Why Normal Cholesterol Can Still Kill You | Hidden Heart Attack Risks EXPLAINED

Think your cholesterol is fine? Think again.
In this eye-opening episode, Dr. Michael Richman, a world-class cardiothoracic surgeon and lipidology expert, breaks down why standard cholesterol tests are dangerously outdated—and what your doctor may not be telling you.

Even if your LDL, HDL, and total cholesterol appear “normal,” you could still be at high risk for a heart attack. Why? Because the real threat isn't your cholesterol level—it's how that cholesterol is transported in your blood.

🎯 Here’s what you’ll learn:

Why over 50% of first heart attacks result in sudden death

How athletes, vegans, and people with “perfect” labs are still dying

What traditional cholesterol tests miss entirely

The role of lipoproteins (the “cars” of cholesterol) and why they matter more

What tests to ask your doctor for (advanced lipoprotein testing, Lp(a), ApoB)

Why genetics are more important than diet

The shocking truth about statins and brain health (spoiler: they don’t cause dementia—they help prevent it)

Why even top cardiologists take lipid-lowering meds—even if their numbers are “normal”

This episode isn’t fear-mongering—it’s about empowering you with knowledge that could literally save your life.

 Resources Mentioned:
👉 PaladinMDs.com — Watch the animated video on how cholesterol enters the artery wall
👉 Look up: “ASTEROID Study” & “METEOR Study” for plaque stabilization with statins
👉 Ask your provider about advanced lipoprotein testing (covered by insurance & Medicare)

Transcript

SPEAKER_00: 0:00

Okay, hello everybody. How are you doing today, Dr. Richmond?

SPEAKER_01: 0:04

Morning, Mike.

SPEAKER_00: 0:05

Okay, so today we're going to talk about probably the most important thing that we can talk about, and that's why I wanted to start us off with this. And it just so happens that my partner is a cardiothoracic surgeon, and he's been doing lipid management for 20 years. He's also on the editorial board of the Journal of Clinical Lipidology, which is a premium peer-reviewed lipid journal. And the reason why I think this is so important is the number of people that die from heart disease every year is astronomical. And if you look at the numbers 20 years ago and the numbers today, it really hasn't changed that much, which is amazing. If you think about all this stuff, all the diets and all the stuff we do, it hasn't really changed that much. And, you know, still being an active surgeon and treating people and, you I still am amazed at how many people are still dying from this. And the other thing that should scare all of us is I know a bunch of people, normal calcium, zero calcium score, they exercise, they work out, they jog. Some of them also had CT NGOs and they all say, oh, my lipids are fine, my cholesterol is fine, and they die. So why are these people dying? You know, on a personal note, my cardiologist referred me to lipid management doctor. And it just so happens Dr. Richmond is one. So for me, it was easy and I did my testing. And this is something that I want everyone to know. And I've been telling friends and patients this, and I'm a surgeon and I still wasn't that up to date on this. So without further ado, I'm going to let my Dr. Richmond come in and share his wealth of knowledge.

SPEAKER_01: 1:51

Thank you. Thank you. So just a little background, expand on what he said. So statistics are a little behind. So in 2021, there were 938,000 cardiovascular deaths. That's stroke, heart attack, peripheral vascular disease. In the year 2000, there were over 950,000. So that makes anywhere between 35% and 39% of all deaths in the United States are due to cardiovascular disease. So like I tell people, when you drive by a cemetery, every one and third tombstone is a cardiovascular death. And it's amazing. It's frightening. So today's topic, really, if you want to get down to it, is... Why are lipid measurements falling short? In other words, what are we doing wrong with cholesterol? And then once we figure that out, what can we do to improve our testing, our risk factor scoring to give people extra life? Because Believe me, I did a presentation that we'll refer to at some point. How does a heart surgeon prevent a heart attack? But, you know, a little background, like Dr. Fiorillo said, I'm a heart surgeon. So a cardiologist is a non-surgeon. A cardiac surgeon is a surgeon. I'm the one who opens up the chest. And one day in 2000, I want to say 2005, I was doing a bypass. And I thought to myself, I don't even know how arteries get blocked. I know how to fix them. but I don't even know how arteries get blocked. So one of the leading lipid experts happens to be in New Jersey and I called him up on the phone and I introduced myself and he hung up on me. Typical Jersey, right? Hung up on me. Thought it was a joke and I called him back and I said, listen, I'm a cardiac surgeon on the West Coast. And I said, I need to learn everything about lipidology because there's no formal training in it. And I spent the next year year really learning everything and reading everything and ultimately getting myself on the editorial board of the Lipid Journal, then was asked to write with him in another academician, Lipid and Lipoprotein Guidelines, how to manage people.

SPEAKER_00: 4:11

Mike, people don't understand, just to jump in real quick, people just go by cholesterol and now a lot of people's HDL, LDL, see a lot of People short saying, oh, my ratio is good. So we'll talk about that. But people just think, oh, I'm good. My cholesterol is good. And we don't want, most people that die of a heart attack probably have good cholesterol is the point. So Mike's going to extrapolate on. It's not just getting your number and saying, okay, I'm good. My cholesterol is good. I'm not going to have a heart attack.

SPEAKER_01: 4:40

Expanding on that. Okay. So we gave a little background with the numbers. Atherosclerosis. is the deposition of cholesterol-laden plaque within the artery wall. And if Brian, if you can show that first picture, I'd appreciate it. Okay, so that is an artery cut end on. And the big part, the pink part, That's called the lumen of the artery, and that's where the blood flows. And then the artery wall has three layers, that really thin layer is called the intima. And then where that yellow is, that's the media, that's the muscular layer. So when you feel your pulse in your wrists, that's because the muscle's pumping. And then you have something called the adventitia. And if you notice, the cholesterol plaque is inside that first layer. It's not where the blood flows. And that's key. That's what people don't understand. Doctors don't even understand that, if you can believe that. So somehow the cholesterol has got to go into the wall of the artery. And when a blockage occurs, so it occurs from the inside of the wall and pushes and blocks and narrows. So that's called atherosclerosis. And atherosclerosis is endemic. It's been around since the... The dawn of time. So how do we know that? Well, in 2013, a mummy study was published, which is really interesting. So they did CT scanning of the coronary arteries of 137 mummies. And these included mummies that spanned 4,000 years. And one group of them was from South America, vegan only. And they found across the board 34% of the mummies had significant atherosclerosis, including women and children mummies who were vegan. So that debunks the myth right there that atherosclerosis is a disease of white men who smoke and go to Dairy Queen. And then if you look at the autopsy studies of the U.S. dead in the Korean War, in Vietnam, in Gulf War, in Afghanistan, upwards of 60% of men between 18 and 35 had significant, I'm not talking 30, but over 50% blockages. So this starts in birth. And if you don't get a handle on it, when you're young, it's a progressive disease. And I'll ask Mike right here, okay? And we'll see if he gets the answer right, because even though he's smart as can be, doctors don't know this. What is the first sign in most people that they're having a heart attack?

SPEAKER_00: 7:31

Well, what we're all taught is pain, right? When you tell me it's not, but we're all taught pain in the chest radiating to the arm.

SPEAKER_01: 7:38

Right. So the first sign is 50% of people is sudden death. You're dead. You're dead. That's the threat.

SPEAKER_00: 7:44

And listen, and this is why we're doing this. This is what scares people, right? People are dropping dead. And I think we all know people that it's happened to. And, oh, my friend runs, you know, three miles a day and he's dead. the next day. So yeah, 100%. We want to know what's inside our artery. And, you know. Okay, so

SPEAKER_01: 8:03

moving along. So the five major risk factors for cardiovascular disease, so in other words, blockages, are age. We all get old. Can't change your age. Smoking, high cholesterol, type 2 diabetes. I'll say a word about that. There's 93 million people in the United States that are pre-diabetic. 28 million diabetics. All pre-diabetics and diabetics have abnormal lipid panels. Okay. Cholesterol testing. And then the final one is high blood pressure. But what is the thing that I didn't say? This is why I don't do traditional risk factor scoring is because they don't mention genetics and everything is related. And everything is related to your genetics. So when people say, oh, you're low risk, you're moderate risk, you're high risk. I just want you to think about it logically and intuitively. So if Mike said to me, Michael, I don't smoke. I'm not going to divulge his age somewhere in the 50s. I don't have high blood pressure. I think I don't have high cholesterol and I know I don't have diabetes. But my dad died at 55 of a heart attack and his uncle died. at 58 of a stroke intuitively. Do you think he's low risk? And the answer is no. Absolutely not. But we base everything on this antiquated, stupid risk factor scoring. And if you look at the Framingham risk factor scoring, there's two points that nobody even, you can't be diabetic. to be accurately risk factor scored in the United States, and you can't have coronary artery disease. Well, we know that coronary artery disease is an epidemic, so clearly we're not adequately risk factor scoring people, okay? So what can we do to enhance the probability of identifying everybody? And that's what we're talking about today is how do we properly test people? Because we do a hundred

SPEAKER_00: 10:05

questions in today's day because people are spending a lot of money going to longevity centers and places and doing prophylactic tests like angiograms and calcium scores. And we're not saying that's a waste of money or a waste of time, but people do need to know that that's not the end all be all.

SPEAKER_01: 10:25

Kind of is a waste of money and kind of waste of time. But that's from a heart surgeon. But that's for a future show. But OK, so we're doing 125 to 135 million cholesterol tests a year. Still, it's the number one killer. OK, and now here's the fun part. OK, so cholesterol, regardless of what all you people think. 80% of your cholesterol in your body is genetic. 20% is dietary. Most cholesterol is made in your liver and in your small intestine based on your genes. So in other words, you cannot diet away your cholesterol. Okay, we make about 800 to 1200 milligrams a day in our body and we eat maybe 200 to 400 milligrams. And of that, you absorb through your intestine about 8%. So I have vegans, who their cholesterols are disasters. Because remember,

SPEAKER_00: 11:21

you can't... Mike, that's a really good point. People do not realize it's very difficult to lower your numbers by just diet. Very hard.

SPEAKER_01: 11:30

Yeah, almost impossible, you know? So, okay, so we're doing all these cholesterol testing. And we know that if you look at the Framingham study, which was 26 years, if you compare people who have heart attacks and who don't, have heart attacks, there's an 80% overlap of cholesterol levels. In other words, if you look at somebody's cholesterol level, the people who had heart attacks and the people who didn't have heart attacks, 80% of them overlap. So in other words, the way we're doing it, you're looking at them, all bets are off. Waste of time. So what is the answer? How does a heart surgeon prevent the heart attack? Well, first of all, The whole lipid hypothesis, and Mike knows because you see all over the internet every day, these fools, for lack of a better word, say eat as much cholesterol as you want. It's good for you. So in 1909, a guy by the name of Anshakov in Eastern Europe, who was in the Imperial Army, force-fed rabbits cholesterol and sunflower oil and induced rapid atherosclerosis, so blockages. And then was able to identify in the wall of the artery, these cells that come in and coalesce together and form cholesterol plaques. So 1909, we're in 2025. And there's people that are still arguing against biology. And we've realized over the years, and this is my little demo thing. This is from an Italian restaurant. And this is balsamic. Sorry about that. Let me put it in the middle. This is balsamic vinegar and olive oil. So when you get regular testing, you know they do a total cholesterol. They do an LDL cholesterol, which is your bad cholesterol. They do an HDL cholesterol, which is your good cholesterol. And they do a triglycerides. First, a little bit about total cholesterol, which Mike didn't even know. And remember, I didn't even know. And we both went to med school. There has never been written one guideline that says you're supposed to look at your total cholesterol. Yet everybody walks around and says, oh, my doctor said my total cholesterol is less than 200. I'm in good shape. Or my total cholesterol is above 200. I'm in bad shape. That's never written into one guideline. OK, so block that out. So what do we look at? Unfortunately, we look at LDL-C, which is your bad cholesterol, which I refer to as the people. So I made this analogy years ago, the Richmond analogy. And the analogy is, if you think of people on a highway, so think of an artery. If you think of people on a highway, is it the number of cars that cause a blockage or the number of people in the car that cause a blockage or a traffic jam? Answer, Mike?

SPEAKER_00: 14:32

Number of cars.

SPEAKER_01: 14:34

Correct. Well, we measure the number of people. So regular cholesterol testing, all they do is they're taking and they're measuring the amount of liquid cholesterol in 100 cc's of blood. And what does that tell you? That tells you absolutely nothing. Because if I turn this on the side right here and I say to you, whoops, if I say to you, get, oh, it's hard. Sorry, guys, I'm moving. If I say to you, mix the oil and the blood. You can't because they're not soluble in each other. So what the body does is it packages the cholesterol in cars, round cars, to allow it to travel where it needs to go and where it doesn't need to go. So in 1967, Dr. Friedrichsen wrote in the New England Journal of Medicine, atherosclerosis, I'm paraphrasing, is a disease of cars. It's a disease of what we call lipoproteins. It is not a cholesterol disease. It's not a people-in-the-car disease, okay? And that's key. So we measure the people in the cars, but we've known since the early 60s, actually 50s, that these cars drive the cholesterol into the wall of the artery, just like we showed you that picture. Yet, Very few people understand it and very few people do.

SPEAKER_00: 15:59

And I think that's why you're starting to see some people saying cholesterol is not bad for you and and saying, you know, these numbers are fine. And and there's a lot of that now on social media. And that's probably why, because in a way, there's some truth to that, too.

SPEAKER_01: 16:14

Right. OK, so if we're measuring one hundred and twenty five million people, same number of people are dying, 50 percent of people. First sign is they're dropping dead. The CDC says 50% of people who survive a heart attack and make it to the emergency room have normal cholesterol. As soon as you do what's called advanced lipoprotein testing, you realize they don't. And all diabetics and pre-diabetics, their cholesterol looks fairly normal on a regular panel. And as soon as you do advanced lipoprotein testing, where you're actually doing an MRI of the blood, covered by insurance, covered by Medicare, FDA-approved, You're measuring the lipoproteins. When you measure lipoproteins, you identify every single person at risk and miss nobody. So how do we reduce? I mean, I wish this would be a staple in the health care system mandatory for everybody. So how would we reduce cardiovascular events in death? Number one. Identify everybody. So if you do lipoprotein testing on everybody, you will identify every single person at risk and miss nobody. Now, nobody will argue with this who knows the field, okay? The second thing is once you identify somebody, okay, at least you've provided the service. If you don't want treatment and you want to try voodoo, God bless you. You know, yes, you need medicines. And Mike's not going to deny that, you know, like you can't diet yourself away. But the problem is if you don't identify people, how do you give them that option? And everybody does come around. Believe me, they diet, they try this diet, that diet, and ultimately they realize, oh my God, I can't diet this away. And it is the number one killer. And I've got to do something about it. So lipoprotein testing. Is

SPEAKER_00: 18:14

the answer there? For people listening who have cardiologists, or even if you don't, ask your cardiologist. Advanced lipoprotein testing. That was something new to me, too, just over the last few years. So, very important takeaway.

SPEAKER_01: 18:28

You know, and so on my website, there is, and I'll give you the website address. If you go up on the top, it says lipid consultation. You scroll down, there's a fantastic animation of... that screenshot that I showed you of an animation, how a lipoprotein gets into the wall of the artery and how atherosclerosis occurs. Okay. And that's www.paladinmds.com. That's P-A-L-A-D-I-N-M-D-S.com. And I want everybody to go watch that video because once you see it, it crystallizes. And how does a particle get into the wall of the artery? Well, inside the artery wall, inside that first layer are holes called pores, P-O-R-E-S, like pores on your face. And if you remember from biology, diffusion, which you may think is osmosis, but it's diffusion, and it's stuff in life flows from where there's a lot to a little. So if you have a lot of cars on the highway running through your blood vessel, They go through the wall of the artery where they get eaten up and they become an atherosclerotic plaque. Okay, Brian, show the second picture. Okay, so there's the atherosclerotic plaque. Now you'll hear a term called angina or angina. So let's talk about classic angina. So as the plaque gets bigger, in other words, It pushes from the bottom up, pushing the wall up. When you get a 50% blockage, a person says, okay, I have chest pain, shortness of breath, fatigue with heavy activity. Then it gets to 75% and it's with moderate activity. Then it gets 90, it's with minimal activity. And then 99%, it's at rest. Now, if this occurs slowly, you can follow them and you can track them and you can intervene. However, it's the plaques like this that are 10%, that are 20%, that have zero calcium, that are young, that are immature, that are constantly changing shape, that rupture. See this plaque ruptured right here? And then the red thing is a blood clot. So now your body sends what's called platelets to block the crack because the plaque ruptured. But the problem is it fills the entire artery wall and blocks blood flow. dead before you hit the ground.

SPEAKER_00: 21:05

So this is the person with the zero calcium score that is running, going to the gym, working out, and dies from a sudden heart attack in their sleep or after activity. So this is the scary part that we all want to know what's going on in our heart, right? What's going on in here? We don't know.

SPEAKER_01: 21:25

And these are the guys, like Mike said, Joe Schmoe, Ran a half marathon on Sunday, felt great on a Monday. I mean, felt great on a Sunday night, got up Monday morning and hit the ground is dead. And everybody's like, oh, my God, his cholesterol is normal. No, it's not. Because we know that 50 percent of people who have normal cholesterol don't. So the whole thing is this is a disease that starts in childhood. The only thing we can do is stop progression or slow progression. We can't. regardless of what you hear on the internet. And please believe me, I've dedicated my life to this. There's nothing that causes regression. In other words, makes the plaque go away to an appreciable extent. Yes, people will say that. And I'm going to get scientific right now because Mike and I like to be evidence-based. So there's two studies. One's called the Meteor Study and the other's called the Asteroid Study. And that's using high-dose resuvastatin, which is a statin. And they put an ultrasound down into the coronary artery and then another one up into the carotid artery. And they measured the plaque volume, which is the three-dimensional plaque volume. The problem was is none of those people had significant blockages. They were 20% or 30%, so they didn't block blood flow. And yes, one of them found, I think, an 8% reduction in overall volume of the plaque, and the other one was like an 11% reduction. But if they didn't limit blood flow, it's irrelevant. And they also didn't look at how many people died or didn't die. So what statins do, besides lowering your cholesterol, is they stabilize plaques. They make those plaques, like you saw in that video, less likely to break. And to me, that's the money. If your cholesterol is borderline, still, I don't know one cardiologist or one cardiac surgeon that doesn't take medicine. Because if you can stabilize that plaque and keep it from breaking, that's the best thing that we can do to prevent sudden death.

SPEAKER_00: 23:34

And Mike, that's another very good point is the whole statin talk. We could almost do another talk as statins, which we will at some point. But all the sudden statins are such a bad rep with a lot of people. And I personally know, People that are stopping statins, they think, you know, it's lowering my testosterone. I don't feel good on them. It's causing dementia. Which

SPEAKER_01: 23:56

is a myth, as you know.

SPEAKER_00: 23:59

One thing that I talked to you, I was somewhere and everyone was talking about, hey, we got to stop statins. Get off them. I knew people that were getting off because they think it was causing early onset Alzheimer's or dementia. And it's quite the opposite. And when we really dove into it, all the studies show that it actually decreases Alzheimer's and dementia risks in well peer-reviewed journals. So the whole stat and talk, we're not going to bore you with that today.

SPEAKER_01: 24:26

Well, I mean, we can say one little thing. So right when Mike and I figured this out, I sent him. So there's a new meta-analysis in the Journal of Alzheimer's Disease, 50% Five studies, randomized studies, 7 million people. They had a reduction of 24% all-cause dementia, 21% in Alzheimer's. We've known this as cardiac surrogates for a long time. And what people also don't understand is the brain cholesterol does not mix with the total body cholesterol. So these lipoproteins, these cards, turn over every three days. So that's why when we're measuring lipoproteins, You don't have to fast for your blood test because you're measuring the transport vehicles. But your brain cholesterol lasts from six months to five years, and it doesn't mix with the body's cholesterol. So when people are saying it lowers your cholesterol in your brain, it does not, number one, because yes, every cell does need cholesterol. But actually, the number one cause of dementia is vascular dementia. are mini strokes caused by atherosclerosis in the small brain arteries. So that's why the best we've got right now is to lower your cholesterol aggressively. But if you're not identified properly, right, Mike, you can talk about yourself.

SPEAKER_00: 25:48

A hundred percent. Someone like myself, no family history. My numbers are marginally high. I've always exercised and worked out. And I'm on a statin. And When I looked into it, I don't want to take anything. I don't like taking anything, to be honest with you. But the studies don't lie. And these are real studies. So that's another takeaway point. Besides all the studies we're talking about, besides the lipid, now we have statins. And these are all stuff we're telling you, not because they're our opinion. And this is why we're doing this podcast. This is peer-reviewed journals. This is studies on thousands of people.

SPEAKER_01: 26:29

Millions. There's no drug that has been studied more than statin. First statin was developed in 1983. The guys who won the Nobel Prize in medicine in 1965, two doctors, discovered how to get rid of lipoprotein particles. In other words, That's what led to statins, that statins increase the number of parking spots in your liver for these lipoproteins to go and bind there, to go and park and can't get out. And then you go to the bathroom and you get rid of them. So but, you know, there's so much more to lipid management. Some people need two drugs, three, but we're not talking about that. What we're talking about is how do you identify every single person at risk?

SPEAKER_00: 27:15

So I think, Mike, I think this is a really good intro and a really good start. And I think people hopefully learned a little bit today. And I think see your cardiologist. And even if you don't have any family history, it's good to know what's going on in here. You know, maybe it makes you sleep a little bit better at night doing some of these stuff and getting some knowledge. But I think this is a really good intro. And I think we're going to talk more, a lot more about this in the future among so many other topics. But this is exciting stuff. And it's great to have an expert like you on here and And as we go on and do more podcasts, we're going to try and bring on experts in every field if we can. And we're really going to try and make it fun and exciting and brief. So we don't bore you, but we want to hit the major topics. And you can always reach out to us individually. If you're lipids, you know, Mike's the guy for that. And that was great.

SPEAKER_01: 28:08

Please, please, you know, if I can say, please just do yourself a favor and go watch the video, the animated narrated video that I made with actually one of my patients. He did because that's what he does. He used to work for Fox. Um, and, um, the narrated video because you want to see how biology works how the particles actually get into the wall of the artery because that'll crystallize everything because you want to be able to tell your friends family and you want to understand it okay that you know that's number one and then also like mike said please understand that what you hear and you see on the internet okay there is not one doctor there was a just a quick anecdote and there was a National Geographic from 2007, which I've entitled The Heart, and it journeys somebody's whole thing who had multiple heart attacks to needing a heart transplant. And they interviewed all the cardiologists at the Cleveland Clinic, which is like the premier place. There's not one cardiologist that doesn't take medicine, okay? Because we say we have no intention of dying of the disease that we treat, okay? So please believe us that what you hear on the internet is not true. that cholesterol is not good for you. It is not good for you.

SPEAKER_00: 29:31

Awesome. Okay.

SPEAKER_01: 29:34

Right. And remember, when it comes to your health, the truth matters because we're all about the truth.

SPEAKER_00: 29:41

All right, everyone. Stay healthy, my friends. Till next time.

SPEAKER_01: 29:44

All right. Thank you.