199. Heart Health Essentials: What Every Woman Should Know About Cholesterol with Dr. Margo B. Minissian

😲 It's time to change the conversation around women's health and take proactive steps to protect our hearts! ❤️

In this episode of the Health Bite podcast, Adrienne interviews Margo B. Minissian, a leading expert in women's heart health. They discuss the critical importance of understanding heart disease, particularly among women, and explore actionable steps for prevention and management.

Who is Margo B. Minissian?

• Cardiologist and expert in women's heart health
• Advocate for proactive heart health management
• Passionate about educating women on cardiovascular risks and prevention

What You'll Discover:
❤️ The shocking statistics about heart disease in women and why it matters
🩺 How to interpret your cholesterol numbers and what they mean for your health
💡 Actionable steps to improve your heart health through lifestyle changes
🔍 The importance of understanding familial hypercholesterolemia and its implications
📊 Key screening tests and additional markers to assess your cardiovascular risk

Why This Episode Matters:
In a world where heart disease is the leading cause of death for women, Margo's insights will empower you to:

• Take charge of your heart health with informed decisions
• Understand the interplay between lifestyle, genetics, and heart disease
• Advocate for yourself in healthcare settings to ensure comprehensive care

🎧 Tune in now and take the first step towards a healthier heart and a longer life!

"More women die of heart disease than cancers combined, and it's crucial we take proactive steps to manage our heart health." - Margo B. Minissian

Connect with Margo:

• Website: https://researchers.cedars-sinai.edu/Margo.Minissian 
• Linkedin: https://www.linkedin.com/in/minissianm/ 

Ways that Dr. Adrienne Youdim Can Support You

1. Join the Monthly Free Mind-Body Workshops: Participate in engaging mind-body practices designed to help manage your stress response. Register here.
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3. Freebie alert. Register for our monthly free MindBody Workshop and receive a downloadable guide on emotional labeling to help you manage your emotions effectively.

Connect with Dr. Adrienne Youdim

• Website :https://www.dradriennespeaks.com/
• Instagram: https://www.instagram.com/dradrienneyoudim/

Transcript

Adrienne Youdim

Margo, I'm so happy to have you on the Health Byte podcast. Welcome, welcome, welcome.

Margo B. Minissian

Thank you so much, Adrienne, for having me today. It's just such a pleasure to have this opportunity to chat with you.

Adrienne Youdim

Well, I love connecting with you always, and you and I have been friends and colleagues for almost two decades now, which is a lot. And we've spoken together in many venues, and every time I hear you speak, I think to myself, Gosh, this information is so important for the general public. Usually when we are speaking, it's to physicians, but I believe there's a disconnect where the information is not getting out to very savvy health conscious people. So again, I thank you for being here because I think this is so important, this topic of women's heart health.

Margo B. Minissian

Well, thank you so much for highlighting it. As we know, more women die of heart disease than cancers combined and it's worldwide. In fact, heart disease affects everyone, men and women worldwide. And I feel that, you know, the topic isn't sexy, you know, the, it's not fun talking about cholesterol. People don't feel their cholesterol, people don't feel their blood pressure. And so it really does take a proactive approach to really manage our blood vessel health, essentially.

Adrienne Youdim

You know, we say this all the time, especially around February, when it's Women's Heart Health Month, about how heart disease is the number one killer in women. And I feel like it doesn't stick because we're all shocked at that statistic. And then we go back to worrying about breast cancer, which in and of itself is an important disease. But heart health is so important because the statistics shouldn't be a It's not negative because there is so much we can do in a proactive way. And so I love talking about this because not only is it important to women's health, but it's actionable. There are steps that we can take.

Margo B. Minissian

Yes, that's so incredibly true. You know, there are risk factors that, you know, we all have. And I think of risk factors as like a deck of cards. And, you know, for you poker players out there, or, you know, Jim Rummy players, you know, you get this deck of cards and some of them you're like, oh, look at these match, like I can do something with these cards. But then there's other cards, you just, you kind of inherited them because they were in the deck. And so risk factors very much work that way. We don't get to choose our parents. you know, we don't get to choose where we were born or, you know, our life, our life circumstances and those situations. We're starting to learn so much more that our social environments really play a very important role in our overall heart health. And so there but with that being said, there's so much that we can do to to really, you know, move the needle towards overall health and well-being. You know, that essence of just really feeling good and having good energy, you know, getting through the day without feeling exhausted. I find that a lot of my patients, when we work on the numbers, that once we get those numbers right and we start getting our lifestyle in alignment, that people just have fabulously more energy.

Adrienne Youdim

It is a proactive approach that does intertwine, as you said, social health, mental and emotional health, and physical health. It's something that we talk about often on this podcast. how these different facets of our mind and body and society are so intertwined in terms of our health and well-being. And again, I want to emphasize the proactiveness of this. And in that vein, I'm going to put myself in the hot seat. I'm going to use this as a free consult by... Love that. And Margo, you really are a lead in this space in terms of clinical practice guidelines, and so you really are the expert. And I'm going to lean in with a message and in the spirit of educating our listeners, I am going to put myself on the hot seat and get a free consult from the expert in this space. So I am a young, I'd like to still call myself young, young lady, a woman. I am coming to you because I have heard that heart health is important and prevention is key. So how would you approach someone like me?

Margo B. Minissian

Well, first and foremost, I would congratulate you for taking an active role in your heart health. So many women just like you, you're beautiful, you're active, you have a healthy weight. If we look at the outside of Adrienne and we set aside Dr. Udim, And we're just talking about beautiful Adrienne who's sitting in front of me. There are stereotypes and connotations just around that. So many providers will reassure you based on your appearance and your looks because you're a healthy weight and you take good care of your physical self. And so with that being said, I just love to congratulate women for thinking about ourselves on the inside and beyond just the bikini exam that we typically get from an OB and sometimes discussions with primary care physicians. Although I do feel that they, they try to touch on as many points as possible. So we're talking to Adrian today. And so the first thing that I'd ask Adrian is, is there anything with your life that's going on right now that you have any concerns or fears or, you know, challenges with?

Adrienne Youdim

So I will say that I am healthy and I walk my talk. So I exercise regularly and eat a healthy diet. But the reason why I came to you is actually because there's a pesky number that I've been dealing with and dismissing. I've known since I was in college actually that my cholesterol was high. Someone told me that it's probably familial and I think it is. My dad has high cholesterol. But again, because I exercise and because I eat a healthy diet and have managed my weight in midlife better than even how I had managed in high school. I'm not so worried about it and yet this number keeps coming up. So I would say that I'm a little bit concerned about the number.

Margo B. Minissian

Okay, great. And so we're talking about your cholesterol then. What is your total cholesterol?

Adrienne Youdim

It's really bad, Margo. When I first had it checked in college, I remember it was in the 170s, 180s. Pre-COVID, it was the same. During COVID, as I shared in my book, Hungry For More, I gained the 10-15, thanks to my husband's sourdough bread and wine. My cholesterol at that time went up to 190s.

Margo B. Minissian

 And that's your total or is that your low density?

Adrienne Youdim

I'm sorry, my my total cholesterol went up to the 290s. I'm sorry you go. OK, and then I got my act together. I lost the COVID weight and my most recent total cholesterol is 295. OK, so 295.

Margo B. Minissian

This is not Adrian driving through McDonald's. This isn't Adrian, you know, not getting her exercise in. So this is an optimized Adrian is what I would hear from like a lifestyle standpoint with everything else is being in alignment. Your weight's good, your exercise is good, and your nutritional regimen is consistent.

Adrienne Youdim

Right. And so can you tell me like how abnormal is 295? What should it be? And what are some of the things that you're considering?

Margo B. Minissian

Cholesterol is interesting when we look at a cholesterol panel. And I think most of your viewers will note that they will see that there's a total cholesterol There's an HDL and an LDL and a triglyceride number. And then there could be some other ones depending on what your provider might order for you. It's interesting because these numbers actually play a role on each other. So we use something called a Freewald's equation to calculate out total cholesterol. And I know that many people will see that total cholesterol number and they will freak out. It's not always warranted the freak out. Sometimes it is, but the total cholesterol is actually a calculation from the other numbers. So we can't make any decisions based off of total cholesterol. Typically, we like it less than 200. For women, women get pregnant, women have children. depending on where you are in your life course, where you are with your hormones in particular, that total cholesterol can vary significantly. So the number one and most important number that we look at when we're looking at risk is LDL, which is otherwise known as low density lipoprotein. How you can remember this one is it's the LDL. So you want it low because it's the lousy one. you don't want this one high. So what's considered high? Well, if you look at national guideline recommendations, if somebody has an LDL that is greater than 190, then they typically will have a diagnosis that is the familial, as you had mentioned, which is familial hypercholesterolemia. So ladies and gentlemen, you can't eat enough. If Adrian was driving through McDonald's every day, if you had not a familial gene, you really couldn't probably eat yourself to an LDL of 190 or greater. So that the National Guidelines has said, there are a few instances when you can have these other kinds of sticky particles that can contribute to a very high cholesterol. But for most people, they get labeled familial hypercholesterolemia.

Adrienne Youdim

Just to clarify, or to reiterate, so we want the total cholesterol to be under 200. and when the LDL we want under well you can tell us what we what we want but we know that if it's over 190 that you can't eat your way to an LDL of 190 or greater that's really something that's coming from your genetics and actually my LDL my most recent LDL was 204 so clearly above 190 so now what okay so

Margo B. Minissian

Let's first answer what normal would be, just to let the audience hear a little bit more about what 204 means, because I gave you the number of 190. We want it under that. So we want definitely under 100 for LDL. So you're more than twice that. If you have a history of heart disease, So you've been told that you have either cholesterol or plaque in your arteries. Then we want your LDL under 70. And if you've had a previous heart attack or a stroke, or you have high blood pressure, or you have something known as a risk enhancing factor, if you have two of these, then we actually suggest that your LDL should be under 55. What we're learning through research is that there's really no good reason why we should even have this lousy cholesterol fat floating around in our peripheral bloodstream. So that philosophy of lower is truly better really does apply. And it does apply to you, Adrienne. What would we do with an LDL that is 204? The good news is, is that we have a plethora of ways to treat and LDL of 204. First and foremost, we lean in on lifestyle and we're doing lifestyle simultaneous now because you are Dr. Udayne and you know exactly what is good for you and you've already incorporated those things. If it was someone else that was learning about these lifestyles, we would implement medication. So a cholesterol lowering medication that is a class 1A, which means we have 40 years of data that if you can take a statin, which is a cholesterol-lowering medication, that you have less chance of having a heart attack, a stroke, or dying from heart disease would be the number one recommendation. And because your LDL is greater than 190, we would put you on a higher intensity statin. And my favorite is rosuvastatin. It happens to be generic. You could try a 20 or a 40 milligram tablet. We see about a 60% reduction in that LDL, the 40 milligram tablet. So I usually would prescribe a 40 and have you cut it in half and see what kind of a response you would get on the 20 milligram after about four to six weeks of taking it.

Adrienne Youdim

So I'm going to step, give you some pushback on me in a second, but I want to address those folks out there who are, they don't have an LDL of over 190. Those are the guys and gals that you're recommending a satin for, but they don't have a stroke history of a stroke or a heart attack. So they don't necessarily need to be at an LDL of less than 100 or 55. Can you talk about the people whose LDLs are between 100 or 130 and 190? Those are the guys who are going to get a little red check next to the lab, right? The lab is going to say, hey, this blood test is abnormal. Yes. Those people need a statin and why or why not talk about that a little, you know, I love that.

Margo B. Minissian

So this is that intermediate category that can just be so tough sometimes. So when we're looking at individuals that, you know, qualify, you know, here's your, here's your cholesterol lowering pill. And they're like, Oh no, do I really have to take this? It's for primary prevention, which means they've never had a heart attack before. That can be sometimes the toughest. If you're a male and you're over 40, or if you're a female and you're 50 or greater, I highly recommend two screening tests. The first one is a coronary calcium score. There's a lot of power behind the number zero. And then the second screening test that we look for is a lipoprotein A. Now that those two screening tests in particular, if they both come out negative, then typically what I do is I go, oh, we have a little more time to work on the lifestyle piece. and to get serious about it. Oftentimes people are not eating as clean or as diligent as they would like, and they may not be moving their bodies through space for at least 30 minutes a day. So it's a wonderful opportunity for us to be able to work on that lifestyle component. Then, you know, it's also very important to look for secondary causes. for an elevated low density lipoprotein. So if you have diabetes, if you have a thyroid disorder, if you are in perimenopause, these are all pulsatile hormones that can affect cholesterol. So you want to work with somebody because if you needed your thyroid adjusted, they would adjust the thyroid and then your cholesterol would even out. And there's also, you know, some evidence that when people have high blood pressure, When we treat high blood pressure, it can also help the dynamic around cholesterol as well. This was actually found out in the all hat trial, like in the nineties, it's like, wow, I'm treating somebody's blood pressure and, and their cholesterol profile improved. Was it because they have more awareness about their cardiovascular health? And so maybe they were making better decisions globally and we were reducing inflammation, which we know can help. reduce cholesterol. High cholesterol is also a form of an inflammatory process. So that's another reason. Basically, most bad things that can happen to us have this inflammatory process in the background, whether we're talking about cancer or heart disease in particular.

Adrienne Youdim

The initial screening test is important. Additional tests that we can get like a coronary calcium score as well as an APO, which is a blood test. But before we get there, what about, and this is something I'm sure your patients are going to tell you. And I, so I want to do some pushback. What about the HDL, right? So we know that the L is lousy, but the H is good. So what if, what, how does HDL come into play in this considering our risk profile?

Margo B. Minissian

Thank you. Cause that's a wonderful question. H stands for high density lipoprotein. We want this number high or higher, I would say. And I like to think of it as the happy cholesterol. It's the good one. You want it higher. So we already learned about the LDL and us wanting it lower because it's the lousy one. Now we've learned a lot about HDL over the last, I would say 10 years. And so we have more to glean from it. We don't per se have a way of treating with medications, somebody who has a naturally low HDL. So what's considered low? For men, if your HDL is under 40 milligrams per deciliter, or if you're a female and your HDL is less than 50 milligrams per deciliter, then this is also considered a form of dyslipidemia. And the best analogy that I can give is if LDL is the lousy cholesterol, think of it as like trash. And the HDL is the happy, good cholesterol. And think of it as like a dump truck. And it comes by and it can pick up trash. It picks up trash every Monday. So if you only have a couple trucks and you're trying to clean out trash, we're in L.A. So we need lots of dump trucks. So we need a high HDL to be able to clean out all the trash. If you don't have that many dump trucks, then the trash is going to start to build up and then that leads to heart disease. So we want to have a good high cholesterol. What can you do to help improve your cholesterol and your HDL specifically? Well, active weight loss actually helps to elevate, sometimes temporarily, but for those who are in active weight loss mode, and maybe you might have a few listeners on this, you know, on this show that are, you know, actively losing weight in an effective way, they may see their HDL pop up, it may not stay there, it once that once the weight starts to even back out again, it may come back to baseline. But it's a nice little, you know, proactive bonus. For those individuals who have a really high HDL, say your HDL is over 60, the cardiovascular screening assessment, you actually gain a point for having HDL that's over 60. What we really don't know what to think of as of yet is an HDL that's over 90. So we are now starting to learn that not all HDL is created equal. There are actually several different types of sub-particles that compose HDL. And our screening blood tests, which is the usual blood panel that we all get at the doctor's office, is not able to see the sub-particles. So many people, in fact, have immature or dysfunctional HDL, even though their number is very high. And back in the 2000s, 2010s, we were maybe falsely reassuring people based on this cholesterol ratio. They say, oh, but my ratio, you know, my HDL is good. And so I don't need to take medication. In fact, their HDL may have been the non-functional type. or the immature HDL and was not cleaning out that trash the way that it should. And so we've stopped doing that. So currently our first and primary target is the LDL. And then when we look at residual risk, the second marker we look at is actually triglycerides to help reduce residual risk.

Adrienne Youdim

We already established that my total cholesterol is high. My LDL is higher than what it would have been if it were related to diet, probably familial. My HDL is in that middle category. So for women, you mentioned that less than 50 is considered a risk, but greater than 90 may also be problematic. So the take home message is, let's get it if we can in that range of 50 to, you know, 90 or above 50 and less than 90. So my HDL is 71. It's in that in that range. And my triglycerides are 88, which is pretty good. It's excellent. And so where would you want the triglycerides to be? And if I had high triglycerides, what could I do to bring that down?

Margo B. Minissian

There are two forms of high hyper triglyceridemia. Now that's a mouthful. We'll just call it high triglycerides. One form can be secondary. So it's, it's fault is because you have uncontrolled diabetes or it's fault is because We're eating a bunch of carbohydrates and we're eating things that are sugary. And basically our triglycerides are kind of like the sugary fats that are floating around in our bloodstream temporarily while we're eating. So if you weren't fasting during your laboratory test, your triglycerides may not be as accurate. There are a few less healthy reasons why triglycerides can be high, like drinking a large amount of alcohol can actually cause elevated triglycerides. So you talked about the pandemic. I saw in our Women's Heart Center, you know, more and more women having their triglycerides going up. Some, some women were, you know, really getting good at their cooking. But some women were also getting quite good with their social wine drinking. And so they were having, you know, two, three glasses of wine a night. People weren't driving and that kind of thing. And so we definitely did see an uptick there. Um, so if you can nutritionally wean it and, you know, we like to think that one glass of wine, if you don't have an alcohol, you know, issue, um, with food, would still be okay for triglycerides. But once again, we just kind of have to look and go on a case by case basis. Your triglycerides look amazing because your nutrition and your regimen is so good.

Adrienne Youdim

So for any women out there who have high triglycerides, because we talk about the LDL a lot and the total cholesterol often, but triglycerides is also a harmful fat particle, as you mentioned, but it is, I think, the one, to your point, that is most easily fixed, right? It is, it is. The alcohol, as you mentioned, taking away sugary or high-carb foods and bringing your weight down can have a really dramatic impact on your triglycerides. So now we've gotten our basic cholesterol panel, and hopefully ladies out there are understanding their total cholesterol, their LDL, their HDL, and their triglyceride goals. But you did mention some additional tests that we can get to understand our risk. And so I did get some of the blood tests. And so you mentioned the APOAs, right? Can you briefly, and for our lay listeners, because we just want to know what to do to get healthy, what other tests should we be asking our doctor potentially to get blood tests and otherwise?

Margo B. Minissian

Absolutely. This is a wonderful question, Adrienne. So for the person who's really trying to just get a good idea around risk assessment, the LPA or lipoprotein A, is the best marker that we really have when we're looking at outcomes. What are outcomes? Outcomes are like bad things that can happen back to those heart attacks, strokes, and dying because of heart disease. And why is that? Because it can make our blood a little more sticky. So if your LPA number was high and you have high LDL, which is the lousy cholesterol, then I'm kind of on my hands and knees begging you to take the medication. If your LPA is normal, then at least we don't have any extraordinary influencers into making things even more, you know, sticky and inflamed than what an already high LDL could do. And there are other biomarkers. So, you know, I always think it's good if individuals see, you know, having an LDL over 200 is, can be common. That's why heart disease is the leading killer still. is because it can be fairly common. Having a cardiologist and ideally a preventive cardiologist, somebody who understands these cholesterol numbers is important to have. And if you have an opportunity to sit with a geneticist who can look at a gamut of what is primarily causing your familial hyperlipidemia, that is always also a great thing to do. And there are three common genes that can cause high cholesterol. And then that also helps inform us on treatment options because now we have injectables in addition to newer pills that are on the market, all that help to lower cholesterol.

Adrienne Youdim

What I'm hearing is if you're kind of in the more extreme case, which I happen to be, that you may want to go down that line. But for our regular listeners who, again, may be in this range of elevated cholesterol, they've already done all the things they're exercising six days or five days a week already. which I am, they're already eating healthy, they have their BMI in a normal range. These other tests that you're talking about are APOA, and did you also mention the LP, LP little A, or am I putting words in your mouth?

Margo B. Minissian

Well, the LP little A is the one I was just talking to. So APOA, APOA1 in particular is associated with HDL. And it's a good marker, so you want it higher. And because your HDL is already high, it makes sense that your APOA1 would also be good. because those two numbers go together. So if they're going up, which is a good thing, they usually go up together. Similarly, LDL, which is the bad one, is more associated with ApoB. And so when people look at their ApoB, oftentimes their ApoB will be high when their LDLs are high. And so that's why for national guidelines, sure, it's great if you do that additional testing for screening, but we really can go off of HDL and LDL and triglycerides because all those other little particles kind of follow along. it's lipoprotein A or LP little a, as you had mentioned it, that is an additional marker that tells us about stickiness and atherogenesis, which is a very fancy word for high inflammation that makes things more sticky.

Adrienne Youdim

So thanks for the clarification. So we can ask our, our physician, or maybe speak to our cardiologist about an APOA, ApoB and an LP little a so I went ahead and got my ApoA and that was 168 and the ApoB was 123 and I guess that as you mentioned goes along with what we already saw in terms of my good cholesterol or my HDL, but I'm happy to report that the sticky particle, the LP little a, which helps me understand a little bit about my risk in terms of having a high LDL, my LP little a is 10, which is wonderful.

Margo B. Minissian

And likely why your father is an older adult and a healthy older adult, if I recall. You know, when we're looking at our family members, you know, we're looking at that first degree relative, so our parents. And if we have parents that had heart disease or died suddenly for no good reason under the age of 50, or they were having a stent placed, or they were having some kind of heart surgery, you know, in their fifties or younger, typically we'll see those high LP little a numbers contributing to, you know, premature early atherosclerosis. There are a handful of genetic cholesterol disorders that can really affect the young. And so if you know of someone anyone who had, who died suddenly, not from an accident, but that maybe they were found. Many times this can be a cardiac cause. And so it's a good, it's a good reason for those family members or those children of those family members to get tested. We suggest in the United States, we suggest that anyone 18, or older should know what their cholesterol is. And if you have a family member who has high cholesterol, that you should have children tested.

Adrienne Youdim

In the last little bit, I do want to get to the screening tests, the imaging tests. because you did mention a calcium score. And so and I do know that there's also other tests like, you know, cardiac stress testing or treadmill tests that our listeners are aware of. Can you just briefly talk a little bit about when you would get the calcium score? And when or why the stress test may not be as reliable in women, a test that we are still being recommended as a primary imaging modality.

Margo B. Minissian

Talk a little bit. Yeah, absolutely. So if you're feeling good and you can walk up a flight of stairs with, you know, a bag or two of groceries and you can make it through and get up there, some of us might be a little short of breath, especially if you're carrying groceries up a flight of stairs. but you should be able to, you know, without bags, you know, be able to run up a flight of stairs and feel good or, you know, walk up a hill then. And that means you're not really having any symptoms. So if you're having no symptoms, no symptoms above your waist, no pressure, heaviness, tightness, then a stress test is not indicated for you. Um, and we don't recommend that people just go and proactively do a stress test because that evidence had never played out to, you know, really save anyone's life. And in fact, um, we can expose, you know, and women in particular to radiation to our chest, which is never good. And then if we ever do need additional testing, you know, we, we want to kind of save those radiation, if you will, those radiation dollars for our breast screenings. And if we were feeling shortness of breath, or we were having chest pressure or heaviness or, you know, back pain in between our shoulder blades, you know, or excessive fatigue, like just really excessive fatigue. That's always my favorite. Ask a woman who isn't excessively tired from time to time, but symptoms really should be clustered together. So if you're feeling excessively fatigued, somebody looks at you and goes, wow, you look really pale and you're kind of sweating, then you need to go, you know, to urgent care or to the emergency room and get looked at. So these symptoms are typically clustering. If that's the case, the best test for a stress test is one that's got some imaging to it. And so pedaling on a bicycle and having an ultrasound of your heart is a really great test to do. Also, these new, um, CT tests, um, the 64 slice CT angiograms are also good for women. They've actually gotten quite better with lower dosing and radiation. And there's also even some components of uh, uh, some breast screening where they can get a calcium score out of it. So imaging and, um, cardiovascular imaging in particular is really getting better for women in general overall. Um, but, um, pedaling on a bicycle, um, is really kind of bold standard still because when we push ourselves and we elevate our own heart rate, it tends to be more sensitive and specific for us, which is great. If you're not, and you should be doing that with a cardiologist, if you're otherwise feeling well, and this is purely for screening, coronary calcium scoring is really the way to go. I feel for that additional imaging component. We used to do ultrasounds of the neck. You can still do that, but the gold standard is currently coronary calcium scoring.

Adrienne Youdim

So just to clarify, the imaging tests like the treadmill test, the CT, Angio, these are things that we should be considering if we're having symptoms that are concerning. But if this is just purely preventive, we've got some numbers that are out of whack and want more information, then the next imaging test would be a calcium score. So tell me when you get a calcium score, how do we, how do we evaluate those numbers?

Margo B. Minissian

So we want to see the number of zero zero is a powerful number. You know, it's in women and women who are younger, like yourself, it can be a little challenging. I'll say, I also have high cholesterol. My father, you know, died young of heart disease. And people wouldn't look at me and think that I was on cholesterol medications or that I was on blood pressure medications, but here I am. Cause I don't want to go down. I'm not even going down that pathway. So when we're thinking, when we're thinking of imaging and someone who is 40, you know, to 55, it can be challenging quite frankly, because it's not as sensitive for us as it is our male counterparts. Men tend to calcify their plaque faster than women do earlier. By the time we're, you know, 60, we have very effective calcium scores. So, um, we feel quite good about that. Um, so when I see somebody who's got an LDL over, you know, one 90, um, I typically, you know, um, asking them to take the medication regardless because it's cheap and it's easy. And if you can take it and not have any symptoms, You know, the medications are essentially free in the United States if you have, you know, insurance or it's $5 at Costco for like a 90 day prescription. So that's typically how I go about it. But once you're over 50 and you're heading more towards 60, the zero calcium score is very, very powerful. So if you've had one now and it's zero, I would look, you know, and Adrian, do you feel comfortable telling people how old you are on?

Adrienne Youdim

I do actually. So I am 48 and I did have a zero calcium score. And so what I'm hearing from you and what we can extrapolate to or what our listeners can take away for themselves is that a calcium score when you're under 50 is reassuring, but is more important after 50 or even more so after 60. So maybe women out there who are in the same situation that I'm in that have an abnormal cholesterol, particularly if they're 50 or greater, they would benefit from a calcium score. I'm not in that category, but again, we are being proactive in our health. So I got a calcium score It's zero. So now I am in a little bit of a quandary, are you? Because I have an LDL over 190. It's something that you at the beginning said slam dunk gets me a statin, but I have a calcium score that's zero. In the last few minutes, can you just kind of give us a synopsis of how you kind of would see this picture now coming together.

Margo B. Minissian

Yeah, absolutely. And thank you so much for having yourself as a really perfect example of bringing this story home. Because to me, taking the cholesterol pill is better than wearing your seatbelt. And even though you have a zero calcium score, we're not 100% sure if it's soft, if there's any soft plaque or uncalcified plaque there, because it is a class 1A recommendation for someone who has an LDL greater than 190. I will still back that. And one thing I'll say is it's made from a derivative of tree bark. So here in LA, like everybody loves the whole plant-based situation. And so it's vegan and And like I said, it's really kind of cheap and easy. Um, so for me, I would, I would continue to recommend that you take the medication. The other good thing is that it's not one of those things that you may be taking for life. It's one of those things that, you know, as we are aging and we want to age gracefully, maybe we're on it for the next five years. I'm with you. I take it too. Um, I have a zero calcium score also. I'm under 50. So. It's like, well, let's see. We also have new medications for people who have a familial high cholesterol. That is an injection that's about once a year. It's like once every like nine months or so. Right now, they save that for higher risk individuals, people who've had heart attacks and you know, their cholesterol is so high that even the highest dose of the statin can't get them to goal. And so they're on a combination of the injection with the medicine. And so that's how we use it currently. But I could see five, 10 years down the road that we're kind of using it as sort of like a vaccine against our cholesterol, even though it's not touted a vaccine. but it is actually an mRNA inhibitor, just like the COVID vaccine is.

Adrienne Youdim

So interesting. So something for people to kind of keep in the backs of their minds are these newer agents, these injectable agents for cholesterol that might be more avidly used. They're not as frequently used now. For now, our kind of bread and butter is still the statins. So I will say that I actually reached out to my primary care doctor, who is my co-resident at Cedars-Sinai, where you still are. So this is a full circle moment. And I told her that in the spirit of prevention, because You know, we all want healthier, not just longer lives, but longer lives in which we're living well. Prescription for the statin is sitting at CVS. I want to thank you, Margo, for indulging me and taking me through this as an example, because I think it is a good way for women out there to acknowledge their risk factors, the importance of taking heart health seriously, how they can look at some of these screening tests, some of the additional tests that you may think about and ask for that may not be offered so readily by your general doctor, and then putting all this information together and making some decisions that aren't always super cut and dry, but require nuance, and that's where the shared decision-making happens.

Margo B. Minissian

It is. It is so true. It's been such a pleasure to be with you and Adrian helped me lose 20 pounds. I like quadrupled the amount of lean protein that I have added to my life and I am actively working out and so I'm also following Um, you know, a prescription of, you know, lifestyle that I also have to do if I want to avoid. I'm not, I'm not going down, you know, my dad's path and, and Adrian, you won't either.

Adrienne Youdim

Thank you, Margo. Thanks for being candid. At the end of the day, we are all human and have the same human conditions and are all striving to do our best.

Margo B. Minissian

So that's right. Ups and downs, but we've got this together.

Adrienne Youdim

Exactly. Thanks again, Margo, for your expertise. And as always, I love spending time with you.

Margo B. MinissianMargo B. Minissian

Likewise. Thank you so much, Dr. Udim, for having me today.