and everything in between with real evidence, not trends, and without the overwhelm. A quick disclaimer. I'm a physician, but this is education, not personalized medical advice. Take what resonates and discuss it with your own healthcare team. Now, let's get into it and talk about what's clearly hormonal and what's not. Hi, everyone. Welcome back to the podcast. Today, we are going to talk about the new American Heart Association cholesterol guidelines, and I'm so excited to have Dr. Harpreet Tsui here with me. She is an internist, obesity medicine specialist, and the founder of Coronado Health, which is a direct primary care in Nevada. And I've had her on the podcast before, Dr. Tsui and I share a background of both being Southeast Asian. We've had a life story that just is really in parallel, even though we grew up on different sides of the country. We wanted to come together and discuss this, especially both being Southeast Asian women who have a significant history of heart disease in our families. We wanted to make sure that we were bringing you all of the new information from these new guidelines and what it means for you. So welcome, Dr. Tsui. Thank you so much for being here.

Dr. Harpreet Tsui 1:51

Thank you so much for having me.

Dr. Komal Patil-Sisodia 1:54

It's always fun when I get to talk to you and compare all of these thoughts that we have about Southeast Asian heart health, about women's heart health, and, you and I both know that women's The number-one cause of death in women is still heart disease, We talk a lot about menopause and midlife changes, but what people don't realize is that this is really where your cardiovascular risk starts to go up. I saw it in my mom. I'm seeing it in me. I think you've had a similar experience as well. Absolutely. Saw it in my

Dr. Harpreet Tsui 2:23

mom

Dr. Komal Patil-Sisodia 2:23

We're gonna talk through why the old, "Your numbers look fine," doesn't cut it anymore. We're gonna go through the different updates, and we're gonna talk about what women need to talk to their doctors about, because they're still not having those conversations. And what happened to my mom happened in the late '90s, and here we are almost 30 years later and really not much has changed. So before we get started, Dr. Tsui, I'm gonna call you Harpreet because you're gonna call me- Please Komal, and that's just much easier. Tell us about your practice and how you got into direct primary care, internal medicine, and obesity medicine.

Dr. Harpreet Tsui 2:55

Yeah. So I opened my office four years ago, and part of the reason was because I had so many female patients who felt like they didn't have enough time. 15 minutes is not enough time to discuss all of the issues. I loved internal medicine from when I was, like, in medical school really, 'cause internal medicine's one of those things that's very detective work-y, it's oh, someone comes in with a problem, figure it out. Nancy Drew

Dr. Komal Patil-Sisodia 3:16

it. CSI, Yeah.

Dr. Harpreet Tsui 3:17

I love doing that. And so for me, in the last four years, I feel like as we are getting older, we're seeing our mothers get older, we're seeing our patients get older. You and I are in specialties where we have probably had patients our entire career, and so now we've got these women who are young and are midlife to older. And I started to say "Okay, you know what? I need to take my primary care practice and build it out into women's health and obesity medicine." And as someone who struggled with obesity myself, and I have my own weight loss journey I understand what that's as a patient and also as a doctor. And so I have built this practice where it's, women's health, primary care, obesity medicine, but as it's kind of everything. It's all together.

Dr. Komal Patil-Sisodia 3:56

Yeah.

Dr. Harpreet Tsui 3:57

Yeah. We've just been able to build a practice where I can continue to enjoy practicing medicine, and I have fun every single day.

Dr. Komal Patil-Sisodia 4:04

I love that, and your patients are so lucky to have you. And like I said before, you and I have very similar stories. I have my own weight loss journey. I have my own heart health journey with both my mom and me, and what I'm trying to tell my sisters they're at risk for, whether they wanna listen to me or not. This is me calling you out, girls. Go get your stuff checked.

Dr. Harpreet Tsui 4:22

If my sister's listening, she knows.

Dr. Komal Patil-Sisodia 4:24

Yeah.

Dr. Harpreet Tsui 4:24

I did call her out on it. See? And I took her to our labs after everything went by... that happened to my mom.

Dr. Komal Patil-Sisodia 4:30

Yeah.

Dr. Harpreet Tsui 4:31

I was like, "Hey girl, when's the last time you did labs?" She's "I don't know, four years ago." I'm like nope, gotta do 'em now."

Dr. Komal Patil-Sisodia 4:36

yep. Now is your sister in medicine?

Dr. Harpreet Tsui 4:38

She's a pharmacist.

Dr. Komal Patil-Sisodia 4:38

My sisters are in healthcare too. One's a therapist and one is a dentist. So let's dive into it, when you and I were residents, we had the set of guidelines that were there, and they actually had pretty clear targets, so I knew, felt like we knew what we were doing, and then all of a sudden the guidelines changed and it was, like, so nebulous. It was like, treat to, you don't have to treat to this target, but we want to see this type of a change. And I was like, "Can you just give me something a little-" Yes. So I know that you had some frustration with that as well. I think all physicians really. And so what's really nice, in my opinion, about these guidelines is they've gotten much more clear, correct?

Dr. Harpreet Tsui 5:17

I think the issue is when we were in training, we would look at patients coming in with a stroke or a heart attack and then realize their LDL was not necessarily that high, But then in residency, the guideline was 100 for the LDL, okay, let's do aggressive. And then, yeah, when we were practicing in early practice, it was like, yeah, just bring it down if you feel like bringing it down. I'm like, I don't know what that means. And you and I were also in our earlier careers fighting the misinformation about statins. Correct. So then it just made it really hard.

Dr. Komal Patil-Sisodia 5:50

And there's a lot of people who are, very anti-statin, and I have a hard time with that because they have data showing that they reduce the risk of heart disease and stroke, And in some of the studies with high enough doses of the right statin, we've actually even seen some plaque regression. So yeah, and that's the part that I think people don't understand because they're like I want to do it naturally." And one of my biggest gripes is that, yes, we can do things naturally up to a point, but we can't out-natural our genetics, You can't out-exercise, out-lifestyle, out-hormone what your genetics are going to be. And so at some point, that's why all of the science and medicine exists, so that we can give you options to get over that.

Dr. Harpreet Tsui 6:29

And one thing I always like to remind patients is I say, the statins lower your cholesterol, and they also prevent secondary- heart attacks and strokes, but they are also anti-inflammatory. And so if I can decrease the inflammation in the arteries- then we're going to decrease the amount of all the inflammatory markers that are gonna make up a plaque, 'cause a plaque isn't just cholesterol just sitting there hanging out. And a lot of patients don't know that, and I go like there's not a plant sterol in the world or like a large amount of omega-3 that's going to give you that anti-inflammatory effect.

Dr. Komal Patil-Sisodia 7:00

Yeah. I agree, and I think, unfortunately statins have gotten a bad rap. I think there's just a lot of mistrust in medicine in general, Yes.

Dr. Harpreet Tsui 7:07

Yes.

Dr. Komal Patil-Sisodia 7:08

Because of what happened decades prior

Dr. Harpreet Tsui 7:10

yes, and I will also start this by saying I prescribed a statin, and I literally stared at it for two weeks. I got the bottle And I put it on my nightstand, and every night I would look at it, and I'd be like, "Tonight's the night." And I'd be like, "Nah, tomorrow night's the night." Even as doctors we-

Dr. Komal Patil-Sisodia 7:26

I've heard that

Dr. Harpreet Tsui 7:26

we also sometimes are scared of taking medications based off of things that we have heard that we know are not true.

Dr. Komal Patil-Sisodia 7:33

And it's very easy to be susceptible to all of those things and go down those rabbit holes. So I have psoriatic arthritis, and, I had started a probiotic. A lot of people will tell you probiotics, they won't do anything, this, that, and the other. But I actually did feel an improvement in my joint inflammation, But I was taking the one from Costco, Align. Great. It's the one my GI friends recommend. That one or Florastor. But then you start seeing all of these new ones that are coming out that claim they're gonna help you with your glucose metabolism, or they have some proprietary blend and blah, blah, blah, blah, blah. And so I went down that train, and I ended up on one that made my psoriasis worse. Everything flared, my joints hurt, and I was like what happened? And you don't understand the impact that these things can have. And even as a physician, sometimes you are susceptible to those things, Yes. So I don't want anybody listening to this podcast to think that we're sitting here telling people, "Oh my gosh," "You can't do this, you can't do that, listen to me because, I know best and I've never gone down a rabbit hole." That's bullshit. We've all go down rabbit holes, We all have these very human reactions to learning that there's something happening in our bodies that we feel blame, shame, guilt over, even though it's just our genetics and It wasn't ever gonna be our fault.

Dr. Harpreet Tsui 8:45

And do you feel like it is even more rampant in South Asian culture? Because from a young age, we have our dadis and our nanis are like, "I'm not gonna take anything." My masi's I don't need anything." And in fact, even my own mother, even though on her side of the family, we all have elevated HDLs. Doctors were like, "Yeah, it doesn't matter that your LDL's slightly high and you're diabetic. Your HDL's in the 90s we don't actually know what to do with that. Fine." And my mom would just be like no. I'm not gonna take anything." And culturally, I feel like that plays a giant role- 100% on the way that we think, even though we're doctors.

Dr. Komal Patil-Sisodia 9:18

I think a lot of it in immigrant families comes from the fact that everybody worked so hard to survive when they got here. And, "I can do it on my own. I can do it without help. I'm gonna push through. I don't wanna be a burden to anybody. I don't want to admit that I need help." And that invades every part of your life really. And so I think you and I both being Southeast Asian daughters who are leading families we grew up with this culture around us where it was like, "No, you have to show up perfectly for all of these things, and asking for help is a sign of weakness," and I have had that moment where I'm, sitting there looking at my arthritis medication and being like if I just out-lifestyled it, it could be better." And then I sit back and I'm like, "What would you tell your patient?" Look in the mirror and pretend you're a patient and say what you would tell your patient, and then, put on your big girl pants and take the pills,

Dr. Harpreet Tsui 10:06

that is my life when it came to bariatric surgery, when it came to GLPs. I would be like I don't really need it anymore," and I'm like, "What am I sitting there telling my patient to do?"

Dr. Komal Patil-Sisodia 10:15

And it was the same thing for a GLP-1 for me. I did all these lifestyle things. Everything looked great, and despite losing weight on my own, My genetics kicked in. Both my parents have diabetes. And when you lose 40 pounds and then your A1C starts to go up, you're like, "Wait, what the hell? What did I do all of that for?"

Dr. Harpreet Tsui 10:35

You become very menopausal and your LDL goes up 100 points overnight. You're like- does that happen? I've lost 100 pounds and my LDL is like, 'No, we're not doing this anymore.'"

Dr. Komal Patil-Sisodia 10:45

Yeah. Exactly right.

Dr. Harpreet Tsui 10:47

Why I texted you and said we have to have this conversation.

Dr. Komal Patil-Sisodia 10:50

Because we've both lived it, and I think a lot of times people will look at their doctors and say, "Oh they must have it all together," i've had patients say to me, and this is really interesting, Because I'm pretty open about this stuff with my patients, because I feel like it's important for them to see that we are not infallible, that we are humans just like them. We have the same genetic and health issues that could pop up. So I'm very open about talking about how when my husband had his heart attack, I went to therapy, because that's another thing that gets stigmatized in our culture. Is "Oh my gosh, you must be crazy if you need therapy," right? But no, I needed coping mechanisms to get over the stress. Or if I'm seeing my A1C go up and it's not in a diabetic range, what am I gonna do to prevent it instead of Getting diagnosed with diabetes. Yes. And so these are all conversations that we have to have, and we have to help people understand that, your genetics are the hand of cards that you're dealt. You could have a shitty hand, and unfortunately, sometimes that requires medication. It always requires lifestyle and foundational stuff, but how do we make people feel like it's not their fault? That is the part that I still struggle with on a day-to-day basis.

Dr. Harpreet Tsui 11:56

Yeah, and I do think it comes down to genetics, and I think one of the things that I really liked about the new lipid guidelines is that they made it so concrete-

Dr. Komal Patil-Sisodia 12:03

Yes

Dr. Harpreet Tsui 12:04

so we can now tell our patients "Yeah, both of your parents have high cholesterol. Your grandparents had heart attacks. You've got all of this ASCVD risk in your family." This is not your fault.

Dr. Komal Patil-Sisodia 12:13

Yes. So let's go through what the key updates are. The first one is that risk-based treatment replaces how we used to chase numbers. So let's talk a little bit about that.

Dr. Harpreet Tsui 12:23

Okay. So when we look at it, it was just always here's your LDL, and then I'm only gonna look at the LDL when we were in training, so your LDL's 140. Here's a statin. Have a nice day. But now I feel like we've built in the calculators, like the new PREVENT ASCVD calculator, plus/minus HDL, plus/minus triglycerides, plus/minus family history, ethnicity. The PREVENT ASCVD calculator even looks at your ZIP code, which I thought was really interesting as well.

Dr. Komal Patil-Sisodia 12:50

Thought that was fascinating, but it makes sense, because it's their attempt to put social determinants of health in there.

Dr. Harpreet Tsui 12:55

Yeah. And I feel like now we're getting just such a round picture, which is what we were trying to do when patients were coming into our office. If I sent a patient to you and I was like, "Oh, Komal, LDL's 285, and now I don't know what to do," or I get the hospital follow-up patient who had a stent placed, and now they're looking at that. Now we can look at more than just oh, the LDL is high. I'm not gonna chase that number. I gotta look at everything. Exactly. Which is similar to what we do for ourselves.

Dr. Komal Patil-Sisodia 13:22

Oh, 100%. It's what we try and do for our patients, for ourselves, and make sure that we're, looking at the whole picture, and I think there's a lot of desire for that out in the community, And some of these phrases are interesting to me, like, when people are like, "I just wanna get to the root cause," or, "I want to a holistic picture." I think, in theory, we're all saying the same thing. Yeah. But the way that we are going about it is a little bit different, and I think the distrust towards medicine is oh, medicine is not trying to get to the root cause. What do you do when the root cause is your genetics?

Dr. Harpreet Tsui 13:54

Yeah. You really have to sit down and have a serious conversation. I had to have such a serious conversation with myself. And I was quick to tell my husband he needed cholesterol meds when he needed it, because- Yeah that's my husband, yeah. I'm treating him like a patient. But when it came to me, I was like, "Ooh, wow." Yeah. "You need to have a real serious conversation about what's happening in your body." And look at myself as a whole picture.

Dr. Komal Patil-Sisodia 14:18

Do as I say, not as I do. It's so much easier to do that, so yes, it is It's definitely a challenge, and definitely something that we wanna do, but I do the fact that we are not number chasing at this point, and I think we've recognized that when we look at the risk that people are going through with their heart health picture, we want to look, based on what you're saying, this PREVENT ASCVD calculator is looking at how your risk is in a time period closer to now, and then 30 years down the line, so it's 10-year and 30-year risk of what is going to potentially happen to you, and based on that, you also pick when you treat and when you intervene and when you just watch and try and do lifestyle stuff, which is different, because before it was just based on a single point in time.

Dr. Harpreet Tsui 15:04

Yeah, and let me ask you, as an endocrinologist who sees adults who are, like, 18 up are you seeing more elevated LDLs in your patients in their 20s or early 30s?

Dr. Komal Patil-Sisodia 15:14

My perspective's a little skewed, because I see diabetes, and with diabetes, people who are struggling with diabetes have already metabolic disease that's happening, so they're gonna be more predisposed to having higher LDLs, especially if their diabetes is not controlled. So I feel like my conversation's a little bit different, but I am seeing more overweight and obesity in the general population. We know that from that perspective. And obesity and overweight are linked to more cardiometabolic dysfunction, so I think as a result of that, I see more elevated LDLs. I also think that the food in our country is not the healthiest, we have a lot of packaged, processed foods that people lean on rather than... And this is not a organic, non-organic, GMO, non-GMO conversation. This is just purely processed versus cooking regularly at home, doesn't have to be all the expensive grocery store stuff, but just the difference in the food quality like that, I think really contributes to our risk to some degree. Now we are looking at that lifetime risk, 10 years. How do you think that this is impacting your younger midlife women, this is something that I'm just starting to pay attention to, and I see women who in their 20s and 30s have totally normal cholesterol panels, And this happened to me. My estrogen levels started declining in perimenopause, and my lipoprotein little a, which runs in my family because that's what caused my mom's heart disease, totally normal before, is now elevated, and I didn't do anything different. If anything, my lifestyle and my foundational habits got better. How are you talking to your patients about that?

Dr. Harpreet Tsui 16:46

I just share my story with patients. I was very shocked to find out that the women on my mom's side of the family started perimenopause symptoms in 43, 44. And so for me, I had been walking around literally with my mom's lipid panel. Low LDL and I would joke with my husband. I'd be like, "Oh, my LDL's 82. It's so good." And not that it... it could've been better, but a high HDL, low LDL, lipoprotein little totally nor- And then I go through peri- start perimenopause. My estrogen starts to drop. My LDL literally went from 77 to 177. My HDL still stayed high. My apoprotein B was elevated. My LP little a was fine, but my dad had heart disease in his 50s, so all the women on their side of that family. And then my mom, who recently just passed from a heart attack, had this, we're starting to find out that in their 70s, her older sisters also had heart disease, which we thought was weight-related so similar to you, where I was like, "Wait a minute. I've done all the things." My diet is cleaner today than it was five years ago, and now I've got this elevated LDL. And so I have the conversation with my patients, especially my midlife women. I say, "If I'm gonna do hormone testing on you, if I'm gonna do full labs on you, let me do an advanced cardiac lipid panel." And I know that the guidelines have now changed that we should do LP little a, at least once in their life. I have always been an LP little a once a year kind of girl. I'll be like, "I don't wanna just go all these years and be like it's fine forever.'" And I find that I am having the conversation about cholesterol-lowering, lipid-lowering medications in the adjunctive space of perimenopause and menopause.

Dr. Komal Patil-Sisodia 18:22

Yes. Same.

Dr. Harpreet Tsui 18:24

Because it is all going together.

Dr. Komal Patil-Sisodia 18:26

And it's interesting because I also think based on our genetics, we're very different in certain ways, like different ethnicities. I have a patient of mine, Caucasian female, who came in and her cholesterol more than doubled when she hit perimenopause, she was like, "I don't know how I feel about statins yet." And I was like, "We have to consider it at some point. Your triglycerides are in a range where it's still safe for me to start you on hormone therapy, but we're gonna repeat your lipids in a month, and if everything is still high, then we're gonna have to talk about doing a statin," and it was interesting, her lipids came down almost like they were maybe 20 points above her baseline compared to before. But then in Southeast Asian women when I do that, I don't see that same drop, so there's some-

Dr. Harpreet Tsui 19:12

I

Dr. Komal Patil-Sisodia 19:12

didn't get that drop Yeah, n- neither did I. I did initially slightly, and then it went away. So yeah, I was like, "Oh look, it dropped a little." And then I was like, "Wait, no. It's not doing what I want it to do. Damn it."

Dr. Harpreet Tsui 19:23

Crush up the Crestor straight into my coronary arteries. Let's just do that.

Dr. Komal Patil-Sisodia 19:27

Honestly, if that's what's gonna prevent my potential heart attack down the line, yes please, I think it's important to understand that. And yes, while we want things to work, they don't always work the way that we want them to, yeah. And then at that point you have to consider something else, so I told this patient whose lipids almost came down to normal, I was like, "We're gonna check again in three months and just make sure they're not rebounding," because there are studies that show when you start women on hormone therapy, you'll see an initial decrease in all of the cholesterol markers, but then six months, some people rebound, and it goes-

Dr. Harpreet Tsui 20:01

we know why

Dr. Komal Patil-Sisodia 20:02

And it's interesting because the transdermal estradiol doesn't work as well as the oral estradiol for lowering the cholesterol numbers. But people are scared to take the oral estradiol even though it's a really good drug because of that slightly increased clot risk, and obviously, if you have a BMI over 30 and you are concerned about blood clot risk- Transdermal estradiol is safer, but if you can't tolerate it, oral estradiol is fine, and you just have to be very careful about monitoring, and so I think what we have to do is really talk people through what their options are, but then also really push for this continued monitoring, like you're saying. And, I'd had the lipoprotein little A done once, and I hit 44, and I told my primary, I was like, "I just have a bad feeling." And she's "But it was fine." And I was like, "I just have a bad feeling. Can you please check it?" And she was so great. She was like, "Sure." And then it came back, and she's "Oh, holy crap." "What do we do now?" And this was, like, three years ago, so yes, before these guidelines came out. So I'm very happy to see lipoprotein little A and apolipoprotein B get called out as separate independent cardiac risk factors. Because your lipid panel, which is your total cholesterol, your low-density lipoprotein, your high-density lipoprotein, which are the LDL and HDL- Yeah bad and good cholesterol, and then your triglycerides, those can all look stone-cold normal, and you can still have elevations in either ApoB or lipoprotein little A that are gonna increase your risk for heart disease, so now that it's actually there in the guidelines, it makes me so happy because we can actually do right by patients.

Dr. Harpreet Tsui 21:36

Yeah, and you know the thing that I find quite interesting, 'cause we do have, both of us have quite a lot of diabetic patients, is I have seen LDL-Cs that are normal and then elevated ApoBs. Yep. But you're not... I think I started checking ApoB in the last year or so, and only, again, because you do the research and you do the reading, and I was like if I'm doing LP little A let me do ApoB."

Dr. Komal Patil-Sisodia 21:56

Why would we not do both,

Dr. Harpreet Tsui 21:58

imagine how many patients are not getting that tested, and they're diabetic, and they have an increased risk, and now they're also perimenopausal, and they're women. It's like this trifecta of insulin resistance, and your LDL's normal, and how, I feel like what we ended up doing and you and I probably around the same time, you before I did, is, you started checking insulin levels in your patients, and we'd be like, "I don't know. Let's just check it." It's high. Now I'm like, now it's time to do ApoB, so I was really happy that they talk about ApoB in the new guidelines.

Dr. Komal Patil-Sisodia 22:27

Yes, and-

Dr. Harpreet Tsui 22:28

Because mine was high, and I was very surprised.

Dr. Komal Patil-Sisodia 22:31

Yes. And these are the things that we don't know about. So for the listeners, apolipoprotein B and lipoprotein little A are genetic cholesterol particles that when they're elevated, they will increase your risk of heart disease, and each one increases risk individually, so that's what we wanna pull together is the traditional panel is not always gonna tell you everything, and you should be having these other levels checked. And it's interesting the guidelines call out lipoprotein little A for at least once in your lifetime. I will go as far as to say for women, if you had it checked prior to perimenopause, you need to do it again when you're perimenopausal and when you're post-menopausal, if not on a more regular cadence with your doctor, because I am living proof that it was normal and then it wasn't, yeah. And a lot of times people will tell you, "Oh y- you only need it that once," and then I don't believe that, and I have proof- in my patients- That it changes. So it's definitely an interesting piece of the puzzle that's there. I think the other thing that was really interesting for me were, like the calling out of the specific female risk factors because- the lack of data in women pisses me off, and I know it pisses you off, but just to see that section was like, it was so satisfying.

Dr. Harpreet Tsui 23:45

So satisfying. I loved it.

Dr. Komal Patil-Sisodia 23:47

Freaking finally, and then I looked at it and I was like, "Oh, shit, I have some of these things."

Dr. Harpreet Tsui 23:52

A slap in the face in a good way. I was like, "Oh, yes. Time to look at my diet." Can I clean things up?"

Dr. Komal Patil-Sisodia 23:59

Yeah. Be a little more

Dr. Harpreet Tsui 24:00

active. And

Dr. Komal Patil-Sisodia 24:01

And I think we are seeing also in... one, I think we do a crappy job of diagnosing women with PCOS, I think we are very scared to label young women who are in their teens as having PCOS because we don't want it to- taint the rest of their lives. And PCOS, for those of you who are listening and don't know, is polycystic ovarian syndrome. But what PCOS does is it increases your lifetime risk for diabetes, for heart disease, for stroke, for metabolic syndrome, high blood pressure, high cholesterol. So if you already have that when you're a kid, we have to watch you more closely, and a lot of times women were just told that it only had reproductive implications, meaning it's gonna be harder for you to get pregnant. But nobody talks about the other pieces that happen after, and I think it becomes very relevant, especially in perimenopause. So I was happy to see that one called out.

Dr. Harpreet Tsui 24:55

Yes.

Dr. Komal Patil-Sisodia 24:56

You also see a lot of women with diabetes now who had gestational diabetes, and that was another call-out that I really appreciated.

Dr. Harpreet Tsui 25:03

That was another one, which is great because you have that conversation, and I think that something about gestational diabetes has changed, where women are like I had gestational diabetes, but I'm not diabetic now."

Dr. Komal Patil-Sisodia 25:12

Yeah.

Dr. Harpreet Tsui 25:14

Yeah, but you have a risk of developing diabetes. Have we checked your insulin. They're a year postpartum. I'm like, "Oh, still high. Yes, your A1C dropped and then you're not technically diabetic, but you're walking around again with this insulin resistance." And I love that they finally called that out because it is so important.

Dr. Komal Patil-Sisodia 25:30

It really is, and one of the biggest gaps we see in my clinic and in other spaces is that, women have babies and then they're so busy taking care of their families, they don't have time for self-care. And the number of women who miss their three-month postpartum glucose tolerance test or testing to see whether they still have insulin resistance, pre-diabetes, diabetes, it's a pretty big number, that is a public health issue. We are missing the boat on catching women there and then counseling them so that they can be healthy later on. So I love that this calls that out. They also called out preeclampsia and gestational hypertension- which I really appreciated. I had high blood pressure at the end of my pregnancy, so I saw that and I was like, "Blah."

Dr. Harpreet Tsui 26:15

The things that we don't talk about with women when they're pregnant, just like maternal mortality, like post-

Dr. Komal Patil-Sisodia 26:23

postpartum

Dr. Harpreet Tsui 26:24

health. Your life changes so much. You have this baby and everyone's "Go home with this baby. You're gonna be fine." And you're like, "Are you sure? Okay, fine."

Dr. Komal Patil-Sisodia 26:31

Cause I don't feel like I'm gonna be fine.

Dr. Harpreet Tsui 26:33

And I really feel like it's always a shock to the patient with preeclampsia who comes in years later who's "Wait, now I'm still on blood pressure meds, and you're telling me that my cholesterol is high?" And you're just like, "Yes." And then you start to talk to them about the family history, which is another thing that I don't think is discussed enough. And then they're like, "Oh yes, the women in my family all developed X, Y, Z at this point in time." And I think also because Komal, I feel like a lot of us will say the women in our family didn't get any of this until they were peri or post-menopausal, until they were older."

Dr. Komal Patil-Sisodia 27:02

It's because they didn't get diagnosed before. It's called avoidance, friends.

Dr. Harpreet Tsui 27:07

You know what? I think that we're all sitting around having this happen. We're having our children later in life, so a lot of us are having- Yes, that is a

Dr. Komal Patil-Sisodia 27:15

big part of it too, I think

Dr. Harpreet Tsui 27:16

yes, in our 30s. Now we're in our 40s, now we're all learning about perimenopause, and I feel like a lot of us are sitting back going, "Oh, no. No, mom. Nope, that was... You were just not diagnosed 'cause you just never went to the doctor."

Dr. Komal Patil-Sisodia 27:29

Correct.

Dr. Harpreet Tsui 27:30

Yeah.

Dr. Komal Patil-Sisodia 27:30

Correct. So yeah, so it's definitely an interesting shift that we're seeing in these guidelines, and I really hope that it makes women more aware of their bodies. One of the things that I counsel my patients on is there's no stagnant point for women in our lifetime, if you think about it, from a hormonal perspective, we go from childhood, like that finger painting in kindergarten. It's probably the most stable I ever was in my life, I don't know about you.

Dr. Harpreet Tsui 27:54

Made a little popsicle house, and that was, like, the best part of my

Dr. Komal Patil-Sisodia 27:58

Life was great, and then you hit puberty, and hormones are changing, and they're changing on a monthly cadence because you have to have menstrual cycles in order to reproduce, and then you hit your reproductive years, and then you hit perimenopause and post-menopause, and all of these things. It's a constant change, so I recorded an episode with a good friend of mine, Dr. Sonja Wright. She is a midlife sex coach. She's phenomenal. But I had given a talk, gosh, I wanna say a year and a half ago, maybe two years ago now, And I was pissed about perimenopause, so I called it Mother Nature is Not a Feminist. I went through all these different changes during perimenopause I think I was still angry about them, so it came through. And, she's "That was a great talk." She's "But I disagree with you. I think Mother Nature is the biggest feminist of them all." And I was like, "How do you mean?" And she's we become resilient with all that change, that's our superpower. We know how to adapt, we know how to change, we know how to do all of those things because we have to go through all of these changes in our lives." And I just thought that was, like, such a beautiful reframe, and honestly, it made me less ragey. So I was like, "Thank you for changing my life," 'cause I was gonna be really angry for the next however many years over this. Sometimes you just need wisdom from a woman who's already gone through it to be like no. It's okay," yeah. Such a beautiful statement. So yeah, so we have talked about, okay, so now we're not chasing numbers on the cholesterol panel. We're looking at your risk overall at 10 years and at 30 years out. We are recognizing female-specific risk factors like menopause, PCOS, preeclampsia, gestational diabetes. We are looking at genetic cholesterol particles. Now, the interesting thing is, and this is where the numbers come in, we're looking at lower LDL targets for higher risk patients. We should talk about that. What are your thoughts on that?

Dr. Harpreet Tsui 29:41

I'm here for it because of a couple of things, and I really do have to say I'm here for it from my lived experience, growing up in a South Asian household, I don't know one South Asian person, male or female, in our age group who did not have somebody who had a massive MI, a stroke. And, like we would joke in our house we would have weddings and, big Punjabi family. And like my- uncle would, dial up his Novolog. He'd be like, "I'm gonna have two extra ladoos. There's paratha in the morning. I'm just gonna give myself a touch of insulin. Just so I'll be fine."

Dr. Komal Patil-Sisodia 30:11

Oh, the extra ladoos.

Dr. Harpreet Tsui 30:12

I actually think that the updated guidelines for LDL targets makes it so that if we can decrease LDLs and decrease inflammation, if you're high risk- your LDLs should be below 50, we should target these. And I went to a lecture pre-pandemic. At a lecture with a bunch of cardiologists and their partners who did veins, and these vascular doctors were literally saying LDL should be 50 or lower because so many, the population in the US, so many of us will end up with peripheral vascular disease and not just coronary artery disease based off of lipids and LDLs that are 100 or higher.

Dr. Komal Patil-Sisodia 30:47

Yeah.

Dr. Harpreet Tsui 30:47

And I was like when I got out of residency, the target was 100, and 70- if you were being aggressive."

Dr. Komal Patil-Sisodia 30:52

Right. 70 was the secondary target.

Dr. Harpreet Tsui 30:54

And now we're like, actually, if you clinically have an ASCVD score and like it's not very high risk, that you should be 70, and if you have a high risk, we really need to drop you down to 55. So I really love that. What are your thoughts?

Dr. Komal Patil-Sisodia 31:07

I feel the same way that you do, I think that we do need to be more aggressive with it. I think that I also liked that they called out that there are treatments other than statins if you can't tolerate the statins, that's where I think a lot of people don't know, and they were expensive for a while, but our PCSK9 inhibitors, which are injectable treatments and people tolerate better than statins, can really make a huge difference on cholesterol levels, so it's not just one way to be aggressive, and it has to be statins. If you truly don't tolerate them, they're causing muscle pain or even just degradation of your muscles, myositis then we can... We have other options which we didn't before, and there's also drugs that are in the pipeline for lowering lipoprotein little A, which I think is interesting, and these other two medications we know lower apolipoprotein B, so there's so much we can do to reduce risk for all patients, and then, yes, I am a big fan of trying to push it lower. Trying to get people on board with that when the recommendations keep changing is hard, because I think a lot of people are like but you told me this five years ago." And it's no, the science has changed now.

Dr. Harpreet Tsui 32:17

I think that's the key though. I think the key is that we, especially us as medicine, especially-

Dr. Komal Patil-Sisodia 32:21

Yeah

Dr. Harpreet Tsui 32:22

it's very important that we let our patients know science changes, medicine changes, and in three years when those phase three drugs come to us for the Lpdrugs, then things will be changing then. The way that I look at it is I don't really have a lot of patients on simvastatin, but when I got out of residency, I had a lot of people on simvastatin, but rosuvastatin came out, and the studies were there, i've got patients who tolerate ezetimibe really well. And I think the important thing is to remind our patients, like, when it comes to cardiovascular health and heart health, the science is there, and it's coming down the pipeline every single day. And so these guidelines are really similar to diabetes guidelines of A1Cs.

Dr. Komal Patil-Sisodia 32:59

Correct.

Dr. Harpreet Tsui 33:00

Very similar that way.

Dr. Komal Patil-Sisodia 33:01

Yeah. We used to say, it was a higher A1C that we were okay with, then we tried to push everybody as low as we could go, and then we realized putting them too low kills them. It's just-- it's-- we have to-- we settle somewhere in the middle. My husband is in PR and marketing and digital, social, and we always kinda laugh about how- The pandemic was advertised. We call it the biggest PR gaffe of our generation because it was the whole flatten the curve and then COVID will go away was the public understanding, that's what my husband told me he thought it was, he's why didn't it go away after two weeks?" And I told him flatten the curve doesn't mean that." He said what does it mean?" I said flatten the curve. So you have a curve, and under the curve are the number of patients who are gonna get sick during this pandemic. When you flatten the curve, the number of patients doesn't change, it just stretches out for a longer period of time." And he was like, why didn't we just say that?" And he's "And why would we do that?" I said, "So we didn't overwhelm the healthcare system and collapse it because everybody got sick at the same time and we couldn't save anybody." And he was like, "We should have just said that." And I said, "I know, but unfortunately the way that it was communicated out was like everybody, isolate for two weeks, we'll flatten the curve, and then it will go away was the presumption." Yes. I don't think we actually ever said that. But it's the same thing with any health guideline that comes out, our data, one, we have to do a good job of representing it to the people who are out there so that they understand why we're making these recommendations. And then second, we have to talk about why our guidelines are gonna change because we're gonna learn new things. I don't know if I ever told you this, Harpreet, but my hospital in Washington where I was working at the start of the pandemic was the first COVID deaths in the country. It was a crazy time because we were situated between five nursing homes, and that's where it started,

Dr. Harpreet Tsui 34:46

no.

Dr. Komal Patil-Sisodia 34:46

And so all of the cases were coming to us as a small community hospital. So the CDC shows up at our hospital and I was on the leadership team. And I remember we all came in on a Saturday when we found out those two cases were positive and we were having these meetings. And we laugh at the photos now 'cause everybody's in the room without a mask touching their face. But then the following Monday the CDC shows up, and we're like, "Oh, thank God. They're here. They're gonna tell us what to do." gonna be okay, and they're like, silently observing, and we're like, "You gonna tell us what to do?" And they're like we're here to learn from you." It's nobody knows right now because it is so fresh and so new. And it was such a surreal experience, to be in that moment where you realize something is happening. We don't have all the science we need to communicate it effectively to people, and it just sowed a lot of mistrust, because people thought that we were intentionally lying to them, and I feel like anytime a new guideline comes out or a recommendation changes, that mistrust is always there. "Oh my gosh, you guys are lying to us." And we're not. We're trying to adapt to changing science. And I don't know, I always preface it like that when I'm talking to my patients. I'm sure you do something similar.

Dr. Harpreet Tsui 35:59

Yes. Especially in our perimenopausal and menopausal, like our midlife women, because I often say to them, "Listen, I'm going through it, too."

Dr. Komal Patil-Sisodia 36:07

Yeah.

Dr. Harpreet Tsui 36:07

The science of what I learned when I graduated residency a decade and a half ago is different than what we learned March 1st. Let's go through it together.

Dr. Komal Patil-Sisodia 36:17

Yeah.

Dr. Harpreet Tsui 36:18

Yeah.

Dr. Komal Patil-Sisodia 36:18

And that's where I think this conversation is really important. Unfortunately, we don't have a ton of time in the traditional healthcare system. I know that's one of the reasons you opened your direct primary care so you get that time- to be able to educate patients. For me, it's a similar thing. I have a small direct care practice that I run on the side, and it is a different practice of medicine in which I get to spend more time with patients, and I really enjoy that, because I feel like we make reasonable changes, and people feel better when they are given information, and they understand what their health goals are.

Dr. Harpreet Tsui 36:51

I also feel like we're really lucky to be practicing medicine in this time.

Dr. Komal Patil-Sisodia 36:57

Yeah.

Dr. Harpreet Tsui 36:57

We get frustrated, but the guidelines that are coming out will mean that every woman that is our age, and honestly, women in their 20s and 30s will live longer, healthier lives because of these guidelines, because of the fact that women like us and other women in medicine and women scientists and PhDs are out there being like, "Nope. Everyone stop. We're gonna talk about women and what the heck is actually going on in our bodies."

Dr. Komal Patil-Sisodia 37:21

I look back at what happened to my mom when I was in high school with her heart disease and not being diagnosed for two years despite having symptoms because everybody was like, "Why is a 40-year-old woman short of breath?" Everybody thought it was her lungs, and it was not. It was her heart. And so by the time they found it, similar story, 80% blockage in her coronary artery. At that point, stents weren't good, so she had to have an open heart surgery, it just was like the beginning of the, a health decline. Yes. But now we are empowered to believe, or at least you and I are, and several other physicians are pushing to believe women when they come into the doctor's office, yeah. Unfortunately, years of being dismissed make it much harder for women to trust the system, but I agree with you. I think this is an amazing time to practice. I think we're going to be able to heal that distrust women have felt in the system- and make it better for the future generations. I don't have a daughter, but I have nieces.

Dr. Harpreet Tsui 38:17

Yes

Dr. Komal Patil-Sisodia 38:18

yeah.

Dr. Harpreet Tsui 38:18

you know what? We have baby sisters.

Dr. Komal Patil-Sisodia 38:20

We do. We have baby sisters. Yeah

Dr. Harpreet Tsui 38:21

we will be on their case forever.

Dr. Komal Patil-Sisodia 38:23

Yeah. If you girls are listening.

Dr. Harpreet Tsui 38:25

If you girls are listening, we're coming

Dr. Komal Patil-Sisodia 38:27

for you. We won't call you out by name, but you know who you are

Dr. Harpreet Tsui 38:31

Let me ask you a question now. As an endocrinologist and menopause specialist, how do you feel that these guidelines are affecting those of us in perimenopause? Where do you see that link?

Dr. Komal Patil-Sisodia 38:42

I think that, my big frustration is we talk a lot about symptoms of menopause, but we don't talk about the fact that this is where your cardiometabolic risk starts increasing pretty significantly. And I think that this is going to force that conversation because the number one killer of women is still heart disease, whether you are struggling with overweight and obesity or not, the number one killer of women is heart disease, period. And we don't do anything about it until something is wrong, instead of watching it and seeing when it will change. And I think a lot of us who are now caring for primarily women in our practices will be pushing that, when I started my direct practice a year ago, I was telling every woman who came in, I was doing a cardiometabolic screen on them and talking about their ancestry, their family history all of, anything in their past medical history that may have contributed. And I would tell them, "I'm going to check these two other genetic cholesterol markers in you." And this was before the guidelines came out. I feel very validated in seeing that. I think it will encourage other people to do that, hopefully. And hopefully it will empower women to say, "Okay, this is something that's happening to me, not something that's my fault- because, my hormones are changing, and so now I need to do something actively to manage it so I can have a great quality of life and good longevity after."

Dr. Harpreet Tsui 40:04

Why is it that when your estrogen starts to drop, your LDL starts to go up?

Dr. Komal Patil-Sisodia 40:09

So I think a lot of it comes down to our body composition changes that happen, when we lose our estrogen, we have a harder time holding onto muscle. We see that we develop more fat tissue because fat tissue produces estrogen, so it's our body's messed up way of saving itself, unfortunately, a lot of that fat tissue that we gain in midlife tends to be right around our abdomen, and it's visceral fat. And you and I know what visceral fat does. It is going to create that environment of insulin resistance and of processing of your cholesterol in a way that those levels stay elevated because you're insulin resistant, and so I think it all comes down to that, and that's why I get so frustrated When women are like, "Oh my gosh, I'm gaining all this weight," but they don't want to understand the cardiometabolic piece of it, or nobody has bothered to explain it to them. I don't think it's that they don't wanna understand it. I think it's that people are not emphasizing how critically important it is going to be- to the quality of their life later on.

Dr. Harpreet Tsui 41:09

Yes. And I will say while not hormone specific and probably more in the cardiometabolic piece of it- i've been checking HSCRPs for many years.

Dr. Komal Patil-Sisodia 41:17

Yes.

Dr. Harpreet Tsui 41:17

Cause I always tell women "Okay, we can have this and we can have that, and we do the apoprotein." And I was really surprised when my cardiologist checked my HSCRP and it was high. And I thought, I did a deep dive on HSCRP in South Asian women with the MASALA trial but-

Dr. Komal Patil-Sisodia 41:35

Yeah

Dr. Harpreet Tsui 41:35

I was really surprised that we don't put that kind of emphasis on an inflammatory marker when, as women, we're dealing with literally more inflammation due to adipose tissue, causing all visceral fat. Like, a vicious cycle.

Dr. Komal Patil-Sisodia 41:48

Yeah. And I think I'm a firm believer that we should check it, I was diagnosed with autoimmune arthritis right at the beginning of the pandemic. We'll talk about that another day-

Dr. Harpreet Tsui 41:57

part two.

Dr. Komal Patil-Sisodia 41:58

Stay tuned, y'all. But the interesting thing was when I was first diagnosed with autoimmune arthritis, I was not quite perimenopausal yet, and my HSCRP was totally normal. The only abnormal inflammatory marker I had was a slightly elevated ESR. And the reason I got diagnosed with autoimmune arthritis was that I had skin psoriasis, and then they saw joint changes on x-ray, but otherwise, my blood markers were totally normal, but then this last year, I checked an HSCRP and it was elevated for the first time, and I was like, "My arthritis is controlled." Make it make sense. So it's like this is all midlife change,

Dr. Harpreet Tsui 42:33

just me

Dr. Komal Patil-Sisodia 42:33

wanting

Dr. Harpreet Tsui 42:34

And so- it's the hormones. Give me the hormones It's- I need the hormones

Dr. Komal Patil-Sisodia 42:38

I... No, at this point, girl, I need a statin. Sign me up,

Dr. Harpreet Tsui 42:41

I have a bunch at my house if you want some.

Dr. Komal Patil-Sisodia 42:43

I have a primary care appointment coming up, so we will definitely chat about that, but this is where we have tools that help women, I have also seen, in women who struggle with overweight and obesity when they get started on GLP-1s or the GLP-1/GIP combination, there's an improvement in their cholesterol as well, so there are different things that we can do. There's an improvement in the inflammation. I think there's new studies coming out in the rheumatology space that show some of the GLP-1s are really good i- for autoimmune conditions as well, there are so many things that we can potentially do to improve somebody's metabolic status I think we just have to keep talking about it. But again, women have never had the opportunity to be educated about these things in midlife.

Dr. Harpreet Tsui 43:26

No, and I have to say just to share my own story- Yeah when I was 44 and I started having what I felt like my brain was falling out of my head. Yeah. And I was having so much brain fog. I'd be in front of a patient and not know a word, and I started on my hormones. You could take my transdermal estrogen out of my cold hands, okay?

Dr. Komal Patil-Sisodia 43:45

Yes.

Dr. Harpreet Tsui 43:45

Love it. It's been such a life-changer, but I still needed a statin with an elevated LDL, an elevated HSCRP, I ended up getting a CTA coronary scan with some really great heart flow studies. I see a cardiologist in San Diego, and now I'm on a plan. And now I just did my labs, and my LDL's back down to under 70. My HSCRP- is down normal. And it's also because I added back in my GLP GIP because I had lost so much weight and I've kept the weight off, but the food waste had come back. Have bilateral family history of di- both sides family just-

Dr. Komal Patil-Sisodia 44:20

right to me. Yeah.

Dr. Harpreet Tsui 44:21

Type 2 diabetes. Everyone in my family is diabetic on both sides, so I feel like that combination really has unlocked the plan that works for me.

Dr. Komal Patil-Sisodia 44:31

And everybody is so genetically diverse, and that was why I gave those examples of those two patients, like my Southeast Asian one and my one who's white, and it's very different what I saw in them. And I will continue to monitor both of them in the same way and suggest interventions based on how their trends change. But we can't not have those conversations with women, and so that's why I am really pushing to figure out how we can emphasize the importance of that, how we can empower women to be able to get information to have conversations with their doctors about how we can make sure our colleagues are stepping up to the plate as well, and I think everybody wants to. It's just the current healthcare system is interesting.

Dr. Harpreet Tsui 45:13

Yes, to say the least.

Dr. Komal Patil-Sisodia 45:16

Doesn't leave a lot of time for shared decision-making visits, no. And that's really hard because I think every person deserves that time. So let's switch gears a little bit and, we talked about statins a little bit, but what I'd love to hear from your perspective is when you counsel your patients these are clearly indicated, or when you can give it a little bit of time and see whether, their lifestyles will work.

Dr. Harpreet Tsui 45:42

So I do feel like lifestyle is important, and that is a whole piece in and of itself. So one thing that I do in my office-

Dr. Komal Patil-Sisodia 45:48

when

Dr. Harpreet Tsui 45:48

patients are coming in, regardless of gender, regardless of age, I really sit down at that first visit and I have a deep dive about what they eat. And I say to them, "Give me just a typical day. I just wanna know what time and what it is you're eating, what your schedule is like." Are you managing multiple jobs? I'm in Las Vegas. Are you a shift worker? We got a lot of people that work swing shift, graveyards, are you in healthcare? Do you have children?

Dr. Komal Patil-Sisodia 46:10

Yeah.

Dr. Harpreet Tsui 46:11

It is very important to be like, "How did you eat and how do you eat now?" Because when I pull some of these labs, I take that into account, so I'm looking at almost, like, how the prevent AHA guidelines have changed. The calculator's different, i'm looking at all of that. And I, living in a city where I live you have to also take into account food prices, They're grocery shopping, all of those things. So if I feel like someone's BMI is high and their LDL is likely elevated along with triglycerides due to poor diet, I will go with that first, and I will give that three months. And for me, it's do, would they benefit from a GLP or a GLPGIP? Will they benefit from some nutrition counseling? I do a body composition on all of my patients on their first visit if we're doing cardiometabolic, hormonal health, and we look at fat-to-muscle ratio and all of those things. And so sometimes with my older patients, especially, can we take a walk? What can we do? Where can we make changes? Can we do a meal delivery service? Oh, is that too expensive? Okay. Let- here are some easy recipes. And then if at the three-month mark the triglycerides have come down to normal, but the LDL is still high, okay. Look, the calculator has changed this much. These are your past medical history. I really think you would benefit from taking a statin. When it comes to the misinformation piece you counsel them about all the stuff that's been debunked. And then a lot of times the patient says, "We're gonna do this for three months."

Dr. Komal Patil-Sisodia 47:28

Yeah.

Dr. Harpreet Tsui 47:28

And then we're gonna- reassess and we're gonna go from there. And sometimes it's adding ezetimibe. Sometimes you're seeing okay, I did that, plus you had high triglycerides, so we put you on an omega-3. It's working, but it's not working, or you have myositis or you have, back pain or you're having leg cramps. Let's try a PSK9 inhibitor. Let's just try it and see what happens. And the other thing I like to add in, I think from a cardiometabo- metabolic standpoint is a calcium score. Like a coronary calcium scan. Because again, you can have a score of zero and that's great, or you could be like me who had a perfect LDL and an elevated HDL and a score of 214. Yeah, at 43. And can I be honest with your listeners and your viewers? I literally just did the coronary calcium score 'cause I was in a competition with my husband, and I was gonna prove to him that my heart was healthier than his, and he still hasn't done his, so I'm calling him out. It's been three years, and he hasn't done

Dr. Komal Patil-Sisodia 48:21

his. The talk.

Dr. Harpreet Tsui 48:21

Yeah. But that led me to be like, "Oh-" Yeah "what we know about HDL is probably..."

Dr. Komal Patil-Sisodia 48:29

Not true

Dr. Harpreet Tsui 48:29

not true.

Dr. Komal Patil-Sisodia 48:30

Yeah.

Dr. Harpreet Tsui 48:31

I- Likely an independent biomarker for atherosclerosis.

Dr. Komal Patil-Sisodia 48:34

And it's interesting because I interviewed a cardiologist, Dr. Ambreen Mohamed, and I'm excited for that episode to come out, but we talk about that. We talk about CT coronary angiogram and the role of that, and there is so much heart disease that we don't know about that's just lying there in wait for us. And I'm glad you had this competition with your husband, and tick-tock, he needs to get on it.

Dr. Harpreet Tsui 48:59

Yeah, come on. He's gotta get on it. That, and his colonoscopy. But you know what? We're gonna get it all done. It's happening.

Dr. Komal Patil-Sisodia 49:05

Yes. But, I mean- Yeah, step by step,

Dr. Harpreet Tsui 49:07

yeah, and I think that the interesting thing is when we were in training, coronary calcium scores weren't a thing. And even then when we were in practice- Yeah, they're- coronary calcium score was not a thing, it's- It,

Dr. Komal Patil-Sisodia 49:18

it's a pretty recent thing, but it's interesting because our cardiology colleagues, they've been doing this for a long time,

Dr. Harpreet Tsui 49:24

long time

Dr. Komal Patil-Sisodia 49:24

I remember when my lipoprotein little A popped up, like I texted one of my colleagues in cardiology and he was like, "Oh yeah, do an ApoB, get a coronary artery calcium score. Come in, we'll do a treadmill te- he just had a whole thing laid out for me, and I was like, "How often do I gotta do that?" He's "Like every three years if it's all negative." And I was like, "Oh, okay. That's good to know. Where's that written down?"

Dr. Harpreet Tsui 49:47

Yeah, nobody wrote it down anywhere.

Dr. Komal Patil-Sisodia 49:49

Yeah, exactly. I've been trying to learn from them because I think unfortunately with the way that m- medicine has become, as we get more specialized and as we gain more knowledge, we naturally get a little bit siloed. And if we're not taking that accountability to learn from each other- We're not really dispensing information in the right way. So I'm glad that he was, like, very open with sharing that with me. How do you manage your s- patients when they start having the symptoms, the myopathy symptoms and things like that. Do you feel like they're more resistant to trying a PCSK9 because they've had a bad side effect to the statin, or do you think that they're more open to it? I don't know, I get a mixed bag.

Dr. Harpreet Tsui 50:30

I get a mixed bag, too. I feel like one thing that I do with statins, and I did learn this from a cardiologist, is some of my older patients and For women, because we know that women metabolize statins differently than men do. So I will often guide them and say, "You may get muscle cramps. You may get leg cramps. But you know what? If that happens, you take it two nights in a row. Why don't you take it every other day for a week," "and then that'll help get you up there," or, "Why don't we start on a lower dose and move our way up to where we need to be," there's a lot of things we can do. I feel like the big thing with PCSK9s, price, if they're not all covered. Yeah, and do you mean I have to inject myself?" or, "What do you mean I have to go to an infusion center and get LEQVIO?" You're just like, "Yeah, I know." And so then I like to tell them, "But it's not all the time."

Dr. Komal Patil-Sisodia 51:11

Yeah.

Dr. Harpreet Tsui 51:12

And then it's like- Every

Dr. Komal Patil-Sisodia 51:13

day,

Dr. Harpreet Tsui 51:14

yeah and then they ask you. Like I know your patients do as well. They'll say, "Okay would you do it?" Yeah, 100%. I'm a young woman who has children and a business and a healthy life and a fabulous life, and I don't wanna die. And over something that could be prevented. And so I feel like having, again, that really open, honest conversation, I can get about 75% of my patients that if they need a PSK9 inhibitor to do it. I will say in Nevada, the difficulty is when I do prior authorizations, which is another topic for another day- a lot of these big insurance companies are asking me to have an endocrinologist, a lipidologist, or a cardiologist on board, and I'm like, "For what?"

Dr. Komal Patil-Sisodia 51:50

like, "I have all

Dr. Harpreet Tsui 51:51

that expertise." I can do it in the meantime.

Dr. Komal Patil-Sisodia 51:52

Yeah. That's crazy work.

Dr. Harpreet Tsui 51:53

So then I'm like calling cardiologists, and they're like okay, I'll see the patient and do the test, but can you manage the PSK9?" I'm like, "That's the whole reason I'm..." "This is what we're trying to do." I'm, like, fighting insurance 25% of the time.

Dr. Komal Patil-Sisodia 52:07

Yeah. It's really frustrating. I agree. And again, this is a topic for another day. I spent a few years as the quality officer for a medical group. Learned way more about insurance and Medicare than I ever wanna know, and I have a lot of thoughts. So we'll do that on a different day because it really does cause patients to suffer and not get the care that they need when they are having difficulty navigating that system. It's really unfortunate. All right. And then let's go through, what are your takeaways for, because we are in different geographic locations. This podcast is going out to... I was looking at the stats. It's hit- Yeah 77 countries in the world. For the people who are listening but don't, are not going to come see us, what do you recommend that they tell their doctor when they come in to talk about their cholesterol or their cardiometabolic risk?

Dr. Harpreet Tsui 52:55

I think the biggest thing is having a really clear history from your family. Sit down with those who are around still, dig deep and find the data the family. When did Auntie Margaret have a heart attack, when did Uncle John stop smoking? Try to find all that out. Take it to your doctor and ask for the PREVENT ASCVD calculator. Say, "I want to have my cholesterol..." We have to advocate for ourselves as patients. Say, "I wanna have my cholesterol checked, cardiovascular health history in the family that I'm worried about. I'm worried about my age or where I'm at hormonally as well. Can we do an apoprotein B? Can I have an LP? Will you do the calculator for me?" Have that conversation because, again, I think the biggest takeaway you and I can take from the new guidelines is we cannot just use total cholesterol, HDL, triglycerides, and LDL, and non-HDL cholesterol. We can't. We have to use these genetic factors. And have the conversation, again and I say this as an obesity medicine doc, have the conversation about GLPs and GIPs. Yes. Please-

Dr. Komal Patil-Sisodia 53:54

Yes

Dr. Harpreet Tsui 53:55

have

Dr. Komal Patil-Sisodia 53:55

that

Dr. Harpreet Tsui 53:56

conversation. And if you have a doctor who's "I don't believe in that, I don't write in that," find another doctor.

Dr. Komal Patil-Sisodia 54:04

Yes, because that person is not up to date on the science.

Dr. Harpreet Tsui 54:07

Yes. Ask for your insulin level. Go in and ask. Again this is a whole other conversation you and I can have. But, menstruating women who are tired, why do we not check ferritin regularly?

Dr. Komal Patil-Sisodia 54:17

Thank you.

Dr. Harpreet Tsui 54:18

Why?

Dr. Komal Patil-Sisodia 54:18

I do.

Dr. Harpreet Tsui 54:19

I

Dr. Komal Patil-Sisodia 54:19

do. So

Dr. Harpreet Tsui 54:20

Patients come into my office and they're like... I have a midlife Asian woman, came in yesterday, has spent bajillions of dollars on functional medicine doctors, seen every specialist, was told that doctors, "Oh, I don't think you need that. You're skinny. I don't think you need that." No, I'm sorry, she has medical problems and hormonal health that needs to be taken care of. And go to your doctor and say, "I want these things." And I think as a physician, if you're listening, it's really behooves you to check insulin levels in your insulin-resistant patients. Talk to your women about PCOS. Do this calculator regardless of ethnicity, but, know that certain ethnicities, like all of my Asian ethnicities, I talk to them about being skinny fat, because it is a legitimate thing. And to the people that are listening, a lot of things can be changed with diet, but don't be scared to start medication. And I think you and I can say that as doctors and as patients ourselves don't be afraid to start medication because there is sometimes no natural way to lower your... There's no natural way to lower your LP little A and your apolipoprotein B. It's just not gonna happen. There's not. And so also know that because I see a lot of families of adults know that you can start checking your children, but if you're going to your doctor and you have your child with you and they're 19 and they haven't had their cholesterol checked, let's start checking it now.

Dr. Komal Patil-Sisodia 55:33

Yes. it's important to do all of that. I think we talked about this. My husband had a heart attack in his late 30s, and I am so type A about... I think I was almost pushing our pediatrician. She's "How about we wait till he's..." 'Cause my son was, like, almost four. He hit eight and I was like, "When do we check his cholesterol?" And she's "Not now. Not now." And I was like, "Okay, that's fair. That might traumatize him with the blood draw," but- If

Dr. Harpreet Tsui 55:55

You can start as early as the age of two if you have a family history of early cholesterol.

Dr. Komal Patil-Sisodia 56:00

Yeah. And back then, that wasn't the guideline,

Dr. Harpreet Tsui 56:02

wasn't the case,

Dr. Komal Patil-Sisodia 56:02

yeah. But we've checked it now, and it seems to be fine, and so we're gonna watch it. But I do think once he hits puberty And things are gonna change throughout your lifetime, all of these different shifts that we have come with new health problems or potential for health problems. Not always health problems, but potential for it, and if you're not watching, you're gonna miss something. So that's really my shout-out to all of our amazing primary care docs who are out there. These amazing physicians and APPs are the ones who keep you in check. So go, make sure you make your visits. Make sure you're seeing a primary care doctor once a year. I know the system is frustrating. What I hear from my patients is "Oh I saw my primary. I really liked them, but then they left." It's a real problem, but when you find somebody, you hold onto them. I drive 20, 30 minutes to see mine 'cause she's that far away, but she's amazing and I will try and follow her wherever she goes.

Dr. Harpreet Tsui 56:52

Primary care doctors need their own primary care doctor. Yeah I haven't had a primary care doctor in a while, but yes.

Dr. Komal Patil-Sisodia 56:57

Yes. Correct. Also, for our physician colleagues, take care of yourselves, especially our female physician colleagues, because I hated that data that came out that showed we have a higher mortality rate than any other profession.

Dr. Harpreet Tsui 57:08

I was at a women's breakfast speaking on a panel and I- shocked the entire room by saying that female physicians have the same risk and age of death as Caucasian males in the US. They were like, "What?" I'm like, "Yeah."

Dr. Komal Patil-Sisodia 57:19

Not a fun stat

Dr. Harpreet Tsui 57:20

check that HSCRP, ladies. Get that done. Let's do it.

Dr. Komal Patil-Sisodia 57:24

Thank you so much for your time today. This was an amazing conversation. I hope it is helpful to all of the listeners that are out there, and I will look forward to seeing you all on the next episode. Harpreet, where can patients find you? If they're in Nevada and lucky enough to see you, tell us about your practice, and then also your socials so they can follow your amazing content.

Dr. Harpreet Tsui 57:44

Thank you so much for having me today. This was great. You can find me in Henderson, Nevada, coronadohealthdpc.com, on socials on Instagram as drharpreet.tsui, on TikTok as dr.harpreet.tsui. But I always tell people, just put Harpreet Tsui into the search Google and you will find me somewhere-

Dr. Komal Patil-Sisodia 58:03

the world. There's only one. I don't know another Harpreet Tsui. That's it for today, but the conversation doesn't have to stop here. Come find me on Instagram or TikTok at drpatilsisodia. And if something from today's episode resonated, I'd genuinely love to hear about it. Leave a review, which makes the podcast searchable, share the episode, or just send me a message. The more women who have access to this information, the better. I'll see you next week on the next episode.